• 52 • Taiwanese Journal of Psychiatry (Taipei) Vol. 32 No.

1 2018
Original Article

Reliability and Factor Structure of the Chinese

Version of Childhood Trauma Questionnaire-short
Form in in Patients with Substance Use Disorder

Ying-Chih Cheng, M.D.1,5, Chun-Hsin Chen, M.S., M.D.2,3, Kuan-Ru Chou, M.D.4,
Po-Hsiu Kuo, Ph.D.5,6*, Ming-Chyi Huang, M.D., Ph.D.3,7,*

Objectives: Childhood Trauma Questionnaire-Short Form (CTQ-SF), a 28-

item retrospective self-report questionnaire, is the most widely used measure to
assess multiple dimensions of childhood trauma exposure (CTE). The CTQ-SF has
been translated into different languages, but the Chinese version have not yet been
studied. In this study, we intended to examine the reliability and factor structure of
the Chinese version of the CTQ-SF (C-CTQ-SF). Methods: We administered the
questionnaire of the C-CTQ-SF to 160 patients with substance use disorder. The
internal consistency and test–retest reliability of the C-CTQ-SF at 2–3 weeks after
initial assessment were evaluated using Cronbach’s α coefficients and intraclass
correlation coefficients (ICCs). We also did confirmatory factor analysis (CFA)
and exploratory factor analysis (EFA), to test the factor structure of the C-CTQ-SF.
Results: The C-CTQ-SF was found to have fair to adequate internal consistency
(Cronbach’s α ranging from 0.574 to 0.895) and test–retest reliability (ICCs rang-
ing from 0.674 to 0.852). The results of CFA showed relatively low factor loading
for the physical neglect subscale. Subsequent EFA yielded a stable five-factor
structure, and some items had cross-loadings with more than one factor. Conclu-
sion: Our results indicated that C-CTQ-SF has adequate reliability and a five-fac-
tor solution, supporting the feasibility of using the C-CTQ-SF to assess CTE in
patients with substance use disorders. Consisting with previous reports, the physi-
cal neglect subscale did not emerge as a stable factor.

Key words: child abuse, child maltreatment, childhood Trauma Questionnaire, neglect
(Taiwanese Journal of Psychiatry [Taipei] 2018; 32: 52-62)

1
Taoyuan Psychiatric Center Ministry of Health and Welfare, Taoyuan County, Taiwan 2 Department of Psychiatry, Taipei Medical
University-Wan-Fang Hospital, Taipei, Taiwan 3 Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medi-
cal University, Taipei, Taiwan 4 Department of Psychiatry, Yuli Hospital, Ministry of Health and Welfare, Hualien, Taiwan 5 Depart-
ment of Public Health and Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan Univer-
sity, Taipei, Taiwan 6 Research Center for Genes, Environment and Human Health, National Taiwan University, Taipei, Taiwan
7
Department of Psychiatry, Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan
Received: September 6, 2017; revised: November 15, 2017; accepted: December 29, 2017
*
Corresponding authors. No. 309, Songde Road, Xinyi District, Taipei 110, Taiwan (Huang7); and Room 521, No. 17, Xuzhou Road,
Taipei 100, Taiwan (Kuo5)
E-mails: Ming-Chyi Huang <mch@tpech.gov.tw>, and Po-Hsiu Kuo < phkuo@ntu.edu.tw>

