AN ANALYSIS OF COPING RESOURCES, TRAUMA AND SIGNIFICANT LIFE EVENTS IN A SAMPLE OF FEMALE PRISONERS

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1 AN ANALYSIS OF COPING RESOURCES, TRAUMA AND SIGNIFICANT LIFE EVENTS IN A SAMPLE OF FEMALE PRISONERS Jacinta Pollard and Deli Baker Caraniche Pty Ltd, Vic Paper presented at the Women in Corrections: Staff and Clients Conference convened by the Australian Institute of Criminology in conjunction with the Department for Correctional Services SA and held in Adelaide, 31 October 1 November 2000

2 Abstract Research and experience with drug abusing female offenders indicates that the issues underlying drug taking often stem from experiences of physical, emotional and or sexual abuse (Mullen 1993). These experiences may lead to a cycle of trauma and loss which perpetuate self destructive behaviour and may impede the development of social, cognitive and emotional coping skills (Harris 1983). This paper explores the relationship between experiences of abuse, current trauma symptoms and the coping skills of 70 women prisoners. The data was collected as part of Caraniche's drug and alcohol service delivery at the Metropolitan Women's Correctional Centre (MWCC) in Victoria. As part of a clinical interview the women were asked to complete the Caraniche Self Report Questionnaire (SRQ), the Coping Resources Inventory (CRI; Hammer, 1983) and the Trauma Symptom Inventory (TSI; Briere, 1995). Among our findings are that this sample of women prisoners report high levels of physical, emotional and sexual abuse in childhood and adolescence. Their results on the TSI indicate that they continue to experience very high levels of post traumatic stress and that their coping skills are lower than the general population. Background The small population of women prisoners and their comparatively short length of sentence has meant that until recently very little research was been conducted into the life history, problems and treatment needs of female prisoners (Keaveny & Zauszniewski, 1999). Over the past decade, the research that has been conducted has highlighted several important issues. Women prisoners have high rates of drug and alcohol abuse, they report high levels of physical, sexual and emotional abuse, psychiatric disturbance and experience significant levels of stress. A 1996 study of the women in Fairlea Prison, Victoria found that 81% reported using drugs other than for medical reasons and 63% reported some form of abuse in childhood. Abuse in childhood was found to be related to poor coping, low self esteem and self destructive behaviour including drug use, self harm and suicide (Jonas, Morison & Kutin, 1994). Keaveny & Zauszniewski (1999) found that female prisoners experienced high levels of stress and significant life events characterised by loss in the 12 months prior to incarceration that were related to their psychological well being and feelings of depression. Teplin, Abram and McClelland (1996) found that amongst women awaiting trial more than three quarters had a psychiatric diagnosis. These included: drug abuse (52%), alcohol dependence (24%), and depression (14%) and almost a quarter suffered Post traumatic Stress Disorder. The connections between abuse in childhood, poor coping and drug use or other psychiatric disturbance are well established. Early experiences of abuse are known to have multiple deleterious effects such as affective disorders, posttraumatic stress and disturbed interpersonal relationships (Drauker, 1995). Experiences of abuse disrupt the development of coping skills and promote the development of avoidant strategies, such as drug use (Briere, 1996). This can lead to a cycle of trauma and loss perpetuating self-destructive behaviour (Mullen, 1993). A child who experiences extreme physical abuse or sexual abuse has few coping mechanisms at his or her disposal to assist them to understand and integrate the experience. In the absence of effective coping skills, the child's only option for psychologically surviving the abuse is to dissociate or shut off the experience from their consciousness. In dissociating, the child alters the normal links between thoughts, feelings and memories (Briere, 1992) and decreases awareness of, or numbs the pain of distressing events (Putnam, 1985). Dissociation is commonly referred to as being "spaced out", blocking things out and being out of touch 2

