Children’s Impact of Traumatic Events Scale-Revised (CITES-R)

DEVISED BY:

Wolfe, V. V., Gentile, C., Michienzi, T., Sas, L. & Wolfe, D.A. (1991).

TYPE OF INSTRUMENT:

The CITES-R is a brief and easy to administer standardised interview for both males and females aged between 8 and 16 years who have been sexually assaulted (Wolfe, et al., 1991).  The instrument is designed to measure post-traumatic stress symptoms, social reactions to disclosure, abuse related attributions, and eroticism (Crouch, Smith & Ezzell, 1999).  Although the instrument is such that a child with good reading skills could complete the questionnaire in a self-report manner, due to the sensitive nature of the information being gathered, it is recommend that the scale be used in the interview format (Wolfe, et al., 1991). 

DESCRIPTION:

The CITES-R consists of 78 items rated on a 3 point Likert scale (‘very true’; ‘somewhat true’; ‘not true’).  These items yield 11 subscales which are grouped into 4 main scales: (1) PTSD (Intrusive Thoughts, Avoidance, Sexual Anxiety, and Hyperarousal); (2) Social Reactions (Negative Reactions by Others and Social Support); (3) Attributions (Self-Blame/Guilt, Dangerous World, Empowerment and Vulnerability); and (4) Eroticism (Wolfe, et al., 1991; Chaffin & Shultz, 2001).  A brief description of the subscales is provided in Table 1.

 

Table 1. A Brief Description of the CITES-R Sub-Scales

 

PTSD

Intrusive Thoughts (IT)

Measures re-experiencing symptoms; nightmares; intrusive thoughts; memories; and images related to the sexual assault.

Avoidance (AV)

Measures avoidance of anything that reminds the individual of the sexual assault; efforts to forget or not think about the sexual assault; and emotional numbing.

Sexual Anxiety (SA)

Measures anxiety associated with sexual issues, such as, becoming upset when thinking about sex, wishing there were no thing such as sex etc.

Hyperarousal (HYP)

Measures irritability; difficulty concentrating; exaggerated startle response; and feelings of restlessness or jumpiness.

SOCIAL REACTIONS

Negative Reactions by Others (NRO)

Measures perceived negative reactions to the disclosure.  High scores on this scale reflect problematic reactions by others.

Social Supports (SS)

Measures whether the victim felt believed and supported by those he/she disclosed to.  High scores on this scale indicate a perception of positive support.

ATTRIBUTIONS

Self Blame/Guilt (SB/G)

High scores on this scale reflect greater tendency for the individual to blame themselves for the sexual assault.

Personal Vulnerability (PV)

High scores on this scale reflect beliefs that sexual assault happens often to children, that sexual assault may occur again, and that the individual has no control over stopping sexual assault.

Dangerous World (DW)

A high score on this scale indicates a tendency to worry that adults cannot be trusted and children will be sexually assaulted.

Empowerment (EMP)

High scores on this scale indicates a sense of empowerment to prevent future sexual assaults from occurring.

EROTICISM

Eroticism (ERO)

High scores reflect frequent sexual feelings.

(Crouch, et al. 1999).

 

RELIABILITY

Internal Consistency

The reliability for the entire scale demonstrated good internal consistency with an alpha value of .89 (Wolfe, et al., 1991).  High levels of reliability were also reported for the PTSD scale, which ranged between an alpha value of .88 and .89 (Wolfe, et al., 1991; Crouch, et al., 1999), and the Social Reactions scale (α = .87).  The Abuse Attributions scale was moderately reliable (α = .78), and the eroticism scale somewhat less reliable with an alpha value of .57 (Wolfe, et al., 1991).  From Table 2 it can be seen that across three separate studies, the IT, SA, NRO, and SB/G subscales all showed good internal consistency.  The HYP subscale indicated moderate reliability, while the AV, DW, EMP, and PV subscales are somewhat lower in reliability.  The alpha levels for SS and ERO subscales varied greatly between the studies (α ranging.57 to .73; and .57 to .77 respectively).

