Traumatic Coping: The Association Between Trauma-related Symptoms and Avoidant Coping Strategies Among Adolescent Females in Residential Care
Master Thesis Forensic Child and Youth Care Graduate School of Child Development and Education University of Amsterdam T.I. van Garderen, 10884432 Supervisor: dr. E.S. van Vugt Second Reviewer: prof. dr. G.J.J.M. Stams Amsterdam, July 2019
Abstract
Objective: The aim of the current study was to explore to what extent trauma-related symptoms were predictive of the use of avoidant coping strategies over time. Method: This study used data from the first five data collection waves of a longitudinal study, carried out among adolescent females who were placed in residential care in Montréal. The sample consisted of 182 adolescent females between the ages of 11 and 18 years (M = 15.12, SD = 1.31) at time of the first assessment. The first assessment corresponded with their admission in care, while the following four assessments were conducted up to eighteen months after admission. At time 1, Trauma-related symptoms were measured with the Trauma Symptom Checklist for Children (TSCC). At time 1 through 5, the use of avoidant coping strategies was measured with the COPE inventory. Latent growth models were conducted to answer the research questions. Results: Findings indicated a decline in the use of avoidant coping strategies, except for self-blame which remained stable over time. In addition, adolescent females who experienced more trauma-related symptoms, also used more avoidant coping strategies at time of admission. At last, findings showed that adolescent females with more trauma-related symptoms at time of admission still used more avoidant coping strategies after eighteen months, despite declines in the use. Implications: the results confirm the need for trauma-sensitive treatment for adolescent females in residential care.
Traumatic Coping: The Association Between Trauma-related Symptoms and Avoidant Coping Strategies Among Adolescent Females in Residential Care
Adolescent youth admitted to residential care typically have a history of adverse life experiences such as child maltreatment (Collin-Vézina, Coleman, Milne, Sell, & Daigneault, 2011). Results of Collin-Vézina and colleagues’ study (2011) showed that a majority (68%) of Canadian youth in residential care reported experiences of emotional abuse and almost all youth (98%) reported some level of physical neglect. Females in residential care have experienced even more negative life experiences than their male peers: they are significantly more often exposed to sexual abuse (Connor, Doerfler, Toscano, Volungis, & Steingard, 2004; Greger, Myhre, Lydersen, & Jozefiak, 2015), physical abuse (Connor et al., 2004) and family violence (Greger et al., 2015). For example, the majority (63%) of the females in the study of Collin-Vézina and colleagues (2011) reported experiences of sexual abuse, in contrast to 17% of the males. Females in residential care also more frequently report poly-victimization, which is the exposure to more than one traumatic experience (Connor et al., 2004; Greger et al., 2015).
Trauma-related Symptoms Among Females in Residential Care
Those high numbers of child maltreatment experiences among adolescent females in residential care tend to be associated with a concerning amount of mental health problems such as depression and anxiety (Fazel, Doll, & Långström, 2008; Greger et al., 2015). A vast amount of research has shown a direct association between child maltreatment and mental health problems (e.g. Fergusson, Boden, & Horwood, 2008; Lansford, Dodge, & Pettit, 2002; Mills et al., 2013). The mental health problems of adolescent females in residential care with a history of child maltreatment experiences could therefore be seen as trauma-related
symptoms (Van Vugt, Lanctôt, Paquette, Collin-Vézina, & Lemieux, 2014). For example, adolescent females who have been exposed to emotional abuse (Van Vugt et al., 2014) or
interpersonal trauma (Leenarts et al., 2013) suffer from trauma-related mental health problems among which anxiety, depression and anger. Females in residential care are also more likely to report clinical levels of posttraumatic stress symptoms, dissociation symptoms and sexual concerns than males (e.g. Collin-Vézina et al., 2011; Connor et al., 2004; Fischer, Dölitzsch, Schmek, Fegert, & Schmid, 2016; Handwerk, Clopton, Huefner, Smith, & Hoff, 2006). Further, research showed that many young people still experienced the negative effects of such mental health problems long after receiving care, resulting in a continued use of health care services in adulthood (Briggs et al., 2012; Krabbendam et al., 2015; Stein & Dumaret, 2011; Van der Molen et al., 2013).
Coping With Stressful Experiences
The question arises how those adolescent females deal with previous maltreatment experiences over time. To cope with maltreatment experiences people often use a variety of coping strategies, which are specific thoughts and behaviors to deal with stressful situations (Folkman, 2013; Sahler & Carr, 2009). The nature of the situation, the context in which the situation occurs and the available coping resources, such as psychological and material resources, affect which coping strategies are used (Folkman, 2013; Stephenson, King, & DeLongis, 2016). However, the use of some strategies may result in positive outcomes, while other strategies could result in maladaptive outcomes.