3 with one s emotions. The tendency to dissociate remains with the child as he/she grows into adulthood and impairs the development of adaptive social, cognitive, and emotional coping mechanisms as well as the sense of self and self identity required for the successful negotiation of life difficulties (Briere, 1996; Harris, 1983). This impairment in self functioning places individuals at risk for being overwhelmed by stress and trauma promoting further avoidant behaviours such as drug taking. Female prisoners typically report comparatively high levels of abuse in childhood, drug use in their early adolescence and continuing experiences of abuse in adulthood. (Blankfield, 1991; Inciardi, 1987; Denton, 1994). Whilst their drug taking is often initiated by trauma it is maintained by a lack of effective coping skills and strategies which leave them individual at risk of further trauma and increased drug use. This explains the cycle of trauma, drug use, crime and imprisonment frequently experienced by women prisoners. This paper aims to increase the understanding of the effects of trauma on the current functioning and coping skills of women prisoners. It examines the life histories of the women, particularly their experiences of trauma and abuse and looks at their current experiences of trauma symptoms and coping resources. It also includes an initial examination of the trauma symptoms of women experiencing different types of childhood abuse comparing those reporting physical, sexual and emotional abuse and the relationship between suicide attempts and trauma. Design & Method Participants The participants consist of a sample of 70 women who were received into MWCC during 1997 or 1998 and had greater than 3 months of sentence. The sample ranged in age from 16 to 47 years with a mean age of 27 years. Most of the sample (90%) report Australia as their country of origin and 14% speak a language other than English. Almost three quarters of the sample obtained year 10 level education or less and almost 80% of the sample reported that they were not working prior to entering prison. Materials Caraniche Self Report Questionnaire (SRQ) The Self-Report Questionnaire (SRQ) was developed by Caraniche staff to explore the demographic, crime, substance and family backgrounds of participants. The SRQ also contains items regarding the women s exposure to potentially traumatising experiences such as being emotionally, physically or sexually abused, being adopted, experiencing miscarriage and self-reports of suicide attempts. The SRQ consists of open and closed questions regarding the following domains: Demographic including questions about age, country of origin, marital status, highest level of education reached and brief employment history. Criminal History including age of first arrest, current minimum sentence, nature of crime(s). Drug and Alcohol History including age of first use of various substances including alcohol, stimulants, opiates (a drug class including heroin) or methadone as well as prescription medications such as benzodiazepines (tranquillisers), pain killers, and antidepressants. 3

4 General & Personal History including questions about family at different times (eg., during childhood, adolescence, and adulthood) or whether participants were adopted or ever lived in foster care. Participants were asked if they ever deliberately hurt or injured themselves or ever attempted suicide. They were also asked if they were ever the subject of abuse. Abuse was defined in the following ways: Physical abuse could range from slaps to pinching, punching, kicking and throwing as well as the use of items to inflict physical pain. Emotional abuse may constitute minds games, put downs, threats and isolation. Sexual abuse could range from nudity (exposure), sexually explicit comments, to sexual touching or intercourse. Trauma Symptom Inventory (TSI) The Trauma Symptom Inventory (TSI) is a 100 item, clinical instrument for evaluating chronic and acute trauma symptomatology. These may include but are not limited to the effects of rape, spouse abuse, physical assault and major accidents as well as the lasting sequelae of childhood abuse and other early traumatic events (Briere, 1995). The TSI is a widely used standardized tool with gender norms for non-clinical samples. The TSI comprises three validity scales and ten clinical scales. The validity scales provide an indication of the validity of responses and how confidently they can be interpreted. The three validity scales are: Response level - High scores suggest a tendency toward defensiveness or under endorsement of symptoms (faking good). Atypical Response - consists of unusual and bizarre items such as Feeling paralyzed for a minute at a time. High scores may reflect psychosis, extreme distress or a general over endorsement of symptoms in order to appear especially disturbed (faking bad). Inconsistent response - the sum of the difference on 10 item pairs -questions most likely to be endorsed consistently. High scores may represent inconsistent responses, be they random or caused by attention, concentration or reading/language difficulties. The ten clinical scales provide a measure of current trauma symptoms. They are: Anxious Arousal (AA) - measuring symptoms of anxiety, especially those associated with posttraumatic hyperarousal (eg., feeling jumpy ). Depression (D) - measures depressive symptomatology, both mood states (eg., sadness) and depressive cognitive distortions (eg.,hopelessness). Anger/Irritability (AI) - self reported anger or irritability and associated angry cognition s and behaviour. Intrusive experiences (IE) - measures intrusive symptoms associated with posttraumatic stress (eg., flashbacks, nightmares). Defensive avoidance (DA) -measures posttraumatic avoidance, both cognitive (eg., pushing painful memories away) and behaviour (avoiding stimuli reminiscent of trauma). Dissociation (DIS) - measures dissociative symptomatology such as depersonalization, derealization (like in a dream) and psychic numbing (not feeling emotions). Sexual concerns (SC) - measuring reported sexual distress like dissatisfaction or unwanted sexual thoughts. 4

