"I Can't Stop Thinking About It”: The Association Between Rumination and Trauma-Related Symptoms among Adolescents Females in Residential Care.
Masterthesis Forensic Child and Youth Care Sciences Graduate School of Child Development and Education University of Amsterdam M.E. Louwes 11324686 University of Amsterdam (Amsterdam, The Netherlands) University of Sherbrooke (Montréal, Canada) First supervisor: Dr. E.S. van Vugt Second supervisor: Dhr. Prof. Dr. G.J.J.M. Stams Amsterdam, August 2018
Table of contents Abstract 3 Introduction 4 Method 8 Results 11 Discussion 15 References 20
Abstract
Aim: The aim of the current study was to examine the relationship between rumination and trauma-related symptoms in a sample of adolescent females in residential care, over and above the incidence of similar symptoms at time of admission.
Method: The sample was composed of 245 female adolescents who participated in both data collection waves used by the current study. At Time 1 (Mean age = 15.29, SD = 1.35), rumination was assessed using the Sadness and Anger Rumination Inventory. At both Time 1 and Time 2 (Mean age = 17.14, SD = 1.45), trauma-related symptoms were assessed by use of the Trauma Symptom Checklist for Children.
Results: Trauma-related symptoms appeared to be moderately to strongly associated with each other in both and late adolescence. Additionally, trauma-related symptoms in mid-adolescence appeared to be related to trauma-related symptoms at late-mid-adolescence, showing that these symptoms can be persistent in adolescent females in residential care. Rumination showed to be particularly associated with trauma-related symptoms in late-adolescence, and to explain a substantial proportion of variance in examined trauma-related symptoms, over and above similar symptoms at time of admission.
Conclusion: The current study underscores that trauma-related symptoms in females in residential care can be viewed as persistent, and that rumination is a maintaining factor of these symptoms. Assessment of the specific treatment needs of females in residential care at admission is important to address possible trauma-related symptoms and maladaptive coping strategies in treatment methods in order to resolve trauma-related symptomology.
Introduction
High levels of trauma-related mental health problems among youth in residential care, among which anxiety, depression and anger are well documented (Brady & Caraway, 2002; Connor, Doerfler, Toscano, Volungis, & Steingard, 2004; Kolko, Hurlburt, Zhang, Barth, Leslie, & Burns, 2010; Collin-Vézina, Coleman, Milne, Sell, & Daigneault, 2011; Ford, Wasser, & Connor, 2011; Van der Molen, Vermeiren, Krabbendam, Beekman, Doreleijers, & Jansen, 2013), and often viewed by researchers as outcomes of traumatic life events, such as family and community violence, and child abuse and neglect (Cook et al., 2005; Kolko et al., 2010; Briggs, Greeson, Layne, Fairbank, Knoverek, & Pynoos, 2012; Leenarts, Vermeiren, Van de Ven, Lodewijks, Doreleijers, & Lindauer, 2013; Van Vugt, Lanctôt, Paquette, Collin-Vézina, & Lemieux, 2014).
Studies on youth in residential care facilities report that almost all youth experience at least one traumatic event, with the majority reporting multiple traumatic experiences
throughout their life (Brady & Caraway, 2002; Abram, Teplin, Charles, Longworth,
McClelland, & Dulcan, 2004; Boyer, Hallion, Hammell, & Button, 2009; Briggs et al., 2012; Leenarts et al., 2013), also known as polyvictimization (Ford, Chapman, Connor, & Cruise, 2012). Compared to their male counterparts, females in residential care are overall more likely to have histories of physical abuse (Connor et al., 2004), emotional abuse (Boyer et al., 2009), and sexual abuse (Connor et al., 2004; Boyer et al., 2009; Collin-Vézina et al., 2011), to be at risk for polyvictimization (Connor et al., 2004; Bloom, Owen, Rosenbaum, & Deschenes, 2003; Ford, Grasso, Hawke, & Chapman, 2013), and report higher levels of trauma-related symptoms (Collin-Vézina et al., 2011).
