Initial Reliability and Validity of a New

Retrospective Measure of Child Abuse and Neglect

David P. Bernstein, Ph.D., Laura Fink, Ph.D., Leonard Handeisman, M.D.,

Jeffrey Foote, Ph.D., Meg Lovejoy, B.A., Katherine Wenzel, M.A.,
Elizabeth Sapareto, M.A., and Joseph Ruggiero, M.A.

Objective: This report presents initial findings on the reliability and validity of a new ret-
rospective measure ofchild abuse and neglect, the Childhood Trauma Questionnaire. Method:
Two hundred eighty-six drug- or alcohol-dependent patients were given the Childhood
Trauma Questionnaire as part ofa larger test battery, and 40 ofthese patients were given the
questionnaire again after an interval of 2 to 6 months. Sixty-eight of the patients were also
given a structured interview for child abuse and neglect, the Childhood Trauma Interview,
that was developed by the authors. Results: Principal-components analysis of responses on
the Childhood Trauma Questionnaire yielded four rotated orthogonal factors: physical and
emotional abuse, emotional neglect, sexual abuse, and physical neglect. Cronbach’s alpha for
the factors ranged from 0.79 to 0.94, indicating high internal consistency. The Childhood
Trauma Questionnaire also demonstrated good test-retest reliability over a 2- to 6-month
interval (intraclass correlation=0.88), as well as convergence with the Childhood Trauma
Interview, indicating that patients’ reports ofchild abuse and neglect based on the Childhood
Trauma Questionnaire were highly stable, both over time and across types of instruments.
Conclusions: These findings provide strong initial support for the reliability and validity of
the Childhood Trauma Questionnaire.
(AmJ Psychiatry 1994; 151:1132-1136)

N urnerous
logical
studies
sequelae
have
of childhood
investigated
trauma,
the psycho-
including
several
naires
methods,
(2), and structured
including chart
interviews
review (10), question-
(4, 5, 1 1 ). How-
posttraumatic stress disorder (PTSD), dissociation, per- ever, published reports on these assessment techniques
sonality disorders, and substance abuse (1-8). How- have usually contained little or no data on their reliabil-
ever, research in this area has encountered a variety of ity and validity (9). Furthermore, most studies have as-
methodological problems. Some of these difficulties are sessed a limited range of traumatic expeniences-usu-
intrinsic to the phenomena being studied, for example, ally, only sexual or physical abuse-making it difficult
the potential for distortion (e.g., repression, denial) in to compare the impact of specific forms of trauma (e.g.,
the recall of temporally distant and emotionally painful abuse versus neglect) (9). While several structured inter-
events and the absence of objective verification in many views have been developed in the past few years to as-
reported cases of abuse (9). Other difficulties appear to sess a wider range of childhood trauma (4, 5, 1 1 ), these
stem from the methods used to study these childhood instruments are usually time-consuming to administer.
experiences, including the need for standardized, ap- This report describes a new self-report instrument, the
propniately validated instruments (9). Childhood Trauma Questionnaire, developed to pro-
Histories of childhood trauma have been obtained by vide brief, reliable, and valid assessment of a broad
range of traumatic experiences in childhood.
In this initial study, the reliability and validity of the
Presented in part at the 146th annual meeting of the American Psy-
Childhood Trauma Questionnaire were assessed for
chiatric Association, San Francisco, May 22-27, 1993. Received April
7, 1993; revision received Dec. 20, 1993; accepted Feb. 14, 1994. 286 drug- or alcohol-dependent patients. This patient
From the Department of Psychiatry, Mount Sinai School of Medicine, population was chosen for study because the high ex-
New York, and the Bronx VA Medical Center. Address reprint re- pected prevalence of abuse and neglect (1 , 3) made it
quests to Dr. Bernstein, Psychiatry Service, VA Medical Center, 130
suitable for factor analytic studies of the Childhood
West Kingsbridge Rd., Bronx, NY 10468.
The authors thank Dr. James Schmeidler for statistical assistance Trauma Questionnaire and because of our interest in
and Drs. David Pogge and Kevin Moreland for comments on an earlier the role of childhood trauma in the pathogenesis of sub-
version of the manuscript. stance use disorders. Childhood Trauma Questionnaire