The identification of coping strategies as adaptive or maladaptive has been a topic in research for a long time (Littleton, Horsley, John, & Nelson, 2007). One primary
conceptualization used in research is the distinction between approach and avoidant coping strategies (Carver, 2013; Littleton et al., 2007; Sahler & Carr, 2009). Approach coping strategies are methods that involve active dealing with the stressor like gathering information or requesting social support (Sahler & Carr, 2009). Avoidant strategies, in contrast, focus on avoidance of the stressor, for example by giving up on dealing with the problem or overall
denial of the stressor (Carver, 2013; Sahler & Carr, 2009). Research showed that approach coping strategies in general promote adaptive development in reaction to traumatic stress (Littleton et al., 2007; Olff, Langeland, & Gersons, 2005). On the other hand, avoidant
strategies such as denial and blaming yourself are mostly considered as maladaptive strategies when dealing with a stressful situation (Horwitz, Hill, & King, 2011; Littleton et al., 2007; Olff et al., 2005; Snyder & Pulvers, 2001). For instance, research indicated that the use of avoidant strategies was associated with a lower future wellbeing among adolescents in residential care (Barendregt, Van der Laan, Bongers, & Van Nieuwenhuizen, 2015). More precisely, the use of avoidant strategies was more predictive of an individual’s future wellbeing than one’s current state of wellbeing (Barendregt et al., 2015).
Using Coping Strategies Over Time
In general, the way of dealing with stressful situations varies between individuals and changes over time, even within individuals (Olff et al., 2005). Coping with a stressful
situation should therefore be seen as a developmental process (Gutner, Rizvi, Monson, & Resick, 2006; Olff et al., 2005). Moreover, research suggested that it is not just the type of coping strategy that is relevant to mental health outcomes, but also the changes in how much those strategies are used (Gutner et al., 2006). For instance, Gutner and colleagues’ study (2006) showed that female victims of sexual or physical assault who increasingly used social withdrawal after the traumatic experience, also experienced more PTSD symptoms after three months. In contrast, women who did not report similar increases of social withdrawal
remained stable in the level of PTSD symptoms (Gutner et al., 2006). Similarly, a decrease in the use of high emotion expression was associated with a greater decline in depression and anxiety scores among adolescents who recently had to cope with an incarcerattion (Brown & Ireland, 2006).
Further, the kind of coping strategies that are used are also age-dependent (Aldwin, 2011; Seiffge-Krenk, Aunola, & Nurmi, 2009; Zimmer-Gembeck & Skinner, 2011). For instance, adolescents show a wider range of possible coping strategies than younger children (Seiffge-Krenk et al., 2009; Zimmer-Gembeck & Skinner, 2011). The results from the study of Seiffge-Krenk and colleagues (2009) suggested that the use of approach coping strategies increases from adolescence to early adulthood. The use of avoidant strategies on the other hand tend to decrease in early adulthood (Kirchner, Forns, Amador, & Muñoz, 2010; Zimmer-Gembeck & Skinner, 2011), although one other study found the use of avoidant strategies to be generally stable in late adolescence (Seiffge-Krenk et al., 2009).
Relation Between Trauma-related Symptoms and Avoidant Coping strategies
Considering the severity of mental health problems among females in residential care, including trauma-related symptoms, it is important to gain insight into the relations between trauma-related symptoms and the use of maladaptive coping strategies. This is especially important in the light of treatment in residential care facilities, which often focuses on
enhancing coping skills (Leichtman, 2006; Zelechoski et al., 2013). Previous research showed a strong association between the use of avoidant coping strategies and trauma-related
symptoms (e.g. Cantón-Cortés & Cantón, 2010; Gutner et al., 2006; Krause, Kaltman, Goodman, & Dutton, 2008; Street, Gibson, & Holohan, 2005). For example, the use of avoidant coping strategies was related to more severe trauma-related symptoms among women who were exposed to domestic violence (Krause et al., 2008; Street et al., 2005) and among students with a history of child sexual abuse (Bal, Van Oost, De Bourdeaudhuij, & Crombez, 2003; Cantón-Cortés & Cantón, 2010). Furthermore, recent results from Vaughn-Coaxum, Wang, Kiely, Weisz, and Dunn’s study (2018) showed that an earlier exposure to trauma was related to a higher use of maladaptive coping strategies among adolescents.