Introduction
Childhood trauma is defined as an adverse
early life experience, including physical, emotion-
al, and sexual abuse (PA, EA, and SA, respective-
ly) and general traumatic experiences such as
emotional neglect (EN), and physical neglect
(PN) [1-3]. Accumulating evidence supports that
childhood trauma exposure (CTE) is an environ-
mental susceptibility factor for various physical or
psychiatric problems in both clinical and commu-
nity samples. Of particular importance, the seri-
ousness of health and psychological consequences
increases with the number of CTE categories ex-
perienced [4, 5]. Previous studies exploring the
consequences of CTE have largely focused on
sexual and physical abuse [6]. But many types of
CTEs often co-occur within the same family [7, 8]
and many maltreated children experience various
victimizations [9, 10]. Therefore, a simultaneous
assessment of a broad spectrum of CTE is needed
to understand the potential impact of CTE [9, 10].
The Childhood Trauma Questionnaire
(CTQ), developed by Bernstein et al. in 1998 [11],
has been widely used as a reliable and valid as-
sessment tool of many types of CTEs covering
childhood abuse or neglect [11]. Its short form
(CTQ-SF) is a 28-item easily self-administered
questionnaire to enable the rapid identification of
five dimensions of CTE ‒ (A) physical abuse
(PA), (B) emotional abuse (EA), (C) sexual abuse
(SA), (D) emotional neglect (EN), and (E) physi-
cal neglect (PN) ‒ to assess the extent of maltreat-
ment. The instruction and test items of CTQ-SF
are phrased in an attempt to describe concrete,
objective events and behaviors. Terms such as
“trauma,” “abuse,” and “neglect” are generally
avoided because they have subjective, evaluative,
and stigmatizing qualities that can elicit defen-
Cheng YC, Chen CH, Chou KR, et al. • 53 •
siveness [12]. Furthermore, researcher-defined
questions used in the CTQ-SF are believed to be
more sensitive than self-defined ones, which usu-
ally ask respondents whether they have been
abused [13]. The CTQ-SF not only serves as an
appropriate research tool for both nonclinical and
clinical samples, but also provides a more eco-
logically valid approach to examine the separate
and combined effects of various types of child-
hood abuse and neglect experiences.
The CTQ-SF has shown adequate internal
consistency for clinical and nonreferred groups
[14], and been validated [14]. To date, it has been
translated into many languages, including German
[15], Swedish [2], Turkish [16], Spanish [17],
French [18], Italian [19], Dutch [20], and Korean
[3]. But the psychometric properties of the
Chinese version of CTQ-SF (C-CTQ-SF) have
not yet been studied. In this study, we intended to
examine (A) the reliability and factor structure of
the Chinese version of the CTQ-SF (C-CTQ-SF)
[12, 14] in a clinical sample of patients with sub-
stance use disorders, and (B) the rate of each type
of CTE in this clinical sample.
Methods
Study participants and procedures
This study protocol was approved by the in-
stitutional review board at Taipei City Hospital
with the requirement of obtaining written in-
formed consent from all participants. We consecu-
tively recruited 160 participants from the outpa-
tient clinics or inpatient units at Taipei City
Psychiatric Center, Taipei City Hospital. The in-
clusion criteria were patients who (A) were aged
between 20 and 50 years; (B) were fulfilling the
diagnostic criteria for substance use disorder, in-
cluding alcohol, amphetamine, hallucinogen, and
other substances, except for nicotine, based on
• 54 • Reliability and Validity of CTQ-SF
DSM-IV-TR, as ascertained by at least two psy-
chiatrists; and (C) had reading and comprehension
ability in signing the informed consent form.
Excluded are those with severe mental illnesses,
such as schizophrenia, bipolar disorder, or major
depressive disorder with psychotic features, and
cognitive disorders or neurological disorders as
well as those had difficulty in understanding the
study content. All participants were given the
C-CTQ-SF, and 96 of them completed the copies
of questionnaire again 2-3 weeks after their first
assessment to evaluate test–retest reliability. We
also reviewed medical records for their clinical
and sociodemographic data.
Childhood Trauma Questionnaire- Short
Form (CTQ-SF)
The original version of CTQ-SF has been
shown to have excellent reliability and validity
[14]. It consists of five subscales, each of which
contains 5 items, and 3 validity items assessing
minimization/denial. The five subscales are de-
scribed as followed [6, 12, 14, 21]: PA is referred
to bodily assaults on a child by an older person
that poses a risk of, or result in, injury; EA is re-
ferred to verbal assaults on a child’s sense of
worth or well-being or any humiliating, demean-
ing, or threatening behavior directed toward a
child by an older person; SA is referred to sexual
contact or conduct between a child and an older
person, including explicit coercion; EN is referred
to the failure of caretakers to provide basic psy-
chological and emotional needs, such as love, en-
couragement, belonging, and support; and PN is
referred to the failure to provide basic physical
needs, including food, shelter, and safety. Each
question is to ask participants in the context of
“when you were growing up” whether he or she
had experienced the maltreatment event, and an-
swers are scored on a five-point scale ranging
from 1 (never true) to 5 (very often true). In this
study, we used the cutoff scores of CTQ-SF for
mild to moderate severity as suggested (8, 9, 6,
10, and 8 for PA, EA, SA, EN, and PN, respec-
tively) [11, 22], to estimate the prevalence of vari-
ous types of CTEs in our study sample.
Translation of CTQ-SF into Chinese ver-
sion
After we obtained approval from the original
author, D. P. Bernstein [6], the CTQ-SF was ini-
tially translated into Chinese by MCH and KRC.
One bilingual mental health professional back-
translated the Chinese version into the English
version, producing versions identical to the origi-
nal one. Then, the version was reviewed again by
Dr Bernstein, who confirmed that translated ver-
sion was consistent with the intended meaning of
the original one.
Statistical analysis
The internal consistency and test-retest reli-
ability of the C-CTQ-SF were evaluated using
Cronbach’s α coefficients and intraclass correla-
tion coefficients (ICCs), respectively. We did con-
firmatory factor analysis (CFA) to test the validity
of the original five-factor structure suggested by
Bernstein, and to test the fit of individual items on
each factor using Mplus [23].
We used the weight least-square with the
mean and variance correction estimation method
to evaluate the chi-square goodness-of-fit of the
CFA methods. Three other indices were chosen to
assess the model fit, i.e. the Tucker–Lewis index
(TLI), the comparative fit index (CFI), and the
root mean square error of approximation
(RMSEA). TLI and CFI values close to 0.95 indi-
cate a good fit [24]. RMSEA values less than 0.05
indicate a good fit, with values between 0.05 and
0.08 indicating a reasonable fit [25-27]. We also
 Cheng YC, Chen CH, Chou KR, et al. • 55 •

