Impact of Childhood Trauma in Borderline Personality Disorder
Mishra Muskan Vipul1*, Dr. Preeti Dixit2
1 PhD Student,Kalinga University, Raipur (CG), India
Email - muskanmishra220@gmail.com
2 PhD Guide, Dept. of Psychology, Kalinga University, Raipur (CG), India
Abstract - Patterns of instability in interpersonal interactions are a hallmark of borderline personality disorder (BPD), a complicated mental health disease, self-image, and affect, accompanied by impulsivity and emotional dysregulation. While the etiology Due to the multifaceted nature of borderline personality disorder (BPD), new research has linked traumatic experiences in early life may play a significant role in its development. This study aims to explore the link between traumatic experiences in childhood and the development of BPD. Through a comprehensive review of existing literature and empirical studies, this research examines the various forms experiences with physical, emotional, and mental trauma throughout childhood sexual abuse, neglect, and family dysfunction, and their potential impact on the neurobiological, psychological, and interpersonal factors in relation to borderline personality disorder. The ways in which traumatic experiences in childhood could bring about and sustain borderline personality disorder symptoms are also explored in this research., such as identity disturbance, affective instability, and difficulties in emotion regulation.
Keywords: personality disorder, trauma, childhood, biomedical systems
INTRODUCTION
More than 30 years of study have investigated whether or whether traumatic experiences in childhood contribute to the development of BPD. There is a high prevalence of intergenerational disordered childhood events, including physical, emotional, sexual, or neglect, and there is a substantial body of research from North American and Western European studies that supports this claim. Specifically, between 40 to 86% of those people with BPD Having come up about having been victims of sexual abuse as children, with McLean and Gallop reporting a high of 94.7 percent in 2003. In addition, between 10% and 73% have said they were physically assaulted by adults in their lives, while between 17% and 25% said they were physically ignored. Patients on the borderline have a history of emotional abuse (reported by 75% of patients) and emotional withdrawal (reported by 70% of patients) in childhood. Borderline individuals are Compared to those without, persons with a history of childhood abuse or neglect are more likely to have an Axis I or Axis II diagnosis.
Childhood sexual assault, according to some experts, is the most important specific social factor in the development of BPD. Those who have experienced sexual abuse as children are far more likely to have symptoms associated with borderline personality disorder (BPD) than those who did not. Persons suffering from a severe personality disorder are prone to report severe sexual abuse symptoms, including: higher rates of intra-familial abuse (72%), more perpetrators (35-79%), earlier onset of abuse (13-60%), use of force (93%), and penetration (33.4-44%). Regardless of the fact that an adult carer abuses 40-75% of borderline patients, Parents are not the only ones that conduct sexual assault on children in borderline samples. On top of that, some people may find it unbearable to remember parental incest when they recollect sexual abuse by grandparents, siblings, or other family members.
Having said that, many variables may increase the likelihood of developing borderline personality disorder (BPD), including sexual abuse. The correlation between sexual abuse in infancy and its effects on Western societies and BPD diagnosis is only minor, according to a meta-analysis of the available literature (including 19 North-American and 2 European studies) done before 1999 by Fossati, Mededdu, and Maffei. Interactions with the risk of sexual abuse and its effects on the development of borderline personality disorder (BPD) are both increased in situations when there are other types of disordered childhood experiences, such as abusive or dysfunctional parental conduct. Caregiver inconsistency, emotional detachment, and physical neglect are more often reported by patients with borderline personality disorder (BPD) who have experienced sexual abuse. They often originate from dysfunctional homes when parents are unable to provide adequate care due to financial hardship or excessive work demands. Be that as it may, those who suffer from borderline personality disorder are predisposed to experiencing relatives with a variety of mental health issues, including but not limited to: anxiety disorders, depression, troubled family dynamics, antisocial behaviour, and drug abuse. Previous studies have shown that instead of only looking at the frequency of sexual abuse, researchers should evaluate a variety of problematic childhood events.
CHILD TRAUMA AND BORDERLINE PERSONALITY DISORDER: INVESTIGATING THE IMPACT ON VARIOUS BIOMEDICAL SYSTEMS
Patterns of emotional dysregulation, impulsivity, identity instability, and problematic relationships characterize borderline personality disorder (BPD). Bipolar disorder (BPD) affects 0.2-1.8% of the general population, 15.5-25% of mental hospital inpatients, and 10% of mental health clinic outpatients. The most widely accepted aetiopathological background on BPD is the one put out by Linehan in 1993. This theory posits that BPD may arise from a combination of biological and psychosocial variables, specifically between temperamental vulnerabilities that are based on biology and painful and distressing events that a child may have had as a child.
