Childhood maltreatment (CM) is defined as “any act of commission or omission by a parent or other caregiver that results in harm, potential harm, or threat of harm to a child. Harm does not need to be intended” [
1]. Hence, CM includes physical, sexual and emotional abuse as well as physical and emotional neglect (see Table 1 in [
1]). CM is both prevalent and consequential and remains a major public health and social welfare problem in high income countries [
1‐
3]. According to Gilbert et al. [
1,
3] about 4–16 % of children are physically abused and around 10 % of children are neglected or psychologically abused [
1]. CM substantially contributes to child mortality and morbidity. The long-lasting effects on mental and physical health, substance abuse, risky sexual behaviour, and criminal behaviour persist into adulthood [
1,
2,
4]. Due to its prevalence as well as its complex and cumulative effects on the developing brain, mind and body CM is perhaps one of the most important factors to assess in a variety of contexts [
5]. Additionally detection and reporting of CM matters to promote child safety and health and to inform professionals in health care, in educational and law system as well as policy makers [
3]. Drawing on the example of the assessment of CM on the population level in Germany and especially of sexual abuse (SA), the challenges and pitfalls of the assessment of CM, will be discussed in the following.
Assessment of CM
Essentially, there are two approaches of quantification of CM on the population level: a top down and a bottom up approach. While the top down approach uses official statistics from child protection agencies or reports to the police, the bottom up approach uses data from epidemiological studies in different populations like children of different ages, adolescents and adults. The prevalence of CM from a bottom up assessment is much higher than from top down sources. This provides strong evidence that a larger proportion of CM is not reported [
3]. This underrecognized and underreported share of CM is called the “dark field of childhood maltreatment”. To light this dark field is one of the major challenges. A combination of evidence from both approaches and all available sources seems promising for the estimation of the true prevalence of CM.
Several well-established instruments for the assessment of CM in clinical and epidemiological research are available to date. The spectrum ranges from self-report measures to (standardized) interviews, and from categorial (yes vs. no; e.g. list of traumatic events) to dimensional measures of CM. A recent systematic review gives an insight into the usually applied assessment methods in population surveys [
6]. In large-scale epidemiological studies economic assessment tools are needed to support feasibility of the study protocols. Thus complex and comprehensive measures are not always the usual assessment tools applied in population surveys [
6].
The most economic assessment is the use of self-report lists of traumatic events, e.g.
Traumalist of the M-CIDI [
7]. These lists usually have a dichotomous format, hence the participants indicate whether they have experienced different kinds of traumatic events or not. This forthright way of assessment requires participants capable of memorizing and critically reflecting upon their experiences as well as a kind of precise phenomenological understanding of a specific traumatic event (e.g. what exactly means sexual abuse). Thus such lists might be suitable for the assessment of commonly defined traumatic events like car accident or natural disaster. However the assessment of emotional neglect or sexual abuse might not work well with a traumalist. Moreover this specific type of list does not allow assessing frequency, duration and severity of the respective experiences and requires self-identification of the respondents.
The
Childhood Trauma Questionnaire (CTQ) [
8] is an internationally established tool for the retrospective assessment of CM in adolescent and adult populations [
9]. The original version of the CTQ was developed from a 70-item questionnaire. In further studies the questionnaire was reduced to a 28-item version using exploratory and confirmatory factor analyses. This 28-item questionnaire is the most commonly used version applied in a vast number of studies in different languages and settings. Based on theoretical assumptions the CTQ consists of five subdimensions: physical abuse (PA; e.g. “…got hit so hard that I had to see a doctor or go to the hospital”), sexual abuse (SA, e.g. “…someone tried to touch me in a sexual way/made me touch him.”), emotional abuse (EA, e.g. “…people in my family called me stupid, lazy or ugly.”), physical neglect (PN, e.g. “…I knew there was someone to take care of me and protect me.”), and emotional neglect (EN, e.g. “…someone in my family helped me feel important or special.”, reverse coded) with five items representing each subdimension with a five-point likert scale for each item (1 = “never” to 5 = “very often”). The sum of the five items for each subscale ranges from 5 to 25. According to the original manual the sumscores of the subscales are classified for severity on four levels [
8]. A slightly different procedure of severity ratings was recommended by Walker et al. [
10] with a dichotomous differentiation of CM. These cut-off criteria had been ascertained by relating CTQ subscale scores to ratings of expert blinds for the CTQ scores who administered detailed clinical interviews. Based on the fulfillment of consensus childhood abuse and neglect criteria, experts determined whether participants had a history of clinically significant abuse or neglect [
10]. Table
1 gives an overview about both scorings. According to Walkers approach PA and PN include all cases from “slight to moderate” up to “extreme” CM, SA and EN include all cases from “moderate to severe” up to “extreme” CM. For EA the cut-off is in the middle of the “slight to moderate”-level.
