Introducing the early trauma inventory self report - Short form and its qualitative and quantitative validation for the Slovenian general population

According to the Diagnostic and Statistical Manual of Mental Disorders V, childhood trauma is defined as exposure to actual or threatened death, serious injury, or sexual violence (1). It has a significant impact on the development of chronic mental and physical conditions in adulthood, which results in increased use of medical services, especially emergency units (2, 3, 4). Childhood trauma is also associated with impaired psycho-social functioning and lower quality of life (2). Experiencing childhood trauma compromises both neural structure and function, rendering individuals susceptible to later cognitive deficits and psychiatric illnesses, such as schizophrenia, depression, bipolar disorder, anxiety, posttraumatic stress disorder (PTSD), substance abuse, and even suicide, in adolescence, young adulthood or later life (5, 6). Somatoform symptoms, which may relate to other psychological consequences of trauma, such as depression, anxiety, dissociation, and PTSD, are also linked to traumatic exposure (7). Stress is associated with a multiple immune and endocrine changes (8). Exposure to multiple and chronic stressors represents a particular risk for asthma, environmental sensitivity in the form of allergies to medications, cardiovascular health, gastrointestinal problems and migraine headaches (2, 4, 8, 9). The more severe the abuse is, the stronger is the association with poor outcomes in adulthood (3). Psychosomatic disorders, which in family practice are also called medically unexplained symptoms (MUS), are frequently associated with a history of traumatization (10). In a Slovenian family medicine practice it was found that 8.6% of patients had MUS attendees (11). A recent study by the Slovenian National Institute of Public Health showed that 76% of participants reported at least one and 27% four or more traumatic experiences in childhood (12). These are important findings for both psychiatrists and primary care physicians (9). To better understand patients’ symptoms, it is important for health professionals to have a structured and comprehensive tool for measuring traumatic events in childhood (13). One of these is the Early Trauma Inventory (ETI) (14), created by Bremner et al. as a comprehensive expert-rated interview. A self-rated version (ETI-SR) was later developed and briefer self-rated short form (ETISR-SF) was made after a psychometric analysis identified redundant items (15). The ETISR-SF has been proven to be a valid instrument for retrospective self-assessment of childhood trauma in diverse populations (subjects with substance use disorders, war veterans, depressive patients and puerperae) (15, 16, 17, 18, 19), and has good test-retest reliability (17, 18, 19). It consists of 27 items in the four domains of physical, emotional, sexual abuse, and general trauma (15). It categorically assesses the existence of these events before the age of 18 (15).

The ETISR-SF has been translated with preserved psychometric properties to several cultural contexts and languages, including: Spanish (17), Korean (18), Brazilian Portuguese (19), Dutch (20) and Swedish (21). However, to the best of our knowledge, it has not yet been translated or psychometrically tested with regard to Slovenian. The benefits of this instrument lay in early, quick and economical screening for traumatic experiences, which could enable health care professionals to prevent more serious health and social consequences and also spare the system some costs due to unnecessary and often invasive diagnostic procedures. This represents a major advantage for the public health system, and gives a starting point for more in-depth exploration in clinical-therapeutic practice and research work.

In this paper, we wanted to validate a Slovenian version of ETISR-SF and it was done in two parts, using both qualitative and quantitative methods.

The qualitative part of the study obtained semantic, cultural and conceptual translation and equivalence of ETISR-SF questionnaire in Slovenian using the Delphi method (Tables 1-5). Consensus was reached in the second round with minor adjustments (Table 6).

In the quantitative part of the study we examined the psychometric properties in clinical and non-clinical samples. The clinical sample was composed of in-hospital patients with substance use disorders (Table 7).

The ETISR-SF results showed statistically significant differences between these two groups, which is an indicator of discriminant validity. Patients with substance use disorders reported more traumatic events than the healthy control group, especially in the domains of general trauma and emotional abuse (Table 8). This was supported by comparing respondents experiencing extreme fear or out-of-body experiences and those without such feelings, which represent emotional responses to traumatic events (Table 9). More reported traumatic events in all domains were statistically significant related to emotional responses. The results from a study by Brajovic et al. showed that physical abuse is more strongly associated with alcohol use patterns than emotional abuse (25). Persons who had experienced four or more categories of childhood exposure to traumatic events, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempts, as well as 2- to 4-fold increases in smoking and poor self-rated health (26). The number of traumatic exposures showed a graded relationship to the presence of adult diseases, including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease (26). The Adverse Childhood Experiences (ACE) Study suggested that the impact of adverse childhood experiences on adult health status is strong and cumulative (26). Secondary prevention of the effects of adverse childhood experiences will first require increased recognition of their occurrence, and then effective understanding of the behavioural coping devices that are commonly adopted to reduce the emotional impact of these experiences (26).

The second psychometric property was reliability. Cronbach’s alpha, as a measure of internal consistency, varied among the different domains. The general trauma and physical abuse domains exhibited lower internal consistency (α=0.64 and α=0.60, respectively) than emotional and sexual abuse (α=0.85 and α=0.82, respectively) (Table 10). Values were lower than those reported in other studies (15, 18, 19, 21) and similar for a Spanish version used with postpartum women (17). In the domain of general trauma, there are a few events which are obviously not typical for our cultural environment, like ”natural disaster”, ”serious illness/injury of sibling” and “saw someone murdered” (Table 11). Within the physical abuse domain there is also an event which exhibits a low correlation with the overall score and reduces the Cronbach’s alpha of the domain. Such events poorly correlate with the overall score on the scale and reduce its reliability, compared to the results found in other research, which indicate possible cultural differences in this regard. Similar findings can be found in a German validation of the inventory (27). The reliability of the scale for the domains of emotional and sexual abuse is very strong. Moreover, the values of the Cronbach’s alpha coefficient are not problematic, and we have thus decided not to exclude items in order to maintain comparability of the questionnaire with other countries.

The test-retest reliability of the Slovenian version of the ETISR-SF is high for all subscales, with correlation coefficients ranging from 0.82 to 0.96 (Table 10). A graphical exploration of the test-retest reliability via a Bland-Altmen plot also indicates high measurement stability on all subscales (Figure 1). That indicates the temporal stability of the measurement, which we want in practice. Similar findings were reported in other countries (17, 19, 21).

Figure 1

Our findings showed that the Slovenian version of the ETISR-SF is a satisfactory instrument for the evaluation of childhood physical, emotional, and sexual abuse, as well as general trauma.

Traumatic experiences in childhood represent an important public health problem that has become a global epidemic in modern times. The consequences of early traumatic experiences can be indicated as psychosomatic and somatoform disorders, causing unnecessary, expensive and invasive diagnostics, and loss of time for starting proper treatment. Therefore, we urgently need a quick and economic measurement tool for early screening of traumatic events in childhood for use in the primary health care system. Such a tool would enable health care professionals to optimize the diagnostic process and refer patients to therapeutic and/or psychiatric treatment in a timely manner.