Disclosure of sexual abuse among youth in residential treatment care: a multiple informant comparison.

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Disclosure of Sexual Abuse among Youth in Residential Treatment Care: A Multiple Informant Comparison a

Lise Milne & Delphine Collin-Vézina

a

a

McGill University, Montreal, Quebec, Canada Accepted author version posted online: 18 Mar 2014.Published online: 12 May 2014.

To cite this article: Lise Milne & Delphine Collin-Vézina (2014) Disclosure of Sexual Abuse among Youth in Residential Treatment Care: A Multiple Informant Comparison, Journal of Child Sexual Abuse, 23:4, 398-417, DOI: 10.1080/10538712.2014.896841 To link to this article: http://dx.doi.org/10.1080/10538712.2014.896841

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Journal of Child Sexual Abuse, 23:398–417, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1053-8712 print/1547-0679 online DOI: 10.1080/10538712.2014.896841

DISCLOSURE AND ASSESSMENT TECHNIQUES FOR ABUSE AND TRAUMA

Downloaded by [University of Cambridge] at 16:12 09 October 2014

Disclosure of Sexual Abuse among Youth in Residential Treatment Care: A Multiple Informant Comparison LISE MILNE and DELPHINE COLLIN-VÉZINA McGill University, Montreal, Quebec, Canada

This exploratory study describes the child sexual abuse experiences of 53 youth (ages 14–17) in child protective services residential treatment care using three informants: youth (via the Childhood Trauma Questionnaire), residential treatment workers (via the Child Welfare Trauma Referral Tool), and the child protective services record. Child sexual abuse was self-reported by 38% of youth, with reporting by females almost four times higher. Child sexual abuse co-occurred with physical abuse, emotional abuse, and neglect in 75% of cases. Agreement between youth and residential treatment worker reports was high, while agreement between youth reports and their child protective services record was low. The study suggests systematic child sexual abuse screening among residential treatment care youth through self-reports and residential treatment worker reports. Case studies are provided, and implications for practice, policy, and future research are discussed. KEYWORDS adolescent, sexual abuse, sexual abuse disclosure, victim

Received 28 May 2012; revised 31 May 2013; accepted 11 July 2013. Address correspondence to Delphine Collin-Vézina, McGill University School of Social Work, Wilson Hall, 3506 University Street, room 321A, Montreal, Quebec, Canada H3A 2A7. E-mail: [email protected] 398


Sexual Abuse Experiences of Youth in Care

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While child sexual abuse (CSA) has become increasingly recognized over the past four decades, a majority of studies have drawn attention to the continuing invisibility of victims (Putnam, 2003). In particular, there is a substantial lack of knowledge regarding the CSA experiences of youth in residential treatment care (RTC) (Baker, Curtis, & Papa-Lentini, 2006; Brady & Caraway, 2002; Collin-Vézina, Coleman, Milne, Sell, & Daigneault, 2011; Dale, Baker, Anastasio, & Purcell, 2007). Specifically, information regarding CSA prevalence, severity, and co-occurring maltreatment for these youth is not well known (Baker et al., 2006). Obtaining a clear picture of the CSA experiences of youth in RTC is critical in light of the association between CSA and negative outcomes including a variety of mental health disorders, dysfunctional behaviors, and neurobiological dysregulation (Putnam, 2003; Trickett, Noll, & Putnam, 2011). Research has also highlighted numerous internalizing and externalizing problems among youth in RTC (Baker, Wulczyn, & Dale, 2005; Brady & Caraway, 2002; Briggs et al., 2012; Huefner, Handwerk, Ringle, & Field, 2009; Wulczyn, Barth, Yuan, Jones Harden, & Landsverk, 2005), although the study of CSA events and impacts for these youth is lacking. To lay the groundwork for crucial future research, this exploratory study provides a portrait of the CSA experiences of a small group of youth in CPS RTC from the perspective of multiple informants. First, CSA prevalence is examined with a focus on severity and co-occurring maltreatment. Second, agreement between informants is examined through comparisons of the reports of youth and RTC workers, who often work most closely with and possess detailed knowledge regarding the youth. These reports are compared to the CPS information system record that includes the current legal reason for CPS service. Findings from these multiple informants are triangulated, which is uncommon in research among this population of youth. Finally, three case studies of youth receiving CPS services for CSA victimization are provided in order to give a more in-depth portrait of the experiences of these vulnerable youth.