However, it is hard to determine causal relationship between coping and trauma-related symptoms because of the retrospective designs used in most studies (Olff et al., 2005). Those studies therefore cannot give a definite answer whether trauma-related symptoms are an antecedent as well as a result of using avoidant coping strategies. Furthermore, longitudinal studies in which coping is measured at more than one measurement are scarce, especially in clinical samples. The results of Gutner and colleagues (2006) among female rape and assault victims suggested that the continuous use of maladaptive coping strategies over time may increase post-traumatic stress symptoms. Similarly, Barendregt and colleagues’ study (2015) showed that the continuous use of avoidant coping strategies was associated with a poorer well-being and a lower self-esteem among adolescent males in residential care.
In summary, existing findings showed the need for understanding the possible long-term effect of trauma-related symptoms on coping strategies in clinical samples. This is especially important for adolescent females in residential care, because of the concerning amount of trauma-related mental health problems they experience (Collin-Vézina et al., 2011; Connor et al., 2004; Fischer et al., 2016; Handwerk et al., 2006; Leenarts et al., 2013). To date, no longitudinal studies are known that have investigated the association between trauma-related symptoms and the use of avoidant coping strategies over time.
Current Study
This study tried to fill this gap by measuring the use of avoidant coping strategies among adolescent females over eighteen months after admission into residential care. In addition, the relation between trauma-related symptoms and the use of avoidant coping strategies were investigated. At last, the relation between trauma-related symptoms and changes in the use of avoidant coping strategies was examined as well. Overall, the main focus of this study was to explore to what extent trauma-related symptoms were predictive of the use of avoidant coping strategies over time.
Method Participants
This study is part of a larger longitudinal study carried out among adolescent females who were placed in residential care in Montréal (Canada) in 2007-2008. The study consisted of six data collection waves starting at time of admission in residential care, during
adolescence, and continued until young adulthood when respondents were out of care. The present study was based on the first five data collection waves for adolescent females who were placed in care for at least three months. This resulted in a sample of 182 adolescent females between the ages of 11 and 18 years (M = 15.12, SD = 1.31) at time of the first assessment, which corresponds with their admission to the care facility. The following four assessments were respectively conducted at: three months (n = 179, Mage = 15.41 years, SD = 1.32), six months (n = 133, Mage = 15.53 years, SD = 1.28), twelve months (n = 121, Mage = 16.00 years, SD = 1.27) and eighteen months (n = 155 , Mage = 16.87 years, SD = 1.37) after admission.
Most of the adolescent females (n = 159, 87.4%) where born in Canada. The main reasons the adolescent females were placed in care were because of behavioral problems which threatened their development and security (n = 75, 41.2%) and parental neglect (n = 43, 23.6%). Other reasons for placement were family emergencies (n = 15, 8.2%), sexual abuse (n = 13, 7.1%), physical abuse (n = 11, 6.0%), psychological maltreatment (n = 10, 5.5%), abandonment (n = 4, 2.2%) and juvenile delinquency (n = 3, 1.6%).
Procedure
The institutional review board of the University of Sherbrooke (Canada) approved the data collection procedures. Formal consent was obtained from the adolescent females at every assessment, including parental consent for adolescent females under the age of 14 years. After consent, interviewers trained in ethics and interview techniques met individually with the
adolescent females to administer the questionnaires. This procedure took about 90 minutes to complete. At the end of the meeting, contact details were obtained for follow-up meetings. Measures
Avoidant coping strategies. The use of avoidant coping strategies was measured with an adapted French version of the COPE inventory (Carver, Scheier, & Weintraub, 1989). The original COPE Inventory consists of 60 items, divided into 15 scales. Only the four avoidant scales were used in the present study, respectively: Mental disengagement, denial, behavioral disengagement and substance use (Baumstarck et al., 2017; Carver et al., 1989; Litman, 2006). In addition, one extra scale was constructed and added to this scale: self-blame, which is also considered an avoidant coping strategy (Baumstarck et al., 2017; Hastings et al., 2005; Snell, Siegert, Hay-Smith, & Surgenor, 2011). Table 1 offers a description and a sample item of each scale. Each scale consisted of four items, with a total of 20 items. The answering options were rated on a four-point Likert scale, ranging from “I usually don't do this at all” (score 1) to “I usually do this a lot” (score 4). As the scale mean was used in analyses, the possible scores ranged from 1 to 4; higher scores indicated a more frequent use of the avoidant coping strategy.
The internal consistencies in our sample were calculated using polychoric correlations, because these type of correlations are more robust when using few ordinal answer categories (Zumbo, Gadermann, & Zeisser, 2007). The internal consistency of the mental disengagement scale was unacceptably low and this scale was therefore excluded from all further analyse
s (α = .28 to α =.62; see Table 1). The internal consistencies of the other scales were acceptable to excellent, with values ranging from α = .70 to α = 1.00 (see Table 1).
