**1. Introduction**

The focus of this chapter is on providing a review of childhood sexual abuse, physical abuse and combined abuse assessment questionnaires. Prevalence rates of childhood abuse in the United States will also be provided along with symptom and diagnostic correlates found to be associated with a childhood history of abuse. The following seven abuse screens are reviewed. (1) The Rape Aftermath Symptom Test; (2) The Scarlett O'Hara v. MMPI Configuration; (3) The Child Abuse and Trauma Scale; (4) The Childhood Trauma Questionnaire; (5) The Trauma Symptom Checklist; (6) The Trauma Symptom Inventory; and (7) The Binghamton Abuse Screen. Finally, a brief discussion of two recommended adult childhood abuse survivor treatment approaches, cognitive behavior therapy and prolonged exposure techniques will be provided.

#### **2. The prevalence of childhood abuse**

Demause (1991) found following a comprehensive review of the literature that agreement exists between social scientists and historians that probation against incest within the immediate family can be found in every known culture. He concluded that it is incest and related forms of childhood abuse itself, not the absence of incest, which represents the true universal statement. Demause's review found that statistical reviews of child molestation in the United States only go back to 1929. He noted that the official incidence figures from the American Humane Association, working from reports from child protective agencies, estimated only 7,000 incidents of child abuse occurred in the United States for 1976. These estimates rose steadily to 113,000 incidents for 1985, which at that time, represented under one percent of American children. It was not until the late 1970's and early 1980's that careful studies began to emerge with samples large enough to warrant statistical analysis.

Once these studies were published, the mental health field was altered to the alarming, frequent and disturbing prevalence rates of childhood sexual abuse (CSA) and physical abuse (CPA) in our society. Estimates were made that one in five women and one in eleven men had experienced some form of childhood abuse (CA) prior to the age of eighteen (Doyle-Peters, Wyatt & Finkelhor, 1986; Wyatt & Doyle-Peters, 1986; Martin, Jesse, Romans, Mullen, & O'Shea, 1993). The magnitude of these earlier reported (CA) prevalence rates were confirmed by later research. For example, Finkelhor, Hotaling, Lewis & Smith (1990) suggested that as many as 27% of all women and 16% of men have experienced some form

A Review of Childhood Abuse Questionnaires and Suggested Treatment Approaches 5

(Zlotnick, Mattia, & Zimmerman, 2001), chronic headaches (Domino & Haber, 1987), maladaptive sexual behavior (Briere & Runtz, 1990); irritable bowel syndrome (Walker, Katon, Roy-Byrne, Jemelka & Russo 1993), dissociative behaviors (Lipschitz, Kaplan, Sorkenn, Chorney, & Asnis, 1996), depression, alcoholism, panic disorder, and social phobia (Dinwiddle et al, 2000), chronic, fatigue, asthma, and cardiovascular problems (Romans, Belaise, Martin, Morris & Raffe, 2002), increased pain and more surgical procedures

Similarly, CPA has been associated with an increase in long-term symptomatology, including self-injurious and suicidal behaviors and physiological and emotional problems such as somatization, anxiety, depression, dissociation, and psychoses (Malinoskey-Rummell & Hansen, 1993). Physical abuse has also been associated with more pain, increased incidence of non-GI-somatic symptoms, more surgeries, and poorer functional status (Lesserman et al. 1996). Additionally, it has been associated with mental retardation (Buchanan & Oliver, 1997), chronic headache (Domino & Haber, 1987), aggression toward others (Briere & Runtz, 1990), substance abuse (Westermeyer J., Wahmanholm, K., & Turas,

Given the above established findings, it is disconcerting that many clinicians still fail to adequately assess and consider in their development of a treatment plan that a potential link between the patient's presenting problem and a history of childhood abuse may exist (Agar, Read, & Bish, 2002; Lothian & Read, 2002). Even if an assessment of CSA or CPA is conducted in the initial intake, too often the response of "no abuse" by the patient is accepted as being accurate, despite the clinical findings from delayed memory recovery patients that evidence for an abuse history often does not emerge until extensive treatment

