INTRODUCING THE EARLY TRAUMA INVENTORY SELF REPORT - 
SHORT FORM AND ITS QUALITATIVE AND QUANTITATIVE VALIDATION 
FOR THE SLOVENIAN GENERAL POPULATION 
Jelena RISTIĆ - ILIĆ1*, Andrej KASTELIC1
1University Psychiatric Hospital Ljubljana, Centre for the Treatment of Drug Addiction, 
Grablovičeva 48, 1000 Ljubljana, Slovenia
*Corresponding author: Tel. + 386 40 184 574; E-mail: jelena.ristic@psih-klinika.si
10.2478/sjph-2020-0031 Zdr Varst. 2020;59(4):245-255
245
PREDSTAVITEV KVALITATIVNE IN KVANTITATIVNE 
VALIDACIJE SLOVENSKE RAZLIČICE KRATKE OBLIKE 
VPRAŠALNIKA ZA SAMOOCENO TRAVM IZ OTROŠTVA
Ristić – Ilić J, Kastelic A. Introducing the early trauma inventory self report - short form and its qualitative and quantitative validation for the Slovenian 
general population. Zdr Varst. 2020;59(4):245-255. doi: 10.2478/sjph-2020-0031.
Received: Jul 7, 2020
Accepted: Sep 16, 2020 
Original scientific article
ABSTRACT
Keywords: 
childhood trauma, 
Early Trauma 
Inventory, 
psychometric 
properties, 
validation studies, 
addictions
IZVLEČEK
Ključne besede: 
travmatske 
izkušnje v otroštvu, 
Vprašalnik za 
samooceno travm 
iz otroštva, 
psihometrične 
lastnosti, 
validacijske študije, 
odvisnosti
Introduction: Traumatic experience in childhood or adolescence has a significant impact on the development of 
chronic mental and physical conditions in adulthood. Thus, it is very important for health professionals, especially 
primary care physicians to have an inventory in order to detect early trauma for planning appropriate treatment, 
such as the Early Trauma Inventory (ETI). The aim of this paper is to test the psychometric properties of the Slovenian 
translation of the short, self-rated version (ETISR-SF), and to further validate the instrument.
Methods: The research was done in two parts – qualitative and quantitative. In the qualitative part, a questionnaire 
was translated and culturally adapted using the Delphi method. For the quantitative part, 51 patients with substance 
use disorders hospitalized at the Centre for the Treatment of Drug Addictions were recruited, along with 133 controls. 
The psychometric properties of the questionnaire were checked. Internal consistency was calculated using Cronbach’s 
alpha, test-retest reliability was examined graphically using a Bland-Altman plot. Discriminant validity between groups 
was gauged using the independent samples t-test.
Results: Consensus in the Delphi study was reached in the second round. Cronbach’s alpha varied between 0.60 - 0.85. 
Of the four domains, physical abuse had the lowest Cronbach’s alpha. The test-retest reliability is high for all domains, 
with correlation coefficients ranging from 0.82 to 0.96. The non-clinical sample differed significantly from the clinical 
sample.
Conclusion: The Slovenian translation of ETISR-SF is a satisfactory instrument for the evaluation of trauma before the 
age of 18.
Uvod: Po poročilu Nacionalnega inštituta za javno zdravje smo v Sloveniji lani prvič ugotavljali razširjenost 
obremenjujočih izkušenj v otroštvu. Večina anketiranih (76 %) je v otroštvu doživela vsaj eno, dobra četrtina (27 %) 
pa štiri ali več obremenjujočih izkušenj. Travmatične izkušnje v otroštvu ali mladostništvu pomembno vplivajo na 
razvoj kroničnih duševnih in telesnih motenj v odrasli dobi in predstavljajo pomemben javnozdravstveni problem 
povsod po svetu. V Sloveniji še nimamo veljavnega in zanesljivega vprašalnika za presejanje, s katerim bi pri odraslih 
lahko ugotavljali zgodnje travmatične izkušnje. Vprašalnik za samooceno travm iz otroštva – kratka oblika (The 
Early Trauma Inventory Self Report – Short Form ETISR-SF) je eden takih vprašalnikov, ki omogoča hiter in zanesljiv 
pregled potencialnih travmatičnih dogodkov v otroštvu in mladostništvu. Z njim lahko hitro dobimo izhodišče za bolj 
poglobljeno raziskovanje v klinično-terapevtski praksi. Namen prispevka je predstaviti preverjanje psihometričnih 
lastnosti slovenskega prevoda kratke samoocenjevalne različice ETISR-SF in dodatno potrditi veljavnost vprašalnika.