It should be noted that all the reliability co-efficients reported by Wolfe, et al. (1991) were calculated using only the 54 original CITES items, the additional 24 CITES-R items were not included in the analyses.  In addition, the study by Crouch, et al. (1999) omitted 3 items from the PV subscale (items 10, 60 and 78), consequently scores from this subscale were calculated using only 6 of the 9 available items.  It would therefore be reasonable to suggest that the alpha co-efficients reported by Chaffin and Shultz (2001), which are somewhat lower than those reported by the above two studies, are more representative of the CITES-R instrument.

Table 2. Reliability of CITES-R Subscales

 

Wolfe, et al. (1991)

Crouch, et al. (1999)

Chaffin & Shultz (2001)

CITES-R Scales & Sub-scales

Sub-Scale α

Sub-Scale α

Sub-Scale α

PTSD

.88

.89

Not Reported

Intrusive Thoughts

.91

.85

.79

Avoidance

Not Reported

.66

.56

Sexual Anxiety

.84

.86

.72

Hyperarousal

Not Reported

.74

.67

Social Reactions

.87

Not Reported

Not Reported

Negative Reactions by Others

.80

.80

.79

Social Support

.57

.67

.73

Abuse Attributions

.78

Not Reported

Not Reported

Self-Blame/Guilt

.78

.81

.73

Dangerous World

.68

.57

.57

Empowerment

.67

.69

.67

Personal Vulnerability

.57

.59

.66

Eroticism

.57

.77

.68

 

VALIDITY:

Construct Validity:

Chaffin and Shultz (2001) reported evidence in support of Construct validity for the CITES-R PTSD scale, finding scores on the CITES-R Attribution and Social Reactions scales to be good predictors of the symptoms in the PTSD subscales (lack of fit Wilks’ Lambda = .003, ns; R2 values ranging from .45 to .52).  In addition, three of the four subscales of the CITES-R PTSD scale (IT; AV; and HYP) were found, over time with treatment, to change in the expected direction (Chaffin & Shultz, 2001).

 

Convergent and Discriminant Validity:

Evidence for convergent and discriminant validity of the CITES-R has been found in several studies (Wolfe, et al., 1991; Crouch, et al., 1999; & Chaffin & Shultz, 2001).  The CITES-R showed high correlations with other measures of similar construct (convergent validity) and low correlations with other measures of dissimilar construct (discriminant validity).  Table 3 outlines the assessment tools used by each study for comparison with the CITES-R.

Wolfe et al. (1991) reported that convergent validity was “evidenced by relatively high correlations” (p.378) between the CITES-R IT, AV and SA subscales and the CBCL PTSD and SAFE scales.  The CITES-R NRO and SS subscales correlated with the CAM, CAF and IPA scales; and the CITES-R SB/G, EMP, PV and DW were correlated with the KASTAN Overall Positive and Negative scales.  Finally, the CITES-R ERO highly correlated with the CBCL Sex Problems scale and the CSBI.  Similarly, Wolfe, et al. (1991) reported support for discriminant validity evidenced by relatively low correlations between CITES-R scales and alternate methods measuring different constructs (e.g., CITES-R PTSD scale and CAM, CAF, and IPA scales).  Once again, due the inclusion of only 54 of the available 78 CITES-R items during analyses, caution must be exercised when interpreting Wolfe, et al.’s (1991) findings.

Further evidence of convergent and divergent validity is found in Crouch, et al.’s (1999) study, where the CITES-R is compared with the TSCC.  Crouch, et al. (1999) found the CITES-R PTSD IT and HYP subscales to be highly correlated (sharing more than 50% of variance) with the TSCC PTS scale (r= .78 and .7 respectively).  In support of discriminant validity, as would be expected the CITES-R PTSD scale and subscales did not significantly correlate with the TSCC anger scale (r: ranging between .10 and .25).  For the CITES-R Social Reactions scale Crouch, et al. (1999) found all subscales shared a small to medium amount of variance with the TSCC measures of Depression (r=-.32(SS); r=.62(NRO)) and Anger (r=-.31(SS); r=.42(NRO)), but was not significantly correlated with the other TSCC clinical scales.  Three of the four CITES-R Attributions subscales (SB/G; PV; EMP) demonstrated a moderate amount of shared variance with the TSCC clinical scales.  Although, as stated above, interpretation of the PV subscale in Crouch, et al’s (1999) study must be made with some caution.  DW subscale was not significantly correlated with any of the TSCC clinical scales.  Finally, the CITES-R Eroticism scale was moderately correlated with the TSCC Sexual Concerns scale (r=.53), this relationship was stronger for the TSCC SC Preoccupations scale (r=.59) than the TSCC SC distress scale (r=.25).  The CITES-R Eroticism scale was not significantly associated with any other TSCC clinical scales.