Table 1
Classification of abuse and neglect along the sum scores of the subscales
Emotional abuse | 5–8 | 9–12 | 13–15 | 16–25 | 10–25 |
Physical abuse | 5–7 | 8–9 | 10–12 | 13–25 | 8–25 |
Sexual abuse | 5 | 6–7 | 8–12 | 13–25 | 8–25 |
Emotional neglect | 5–9 | 10–14 | 15–17 | 18–25 | 15–25 |
Physical neglect | 5–7 | 8–9 | 10–12 | 13–25 | 8–25 |
There is mixed evidence about the dimensionality of the CTQ, with some indications that its structure may vary across different groups. Especially the psychometric properties of the PN subscale are subject to a critical debate [
8,
11‐
14]. The internal consistencies of the subscales lay between 0.62 and 0.96 [
8]. As a measure of test–retest reliability at a median interval of 6 weeks, the intraclass coefficient were 0.77 for the CTQ as a whole and 0.58–0.81 for the subscales [
15]. The results of the CTQ show moderate correlations with those of semistructured interviews (from 0.43 for physical and emotional abuse to 0.57 for sexual abuse) [
16]. Furthermore, the results of the CTQ show correlations with ratings by psychotherapists from 0.42 for physical neglect to 0.72 for sexual abuse [
17].
Despite the fact that some evidence suggests moderate to good consistency of self-reports of maltreatment over time, the retrospective nature of the CTQ carries some risk of response bias that could possibly undermine the validity of this instrument. Hence, besides the 25 items representing five subscales of the CTQ another 3-item-response-bias scale called minimization-denial scale (MD) was included by the original authors. Unfortunately, the overwhelming majority of studies reporting CTQ data neither include information about MD items nor take these items into account for analyses and interpretation [
18]. Thus little is known about this MD measure. Moreover, if response biases are common and consequential, current practices of minimizing the MD scale deserve revision. Thus, a recent re-analysis of data from 24 multinational samples with a total of 19,652 participants was performed [
19]. Overall, results of this analysis suggest that a minimizing response bias—as detected by the MD subscale—has a small but significant moderating effect on the discriminative validity of the CTQ. Researchers and clinicians should be cautioned about the widespread practice of using the CTQ without the MD scale, or collecting MD data but failing to control for its effects on outcomes or dependent variables [
19].
To support the economic assessment CM a short screening instrument was developed based on the German version of the CTQ. The
Childhood Trauma Screener (CTS) consists of 5 items (each item representing one subscale of the CTQ [
20]. The correlations between the 5 items and the respective subscales of the CTQ range between r = 0.55 and r = 0.87. Internal consistency of the CTS was good (α = 0.757) [
20]. To support the application of the CTS for categorical diagnostics cut-offs of the different dimensions of CM have been defined based on two large-scale population studies in Germany [
21]. A further investigation of psychometric properties of the CTS is necessary.
CM on the population level in Germany
The findings from several studies investigating CM on the population level in Germany are outlined and discussed below. Table
2 gives an overview about the core methodological characteristics of the different studies. Frequency and severity of CM in the adult German population was investigated using the CTQ in a population-based representative study in 2010 [
22]. The data have already been published. For more detailed information please refer to the original publications [
22,
23]. Table
3 gives an overview about the frequency of CM according to the four severity levels recommended by Bernstein [
8,
23] and according to the dichotomous approach recommended by Walker [
10,
22] from this study. The application of different cut-offs for the definition of caseness leads to different statements about the frequency of CM on the population level (Table
3).
