Can we develop a more effective and widely accessible screening

In Chapter 5 we described a study where we developed and validated a novel screening tool of family aggression – in other words, exposure to physical abuse,

emotional abuse and intimate partner violence (IPV). The Family Aggression Screening Tool (FAST) features three key advantages. First, it enables to detect both experiences of direct victimization and exposure to IPV. Second, it records information about the characteristics of family aggression, including the identity of perpetrator and victim, as well as the directionality of aggression between family members. Third, the FAST is the first instrument, to our knowledge, to screen for experiences of family aggression making use of non-verbal pictorial representations, making it easily understood and widely accessible to a range of populations. In addition, the FAST is freely available and quick to complete. In order to establish its utility as a screening tool, we examined four psychometric properties. Overall, findings from this study provided initial support for the reliability, validity and diagnostic accuracy of the FAST in detecting multiple forms of family aggression.

With regards to reliability, we found that the FAST showed good internal consistency. Correlations indicated that the FAST subscales were distinct from one another but also related. These findings are consistent previous evidence documenting

149 the considerable overlap between experiences of direct victimization and IPV exposure (Hamby et al., 2010; Holt et al., 2008). We then examined associations between the FAST and the Childhood Trauma Questionnaire (CTQ, Bernstein & Fink, 1998), in order to establish convergent validity. We found that the FAST and CTQ were highly associated, suggesting that they measure largely overlapping constructs. This was particularly noteworthy, given the limited number of corresponding scales between these two instruments and the use of markedly different approaches to assess childhood experiences (i.e. verbal versus pictorial). In line with expectations, associations between corresponding scales on the FAST and CTQ were stronger than those found between non-corresponding scales, supporting the ability of the FAST to discriminate between forms of family aggression. Importantly, the strength of associations observed was comparable to that reported in studies validating other self-report verbal instruments of maltreatment using the CTQ (e.g. DiLillo et al., 2010; Lobbestael et al., 2009).

Concurrent validity of the FAST was supported by significant associations with multi-informant reports of psychiatric symptomatology. More specifically, the FAST subscales were positively associated with increased psychiatric symptoms across domains of internalizing, externalizing difficulties and trauma-related symptomatology. Interestingly, we found that emotional victimization was the strongest correlate of symptom severity across the majority of psychiatric domains, both self- and other- report. These findings are consistent with those reported in Chapter 3, where emotional abuse (as measured by the CTQ) emerged as the most powerful predictor of mental health outcomes. Together, findings point to the need for increased recognition of emotional abuse within research, legal and clinical settings.

Finally, we examined diagnostic accuracy of the emotional and physical

victimization FAST subscales using the CTQ as the validity criterion. Other subscales of the FAST could not be tested for diagnostic accuracy, as they did not directly correspond with the CTQ. Using the area under the curve (AUC) statistic, we found a highly significant support for the scales’ ability to detect experiences of emotional and physical victimization (i.e. good overall diagnostic accuracy). We then selected cut-offs for each scale that provided the best trade-off between sensitivity and specificity. These cut-offs demonstrated adequate sensitivity in correctly classifying youth who had experienced aggression, and excellent specificity in correctly identifying those who had little or no experience of it. Classifications based on the FAST and CTQ cut-offs were highly concordant (i.e. high agreement between classification systems).

150 Together, preliminary findings indicate that the FAST is a valid and reliable non- verbal measure of family aggression. As such, the FAST has the potential to be widely applicable in both research and clinical settings. By recording both experience of direct victimization and IPV exposure, the FAST may be used in research to investigate how different forms of family aggression affect developmental outcomes, individually and in combination. As a screening tool, the FAST can be used to obtain a ‘snapshot’ of family aggression patterns, and inform the need of more comprehensive follow-up assessments. Due to sample size limitations, it was unfortunately not possible to examine the specific characteristics of family aggression recorded by the FAST. Future studies will be needed to test whether these characteristics may be clinically useful for informing risk assessment and treatment formulation. Finally, because of its non-verbal format, the FAST may be particularly accessible to traditionally ‘difficult-to-screen’ populations, including individuals with reading difficulties, non-English speakers and younger respondents. In future, it will be important to validate the applicability of the FAST with these populations. The use of pictorial representations may also provide a means for clinicians to initiate a dialogue about experiences of family aggression in a way that is potentially less invasive than verbal screening tools.

In summary, the findings described in Chapter 5 provide initial support for the

reliability, validity and diagnostic accuracy of the FAST in detecting multiple forms of family aggression. Although future studies will be needed to establish the full

psychometric properties of the FAST using a range of different validation measures as well as examining its application to different populations, this measure shows promise as a non-verbal tool for the rapid detection of family aggression.