1132 AmJ Psychiatry 151:8, August 1994

 BERNSTEIN, FINK, HANDEUSMAN, ET AL.

factors were derived empirically and validated against Patients were administered two additional measures assessing vo-
cabulary levels and social desirability, a form of response bias. The
a structured interview for childhood trauma, the Child-
Shipley Institute for Living Scale (13) is an extensively validated self-
hood Trauma Interview ( 12), which we recently devel-
report measure of intelligence. In this study, only the Shipley 40-item
oped. The test-retest reliability of the Childhood Trauma vocabulary scale was used. The Personality Diagnostic Question-
Q uestionnaire was determined for a subgroup of 40 naire-Revised (14) is a 134-item self-report measure of the DSM-III-
outpatients to whom the questionnaire was neadminis- R personality disorders. In this study, only the “Too Good” validity
scale of that questionnaire, a measure of the bias toward giving so-
tered after a 2- to 6-month interval.
cially desirable responses, was used (findings regarding personality
disorders are presented elsewhere).
The testing procedure was as follows. In their second or third week
METHOD of treatment, patients were given two booklets containing the Child-
hood Trauma Questionnaire and several other self-report measures.
Three hundred twenty-two patients undergoing treatment for drug Outpatients completed the booklets in group testing sessions (VA pa-
and/or alcohol dependence were recruited from two urban hospitals, tients) or individual sessions (Mount Sinai patients) with an examiner
the Mount Sinai Medical Center in New York City (N=91) and its present; inpatients were instructed to complete the booklets on their
affiliate, the Veterans Affairs (VA) Medical Center in Bronx, N.Y. own over a period of 1-2 days, with the examiner providing assis-
(N=231). Thirty-six VA patients did not complete the study protocol, tance as needed. All VA patients were literate and able to complete
typically because they did not have time to fill out both of the ques- the booklets with only minimal help (e.g., defining words) from the
tionnaire booklets before being discharged from the hospital, leaving examiner; however, several Mount Sinai patients with poor reading
a final combined group of 286 (Mount Sinai, N=91; VA, N=195). skills (N=S) were administered some or all ofthe self-report measures
Most of the patients who completed the study were male (85.3%, verbally.
N=244), and they ranged in age from 24 to 68 years (mean age=40.2 The Childhood Trauma Questionnaire was readministered to 40
years, SD=9.1 ). Most were African American or Latino (African Mount Sinai outpatients after a mean intertest interval of 3.6 months
American, 51.2%; Latino, 30.9%; white (non-Latino), 14.8%; other, (SD=1 .0, range=1 .6-5.6). The patients chosen for retesting were from
3.1%), had a high school education (73.6% completed high school), a continuous series, consisting of the first 46 methadone-maintained
and were unemployed or working less than full-time (employed full- outpatients recruited for the study. There were no significant differ-
time, 29.3%; employed part-time, 10.5%; unemployed, 52.0%; ences in the variances of Childhood Trauma Questionnaire scores
other, 8.2%). Most of the patients reported extensive lifetime histo- between the 40 retested patients and the slightly larger group from
ries of polysubstance abuse; the highest lifetime prevalences were for which they were drawn. Sixty-eight randomly selected patients from
alcohol (79.2%), cocaine (78.3%), heroin (59.3%), and cannabis both hospitals were also given the Childhood Trauma Interview. In-
(57.0%). Mount Sinai and VA patients were similar with regard to terviews were conducted by master’s-level psychologists trained by us
most demographic and clinical characteristics, although the Mount and were scored by us with respect to the frequency and severity of
Sinai subgroup had a larger proportion of female patients (Mount physical and sexual abuse. Administration and scoring of the Child-
Sinai, 42.7%; VA, 2.4%; X2=68.76’ df=1, p<0.001) and a smaller hood Trauma Interview were carried out blind to the results of the
proportion of full- or part-time employed patients (Mount Sinai, Childhood Trauma Questionnaire.
14.6%; VA, 53.3%; X2=36.25, df=1, p<0.001). At the time of the Principal-components analysis with a varimax rotation was used
study, patients were receiving a variety of clinical services, including to derive factors from the Childhood Trauma Questionnaire. Ten of