Table 3 Comparable Measures used by Three Studies for Validity Analyses for the CITES-R

 

aComparable Scales Used by Studies

CITES-R Scales

Wolfe, et al. (1991)

Crouch, et al. (1999)

Chaffin & Shultz (2001)

PTSD

CBCL-PTSD Scale

TSCC

DICA-RC PTSD

 

SAFE-Sexual Fears

 

DICA-RP PTSD

 

SAFE-Interpersonal

Discomfort

 

CBCL anxiety & depression

 

 

 

TRF anxiety & depression

Social Reactions

CAM

TSCC

SSSC parent support

 

CAF

 

SSSC classmate support

 

IPA

 

SSSC teacher support

 

 

 

SSSC friend support

 

 

 

PRADS

Attributions

KASTAN-positive

TSCC

SAFE

 

KASTAN-negative

 

 

Eroticism

CBCL-sex problems

TSCC

CBCL-sex problems

 

CSBI-total score

 

 

aA glossary of the test acronyms is provided in Appendix I.

In their analysis of convergent validity, Chaffin & Shultz (2001) found evidence to support all four CITES-R scales, although some were of only a moderate level.  The CITES-R PTSD and Eroticism scales, although correlating well with self-report measures, were largely uncorrelated with the parent report DICA-R or CBCL.  This minimal correlation between parent and child appeared to be consistent across all four CITES-R scales (Chaffin & Shultz, 2001).  Support for Convergent Validity on the CITES-R Attributions Scale was reported by Chaffin and Shultz (2001) to be variable, with the SB/G and PV subscales showing correlations with DICA-R of .88 and .87 respectively, while the EMP and DW subscales appeared largely uncorrelated with any of the comparable scales used.  Chaffin and Shultz (2001) failed to find evidence of Convergent Validity for the Social Supports scale; neither the NRO nor SS subscales correlated with generic or abuse-specific measures of social support.  Chaffin and Shultz (2001) conclude that the main symptom subscales (IT; AV; and HYP) and the SB/G subscale are robust and useful in both a clinical and research settings.  They caution the interpretation of the less robust subscales: DW, SS and EMP.  In addition, they state that it is important to recognise that the scores obtained on the CITES-R, as with other child-report measures, will often be unrelated to parent-reports.

Scoring Method:

Procedure for score can be obtained from Dr Vicky Wolfe (Vicky,Wolfe@LHSC.ON.CA) at the Children’s Hospital of Western Ontario, Department of Psychiatry, 800 Commissioners Road East, London, Ontario, Canada, N6A 5C2.

Norms:

Table 4 lists some of the characteristics of the samples used in the studies cited above, which consist of a total of 392 children obtained from both clinical and non-clinical sources.

Table 4 Normative Data for CITES-R Across Three Studies

 

Wolfe, et al. (1991)

Crouch, et al. (1999)

Chaffin & Shultz (2001)

Source

Family and Children’s Services

Victim Witness Court Preparation

(n=26) Inpatient and

(n=71) Outpatient at

Clinic for Trauma

Victims

(48%) Children’s A&E

(23%) Outpatient s/a clinic

(21%) Inpatient psych hospital

(8%) Community support   group            for s/a children

N

61

76

97

158

N(female)

53

56

83

118

N(male)

8

20

14

40

Ethnicity

N/A

N/A

60 Caucasian

37 African American

119 Caucasian

39 African American

Age

8 to 16yrs

M=11.6

SD=2.8

8 to 17yrs

M=12.5

SD=2.4

8 to 17yrs

M=12.76

SD=2.70

6 to 13yrs

M=10

Months Since

Disclosure

1 to 72mths

M=8.1

SD=11

N/A

N/A

At least 1 month prior to assessment

Months Since

S/A Ceased

1 to 91mths

M=15.6

SD=2.5

N/A

N/A

Median=12mths

Abuse History

65.7%     emotional

                abuse

29.5%     neglect

26.3%     physical

                abuse

39.3%     family                 violence

N/A

N/A

80% s/a only

32% additional history of           physical abuse

Type of S/A

44%     vaginal/anal             intercourse

35%     digital./object             penetration

 

32%     vaginal/anal

            intercourse

8%       digital./object

            penetration

 

N/A

35%     vaginal/anal

            intercourse

14%     digital./object

            penetration

16%     fondling alone

 

References:

Achenbach, T.M. (1991a). Manual for the Child Behavior Checklist/4-18 and 1991 Profile. Burlington, VT: University of Vermont Department of Psychiatry.