SCOPE OF THE PROBLEM CSA is increasingly viewed as an important global problem with devastating consequences. A meta-analysis of CSA-related publications between 1982 and 2008 involving nearly 10 million participants revealed a worldwide CSA lifetime prevalence of 13%, which represents one out of eight individuals (Stoltenborgh, van IJzendoorn, Euser, & Bakermans-Kranenburg, 2011). In sharp contrast to these prevalence study findings, the meta-analysis found a CSA incidence rate of only 0.4% worldwide, 30 times lower than the global prevalence rate. This discrepancy is largely due to the tendency for incidence studies to count only official reports by professionals


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of incidents occurring within the past year (Stoltenborgh et al., 2011). This failure to count unreported maltreatment cases is recognized as a major limitation (Hussey, Chang & Kotch, 2006). Indeed, relying solely on official records of CSA cases severely underestimates the true extent of the problem. This underestimation is highly problematic in light of research that overwhelmingly suggests a host of potential short- and long-term impacts of CSA, including depression, posttraumatic stress disorder (PTSD), neurobiological alteration, anger, anxiety, borderline personality, dissociation, somatization, self-esteem impairment, sexualized behaviors, self-mutilation, suicidal ideation and behavior, sexual adjustment, substance abuse, and eating disorders (see review of meta-analyses by Hillberg, Hamilton-Giachritsis, & Dixon, 2011; and reviews by Putnam, 2003, and Romano & Deluca, 2001).

Youth in RTC Studies regarding the CSA experiences of youth in RTC have mostly emerged in the past decade. This population is considered particularly vulnerable for a number of reasons. On the continuum of restrictiveness, RTC facilities trail only inpatient psychiatric facilities and juvenile justice facilities (Walter, 2007). These youth are known to have serious maltreatment histories (Brady & Caraway, 2002; Briggs et al., 2012; McCloskey & Walker, 2000) as well as myriad problems including substance abuse (Baker et al., 2006; Dale et al., 2007), suicidal behaviors (Baker et al., 2006; Dale et al., 2007), self-injurious behaviors, sexual acting out or offending (Baker et al., 2006; Baker & Purcell, 2005; Dale et al., 2007; Farmer & Pollock, 2003), and conduct disorders (James, Landsverk, Leslie, Slymen, & Zhang, 2008; Walter, 2007). Overall, youth in RTC exhibit higher mental health symptom levels and fewer adaptive behaviors than youth treated outside of RTC settings (Briggs et al., 2012; Foltz, 2004; Frensch & Cameron, 2002). These untreated trauma symptoms can lead to long-term problems in adulthood (Anda et al., 2006; Bonanno, Noll, Putnam, O’Neill, & Trickett, 2003; Courtney, Piliavin, Grogan-Kaylor, & Nesmith, 2001; Hillberg et al., 2011). Moreover, complex, chronic, and multiple maltreatment experiences is the rule rather than the exception for maltreated youth (Finkelhor, Ormrod, & Turner, 2007). These findings are important in light of research demonstrating that the effect of a single type of maltreatment is less related to developmental outcomes than the cumulative impact of multiple and varied traumatic experiences throughout childhood (Finkelhor et al., 2007; Lau et al., 2005). While prevalence studies specifically examining youth in foster care have consistently shown high prevalence of CSA, with rates between 37% and 81% (Auslander et al., 2002; Dowdell, Cavanaugh, Burgess, & Prentky, 2009; Mendle, Leve, Van Ryzin, Natsuaki, & Ge, 2011), studies conducted specifically among youth in RTC are relatively rare. In the first



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in-depth analysis of the CSA histories of a national sample of youth entering RTC, Baker and colleagues (2006) found that nearly a third of more than 1,000 youth had documented CSA histories. More recently, Briggs and colleagues (2012) examined trauma exposure, functional impairments, and treatment outcomes for more than 10,000 youth and found nearly twice the prevalence of CSA and higher rates of impairments among youth in RTC compared to youth in nonresidential settings. Moreover, as the number of cooccurring trauma types increased, so did the rates of impairment. In another study of nearly 400 youth in RTC, a third reported CSA, with reporting by girls nearly three times higher (Connor, Doerfler, Toscano, Volungis, & Steingard, 2004). Finally, Dale and colleagues (2007) studied the characteristics of youth entering RTC and found that nearly half of the youth had been sexually abused (60% of girls; 43% of boys). High rates of internalizing and externalizing psychopathology were found among CSA victims, with girls demonstrating elevated levels of symptoms. Taken together, these studies show that at one of the highest levels of care for youth, rates of CSA are alarming, especially among girls.