5 Dysfunctional sexual behaviour (DSB) - measuring in problematic sexual behaviour (eg., harmful, indiscriminate, inappropriate). Impaired self reference (ISR) - measures problems in the self domain such as identity confusion (eg., feeling empty inside ). Tension reduction behaviour (TRB) - measuring tendencies toward external methods of reducing inner symptoms of distress (eg., self mutilation, angry outbursts and suicide threats). Coping Resources Inventory (CRI) The 60-item Coping Resources Inventory (Hammer, 1983) is designed to identify the personal coping resources available to individuals for managing stress at a particular point in time. It is an instrument with demonstrated reliability and validity in addition to being gender normed. For each item in the inventory the prisoner has to indicate how representative the statement is of them in the last 6 months with N=never or rarely, S=sometimes, O=often and A=always or almost always. The responses are then grouped and profiled according to one of five domains: Cognitive, Social, Emotional, Spiritual/Philosophical and Physical. Definitions for each of these domains are as follows: Cognitive -The extent to which individuals maintain a positive sense of self-worth, a positiveoutlook towards others, and optimism in general (eg., I feel as worthwhile as anyone else.) Social - The degree to which individuals are embedded in a social network able to provide support in times of stress. (eg., I am part of a group, other than my family, that cares about me. ) Emotional - The degree to which individuals are able to accept and express a range of affect, aiding the amelioration of long term negative consequences (eg., I can cry when sad ). Spiritual - The degree to which actions of individuals are guided by stable and consistent values such as those derived from religious, familial or cultural traditions or personal philosophies. (eg., I know what is important in life ). Physical - The degree to which individuals enact health-promoting behaviours thought to improve physical well-being (eg., I exercise vigorously 3-4 times a week ). Procedure The SRQ, TSI and CRI were administered to all prisoners with a sentence of longer than 3 months. They were administered to individual prisoners under the supervision of a psychologist in the course of a clinical interview used for the purposes of developing a treatment plan. The data was coded into an SPSS database and analyzed using SPSS. Results Personal Histories Table 1 shows the percentage of prisoners experiencing significant events in their personal histories. A significant minority report a disrupted childhood and family of orison. 41% of the womens' parents separated during their childhood or adolescence, with 21% being placed in foster care as children and 12% place in foster care as adolescents. Over half the prisoners reported drug or alcohol problems in their family of origin. 5

6 Table 1 - Percentage of prisoners reporting significant events in their personal history. Personal History % Family of origin D&A problems Parental separation Foster care in childhood/adolescence Adopted Relationships Currently in a married or defacto relationship Divorced or separated Most recent partner had D&A problems Pregnancy & children Have children Miscarriage (teens) Abortions A quarter of the women report never having been married or in a defacto relationship, 45% report being married or in a defacto relationship and 20% report being separated divorced or widowed. 65% reported that their most recent partner had a drug or alcohol problem. More than half the women (57%) have children. Criminal Histories Table 2 shows data regarding the criminal histories of the women. Based on the self report of the women, the majority (52%) were currently serving sentences of less than 1 year. Their current offences were predominantly property crimes (41%), with violent crimes (8%), drug related crimes (14%) and 23% committing a combination of offences and 13% other. More than a third (35%) of the sample are serving their first jail term, but 28% have served more than three sentences. Age of first arrest ranges from 9 to 42 with an average of 18 years, 51% were first arrested before the age of 16. More than a quarter of the sample reporting having been in a Youth Training Centre (YTC). First arrested at 16 years or less Sentenced to YTC On first sentence Three or more times in prison Current Offence Homicide Assault Property Drugs Other Current sentence less than 1 year Table 2 - Criminal history data Criminal History %