used exploratory factor analysis (EFA) to examine Table 1. Demographic and clinical characteristics for
the underlying factor structure for our clinical respondents (N = 160)
samples to identify whether an improved solution Clinical sample
Characteristic (%)
existed for the C-CTQ-SF. The number of factors (N = 160)
retained was determined using eigenvalues and Age in years (mean ± SD) 31.1 ± 7.31
the variance explained by each factor. Factors Male 117 (73)
with engenvalues higher than 1 were extracted. Educational years (mean ± 12.6 ± 2.7
We did EFA with an oblique rotation to evaluate SD)
Occupation
the chosen factor structure. A salient factor load-
Employed 126 (79)
ing of being greater than 0.4 was used to deter-
Unemployed 29 (18)
mine the items for each factor [12].
Student 5 (3)
Marriage status
Results Single 118 (74)
Married 26 (16)
Table 1 lists the demographic data and clini- Divorced 16 (10)
cal characteristics for respondents (N = 160). Primary Substance Use
Table 2 describes internal consistency and test- Methamphetamine 72 (45)
retest reliability of the Chinese Trauma MDMA 46 (29)
Questionnaire-Short Form. Table 3 shows factor Ketamine 10 (6)
loading for 25 items of Chinese Trauma Alcohol 16 (10)
Questionnaire-Short Form from the confirmatory Others 16 (10)
factor analysis of the original 5 factor model. C-CTQ-SF scale scores
(mean ± SD), (%)§
Table 4 displays factor loadings for 25 items of
Physical abuse 7.7 ± 3.8 (35)
Chinese Trauma Questionnaire-Short Form from
Emotional abuse 8.4 ± 3.4 (38)
the exploratory factor analysis of the 5 factor
Sexual abuse 5.8 ± 1.6 (29)
model. Table 5 are correlations among total and
Emotional neglect 12.3 ± 4.8 (71)
sub-scales of the Childhood Trauma Questionnaire-
Physical neglect 9.4 ± 3.1 (70)
Short Form from the original 5 factor model (N =
CTQ-SF, Childhood Trauma Questionnaire-Short Form
160). §
Cut-off scores for various types of childhood trauma
experiences: 8 for physical abuse, 9 emotional abuse, 6
Discussion sexual abuse, 10 emotional neglect, and 8 physical neglect