Adding to the difficulty of obtaining an accurate initial assessment of CSA or CPA is the finding that adult survivors of childhood abuse often are reluctant to be honest due to their concern regarding the social stigma attached to their abuse or the feeling of guilt or intense fear associated with revealing the secret and not being believed (Curtis, 1976; Layman, Gidy, & Lynn 1996). Other inhibiting factors impeding abuse, the victim's memory recall is the presence of a strong cognitive defense structure of denial, including amnesia (Briere, & Contes 1991; Herman & Schatnow 1987; Williams (1994) and malingering (Briere, 1989,

Finally, some resistance by practitioners to deal with the content of abusive trauma may exist because of the difficulty of having to witness the patient's pain in re-experiencing their historical trauma or in their concerns that the memories uncovered are false and may subject

Clinicians should not be overly concerned about the elicitation of false memories, (Robbin 1995) reports that 75% of the studies on false memory did not manufacture false memories in the experimental situation despite the implicit pressure to produce one. From the present authors' viewpoint, the abundance of cognitive research on the false memory topic has little bearing on the clinical field, largely because experimental studies on false memories have

However, as Briere (1992a) warned, the possibility exists that abuse reports could reflect fantasies, delusions, or intentional misinterpretations for secondary gain. Nevertheless, it is

not been conducted with a clinical abuse population (see Levis 1999).

(Finestone, et al., 2000).

2001) and purging (Perkins, Luster, & Jank, 2002).

has been conducted (Bell & Belicki, 1998).

1992a, 1992b).

them to legal ramifications.

of childhood abuse. Additional data estimated the prevalence rate of (CSA) in outpatient populations to be 28% (Coverdale & Turboth, 2000) and 40% of in-patient populations (Jacobson 1990). More recent data from the Fourth National Incident of Child Abuse and Neglect found that 58% of the 533,300 children studied suffered from childhood physical abuse (CPA) and 24% from CSA. The projection was made that one out of 58 children in the U.S. will experience some form of maltreatment within a given year (Sedlak, Mittenberg, Basina, Petla, McPherson, Green & Li, S., 2010).

Additional reports on the prevalence of CPA suggest that 10 to 20% in non-clinical community samples experience physical abuse (Gelles & Straus, 1987), while in a clinical population, CPA prevalence has been estimated at 38% in outpatient populations and 49% in inpatient populations (Jacobson, 1989). These findings were supported by Macmillan et. al (1997) findings that 21% of women and 31.2% of men have experienced some form of CPA. Furthermore, it appears that despite changes in social policy aimed at combating incidences of CPA, the prevalence of CPA is not evidencing any significant change (Kunston & Selner, 1994).

It should be recognized that CPA and CSA often co-exist simultaneously and that there are commonalities associated with CPA and CSA (Briere & Runtz, 1990; Browne & Finklehor, 1986; Rosenberg 1987. Most types of maltreatment do occur in the presence of other types of abuse, especially among those who request services as adults (Briere, 1992b). In a study by Surrey, Swett, Michael & Levin (1990), fifty-six (74%) of the seventy-six outpatient women reported an episode of either CPA or CSA before the age of 18. Of these participants, twenty-eight (37%) reported both kinds of abuse compared to twelve (16%) women who reported CSA only and sixteen women (21%) who reported CPA only. In other studies, the occurrences of combined abuse in families in treatment for CSA, was estimated to be 19.7% (Daro, 1988). Similarly, combined abuse prevalence in female non-clinical populations has been estimated to be 17% (Wind & Silvern, 1992). It is evident from these data that it is not uncommon for the occurrence of CSA and CPA to occur in the presence of each other.

### **3. Symptom and diagnostic correlates with a history of childhood abuse**

The association between long-term psychological problems and CSA and CPA has also been well documented. A comparison between individuals with a reported history of childhood abuse with those who reported no history of abuse, indicate that those with a history of abuse are at greater risk for developing psychological disorders (Mullen, Martin, Anderson, Romans, and Herbson, 1996; Polusny, & Follett, 1995; Malinowsky-Rummel & Hansen 1993; Wind & Silvern 1992), for developing more severe symptomatology (Surrey, Swett, Michaels, & Levin, 1990) and for receiving multiple diagnosis (Briere & Runtz, 1990).