7 Substance abuse The womens' self reported history of substance use is shown in Table 3. More than half (53.5%) of the sample report coming from a family where alcohol was a problem and almost a third (30%) report having an alcohol problem themselves. Table 3 - Substance use data Drug & Alcohol History % Alcohol problem Drug use Ever prescribed methadone Currently prescribed medication Anti depressants Tranquilizers Pain killers Combination Began using marijuana before age 15 Began using opiates before age 15 The vast majority (93%) of the women admitted to using drugs. Their drug use commenced relatively early with 73% using marijuana by the age of 15, 56% using inhalants, 45% using stimulants, 31% using hallucinogens and 29% using opiates by this age. 55% reported being prescribed methadone in then past and 24% were on methadone at the time of filling in the questionnaire. A large proportion (80%) of participants reported being on prescription medications including anti-depressants, tranquillisers and combinations of medications whilst in prison. Psychological Problems The self report of the women indicates a long history of psychological difficulties with adolescence being a particularly difficult time. In adolescence, 28% self harmed, 35% attempted suicide and 23% had an eating disorder. In adulthood, 33% have or had eating disorders, 32% self harmed and 26% had attempted suicide. The majority of the women (70%) reported that they had psychological problems

8 Table 4- Percentage of prisoners reporting psychological problems Psychological Problems % Eating disorder in teens Eating disorder in adulthood Suicide attempt in teens Suicide attempt in adulthood Self harm in teens Self harm in adulthood Psychological problems in adulthood Experiences of Trauma & Abuse More than three quarters (76%) of the sample reported having experienced some form of abuse in childhood or adolescence. As can be seen from Table 5, more than half (52.2%) of the participants report experiencing physical abuse during childhood or adolescence. This was most often at the hands of a parent although in adolescence it was also at the hand of their partners. Table 5. Frequency and percentage of participants reporting whether physically abused between age 0 & 18 years Yes No Total Frequency Percent 52.9 % 47.1 % 100 % Table 6 shows that two thirds (66.2%) of the women in the study report being the victim of emotional abuse during childhood or adolescence. Again emotional abuse was most often by parents, but later it was also perpetrated by partners. Table 6. Frequency and percentage of participants reporting whether emotionally abused between age 0 & 18 years. Yes No Total Frequency Percent 66.2 % 33.8 % 100 % Table 7. below reveals that more than a third (38%) of the women participating in this study report being sexually abused prior to age 18, with 31% of the sample reporting that their sexual abuse began before the age of 12. 8% reported being sexually abused by a parent, 4% by a step parent and 13% by another family member. 13% were sexually abused by a stranger and 33% by an acquaintance. 8

9 Table7. Frequency and percentage of participants reporting whether sexually abused between age 0 & 18 years. Yes No Total Trauma Symptom Inventory Frequency Percent 37.7 % 62.3 % 100 % Figure 1 plots the sample group's mean scores on the Trauma Symptom Inventory. The standard mean score for the TSI is 50 and is represented on the TSI profile by lower horizontal line. The second horizontal line (T=65) represents 1.5 standard deviations above the mean. For clinical purposes any T score that is over 65 is significant. The group mean scores on the validity subscales all fell within acceptable limits Atypical Response (T=69), Response Level (T=44) and Inconsistent Response (T=49). The group profile indicates some atypical responding but this is not high enough to make the data invalid, the low scores on both Response Level and Inconsistent Response scales indicate that the women were neither minimizing or inconsistent in their report of symptoms. All the clinical sub-scales exceed 50, this indicates that the prisoners have a higher level of trauma symptoms in all sub-scale areas than the general population. Of particular interest are the group mean scores which have a T score over 65 which indicates that the women have clinically significant symptoms in these areas. These subscales were Depression, Defensive Avoidance and Dissociation. These clinical scales indicate that the women are generally depressed and are likely to feel worthless and hopeless about the future. The Defensive Avoidance score indicates that the women tend to try and avoid or escape negative thoughts and feelings and suggests that one reason for the high level of illicit drug use and medication amongst the women is to the avoid of painful thoughts and feelings. The Dissociation score indicates that the women unconsciously separate off parts of their experience because it is too traumatic or overwhelming. Dissociative experiences include: depersonalization, derealization and emotional numbing. Notably high scores were also achieved on Anxious Avoidance (T=63), Intrusive Experiences (T=64), Impaired Self Reference (T=64) and Tension Reduction Behaviours (T=64). These scales indicate high levels of anxiety, flashback, intrusive thoughts or nightmares relating to traumatic experiences, impaired sense of self and identity confusion and a tendency to act out negative feeling states. The Depression score combined with the above average (T=64) score on Tension Reduction Behaviour indicates risk of suicidal behaviour. 9