Table 2
Methodological characteristics of the population studies discussed in the paper
Area covered by the study | Population-based representative study for Germany | Population-based representative study for Germany | Population-based representative study for Germany | Population-based study in the northeastern part of Germany (Pomerania) |
Sample size | 2426 | 2510 | 2504 | 2400 |
Response rate | 60.9 % | 61.9 % | 56 % | Of the n = 4308 participants at SHIP-baseline, n = 3669 were invited for SHIP-Legende. Of those 92 died between 2007 and 2010, 1011 refused participation, 132 were not reached and 35 did not attend the assessments |
Age range (years) | 14–93 | 14–92 | 14–90 | 29–89 |
% Female participants | 53.9 | 54.5 | 53.2 | 52.4 |
Mode of assessment | All subjects were visited by a study assistant, informed about the investigation, and self-rating questionnaires were presented. Assistant waited until participants answered all questionnaires and offered help if persons did not understand the meaning of questions | All subjects were visited by a study assistant, informed about the investigation, and self-rating questionnaires were presented. Assistant waited until participants answered all questionnaires and offered help if persons did not understand the meaning of questions | All subjects were visited by a study assistant at home, informed about the investigation, and self-rating questionnaires were presented. Assistant waited until participants answered all questionnaires and offered help if persons did not understand the meaning of questions | All subjects were supported by a study assistant, informed about the investigation, and self-rating questionnaires were presented in the private homes or in one of the both SHIP-study centers. The assistants offered help if persons did not understand the meaning of questions |
Instruments assessing CM | Trauma-list (M-CIDI) | Trauma-list (M-CIDI) | CTQ/CTS | CTS |
Related publications | | | | |
Funding | University of Leipzig | University of Leipzig | University of Leipzig | German Research Foundation |
Department of Medical Psychology and Medical Sociology | Department of Medical Psychology and Medical Sociology | Department of Medical Psychology and Medical Sociology |
Table 3
Frequency and severity of CM in the German general population
Emotional abuse | 2123 | 84.8 | 259 | 10.3 | 75 | 3.0 | 40 | 1.6 | 254 | 10.2 | 110 | 5.2 | 170 | 6.7 |
Physical abuse | 2198 | 87.8 | 162 | 6.5 | 70 | 2.8 | 69 | 2.7 | 301 | 12.0 | 99 | 4.7 | 132 | 5.3 |
Sexual abuse | 2186 | 87.3 | 158 | 6.3 | 109 | 4.3 | 47 | 1.9 | 156 | 6.2 | 92 | 4.3 | 172 | 6.9 |
Emotional neglect | 1259 | 50.3 | 888 | 35.5 | 184 | 7.3 | 164 | 6.5 | 348 | 13.9 | 214 | 10.1 | 167 | 6.7 |
Physical neglect | 1288 | 51.4 | 491 | 19.6 | 450 | 18.0 | 269 | 10.8 | 1210 | 48.4 | 226 | 10.6 | 364 | 14.7 |
The CTS as a short screening tool out of the CTQ was used in two samples to quantify the frequency of CM [
21]. One study is a large-scale community sample (Study of Health in Pomerania) from northeastern Germany the other one is the population-based representative sample mentioned above (for more details see Table
2). The prevalences of CM from both studies are presented in Table
3. The results differ slightly in both samples. Currently it is impossible to determine whether this is attributable to the differences in both samples (population-based representative German sample vs. community sample from northeast of Germany, see Table
2) or to the psychometric problems of a short screener, such as the CTS. Further research is needed to verify the psychometric properties of the CTS.
Additionally, in 2005 and 2007 two population based representative surveys assessed the frequency of traumatic events in Germany, including childhood sexual abuse (up to the age of 14), using a traumalist [
24,
25] (for more details concerning methodology see Table
2). The findings of both studies are comparable with a prevalence of childhood sexual abuse of 1.2 % in the study of 2005 [
25] and 1.0 % in the study of 2007 [
24].