Childhood abuse has been associated with the development and diagnosis of Post Traumatic Stress Disorder (PTSD) (Kendall-Tachett 2000); Zlotnick, Mattia, & Zimmerman 2001). In a study examining adults with CSA histories, Rodriguez, Ryan, Rowan & Foy (1996) reported that 72% of their sample met full DSM-III criteria for current PTSD, while 86% met criteria for lifetime PTSD. Rowan, Foy, Rodriguez, & Ryan (1994) found that of 47 adults who disclosed histories of CSA, 69% met full DSM-III criteria for PTSD, while another 19% met criteria for partial PTSD. Furthermore, CSA has been associated with mood disorders, anxiety disorders, conduct disorders, substance abuse disorders, suicidal behaviors (Fergusson, Horwood & Lynesky, 1996); and with borderline personality disorder

of childhood abuse. Additional data estimated the prevalence rate of (CSA) in outpatient populations to be 28% (Coverdale & Turboth, 2000) and 40% of in-patient populations (Jacobson 1990). More recent data from the Fourth National Incident of Child Abuse and Neglect found that 58% of the 533,300 children studied suffered from childhood physical abuse (CPA) and 24% from CSA. The projection was made that one out of 58 children in the U.S. will experience some form of maltreatment within a given year (Sedlak, Mittenberg,

Additional reports on the prevalence of CPA suggest that 10 to 20% in non-clinical community samples experience physical abuse (Gelles & Straus, 1987), while in a clinical population, CPA prevalence has been estimated at 38% in outpatient populations and 49% in inpatient populations (Jacobson, 1989). These findings were supported by Macmillan et. al (1997) findings that 21% of women and 31.2% of men have experienced some form of CPA. Furthermore, it appears that despite changes in social policy aimed at combating incidences of CPA, the prevalence of CPA is not evidencing any significant change (Kunston

It should be recognized that CPA and CSA often co-exist simultaneously and that there are commonalities associated with CPA and CSA (Briere & Runtz, 1990; Browne & Finklehor, 1986; Rosenberg 1987. Most types of maltreatment do occur in the presence of other types of abuse, especially among those who request services as adults (Briere, 1992b). In a study by Surrey, Swett, Michael & Levin (1990), fifty-six (74%) of the seventy-six outpatient women reported an episode of either CPA or CSA before the age of 18. Of these participants, twenty-eight (37%) reported both kinds of abuse compared to twelve (16%) women who reported CSA only and sixteen women (21%) who reported CPA only. In other studies, the occurrences of combined abuse in families in treatment for CSA, was estimated to be 19.7% (Daro, 1988). Similarly, combined abuse prevalence in female non-clinical populations has been estimated to be 17% (Wind & Silvern, 1992). It is evident from these data that it is not uncommon for the occurrence of CSA and CPA to occur in the presence of each other.

**3. Symptom and diagnostic correlates with a history of childhood abuse** 

Michaels, & Levin, 1990) and for receiving multiple diagnosis (Briere & Runtz, 1990).

The association between long-term psychological problems and CSA and CPA has also been well documented. A comparison between individuals with a reported history of childhood abuse with those who reported no history of abuse, indicate that those with a history of abuse are at greater risk for developing psychological disorders (Mullen, Martin, Anderson, Romans, and Herbson, 1996; Polusny, & Follett, 1995; Malinowsky-Rummel & Hansen 1993; Wind & Silvern 1992), for developing more severe symptomatology (Surrey, Swett,

Childhood abuse has been associated with the development and diagnosis of Post Traumatic Stress Disorder (PTSD) (Kendall-Tachett 2000); Zlotnick, Mattia, & Zimmerman 2001). In a study examining adults with CSA histories, Rodriguez, Ryan, Rowan & Foy (1996) reported that 72% of their sample met full DSM-III criteria for current PTSD, while 86% met criteria for lifetime PTSD. Rowan, Foy, Rodriguez, & Ryan (1994) found that of 47 adults who disclosed histories of CSA, 69% met full DSM-III criteria for PTSD, while another 19% met criteria for partial PTSD. Furthermore, CSA has been associated with mood disorders, anxiety disorders, conduct disorders, substance abuse disorders, suicidal behaviors (Fergusson, Horwood & Lynesky, 1996); and with borderline personality disorder

Basina, Petla, McPherson, Green & Li, S., 2010).