Trauma-related symptoms. Trauma-related symptoms were measured at the first assessment with the French version of the Trauma Symptom Checklist for Children (TSCC; Briere, 1996; Wright, Sabourin, & Lussier, 1996). The TSCC is developed for children aged 8
to 16 years who have experienced traumatic life events. The TSCC consists of 54 statements with answer options on a four-point Likert scale, ranging from “Never” (score 0) to “Almost all of the time” (score 3). The questions are divided over six domains: anxiety (e.g.
“Worrying about things”), depression (e.g. “Feeling sad or unhappy”), post-traumatic stress (e.g. “Bad dreams or nightmares”), sexual concerns (e.g. “Want to say vulgar words”), dissociation (e.g. “Feeling like I'm not in my body”) and anger (e.g. “Feeling mad”). The mean of the scales was used in the analyses, ranging from 0 to 3, with higher scores indicating higher levels of trauma-related symptoms. The internal consistencies of the scales, as
calculated with polychoric correlations, were good to excellent in our sample, with values ranging from α = .81 to α = .92 (see Table 2). Again, polychoric correlations were used
because these are more robust when using few ordinal answer categories (Zumbo et al., 2007). Control variable: Type of treatment. The adolescent females were non-randomly assigned to a residential center with a cognitive behavioral treatment program (CBT; n = 104, 57.1%) or a residential center with treatment as usual (TAU; n = 78, 42.9%).
Data-analysis Strategy
To answer the research questions, latent growth models were conducted via a structural equational framework using Mplus 7.2. To examine the use of coping strategies over time, a separate latent growth model was estimated for each of the coping strategies. Furthermore, the variance in the use of coping strategies over time was examined. When variance on both the intercept and the slope was found, trauma-related symptoms were added to the model. First, the effects of trauma-related symptoms on the use of coping strategies were examined at time of admission. Second, the effects of trauma-related symptoms on the use of coping strategies over time were examined. When adding the trauma-related
symptoms, a separate analysis was performed for every trauma-related symptom to avoid multicollinearity. All the models were corrected for age and type of treatment.
To determine the fit of the models, three types of fit indices were used: Chi-square test, the Root Mean Square Error of Approximation (RMSEA) and the Confirmatory Fit Index (CFI). For the Chi-square test, the p-value had to be non-significant (p ≥ .05) to indicate a good fit. RMSEA-values less than .06 indicated a good fit, and values between .08 and .06 indicated an acceptable fit. CFI-values equal to or greater than .95 indicated a good fit, while CFI-values between .90 and .95 indicated an acceptable fit (Hu & Bentler, 1999).
When variance on the intercept was found, but not on the slope, linear regression models were used to identify the relation between trauma-related symptoms and avoidant coping strategies at time of admission in care. To avoid multicollinearity, individual analyses were performed for each trauma-related symptom. These models were corrected for age and conducted with SPSS Statistics version 23. Partial coefficients of determination (rpartial2) were calculated to examine the size of the effects. Values between .01 and .06 indicated a small effect, values between .06 to .14 indicated a medium effect, and values of .14 or higher indicated a large effect.
Results
Table 2 offers an overview of the means and standard deviations of the presence of trauma-related symptoms at time of admission. The means and standard deviations of the avoidant coping strategies at the five data assessments are shown in Table 3.
Changes in the Use of Coping Strategies Over Time
With use of latent growth curve models, the use of coping strategies over time were examined. The results are shown in Table 4 and a graphic overview of the models is displayed in Figure 1. The models justified the use of linear models and showed an acceptable to good fit (see Table 4).
Figure 1. The use of coping strategies over time.
The results show a significant decrease in the use of denial, behavioral disengagement and substance use over time (see Table 4 and Figure 1). This indicates that at time of the fifth assessment, adolescent females experienced less difficulties in believing their problems were real, experienced less difficulties in dealing with their problems and used less drugs and alcohol to deal with their problems when compared to the first assessment. For self-blame, however, no significant in- or decrease over time was found (see Table 4). More specifically, adolescent females criticized themselves for being responsible for their problems as much at time of the fifth assessment as they did at time of admission.
Trauma-related Symptoms and the Use of Coping Strategies
The results show no variance over time in the use of denial as a coping strategy (see Table 4). On the other hand, significant variance over time was found in the use of behavioral disengagement, substance use and self-blame. Therefore, trauma-related symptoms were added to the models of the latter three coping strategies to identify the effects of these symptoms on the use of avoidant coping strategies over time. All models were corrected for age and type of treatment. The results of these models can be found in Table 5.
