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Child & Youth Care ForumJournal of Research and Practice inChildren's Services ISSN 1053-1890Volume 40Number 5 Child Youth Care Forum (2011)40:345-362DOI 10.1007/s10566-010-9124-4
Assessing the Sensitivity and Specificity ofthe MAYSI-2 for Detecting Trauma amongYouth in Juvenile Detention
Patricia K. Kerig, Melissa ArnzenMoeddel & Stephen P. Becker
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ORI GIN AL PA PER
Assessing the Sensitivity and Specificity of the MAYSI-2for Detecting Trauma among Youth in JuvenileDetention
Patricia K. Kerig • Melissa Arnzen Moeddel • Stephen P. Becker
Published online: 29 September 2010� Springer Science+Business Media, LLC 2010
Abstract This study investigated the sensitivity and specificity of the most widely used
mental health screening instrument in juvenile detention, the Massachusetts Youth
Screening Instrument (MAYSI-2), for detecting trauma and symptoms of posttraumatic
stress disorder (PTSD) among detained youth. The MAYSI-2 scales measuring Substance
Use, Anger/Irritability, Depression/Anxiety, and Traumatic Experiences contributed to
the prediction of PTSD symptoms; however, only Depression/Anxiety contributed to the
prediction of associated symptoms for girls. The ROC curves technique indicated that the
Traumatic Experiences scale was a moderately accurate predictor of likely Full or Partial
PTSD but not superior to the other MAYSI-2 scales. These results suggest further work is
needed to develop measures that are sensitive to the experiences of delinquent youth with
histories of complex trauma.
Keywords PTSD � Trauma � Delinquency � Gender � Assessment
In recent years, increasing attention has been drawn to the role that trauma might play in
the developmental psychopathology of juvenile delinquency (Ford 2002; Ford et al. 2006;
Greenwald 2002; Kerig and Becker 2010). Across multiple samples and settings, research
confirms that a significant number of youth involved in the juvenile justice system report
exposure to traumatic events (e.g., Cauffman et al. 1998; Dixon et al. 2005; Ford et al.
2008b; Kerig et al. 2009; Lawyer et al. 2006; Martin et al. 2008; Steiner et al. 1997; Wood
et al. 2002). For example, Abram et al. (2004) assessed 898 youth in a short-term detention
facility and found that 93% of the boys and 84% of the girls had experienced a traumatic
P. K. Kerig (&)Department of Psychology, University of Utah, Salt Lake City, UT 84112, USAe-mail: [email protected]
M. A. Moeddel � S. P. BeckerDepartment of Psychology, Miami Unviversity, Oxford, OH 45056, USAe-mail: [email protected]
S. P. Beckere-mail: [email protected]
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life event, with the typical youth having experienced as many as 14 traumatic stressors in
his or her lifetime. Similarly Ford et al. (2008a) found that 61% of a sample of youth drawn
from a pre-trial detention center had experienced a traumatic event consistent with the
DSM-IV (American Psychiatric Association (APA) 2000) criteria. Symptoms of Post-
traumatic Stress Disorder (PTSD) also are prevalent in detained samples, with rates that are
three to eight times higher than those seen in community samples (e.g., Cauffman et al.
1998; Dixon et al. 2005; Wolpaw and Ford 2004).
Further, there is evidence from prospective longitudinal research that exposure to
trauma in early childhood is predictive of engagement in the kind of serious antisocial
behavior that leads to involvement in the juvenile justice system (e.g., Cernkovich et al.
2008; Egeland et al. 2002; Feiring et al. 2007; Lansford et al. 2007; Stewart et al. 2008;
Tyler et al. 2008; Widom et al. 2006). As Putnam (2006) suggests, trauma has significant
effects on neuropsychological and psychosocial development that in turn contribute to
difficulties in emotional, cognitive, and interpersonal functioning that increase the risk of
delinquency (Ford et al. 2006).
Given the prevalence of posttraumatic stress among juvenile justice-involved youth, and
the possible role that trauma plays in delinquent behavior, it is important to develop
strategies for identifying traumatized youth and diverting them to appropriate treatment
programs. The most widely used tool for mental health screening in juvenile justice
facilities is the Massachusetts Youth Screening Instrument (MAYSI-2; Grisso and Barnum
2006). Although the performance of specific items and scales of the MAYSI-2 has varied
in some samples (Cauffman and MacIntosh 2008; Ford et al. 2008a), the measure has
shown evidence for reliability, validity, and clinical utility in samples of detained youth
(Cauffman 2004; Goldstein et al. 2003; Grisso and Barnum 2006; Grisso and Quinlan
2005; Wasserman et al. 2005). The MAYSI-2 also includes a Traumatic Experiences (TE)
scale that was designed to assess lifetime exposure to traumatic events. Although the scale
originally was conceptualized as a screen for PTSD, and was comprised of items assessing
both trauma exposure and posttraumatic stress symptoms, factor analyses of the original
item pool showed that these items failed to cohere on a single factor. Therefore, the
developers caution that the TE scale is not intended to identify the presence of PTSD per
se, just as the other MAYSI-2 scales are designed to screen for mental health problems
rather than to correspond to any specific DSM-IV diagnosis (Grisso and Barnum 2006).