Previous research found that one third of youth admitted to a residential care facility showed a continued presence of problems post-treatment (Briggs et al., 2012). For instance, a number of studies found that the majority of former-institutionalized females show continuing
mental health problems such as depression, dissociation, and PTSD after transitioning out of care (Van der Molen et al., 2013; Krabbendam, Colins, Doreleijers, Van der Molen,
Beekman, & Vermeiren, 2015; Van Delft, Finkenauer, & Verbruggen, 2016). One of the explanations might be that youth who enter residential care with post-traumatic stress as a result of a history of childhood trauma are less likely to benefit from treatment during their placement compared to youth without such histories (Connor, Miller, Cunningham, & Melloni, 2002; Boyer et al., 2009). Previous studies therefore argued that treatment in
residential care might not be specialized enough to address trauma-related symptoms (Connor et al., 2002; Collin-Vézina et al., 2011; Van der Molen et al., 2013; Krabbendam et al., 2015).
In order to better meet the therapeutic needs of adolescent females in residential care with trauma-related symptoms, it is important to gain knowledge about the underlying factors that maintain these symptoms. For example, it is known that exposure to childhood trauma affects the development of emotion regulation skills in young women (O’Mahen, Karl, Moberly, & Fedock, 2015). Previous research suggested that recovery from trauma-related symptoms may be blocked by engaging in negative coping strategies (Ehlers & Clark, 2000; Walser & Hayes, 2006). Moreover, negative coping was found to predict higher levels of both trauma-related symptoms and psychological impairment (Im & Follette, 2016).
Rumination is an example of a maladaptive cognitive coping strategy and is
characterized by intrusive, aversive, and repetitive thinking (Nolen-Hoeksema, 1991). The concept of rumination was first defined as part of the response styles theory by
Nolen-Hoeksema (1991), in an attempt to explain the duration and responses to depressive episodes in the general population. Individuals may engage in rumination in order to avoid negative internal responses (Walser & Hayes, 2006). Unfortunately, rumination usually leads to adverse effects by maintaining or increasing levels of distress instead of resolving distress (Nolen-Hoeksema, 1991; Spasojevic & Alloy, 2002).
There is a noticeable trend in the literature towards examining the relationship between rumination and relatively common health problems in non-clinical samples, such as depression (Hart & Thompson, 1996; Schwartz & Koenig, 1996; Burwell & Shirk, 2007; Abela & Hankin, 2011; Paredes & Calvete, 2014), bulimic disorder (Nolen-Hoeksema, Stice, Wade, & Bohon 2007), and substance abuse (Nolen-Hoeksema et al., 2007; Skitch & Abela, 2008). However, we still lack research into the association between rumination and trauma-related symptoms in clinical samples.
Research on this topic is needed for at least two reasons. First, rumination is suggested to be more common in clinical samples due to elevated levels of distress (Spasojevic & Alloy, 2002; Sarin & Nolen-Hoeksema, 2010). In an attempt to internally process and control the profound distress that is caused by the experience of, for instance, childhood trauma, victims may develop a predisposition for rumination (Spasojevic & Alloy, 2002). Second, in adult non-clinical samples with a wide range of traumatic experiences rumination has found to contribute to the continuance of trauma-related symptoms, such as PTSD (Ehlers & Clark, 2000; Ehring, Frank, & Ehlers, 2008; Bennett & Wells, 2010; Goldwin, Behar, & Sibrava, 2013).
In an extensive overview paper on trauma-related disorders in children and
adolescents, rumination is only briefly discussed as a potential explanatory factor (Connor, Ford, Arnsten, & Greene, 2015). We were able to identify one community-based study that examined rumination among adolescents with histories of child abuse and neglect. More specific, results of this study showed that a ruminative coping style provoked maladaptive reactions to distress and mediated the association between childhood trauma and mental health disorders (Heleniak, Jenness, Vander Stoep, McCauley, & McLaughlin, 2016). This finding might be of great importance as it is well described in the literature that youth in residential care are at risk for traumatic childhood experiences (Brady & Caraway, 2002;
Abram et al., 2004; Connor et al., 2004; Bloom et al., 2003; Boyer et al., 2009; Kolko et al., 2010; Collin-Vézina et al., 2011; Briggs et al., 2012; Brown, McCauley, Navalta, & Saxe, 2013; Leenarts et al., 2013; Zelechoski, Sharma, Beserra, Miguel, DeMarco, & Spinazzola, 2013; Van Delft et al., 2016). Yet, while the interest for the effects of rumination on several mental health problems is growing, no study to our knowledge has attempted to examine the relationship between rumination and trauma-related symptoms in a sample of female
adolescents in residential care.
