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All youth 18 years of age and older provided informed consent to participate in this study. Child Youth Care Forum. Author manuscript; available in PMC Jun 1. Sarah J. Beal , a, b Twila Wingrove , c Constance A. Mara , a, b Nathan Lutz , d Jennie G. Noll , e and Mary V. Greiner a, f. Constance A.

Jennie G. Mary V. Author information Copyright and License information Disclaimer. Corresponding Author: Sarah J. Copyright notice. The publisher's final edited version of this article is available free at Child Youth Care Forum.

Abstract Background: Childhood adversity is linked to a number of adult health and psychosocial outcomes; however, it is not clear how to best assess and model childhood adversity reported by adolescents with known maltreatment exposure.

Objective: This study sought to identify an empirically-supported measurement model of childhood adversity for adolescents in child protective custody and associations among childhood adversity and adolescent outcomes.

Methods: Self-report survey data assessed childhood adversity and adolescent outcomes, including psychological wellbeing, quality of life, and substance use, in adolescents ages 16 to 22 in protective custody with a documented maltreatment history. Results: Findings suggest that, among youth with complex trauma histories, it is important to distinguish among risk related to unexpected tragedy e. Conclusions: Among adolescents with complex trauma histories, childhood adversity assessments reflect multiple domains of adversity, each of which are differentially related to adolescent risks.

Keywords: child maltreatment, adolescence, adverse childhood experiences, foster care. Procedures A list of eligible youth was created by Jobs and Family Services i.

Statistical Analysis The parent study from which these data are derived sought to understand changes in healthcare use as adolescents emancipated from protective custody; power analyses indicated that a sample size of would be sufficient to detect that change as significant.

Results Descriptives Descriptive statistics are provided in Table 1. Open in a separate window. Table 3. A B Factor Risk for unexpected tragedy Family instability Risk for unexpected tragedy Family instability Risk for unexpected tragedy -- -- -- -- Family instability 0. Path Analysis Models We used the observed sum scores for risk for unexpected tragedy, family instability, and family violence as predictors of each outcome quality of life, psychological well-being, and substance use in three separate models.

Risk for unexpected tragedy 0. Discussion The purpose of this study was to examine measurement models of childhood adversity in adolescents with complex trauma, and to estimate associations among types of childhood adversity and indicators of adolescent wellbeing.

Limitations The findings from this study should be interpreted within the context of several limitations. Conclusion Despite these limitations, this study makes an important contribution to the literature examining measurement approaches in child maltreatment. Acknowledgments Author note and acknowledgments: This study is based on data from an observational study where clinical trials registration was not required.

Footnotes Ethical approval. Brown SA Substance involvement among youths in child welfare: The role of common and unique risk factors. American Journal of Orthopsychiatry , 78 3 , Health outcomes in young adults from foster care and economically diverse backgrounds.

Pediatrics , 6 , — Adverse childhood experiences and smoking during adolescence and adulthood. Journal of the American Medical Association , 17 , — Behavioral problems following reunification of children in long-term foster care. Children and Youth Services Review , 30 2 , — The childhood experience of care and abuse questionnaire CECA. Q : validation in a community series.

British Journal of Clinical Psychology , 44 4 , — Traumatic events and posttraumatic stress disorder in an urban population of young adults. Archives of General Psychiatry , 48 3 , — The impact of adverse childhood experiences on an urban pediatric population. Adverse childhood events as risk factors for negative mental health outcomes. Psychiatric Annals , 37 5 , The prevalence of potentially traumatic events in childhood and adolescence.

Midwest evaluation of the adult functioning of former foster youth: Outcomes at age Midwest evaluation of the adult functioning of former foster youth: Conditions of youth preparing to leave state care : Chapin Hall Center for Children at the University of Chicago. Long-term consequences of child abuse and neglect on adult economic well-being.

Child Maltreat , 15 2 , — Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. Journal of the American Medical Association , 24 , — Adverse childhood experiences and personal alcohol abuse as an adult. Addictive behaviors , 27 5 , — Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study.