People that suffer from borderline personality disorder– exhibit elevated emotional sensitivity, difficulty to control considerable emotional responses, followed by a lag in the resumption of emotional baseline, since this condition is mainly defined by dysregulation of emotions. Additionally, Linehan posited that the inability to communicate one's innermost feelings as a kid constitutes a dehumanizing environment throughout childhood that has a role in the development of BPD. Consequently, kids who grow up in such a toxic setting struggle to control their emotions and instead swing wildly between repressing their feelings and acting out completely out of character.
Hughes et al. (2019) added to the etiopathogenetic model in cases when BPD is suspected the idea that an individual's inability to regulate their emotions due to a lack of social closeness or response from important carers contributes to the onset of BPD symptoms. Some have hypothesized that issues with affect regulation mediate the connection between traumatic experiences in childhood and personality disorder with borderline symptoms (BPD). Thirty to ninety percent of those who suffer from borderline personality disorder are also likely to mistreat or neglect children, according to a number of studies. This rate is higher than that of any other personality disorder.
The intensity of BPD symptoms is also correlated with adverse childhood events. Widom and colleagues found that a higher percentage of abused and neglected children fulfilled adult signs of BPD compared to controls, and they followed 500 children who had endured sexual and physical abuse and neglect together with 396 comparably situated controls. Although some persons did not develop signs of borderline personality disorder (BPD) until maturity, others did. Regardless of whether a risk factor, such as unpleasant childhood experiences, was enough to explain this difference.
Recent research by the intensity of borderline personality disorder (BPD) may be determined by a combination of temperamental traits and early trauma, according to research by Martin-Blanco and colleagues. To that end, they analysed 130 BPD patients' self-reported trauma histories, psychobiological temperamental features, and symptom severity. The data indicated that there was a connection between extroversion and maltreatment in childhood, but no additional link was discovered. Not to mention how serious the disease was shown to be connected with the interplay between strong neuroticism-anxiety features and the occurrence of severe emotional abuse.
LITERATURE REVIEW
Paola Bozzatello et.al (2021) The correlation between early life experiences and the emergence of borderline personality disorder (BPD) in adolescence has been the subject of much study. Childhood trauma is one of several potential risk factors for the development of borderline personality disorder (BPD), according to the most popular explanations among order to find out if particular types of borderline personality disorder (BPD) are more common among people who experienced trauma as children, such as sexual and physical abuse or neglect. We searched PubMed for studies published during the last 20 years to make conclusions about its causes and effects on its clinical presentations. Mood, anxiety, obsessive-compulsive disorder (OCD), somatoform, dissociative, addictive, psychotic, and comorbidities are common among individuals with borderline personality disorder (BPD), which commonly stems from traumatic events experienced during childhood. These cases often have a long duration, are quite severe, and are resistant to treatment. Childhood maltreatment is more common among those with severe personality disorder than among individuals with other types of personality disorders. Early life trauma has long-lasting impacts on several biological systems, including the hypothalamic-pituitary-adrenal (HPA) axis, neurotransmission pathways, endogenous opioid systems, grey matter volume, and white matter connections. Growing research suggests that environmental variables, including emotional and physical neglect, interact with genes, including FKBP5 polymorphisms and CRHR2. variations.
Ellen F Finch et.al (2019) The "treatment as usual" (TAU) treatment for BPD is typically seen as ineffectual or perhaps iatrogenic in this evidence-based medicine age. The purpose of this meta-analysis was to assess the efficacy of TAU for BPD by pooling information from randomized controlled trials that included manualized psychotherapies and included TAU as one of their treatment arms. A thorough bibliographic search was used to identify the studies. Sixteen research were deemed eligible for inclusion. The effect sizes were computed and pooled using Comprehensive Meta-analysis V3 software. In 11 trials, Hedges' g for the main outcome category of BPD symptoms improved somewhat to moderately under TAU settings (95% CI: 0.246, 0.495). Included as secondary outcomes were self-harm/suicidality, global functioning, and general psychopathology. In 14 trials, Hedges' g was 0.119 (95% CI [0.025, 0.214]) and in 10 studies, g was 0.254 (95% CI [0.123, 0.384]), indicating minor improvements in general psychopathology and global functioning, respectively. There was no discernible impact on changes in suicidality or self-harm (four trials; g = 0.003; 95% CI [-0.193, 0.199]). Based on these results, it seems unlikely that TAU for BPD is intrinsically iatrogenic. Therefore, ordinary accessible care might be a viable alternative to specialized therapy for BPD if necessary. All rights reserved, 2019 APA, PsycINFO Database Record.