In summary, there appears to be a general lack of empirical studies among cognitive factors that maintain trauma-related symptoms in youth placed in residential care facilities (Collin-Vézina et al., 2011). Although youths are usually placed in residential care for behavior problems, such as aggression (Connor et al., 2004), another typical characteristic of this target group is their trauma-related symptoms often caused by histories of complex trauma, among which child maltreatment and family violence (Ford et al., 2013). Further, it is known that histories of complex trauma can cause deficits in several cognitive domains in children and adolescents (Cook et al., 2005). Since rumination is hypothesized to usually be triggered by feelings of distress and a negative mood, it might be more common amongst individuals in clinical populations (Sarin & Nolen-Hoeksema, 2010). Although previous literature outlines the need for a better understanding of severe and persistent trauma-related symptoms in youth placed in residential care, there is currently a gap concerning integrating this into research and practice (Collin-Vézina et al., 2011; Briggs et al., 2012).
The current study aimed to gain more insight in the associations between trauma-related symptoms and maladaptive rumination in female adolescents in residential care. The first aim was to assess associations between trauma-related symptoms and rumination in a sample of adolescent females right after admission and after being rehabilitated in the
admission on trauma-related symptoms, in average, two years later in female adolescents in residential care, while controlling for trauma-related symptoms at time of admission.
Method Participants
The present study is part of the Montreal longitudinal study on adolescent females in residential care (Lanctôt & Lemieux, 2012). Placement in residential care is used for
vulnerable youth with serious behavioral and/or emotional problems when their difficulties can no longer be addressed in their current life settings without specialized support. Services are provided by the welfare system to adolescents and their families, and are carried out by qualified practitioners such as psychologists, psychoeducators, criminologists, or social workers. The programs and services provided are based on psychosocial rehabilitation principles (Association des Centres Jeunesse du Québec, 2012). To be included in the study, adolescent females had to be placed in the youth center for a minimum duration of three months. The total data collection of the longitudinal study consisted of six data collection waves (T1-T6), covering the period from mid-adolescence to emerging adulthood. The present study was based on the data collection from wave one (Mean age = 15.29, SD = 1.35;
referred to as Time 1 in the present study) and wave five (Mean age = 17.14, SD = 1.45; referred to as Time 2 in the present study). The sample of the present study consisted of n = 245 female adolescents who participated in both data collection waves. The first wave was completed at time of admission to residential care while the fifth wave was completed, in average, two years later (M = 22 months). At wave 5, sixty females of the current sample were still in placement. Out of the females in this sample, 87.8% were born in Canada (n = 215). According to child protection services females in our sample often had substantiated reports of neglect (51,4%), psychological abuse (12,2%), physical abuse (18,8%), and sexual
abuse (15,9%). Attrition was tested in regard to individual trauma-related symptoms and rumination at Time 1. There appeared to be no significant differences between the attrition group and sample included in the analysis regarding scores on rumination and trauma-related symptoms.
Procedures
The data collection procedures of the longitudinal study were approved by the Institutional Review Board of the University of Sherbrooke, Canada. All female adolescents formally consented to participate at each wave of the data collection. For female adolescents under the age of 14, formal parental consent was obtained. The interviews were administered after obtaining the consent by an interviewer trained in interviewing techniques and research ethics. The administering of the questionnaire took approximately 90 minutes. At the end of the interviews, all female adolescents were asked to provide contact details for follow-up assessments.
Measures
Trauma-related symptoms: Trauma-related symptoms were evaluated both at Time 1
and Time 2, using the Trauma Symptom Checklist for Children (TSCC; Brière, 1996). The TSCC is a 54-item self-report trauma symptoms instrument measuring a wide range of symptom domains in relationship to unspecified traumatic events. The instrument is designed to assess the effects of childhood trauma in children aged 8-17 (Brière, 1996). For the present study, we used all six scales of the TSCC. An example of an item of the Anxiety scale is: “I am afraid that an unfortunate event will occur”. For the Depression scale, an example of an item is: “I feel sad or unhappy”. The Post-Traumatic Stress scale was for example measured with the item: “I have bad dreams or nightmares”. Dissociation was examined with “I pretend I am someone else” as an item. The Anger scale was measured with items such as: “Getting angry without being able to calm down” and “I want to say vulgar words” is an example of an
item of the Sexual Disturbance scale. A Four-Point-Likert scale was used, ranging from 0 (never) to 3 (almost all the time) to rate how often the adolescent females had experienced trauma-related symptoms. Higher mean scores indicated more trauma-related symptoms. For this sample of females, the Cronbach’s alphas for the various scales ranged from .76 to .89 at Time 1, and .78 to .91 at Time 2.