inpatient detoxification (VA, N=106) and rehabilitation (VA, N=83) the 70 questionnaire items were excluded from the principal-com-
and outpatient methadone maintenance (Mount Sinai, N=91) and ponents analysis: one item that needed to be rewritten because of its
“drug-free” groups (VA, N=6). ambiguity, three items that were included in the questionnaire as a
Patients were given two measures of childhood abuse and neglect: validity scale (the analysis of these items is presented in another re-
the Childhood Trauma Questionnaire and the Childhood Trauma port), and six items that exhibited low multiple correlations (i.e.,
Interview. The Childhood Trauma Questionnaire is a 70-item self-re- R’zO.20) with the other items in the scale. Several different factor
port instrument developed by us that retrospectively assesses experi- extractions were attempted, and a four-factor solution was chosen
ences of abuse and neglect in childhood, as well as related aspects of for its parsimony and interpretability (see Results). Items were as-
the child-rearing environment. Following an extensive review of the signed to factors on which they exhibited loadings 0.40; items load-
literature on child abuse and neglect, two of us (D.P.B. and L.F.) ing highly on more than one factor were assigned to the single factor
wrote items reflecting physical, sexual, and emotional abuse, physical with the highest loading. Items were reverse-coded where appropri-
and emotional neglect, and related aspects of family dysfunction (e.g., ate, and factor scores were computed by taking simple sums of un-
substance abuse). Items on the Childhood Trauma Questionnaire be- weighted item scores. Childhood Trauma Questionnaire total scores
gin with the phrase “When I was growing up,” and are rated on a were produced by averaging the four factor scores. The internal con-
S-point Likert-type scale according to the frequency with which cx- sistency of the questionnaire factors and the entire scale was deter-
periences occurred. Response options range from “never true” to mined by Cronbach’s alpha, while the test-retest reliability of the
“very often true.” The questionnaire requires 10-15 minutes to ad- questionnaire and its factors was assessed by intraclass correlation
minister and is intended for use with adults and adolescents in clinical coefficient (ICC). The association of the Childhood Trauma Ques-
settings. Further information regarding the validation of the question- tionnaire with measures of vocabulary and response bias was deter-
naire is presented in the Results section. mined by Pearson correlations. Exploratory analyses of the relation
The Childhood Trauma Interview (12) is a brief(10- to 20-minute) between Childhood Trauma Questionnaire scores and demographic
structured interview developed by us to assess childhood trauma in variables were performed by t tests without correcting for experi-
several areas: physical, sexual, and emotional abuse, physical neglect, mentwise type I error.
separation, and witnessing domestic violence. Through the use of in- The relation between Childhood Trauma Questionnaire factors
itial queries and follow-up probes, data on the nature, severity, fre- and Childhood Trauma Interview ratings of the severity of physical
quency, and duration of childhood trauma are gathered, as well as and sexual abuse was evaluated by Pearson correlations and by par-
other qualitative information (e.g., the number and type of perpetra- tial correlation, the latter controlling for the effects of the Childhood
tors, the age of the subject at the time of victimization). Each trau- Trauma Questionnaire total score (thus representing an estimate of
matic experience is rated on a 7-point scale of frequency and severity; association from which the effects of general maltreatment had been
objective scoring criteria and examples are provided in a manual. statistically removed). Two hierarchical multiple regression analyses
While this instrument is currently undergoing validation, preliminary were then performed, with the Childhood Trauma Questionnaire
studies of 66 cases indicate high levels of interrater reliability for rat- physical and emotional abuse and sexual abuse factors as the respec-
ings of the severity and frequency of physical and sexual abuse (in- tive dependent variables and Childhood Trauma Interview ratings of
traclass correlations=0.92-0.99) and convergent validity with meas- severity and frequency of physical or sexual abuse (and their Severity
ures of PTSD and personality disorders. by Frequency interactions) as the independent variables.