Sophie A. Rameckers et.al (2021) We conducted a comprehensive meta-analysis that included all trial types in order to ascertain if psychotherapies are effective for individuals with borderline personality disorder (PROSPERO ID: CRD42020111351). Setting, BPD symptom domain, mean age, and trial and outcome type (continuous vs. dichotomous) were among the factors that were investigated. The 87 studies (N = 5881) were culled from four databases searches conducted between 2013 and 2019. We accounted for variations in treatment duration and the reality that a logarithmic correlation between the two. Excluding outliers and giving total scale scores precedence when reporting both subscale and total scores allowed for sensitivity studies. Effect sizes were smaller for treatment-as-usual and larger for schema therapy, mentalization-based treatment, and decreased dialectical behaviour therapy. Dissociation, rage, impulsivity, and suicidality/self-injury shown the least improvement, whereas general severity and emotional instability demonstrated the most. As the age of the subjects grew, the efficacy of the treatment reduced. The impacts were bigger for dichotomous outcomes, while the effects were reduced for analyses based on the final observation. Some specialized psychotherapies showed much larger decreases than average. With some variation, all BPD domains showed improvement. Many other contexts could benefit from the findings. Although the results were unaffected by the design type, we are unable to draw causal conclusions from them.
Nikolaus Kleindienst et.al (2020) The link between illness known as borderline personality disorder and reported childhood adversity (CA) was examined in a recent meta-analysis published in Acta Psychiatric Scandinavica (1). Because it incorporates stratified analyses, this meta-analysis is very illuminating. The kind of main studies and the type of control group both have significant impacts on the effect size estimate, as shown by the meta-analysis. Nevertheless, we are pleased to provide further analyses in support of this significant work. The goal of these further studies is to elucidate the findings from the meta-analysis in a more thorough and precise manner.
Irene Álvarez-Tomás et.al (2019) For context, this study synthesizes results from prospective studies on the long-term trajectory of BPD in adult clinical populations, making it the first of its kind. Methods: From 1990 to 2017, we systematically searched Medline, PsycINFO, PsycArticles, PubMed, and Scopus. To be eligible for inclusion, a group of men as well as ladies that suffer from BPD) was required, along with (1) a validated, semi-structured interview for diagnosis, (2) two or more prospective evaluations of outcomes, and (3) a follow-up duration of five years. The Systematic Evaluation of the Quality of Observational Research (SAQOR) was used to grade the evidence's quality. Remission from BPD diagnosis, suicide attempt completion, depressive symptoms, and functioning were the four outcomes that were meta-analyzed using mixed-effect techniques. We looked at possible modifiers related to the first therapy and the natural course. The results show that 837 people from 9 different countries were followed by 11 studies that fulfilled the inclusion criteria. Half to three quarters of the BPD patients were able to attain long-term remission. Additionally, there were significant decreases in both functional disability and depression. A suicide rate of 2% to 5% was found on average. Remission was more likely to occur in younger patients. A lower level of functional improvement was associated with being female. The long-term result was not significantly correlated with treatment moderators, even if there were some encouraging indications. Conclusions: The results indicate that the progression of condition characterized by a disturbed personality is marked by an improvement in symptoms and, eventually, a little enhancement in functional capacity. When allocating treatment funds, It must be considered age and gender affect the long-term prognosis. Strong findings about the long-term impacts of psychotherapy therapies need more study.