Metode: Raziskava je bila izvedena v dveh delih. V kvalitativnem delu je bil vprašalnik preveden in kulturološko 
prilagojen s pomočjo študije delphi. Od povabljenih 51 specializantov psihiatrije se jih je v študijo delphi vključilo 
8. V kvantitativnem delu so bile preverjene psihometrične lastnosti vprašalnika v klinični in neklinični populaciji. 
Vključenih je bilo 51 pacientov z motnjo odvisnosti od psihoaktivnih snovi, hospitaliziranih na Centru za zdravljenje 
odvisnih od prepovedanih drog, in 133 oseb v kontrolni skupini. Notranja konsistentnost je bila izračunana z uporabo 
koeficienta alfa Cronbach, zanesljivost preizkusnega testiranja je bila grafično preučena s pomočjo ploskve Blanda 
Altmana. Diskriminantna veljavnost med skupinami je bila ocenjena s t-testom za neodvisne vzorce.
Rezultati: V kvalitativnem delu raziskave je bilo soglasje s prevodom doseženo po dveh krogih delphi z nekaj 
manjšimi jezikovnimi popravki. V kvantitativnem delu raziskave se je 56 (42 %) oseb iz kontrolne skupine odzvalo na 
ponovno izpolnjevanje vprašalnika čez 14 dni. Zanesljivost preizkusa ponovnega testiranja je visoka za vsa področja 
s korelacijskimi koeficienti od 0,82 do 0,96. Koeficient Cronbach alfa se je gibal med 0,60 in 0,85. Del o fizični zlorabi 
je pokazal nižjo vrednost Cronbach alfe kot ostali deli (splošna travma, psihična in spolna zloraba). Zanesljivost dela 
o čustveni in spolni zlorabi je visoka (α = 0,85 in α = 0,82). Neklinični vzorec se je statistično značilno razlikoval od 
kliničnega vzorca.
Zaključek: Slovenski prevod ETISR-SF je zadovoljiv instrument za hitro oceno travmatskih izkušenj do 18. leta starosti.
© Nacionalni inštitut za javno zdravje, Slovenija. 
1 INTRODUCTION
According to the Diagnostic and Statistical Manual of 
Mental Disorders V, childhood trauma is defined as 
exposure to actual or threatened death, serious injury, 
or sexual violence (1). It has a significant impact on the 
development of chronic mental and physical conditions 
in adulthood, which results in increased use of medical 
services, especially emergency units (2-4). Childhood 
trauma is also associated with impaired psycho-social 
functioning and lower quality of life (2). Experiencing 
childhood trauma compromises both neural structure 
and function, rendering individuals susceptible to later 
cognitive deficits and psychiatric illnesses, such as 
schizophrenia, depression, bipolar disorder, anxiety, 
posttraumatic stress disorder (PTSD), substance abuse, 
and even suicide, in adolescence, young adulthood or 
later life (5, 6). Somatoform symptoms, which may relate 
to other psychological consequences of trauma, such 
as depression, anxiety, dissociation, and PTSD, are also 
linked to traumatic exposure (7). Stress is associated 
with a multiple immune and endocrine changes (8). 
Exposure to multiple and chronic stressors represents 
a particular risk for asthma, environmental sensitivity 
in the form of allergies to medications, cardiovascular 
health, gastrointestinal problems and migraine headaches 
(2, 4, 8, 9). The more severe the abuse is, the stronger 
is the association with poor outcomes in adulthood (3). 
Psychosomatic disorders, which in family practice are 
also called medically unexplained symptoms (MUS), are 
frequently associated with a history of traumatization 
(10). In a Slovenian family medicine practice it was 
found that 8.6% of patients had MUS attendees (11). 
A recent study by the Slovenian National Institute of 
Public Health showed that 76% of participants reported 
at least one and 27% four or more traumatic experiences 
in childhood (12). These are important findings for both 
psychiatrists and primary care physicians (9). To better 
understand patients’ symptoms, it is important for health 
professionals to have a structured and comprehensive tool 
for measuring traumatic events in childhood (13). One of 
these is the Early Trauma Inventory (ETI) (14), created by 
Bremner et al. as a comprehensive expert-rated interview. 
A self-rated version (ETI-SR) was later developed and 
briefer self-rated short form (ETISR-SF) was made after 
a psychometric analysis identified redundant items (15). 