Am J Psychiatry 1 51 :8, August 1994 1133

NEW MEASURE OF CHILD ABUSE AND NEGLECT

TABLE 1. Characteristics of Childhood Trauma Questionnaire Factors and the Total Scal e in a Study of Alcoh ol- and Drug-Depen dent Patients

Sum of Item Internal

Raw Scores Consistency Test-
Percent of Number (Chronbach’s Retest
Childhood Trauma Questionnaire Eigenvalue Variance of Itemsa Mean SD alpha) Reliabilityt’

Factor
I: Physical and emotional abuse 17.9 29.9 23 48.3 18.6 0.94 0.82
II: Emotional neglect 4.6 7.7 16 35.7 12.5 0.91 0.83
III: Sexual abuse 3.5 5.9 6 8.8 5.3 0.92 0.81
IV: Physical
Totalscale
neglect
-2.5
- 4.1 11
56
17.5
110.8
6.2
34.1
0.79
0.95
0.80
0.88
altems with loadings0.40, based on principal-components analysis with varimax rotation (N=286).
bIntraclass correlation; intertest interval: 1.6-5.6 months (mean=3.6 months, SD=1.0) (N=40).

TABLE 2. Sample Items From the Childhood Trauma Questionnaire responded closely to the content areas for which Child-
and Their Factor Loadings in a Study of Alcohol- and Drug-Depend- hood Trauma Questionnaire items were written: physi-
ent Patients
cal and emotional abuse (23 items), emotional neglect
Factor (i.e., lack of emotional support, when most of the items
Itema Loading on this factor were reverse-coded) (16 items), sexual
Factor I: Physical and emotional abuse (23 items) abuse (six items), and physical neglect ( 1 1 items). Se-
People in my family hit me so hard that it left me lected questionnaire items and their corresponding
with bruises or marks. 0.75 factors are shown in table 2 (the complete scale is
The punishments I received seemed cruel. 0.73 available from the first author on request). The four
I was punished with a belt, a board, a cord, or some
factors displayed high levels of internal consistency
other hard object. 0.68
Someone in my family yelled and screamed at me. 0.68 (Cronbach’s alpha=0.79-0.94), as did the entire scale
People in my family said hurtful or insulting things (alpha=0.95, excluding items not used in the principal-
tome. 0.67 components analysis) (table 1). The test-retest reliabil-
Factor II: Emotional neglect (1 6 items)
ity of the Childhood Trauma Questionnaire was also
I felt like there was someone in my family who
wanted me to be a success.’ 0.74 high, both for the individual factors (ICC=0.80-0.83)
There was someone in my family who helped me feel and for the entire scale (ICC=0.88) (table 1). Intercor-
that I was important or specia1.’ 0.73 relations among the Childhood Trauma Questionnaire
My family was a source of strength and support.’ 0.67 factors ranged from 0.25 to 0.58, with a median of
People in my family felt close to each other.b 0.67
0.47 (table 3).
Someone in my family believed in me)’ 0.66
Factor III: Sexual abuse (six items) No significant correlations were found between the
I believe that I was sexually abused. 0.88 Childhood Trauma Questionnaire factors or total score
Someone molested me. 0.88 and measures of vocabulary and social desirability
Someone tried to make me do sexual things or watch
(r<0.10 for all correlations).
sexual things. 0.86
Someone tried to touch me in a sexual way or tried Female patients exhibited significantly higher mean
to make me touch them. 0.84 levels of sexual abuse than male patients (t=-2.87,
Someone threatened to hurt me or tell lies about me df=284, p<O.Ol). In addition, outpatients showed sig-
unless I did something sexual with them. 0.78 nificantly higher levels of sexual abuse than inpatients
Factor N: Physical neglect (1 1 items)
There was enough food in the house for everyone.’ 0.61
(t=2.SS, df=284, p<O.OS), and Mount Sinai patients
I lived in a group home or a foster home. 0.61 showed greater sexual abuse than VA patients (t=2.28,
I had to wear dirty clothes. 0.59 df=284, p<0.OS), probably because of the greater pro-
I was living on the streets by the time I was a teen- portion of female patients in the Mount Sinai outpa-
ager or even earlier. 0.51
tient group. No other differences in Childhood Trauma
I knew that there was someone to take care of me
and protect me.1’
#{216}49 Q uestionnaire scores with respect to gender, patient
status (inpatient versus outpatient), on study site (VA
aEach item begins with the phrase “When I was growing up,” and is
versus Mount Sinai) were found.
rated on a S-point Likert-type scale. Response options are “never
true,” “rarely true,” “sometimes true,” “often true,” and “very often Childhood Trauma Questionnaire sexual abuse
true.” scores were highly and significantly correlated with rat-
bReverse.oded item. ings of severity of sexual abuse on the Childhood
Trauma Interview, while Childhood Trauma Question-
name physical and emotional abuse scores were signifi-
RESULTS cantly correlated with Childhood Trauma Interview
ratings of both physical abuse and sexual abuse (table
Principal-components analysis of the Childhood 3). When partial correlations, controlling for the effects
Trauma Questionnaire yielded four factors accounting of general maltreatment (i.e., the Childhood Trauma
together for 47.6% of the total variance between items Q uestionnaire total score), were computed, the relation
(table 1 ). After varimax rotation, the four factors cor- between the two sets of abuse ratings was highly spe-