Co-occurrence of CSA with Other Maltreatment Types Research demonstrates that CSA rarely occurs in isolation, often overlapping with multiple maltreatment types (Cyr et al., 2012; Daigneault, Tourigny, & Cyr, 2004; Dong et al., 2004; Finkelhor et al., 2007). In fact, Finkelhor and colleagues (2007) cautioned that multiple victimizations are so common that studies focusing solely on one victimization type cannot capture the true experiences of the combined maltreatment of most youth, with effects of multiple maltreatment experiences more perilous than any one type. In their study of more than 2,000 children in the general population, Finkelhor and colleagues (2007) found that nearly all victims of rape had been polyvictimized (four or more types of victimization) in the past year alone. Similarly, in a study of youth receiving general CPS services, Cyr and colleagues (2012) found that more than half of CSA victims had experienced other types of maltreatment in the past year. Studies specific to youth in RTC have found important numbers of youth to be victims of both CSA and physical abuse (e.g., Ackerman, Newton, McPherson, Jones, & Dykman, 1998; Connor et al., 2004; Dale et al., 2007) as well as victims of CSA, physical abuse, and neglect combined (Baker et al., 2006). A recent study by Collin-Vézina and colleagues (2011) regarding youth in CPS RTC found that the experience of such multiple victimizations was associated with symptoms within the clinical range for depression, anger, PTSD, and dissociation. It has also been suggested that the negative consequences of multiple maltreatment may be the reason some youth develop behavior problems that lead to placement in restrictive settings such as RTC (Baker et al., 2006).

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Sources of Information Used in CSA Studies


According to Amaya-Jackson, Socolar, Hunter, Runyan, and Conlindres (2000), indirect methods for gathering information about children such as official records, adult recall, parent reports, and clinician reports make useful and valuable contributions but “offer imprecise estimates of abuse prevalence and associated effects” (p. 725). Decisions regarding which sources to use in studies can have a dramatic impact on the level of information provided as well as the overall results. Research employing direct sources of information (e.g., youth self-reports) and indirect sources (e.g., CPS RTC worker reports and CPS records) is examined here.

YOUTH

SELF - REPORTS

McGee, Wolfe, Yuen, Wilson, and Carnochan (1995) asserted that from a sociological perspective, maltreatment should be subjectively and operationally defined by youth self-reports of occurrence and severity rather than objective criteria dictated by CPS laws. Surprisingly, youth perspectives are often excluded from CSA studies. According to Ungar, Barter, McConnell, Tutty, and Fairholm (2008), “a substantial portion of victims . . . may go unrecognized unless specifically queried regarding victimization” (p. 344). Indeed, some researchers suggest potentially negative, deleterious consequences of not asking about abuse, including obscuring the role of abuse and overestimating the strength of other factors that impact youth (Putnam, Liss, & Landsverk, 1996). Moreover, when youth are not asked about abuse-related trauma but are asked about other sensitive problems, they may perceive the abuse as unimportant. Youth may also feel that researchers and practitioners are uncomfortable asking abuse-related questions, which may increase feelings of stigma (Becker-Blease & Freyd, 2006). While it is commonly known that victims of CSA usually delay reporting or never disclose their abuse (London, Bruck, Ceci, & Shuman, 2005; London, Bruck, Wright, & Ceci, 2007; Paine & Hansen, 2002), studies illustrate that when suspected victims are asked, they are more likely to disclose than to deny (Bruck & Ceci, 2004; London et al., 2007; Priebe & Sveiden, 2008). In addition, researchers have suggested that adolescent retrospective reports of CSA are valid and often consistent with reports by therapists and social workers with access to several information sources (Everson et al., 2008). For example, high agreement has been found between youth selfreports and therapist reports (Bernstein, Ahluvalia, Pogge, & Handelsman, 1997) as well as between youth self-reports and CPS files/social work reports (McGee et al., 1995) on the occurrence and non-occurrence of CSA. Agreement among informants is generally higher for CSA than other maltreatment types.



CPS RTC

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WORKERS

Although some studies have included therapists as sources of information (e.g., Bernstein et al., 1997; Winegar & Lipschitz, 1999), few studies have included the perspective of CPS RTC workers, despite the close, nearly daily contact they have with youth. Baker and colleagues (2006) conducted one of the only known studies involving RTC staff where CSA was already documented and confirmed in the case file. In McGee and colleagues (1995), CPS case workers made a global rating of the CSA experiences of youth who had open CPS files (placement status unspecified) and found high agreement (88%) with youth on the occurrence and non-occurrence of CSA. The lack of inclusion of RTC workers, who are potentially rich sources of information about the youth with whom they work, is a clear research gap. Nevertheless, some limitations to using workers as informants have been noted by McGee and colleagues (1995), including the tendency to make CSA determinations based solely on CPS laws, to define CSA severity in relative terms based on experience with other cases, and the high worker turnover that can result in a lack of awareness of the CSA experiences of some youth. CPS

RECORDS

While studies employing CPS records have been used to describe the extent of CSA, such studies are susceptible to report, investigation, and substantiation biases (Walsh, Jamieson, MacMillan, & Trocmé, 2004) and may provide inaccurate estimates of CSA prevalence. For example, some researchers have highlighted the precariousness of using CPS records as the sole source of information in studies given that few CSA victims were found to be involved with CPS (MacMillan, Jamieson, & Walsh, 2003; McGee et al., 1995). Furthermore, according to the U.S. National Incidence Study (NIS-4) (Sedlak et al., 2010), community professionals receive over a third of all maltreatment reports, suggesting that CSA may be known to organizations other than CPS. Thus, the CPS record alone may be a crude and potentially inaccurate representation of the experiences of many youth (McGee et al., 1995). MULTIPLE