Behavioral disengagement. Looking at the use of behavioral disengagement at time of admission, the results show that adolescent females with higher levels of trauma-related anxiety, depression, dissociation and anger used more behavioral disengagement when they
1,5 1,6 1,7 1,8 1,9 2 2,1 2,2 U se o f C op in g St ra te gy Denial Behavioral Disengagement Substance Use Self-blame
entered into care. This indicates that females who entered into care with higher levels of trauma-related symptoms experienced more problems in dealing with stressful situations at that time. No associations were found between trauma-related post-traumatic stress or sexual concerns and behavioral disengagement at time of admission.
Examining the use of behavioral disengagement over time, the results show that when adolescent females reported higher levels of trauma-related symptoms at time of admission, the use of behavioral disengagement decreased more over time. Specifically, adolescent females with higher levels of trauma-related depression, post-traumatic stress, dissociation and anger were more able to deal with their problems over time, when compared to adolescent females with lower levels of these trauma-related symptoms. Despite the decline, however, females with higher levels of trauma-related depression, dissociation or anger at time of admission continued to report slightly more difficulties in dealing with their problem at time of the fifth assessment.
Additionally, adolescent females with higher levels of trauma-related anxiety at time of admission did not show a decline in the use of behavioral disengagement over time. Adolescent females who experienced more trauma-related anxiety therefore were less able to deal with their problems from the first through the fifth assessment when compared to
adolescent females who experienced less trauma-related anxiety. Further, no effects of trauma-related sexual concerns were found on the use of behavioral disengagement as a coping strategy.
Substance use. The results further show a positive relation between most trauma-related symptoms and substance use at time of admission, except for anxiety and post-traumatic stress. In other words, adolescent females with higher levels of trauma-related depression, sexual concerns, dissociation or anger at time of admission, used more alcohol and/or drugs to deal with their problems than females with less of these symptoms.
When looking at the trajectory of substance use, the results show a significant decrease in substance use as coping strategy for adolescent females with more trauma-related sexual concerns or anger at time of admission. This indicates that adolescent females with higher levels of trauma-related sexual concerns or anger over time used less alcohol and/or drugs to deal with their problems when compared to females with less trauma-related sexual concerns or anger. Nevertheless, as adolescent females with more trauma-related sexual concerns or anger used more substances to deal with their problems at time of admission, they continued to report more alcohol and drug use as a coping strategy at time of the fifth assessment. Further, no significant effect of depression or dissociation on substance use was found over time, despite the positive association at time of admission. This indicates that adolescent females with more trauma-related depression or dissociation showed higher levels of substance use from time of admission to time of the fifth assessment, when compared to adolescent females with less trauma-related depression or dissociation.
Additionally, the results show a significant positive relation between age and the use of substances as a coping strategy: Intercept (SE) = .23 (.06), p <.001. This indicates that adolescent females who were older at time of admission used more substances to reduce their distress than younger adolescent females. The results further show that over time, the use of substances as coping strategy decreases more for older than younger adolescent females: Slope (SE) = -.04 (.02), p = .01. However, at time of the fifth assessment, older adolescent females still use more substances to reduce distress than younger adolescent females.
Self-blame. When looking at the results at time of admission, it shows that adolescent females who experienced more trauma-related symptoms at time of admission, criticized themselves more for being responsible for the situation than adolescent females with lower levels of these symptoms. Examining the use of self-blame over time, no effects were found for post-traumatic stress, trauma-related sexual concerns, dissociation and anger on the use of
self-blame over time. This indicates that adolescent females with higher levels of post-traumatic stress, trauma-related sexual concerns, dissociation or anger at time of admission, continued to blame themselves at the same level for being responsible for their situation from the first through the fifth assessment. However, adolescent females with higher levels of trauma-related anxiety or depression at time of the first assessment showed a decrease in the use of self-blame over time. Nevertheless, the decline in self-blame did still result in more self-criticism at time of the fifth assessment for adolescent females with higher levels of trauma-related anxiety.
Denial. As no variance was present on the slope, additional regression analyses were conducted to identify the relation between trauma-related symptoms and the use of denial as coping strategy at time of admission. The results, as shown in Table 6, indicate that trauma-related symptoms at time of admission were associated with more use of denial as a coping strategy. More specifically, adolescent females who experienced higher levels of trauma-related anxiety, depression, dissociation and anger at time of admission were experiencing more problems in believing their problems were real or behaved as if their problems did not exist. Although significant, the effects of these associations were small (rpartial2 = .04 to .06, see Table 6).