Nevertheless, the TE scale has potential utility as a ‘‘red flag’’ to alert assessors to the
possibility that a given youth has experienced the kinds of traumatic events that might be
associated with posttraumatic stress. However, in contrast to all of the other scales on the
MAYSI-2, which were validated through comparison to comparable scales on other well-
established inventories, the validity of the TE scale has not been substantiated through
comparison with any other measures. The TE scale also is the only MAYSI-2 scale with no
cutoff scores established to identify when a youth’s response indicates a need for further
assessment. Therefore, further research is needed to investigate the sensitivity and speci-
ficity of the TE scale of the MAYSI-2 as a measure for screening for the presence of
trauma and its sequelae among detained youth, and to establish potential benchmarks for
determining when a given TE score contributes to the identification of youth in need of
further mental assessment and services.
Another issue that requires attention is the possibility that trauma is a particularly salient
risk factor for the development of delinquency amongst girls (Acoca 1999; Bloom et al.
2002; Chamberlain and Moore 2002; Kerig and Becker in press). In some studies, detained
girls report exposure to more traumatic experiences and PTSD symptoms than do boys
(Belknap and Holsinger 2006; Ford et al. 2008a; Kerig et al. 2009; Martin et al. 2008;
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McCabe et al. 2002; Stewart et al. 2008), although girls are not always more likely than
boys to meet criteria for a PTSD diagnosis (e.g., Abram et al. 2004; Dembo et al. 1998;
Ford et al. 2008b). Alternatively, other research suggests that delinquent girls have been
exposed to different kinds of traumas than boys. A number of investigators have found that
girls have been exposed disproportionately to interpersonal traumas, such as abuse at the
hands of parents or romantic partners (e.g., Cauffman 2004; Chamberlain and Moore 2002;
Steiner et al. 1997; Wood et al. 2002). Gender differences are evident particularly for the
interpersonal trauma of sexual abuse, which consistently is found to be more prevalent for
delinquent girls than boys (e.g., Abram et al. 2004; Belknap and Holsinger 2006; Dembo
et al. 2007; Ford et al. 2008b; Johansson and Kempf-Leonard 2009; Kerig et al. 2009;
Tyler et al. 2008; Wareham and Dembo 2007; Wood et al. 2002). Moreover, sexual abuse
does not comprise a single event for many of these youth: for example, McCabe et al.
(2002) found that detained girls had experienced on average four sexual assaults before the
age of 12.
The importance of attending to these different kinds of traumatic experiences is that
they may be associated with different symptom constellations (Ford 2005). The DSM-IV
diagnosis of PTSD tends to focus on discrete or ‘‘Type I’’ (Terr 1991) traumas such as
natural disasters or accidents; however, the DSM-IV criteria may not capture the devel-
opmental effects of early onset, repeated, interpersonal ‘‘Type II’’ (Terr 1991) traumas
such as chronic childhood maltreatment (Cook et al. 2005; Ford 2005). This more insidious
form of trauma may result in a pervasive and persistent constellation of symptoms which
has been termed complex PTSD (Herman 1992; Ford and Courtois 2009) or Develop-
mental Trauma Disorder (van der Kolk et al. 2005). In the current DSM-IV (APA 2000),
symptoms related to Type II traumas are relegated to a section describing associated
features ‘‘more commonly seen in association with an interpersonal stressor; e.g., child-
hood sexual or physical abuse’’ (p. 425). Given the prevalence of more chronic, early-onset
traumatic experiences among detained youth, it is important to determine whether the
measures used to screen for mental health problems in detention settings are sensitive to
detecting Type II traumas and their sequelae (Ford et al. 2006, 2008a).
To summarize, the primary purpose of the present study was to investigate the sensi-
tivity and specificity of the MAYSI-2 TE scale as a screening device for detecting trauma
exposure and posttraumatic reactions among detained boys and girls. In light of research
suggesting that delinquent girls have experienced more of the kinds of interpersonal
traumas associated with complex PTSD, a second purpose of this study was to examine
possible gender differences in the relationships between the MAYSI-2 scales and measures
of PTSD and associated symptoms.
Method
Participants
Participants in this study included 498 youth remanded to the custody of a county juvenile
detention center in the Midwest. Among the 337 boys and 161 girls, 67% were of European
American descent, 23% were African American, 3% were Hispanic, 3% were multiracial,
1% were American Indian/Pacific Islander, and 0.5% were Asian. Youth ranged in age
from 12 years, 0 months to 17 years, 11 months, with an average age of 15.5. Forty
percent of the youth were charged with violent offenses, such as assault or domestic
violence, 37% were charged with non-violent offenses such as arson or theft, 8% were
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charged with sexual offenses, 8% were charged with miscellaneous offenses such as
trespassing, and 6% were charged with status offenses such as truancy or curfew violations.
Measures
Massachusetts Youth Screening Instrument—Second Version (MAYSI-2; Grisso and
Barnum 2006). Designed specifically for use in juvenile detention centers, the MAYSI-2 is
a brief self-report inventory used to screen for mental health problems among detained
youth and to serve an ‘‘alerting function’’ for juvenile justice personnel (Grisso and Bar-
num 2006, p. 38). The MAYSI-2 was designed to be administered by detention center staff
with minimal training, ideally within 24–48 h of a youth’s admission to a juvenile
detention facility. Factor analyses of the 52 items on the MAYSI-2 have confirmed 5 scales
for both boys and girls, including Alcohol/Drug Use (e.g., ‘‘Have you gotten in trouble you
when you’ve been high or have been drinking?’’), Anger-Irritability (e.g., ‘‘When you have
been mad, have you stayed mad for a long time?’’), Depression-Anxiety (e.g., ‘‘Have
nervous or worried feelings kept you from doing things you want to do?’’), Somatic
Complaints (e.g., ‘‘When you have felt nervous or anxious, has your stomach been
upset?’’), Suicide Ideation (e.g., ‘‘Have you felt like life was not worth living?’’). A sixth
scale, Thought Disturbance, has been found to form a reliable subscale only for boys and
therefore, was not included in the present study. Each MAYSI-2 scale contains 5–9 items
requiring a ‘‘yes’’ or ‘‘no’’ response and ‘‘yes’’ responses are tallied to create a total score.