INFORMANTS

Official objective and subjective estimates of maltreatment will always vary given the unique information each reporting source possesses as well as the different standards and thresholds for evaluating what constitutes CSA (McGee et al., 1995). Accordingly, a “gold standard” of CSA verification is rarely possible, suggesting the importance of using as many informants as possible to provide a comprehensive picture of CSA experiences. Studies examining CSA experiences using several informants are rare and generally


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involve community samples (e.g., Brown, Cohen, Johnson, & Smailes, 1999; MacMillan et al., 2003) or “at risk” or clinical samples (e.g., Bernstein et al., 1997; Winegar & Lipschitz, 1999). The few studies specific to the CSA experiences of youth in RTC have relied on one informant (e.g., Baker et al., 2006; Connor et al., 2004; Dale et al., 2007; Edmond, Auslander, Elze, McMillen, & Thomspon, 2003). In one of the few known studies to use three informants, McGee and colleagues (1995) recruited youth, CPS workers, and researchers (who examined detailed youth case files) to determine CSA rates. Overall, the literature has highlighted important research gaps regarding potential CSA victims in RTC, including a lack of comprehensive studies using multiple informants, specifically those including the perspectives of youth and their RTC workers. Thus, for the purposes of this study, it is considered essential to provide a voice to youth to ensure that their lived experiences are included. In addition, given the pivotal role of RTC workers in the lives of these youth, efforts are made to recognize their knowledge and expertise by including their perspectives. Finally, CPS information systems records are examined to determine to what extent they reflect reports made by youth and RTC workers.

METHOD Data Collection Procedures McGill University Research Ethics Board approval was received for this research. Youth placed in six CPS RTC units from a Quebec, Canada, CPS agency were invited to participate in the study. Over a period of one year, RTC workers (who work directly with the youth in the units) or the unit managers identified the parents of 60 youth. Verbal or written consent was obtained from 56 of the 60 parents, with four refusals. Of the 56 youth, 54 expressed an interest in participating. A member of the research team met individually with the participating youth. Verbal consent and written assent were obtained from the youth prior to completing the measures, which included consent for filling out questionnaires as well as for their RTC workers to fill out a questionnaire. One youth chose to withdraw from the study while filling out the questionnaire, resulting in a final sample of 53 youth. Participants received $10.00 gift cards in recognition of their cooperation and participation. Fourteen RTC workers also agreed to participate in the study, for which they signed consent forms. All study material was de-identified and is kept in a secure data lab at McGill University.

Sample Males composed just over half of the sample (n = 29; 54.7%). The age range was 14 to 17 (M = 15.5; SD = 1.1). Nearly 38% of youth identified as


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Caucasian, 23% as Aboriginal (First Nations, Inuit, or Métis), 19% as Black, and 20% of mixed or other ethnic background. According to the CPS record, the majority of youth were legally involved with CPS due to serious behavioral problems their caregivers were unable to manage as well as for various forms of abuse and neglect. More details are provided in the subsequent “CPS record” section.

Measures


CHILDHOOD TRAUMA QUESTIONNAIRE Administered to participating youth, the Childhood Trauma Questionnaire short form (CTQ-SF) is a 28-item self-report inventory that screens for a history of abuse and neglect (Bernstein & Fink, 1998). It yields scores for five empirically derived subscales: physical abuse, emotional abuse, sexual abuse, physical neglect, and emotional neglect. Each subscale is composed of five items rated on a 5-point Likert scale ranging from 1 (never true) to 5 (very often true), thus enhancing reliability and maximizing statistical power (Bernstein et al., 2003). Total scores range from 5 to 25. Cutoff scores have been set by the CTQ authors for each type of trauma at four severity levels of maltreatment: none or minimal, low to moderate, moderate to severe, and severe to extreme. The CTQ-SF has been referenced in numerous studies, translated in several languages (Thombs, Bernstein, Lobbestael, & Arntz, 2009), and used in clinical, field, and population based community settings (Forde, Baron, Scher, & Stein, 2012). The internal consistency and test-retest reliability of the instrument has been shown as satisfactory, with very high coefficients for the sexual abuse subscale (Bernstein & Fink, 1998; Garrusi & Nakhaee, 2009; Scher, Stein, Asmundson, McCreary, & Forde, 2001). With some mixed results, the factorial structure of the CTQ-SF has also been demonstrated (Forde et al., 2012; Paivio & Cramer, 2004; Scher et al., 2001; Thombs et al., 2009; Wright et al., 2001). Confirmatory factor analyses have shown that CTQ-SF items performed consistently across four diverse populations with differing maltreatment histories, supporting the measurement invariance of the instrument (Bernstein et al., 2003). Finally, the CTQ-SF has shown good criterion-related validity in a subgroup of psychiatrically referred adolescents (Bernstein et al., 2003). CHILD WELFARE TRAUMA REFERRAL TOOL (CWT) Administered to participating RTC workers, the CWT measure is designed to help child welfare workers make trauma-informed decisions for referral to trauma-specific and general mental health services (National Child Traumatic