The ETISR-SF has been proven to be a valid instrument 
for retrospective self-assessment of childhood trauma in 
diverse populations (subjects with substance use disorders, 
war veterans, depressive patients and puerperae) (15-19), 
and has good test-retest reliability (17-19). It consists of 27 
items in the four domains of physical, emotional, sexual 
abuse, and general trauma (15). It categorically assesses 
the existence of these events before the age of 18 (15).
10.2478/sjph-2020-0031 Zdr Varst. 2020;59(4):245-255
246
The ETISR-SF has been translated with preserved 
psychometric properties to several cultural contexts and 
languages, including: Spanish (17), Korean (18), Brazilian 
Portuguese (19), Dutch (20) and Swedish (21). However, to 
the best of our knowledge, it has not yet been translated 
or psychometrically tested with regard to Slovenian. 
The benefits of this instrument lay in early, quick and 
economical screening for traumatic experiences, which 
could enable health care professionals to prevent more 
serious health and social consequences and also spare the 
system some costs due to unnecessary and often invasive 
diagnostic procedures. This represents a major advantage 
for the public health system, and gives a starting point for 
more in-depth exploration in clinical-therapeutic practice 
and research work.
2 METHODS
2.1 Aims 
The aims of this study were to obtain semantic, cultural 
and conceptual translation and equivalence of the ETISR-
SF questionnaire in Slovenian, examine the psychometric 
properties and further validate the instrument. 
2.2 Instruments
2.2.1 Socio-Demographic Characteristics Questionnaire 
The participants answered demographic questions 
assessing gender (male/female), age (years), marital 
status (single/married/in relationship/separated/
widowed), children (yes/no), number of children, with 
whom currently living (alone/with parents/with child/with 
partner/with partner and child/with friends/homeless/
other), level of education (several options were offered), 
employment status (several options were offered). The in-
patients group gave additional data: participation in drug 
substitution programme, history of overdose, self-injury, 
attempted suicide and age of drug use. 
2.2.2 The Early Trauma Inventory Self Report – Short 
Form 
The ETISR-SF is a 27-item questionnaire, used for the 
assessment of physical, emotional, and sexual abuse, 
as well as general traumatic experience that may have 
occurred before the age 18, and it can be self-administered 
in about 15 min. Each of the items is answered ‘yes’ (coded 
as 1) or ‘no’ (coded as 0). There are an additional three 
items, which are at the end of questionnaire. One of these 
asks the subjects to choose one event that had the greatest 
impact on his/her life, and other two items measure the 
subsequent reactions, i.e. fear or depersonalization. 
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2.3 Design and Participants of the Study
Validation of the ETISR-SF questionnaire was done in two 
parts of the study, using qualitative and quantitative 
methods. 
2.3.1 Qualitative Part of the Study
The ETISR-SF was translated from its original English 
version with permission from J. D. Bremner. It was first 
translated from English to Slovenian by two doctoral 
students, employed at the University Psychiatric Hospital 
Ljubljana, with fluent knowledge of English. In order to 
reconcile the equivalence of the translated versions of 
the inventory, these were compared and discussed by a 
team of six health care experts from the Centre for the 
Treatment of Drug Addiction (three psychiatrists, two 
psychologists and social worker), with all having good 
knowledge of English and Slovenian, resulting in few minor 
corrections. A sample of 51 residents of psychiatry at the 
University Psychiatric Hospital Ljubljana were invited 
via email to participate in the Delphi method to achieve 
consensus. All participants were provided with a written 
explanation of the aims and procedure of the study. 
Among those 51 invited experts, eight took part in the 
study. Each participant was asked to validate or reject a 
translation by rating each statement on a scale from 1 to 5, 
where 1 meant “strongly disagree” and 5 “totally agree”. 
If they rated a translation with 3 or less they were asked 
to explain their disagreement and possibly propose more 
a suitable translation. The principal researcher evaluated 
the answers. Successful validation for each statement was 
obtained when at least 75% of the participants rated it 4 
or above. If a statement did not meet this criterion, the 
principal researcher proposed a new translation, taking 
into account the participants’ suggestions, which was 
then again sent to the group. Consensus was reached in 
the second round. Two independent English translators 
undertook back-translation. The back-translated inventory 
was very similar to the original version, and was confirmed 
by the author. 
Table 1. ETISR-SF part one – General trauma scale Likert scores, mean and median – Round 1 (N=8).