Alpha coefficients for the scales in this sample were as follows: Alcohol/Drug Use,
a = .86; Anger-Irritability, a = 79; Depression-Anxiety, a = 73; Somatic Complaints,
a = 73; and Suicide Ideation, a = 86.
A seventh scale, Traumatic Experiences, provides information about lifetime traumatic
events and posttraumatic reactions. The TE scale was developed through four stages. First,
a pool of potential questions regarding experiences and symptoms known to be associated
with PTSD was compiled (Grisso and Barnum 2006). This pool of potential questions was
submitted for review to experts in the assessment of adolescents and mental health pro-
fessionals in the juvenile justice system. Items were then administered to a small sample of
youth in the Massachusetts Department of Youth Services and assessed for readability and
comprehension. Next, the instrument underwent pilot-testing with an additional sample of
detained youth. Finally, data from these studies were used to finalize the questions to be
used on the MAYSI-2 scale. Analyses of item-total correlations, alpha coefficients, and
factor analyses were used to determine which items in each scale should be retained,
deleted, or added to maximize the scale’s internal consistency. The majority of items
reflecting PTSD symptoms did not cluster with the items related to trauma exposure, and
therefore, the final item pool was reduced substantially and the purpose of the scale recast
as screening for traumatic experiences. The resulting scale includes five items in total, four
items that are identical for boys and girls and one item that is unique to each gender. The
items common to both genders include three questions regarding exposure to traumatic
experiences (e.g., ‘‘Have you ever in your whole life had something very bad or terrifying
happen to you?’’) and one question reflecting posttraumatic reactions (e.g., ‘‘Have you had
a lot of bad thoughts or dreams about a bad or scary event that happened to you?’’). A fifth
item reflecting trauma exposure appears only on the scale for girls, (e.g., ‘‘Have you ever
been raped or been in danger of getting raped?’’) and a fifth item reflecting posttraumatic
hypervigilence appears only scale for boys (e.g., ‘‘Have people talked about you a lot when
you’re not there?’’) In the present sample, the internal consistencies were a = .81 for girls
and .60 for boys.
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With the exception of the TE scale, the other six MAYSI-2 scales have been validated
through comparisons to similar scales on the Millon Adolescent Clinical Inventory (MACI;
Millon 1993) and the Youth Self Report (YSR; Achenbach and Edelbrock 1991). However,
because none of the measures used in those validation studies include scales related to
trauma, there has been no validation performed to date on the TE scale. In addition, norms
for the other six scales have allowed the establishment of ‘‘caution’’ and ‘‘warning’’ cutoff
scores to indicate that the youth’s responses suggest a need for further mental health
evaluation. Scores above the caution cutoff indicate a possible basis for concern whereas
scores above the warning cutoff indicate that a youth has scored exceptionally high in
comparison with other detained youth (Grisso and Barnum 2006). However, because of the
lack of a trauma-related criterion measure in the psychometric research performed with
the MAYSI to date, there are no cut-off scores established for the TE scale. Further, for
the other scales, the MAYSI-2 includes ‘‘secondary screening’’ questions which allow
detention center staff to judge whether high scores warrant particular immediate attention;
however, these secondary questions have not been developed for the TE Scale.
UCLA Posttraumatic Stress Disorder Reaction Index for DSM-IV, Adolescent Version(PTSD-RI; Pynoos et al. 1998). The PTSD-RI is a 49-item measure used to screen for
exposure to traumatic events and symptoms of PTSD among adolescents. Items on the
PTSD-RI map onto DSM-IV and provide information regarding the likelihood that the
youth meets criteria for the diagnosis of PTSD. The first 13 questions on the PTSD-RI
assess trauma exposure by asking the youth to answer ‘‘yes’’ or ‘‘no’’ as to whether he or
she has been exposed to a variety of traumatic events (e.g., ‘‘[Have you ever been] hit,
punched or kicked very hard at home?’’). If a youth answers ‘‘yes’’ to any of the questions
about trauma exposure, question 14 asks the youth to identify the one event that currently
is the most distressing to him or her and to provide a brief description of that event.
Questions 15–21 and 22–27 assess for Criterion A in regard to that event, including the
presence of a real or perceived threat to physical integrity, as well as the youth’s subjective
experience of fear, helplessness, horror, agitation, or disorganization. If Criterion A is met,
the next set of questions on the PTSD-RI assess for the frequency of symptoms experi-
enced in the past month in the three DSM-IV clusters associated with Criterion B (reex-
periencing), Criterion C (avoidance), and Criterion D (arousal). Responses to the questions
are presented in a Likert scale format ranging from 0 = none of the time in the past monthto 4 = most of the time in the past month. Given that the PTSD-RI was being used as a
screening instrument in the present study, a liberal cut-off of a score of ‘‘2’’ was used to
indicate the likely presence of each symptom (Steinberg et al. 2004). The PTSD-RI pro-
vides instructions for calculation of a Total PTSD symptoms score; subscores on symptom
levels for Criteria B, C, and D; and total trauma exposure. For purposes of this study, we
also calculated separately total scores for interpersonal and noninterpersonal trauma
exposure. Additionally, the instrument provides information as to whether a Full or Partial
diagnosis of PTSD is likely (Rodriguez et al. 1999). For a likely Full diagnosis, Criteria A,
B, C, and D must all be met. For a likely Partial diagnosis, Criterion A must be met, as well
as two of the other three criteria.