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Stress Network, 2008). The worker most familiar with the youth completes the measure through file reviews and key informants, reporting on a variety of trauma exposures and the age range over which each trauma was experienced. Sexual abuse (by parent/caregiver) or assault/rape (by noncaregiver) is indicated by responding “yes,” “suspected,” “no,” or “unknown.” For the purposes of this study, “no” and “unknown” responses were combined and recoded into a new variable “no/unknown.” The worker also records current stress reactions (reexperiencing, avoidance, numbing, arousal), attachment difficulties, behaviors requiring immediate stabilization (suicidal intent, active substance abuse, eating disorder, serious sleep disturbance), and current stress reactions, behavior, and functioning (anxiety, dissociation, self-harm, conduct problems, etc.). For this study, the youth’s primary RTC worker who worked closely with the youth on the RTC unit was selected to complete the CWT. CPS

RECORD

For a youth to receive CPS services in Quebec, an investigation by a case manager (social worker) who carries the legal mandate must conclude that his or her security or development is threatened or compromised in accordance with one or more articles under provincial CPS legislation. Upon completion of an investigation, the CPS case manager determines which of the articles are the primary, secondary, or tertiary reasons for service (implying that youth can be involved for more than one reason) and enters the decision into the CPS information system. For this study, the primary, secondary, and tertiary legal reasons for CPS service for each youth were retrieved from the information system and added to the data set for analysis (this CPS record does not include the full case manager file notes for the youth).

RESULTS Youth Reports CTQ results revealed high rates of self-reported CSA experiences by the 53 youth, with the mean score for the sexual abuse subscale as 9.08 out of 25 (SD = 6.70). Using the CTQ cutoff scores, 12 youth reported CSA in the severe to extreme range, five youth reported moderate to severe CSA, and three youth reported low to moderate CSA. When all maltreatment experiences were considered, from low to extreme severity levels, 20 youth in total (38% of the sample) reported being sexually abused. A gender difference was found for female victims of CSA, X2 (2, N = 53) = 11.44, p < 0.001. Among the girls, 63% reported sexual abuse in contrast to 17% of the boys.

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TABLE 1 Agreement Regarding CSA between Youth (CTQ),1 RTC Worker (CWT),2 and the CPS Record

Youth and RTC worker YES Youth and RTC worker NO Agreement between youth and RTC worker (%) Youth YES, RTC worker SUSPECTED Total agreement between youth and RTC worker (%) Youth, RTC worker, CPS record YES Youth, RTC worker, CPS record NO Overall agreement between youth, RTC worker, and CPS record


1

N

%

8 29

15 55 70 15 85 4 55 59

8 2 29

Childhood Trauma Questionnaire. 2 Child Welfare Trauma Referral Tool.

In terms of CSA victimization by ethnicity, seven of 12 Aboriginal youth, four of 10 Black youth, eight of 20 Caucasian youth, and one of 11 “other” youth reported CSA.

RTC Worker Reports Using the CWT, 14 RTC workers reported that nine youth were CSA victims, and CSA was suspected for an additional eight youth. RTC workers were unaware of CSA victimization for the remaining 36 youth. As in Table 1, when all youth reports of CSA were compared to RTC worker reports, there was agreement in the majority of cases (n = 37; 70%) on the occurrence and non-occurrence of CSA: in eight cases both the youth and the RTC worker agreed that CSA had occurred, while in 29 cases the youth and the RTC worker agreed that CSA had not occurred. In another eight cases the youth reported CSA while the RTC worker suspected it. In the remaining eight cases, the RTC worker suspected CSA but the youth did not report it. When suspected cases were included, the agreement between youth reports and RTC worker reports on the occurrence and non-occurrence of CSA rose to nearly 85%. To obtain a measure of interrater reliability for all cases, including suspected cases, the AC1 statistic was used, which is considered a more robust measure of agreement among multiple raters than the generalized kappa. The AC1 can be interpreted similarly but is more resilient to the generalized kappa’s limitations (King, 2004). The AC1 coefficient result was 0.60, which is considered to be on the border of “substantial” concordance among youth and worker sources. For the sake of comparison, rates of agreement between youth and RTC worker reports were examined for other maltreatment types such as physical abuse, emotional abuse, and neglect. Results showed that the agreement between youth and RTC worker reports for CSA was nearly double that for physical abuse and more than one and a half times higher for emotional abuse and neglect. As with CSA, when suspected cases were included for the other maltreatment types, agreement rates rose significantly.