10 Figure 1. Trauma Symptom Inventory profile form showing group mean scores. TSI Scores and Experiences of Abuse Preliminary analyses were conducted on the TSI scores of women reporting different forms of abuse ie: physical, sexual and emotional abuse in childhood or adolescence. In these analyses women reporting experiences of a form of abuse were compared with those women not reporting that experience of abuse, they may however have experienced a different form of abuse which potentially distorts the data. Women who reported being physically abused scored significantly higher on Intrusive Experiences (t(67)=2.13, p. <.05); and Dissociation (t(67)=2.00, p. <.05) than those women who did not report physical abuse. This indicates that women who have been physically abused are more likely to experience intrusive thoughts or flashbacks and have learnt to split off aspects of their experiences in order to cope. Women who reported being emotionally abused scored significantly higher on Anxious Arousal (t(68)=2.68, p. <.01); Depression (t(68)=3.02, p. <.01); Anger/Irritability (t(67)=2.18, p. <.05); Intrusive Experiences (t(68)=3.27, p. <.01); Dissociation (t(68)=3.19, p. <.01); Dysfunctional Sexual Behaviour (t(68)=2.57, p. <.05); Impaired Self Reference (t(68)=3.0, p. 10

11 <.01);and Tension Reduction Behaviour (t(67)=2.93, p. <.01) than those women not reporting emotional abuse. Emotional abuse accompanies both physical and sexual abuse, so the group of women reporting emotional abuse are likely to have also experienced these other forms of abuse as well. This makes it impossible to make clear statements about the effects of emotional abuse in isolation from this data. Women who reported being sexually abused scored significantly higher on Anxious Arousal (t(66)=2.61, p. <.01); Depression (t(66)=2.25, p. <.05); Dysfunctional Sexual Behaviour (t(66)=2.59, p. <.05); Impaired Self Reference (t(66)=3.63, p. <.001); Sexual Concerns (t(66)=3.28, p. <.01); and Tension Reduction Behaviour (t(66)=2.28, p. <.05). In this comparison the women reporting sexual abuse were being compared with women who had not experienced abuse or had experienced physical or emotional abuse. Based upon this data the women who experienced childhood sexual abuse are more likely to feel anxious and depressed, have a poorer sense of self or identity and are more likely to express or act out their distress through self harm, aggression or suicide. Those women reporting sexual abuse also experience more distress and dysfunction in their sexual behaviour and are more likely to engage in problematic sexual behaviour than those women not reporting experiences of sexual abuse. The combination of the elevated Tension Reduction Behaviours, Impaired Self Reference and Dysfunctional Sexual Behaviour scales is commonly associated with personality disorder. Coping Resources Inventory The standard mean score for the CRI scale is 50 with a standard deviation of 10 and 95% of the normal population will have a score between 30 and 70. As can be seen from Figure 2, the group mean scores on all subscales of the CRI fall in the lowest 40% of the normative sample. This indicates that the women have poorer coping skills than most women and that the women prisoners sampled generally have lower self worth, a more negative outlook, less social support, more difficulty expressing emotion, lack a set of values or sense of direction and are less likely to engage in health promoting behaviours. Discussion Table 8 - The group mean scores on the Coping Resources Inventory CRI Normative Prisoners group mean Scale Sample Cognitive Social Emotional Spiritual Physical Total The prisoners personal history information reveals that women prisoners often come from disturbed family backgrounds with significant levels of family breakdown parental drug and alcohol use and violence. The women report comparatively high level of childhood trauma and abuse with 53% having been physically abused, 66% emotionally abused and 38% reporting sexual abuse. 11