Discussion
The aim of the current study was to explore to what extent trauma-related symptoms were predictive of the use of avoidant coping strategies over time. To that end, the use of avoidant coping strategies was measured among adolescent females over a period of eighteen months, starting from admission into residential care until late adolescence. Findings
indicated a decline in the use of avoidant coping strategies for the adolescent females in our sample, except for self-blame which remained stable over time. In addition, the relation between trauma-related symptoms and the use of avoidant coping strategies at time of
admission was explored. Adolescent females who experienced more trauma-related symptoms, also used more avoidant coping strategies at time of admission. At last, the relation between trauma-related symptoms and changes in the use of avoidant coping strategies over time was examined. Findings showed that despite a decline in the use of avoidant coping strategies, adolescent females with more trauma-related symptoms at time of admission still used more behavioral disengagement, substance use and self-blame strategies after eighteen months. Implications of these findings will be discussed below.
There are several explanations for the results that were found. First, the general decrease in use of denial, behavioral disengagement and substance use over time could be an age-dependent decline during adolescence. It is possible that adolescent females in residential care experience a similar decline in the use of avoidant coping strategies as their peers in non-clinical environments (Kirchner et al., 2010; Zimmer-Gembeck, & Skinner, 2011). Another explanation could be a decline because of a general treatment effect. However, no significant effect of type of treatment was found on the decline. This suggests that, at best, CBT and TAU both contributed equally to a decrease in the use of avoidant coping strategies. Future studies could explore which elements of residential treatment could help decrease the use of those strategies by comparing the use of avoidant strategies between adolescent females with and without specific treatment elements.
In contrast, no decline was found for the use of self-blame over time. Previous
research showed that many adolescents who experienced some form of child maltreatment are blaming themselves for the negative experiences (Harter, 1998; Ullman & Filipas, 2005; Wekerle & Wolfe, 2003). This could result in a long-term incorporation of the idea that they are to blame for everything that happened, which could result in a unhealthy view of the self (Harter, 1998; Wekerle & Wolfe, 2003). Self-blame might therefore be more stable over time than other avoidant coping strategies. Additionally, no significant effect of type of treatment
was found, indicating that neither CBT nor TAU was able to change the course of self-blame. This is certainly unfortunate considering that research showed that self-blame is associated with more depression (Alix, Cossette, Hébert, Cyr, & Frappier, 2017; Horwitz et al., 2011) and more trauma-related symptoms (Alix et al., 2017; Daigneault, Tourigny, & Hébert, 2006) among adolescents who experienced child sexual abuse. Overall, these results show the need for treatment to focus on reducing self-blame or implement more efficient methods to reduce self-blame. Results of an experimental study showed promising results of a co-operative cross-age teaching intervention (CATS) in reducing self-blame among adolescent victims of bullying, by reststructuring existing self-beliefs (Boulton & Boulton, 2017).For this
intervention, older students informed younger students that victims have no reason to feel bad about themselves and that seeking help might be benificial (Boulton & Boulton, 2017). When applied more widely, future studies could examine the possible effects of this type of
intervention to reduce self-blame among adolescent females in residential care.
The present study confirmed the strong association between trauma-related symptoms and the use of avoidant coping strategies as found in earlier studies among college students (Bal et al., 2003; Cantón-Cortés & Cantón, 2010) and female crime victims (Gutner et al., 2006; Krause et al., 2008; Street et al., 2005). This is an important finding, especially in light of earlier research that showed that the use of avoidant coping strategies was predictive of later poorer well-being among adolescent males in residential care (Barendregt et al., 2015). Interestingly, of the trauma-related symptoms, post-traumatic stress was only associated with self-blame and none of the other avoidant coping strategies at time of admission. This finding is not in line with earlier research that found post-traumatic stress to be associated with avoidant coping in general (Bal et al., 2003). It might be possible that post-traumatic stress is not a predictive trauma-related symptom in this specific sample of adolescent females in residential care.
Further, the findings showed that adolescent females who experienced more trauma-related symptoms at time of admission, still experienced more avoidant coping strategies after eighteen months when compared to adolescent females with fewer symptoms at time of admission. However, a decrease in the use of avoidant coping strategies was found for some of the trauma-related symptoms. This indicates that the differences in the use avoidant coping strategies between adolescent with lower and higher levels of trauma-related symptoms at time of admission decreased over time. This might be the result of the treatment the females received in residential care. However, no effects were found for the type of treatment,
indicating that both TAU and CBT had a similar (lack of) effect on the use of avoidant coping strategies.