& Selner, 1994).

(Zlotnick, Mattia, & Zimmerman, 2001), chronic headaches (Domino & Haber, 1987), maladaptive sexual behavior (Briere & Runtz, 1990); irritable bowel syndrome (Walker, Katon, Roy-Byrne, Jemelka & Russo 1993), dissociative behaviors (Lipschitz, Kaplan, Sorkenn, Chorney, & Asnis, 1996), depression, alcoholism, panic disorder, and social phobia (Dinwiddle et al, 2000), chronic, fatigue, asthma, and cardiovascular problems (Romans, Belaise, Martin, Morris & Raffe, 2002), increased pain and more surgical procedures (Finestone, et al., 2000).

Similarly, CPA has been associated with an increase in long-term symptomatology, including self-injurious and suicidal behaviors and physiological and emotional problems such as somatization, anxiety, depression, dissociation, and psychoses (Malinoskey-Rummell & Hansen, 1993). Physical abuse has also been associated with more pain, increased incidence of non-GI-somatic symptoms, more surgeries, and poorer functional status (Lesserman et al. 1996). Additionally, it has been associated with mental retardation (Buchanan & Oliver, 1997), chronic headache (Domino & Haber, 1987), aggression toward others (Briere & Runtz, 1990), substance abuse (Westermeyer J., Wahmanholm, K., & Turas, 2001) and purging (Perkins, Luster, & Jank, 2002).

Given the above established findings, it is disconcerting that many clinicians still fail to adequately assess and consider in their development of a treatment plan that a potential link between the patient's presenting problem and a history of childhood abuse may exist (Agar, Read, & Bish, 2002; Lothian & Read, 2002). Even if an assessment of CSA or CPA is conducted in the initial intake, too often the response of "no abuse" by the patient is accepted as being accurate, despite the clinical findings from delayed memory recovery patients that evidence for an abuse history often does not emerge until extensive treatment has been conducted (Bell & Belicki, 1998).

Adding to the difficulty of obtaining an accurate initial assessment of CSA or CPA is the finding that adult survivors of childhood abuse often are reluctant to be honest due to their concern regarding the social stigma attached to their abuse or the feeling of guilt or intense fear associated with revealing the secret and not being believed (Curtis, 1976; Layman, Gidy, & Lynn 1996). Other inhibiting factors impeding abuse, the victim's memory recall is the presence of a strong cognitive defense structure of denial, including amnesia (Briere, & Contes 1991; Herman & Schatnow 1987; Williams (1994) and malingering (Briere, 1989, 1992a, 1992b).

Finally, some resistance by practitioners to deal with the content of abusive trauma may exist because of the difficulty of having to witness the patient's pain in re-experiencing their historical trauma or in their concerns that the memories uncovered are false and may subject them to legal ramifications.

Clinicians should not be overly concerned about the elicitation of false memories, (Robbin 1995) reports that 75% of the studies on false memory did not manufacture false memories in the experimental situation despite the implicit pressure to produce one. From the present authors' viewpoint, the abundance of cognitive research on the false memory topic has little bearing on the clinical field, largely because experimental studies on false memories have not been conducted with a clinical abuse population (see Levis 1999).