1134 Am J Psychiatry 1 51 :8, August 1994

 BERNSTEIN, FINK, HANDELSMAN, ET AL.

TABLE 3. Correlations Among Childhood Trauma Questionnaire Factors and Between Childhood Trauma Questionnaire Factors and Childhood
Trauma Interview Ratings of Severity of Physical and Sexual Abuse in a Study of Alcohol- and Drug-Dependent Patients

Childhood Trauma Interview Severity Rating

Pearson Zero-Order Partial Correlation

Pearson Correlation (N=286) Correlation (N=68) (N=68)a

Childhood Trauma Factor Factor Factor Physical Sexual Physical Sexual

Questionnaire Factor II III IV Abuse Abuse Abuse Abuse

I: Physical and emotional abuse 0#{149}58b 0#{149}42b 0#{149}51b 038b 032b 032b
II: Emotional neglect 0.2SL 056b 0.09 0.06 .O.2Sc
III: Sexual abuse 030b 0.22 065b 0.08 061b
IV: Physical neglect 0.08 0.06 -0.19 -0.15
aControlling for Childhood Trauma Questionnaire total score.
b,<001
Cp<O.OS.

TABLE 4. Childhood Trauma Questionnaire Physical and Emotional Abuse and Sexual Abuse Factors Regressed on Analogo us Childhood
Trauma Interview Ratings in a Study of Alcohol- and Drug- Dependent Patients (N=68)

Childhood Trauma Questionnaire

Childhood Trauma Interview Variable Beta F for Beta df for Beta R2 for Set F for Set df for Set

Physical and Emotional Abuse Factor

Physical abuse
SetA - - - 0.17 6.69a 2,65
Severity 0.45 6.82a 1, 65 - - -
Frequency -0.06 0.13 1, 65 - - -
Set B: interaction of severity and frequency 0.35 7#{149}93a , 64 0.09 7#{149}93a , 64