These results showed the importance of trauma-sensitive treatment, as trauma-related symptoms seem to be associated with more use of avoidant coping strategies. Trauma-sensitive treatment is treatment which does not just focus on reducing trauma-related
symptoms, but is sensitive to these symptoms in relation to the treatment of other internalizing or externalizing problems as well (Hodgon, Kinniburgh, Gabowitz, Blaustein, & Spinazzola, 2013; Zelechoski et al., 2013). As residential care is an ongoing treatment, 365 days a year, trauma-sensitive treatment should also include being sensitive to trauma-related symptoms in all aspects of the daily routine (Hodgon et al., 2013). An important first step would be to educate the whole staff about trauma and the possible trauma-related symptoms among adolescents (Zelechoski et al., 2013). After that, implementing an institution-wide trauma-sensitive program is necessary to create a holistic trauma-trauma-sensitive treatment framework in which youth receive ongoing support in the daily routine as well (Hodgon et al., 2013; Zelechoski et al., 2013).
Some promising trauma-sensitive treatment programs have already been developed, among which Attachment, Regulation and Competency (ARC; Blaustein & Kinniburgh,
2010) and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; Cohen, Mannarino, Kliethermes, & Murray, 2012; Zelechoski et al., 2013). Both ARC and TF-CBT show promising effects in reducing trauma-related symptoms among adolescent females in care (Avinger & Jones, 2007; Hodgon et al., 2013). Both treatment programs also include
replacing maladaptive coping strategies with adaptive strategies (Cohen et al., 2012; Blaustein & Kinniburgh, 2010). However, it seems that reducing trauma-related symptoms is
considered a main outcome of the programs, not a specific factor towards replacing
maladaptive coping strategies. The results of the current study suggested that trauma-related symptoms predict the changes in the use of coping strategies over time. Therefore, future implementations of these treatment programs should examine possible ways to target existing trauma-related symptoms while trying to replace the maladaptive coping strategies.
Limitations and Concluding Remarks
Some limitations of this study should be mentioned. First, just one trauma-related symptom was added per model because of concerns about multicollinearity. It might however be possible that the trauma-related symptoms interact. Future studies could therefore examine ways to include all trauma-related symptoms in one model. This could also show which trauma-related symptoms are most predictive of the use of avoidant coping strategies, so treatment could target those specific symptoms.
Second, mental disengagement was left out of the analyses because of the poor internal consistency. Additionally, no variance was found in the use of denial over time. It was therefore not possible to investigate possible effects of trauma-related symptoms on these coping strategies over time. Furthermore, there are more avoidant coping strategies possible to examine, such as distraction and venting of emotions (Hastings et al., 2005; Snell et al., 2011). It might be insightful to include these other avoidant coping strategies in future
research to determine whether the current findings could be generalized to all avoidant coping strategies.
Third, this study was able to examine the associations between trauma-related symptoms and coping strategies for a period of ‘only’ eighteen months. It would be
interesting to see if after a longer period of time, the differences in the use of avoidant coping strategies between adolescent females who experienced more or less trauma-related
symptoms disappear. At last, the sample of the current study consisted of a specific clinical subgroup of adolescent females in residential care in Canada. Despite the importance of this topic for this at-risk group, it might not be generalizable to other subgroups, like non-clinical, male samples or to adolescent females in residential care in other countries.
Overall, the results showed the importance of trauma-sensitive treatment in residential care facilities, as trauma-related symptoms seem to be associated with a more frequent use of avoidant coping strategies. Furthermore, the results emphasized that coping should be seen as a developmental process, rather than a static state (Gutner et al., 2006; Olff et al., 2005). This shows the importance and possibilities for treatment to focus on the use of adaptive coping strategies, as treatment programs should target changeable aspects. At last, the results showed the importance of longitudinal studies in which the use of coping strategies is measured over time. Future studies should therefore consider the long-term effects of trauma-symptoms and avoidant coping strategies and vice versa. This would preferably be done with prospective longitudinal research to explore causal associations over time.
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Table 1
Description, Example Items and Internal Consistency of the Avoidant Coping Strategies as Measured with the COPE Inventory
Scale Description Example item Internal consistency (α)a
Mental
disengagement
Using activities to distract oneself from thinking about the problem or goals with which the problem is
interfering
I turn to work or other substitute activities to take my mind off things.
.28 – .62
Denial Refusing to believe the problem is real or trying to act
as though the problem does not exist
I say to myself "this isn't real". .70 – .76
Behavioral disengagement
Giving up on dealing with the problem, even giving up the attempt to attain goals with which the problem is interfering
I admit to myself that I can't deal with it and quit trying.
.75 – .82
Substance use Using alcohol or drugs to reduce distress I use alcohol or drugs to make
myself feel better.