In our study (Table 2), the C-CTQ-SF was
found to have adequate test–retest reliability and
internal consistency, except for the PN subscale,
in a clinical sample of substance use disorders. All
listed factor loadings in PN1, PN2, PN4, PN6 and
PN 26 were mostly lacking because those values
were smaller than 0.4 (Table 4). Otherwise, CFA
showed favorable factor loadings for the sub-
scales, except a relatively low factor loading for
the PN. The subsequent EFA suggested a five-
factor model, with four latent factors in agreement
with the corresponding subscales of the original
version of the CTQ-SF: factor 1 reflecting EA,
factor 2 reflecting EN, factor 4 reflecting PA, and
factor 5 reflecting SA. But a stable latent factor
could not be obtained for the items of PN.
• 56 • Reliability and Validity of CTQ-SF
Table 2. Internal consistency and test-retest reliability
of the Chinese Trauma Questionnaire-Short Form
Internal Test-retest
consistency§ reliability†
Physical abuse 0.895 0.839
Emotional abuse 0.774 0.852
Sexual abuse 0.710 0.674
Emotional neglect 0.859 0.771
Physical neglect 0.574 0.762
Total scale 0.884
§
The internal consistency for each domain uses Cron-
bach’s α coefficients
†
Test-retest reliability was assessed with the intraclass
correlation coefficient
The finding that the PN subscale had inade-
quate internal consistency and low factor loading
in C-CTQ-SF. As shown in Table 2, the PN score
for internal consistency was only 0.574. This
finding is consistent with the observations of the
original version of CTQ-SF [14] and other studies
that examined the factor structures of the CTQ-SF
[2, 3, 20, 28, 29]. In fact, the neglect construct of
the EN and PN subscales might exhibit some con-
ceptual overlap, resulting in poor differentiation
between these two subscales. EN is referred to the
failure of caretakers to provide basic psychologi-
cal and emotional needs whereas PN is referred to
failure to provide basic physical needs including
food, shelter, and safety. It is conceivable that
both of them may occur concurrently when people
report that their families did not care for them or
did not fulfill their needs. In line with this notion,
both our results (Table 5) showing 0.803 in score,
and previous evidence [1, 12, 15, 30] showed that
PN and EN had the highest correlation among all
subscales, implying an overlaying construct
shared between EN and PN.
Gerdner and Allgulander (2009) suggested
that the PN of the CTQ consists of two related di-
mensions: “lack of care” (items PN2 and PN26)
and “lack of supervision” (items PN1, PN4, and
PN6) [2]. The dimension of “lack of care” (item 2:
“I knew that there was someone to take care of me
and protect me” and item 26: There was someone
to take me to the doctor if I needed it) focused on
the lack of care by the families. This dimension
has both physical and emotional connotations, and
it is implicated in both PN and EN. The other di-
mension of “lack of supervision” (item 1: I didn’t
have enough to eat, item 4: My parents were too
drunk or high to take care of the family, and item
6: I had to wear dirty clothes) focused on the par-
ents’ misuse problem rather than whether care is
actually lacking; it may have less emotional con-
notation to intermingle with EN [2]. The two sep-
arate dimensions might account for the heteroge-
neity of the PN subscale. It is likely that the
heterogeneity of the PN subscale contribute to the
inadequate goodness-of-fit revealed by CFA and
the complicated loading patterns of EFA.
Consisting with previous studies [2, 3], item PN2
and item PN26 in EFA were loaded on the latent
factor referring to EN, suggesting that the two
items may conceptually overlap with EN. In addi-
tion, two items in the PN subscale did not have
salient factor loading, and a factor representing
PN did not emerge in EFA, further indicating the
structure ambiguity of the neglect construct. This
might in turn cause difficulty for creating a cutoff
point in the C-CTQ-SF and for distinguishing the
severity of each trauma subtype [31].
The factor structure of the PN subscale in our
study (Table 4) was not stable. This observation
might be due to gender effect (Table 1), in which
we enrolled 73% (117 out of 160) of male partici-
pants. The disproportionate sex distribution could
have influenced One previous study evaluating
the factor validity of the CTQ-SF according to sex
suggested sex differences in the factor structures
 Cheng YC, Chen CH, Chou KR, et al. • 57 •

Table 3. Factor loadings for 25 items of Chinese Trauma Questionnaire-Short Form from the confirmatory factor
analysis of the original 5 factor model§