Legend: n – number of participants; Q – question
>3 (n/8)
>3 (%)
Mean
Median
6
75
4
4
1
12.5
2.875
3
7
87.5
4
4
3
37.5
3
3
8
100
4.25
4
8
100
4.37
4
7
87.5
4
4
6
75
4
4
8
100
4.25
4
8
100
4.37
4
8
100
4.25
4
Results Q8Q5 Q10 Q11Q7Q4Q2 Q9Q6Q3Q1
2.3.2 Quantitative Part of the Study
In the second part, ETISR-SF questionnaires were 
distributed to non-clinical and clinical populations. The 
non-clinical population was recruited among employees 
at the University Psychiatric Hospital Ljubljana, in order 
to examine the test-retest reliability. Questionnaires were 
distributed to 160 participants and were anonymous. In the 
first round 133 were returned, and after 14 days a further 
56 questionnaires. Questionnaires were also completed by 
51 in-patients at the Centre for the Treatment of Drug 
Addiction. Patients signed Consent Forms in which they 
were given all the related information about the study.
As the items were dichotomous, the means and standard 
deviations per item were calculated with means indicating 
the percentage of respondents who had experienced a 
particular traumatic event. Total score and the scores for 
each domain were obtained by counting the number of 
endorsed items (15). Discriminative validity was assessed 
by comparison of the following groups with regard to 
the ETISR-SF numerical score: patients with a history of 
drug abuse and healthy subjects (controls), and subjects 
experiencing severe fear, horror or out-of-body experiences 
at the time of traumatic the event, and subjects without 
such feelings. The independent samples t-test was used. 
Test-retest reliability was examined graphically by means of 
a Bland-Altman plot and the correlation between the two 
measurements was calculated. Cronbach’s coefficient alpha 
was calculated as a measure of internal consistency of the 
questionnaire. Item-to-total correlation and Cronbach’s 
alpha minus item reliability was calculated to identify items 
that influence the poorer validity and internal consistency 
of a particular subscale. P values<0.05 were considered 
statistically significant. Statistical analysis was performed 
using SPSS version 26.
3 RESULTS
3.1 Qualitative Part of the Study
The first Delphi round for the four parts of ETISR-SF plus 
three additional questions at the end of the inventory 
showed acceptable agreement in most of the statements. 
The first part of the inventory, on general trauma, showed 
agreement in all except two statements (Q5, Q11). Q5 was 
rated as adequate by only 1/8 (12.5%) of participants and 
Q11 by 3/8 (37.5%) participants (Table 1).
248
10.2478/sjph-2020-0031 Zdr Varst. 2020;59(4):245-255
The, second part of the inventory, on physical abuse, 
showed agreement in all except one statement (Q4). 
Q4 was rated as adequate by just 1/8 (12.5%) of the 
participants (Table 2).
Table 2.
Table 3.
Table 4.
Table 5.
ETISR-SF part two – Physical abuse scale Likert scores, mean and median – Round 1 (N=8).
ETISR-SF part three – Emotional abuse scale Likert scores, mean and median – Round 1 (N=8).
ETISR-SF part four – Sexual abuse scale Likert scores, mean and median – Round 1 (N=8).
ETISR-SF additional three items scale Likert scores, mean and median – Round 1 (N=8).
Legend: n – number of participants; Q – question
Legend: n – number of participants; Q – question.
Legend: n – number of participants; Q – question.
Legend: n – number of participants; Q – question.
>3 (n/8)
>3 (%)
Mean
Median
>3 (n/8)
>3 (%)
Mean
Median
>3 (n/8)
>3 (%)
Mean
Median
>3 (n/8)
>3 (%)
Mean
Median
6
75
4.25
4.5
8
100
4.625
 5
2
25
2.875
2.5
7
87.5
4.25
4
1
12.5
2.875
3
5
62.5
3.75
4
8
100
4.5
4.5
7
87.5
4.25
4
2
25
3
3
8
100
4.25
4
7
87.5
4.125
4
6
75
3
3
1
12.5
2.75
3
8
100
4.37
4
7
87.5
4.25
4.5
8
100
4.625
5
8
100
4.25
4
5
62.5
3.875
4
7
87.5
4.125
4
Results
Results
Results
Results
Q5
Q5
Q5 Q6
Q4
Q4
Q4
Q2
Q2
Q2
Q2
Q3
Q3
Q3
Q3
Q1
Q1
Q1
Q1
The third part of the inventory, on emotional abuse, 
showed agreement in all except two statements (Q2, Q3). 