.99 – 1.00
Self-blameb Criticizing oneself for responsibility in the situation I criticize myself. .80 – .85
Note. aN = 182. bThis coping strategy was added for this study only and is not part of the original COPE inventory
Table 2
Correlations Between Trauma-related Symptoms and Means, Standard Deviations and Internal Consistency of Trauma-related Symptoms as Measured with the Trauma Symptom Checklist for Children (N = 181)
1 2 3 4 5 6 M SD Internal consistency (α) 1. Anxiety - 1.10 0.56 .81 2. Depression .74** - 1.40 0.67 .88 3. Post-traumatic stress .75** .73** - 1.43 0.63 .88 4. Sexual concerns .47** .43** .44** - 0.71 0.53 .86 5. Dissociation .72** .75** .66** .48** - 1.12 0.65 .88 6. Anger .52** .63** .56** .43** .67** - 1.22 0.76 .92 Note. **p <.01.
Table 3
Means and Standard Deviations of the Use of Coping Strategies Over Time T1 (admission) (n = 182) T2 (3 months) (n = 176) T3 (6 months) (n = 132) T4 (12 months) (n = 122) T5 (18 months) (n = 155) Coping strategy M SD M SD M SD M SD M SD Denial 1.97 0.67 1.90 0.62 1.86 0.63 1.75 0.59 1.75 0.58 Behavioral disengagement 2.00 0.74 1.97 0.63 1.86 0.64 1.79 0.59 1.77 0.59 Substance use 2.21 1.23 1.90 1.03 1.70 1.03 1.63 0.97 1.63 0.93 Self-blame 2.33 0.81 2.21 0.78 2.23 0.79 2.26 0.74 2.32 0.71 Table 4
Outcomes of Four Latent Growth Models with One Coping Strategy per Model as Dependent Variable Over Time (N =182)
Means/intercepts Variance Model fit
Coping strategy Intercept se Slope se Intercept se Slope se χ2 (df = 16) p RMSEA CFI
Denial 1.96*** 0.04 -0.06** 0.01 0.12*** 0.03 0.01 0.00 15.66 .11 .06 0.93
Behavioral disengagement 2.01*** 0.05 -0.06*** 0.02 0.28*** 0.05 0.01* 0.01 8.03 .63 .00 1.00
Substance use 2.08*** 0.09 -0.12*** 0.02 0.96*** 0.12 0.04** 0.01 22.15 .01 .08 0.93
Self-blame 2.26*** 0.06 0.00 0.02 0.41*** 0.05 0.02*** 0.01 16.32 .09 .06 0.97
Note. RMSEA = Root Mean Square Error of Approximation. CFI = Confirmatory Fit Index.
**p <.01. **p <.01. ***p <.001.
Table 5
Outcomes of 18 Latent Growth Models with One Trauma-related Symptom per Model, All Corrected for Age and Type of Treatment (N =181)
Behavioral disengagement Substance use Self-blame
Intercept se Slope se Intercept se Slope se Intercept se Slope se
Anxiety 0.24* 0.09 -0.05 0.04 0.14 0.16 -0.00 0.04 0.60*** 0.10 -0.08* 0.03 Depression 0.22** 0.07 -0.05* 0.02 0.32** 0.12 -0.02 0.03 0.62*** 0.08 -0.07** 0.03 Post-traumatic stress 0.11 0.08 -0.05* 0.02 0.24 0.13 -0.03 0.03 0.43*** 0.09 -0.04 0.03 Sexual concerns 0.15 0.10 -0.04 0.03 0.63*** 0.16 -0.09* 0.04 0.32** 0.11 -0.02 0.03 Dissociation 0.33*** 0.07 -0.07** 0.02 0.42** 0.13 -0.05 0.03 0.42*** 0.08 -0.02 0.03 Anger 0.28*** 0.06 -0.06*** 0.02 0.42*** 0.11 -0.05* 0.05 0.17* 0.08 -0.01 0.02 Note. *p < .05. ** p <.01. ***p < .001.
Table 6
Outcomes of Six Regression Analyses with the Use of Denial as Dependent Variable and One Trauma-related Symptom per Model as Independent Variable. All Models Are Corrected for Age (N = 181)
b (SE) t rpartial2 Anxiety .23 (.09) 2.63** .04 Depression .16 (.07) 2.15* .03 Post-traumatic stress .10 (.08) 1.27 .00 Sexual concerns .13 (.10) 1.37 .01 Dissociation .25 (.08) 3.26** .06 Anger .18 (.07) 2.84** .04 Note. *p < .05. **p <.01.