Pediatrics , 3 , — The impact of adverse childhood experiences on health problems: evidence from four birth cohorts dating back to Preventive Medicine , 37 3 , — Adverse childhood experiences and the association with ever using alcohol and initiating alcohol use during adolescence. Journal of Adolescent Health , 38 4 , Health insurance coverage and use of family planning services among current and former foster youth: implications of the health care reform law. Journal of Health Politics, Policy, and Law , 38 2 , — Addressing the mental health service needs of foster youth during the transition to adulthood: how big is the problem and what can states do?

Journal of Adolescent Health , 44 1 , 1—2. Homelessness and the transition from foster care to adulthood. Child Welfare , 88 4 , 23— The risk of teenage pregnancy among transitioning foster youth: Implications for extending state care beyond age Children and Youth Services Review , 32 10 , — Cambridge, England: Cambridge University Press. Marks JS Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences ACE Study.

American journal of preventive medicine , 14 4 , — Emerging adulthood and leaving foster care: settings associated with mental health. American Journal of Community Psychology , 47 3—4 , — Burden and consequences of child maltreatment in high-income countries.

The Lancet , , 68— Health risk behavior of youth in foster care. Journal of Child and Adolescent Psychiatric Nursing , 22 2 , 77— Pynoos RS Complex trauma and mental health in children and adolescents placed in foster care: Findings from the National Child Traumatic Stress Network.

Child Welfare , 90 6 , Children and Youth Services Review , 35 1 , — The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial consequences, and fetal death. Pediatrics , 2 , — Fit indices in covariance structure modeling: Sensitivity to underparameterized model misspecification.

Psychological methods , 3 4 , — New York: Oxford University Press. Health and well-being of children in foster care placement. Pediatric Reveiew , 27 1 , 34— Age of onset of child maltreatment predicts long-term mental health outcomes.

Journal of Abnormal Psychology , 1 , Cortisol awakening response in adolescents with acute sexual abuse related posttraumatic stress disorder.

Depression and anxiety , 31 2 , — Social service review , 81 3 , — Assessment of complex trauma exposure, responses, and service needs among children and adolescents in child welfare. Journal of family violence , 29 1 , 1— Layne CM Creating trauma-informed systems: child welfare, education, first responders, health care, juvenile justice.

Professional Psychology: Research and Practice , 39 4 , Homelessness and health care access after emancipation: results from the Midwest Evaluation of Adult Functioning of Former Foster Youth. Archives of Pediatrics and Adolescent Medicine , 10 , — Farah MJ Childhood socioeconomic status and childhood maltreatment: Distinct associations with brain structure.

PLoS One , 12 4 , e Independent living services, adjudication status, and the social exclusion of foster youth aging out of care in the United States. Journal of Youth Studies , 1— Health-risk behaviors in young adolescents in the child welfare system. Journal of Adolescent Health , 47 1 , 26— Children in foster care: Factors influencing outpatient mental health service use.

Fostering health: Health care for children and youth in foster care. Medicine and Health Rhode Island , 94 7 , — Child sexual abuse, peer sexual abuse, and sexual assault in adulthood: A multi-risk model of revictimization. Journal of traumatic stress , 14 2 , — Young adult outcomes and the life-course penalties of parental incarceration. Journal of Research in Crime and Delinquency , 53 1 , 3— Impacts of adverse childhood experiences on health, mental health, and substance use in early adulthood: A cohort study of an urban, minority sample in the US.

Children in foster care: mental health, service use and costs. European Child and Adolescent Psychiatry , 15 2 , 63— Associations between types of maltreatment and substance use during adolescence. Vulnerable populations and the transition to adulthood. Future Child , 20 1 , — History of maltreatment and mental health problems in foster children: a review of the literature. Journal of Pediatric Psychology , 35 5 , — Adverse childhood experiences and the cardiovascular health of children: a cross-sectional study.

BMC pediatrics , 13 1 , Studies in mathematical psychology: I Probabilistic models for some intelligence and attainment tests. Parenting and family stress as mediators of the long-term effects of child abuse. Precursors of adolescent substance use from early childhood and early adolescence: Testing a developmental cascade model. Development and psychopathology , 26 1 , — The relationship between time spent living with kin and adolescent functioning in youth with a history of out-of-home placement.

Children who return home from foster care: A 6-year prospective study of behavioral health outcomes in adolescence. Pediatrics , 1 , e10—e What do Youth Report as a Traumatic Event?