Physical Emotional Sexual Emotional Physical

abuse abuse abuse neglect neglect
Physical abuse
PA9-Hit hard enough to see a doctor 0.956
PA11-Hit hard enough to leave bruises 0.922
PA12-Punished with hard objects 0.853
PA15-Was physically abused 0.867
PA17-Hit badly enough to be noticed 0.900
Emotional abuse
EA3-Called names by family 0.694
EA8-Parents wished was never born 0.796
EA14-Family said hurtful things 0.842
EA18-Felt hated by family 0.774
EA25-Was emotionally abused 0.595
Sexual abuse
SA20-Was touched sexually 0.794
SA21-Hurt if didn’t do something sexual 0.827
SA23-Made to do sexual things 0.866
SA24-Was molested 0.916
SA27-Was sexually abused
Emotional neglect
EN5-Made to feel important (R)† 0.600
EN7-Family felted loved (R)† 0.799
†
EN13-Was looked out for (R) 0.837
†
EN19-Family felt close (R) 0.908
†
EN28-Family was source of strength (R) 0.839
Physical neglect
PN1-Not enough to eat 0.491
†
PN2-Got taken care of (R) 0.651
PN4-Parents were drunk or high 0.557
PN6-Wore dirty clothes 0.673
PN26-Got taken to doctor (R)† 0.446

PA, physical abuse; EA, emotional abuse; SA, sexual abuse; EN, emotional neglect; PN, physical neglect
§
Highest Factor loading plus factor loading > 0.4 are shown, loading smaller 0.4 were not displayed.
†
Items presented in abbreviated form (R) indicates reverse coded and scored
• 58 • Reliability and Validity of CTQ-SF

Table 4. Factor loadings for 25 items of Chinese Trauma Questionnaire-Short Form from the exploratory factor
analysis of the 5 factor model

F1 F2 F3 F4 F5
Physical abuse
PA9-Hit hard enough to see a doctor 0.899
PA11-Hit hard enough to leave bruises 0.871
PA12-Punished with hard objects 0.824
PA15-Was physically abused 0.579
PA17-Hit badly enough to be noticed 0.873
Emotional abuse
EA3-Called names by family 0.843
EA8-Parents wished was never born 0.673
EA14-Family said hurtful things 0.622
EA18-Felt hated by family 0.493
‡
EA25-Was emotionally abused 0.527 0.449
Sexual abuse
SA20-Was touched sexually 0.816
SA21-Hurt if didn’t do something sexual‡ 0.889 0.421
SA23-Made to do sexual things 0.761
SA24-Was molested 0.939
SA27-Was sexually abused
Emotional neglect
EN5-Made to feel important (R)† 0.512
EN7-Family felted loved (R)† 0.703
†
EN13-Was looked out for (R) 0.922
†
EN19-Family felt close (R) 0.913
EN28-Family was source of strength (R)† 0.798
Physical neglect
PN1-Not enough to eat
PN2-Got taken care of (R)† 0.727
PN4-Parents were drunk or high
PN6-Wore dirty clothes 0.469
†
PN26-Got taken to doctor (R) 0.591
Engenvalues 9.767 3.243 2.239 1.431 1.113
Percentages total variance 40.7 13.5 9.3 6.0 4.6

PA, physical abuse; EA, emotional abuse; SA, sexual abuse; EN, emotional neglect; PN, physical neglect
§
Highest Factor loading plus factor loading > 0.4 are shown, loading smaller 0.4 are not displayed.
†
Items presented in abbreviated form (R) indicates reverse coded and scored
‡
Indicates cross-loading of item on more than one factor