Rumination: Rumination was assessed at Time 1 using the Sadness and Anger
Rumination Inventory (SARI; Peled & Moretti, 2007). This 22-item questionnaire consists of 11 analogous items for each type of rumination. An example of an item is: “When I think about my sadness/anger, I become sadder/ more upset”. Items were scored on a Five-Point-Likert-Scale, indicating how often participants ‘did the following things’ in case of sadness or anger, ranging from 1 (never) to 5 (always) (Peled & Moretti, 2007). Considering the strong correlation (r = .70) between the two original scales of the SARI (Rumination on Anger, and Rumination on Sadness), the current study combined the scales into one total scale
(Rumination). Higher mean scores indicated higher levels of rumination. The Cronbach’s alpha for this sample was α= .94.
Data Analysis Strategy
SPSS statistics version 21 was used to conduct the statistical analyses. First, Pearson’s correlation analyses were performed to examine intercorrelations between all research
variables, respectively demographic variables, trauma-related symptoms at Time 1 and Time 2, and rumination at Time 1. Cohen’s (1988) criteria were used to interpret the strength of the observed correlations, wherein r = .10-.29 was considered to be a small, r = .30-.49 a
moderate, and r ≥ .5 a strong correlation. Second, hierarchical regression analyses were conducted to examine the contribution of rumination at Time 1 on trauma-related symptoms at Time 2. The following variables were controlled for: demographic variables, and all types of trauma-related symptoms at Time 1. The current study applied Bonferroni corrections to
the dataset. The data was checked for outliers. Multicollinearity was tested and appeared to be at an acceptable level.
Results
Descriptive statistics and associations between all research variables
Pearson’s correlation analyses were conducted to examine the relation between all research variables. An overview of the means, standard deviations, and the correlation coefficients are presented in Table 1.
In sum, several significant associations were found between demographic variables age, being in residential care at Time 2 and being born in Canada, and trauma-related symptoms at Time 2. However, r values only ranged from -.16 to .18. It was found that trauma-related symptoms were all moderate to strongly associated with each other at Time 1, and all strongly associated at Time 2. More precisely, the internalizing scales Anxiety, Depression and PTSD appeared to have the strongest associations with each other at both measurement times (similar associations were found of r = .73, p = .000, at Time 1 and r = .84, .81, and .80, p = .000, at Time 2). Some continuity was observed over time regarding the presence of trauma-related symptoms in adolescence. The presence of trauma-related
symptoms in mid-adolescence was moderately to strongly associated to similar symptoms in late adolescence (r between .36 and .52).
Although rumination and trauma related-symptoms were weakly associated in mid-adolescence (r ranging from .23 to .26), the association between rumination Time 1 and trauma-related symptoms in late-adolescence appeared to be stronger, showing moderate r values between .45 and .59. The observed associations between rumination and trauma-related symptoms were all significant at both T1 and T2 (p < .001).
Second, we performed a number of hierarchical regression analyses to examine the contribution of rumination to the level of trauma-related symptoms in late-adolescence, while
controlling for demographic variables and the level of trauma-related symptoms in mid-adolescence. For each trauma-related symptom domain, three models were examined. Model 1 controlled for age, being in residential care at Time 2 and being born in Canada.
Subsequently, model 2 included the prevalence of trauma-related symptoms at Time 1. Finally, model 3 examined to which extent trauma-related symptoms at Time 2 were associated with rumination at Time 1, over and above demographic variables, and the prevalence of trauma-related symptoms at Time 1. The results of the final model are displayed in Table 2.