The PTSD-RI has evidenced convergent validity with other diagnostic interview
measures, including the Schedule for Affective Disorders and Schizophrenia for School-Age Children (r = .70) and the Clinician Administered PTSD Scale for Children andAdolescents (r = .82). Good internal consistency also has been found, with alphas around
.90 (Steinberg et al. 2004). Finally, test–retest reliability of .84 has been reported over a
7-day period (Steinberg et al. 2004). In the current sample, Cronbach’s alphas were
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acceptable to high: a = .84 for Criterion B, a = .78 for Criterion C, a = .69 for Criterion
D, and a = .89 for the Total PTSD score.
Associated Symptoms
A subscale of associated symptoms related to complex PTSD was drawn from the Clini-cian Administered PTSD Scale for Children and Adolescents (CAPS-CA; Newman et al.
2004). The CAPS-CA is a downward extension of the CAPS (Blake et al. 1995), a well-
validated diagnostic tool for PTSD in adults which is considered by many to be the ‘‘gold
standard’’ in the field (Briere and Scott 2006). The associated symptoms subscale includes
7 questions that enquire about associated features of PTSD that are described in DSM-IV
as being likely to arise in response to chronic interpersonal traumas, including guilt, shame,
disrupted attachments, and dissociation (e.g., ‘‘How often during the past month did you
feel spacey or like you had gone away in your mind?’’). Each item is rated by the youth on
a scale ranging from 0 = none of the time to 4 = most of the time. In the current sample,
Cronbach’s alpha for the Associated Symptoms scale was acceptable at a = .73.
Procedure
All procedures followed in this study were reviewed and approved by the Internal Review
Boards of Miami University and the Butler County Juvenile Justice Center and used
de-identified archival data collected as a part of the detention center’s standard mental
health screening for all new admissions. Within 24 h of entry into the detention center,
each remanded youth was administered the MAYSI-2 via the MAYSIWARE Voice For-
mat (Maney and Grisso 2006) on a laptop computer. Youth used the computer touch pad to
indicate yes or no to each question. A staff member was present in the room during the
administration of the measure to answer questions and follow up on critical items, but was
not able to view the screen or to see the youth’s responses.
Subsequently to the administration of the MAYSI-2, within 3 days of admission youth
also were administered the PTSD-RI in an individual interview conducted by a trained
clinician who read the instructions and questions aloud to the adolescents and recorded
their responses. The CAPS Associated Symptoms scale items also were administered orally
in the same session and youth’s Likert scale responses were recorded. All interviewers
underwent extensive training in the administration and scoring of the PTSD-RI and the
application of the DSM-IV diagnostic criteria, including the web-based training devised by
the measure’s developers (http://www.nctsnet.org/nccts/asset.do?id=314), as well as
training from a master clinician who met monthly with the interviewers in order to
recalibrate scoring. Although the PTSD-RI was devised to allow for administration as a
self-report questionnaire or as an interview, the interview format was implemented for
several reasons. Most important were concerns for youth well-being, with the interview
format allowing clinicians to gauge the youth’s reaction to discussing distressing events so
as to respond with the provision of support or intervention as needed. A second reason for
administration by a trained interviewer was to reduce the likelihood that the low literacy
rates among detained youth would not allow questions to be misinterpreted by those with
poor reading skills. A third reason was to ensure that diagnostic criteria were confirmed as
met or not met according to the formal DSM-IV (APA 2000) definitions. A subset of 30
PTSD-RI protocols were randomly selected from interviews performed throughout the
course of the study in order to perform reliability checks on scoring of the diagnostic
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criteria. Reliability of raters with the master coder ranged from 95 to 100% correct at the
cumulative score level.
Results
Descriptive Statistics and Main Effects of Gender
The proportion of youth meeting criteria for ‘‘Caution’’ and ‘‘Warning’’ cut-offs scores is
reported in Table 1. These proportions correspond to those reported by Grisso and Barnum
(2006) for the original validation sample on the Angry-Irritable scale (e.g., 59% of girls
and 40% of boys in the current sample were at or above the Caution cut-off on, compared
to 54% of girls and 38% of boys in the validation sample). However, the present sample
included a higher percentage of girls who reached the Warning cut-off level on the
Alcohol/Drug Use scale than in the validation sample, as well as higher percentages of
youth who reached cut-offs on the Depressed-Anxious and Somatic Complaints scales. As
Grisso and Barnum (2006) note, differences among samples from diverse geographic
regions were found in their validation studies and are to be expected given the diversity
that exists among subgroups of youth, juvenile justice facilities, intake procedures and
holding criteria, and regional and gender arrest patterns.