Q2 was rated as adequate by 2/8 (25%) of participants, 
and Q3 by only 1/8 (12.5%) of the participants (Table 3).
The fourth part of the inventory, on sexual abuse, showed 
agreement in all except one statement (Q5). Q5 was rated 
as adequate by 2/8 (25%) of participants (Table 4).
Three additional questions at the end of the inventory 
showed agreement in all statements (Table 5).
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249
Table 6. Mean and median:  ETISR-SF – general trauma Q5, Q11, physical abuse Q4, emotional abuse Q3 and sexual abuse 
Q5 – Round 2 (N=8).
Legend: GT – general trauma; PA - physical abuse; EA - emotional abuse; SA - sexual abuse; Q – question
Mean
Median
4.625
 5
4
4
4.5
4.5
4
4
4.25
4
Results SA - Q5EA – Q3GT – Q11 PA – Q4GT – Q5
In second Delphi round, concerning Q5 and Q11 for the 
part on general trauma, Q4 for the part on physical abuse, 
Q3 for the part on emotional abuse and Q5 for the part on 
sexual abuse, the participants proposed few alternative 
translations, which were discussed by the team from the 
Centre for the Treatment of Drug Addiction and then sent 
back to the participants for valuation. Consensus was thus 
reached in the second round (Table 6).
Table 7. Participants’ characteristics.
Sex 
Female 
Male
Mean age (SD) in years
Education 
Elementary school 
Vocational school 
High school 
University or more
Working status 
Unemployed 
Employed 
Student 
Retired
Group
Controls
Patients 
Drug substitution program 
Overdosed 
Self-injury 
Suicide attempt 
Mean age (SD) of 1st drug use
  
97 (52.7) 
87 (47.3)
37.8 (9.2)
 
27 (14.7) 
22 (12) 
51 (27.7) 
84 (45.7)
 
40 (21.7) 
138 (75) 
5 (2.7) 
1 (0.5)
133 (72.3)
51 (27.7) 
29 (56.9) 
21 (41.2) 
11 (21.6) 
14 (27.4) 
15.1 (3)
n=184 (%)
3.2 Quantitative Part of the Study - Study Subjects
Overall, 184 subjects agreed to participate in this 
research, 51 (27.7%) patients with substance use disorders 
and 133 (72.3%) healthy subjects (controls). Ninety-seven 
(52.7%) of the participants were female. The mean (SD) 
age of the participants was 37.8 (9.2) years. More than half 
(54.3%) had less than university education. The majority 
of participants (75%) were employed. Twenty-nine (56.9%) 
participants with substance use disorders were included 
in an opioid substitution programme, 21 (41.2%) reported 
the experience of overdose, 11 (21.6%) self-injury and 
14 (27.4%) attempted suicide. The mean age (SD) of the 
patients with substance abuse disorders when trying their 
first drug was 15.1 (3) years.  
3.3 Quantitative Part of the Study - Validity
The validity of ETISR-SF was measured by its ability to 
distinguish between patients with known drug abuse 
and healthy controls. It was also assessed by comparing 
participants reporting experiencing severe fear, horror, 
frustration or having out-of-body experiences when 
experiencing any traumatic event described in the ETISR-
SF and participants without such feelings. 
The results of the comparison in all ETISR-SF subscales’ 
scores between patients and healthy controls are 
summarized in Table 8. The controls had statistically 
significantly lower scores on all ETI domains. 
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250
Table 8.
Table 9.
Mean ETI scores in healthy subjects (controls) and patients and results of an independent samples t-test.
Mean ETI scores in subjects experiencing severe fear or having out-of-body experiences and subjects without such feelings 
and the results of the independent samples t-test.
General trauma (0 - 11)
Physical abuse (0 - 5)
Emotional abuse (0 - 5)
Sexual abuse (0 - 6)
General trauma (0 - 11)
Physical abuse (0 - 5)
Emotional abuse (0 - 5)
Sexual abuse (0 - 6)
< 0.001
0.005
< 0.001
0.012
<0.001
<0.001
<0.001
<0.001
-4.66
-2.88
-5.09
-2.6
-7.04
-3.84
-8.49
-4.19
2.2 (1.9)
2.2 (1.4)
1.1 (1.6)
0.4 (0.8)
1.7 (1.5)
2 (1.3)
0.6 (1.2)
0.2 (0.5)
3.7 (2.2)
2.8 (1.3)
2.6 (1.9)
1.1 (1.9)
3.7 (2.2)
2.8 (1.3)
2.5 (1.8)
1 (1.6)
Subscale (range)
Subscale (range)
P
P
t value
t value
Controls (n=133)
No severe fear or out of body 
experience (n=95)
Patients (n=51)
Severe fear or out of body 
experience (n=89)
The results of the comparison in all ETISR-SF domains’ 
scores between subjects that experienced severe fear, 
horror, out-of-body experiences during the traumatic 
event and those without such feelings are summarized 
in Table 9. Those without such feelings had statistically 
significantly lower scores on all ETI domains.