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CPS Information Systems Record The CPS record reflects the primary, secondary, and tertiary reasons for current youth involvement entered into the CPS information system. Of the 53 youth, only 3 were presently involved with CPS directly due to CSA either as a primary, secondary, or tertiary reason. This infers that for 17 of the 20 cases where a youth reported CSA, there was no indication of CSA in the current CPS information systems record. The great majority of youth (n = 44) was involved for serious behavior problems, a result unsurprising in light of this population. Fourteen youth were involved for neglect, and a smaller number were involved for reasons such as not attending school, physical abuse, or emotional abuse (some youth were involved for more than one type of maltreatment or behavior problems). Of the three CSA cases reflected in the CPS record, two were in complete agreement with youth and RTC worker reports (in the third case, the worker suspected CSA). Overall, there was complete agreement regarding the occurrence and non-occurrence of CSA among the three informants in 59% of cases (see Table 1).

Co-occurrence with Other Maltreatment Types Youth CTQ responses were used to determine the co-occurrence of CSA with physical abuse, emotional abuse, and neglect. For the 20 youth who reported CSA, there was high correlation with all other types of maltreatment; every youth who reported CSA also reported at least one other maltreatment type. The great majority (n = 15; 75%) reported all four maltreatment types (CSA with physical abuse, emotional abuse, and neglect). For the remaining youth (n = 5), CSA co-occurred with one or two other types of maltreatment. Chisquare results showed a significant association between CSA and physical abuse, X2 (1, N = 53) = 5.17, p < .05; no significant association with neglect or emotional abuse was detected due to the small sample.

Case Studies of Youth Victims of CSA To bring to life the experiences of the three youth involved with CPS directly due to CSA, information provided from all three informants was used to develop detailed case studies. YOUTH 1 This 15-year-old Caucasian female was involved with CPS due to CSA and abandonment. She scored within the severe to extreme range for CSA, with the highest possible score on the CTQ sexual abuse scale. She was also reported by her RTC worker to have been sexually abused by a family member at an early age, around which time she was neglected and experienced traumatic grief or separation. Importantly, this youth had moved several times


409

in the past five years. The youth was described as presently at risk in the community due to drug use, overall impulsivity including shoplifting and skipping school, and her association with negative peers. Despite intellectual capacities within the borderline range, she was on grade level and passing her school subjects. She remained in RTC for approximately two years.


YOUTH 2 This 15-year-old Aboriginal and Caucasian female was involved with CPS due to CSA in early adolescence as well as school truancy. The RTC worker suspected that the youth had also been neglected and emotionally abused. As with the previous youth, CTQ results showed scores in the severe to extreme range for CSA, with the highest possible score on the sexual abuse scale. Present concerns included school fighting, not following parental authority, and sexualized behavior. The worker reported that the youth had been diagnosed with conduct disorder with traits of borderline personality disorder. In addition, she was demonstrating multiple current traumatic stress reactions such as reexperiencing, avoidance, arousal, substance abuse, eating disorder, anxiety, depression, affect dysregulation, somatization, selfharm, regression, impulsivity, oppositional behaviors, and conduct problems. The youth was also self-mutilating through cutting. She remained in RTC for approximately one year. YOUTH 3 This 16-year-old Black female was involved with CPS due to CSA and severe behavioral problems. According to the RTC worker, she also had a history of traumatic grief or separation. While the RTC worker reported that the youth had been sexually victimized at various points throughout early and late adolescence, the worker was not aware that she was currently involved with CPS directly due to CSA. As with the two previous youth, she scored in the severe to extreme range for sexual abuse. Presenting concerns included family violence, drug abuse, multiple suicide attempts, and chronic suicidal ideation. According to the youth, she was diagnosed with attention-deficit disorder and a learning disability but was not receiving related services. The RTC worker reported that the youth’s traumatic stress reactions and other problems included reexperiencing, numbing, arousal, attachment difficulties, anxiety, depression, affect dysregulation, oppositional behaviors, and conduct problems. As with the first youth, this youth had moved several times in the previous five years. She was still in RTC at the time of the study. These case studies illustrate the myriad difficulties and complex problems that young victims of CSA in RTC might face. All three youth were female (suggesting that male victims may be less likely to come to the attention of CPS for CSA). They all reported severe to extreme CSA