Achenbach, T.M. (1991b). Manual for the Teacher’s Report From and 1991 Profile. Burlington, VT: University of Vermont Department of Psychiatry.

Briere, J. (1996). Trauma Symptom Checklist for Children-professional manual. Odessa, FL: Psychological Assessment Resources, Inc.

Chaffin, M. & Shultz, S.K. (2001). Psychometric evaluation of the Children’s Impact of Traumatic Events Scale-Revised. Child Abuse and Neglect, 25, 401-411.

Crouch, J.L., Smith, D.W., Ezzell, C.E., & Saunders (1999). Measuring reactions to sexual trauma among children: Comparing the Children’s Impact of Traumatic Events Scale and the Trauma Symptom Checklist for Children. Child Maltreatment, 4, 255-263.

Friedrich, W.N., Grambsch, P., Koverola, C., Hewitt, S., Damon, L., Lang, R., & Wolfe, V.V. (1990). The Child Sexual Behavior Inventory: A comparison of normal and clinical populations. Paper presented at the meeting of the National Symposium on Child Victimization, Atlanta.

Harter, S. (1985). Manual for the Social Support Scale for Children. Denver, CO: University of Denver.

Hudson, W.W. (1982). One Clinical Measurement Package: A field manual. Homewood, IL: Dorsey Press.

Kaslow, N.J., Tannenbaum, R.L., & Seligman, M.E.P. (1978). The KASTAN-R: A Children’s Attributional Style Questionnaire (KASTAN-R CASQ). Unpublished manuscript. University of Pennsylvania.

Reich, W., & Shayka, J.J. (1991). The Diagnostic Interview for Children and Adolescents-Revised. St. Louis, MO: Department of Psychiatry, Washington University.

Runyon, D.K., Hunter, W.M., Everson, M.D., & DeVos, E. (1992). Maternal support for child victims of sexual abuse: determinants and implications (final report). Washington, DC: National Clearinghouse on Child Abuse and Neglect.

Wolfe, V.V., Gentile, C., Michienzi, T., Sas, L., & Wolfe, D.A. (1991). The Children’s Impact of Traumatic Events Scale: a measure of post-sexual abuse PTSD symptoms. Behavioral Assessment, 13, 159-383.

Wolfe, V.V., & Wolfe, D.A. (1986). The Sexual Abuse Fear Evaluation (SAFE): a subscale for the Fear Survey Schedule for Children-Revised. Unpublished questionnaire. University of Western Ontario, London, Ontario.

APPENDIX I

Glossary of Test Acronyms

CAF                        Child’s Attitude Toward Father (Hudson, 1982)

CAM                       Child’s Attitude Toward Mother (Hudson, 1982)

CBCL                      Child Behavior Checklist (Achenbach 1991a).

CSBI                        Child Sexual Behavior Inventory (Friedrich, et al., 1990).

DICA-R                    Diagnostic Interview for Children and Adolescents-Revised (Reich & Shayka, 1991)

IPF                            Index of Parental Attitudes (Hudson, 1982)

KASTAN Attributional Style Questionnaire for Children (Kaslow, Tannenbaum & Seligman, 1978)

PRADS                     Parental Response to Abuse Disclosure (Runyon, Hunter, Everson, & DeVos, 1992).

SAFE                        Sexual Abuse Fear Evaluation Subscale (Wolfe & Wolfe, 1986)

SSSC                        Social Support Scale for Children (Harter, 1985)

TRF                           Teacher Rating Form (Achenbach, 1991b)

TSCC                        Trauma Symptom Checklist for Children (Briere, 1996)

 

See here for questionnaire availability

Above written by: Ms. Gabbie Unsworth

Reviewed, edited and approved by: Dr. Grant J. Devilly