Irene Álvarez-Tomás et.al (2018) For context, this study synthesizes results from prospective studies on the long-term trajectory of BPD in adult clinical populations, making it the first of its kind. Methods: From 1990 to 2017, we systematically searched Medline, PsycINFO, PsycArticles, PubMed, and Scopus. The following were required to be where a part of the research: (1) a group of people diagnosed with BPD using a validated, semi-structured interview; (2) there had to be two or more prospective evaluations of outcomes; and (3) there had to be a follow-up period of five years or more. The Systematic Evaluation of the Quality of Observational Research (SAQOR) was used to grade the evidence's quality. Remission from BPD diagnosis, suicide attempt completion, depressive symptoms, and functioning were the four outcomes that were meta-analyzed using mixed-effect techniques. We looked at possible modifiers related to the first therapy and the natural course. The results show that 837 people from 9 different countries were followed by 11 studies that fulfilled the inclusion criteria. Half to three quarters of the BPD patients were able to attain long-term remission. Additionally, there were significant decreases in both functional disability and depression. A suicide rate of 2% to 5% was found on average. Remission was more likely to take place in younger patients. A lower level of functional improvement was associated with being female. The long-term result was not significantly correlated with treatment moderators, even if there were some encouraging indications. Conclusions: The results indicate that the progression in cases when BPD is suspected is marked by an improvement in symptoms and, eventually, a little enhancement in functional capacity. When allocating treatment funds, it is important to take into account the fact that age and gender affect the long-term prognosis. Strong findings about the long-term impacts of psychotherapy therapies need more study.
C. Porter et.al (2019) Objective That is why we conducted this meta-analysis: to look at how background trauma, BPD, and traumatic events in childhood in various research, including case-control, epidemiological, and prospective cohort studies. The objective was to determine the strength and consistency of this correlation. Method Three search engines were searched using phrases related to adversity with BPD and other related disorders, as per the findings of the review process (CRD42017075179). The magnitude and reliability of the effects were synthesized by random-effects meta-analysis. Final Product With 97 trials totaling k=40, BPD was compared to both non-clinical and clinical controls, respectively. A meta-analysis of case-control studies found that compared to non-clinical controls, People with BPD are almost 13.9 times more likely to report having compared to the general population. experienced childhood hardship. Taking into account epidemiological (OR: 2.56, 95% CI 1.24-5.30) and retrospective cohort (OR: 2.59; 95% CI 0.93-7.30) studies reduced the magnitude of this impact. Neglect (OR: 17.73, 95% CI = 13.01-24.17) and emotional abuse (38.11, 95% CI: 25.99-55.88) showed the biggest impacts across the various forms of adversity, while the results were significant across the board. Borderline personality disorder patients were 3.15 (95% CI 2.62-3.79) times more likely to report experiencing childhood hardship compared to other mental health categories. Final thoughts This meta-analysis lends credence to the idea that traumatic events in one's life could lead to borderline personality disorder (BPD). It emphasises that while dealing with BPD, it's important to take childhood trauma into account.
Giorgia Degasperi, et.al (2021) Numerous functional magnetic resonance imaging (fMRI) investigations investigated the neurological bases of borderline personality disorder (BPD), however, results varied between tasks. Regarding functional magnetic resonance imaging (fMRI) studies comparing healthy controls (HC) to those who suffer from individuals with BPD, we performed a meta-analysis that included a comprehensive analysis and activation likelihood estimate (ALE). With database-specific queries such as 'fMRI,' 'Neuroimaging,' and 'borderline,' we methodically searched PubMed and PsychINFO from their establishment until July 9th, 2020. Eligible studies evaluated groups of individuals that suffer from BPD or healthy controls (HC) using functional magnetic resonance imaging (fMRI) of the brain while they were doing any behavioural activity. We included 52 papers (depicting 54 experiments) after reviewing 92 full-texts from 762 entries. No cluster of substantial convergence of differences was seen in any of the studies when the HC > BPD and BPD > HC meta-analyses were used. For the BPD> HC meta-analysis, two notable clusters of activation were found in the bilateral hippocampal/amygdala complex and the anterior cingulate, according to analyses limited to studies of emotion processing. Significant results did not seem to be robust, according to fail-safe N and sensitivity analysis of a single trial. In the emotional processing subgroup, a different meta-analysis approach (difference of convergence) revealed a cluster in the insula/inferior frontal gyrus for the HC> BPD comparison, based on a limited number of trials that provided data for each group independently. Amygdala dysfunction was observed across emotion processing tasks, suggesting a possible pathophysiological mechanism that could be transdiagnostic, but no consistent pattern of altered brain activity for BPD was found, indicating substantial heterogeneity of processes and populations studied.