Results of the hierarchal regression analyses show that rumination at Time 1 was strongly associated with trauma-related symptoms at Time 2. First, step 1 showed that the demographic variable being in placement at Time 2 was significantly related to depression, PTSD, dissociation, and marginally to anxiety. The demographic variable age showed a significant relationship with sexual disturbance at Time 2. Demographic variables contributed significantly to the explained variance of anxiety, PTSD, sexual disturbance, and marginally to dissociation in late adolescence, although the contributions were small. Second, step 2 confirmed that related symptoms are persistent over time. Results show that trauma-related symptoms at Time 1 contributed between 12% and 27% to the explained variance of the same symptom domains at Time 2. The largest contributions were found for sexual disturbance (∆R2 = 23%) and anger (∆R2 = 27%). Third, after adding rumination at T1 to the
model we found that rumination explained a substantial level of variance of all trauma-related symptoms domains at T2, over and above demographic variables, and trauma-related
symptoms at Time 1. More precisely, rumination at Time 1 contributed substantially to the explained variance of anxiety (∆R2 = 20%, p < .001), depression (∆R2 = 21%, p < .001),
PTSD (∆R2 = 27%, p < .001), sexual disturbance (∆R2 = 11%, p < .001), dissociation (∆R2 =
Table 1. Intercorrelations between all research variables (n = 245). * p < .05, **p < .01, ***p < .001. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 M SD 1. Age T5 - 17.14 1.45 2. Placement T5 -.29*** - - - 3. Canada -.01 -.14** - - - 4. Anxiety T1 -.01 -.09* -.11 - 1.07 .57 5. Depression T1 -.02 -.07* -.01 .73*** - 1.32 .68 6. PTSD T1 -.07 -.03* -.05 .73*** .73*** - 1.38 .67 7. Sexual disturbance T1 -.09 -.01 -.11 .48*** .47*** .48*** - .70 .56 8. Dissociation T1 -.09 -.04 -.01 .68*** .72*** .67*** .51*** - 1.09 .64 9. Anger T1 -.02 -.02 -.05 .55*** .64*** .54*** .52*** .66*** - 1.19 .76 10. Anxiety T5 -.03 -.10 -.16* .36*** .34*** .34*** .26*** .34*** .29*** - .84 .58 11. Depression T5 -.03 -.13* -.03 .31*** .44*** .32*** .31*** .36*** .36*** .80*** - .93 .65 12. PTSD T5 -.06 -.16* -.12 .32*** .37*** .37*** .30*** .38*** .34*** .84*** .81*** - 1.04 .67 13. Sexual disturbance T5 -.18** -.03 -.16* .26*** .25*** .28*** .51*** .38*** .34*** .56*** .51*** .53*** - .56 .45 14. Dissociation T5 -.02 -.15* -.07 .30*** .33*** .31*** .30*** .40*** .36*** .75*** .76*** .79*** .58*** - .78 .61 15. Anger T5 -.02 -.06 -.07 .28*** .30*** .25*** .33*** .34*** .52*** .64*** .73*** .67*** .56*** .71*** - .93 .70 16. Rumination -.06 -.05 -.08 .23*** .23*** .26*** .26*** .25*** .23*** .52*** .54*** .59*** .45*** .52*** .54*** - 3.01 1.00
Table 2. A hierarchical regression analysis on the contribution of rumination on trauma-related symptoms in late adolescence, controlled for similar trauma-related symptoms at time of placement (n = 245).
†p <.10, * p < .05, **p < .01, ***p < .001.
Trauma-Related Symptoms (TSCC) T5
Anxiety Depression PTSD Sexual Disturbance Dissociation Anger
β R2Ch Fchange β R2Ch Fchange β R2Ch Fchange β R2Ch Fchange β R2Ch Fchange β R2Ch Fchange
Step 1: .04 2.97*** .02 1.86*** .05 3.92*** .06 5.24*** .03 2.35† .01 0.59*** Age -.03 .04*** -.07*** -.15*** -.02*** .03*** -Placement -.11† .15*** -.20*** -.07*** -.16*** .06*** -Canada -.08 .03*** -.04*** -.07*** -.01*** .00*** Step 2 : .12 32.35*** .18 54.79*** .12 35.86*** .23 78.41*** .15 43.5*** .27 90.1*** TSCC T1 -.24*** .32*** -.22*** -.41*** -.27*** .42*** -Step 3 : .20 74.27*** .21 83.75*** .27 113.80*** .11 44.57*** .20 74.42*** .19 82.82*** Rumination -.46*** .47*** -.54*** -.34*** -.46*** .45***
-Discussion
The current study examined the relationship between rumination and trauma-related symptoms in a sample of adolescent females in residential care, over and above the incidence of similar symptoms at time of admission. Results indicated that all trauma-related symptoms are associated with eachother in both mid- and late-adolescence, and that rumination was associated with persistent trauma-related symptoms in female adolescents in our sample. Moreover, rumination appeared to explain a substantial amount of variance in trauma-related symptoms in late-adolescence, over and above the incidence of trauma-related symptoms at time of admission.