Table 5. Correlations among total and sub-scales of the Childhood Trauma Questionnaire-Short Form from the
original 5 factor model (N = 160)
C-CTQ–SF Physical
Total abuse
Physical abuse 0.733*** 1 0.557***
Emotional abuse 0.789***
Sexual abuse 0.340***
Emotional neglect 0.801***
Physical neglect 0.803***
*p < 0.05, **p < 0.01, ***p < 0.001
CTQ-SF, Childhood Trauma Questionnaire-Short Form
[32]. In their CFA, a relatively poor fit with the
predicted factor structure and the PN items (item
PN2 and item PN26) loaded onto the EN factor is
noted for men. The disproportionate sex distribu-
tion could have influenced the factor structure.
Therefore, in addition to the possible heterogene-
ity of the PN subscale, the male predominance in
substance use populations may also contribute to
the disfavored psychometric properties of the PN
subscale.
We found item SA27 (I believe I was sexu-
ally abused) is not informative in the C-CTQ-SF.
All participants denied history of SA in item
SA27. The underlying reason is not clear and
might be attributable by cultural differences. In
the Chinese culture in the Taiwanese society,
Taiwanese are reluctant to disclose their abuse ex-
perience, in particular SA [33]. When being en-
countered SA, Taiwanese tend to conceal the ex-
periences owing to the guilty and shameful
feeling. Previous evidence also suggests that men
report less SA than women. Among individuals
with a history of documented SA in childhood, far
fewer men than women considered their child-
hood trauma experience as SA [34]. Collectively,
the failure to admit this item may result from the
culture factor in Taiwanese society and the dispro-
portionate sex distribution in our samples.
Cheng YC, Chen CH, Chou KR, et al. • 59 •
Emotional Sexual Emotional Physical
abuse abuse neglect neglect
0.180* 0.377*** 0.399***
1 0.296** 0.453*** 0.501***
1 0.040 0.234*
1 0.676***
1
Among CTE types, we found that our partici-
pants had a high rate of CTE, with neglect (EN
and PN) being the most prevalent type and SA the
least. Compared with nonreferral samples [22,
35], the rate of PN or EN in our patients was high-
er. In addition, in agreement with our finding, pre-
vious study using the CTQ-SF with similar cutoff
scores in different populations also reported that
neglect was the most frequently encountered CTE
type [22, 35]. Only limited studies so far have ad-
dressed the prevalence of childhood neglect or
abuse in substance use individuals [5, 36].
Although it is difficult to directly compare our re-
sults regarding the rates of CTE with other studies
that employed different measurements of CTE or
enrolled different populations, nevertheless, the
greater prevalence of childhood neglect in pa-
tients with substance abuse problems indicates a
critical need for a validated assessment tool that is
able to broadly evaluate multiple types of CTE.
Study limitations
The readers are warned not to over-interprete
the study results because this study has three ma-
jor limitations.
• We only recruited patients with substance use
disorders, and 73% of our study patients were
men. The specific nature of the study partici-
• 60 • Reliability and Validity of CTQ-SF
pants may limit the generalizability of our re-
sults to other groups of individuals.
• The relatively small sample size in this study
may also limit the representativeness of this
study. Therefore, additional studies with larger
sample size using nonclinical participants are
needed to validate the utility of the C-CTQ-SF.
• The retrospective self-report of CTE may be
subjective to recall bias. We did not collect col-
lateral information or use other instrument of
childhood trauma to verify the subjective expe-
riences and in the meantime examine the dis-
criminative and concurrent validity of the
CTQ-SF.
Summary
The adequate reliability and factor structure
of C-CTQ-SF support the use of this instrument in
substance use populations. Being consistent with
reports in the literature, the PN subscale has rela-
tively low internal consistency and factor load-
ings. Considering the structural ambiguity within
the CTQ-SF constructs, in particular the PN sub-
scale, additional studies including both clinical
and healthy participants are required to create a
more optimal factor solution for the C-CTQ-SF
across different populations. Future work is need-
ed to establish an appropriate severity threshold,
along with proper revision, or even elimination, of
some weak items, for distinguishing and a better
characterization of each CTE type.
Acknowledgments
We thank David P. Bernstein for agreeing on
this validation work for the Chinese Version of
Childhood Trauma Questionnaire-Short Form.
We also thank Heng-Hsiu Liu for the help in sta-
tistical analyses. This work was supported by
grants from Taipei City Hospital (grant number
10501-62-040, 10601-62-018), and Ministry of
Science and Technology, Taiwan. (grant number
MOST 103-2628-B-532 -001 -MY3, 106-2314-
B-532 -005 -MY3).
All authors approved the final manuscript.
All authors declare that they have no potential
conflicts of interest in writing this article.
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