The results of this set of analyses indicate that histories of childhood adversity obtained retrospectively from psychosis patients showed evidence of reasonable reliability and comparability in this sample. Specifically, it has been demonstrated that (i) reports of adversity are fairly stable over a long period of time (test-retest reliability), (ii) current psychopathology does not appear to measurably influence the likelihood of reporting childhood abuse, (iii) reports of antipathy and neglect are similar when obtained by different assessment instruments (concurrent validity), and (iv) childhood abuse documented in clinical case notes is also self-reported on a questionnaire (convergent validity).
The consistency in reporting on the CECA.Q and PBI is in keeping with previous studies in depressed samples. These have demonstrated high levels of agreement between the CECA.Q antipathy and neglect subscale scores and the PBI care and protection (antipathy only) scores.23,29
The current study confirms that this can be extended to psychosis patients, at least in this sample.
The reasonably large proportion of case subjects whose abuse was not documented in their case notes despite being reported on the CECA.Q is not surprising given previous research in this area.33,34
To a degree, this discrepancy may be inevitable given that the specific questions asked during the CECA.Q were more likely to have elicited abusive experiences than the potentially more general questions involved in obtaining a clinical history. It is not possible to determine if this was actually the case as clinicians did not document exactly what they asked patients rather just what the responses were. Nevertheless, failure to inquire about abusive experiences has been shown to be common among clinicians.34–38
This is particularly the case when patients are severely disturbed18
as many of those in the current study would have been during their initial presentation to services for psychosis. Moreover, as clinicians usually have a professional duty to report disclosures of childhood abuse to social services or the police, patients may be less likely to tell them about such experiences for fear that it will have legal ramifications. Despite this, mental health clinicians clearly need to inquire more frequently about childhood abuse, and there is a move in the United Kingdom to make this part of all routine psychiatric assessments.39
Previous studies have also demonstrated that reports of childhood abuse by adult psychiatric patients are reasonably reliable over time,40,41
and reports by those with schizophrenia have been shown to be as reliable as those made by the general population.42
The higher rate of failure to report previously disclosed abuse at 7-year follow-up than to provide new reports of abuse in the current study is consistent with findings that individuals are more likely to fail to report abusive experiences than to falsely claim that they have been abused.41,43,44
Therefore, contrary to the fears of some researchers,17,18
patients may actually be more likely to underreport instances of abuse rather than overexaggerate their occurrence.45,46
It is also possible that some individuals may actually have a greater tendency to disclose genuine abuse when actively psychotic if this is accompanied by disinhibition.
The lack of impact of current mood on reporting of childhood abuse in this sample concurs with previous findings47,48
that depression does not appear to particularly bias retrospective abuse reporting. The nonsignificant results for influence of severity of symptoms also go some way to counter claims that those experiencing acute psychosis are more prone to reporting abuse as they are detached from reality19
or confused about what is real.17
Indeed, Darves-Bornoz et al42
commented that there was no clear link between having a current diagnosis of schizophrenia and allegations of sexual abuse in their sample, inline with the findings of the present study. However, associations between severity of psychotic symptoms and reported exposure to childhood adversity might have been expected given the previous literature in this area.1
The use of total number of psychotic symptoms reported as the measure of severity in the current study rather than severity of each individual symptom may explain these discrepant findings. Additionally, the lack of overlap between symptom content and reporting of childhood abuse can also be interpreted as running contrary to previous reports that suggested a direct influence of early experiences on the content of psychotic symptoms.49
Further exploration of this issue is thus required.
This study has a number of potential methodological limitations. Firstly, the samples used in each study were subsets of the full ÆSOP epidemiological sample, and therefore, this may have introduced selection bias into the sample and potentially affected reporting of childhood adversity. However, analysis revealed that there were no significant differences between participants included in each study and those in the full sample in terms of gender, ethnicity, diagnosis distribution, or age at baseline interview. The sample employed was also reasonably modest in size and restricted to 2 catchment areas in the United Kingdom. This has potential implications for the power and generalizability of the results. Therefore, replication of these findings is required in larger samples from different geographical locations.
Moreover, as it is difficult to determine a “gold standard” criterion for establishing the accuracy of reported childhood abuse, we had to rely on making comparisons with the reports participants had provided during their baseline assessments. This is clearly a limitation of the current study, and the results of the test-retest reliability may have been affected by more acute symptoms at baseline. Nevertheless, we have shown that severity of symptoms did not increase the likelihood that case subjects would report an abusive history. Ideally, though, the validity of retrospective self-reports of childhood abuse should be established by comparison with childhood disclosures or social services’ records of corroborated abuse. However, it is probably unethical to obtain reports of abuse from children,50
and they may be likely to underreport such experiences due to the operation of defense mechanisms, such as denial, repression, or dissociation,41,51,52
or because they have been convinced by the perpetrator that it is somehow “normal” or their own fault. Thorough and repeated assessments of children's abusive experiences at regular intervals that are corroborated by family members, teachers, or doctors may overcome some of these problems.5
Additionally, the relevant approval was not available for this study to obtain corroboration of childhood abuse reports from social services’ records. Nevertheless, these would probably not have been useful anyway for the majority of cases as very few incidents of abuse are ever reported to the authorities.53
Other forms of corroboration (eg, family reports, documentation by different professionals)41,54
have been shown to be useful in previous studies and should therefore be included in future research.
Finally, this study focused only on specific forms of reliability and validity. Information was not available to explore the potential impact of long-term memory impairment on encoding, retrieval, and recall of childhood abuse;16
previous disclosure of abuse;55
discussion or rehearsal of the events;56
interpretative influence of parents or perpetrators of abuse;57
or past depression.58
Nevertheless, most of these would be anticipated to be likely to lead to underreporting of abuse and more conservative prevalence estimates.
In conclusion, the findings reported in this article provide further evidence that retrospective self-reports of childhood adversity by psychosis patients can be considered to be reasonably reliable. Consequently, this method of data collection is justified in future evaluations of childhood adversity in psychotic populations. However, such studies should also use comprehensive measurement tools that assess severity, frequency, and timing of adversity and rely on investigator-based judgments of abuse based on concrete examples rather than subjective interpretation.5