3.4 Quantitative Part of the Study - Reliability
The internal consistency of the domains, as measured by 
Cronbach’s alpha, is above Nunnally’s proposed threshold 
of 0.7 (22) for the emotional abuse and sexual abuse 
domains (Table 4), and under this (around 0.60) for the 
general trauma and physical abuse domains. Values 
of Cronbach’s alpha ≥0.60 are, however, considered 
acceptable (23,24). Test-retest reliability is high for all the 
domains, with correlation coefficients ranging from 0.82 
to 0.96 (Table 10).
Table 10. Internal consistency and test-retest reliability.
***p<0.0001
General trauma
Physical abuse
Emotional abuse
Sexual abuse
0.84***
0.82***
0.93***
0.96***
0.64
0.60
0.85
0.82
Test - retest 
(n=58)
Cronbach’s α 
(n=184)
Subscale
Descriptive statistics by item are provided in Table 
11. The most commonly experienced events are being 
slapped in the face (81%) and being pushed or shoved 
(67%). The item-to-total correlation indicates items that 
threaten the domain’s validity and internal consistency, 
while the Cronbach’s alpha values are listed if an item is 
omitted from the domains. In the physical abuse domain 
one item that is poorly correlated with the total domain 
score, and for which its omission would result in a higher 
Cronbach’s alpha, is the experience of being “burned 
with a cigarette”. In contrast, the omission of none of the 
general trauma domain items would result in the higher 
internal consistency of the domain.
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251
Table 11. Frequency of traumatic events, item-to-total correlation and value of Cronbach’s alpha if item is omitted. 
General trauma
Natural disaster
Serious accident
Serious personal injury
Serious injury/illness of parent 
Separation of parents
Serious illness/injury of sibling
Serious injury of friend
Witnessing violence
Family mental illness
Alcoholic parents
See someone murdered
Physical abuse
Slapped in the face
Burned with a cigarette
Punched or kicked
Hit with a thrown object
Pushed or shoved
Emotional abuse
Often put down or ridiculed
Often ignored or made to feel you didn’t count
Often told you are no good
Most of the time treated in cold or uncaring way
Parents fail to understand your needs
Sexual abuse
Touched on intimate parts in a way that was uncomfortable
Someone rubbing their genitals against you
Forced to touch someone’s intimate parts
Someone had genital sex with you against your will
Forced to perform oral sex
Forced to kiss someone in sexual way
 
0.64
0.62
0.61
0.61
0.62
0.63
0.62
0.57
0.59
0.60
0.64
0.58
0.64
0.46
0.48
0.49
0.82
0.82
0.82
0.80
0.83
0.85
0.79
0.78
0.77
0.78
0.81
 
0.13
0.26
0.33
0.33
0.24
0.17
0.29
0.49
0.41
0.34
0.14
0.27
0.11
0.48
0.45
0.44
0.67
0.65
0.65
0.74
0.62
0.52
0.62
0.67
0.71
0.69
0.53
10% (31)
22% (41)
27% (45)
33% (47)
22% (41)
10% (31)
41% (49)
37% (48)
23% (42)
28% (45)
9% (29)
81% (39)
13% (34)
39% (49)
40% (49)
67% (47)
27% (45)
39% (49)
26% (44)
26% (44)
35% (48)
24% (43)
8% (27)
8% (27)
7% (25)
5% (23)
5% (22)
Subscale (range) Cronbach’s α (minus item)Item-to-Total CorrelationMean (SD)
The agreement between the first and second measurements 
was also examined graphically, using a Bland-Altman plot. 
The mean score for each domain on the two measurements 
for each participant was calculated and is shown on the 
x-axis, while the difference between scores is depicted 
on the y-axis. The expected mean difference between 
the scores of the two measurements is 0. The horizontal 
solid line shows the mean difference between the scores 
of the two measurements and is an estimate of bias, 
while the dotted lines represent 95% limits of agreement. 