Table 1 Gender differences on MAYSI and PTSD scales
Variable Girls Boys v2 (2) Odds ratioa
(95% confidenceinterval)Caution
(%)Warning(%)
Caution(%)
Warning(%)
Percentage of youth scoring at cut-offs on MAYSI scales
MAYSI alcohol/drug use 12.5 22.8.3 14.2 14.5 4.98 1.15 (.76–1.74)
MAYSI Angry-Irritable 38.2 20.6 28.0 12.3 13.76** 1.57 (1.08–2.30)
MAYSI Depressed-Anxious 36.8 23.5 28.9 10.7 20.18*** 1.76 (1.20–2.57)
MAYSI somatic complaints 53.7 25.7 46.9 13.8 18.56*** 1.54 (1.04–2.28)
MAYSI suicidal ideation 5.9 27.9 4.7 13.2 15.11** 1.97 (1.26–3.07)
MAYSI thought disturbance – – 28.3 11.6 – –
Variable M SD M SD F g2
Mean differences on continuous scales
MAYSI traumatic experiences 2.24 1.52 1.99 1.56 -3.78 .010
PTSD-RI total trauma 3.74 2.55 3.03 2.27 -7.65** .020
PTSD-RI interpersonal trauma 2.77 2.02 2.18 1.83 -11.16** .029
PTSD-RI Non-Interpersonal .81 .87 .64 .83 -1.46 .004
PTSD-RI total PTSD symptoms 30.31 17.12 21.81 15.09 -27.54*** .069
PTSD-RI reexperiencing 7.71 5.56 4.91 4.78 -22.04*** .056
PTSD-RI avoidance 11.92 7.70 8.72 6.81 -19.68*** .050
PTSD-RI arousal 10.53 5.78 8.28 5.30 -17.54*** .045
CAPS-CA associated symptoms 12.40 7.71 9.25 6.30 -17.87*** .046
a The odds ratios reflect the proportion of girls above any clinical cut off when compared to boys
** p \ .01; *** p \ .001
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In order to determine whether there were gender differences in the probability that youth
scored at or above the cutoffs for ‘‘caution’’ or ‘‘warning’’ on the five MAYSI-2 scales for
which such cutoffs have been established, v2 analyses were conducted. As the results reported
in Table 1 show, with the exception of the Alcohol/Drug Use scale, girls were more likely
than boys to meet criteria for a cutoff score for each of the MAYSI-2 scales. A MANOVA was
conducted to test for main effects of gender on the measures of traumatic exposure and PTSD.
The results revealed a significant pattern of gender differences across the variables, Wilks’
Lamba (14, 360) = 3.50, p \ .001. Follow-up univariate ANOVAs were performed and the
results of these analyses are reported in Table 1. The results show girls reported significantly
higher scores than boys on the PTSD-RI scales of total trauma exposure, interpersonal
trauma, Total PTSD, reexperiencing, avoidance, and arousal; and the CAPS-CA associated
symptoms scale. However, there were no gender differences on the PTSD-RI scale of non-
interpersonal trauma, nor on the MAYSI scale of Traumatic Experiences.
Gender differences also were found for the prevalence of youth who likely met criteria
for a Full or Partial diagnosis of PTSD. Among the girls in this sample, 85.1% met Criterion
A for exposure to a traumatic event in comparison to 72.1% of the boys, a significant gender
difference v2 (2) = 10.59, p \ .01, Likelihood Ratio = 11.34, p \ .01. Among the youth
who met Criterion A, indicating that they had experienced a traumatic event as defined by
DSM-IV, 44.9% of boys and 60.6% of girls met criteria for a likely diagnosis of Full PTSD,
a significant gender difference, v2 (2) = 10.98, p \ .01, Likelihood Ratio = 12.44,
p \ .01. A further 27.6% of those boys and 24.8% of those girls likely met criteria for
Partial PTSD. Among the youth who likely met criteria for a Partial diagnosis, by definition
100% met Criterion A while 78.4% also met Criterion B (reexperiencing), 37.3% also met
Criterion C (avoidance), and 90.2% also met Criterion D (arousal).
Intercorrelations
Intercorrelations among the variables are reported in Table 2, reported separately by
gender. Neither age nor months since the trauma were correlated with any other variables
and therefore, these scores are not included. With the exception of the Alcohol/Drug Use
scale for girls, each of the MAYSI-2 scales was positively correlated with each of the
PTSD scales. The correspondence between the TE scale and the PTSD indices was
moderate, ranging from .44 to .63 for boys and from .39 to .56 for girls.
Multiple Regressions
Separate all-possible-subsets multiple regression analyses for boys and girls were per-
formed to evaluate the relative contributions of the MAYSI-2 scales to the statistical
prediction of PTSD scores. The first set of regression analyses was conducted to evaluate
the contribution of the MAYSI-2 scales to the statistical prediction of Total PTSD (see
Table 3). For girls, the MAYSI-2 scales together accounted for 60% of the variance in
Total PTSD with scores on the Angry-Irritable, Depressed-Anxious, Somatic Complaints,
and TE scales contributing significantly to the equation, F (6, 120) = 30.01, p \ .001. For
boys, the MAYSI-2 scales together accounted for 42% of the variance in Total PTSD, with
scores on the Angry-Irritable, Depressed-Anxious, and TE scales contributing, F (7,
281) = 29.00, p \ .001.
The second set of regression analyses was conducted to evaluate the relative contri-
bution of the MAYSI-2 scales to the prediction of the Associated Symptoms scale, again
separately for boys and girls. For girls, the MAYSI-2 scales together accounted for 19% of
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Tab
le2
Inte
rco
rrel
atio
ns
Var
iab
le1
23
45
67
89
10
11
12
13
14
15
1.
Alc
oho
ld
rug
use
–.3
5**
.1
8.
23
*.2
6*
n/a
.44
**
.1
9.2
0.2
4*
.24
*.3
4*
*.3
4**
.23
*.1
8
2.
An
gry
-Irr
itab
le.4
0**
–.6
3**
.5
7*
*.5
5**
n/a
.50
**
.53
**
.56
**
.63
**
.64
**
.49
**
.48
**
.33
**
.42
**
3.
Dep
ress
ed-A
nxio
us
.34
**.6
1**
–.
63
**
.60
**
n/a
.51
**
.68
**
.72
**
.56
**
.74
**
.50
**
.48
**
.35
**
.56
**
4.
So
mat
icco
mp
lain
ts.2
2**
.38
**.5
2**
–.3
7**
n/a
.34
**
.53
**
.46
**
.45
**
.54
**
.40
**
.42
**
.22
**
.36
**
5.