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victimization and exhibited many concerning behaviors, which may have led to their situations being reported to CPS. A review of RTC worker responses regarding the other nine youth who reported severe to extreme CSA revealed that while their victimization was not reflected in the CPS information systems record, their RTC workers nonetheless either confirmed or suspected CSA. In addition, RTC workers reported a multitude of serious internalizing and externalizing behaviors for these nine youth, including running away, selfmutilation, suicidal ideation and attempts, stealing, drug and alcohol abuse, involvement in prostitution, sexual aggression, sexual behavior problems, boundary issues, and depression, among others. Importantly, these portraits reflect the extensive knowledge that RTC workers often have regarding the youth with whom they work closely. Clearly, the CPS record alone cannot reflect the true extent of the problems associated with CSA; however, it is unclear the extent to which the rich information provided by the youth and their RTC workers in this study was shared, communicated, and utilized in clinical practice to ensure appropriate services and treatment for the youth.

DISCUSSION The primary aim of this exploratory study was to document and contrast the CSA experiences of youth from the perspective of multiple informants, namely youth in CPS RTC, their RTC workers, and the CPS information systems record. A review of the literature revealed the relative paucity of comprehensive, multi-informant research focusing on CSA victimization among CPS populations, especially regarding youth in RTC. The study found that among the 53 youth, well over a third reported an experience of CSA, nearly three times higher than prevalence rates in the general population (Stoltenborgh et al., 2011). Girls were almost four times more likely to be victims of CSA, double the rate of what is generally found in CSA research (Putnam, 2003). These girls are known to be at higher risk for clinical levels of sexual concerns, PTSD, and dissociation symptoms (Collin-Vézina et al., 2011). The study also found high agreement between youth reports of CSA and the reports of their RTC workers. Youth and RTC workers who reported the occurrence or non-occurrence of CSA resulted in agreement in almost 70% of cases, a much higher rate than for all other maltreatment types. This agreement rate increased substantially when cases of suspected CSA were included. With respect to the CPS record, as Quebec child protection law applies only to the present situation as opposed to lifetime victimization, it was not expected that CSA reports by youth and their RTC workers would be significantly correlated with the CPS record. It was nonetheless surprising to learn that while 20 youth self-reported CSA, only three had CPS records reflecting CSA. For two of these cases, there was perfect agreement



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between the three informants, while in one case the worker suspected CSA. Complete agreement among the three informants on the occurrence and non-occurrence of CSA was nearly 60%, lower than levels of agreement between youth and RTC worker reports. Detailed case studies of these youth illustrated the myriad problems these youth have that may potentially be associated with their CSA victimization. The case studies also highlighted the detailed and complex information RTC workers possess regarding the youth with whom they work and the importance of including their perspectives in studies. With respect to multiple maltreatment experiences, very high levels of co-occurrence were found between CSA and other maltreatment types. All of the self-reported CSA cases co-occurred with at least one other maltreatment type, and 75% co-occurred with all other maltreatment types, namely physical abuse, emotional abuse, and neglect. These results are particularly concerning as youth subjected to multiple forms of victimization are known to be at high risk for traumatic psychological impacts (Finkelhor et al., 2007). Overall, while this cross-sectional, exploratory research has captured rich information from youth and their RTC workers, it highlights the need for this information to be systematically captured, documented, and communicated in order to ensure the provision of specialized, effective, and coordinated services for youth. Indeed, it remains unclear the extent to which this information would be provided and communicated outside of a research context, suggesting the benefits of a standardized, clinical assessment protocol for youth entering RTC. The findings of this study partially address the “tip of the iceberg” phenomenon in which a fraction of CSA situations are visible and a much higher proportion are undetected (MacMillan et al., 2003). In particular, the alarmingly high rate of CSA among girls (63%) makes a strong argument for systematically screening for CSA among youth in RTC. The study demonstrates the capacity of youth to self-report CSA and for RTC workers to reliably identify victims. Finally, the study highlights the need for CPS records to include easily accessible complete maltreatment profiles of youth. Adapting the information system to reflect multiple maltreatment types (present and past) would benefit CPS-involved youth and their families and assist agencies in better knowing their clientele, thereby increasing their ability to advocate for their needs. This research revealed other implications for social policy. While CSA is considered a serious global problem, it has yet to be addressed in a coherent and comprehensive way. Many victims are still reticent to disclose to authorities, implying a need for changes to the way CPS and other official bodies handle reports. Furthermore, a systematic CSA screening method among this population would fit extremely well with any initiative looking at implementing a trauma-informed model of care for youth in RTC. The National Child Traumatic Stress Network (NCTSN, 2008) and trauma