Psychological Trauma , 1 2 , 91— Complex Trauma. The experience with independent living services for youth in care and those formerly in care. Children and Youth Services Review , 84 , 17— Posttraumatic stress disorder in abused and neglected children grown up.

American Journal of Psychiatry , 8 , — Solving measurement problems with the Rasch model. Journal of Educational Measurement , 14 2 , 97— Health-related quality of life surveillance—United States, — Copy Download. Risk for unexpected tragedy. Finally, substance use was assessed using items adapted from Johnston and colleagues to capture tobacco, alcohol, marijuana, and illicit substance use in the last 30 days.

Demographic characteristics were based on child welfare records and self-report. These variables were included as potential covariates. The parent study from which these data are derived sought to understand changes in healthcare use as adolescents emancipated from protective custody; power analyses indicated that a sample size of would be sufficient to detect that change as significant. The analysis plan for this study was as follows: First, a confirmatory factor analysis CFA was conducted to examine whether the covariance among all the item responses was accounted for by a single underlying dimension.

To determine whether the CTES was actually comprised of several underlying dimensions i. If this model is a good fit, we can be more confident that the raw sum scores are sufficient estimates of each of the domains. This was essential to test given that the CTES will likely be scored via sum scores, whether unidimensional or multidimensional.

Missing data were handled via maximum likelihood estimation. Finally, path analysis models in Mplus were conducted to evaluate the impact each of the predictors on each of our outcomes. Descriptive statistics are provided in Table 1. Adolescents endorsed an average of 10 out of 26 items on the CTES; measures of quality of life and psychosocial functioning also indicated poor functioning on average. Approximately one third of youth were using substances.

We then tested our exploratory, alternative 3-factor model using a CFA with the 26 items to see if it was an improved fit over the unidimensional model. The factor loadings for all 25 items were all high and significant on their respective factors see Table 2.

Correlations among the factors were moderate to high see Table 3 , further indicating that the three maltreatment dimensions of risk for unexpected tragedy, family instability, and family violence, while related, are distinct. Thus, based on our review of item content and our factor analyses, we propose that the CTES be revised to include only 25 items and be scored to reflect these three distinct dimensions.

We used the observed sum scores for risk for unexpected tragedy, family instability, and family violence as predictors of each outcome quality of life, psychological well-being, and substance use in three separate models.

Coefficient estimates see Table 4 indicated that family violence was significantly associated with poorer QoL and psychological wellbeing, while family instability significantly predicted increased cigarette and marijuana use, but not alcohol or illicit drug use. Risk for unexpected tragedy was not associated with any outcome. Demographic and child welfare characteristics were not significantly associated with any outcomes. The purpose of this study was to examine measurement models of childhood adversity in adolescents with complex trauma, and to estimate associations among types of childhood adversity and indicators of adolescent wellbeing.

Results suggest that a measurement model that distinguished among subtypes of childhood adversity fit adolescent-reported data better than approaches treating adverse events as unidimensional. Further, measurement models where factor loadings were constrained to be equivalent, mirroring the approach taken to sum items across subscales, did not substantially impact fit, indicating that it is sufficient to use sum scores of these subscales with this population.

In addition to examining measurement, this study found that subtypes of adverse events i. Specifically, an increase in the number of family violence exposures was associated with poorer quality of life and psychosocial wellbeing, while family instability was associated with increased cigarette and marijuana use. An increase in risk for unexpected tragedy was not associated with any indicators of adolescent wellbeing.

This provides further evidence of the importance of distinguishing among subtypes of childhood adversity, as the subscales are associated with unique risk outcomes. Our findings that the measurement model for CTES best fit with a three-factor rather than a single-factor model structure is consistent with research demonstrating that experiencing abuse is distinct from experiencing other sorts of early life stressors Lawson et al.

Importantly, this was detected in a sample of adolescents in child welfare protective custody; it may be the case that in samples where maltreatment is less prevalent, both measurement structure and associations with indicators of wellbeing would differ from what was found here. For example, more items on the family violence subscale may have been endorsed by this sample than would have occurred with a community sample of adolescents.

Consistent with this interpretation, the average score on CTES was Further, while unexpected tragedy, instability, and violence can have detrimental impact on child and adolescent outcomes, research has previously suggested that the familial context within which these events occur e. It is possible that for this sample, findings reflect the impact of childhood adversity in the absence of parental support; this may not be the case in associations of childhood adversity with outcomes for youth still residing with their parents.