Su
icid
eid
eati
on
.32
**.4
6**
.62
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the variance in Associated Symptoms with scores only on the Depressed-Anxious scale
contributing to the equation, F (6, 111) = 5.66, p \ .001. For boys, the MAYSI-2 scales
together accounted for 27% of the variance in Associated Symptoms with scores on the
Depressed-Anxious and TE scales contributing to the equation, F (7, 257) = 13.45,
p \ .001.
Receiver Operating Characteristics (ROC) Curves
The ROC curves technique was used to determine how well the MAYSI-2 TE scale
detected the 168 boys and 96 girls who met criteria for either a likely Full or Partial
diagnosis of PTSD as determined by their scores on the PTSD-RI, and to identify the most
effective cutoff score on the TE scale to screen for the probable presence of PTSD among
detained youth. The sensitivity (the ability of the test to accurately detect individuals with
the disorder in question) and 1-specificity (the percentage of false positives) were calcu-
lated for each cut-off score on the MAYSI-2. An optimal cut-off score maximizes the
ability of the test to detect individuals who meet criteria while minimizing the number of
false positives. Table 4 displays the possible cut-off scores for girls and boys, which
yielded similar results. A cut-off score of 1 on the TE scale would accurately identify 89%
of girls and 91% of boys who met criteria for likely Full or Partial PTSD; however, 60% of
girls and 67% of boys who did not meet criteria would be erroneously screened as positive.
A cut-off score of 2 would correctly screen 76% of boys and 72% of girls as likely meeting
criteria for PTSD, but would result in a false positive rate of 37%. In turn, a cut-off score of
3 on the TE scale would accurately screen 55% of girls and 54% of boys who likely met
criteria for PTSD, and would incorrectly screen 15% of youth as being positive for PTSD
when they likely did not meet criteria.
Finally, the sensitivity and 1-specificity for each cut-off score were plotted on graphs in
order to allow for the area under an ROC curve to be calculated (see Fig. 1). The area
under the curve (AUC) statistic measures the probability that the TE scale will yield a
higher score for a randomly chosen youth who likely met criteria for PTSD than for a
randomly chosen youth who likely did not meet criteria for the disorder (Lasko et al. 2005).
The further the ROC curve deviates from the straight line and the closer it appears to the
upper left hand corner, the better the sensitivity and specificity of the test. In the current
sample, the AUC statistic for girls was .754, SE = .045, p \ .001 and for boys was .758,
Table 3 Summary of multiple regression analyses predicting PTSD scores from the MAYSI-2 scales
Predictor entered Girls Boys
B SE B b B SE B b
Dependent variable: Total PTSD-RI score
Angry-Irritable 1.40 .50 .22** 1.06 .33 .20**
Depressed-Anxious 2.00 .60 .30** 2.15 .48 .33***
Somatic complaints 1.28 .61 .15* 0.48 .41 .06
Traumatic experiences 2.25 .97 .20* 1.91 .66 .20**
Dependent variable: associated symptoms
Depressed-Anxious .65 .36 .22** 0.60 .25 .21*
Traumatic experiences .72 .43 .16 1.03 .29 .24**
* p \ .05; ** p \ .01; *** p \ .001
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Table 4 Sensitivity and (1-Specificity) of MAYSI scale scores for predicting full or partial PTSD diagnosis
Score MAYSI traumatic experiences MAYSI Anger-Irritability MAYSI Depression-Anxiety
Sensitivity 1-Specificity Sensitivity 1-Specificity Sensitivity 1-Specificity
Girls
0 1.00 1.00 1.00 1.00 1.00 1.00
1 .89 .60 .98 .80 .99 .73
2 .73 .38 .94 .70 .83 .55
3 .55 .15 .91 .60 .73 .30
4 .36 .08 .82 .43 .57 .20
5 .13 .03 .70 .33 .42 .15
6 – – .58 .33 .29 .08
7 – – .46 .18 .18 .00
8 – – .26 .08 .08 .00
9 – – .05 .00 .03 .00
Boys
0 1.00 1.00 1.00 1.00 1.00 1.00
1 .91 .67 .95 .75 .95 .53
2 .76 .37 .89 .55 .72 .33
3 .54 .15 .78 .40 .59 .18
4 .33 .06 .70 .30 .41 .09
5 .09 .01 .58 .20 .29 .05
– – .48 .14 .17 .04
– – .30 .09 .10 .03
– – .19 .05 .07 .01
– – .03 .02 .01 .01
Fig. 1 The ROC curves for identifying full or partial PTSD for each score on the MAYSI-2 traumaticexperiences scale
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SE = .027, p \ .001 and for boys. According to Streiner and Cairney (2007), an AUC
statistic between .70 and .90 is considered moderately accurate.
Because the regression analyses indicated that the MAYSI-2 Angry-Irritable and
Depressed-Anxious Scales were stronger predictors of the Total PTSD-RI score than was
the MAYSI-2 TE score, ROC analyses also were performed to assess the sensitivity and
specificity of these scales for detecting likely Full or Partial PTSD (see Table 4). For the
Angry-Irritable scale, the AUC for girls was .739, SE = .048, p \ .001 and for boys was
.756, SE = .027, p \ .001 and for boys. For the Depression-Anxiety scale, the AUC for
girls was .762, SE = .045, p \ .001 and for boys was .785, SE = .026, p \ .001 and for
boys. These results suggest that likely Full or Partial PTSD can be detected about equally
well by any of these three MAYSI-2 scales and that the TE scale is not a significantly more
sensitive or specific measure than the others.