Outliers lie above the upper and below the bottom dotted 
line. The indicator of high agreement between the two 
measurement occasions is if most points lie inside the 
mean±1.96 SD difference interval. The agreement between 
measurements is highest for the emotional abuse scale, 
but evident also for other domains.
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252
Figure 1. Bland-Altman plots for the test-retest reliability. Each plot illustrates the agreement between time 1 and time 2 
measurements and identifies possible outliers. Each participant is represented on the graph with the mean value of the two 
assessments (x-axis) and difference between the assessments (y-axis). Reference lines show the mean difference between 
time 1 and time 2 (solid line), and 95% limits of agreement for the mean difference (dotted lines).
4 DISCUSSION 
In this paper, we wanted to validate a Slovenian version 
of ETISR-SF and it was done in two parts, using both 
qualitative and quantitative methods. 
The qualitative part of the study obtained semantic, 
cultural and conceptual translation and equivalence of 
ETISR-SF questionnaire in Slovenian using the Delphi 
method (Tables 1-5). Consensus was reached in the second 
round with minor adjustments (Table 6). 
In the quantitative part of the study we examined the 
psychometric properties in clinical and non-clinical 
samples. The clinical sample was composed of in-hospital 
patients with substance use disorders (Table 7). 
The ETISR-SF results showed statistically significant 
differences between these two groups, which is an 
indicator of discriminant validity. Patients with substance 
use disorders reported more traumatic events than the 
healthy control group, especially in the domains of general 
trauma and emotional abuse (Table 8). This was supported 
by comparing respondents experiencing extreme fear or 
out-of-body experiences and those without such feelings, 
which represent emotional responses to traumatic 
events (Table 9). More reported traumatic events in all 
domains were statistically significant related to emotional 
responses. The results from a study by Brajovic et al. 
showed that physical abuse is more strongly associated 
with alcohol use patterns than emotional abuse (25). 
Persons who had experienced four or more categories 
of childhood exposure to traumatic events, compared 
to those who had experienced none, had 4- to 12-
fold increased health risks for alcoholism, drug abuse, 
depression, and suicide attempts, as well as 2- to 4-fold 
increases in smoking and poor self-rated health (26). 
The number of traumatic exposures showed a graded 
relationship to the presence of adult diseases, including 
ischemic heart disease, cancer, chronic lung disease, 
skeletal fractures, and liver disease (26). The Adverse 
Childhood Experiences (ACE) Study suggested that the 
impact of adverse childhood experiences on adult health 
status is strong and cumulative (26). Secondary prevention 
of the effects of adverse childhood experiences will 
first require increased recognition of their occurrence, 
and then effective understanding of the behavioural 
coping devices that are commonly adopted to reduce the 
emotional impact of these experiences (26). 
The second psychometric property was reliability. 
Cronbach’s alpha, as a measure of internal consistency, 
varied among the different domains. The general 
trauma and physical abuse domains exhibited lower 
internal consistency (α=0.64 and α=0.60, respectively) 
than emotional and sexual abuse (α=0.85 and α=0.82, 
respectively) (Table 10). Values were lower than those 
reported in other studies (15, 18, 19, 21) and similar for a 
Spanish version used with postpartum women (17). In the 
domain of general trauma, there are a few events which 
are obviously not typical for our cultural environment, like 
”natural disaster”, ”serious illness/injury of sibling” and 
“saw someone murdered” (Table 11). Within the physical 
abuse domain there is also an event which exhibits a 
low correlation with the overall score and reduces the 
Cronbach’s alpha of the domain. Such events poorly 
correlate with the overall score on the scale and reduce 
its reliability, compared to the results found in other 
research, which indicate possible cultural differences in 
this regard. Similar findings can be found in a German 
validation of the inventory (27). The reliability of the 
scale for the domains of emotional and sexual abuse is 
very strong. Moreover, the values of the Cronbach’s alpha 
coefficient are not problematic, and we have thus decided 
not to exclude items in order to maintain comparability of 
the questionnaire with other countries.
The test-retest reliability of the Slovenian version of 
the ETISR-SF is high for all subscales, with correlation 
coefficients ranging from 0.82 to 0.96 (Table 10). A 
graphical exploration of the test-retest reliability via 
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a Bland-Altmen plot also indicates high measurement 
stability on all subscales (Figure 1). That indicates the 
temporal stability of the measurement, which we want in 
practice. Similar findings were reported in other countries 
(17, 19, 21). 