The results of the current study confirmed that both internalizing and externalizing trauma-related symptoms at time of admission are associated with the same trauma-related symptoms after receiving treatment in residential care. Therefore, trauma-related symptoms among female adolescents in residential care can be perceived as persistent, which is in line with results of previous research on mental health issues (Van der Molen et al., 2013; Krabbendam et al., 2015; Van Delft et al., 2016), possibly resulting from previous traumatic life experiences (Van Vugt et al., 2014; Van Delft et al., 2016). Additionally, placement in residential care itself may increase and maintain trauma-related symptoms, as separation from familiar environments and people might trigger anxiety and distress (Wilmshurst, 2002; Underwood, Barretti, Storms, & Safonte-Strumolo, 2004; Bettmann, & Jasperon, 2009).
Next, in the current study rumination was able to substantially and significantly contribute to the explained variance in trauma-related symptoms, over and above initial trauma-related symptoms. Even though no study to our knowledge has examined rumination on trauma-related symptoms in a similar target group before, our results are in line with results from a non-clinical study by Ehring et al. (2008) in which ruminating after a traumatic traffic accident was not only related to immediate PTSD symptoms, but also to PTSD
symptoms six months after the event, over and above original levels of trauma-related symptoms. Based on results of the current study rumination can be viewed as a maintaining factor in trauma-related symptoms, as previously theorized by Ehlers and Clark (2000). In their theoretical framework focused on cognition, maladaptive coping strategies are proposed to maintain and enhance trauma-related symptoms by creating a constant sense of present threat in the mind, leading to unresolved symptomology (Ehlers & Clark, 2000).
Rumination especially contributed to the explained variance of PTSD and depression in the present study. As rumination was first described by Nolen-Hoeksema (1991) as part of the Response Style Theory (RST), it was specifically hypothesized to increase and maintain symptoms of depression. To date, this theory has been well-supported by results of several non-clinical sample studies on the relationship between rumination and depression (Hart & Thompson, 1996; Schwartz & Koenig, 1996; Thomsen, 2006; Burwell & Shirk, 2007; Abela & Hankin, 2011; Paredes & Calvete, 2014), and might be explained by the way rumination supports negative thinking and blocks active problem-solving, leading to a pessimistic perspective on the current situation, and therefore specifically fuels depression (Nolen-Hoeksema, Wisco, & Lyubomirsky, 2008).
Additionally, in relationship to PTSD it is suggested that rumination contributes to persistent trauma-related symptoms by cognitively suppressing traumatic memories (Ehlers & Clark, 2000), which blocks the processing of trauma (Michael, Ehlers, Halligan, & Clark, 2005), and therefore elevating the level of PTSD symptoms (Ehring et al., 2008). The present study adds to this body of knowledge that rumination might impact all types of trauma-related symptoms in females in residential care to a high degree, and results in persistency of these symptoms during their placement.
Some limitations of the current study should be mentioned. First of all, there is currently no consensus in the definition of rumination. Previous studies have used different
concepts of rumination, such as hostile, angry and depressive (Zielinski, Borders, & Giancola, 2015), where the current study looked at rumination in general due to the high association between the subscales of the SARI (Peled & Moretti, 2007). Rumination is also defined as a concept with different subtypes, such as brooding (Raes & Hermans, 2008). Nevertheless, across all types of rumination identified by researchers, rumination is seen as a maladaptive coping strategy that puts individuals at elevated risk for negative mood, poor decision-making, as well as unresolved trauma-related symptoms, such as depression and anxiety (Nolen-Hoeksema et al., 2008).
Second, due to the specific sample used in this study, generalizability is limited. For example, females in comparison to males in residential care are characterized by both higher levels of rumination (Peled & Moretti, 2007), and trauma-related symptoms (Collin-Vézina et al., 2011). Therefore, it is possible that the specific strengths and limitations of ruminating females in residential care with trauma-related symptoms differ from males with similar histories of trauma.