12 The women report significant levels of psychological disturbance commencing in childhood and continuing into adulthood. In adolescence, 23% had an eating disorder, 35% attempted suicide and 28% self harmed. These rates of disturbance continued into adulthood and 70% of the women believe that they have psychological problems. The women also began offending at an early age with over half arrested for the first time before the age of 16 and 25% sentenced to YTC. Whilst 35% were first time prisoners, the majority had been imprisoned previously and 28% had had at least three prison sentences. As is common with women prisoners over half had sentences of less than 12 months and this data suggests that a significant proportion of the women were in a cycle of returning to the prison system. The majority of the women report drug or alcohol use with 93% using drugs for non-medical reasons and 30% stating they have an alcohol problem. Their drug use generally commenced at an early age with 73% using marijuana and 29% using opiates by the age of % having been prescribed methadone. Both illicit and licit drug use continues within prison. Estimates of illicit drug use are unreliable due to underreporting, despite this 14% admitted to using opiates in prison, 11% to using stimulants and 20% to sniffing inhalants and 10% to using marijuana in prison. Reports of medication provide a more accurate picture of the women's reliance on drugs and medication to cope. 80% of the women were on prescription medication at the time of interviewing. Medication included antidepressants, tranquillizers and painkillers with over half the women on a combination of medications. The high rates of medication are consist with high levels of trauma and poor coping skills. Poor coping skills across a range of domains was also indicated in the groups scores on the Coping Resources Inventory. The Trauma Symptom Inventory showed that the women as a whole experience more trauma symptoms than most women in the community and that these extend across a broad range of symptoms. In particular, women prisoners are generally anxious and depressed, have intrusive thoughts, have an impaired sense of self and are likely to externalise their distress by acting out. A significant proportion of the women are likely to have a chronic Post Traumatic Stress Disorder. An initial examination of experiences of different forms of abuse and trauma symptoms on the TSI indicated that women who have been sexually abused experience different trauma symptoms from those who have not been sexually abused. In particular they are more anxious and depressed, have a poorer sense of self or identity and are more likely to express or act out their distress through self harm, aggression or suicide. Their difficulties also extend into their sexual behaviour and are commonly associated with personality disorder. Further analysis is required to examine more closely particular experiences of abuse, trauma symptoms, drug and medication use and coping. In particular, an analysis of trauma, coping and problematic in-prison behaviours such as drug use and self harm is warranted to assist in the development of appropriate strategies for managing such behaviour. In summary, this study confirms earlier findings of high rates of trauma in the backgrounds of female prisoners, particularly of childhood physical emotional and sexual abuse, poor coping and significant trauma symptoms. The data suggests a possible link between these experiences and the use of drugs and medication to cope with trauma symptoms. More analysis is required to further examine these issues. 12

13 References Blankfield, A. (1991). Women, alcohol dependence and crime. Drug and Alcohol Dependent, 27, Bennett, G., & Rigby, K. (1991). Psychological changes during resident in rehabilitation centre for drug misuse. Drug and Alcohol Dependent, 27, Briere, J. (1992). Child abuse trauma: Theory and treatment of the lasting effects. Newbury Park, CA: Sage. Briere, J. (1995). Trauma Symptom Inventory (TSI): Professional manual. Odessa, FL: Psychological Assessment Resources Inc: Briere, J. (1996). A self-trauma model for treating adult survivors of severe child abuse. In J. Briere, L. Berliner, J. Bulkey, C. Jenny, and T. Reid (Eds.). The APSAC Handbook on child maltreatment. Newbury Park, CA: Sage. Draucker, C. (1995) A coping model for adult survivors of childhood sexual abuse. Journal of Interpersonal Violence 10 (2) Hammer, A.L. (1983). Coping Resources Inventory. Palo Alto, CA: Consulting Psychologists Press. Inciardi, J. (1987). Heroin use and street crime in C. Chambers, J. Inciardi, D. Peterson, H. Siegal, and L. White (Eds.). Chemical dependencies: Patterns costs and consequences. Athens: Ohio University Press. Jonas, A., Morison, M. & Kutin, K. (1994) Fairlea Women: Drug taking, coping resources and personal history. An unpublished report for Office of Corrections, Department of Justice, Melbourne: Victoria. Keaveny, M. & Zauszniewski, J. (1999) Life events and psychological well being in women sentenced to prison. Issues in Mental Health Nursing, 20: Mullen, P. (1993). Victimisation and development: The long term effects of child sexual abuse. Paper presented at the R.G. Myers Memorial Lecture, February 11, Australian and New Zealand Association of Psychiatry, Psychology and the Law. Temby, I. (1989). Preventing custodial deaths: A systematic approach. Australian and New Zealand Journal of Criminology, 22, Putnam, F.W. (1985). Dissociation as a response to extreme trauma. In R.P. Kluft (Ed.), Childhood antecedents of multiple personality (pp 65-97). Washington, DC: American Psychiatric Press. Pynoos, R.S. (1993). Traumatic stress and deve;opment psychopathology in children and adolescents. In R.S. Pynoos (Ed.). Post-traumatic stress disorder: A clinical review (65-98). Lutherville, MD: Sindran. 13