These results indicated significant associations between family violence and two indicators of adolescent wellbeing among youth in protective custody: quality of life and psychological wellbeing. Specifically, as family violence exposures increased, adolescents reported significantly more days with mental and physical health challenges and more difficulties with depression, anxiety, and social support. Poor quality of life was quite high in this sample, with roughly one-third of youth reporting challenges with daily life across multiple domains of daily functioning.

The average rates described here are higher than those observed in the general population Zahran et al. The results of these models also indicated that family instability was associated with adolescent cigarette and marijuana use, while family violence and risk for unexpected tragedy were not. The differential association of substance use by type of childhood adversity is important, as it provides further evidence of the value of distinguishing among subtypes of childhood adversity in order to improve intervention and service delivery.

In this case, childhood adversity due to family instability may indicate a need for substance use prevention, while this may not be necessary if childhood adversity results from risk for unexpected tragedy or family violence. Of note, family instability was related to cigarette and marijuana use, but not to alcohol use or illicit substance use.

Future research may identify mechanisms that explain these differential relations. The findings from this study should be interpreted within the context of several limitations. First, these data are cross-sectional. Secondly, this study included only adolescents in child welfare custody; while studies have previously suggested that adolescents in protective custody are at greatest risk for poor adult outcomes Courtney et al.

Finally, the sample size for this study is relatively small and geographically limited. While our findings indicate a strong signal for effect, larger scale studies to confirm multidimensional aspect of the CTES are needed, with studies designed to take contemporary measurement methods into account. Despite these limitations, this study makes an important contribution to the literature examining measurement approaches in child maltreatment.

Specifically, these findings highlight the importance of distinguishing among various aspects of adverse childhood experiences — first as a means of accounting for and modeling variance in a manner that best reflects the data, and second because the associations between risk for unexpected tragedy, family instability, and family violence with adolescent outcomes differed. This points to a potential opportunity to use existing measures of childhood adversity in a novel way to stratify populations at risk, in order to deliver effective prevention services to the young people who are most likely to benefit.

Future research studies emphasizing the mechanisms that explain differences in subtypes of childhood adversity and health and psychosocial outcomes, particularly in the context of larger longitudinal studies, are warranted. Author note and acknowledgments: This study is based on data from an observational study where clinical trials registration was not required.

The findings reported in this manuscript have not been previously published or presented at any conference proceedings. Lutz, declare that they have no conflicts of interest. Beal takes full responsibility for the integrity of the data and data analysis for this study.

Finally, we thank the foster youth and their caseworkers for participation and facilitating the completion of this study. Ethical approval. Informed consent: For youth under 18 years of age, informed consent to participate in this study was obtained from the legal custodian Child Protective Services and all youth provided informed assent to participate. All youth 18 years of age and older provided informed consent to participate in this study. Child Youth Care Forum. Author manuscript; available in PMC Jun 1.

Sarah J. Beal , a, b Twila Wingrove , c Constance A. Mara , a, b Nathan Lutz , d Jennie G. Noll , e and Mary V. Greiner a, f. Constance A. Jennie G.

Mary V. Author information Copyright and License information Disclaimer. Corresponding Author: Sarah J. Copyright notice. The publisher's final edited version of this article is available free at Child Youth Care Forum. Abstract Background: Childhood adversity is linked to a number of adult health and psychosocial outcomes; however, it is not clear how to best assess and model childhood adversity reported by adolescents with known maltreatment exposure.

Objective: This study sought to identify an empirically-supported measurement model of childhood adversity for adolescents in child protective custody and associations among childhood adversity and adolescent outcomes.

Methods: Self-report survey data assessed childhood adversity and adolescent outcomes, including psychological wellbeing, quality of life, and substance use, in adolescents ages 16 to 22 in protective custody with a documented maltreatment history. Results: Findings suggest that, among youth with complex trauma histories, it is important to distinguish among risk related to unexpected tragedy e.