Third, trauma-related symptoms were measured by the use of a self-report instrument. Even though self-report is viewed by researchers as a reliable method to assess trauma-related symptoms, it can be influenced by biases, such as shame, guilt and denial (Swahn et al., 2006). Therefore, to avoid underestimation and in order to get a more integral perspective on trauma-related symptoms in females in residential care, adding a measurement that assesses the females’ primary caretaker perspective could be an adequate addition (McGee, Wolfe, Yuen, Wilson, & Carnochan, 1995).
All female adolescents in the sample of the current study received some form of treatment in a residential care facility, of which some cognitive-behavorial therapy. A meta-analysis regarding the effectiveness of residential care showed that cognitive behavior therapy is the only type of treatment that leads to significant treatment outcomes in residential care
(De Swart et al., 2012). However, results generally tend to be modest (Anglin & Knorth, 2004; Knorth, Harder, Zandberg & Kendrick, 2008), and short lived (Knorth et al., 2008; De Swart et al; 2012; Lanctôt, Hauth-Charlier, & Lemieux, 2015). The need to identify targets of treatment that contribute to effective long-term outcomes for youth in residential care
therefore remains important (Knorth et al., 2008). Especially since results from previous studies showed that current screening tools for trauma-related symptoms in residential youth are inadequate (Romanelli et al., 2009), and cognitive behavior therapy tends to be gender-neutral (Bloom et al., 2003; Connor et al., 2004; Kerig & Schindler, 2013; Lanctôt et al., 2015; Krabbendam et al., 2015). It is therefore suggested that adaptions in treatment programs should be made to better match treatment needs of females in residential care (Bloom et al., 2003; Connor et al., 2004; Collin-Vézina et al., 2011; Kerig & Schindler, 2013; Lanctôt et al., 2015; Krabbendam et al., 2015).
In interviews with incarcerated female adolescents it was underscored that histories of trauma are often not recognized by the staff nor integrated in the treatment they received in residential care (Bloom et al., 2003). Therefore, the current tendency to focus on reducing behavorial symptomology seems to specifically lack treating the underlying trauma-related symptoms in this target group. Among all subgroups of adolescents in residential care, levels of emotional well-being are reported to be the lowest for youth with histories of childhood trauma (Greger, Myhre, Lydersen, & Jozefiak, 2016). Taking into account that results of the same study found the highest rates of trauma exposure among females, the quality of life among female adolescents in residential care can be considered as notably poor (Greger et al., 2016). Hence, integrating a trauma-based approach adapted to the needs of adolescent females in residential care is of great clinical importance.
The present study adds to preliminary knowledge that addressing maladaptive coping strategies might be important in order to resolve trauma-related symptoms in residential
females. A recent study by Im and Follette (2016) argued that mindfulness might be an eligible approach to address rumination as they found that trauma-related symptoms are negatively associated with mindfulness. Moreover, results of their study showed that higher levels of mindfulness decreased the risk to engage in rumination, which in turn led to reduced levels of trauma-related symptoms. An explanation for this might be that individuals who engage in mindfulness are trained to understand that their mind is distant from themselves and does not control their behaviour (Segal, Williams, & Teasdale, 2018), and therefore targets the negative and repetitive character of ruminative thinking (Nolen-Hoeksema et al., 2008).
An example of another therapeutic framework that addresses both trauma-related symptoms and self-regulation problems is the Attachment, Regulation, Competency (ARC) intervention. This intervention is designed as a flexible framework in the treatment of youth with histories of complex trauma (Kinniburg, Blaustein, Spinazzola, & Van der Kolk, 2005). ARC underscores the importance of enhancing adaptive coping skills in traumatized youth in order for these youths to grow and heal (Kinniburg et al., 2005), and might therefore be worth exploring for youth in residential care who engage in rumination.
The current study highlighted the fact that trauma-related symptoms among females in residential care can be viewed as persistent. This can be can be explained by their tendency to engage in rumination, which was found to be a maintaining factor of trauma-related
symptoms. The present study underscores the importance to clearly identify the needs of females with trauma-related symptoms in residential care. Interventions for adolescent females in residential care should aim to detect trauma-related symptoms at an early stage, and address maladaptive coping strategies in order to resolve trauma-related symptoms.
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