4.1 Limitations of the Study
One limitation of this research in the first, qualitative part 
was the poor response rate of the invited participants, 
although a higher number would probably not significantly 
affect the results of the translation. In the second, 
quantitative part a limitation is that there is no similar 
instrument in Slovenia to determine the external validity 
of the ETISR-SF. As yet there is nothing similar to the 
ETI interview, which can be used to ascertain trauma-
related characteristics such as duration, start, frequency, 
seriousness, perpetrator relationship or subjective 
significance for trauma survivor. A disadvantage of 
questionnaires is that they only capture a few properties 
of potentially traumatic events, and not the subjective 
meaning that they have for the person who experienced 
them (28). 
In spite of these limitations, this study’s validation of the 
first questionnaire in Slovenian for the detection of early 
traumatic experience in adults showed that the instrument 
is valid for use in various part of the health care system. 
5 CONCLUSION 
Our findings showed that the Slovenian version of the 
ETISR-SF is a satisfactory instrument for the evaluation of 
childhood physical, emotional, and sexual abuse, as well 
as general trauma.
Traumatic experiences in childhood represent an 
important public health problem that has become a global 
epidemic in modern times. The consequences of early 
traumatic experiences can be indicated as psychosomatic 
and somatoform disorders, causing unnecessary, 
expensive and invasive diagnostics, and loss of time for 
starting proper treatment. Therefore, we urgently need a 
quick and economic measurement tool for early screening 
of traumatic events in childhood for use in the primary 
health care system. Such a tool would enable health care 
professionals to optimize the diagnostic process and refer 
patients to therapeutic and/or psychiatric treatment in a 
timely manner.
CONFLICTS OF INTEREST
The author declares that no conflicts of interest exist.
FUNDING
No funding has been received for the execution of this 
study and/or preparation of this manuscript.
ETHICAL APPROVAL
The study protocol was approved, as a part of PhD thesis 
by the Slovenian National Medical Ethics Committee No. 
0120-121/2019/9 on 22nd October 2019.
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Appendix 1. Vprašalnik za samooceno travm iz otroštva – kratka oblika (ETISR-SF).
Prvi del. Splošne travme. Pred 18. letom.
Drugi del. Fizično kaznovanje. Pred 18. letom.
Tretji del. Čustvena zloraba. Pred 18. letom.
Četrti del. Dogodki, povezani s spolnostjo. Pred 18. letom.
Če ste na katerokoli od zgornjih vprašanj odgovorili z “DA”, odgovorite na naslednji vprašanji za tisti dogodek, ki je najbolj 
vplival na vaše življenje. Pri odgovarjanju upoštevajte, kako ste se počutili v času dogodka.
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Ali so se vaši starši razšli ali ločili?
Ali ste kdaj doživeli smrt ali hudo poškodbo brata ali sestre?
Ali ste kdaj doživeli smrt ali hudo poškodbo prijatelja?
Ali ste bili kdaj priča nasilju nad drugimi, vključno z družinskimi člani?
Ali je kdo v vaši družini imel duševno motnjo ali doživel “živčni zlom”?
Ali so imeli vaši starši ali skrbniki težave z alkoholom ali drogami?
Ali ste kdaj videli nekoga umorjenega?
Ali ste kdaj dobili klofuto?
Ali so vas kdaj opekli z vročo vodo, cigareto ali čim drugim?
Ali so vas kdaj tepli ali brcali?
Ali vas je kdaj zadel predmet, ki ga je kdo vrgel v vas?
Ali so vas kdaj porinili ali odrinili?
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Ali vaši starši ali skrbniki pogosto niso uspeli razumeti vas ali vaših potreb?
Ali se je kdo kdaj dotaknil vaših intimnih ali drugih delov telesa (npr. prsi, 
stegen, spolovil) na način, ki vas je presenetil ali vam je bil neprijeten?
Ali je kdaj kdo drgnil svoje spolovilo ob vas?
Ali ste bili kdaj prisiljeni v dotikanje druge osebe po intimnih ali zasebnih delih njihovega telesa?
Ali je kdo imel z vami spolni odnos proti vaši volji?
Ali ste bili kdaj prisiljeni imeti oralni spolni odnos proti vaši volji?
Ali ste bili kdaj prisiljeni poljubiti nekoga na seksualni in ne prijateljski način?
Ali ste občutili hud strah, grozo ali nemoč?
Ali ste imeli občutek, kot da bi bili izven svojega telesa ali kot da bi bili v sanjah?
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