Corinna Reichl et.al (2021) Within the framework of borderline personality disorder (BPD), this article provides a limited review of current research on the function of no suicidal self-injury (NSSI) and suicidal conduct. Researchers have shown that self-harming behaviour, especially non-sexual self-injury (NSSI), may be used as a simple indicator to identify people who early-stage borderline personality disorder (BPD) development is possible. The study goes on to summaries research that looked at how different aspects with time, those with borderline personality disorder (BPD) were associated with acts of self-harm. Suicide thoughts and actions are more common among borderline personality disorder (BPD) patients who report high levels of emotional instability, according to the research. may contribute to the persistence of NSSI. The presentation concludes with findings about the efficacy of treatment programmes in reducing self-harming behaviour in BPD patients.
CHILDHOOD TRAUMA AND BORDERLINE PERSONALITY DISORDER (BPD)
Scientific evidence is mounting in support of the concept that exposure to early trauma increases the risk those suffering from BPD. What some people experience when they have borderline personality disorder (BPD) include unstable affect, trouble controlling one's emotions, and harmful behaviors that start in childhood. The influence of traumatic events is crucial since it seems to limit the ability to conceptualize or represent emotions, particularly during formative years. The strongest evidence linking borderline personality disorder to the following variables (BPD) symptoms in persons between the ages of 14 and 19 in recent research were physical and emotional stress, mental illness in the family, and economic hardship in childhood.
This persisted even after accounting for socioeconomic status and parental psychopathology. Children who experienced ACEs were more likely to develop borderline personality characteristics as adults.
According to diathesis-stress Borderline personality features may be attributed to a combination of factors, including ideas on the origins of the disorder, specific temperamental traits, genetic polymorphisms, and early traumatic experiences such as abuse and neglect. This theory proposes that a myriad of contextual factors interact intricately to bring about borderline personality disorder manifestations (BPD). and biological variables, rather than any one of these elements acting alone. Additionally, traumatic events may build upon one another; borderline personality traits were much more severe in young people who had suffered extensive childhood trauma and abuse.
Below, we will go over the information that is currently available about this matter, specifically with childhood maltreatment, whether by adults in the child's life or by their peers, may lead to the onset of borderline personality disorder. Some risk factors for the early emergence of borderline personality disorder (BPD) include sexual, emotional, and physical abuse, as well as neglect in childhood verbal, and emotional abuse victimization by peers.
Following this partThis section will focus on studies that looked at how various risk factors for borderline personality disorder (BPD) manifested in its early stages, as well as how these variables interacted with one another. Some of these studies are similar to those mentioned in the preceding section, which focuses on environmental and temperamental variables.
Table 1: Examining the links between environmental variables and early onset borderline personality disorder
Temperament and environment | Study design | Recruitment age (mean or range)/ patients (n) | Outcomes |
Fossati et al. (28) | Retrospective study; Clinical outpatients and community population | 44 BPD 207 CC 206 HC | Novelty seeking is temperament as it pertains to borderline personality disorder |
Joyce et al. (26) | Longitudinal study; Clinical outpatients | 18–35 yrs 180 MDD | Predictors of borderline personality disorder (BPD) included a propensity for extreme risk-taking and an insatiable need for new experiences, as well as psychopathology and unpleasant memories from childhood. |
Crawford et al. (38) | Longitudinal study; Community population | At birth 766 children | Early onset of borderline personality disorder symptoms is associated with anger/tantrum characteristics |
Gratz et al. (36) | Longitudinal study; Community population | 9–13 yrs 263 children | Predictors of early onset borderline personality disorder include impulsivity, emotional instability, and poor self-control. |
Tragesser et al. (34) | Longitudinal study; Community population | 18–20 yrs 353 adults | Low self-control, impulsivity, and affective instability were predictors of early onset BPD |
Belsky et al. (23) | Longitudinal study; Community population (ERLTS) | At birth 2,232 twins | Symptoms of borderline personality disorder (BPD) include impulsivity, aggressiveness, inappropriate anger, negative affectivity, and negative emotionality. |
Barnow et al. (42) | Longitudinal study; Community population | 15 yrs 323 children | Maternal BPD as predictor of BPD onset in adolescence (15 years) |
Jovev et al. (37) | Longitudinal study; Community population | 11–13 yrs 245 children | Distressing childhood experiences is a significant risk factor for the development of BPD in early age. |
Kaess et al. (27) | Randomized controlled study; Clinical outpatients | 13–18 yrs 33 BPD 35 CC 31 HC | High harm avoidance and novelty seeking but low reward dependence represented a biological vulnerability for developing BPD |
Hecht et al. (24) | Longitudinal study; Community population | 11,30 yrs 314 maltreated children 285 non-maltreated children | Maltreated children were more likely to be at high risk for development of BPD |
Cramer et al. (29) | Longitudinal study; Community population | 11 yrs 100 children | Childhood personality traits predicted adult BPD features |
Stepp et al. (33) | Longitudinal study; Community population | 16–18 yrs 113 girls | Maternal BPD as predictor of BPD onset in early adulthood (around 24 years) and negative emotional reactivity predicted BPD |
Sexual Abuse
Engaging in sexual activity on a victim without their permission, while they were unable to provide their consent, or when they were coerced into giving it is considered sexual abuse.