Discussion
One purpose of this study was to examine gender differences related to trauma and its
sequelae, particularly related to complex PTSD. The results reported here are consistent
with previous research that has found detained girls to evidence more mental health
problems than their male counterparts (e.g., Antonishak et al. 2004; Kerig et al. 2009;
Timmons-Mitchell et al. 1997). Girls in this sample provided higher ratings than boys on
all of the MAYSI-2 scales with the exception of Alcohol/Drug Use and Traumatic
Experiences. Girls also reported exposure to a larger number of traumas overall, as well as
the interpersonal traumas which are associated particularly with complex PTSD. In
addition, consistent with some prior studies (Cauffman et al. 1998; Kerig et al. 2009;
Martin et al. 2008; Wood et al. 2002), girls in this sample also gave significantly higher
ratings than boys on all the symptom clusters associated with PTSD, including symptoms
of reexperiencing, avoidance, arousal, as well as associated symptoms. This gender dif-
ference is one seen across ages and samples, in which females consistently endorse higher
levels of posttraumatic symptoms than males even when controlling for type of traumatic
stressor experienced (Tolin and Foa 2006).
The other main purpose of the study was to examine the effectiveness of the MAYSI-TE
scale for detecting trauma and its sequelae among detained youth. Results of the regression
analyses indicated that the TE scale made a modest contribution to the prediction of Total
PTSD scores, in combination with other mental health problems that likely accompany
posttraumatic stress—specifically, anger and depression for boys, and anger, depression,
and somatic complaints for girls. The finding that somatic complaints were differentially
prevalent among traumatized girls is consistent with other research on adolescents exposed
to or victimized by violence (e.g., Darves-Bornoz et al. 1998; Hilker et al. 2005;
Pat-Horenczyk et al. 2007), including youth in detention settings (Ford et al. 2008a). These
results suggest that symptoms of physical distress may provide a particularly helpful ‘‘red
flag’’ for screening for trauma amongst girls, and that trauma-awareness training for
medical staff in detention settings would be of great value. As Bailey et al. (2005) suggest,
‘‘Children presenting with physical symptoms for which no organic cause is clearly evident
may very well be manifesting problems associated with exposure to violence or some other
trauma causing stress’’ (p. 347).
A more surprising finding is that, for girls, the TE scale was not a contributor to the
prediction of associated symptoms. One possible explanation is that the questions included
in the TE scale more effectively probe for single-incident traumatic events, such as being
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in a car accident, escaping a fire, or witnessing a deadly fight, rather than the chronic,
pervasive, interpersonal stressors that are associated with complex PTSD (Herman 1992).
Specifically, one form of interpersonal trauma that is consistently found to be more pre-
valent among detained girls is the experience of repeated sexual abuse (e.g., Acoca 1999;
McCabe et al. 2002). Although the MAYSI-2 inquires about such experiences by using the
term ‘‘rape,’’ research has shown that over half of the women who have been forced to have
sex do not label their experience with that word (Littleton et al. 2007). This may have been
true in our sample as well, with many girls denying having been raped on the TE scale and
yet going on to describe on the PTSD-RI unwanted sexual experiences that did not fit their
definition of the term, such as those involving molestation by family members, coercion by
dating partners, gang initiations, or intoxication. For example, one girl interrupted the
MAYSI-2 administration to ask, ‘‘Does it count as rape if you were too drunk to say no?’’
Therefore, screening for traumatic experiences would benefit from the use of language that
avoids stigmatizing or narrowing youths’ response set, such as by replacing the term
‘‘rape’’ with the PTSD-RI’s inquiry regarding someone ‘‘touching your private sexual body
parts when you did not want them to.’’
The ROC analyses also indicated that the TE scale is a moderately accurate predictor of
PTSD symptoms for both boys and girls. If the TE is used as a screening measure designed
to cast a wide net, the results of the present study indicate that a cut-off score of 2 would
accurately identify 80% of youth and would result in false positives about half of the time,
whereas a more stringent cut-off score of 3 would result in false positives in only a quarter
of instances but would accurately identify only 62% of youth. The benefits of ‘‘red-
flagging’’ any youth in need of further evaluation are clear, including the provision of a
more in-depth psychological assessment that could assist the judicial system in developing
an appropriate rehabilitation plan (Ford et al. 2006). Further, the costs associated with
failing to identify youth who suffer from PTSD reactions are high, given that detained
youth whose mental health problems are left untreated are at significant risk for escalating
psychiatric problems, substance abuse, school dropout, and future recidivism (Abram et al.
2004; Ford et al. 2008a; Leve and Chamberlain 2005). However, it is the case that many
jurisdictions have limited resources that would prohibit them from paying the considerable
costs associated with following up with every youth who might benefit from a more
extended professional psychological evaluation. Therefore, a cost-benefit analysis will be
needed to help determine the most appropriate cut-off score for a given detention facility.
As Grisso and Barnum (2006) point out, such decisions require weighing considerations of
responsibility (the obligation to respond to the mental health needs of youth in custody),
responses (the type of intervention best suited to the identified mental health need), and
resources (the financial and administrative support necessary to provide the response).