However, as Briere (1992a) warned, the possibility exists that abuse reports could reflect fantasies, delusions, or intentional misinterpretations for secondary gain. Nevertheless, it is

A Review of Childhood Abuse Questionnaires and Suggested Treatment Approaches 7

greater than 300 participants is needed. Nevertheless, the RAST has provided good testretest reliability with non-rape victims (r = .95 at 2.5 month intervals) and good internal consistency reliability (α = .95). Criterion related validity was determined by discriminating statistically between scores of non-rape victims and rape victims at 6 to 21 days, 3 months, 6 months, and at 1, 2, and 3 years past the rape experience (Kirpatrick 1988; Resnick,

The psychometric properties of the RAST could be improved by increasing its validation size and by establishing convergent and discriminatory validity. Since the RAST, items are related to a rape experience, it directs relevance to the assessment of childhood abuse is

Goldwater & Duffy (1990) found that their Minnesota Multiphasic Inventory (MMPI) V configuration is suggestive of parental alcoholism which is frequently found in the history of childhood abused victims. Their "V" configuration refers to the MMPI scales 4 and 6 being elevated with T-scores of 65 or above, and scale 5 falling at least 30 T-scores below

The test-retest reliability of the subscales used in the Scarlett O'Hara V configuration are as follows: Scale 4 r = .79, α = .60, 5 r = .73; α = .37; scale 6 r = .58, α = .34 (Hathaway McKinley, 1989). Criterion related validity was determined by the test ability to discriminate between participants with a history of abuse (or an alcoholic parent) and non-abuse. Histories of abuse or parental alcoholism were extracted from patients' hospital charts after discharge. The sample size evaluated consisted of 79 adult female inpatients. A key advantage of the Scarlett O'Hara V MMPI configuration is the ability to add additional information on personality structure and psychopathology. However, the test was developed using a small and restricted sample size. Further, the test-retest and/or internal consistency reliability for some of the scales are lower than desired. Finally, the presence of a parental history of alcoholism does not in and of itself provide any direct confirmation that the parental offspring have been subjected to an abusive childhood history. It simply represents a

This questionnaire, developed by Sanders & Becker-Lausen (1995), was initially created as a research scale but later it was considered to be a useful tool in clinical assessment as an initial screening instrument. The scale consists of thirty-eight items to assess various forms of childhood physical, sexual, and maltreatment abuse. Part of the research objective of the scale was to combat respondent tendencies toward giving socially desirable responses. To achieve this objective, the scale was made up of general questions about the frequency of different childhood abuse experiences while allowing the respondent to determine his own evaluation of the severity of the stress experiences. Internal consistency of the entire CAT, as reflected in Cronbade's alpha was established to be .90. Test-retest reliability, determined over 6-8 weeks intervals, was .89. Besides measures of reliability, convergent validity of the CAT has been demonstrated in establishing correlations with dissociation (r = .29). The CAT also scored higher when a group diagnosed with Multiple Personality Disorder was

Kirpatrick, & Lizovashky, 1991).

2. The Scarlett O'Hara VMMPI Configuration

hypothesis in need of further confirmation.

3. The Childhood Abuse and Trauma Scale (CAT)

compared to a normative sample (Sanders & Becker-Lausen, 1995).

somewhat limited.

scales 4 and 6.

this author's opinion that if abuse trauma memories are forthcoming, one should never agree they are factual. This responsibility must be left up to patients to decide what's true and what's not true. The key responsibility of the therapist is to determine whether the release and extinction of the affect associated with a reported trauma leads to therapeutic gains. It has been my extensive experience (30 years) from providing treatment for adult survivors of childhood abuse that it does, a finding I am sure can be confirmed by many other therapists who treat abused patients. Finally, Briere's (1992b) conclusion is correct that most researchers in the area of child abuse agree that only a small proportion of people who describe abuse experiences make them up.

Although the establishment of external corroboration of reported abuse memory recovery is desirable, it is difficult to achieve (Briere, 1992a), some success in achieving this objective has been reported (e.g., Herman & Schatzow 1987); Feldman-Summers & Pope 1994). For example, Herman & Schatzow (1987) had a group therapy treatment of CSA survivors and encouraged them to obtain corroborating information from internal sources (e.g., sibling, family memories, medical records, court proceedings, etc.). They found that 39 out of their 53 group participants (74%) found some external confirmatory evidence. Although such evidence is not definitive, it represents a first step in the attempt to provide some form of external corroboration.