The majority of research has linked sexual abuse in childhood (CSA) to the developing BPD at its earliest stages. Having said that, not every study came to the same conclusions. Hect et al. found no association between borderline personality disorder and sexual abuse. It is crucial to consider the study's limitations— such as the study's limited sample size and the possibility that the effects of sexual abuse don't show up until far later in life than the middle childhood years that Hect examined—when trying to make sense of this result. Sexual trauma is more common among teenagers with borderline personality disorder (BPD) compared to both healthy adolescents and mental patients who do not have BPD according to several studies. studies.
Adolescents with borderline personality disorder (BPD) are more likely to be victims of sexual abuse, according to many research. This is in contrast to depressed teens or healthy controls. Adolescents with borderline personality disorder were more likely to engage in suicidal thoughts and behaviours if they had experienced sexual abuse. Sharing information about CSAs does not alleviate their psychological impact. Unfortunately, this is also a vulnerable time when personality problems and suicidal thoughts are more common. Specifically, a cohort study comparing the prevalence of various mental diagnoses in CSA survivors reported that The incidence of borderline personality disorder (BPD) increased significantly in the first year after the first documented CSA incident; this diagnosis was the only one that had not been present before the disclosure of CSA experience. Additionally, these findings support the idea that precocious BPD development is linked to particular experiences of precocious sexual abuse.
CONCLUSION
Childhood trauma is very common in borderline personality disorder (BPD) subjects and is the main environmental element in BPD development (Martín-Blanco et al., 2014). Trauma-Focused Cognitive-Behavior Therapy (TF-CBT), Alternatives for Families - Cognitive Behavioral Therapy (AF-CBT), relaxation training, and social skills training are potentially useful interventions for children who have endured childhood maltreatment and have difficulty with social, emotional, and psychological development as well as the ability to foster and sustain interpersonal relationships. This study employed a meta-analytic strategy to explore how the relative importance of all forms of childhood maltreatment contributes to BPD in adults, treatments for CM, interventions for BPD, as well as the examination of the potential moderating effects of the type of CM and the type of BPD symptomology being measured. The finding of overall effect size for CM as it contributes to BPD in adults of 0.34 supports a medium effect. Balancing this medium effect with multiple forms of interventions for both CM and BPD in adults should persuade patients and therapists to recognize the benefits of therapy.
Several psychotherapeutic approaches have been demonstrated to be effective in the treatment of adults to help manage symptoms of BPD, such as cognitive behavioral therapy (CBT), schema‐focused therapy (SFT), and dialectical behavior therapy (DBT), and pharmacotherapy (O’Connell & Dowling, 2014). These theoretical orientations help individuals recognize and modify core beliefs and behaviors that cause inaccurate perceptions of themselves and others, decrease impulsivity, learn skills to control intense emotions/emotion regulation, reduce self-destructive and suicidal behaviors, and improve relationships through mindfulness and acceptance or being aware of and attentive to the current situation and emotional state (Fassbinder, Schweiger, Martius, Wilde, & Arntz, 2016; National Institute of Mental Health (NIMH), 2011; Neacsiu & Linehan, 2014). Additional research into all forms of CM as it contributes to BPD is warranted. An emphasis on using standardized measures to evaluate outcomes will be important in analyzing results for validity and reliability. REFERENCE
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