The potential of the MAYSI-2 TE scale as a screening tool for traumatic exposure is
high, given its ease and cost-effectiveness of administration. However, further consider-
ation will be needed to established benchmarks to enhance its utility. One of the impli-
cations of the present study is that it is important for mental health assessors to view
youths’ responses on the TE scale within a broader context. The results of this study
suggest that many youth evidence posttraumatic symptomatology even when very few TE
items are endorsed and, further, that youth who likely meet criteria for a diagnosis of PTSD
also evidence symptoms in a variety of clusters on the MAYSI-2. Consistent with the
findings of other researchers (e.g., Ford et al. 2008b), youth with extensive trauma histories
may indicate mental health distress through elevated responses on other MAYSI-2 scales,
either independently or in conjunction with the TE scale. Given this, mental health pro-
fessionals working within juvenile justice settings should be sensitive to the possibility that
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PTSD is revealed in a diverse array of presentations among youth in detention settings.
Screening for trauma among youth in detention, therefore, will require a multi-faceted
approach that attends not only to youth reports of stressful life events, and to DSM-IV
symptoms of PTSD, but also to their endorsement of other symptoms, including depres-
sion, irritability, or somatic complaints, which may emerge when affect modulation and
cognitive processing have been disrupted by adverse experiences in childhood (Ford 2005;
Ford et al. 2008b). In addition, it is noteworthy that other MAYSI-2 scales were at least as
accurate at detecting likely PTSD as was the TE scale. Further refinement of the MAYSI-2
might capitalize on this fact by making those other scales more trauma-informed, such as
by adding to the secondary screening items an inquiry as to whether youth began expe-
riencing those symptoms, or an increase in those symptoms, following a particular life
event. Asking this question in an open-ended format (e.g., ‘‘did anything particularly
stressful or unusual happen around the time you started feeling this way?’’) also may help
to prevent foreclosing youths’ responses in the ways that more stigmatizing language (e.g.,
‘‘were you raped?’’) might.
The findings of the present study also suggest that interventions for delinquent youth
will need to be multi-faceted as well as gender-sensitive. Complex PTSD may be partic-
ularly salient for delinquent girls, who report comparatively higher rates of exposure to the
kinds of interpersonal traumas that are related to the development of DTD (Kerig and
Becker in press). Only recently have delinquent girls been the focus of specific attention
and has consideration been given to the possibility that they may have unique treatment
needs, particularly related to their histories of chronic trauma and disrupted relationships
with caregivers (Bloom et al. 2002; Leve et al. in press).
A number of limitations to this study should be noted. First, this investigation utilized
only self-report measures, which are subject to the unreliability of youths’ recall of their
reactions following traumatic events. Future research would benefit from the use of
multiple measures from multiple perspectives, including caregivers; however, it is worth
noting that parent and teacher ratings may not be as reliable as children’s own reports of
their traumatic experiences (Hill and Jones 1997). In addition, youth completed the
MAYSI-2 and the trauma measures at different time points during their detention stay.
Responses on the MAYSI-2 may have been elevated due to distress youth experienced at
the time of first entering the facility. Another limitation to the generalizability of this study
is that it included only youth remanded to the custody of the detention center. Youth who
are first-time offenders or who are arrested for minor crimes generally are released after
only a few hours and thus do not undergo the mental health screening procedure; conse-
quently, this study includes a subsample of youth comprised of relatively serious offenders,
with relatively high rates of mental health problems. Another limitation concerns the
accuracy of the ROC analysis, which assumes the availability of an instrument comprising
a ‘‘gold standard’’ for diagnosis (Streiner and Cairney 2007). Although there is no defin-
itive gold standard established for the assessment of PTSD among children and adoles-
cents, this study used the most widely used and well validated measures available to date as
an initial step toward achieving this goal. Finally, because these data were gathered in the
context of an intake assessment in the detention setting, time constraints demanded that all
measures be time-efficient to administer and score. The brief index of associated symptoms
used here, although derived from an established measure, cannot claim to fully capture the
construct of complex PTSD (Ford and Courtois 2009). The construct of complex trauma
comprises a constellation of symptoms including sensorimotor difficulties, affect dysreg-
ulation, dissociation, behavioral undercontrol, cognitive distortions, and poor self-concept
(Cook et al. 2005; van der Kolk et al. 2005). As Briere and Spinazzola (2009) note,
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currently there are no validated measures for youth that encompass the multitude of
dysfunctions implicated in complex PTSD, nor are there measures that clearly distinguish
PTSD-related symptoms from those of other childhood disorders. Although promising
measures for DTD are under development (e.g., Pelcovitz et al. 2004), the length and
extensive training needed to implement such measures may impose an impediment to their
routine use in detention settings. The development of screening tools that are sensitive to
complex trauma and its sequelae likely will be a challenging task but is well-worth pur-
suing. In particular, future research investigating methods for detecting complex PTSD
among detained samples might benefit from an evaluation of the incremental utility of the
PTSD-RI criterion scores for contributing to the prediction of complex PTSD symptoms by
using methods such as the associated symptoms index administered here.
In conclusion, the high rates of traumatic exposure and PTSD symptoms seen among
delinquent youth underscore the need to screen for trauma in detention settings (Ford et al.
2008a, b; Newman 2002). Increasing awareness of the possible role that trauma might play
in delinquent behavior, and the diverse ways in which it is revealed in youths’ mental
health symptoms, will be valuable for improving rehabilitation and treatment planning in
the juvenile justice system. By the same token, recognition of the more subtle and per-
vasive symptom picture related to complex PTSD, and the development of strategies for
assessing Type II traumas, will be of particular importance. In our current diagnostic
system, youth whose behavior problems are related to extensive trauma histories are more
likely to be diagnosed with other disorders, such as anxiety and oppositional defiance,
rather than with PTSD (van der Kolk et al. 2005). By correctly targeting treatment to the
underlying trauma, and particularly to the developmental functions that have been dis-
rupted by pervasive and chronic adverse childhood experiences, efforts to deter youth from
a delinquent trajectory can be made more effective.
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