Conclusions: Among adolescents with complex trauma histories, childhood adversity assessments reflect multiple domains of adversity, each of which are differentially related to adolescent risks. Keywords: child maltreatment, adolescence, adverse childhood experiences, foster care. Procedures A list of eligible youth was created by Jobs and Family Services i. Statistical Analysis The parent study from which these data are derived sought to understand changes in healthcare use as adolescents emancipated from protective custody; power analyses indicated that a sample size of would be sufficient to detect that change as significant.

Results Descriptives Descriptive statistics are provided in Table 1. Open in a separate window. Table 3. A B Factor Risk for unexpected tragedy Family instability Risk for unexpected tragedy Family instability Risk for unexpected tragedy -- -- -- -- Family instability 0. Path Analysis Models We used the observed sum scores for risk for unexpected tragedy, family instability, and family violence as predictors of each outcome quality of life, psychological well-being, and substance use in three separate models.

Risk for unexpected tragedy 0. Discussion The purpose of this study was to examine measurement models of childhood adversity in adolescents with complex trauma, and to estimate associations among types of childhood adversity and indicators of adolescent wellbeing. Limitations The findings from this study should be interpreted within the context of several limitations.

Conclusion Despite these limitations, this study makes an important contribution to the literature examining measurement approaches in child maltreatment. Acknowledgments Author note and acknowledgments: This study is based on data from an observational study where clinical trials registration was not required.

Footnotes Ethical approval. Brown SA Substance involvement among youths in child welfare: The role of common and unique risk factors. American Journal of Orthopsychiatry , 78 3 , Health outcomes in young adults from foster care and economically diverse backgrounds.

Pediatrics , 6 , — Adverse childhood experiences and smoking during adolescence and adulthood. Journal of the American Medical Association , 17 , — Behavioral problems following reunification of children in long-term foster care. Children and Youth Services Review , 30 2 , — The childhood experience of care and abuse questionnaire CECA. Q : validation in a community series.

British Journal of Clinical Psychology , 44 4 , — Traumatic events and posttraumatic stress disorder in an urban population of young adults. Archives of General Psychiatry , 48 3 , — The impact of adverse childhood experiences on an urban pediatric population. Adverse childhood events as risk factors for negative mental health outcomes. Psychiatric Annals , 37 5 , The prevalence of potentially traumatic events in childhood and adolescence.

Midwest evaluation of the adult functioning of former foster youth: Outcomes at age Midwest evaluation of the adult functioning of former foster youth: Conditions of youth preparing to leave state care : Chapin Hall Center for Children at the University of Chicago.

Long-term consequences of child abuse and neglect on adult economic well-being. Child Maltreat , 15 2 , — Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study.

Journal of the American Medical Association , 24 , — Adverse childhood experiences and personal alcohol abuse as an adult. Addictive behaviors , 27 5 , — Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study.

Pediatrics , 3 , — The impact of adverse childhood experiences on health problems: evidence from four birth cohorts dating back to Preventive Medicine , 37 3 , — Adverse childhood experiences and the association with ever using alcohol and initiating alcohol use during adolescence.

Journal of Adolescent Health , 38 4 , Health insurance coverage and use of family planning services among current and former foster youth: implications of the health care reform law. Journal of Health Politics, Policy, and Law , 38 2 , — Addressing the mental health service needs of foster youth during the transition to adulthood: how big is the problem and what can states do? Journal of Adolescent Health , 44 1 , 1—2. Homelessness and the transition from foster care to adulthood.

Child Welfare , 88 4 , 23— The risk of teenage pregnancy among transitioning foster youth: Implications for extending state care beyond age Children and Youth Services Review , 32 10 , — Cambridge, England: Cambridge University Press.

Marks JS Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences ACE Study.

American journal of preventive medicine , 14 4 , — Emerging adulthood and leaving foster care: settings associated with mental health. American Journal of Community Psychology , 47 3—4 , — Burden and consequences of child maltreatment in high-income countries. The Lancet , , 68— Health risk behavior of youth in foster care. Journal of Child and Adolescent Psychiatric Nursing , 22 2 , 77— Pynoos RS Complex trauma and mental health in children and adolescents placed in foster care: Findings from the National Child Traumatic Stress Network.

Child Welfare , 90 6 , Children and Youth Services Review , 35 1 , — The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial consequences, and fetal death. Pediatrics , 2 , — Fit indices in covariance structure modeling: Sensitivity to underparameterized model misspecification.

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