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researchers such as Taylor and Siegfreid (2005), Igelman and colleagues (2007), and Briere and Lanktree (2013) support the use of standardized assessments for both trauma-related and general symptoms among children. There has been a recent proliferation of tools to measure traumatic events and symptoms separately or in combination (Strand, Sarmiento, & Pasquale, 2005). For example, the Child and Adolescent Needs and Strengths (CANS; Lyons, Small, Weiner, & Kisiel, 2008) is an information integration and decision support tool that incorporates data from multiple sources to identify traumatic experiences, trauma-related symptoms, and the relationship between the number and types of experiences and the number and types of symptoms. A major strength of this study is the inclusion of three informants to triangulate the findings. In addition, the study measures are considered both reliable and valid. Moreover, the sample includes a large percentage of Aboriginal youth, which is in keeping with the documented overrepresentation of Aboriginal children in the Canadian CPS system (Sinha et al., 2011). More than half of Aboriginal youth reported CSA, supporting the need to explore the specific needs of these youth in relation to CSA. A study limitation included the relatively small convenience sample of youth drawn from a single CPS agency, without a comparison group. Given the number of gatekeepers involved in identifying youth for participation in the study, including the need for parental consent, a number of youth with CSA histories were likely excluded from the sample. Thus, the findings may not be generalizable beyond the sample. Other limitations include the lack of definitional consistency for what constitutes CSA across the three informants so that comparisons made are not completely reliable. Taken together, the findings of this exploratory study warrant serious consideration. The study provides a useful glimpse into the array of issues that CSA victims living in CPS RTC might face and lays the foundation for important future research. This research should involve larger samples in order to facilitate cluster analyses that would more precisely identify the profiles of these youth. Whether in a research or clinical context, a protocol of measures of traumatic events such as CSA and related symptoms could be administered to youth and workers over different periods to detect change over time. Administering these measures across several CPS populations would also facilitate comparisons. These findings would have the potential to inform CPS agencies, referrals, and therapeutic programs implemented for CSA victims in RTC and would be a step toward rebuilding their emotional security.

FUNDING Work on this project was supported by grants from the Canadian Foundation for Innovation and from the Centre for Research on Children and Families


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to Dr. Delphine Collin-Vézina (principal investigator). The authors wish to express their sincere gratitude to the youth who agreed to participate in this study and to share some of the struggles they have faced in their lives as well as to the staff members who committed additional time and energy to contribute to the success of this research project.


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AUTHOR NOTES Lise Milne, MSW, PhD candidate, is a sessional lecturer at McGill University in the School of Social Work. Her current research interests focus on child sexual abuse and trauma among children and youth in residential treatment care. She received her MSW from McGill University and has worked in child protection agencies for 13 years. Delphine Collin-Vézina, PhD, is the Tier II Canada Research Chair in Child Welfare and an associate professor in the School of Social Work at McGill University. Her research program focuses on implementing and assessing trauma-informed protocols and practices for sexually abused and complexly traumatized children and youth in child welfare.

Adult Disclosure of Child Sexual Abuse: A Literature Review.

Responding to prenatal disclosure of past sexual abuse.

Residential PTSD treatment for female veterans with military sexual trauma: does a history of childhood sexual abuse influence outcome?

Prevalence and comorbidity of mental disorders among adolescents living in residential youth care.

Use of Psychotropic Medications among Youth in Treatment Foster Care.

Indirect and verbal victimization by peers among at-risk youth in residential care.

A preliminary mapping of individual, relational, and social factors that impede disclosure of childhood sexual abuse.

Factors associated with adolescents' disclosure of sexual abuse experiences in Hong Kong.

How Attorneys Question Children About the Dynamics of Sexual Abuse and Disclosure in Criminal Trials.

Hispanic Residential Isolation, ADHD Diagnosis and Stimulant Treatment among Medicaid-Insured Youth.

Recent Violence Among Persons Entering Short-Term Residential Mental Health and Substance Abuse Treatment.

The effects of residential dual diagnosis treatment on alcohol abuse.

A Preliminary Examination of Negative Affect, Emotion Dysregulation, and Risky Behaviors among Military Veterans in Residential Substance Abuse Treatment.

Cognitions and distress in caregivers after their child's sexual abuse disclosure.

Assessment of sexual health and sexual needs in residential aged care.

Perceptions about recovery needs and drug-avoidance recovery behaviors among youth in substance abuse treatment.

Is Anybody Listening? The Literature on the Dialogical Process of Child Sexual Abuse Disclosure Reviewed.

An integrated model for prevention and treatment of drug abuse among American Indian youth.

Development and validation of a Social Images Evaluation Questionnaire for youth in residential care.

Effects of a structural intervention and implementation on physical activity among youth in residential children's homes.

Youth Sexual Health: Sexual Knowledge, Attitudes, and Behavior Among Students at a University in Turkey.

Advances in Substance Abuse Prevention and Treatment Interventions Among Racial, Ethnic, and Sexual Minority Populations.

Predictors of victim disclosure in child sexual abuse: Additional evidence from a sample of incarcerated adult sex offenders.

Patterns of child sexual abuse knowledge among professionals.