Sexual Abuse Factor

Sexual abuse
Set A - - - 0.44 27.l3’ 2, 65
Severity 0.52 l8.22’ , 65 - - -
Frequency 0.19 2.55 1, 65 - - -
Set B: interaction of severity and frequency 0.31 S.65’ , 64 0.04 S.65’ 64
ap<O.O1, two-tailed.
b<0001, two-tailed.
Cp<O.OS, two-tailed.

cific: Childhood Trauma Questionnaire sexual abuse Q uestionnaire were based on the interaction between
was associated only with Childhood Trauma Interview severity and frequency dimensions.
sexual abuse, and Childhood Trauma Questionnaire
physical and emotional abuse was associated only with
Childhood Trauma Interview physical abuse (table 3). DISCUSSION
When multiple regression/correlation analyses were
performed (table 4), two sets of Childhood Trauma In- These findings provide
strong initial support for the
terview predictor variables, severity and frequency of reliability and of the Childhood
validity Trauma Ques-
physical on sexual abuse (set A) and the interactions tionnaine. Four notated factors, interpreted as physical
between these dimensions (set B), accounted curnula- and emotional abuse, emotional neglect, sexual abuse,
tively for 26% of the variance in Childhood Trauma and physical neglect, were identified by principal-corn-
Questionnaire physical and emotional abuse (R=0.S1; ponents analysis, accounting together for nearly 50%
F=7.57, df=3, 64, p<O.OOl) and for 48% of the van- of the variance between items. The four factors exhib-
ance in Childhood Trauma Questionnaire sexual abuse ited high levels of face validity, internal consistency,
(R=0.70; F=21.21, df=3, 64, p<O.OO1). Both the main and test-retest reliability oven a 2- to 6-month interval.
effect of Childhood Trauma Interview severity and fre- The Childhood Trauma Questionnaire also exhibited
quency ratings (R2 change for set A) and the interac- good convergent validity with the structured interview
tion of severity and frequency scores (R2 change for set we developed that assesses severity and frequency of
B) accounted for a significant portion of the variance physical and sexual abuse, and good discniminant Va-
in Childhood Trauma Questionnaire physical and lidity with measures of verbal intelligence and social
emotional abuse and sexual abuse scores, suggesting desirability.
that patients’ responses to the Childhood Trauma The excellent test-retest reliability of the Childhood

AmJ Psychiatry 151:8, August 1994 1135

NEW MEASURE OF CHILD ABUSE AND NEGLECT

Trauma Questionnaire and its high level of convergence tionnaine can be followed by more extensive structured
with a structured interview indicate that addicts’ re- interviews. Second, since it is less time-consuming to
ports about their histories of childhood abuse and ne- administer than most interviews, the Childhood
glect were consistent across both testing sessions and Trauma Questionnaire is suitable for large-scale come-
types of instruments. This is a striking finding, given the lational studies of the adult sequelae of childhood
unstable nature of this population, the relatively uncon- trauma, which in the past have often been limited by
trolled setting in which the reliability study took place poor statistical power resulting from small sample sizes
(an outpatient methadone clinic), and the lengthy inter- (9). The Childhood Trauma Questionnaire’s use of con-
val between testing sessions. These findings are consis- tinuous (i.e., factor) scores rather than dichotomous
tent with those of a previous study (1 5) that found high ratings of trauma (i.e., present/absent) is also advanta-
levels of reliability in abuse histories obtained by two geous from the perspective of statistical power (18). Fi-
methods. They are also consistent with several studies nally, the questionnaire’s assessment of multiple con-
indicating that retrospectively obtained histories of tent areas should facilitate studies comparing the
childhood experiences are generally stable over time, impact of different types of trauma (e.g., abuse versus
show good agreement with reports of other informants neglect) and studies attempting to distinguish between
(e.g., siblings), and are often verified when archival data the specific effects of trauma and other features of the
are available (for a recent review, see Brewin et al. [16]). child-rearing environment.
This initial validation study was subject to several
limitations. First, different factor solutions might have
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