The Role of Children’s Appraisals on Adjustment
Following Psychological Maltreatment: A Pilot Study
Fiona J. Leeson & Reginald D. V. Nixon
Published online: 14 April 2011
# Springer Science+Business Media, LLC 2011
Abstract Little is known about the cognitive mecha-
nisms involved in the development of psychopathology
following psychological maltreatment in children. This
study therefore examined the role of thinking styles on
children’s outcomes following this subtype of maltreat-
ment. Children who had experienced past maltreatment
(n=24) and a control group (n=26) were assessed using
self-report questionnaires. Maltreatment history, cognitive
styles and psychological outcomes, such as depression,
posttraumatic stress disorder (PTSD) and self-esteem were
assessed. Parents/caregivers also completed a measure of
child internalizing and externalizing behaviours. Psycholog-
icalmaltreatmentmadea significant contributiontochildren’s
self-reported depression and low self-esteem, and parent
reported internalizing and externalizing problems, even after
controlling for other abusive experiences. This was not the
case for PTSD symptoms. Further, children’s cognitive styles
were associated with self-reported depression, self-
esteem and PTSD. They did not, however, predict
parent-rated emotional and behavioural problems. This
study provides preliminary support for a cognitive model
of adjustment following psychological maltreatment. The
results indicate the need for enhanced community
awareness about the impact of psychological maltreatment,
and suggest a direction for therapeutic intervention.
Keywords Psychological abuse.Emotional abuse.Child
Child maltreatment is a serious problem worldwide.
Accurate figures for its prevalence are difficult to derive
however it is reported that maltreatment was substantiated
in 10.6 per 1,000 children in the USA in 2007, with
psychological maltreatment accounting for a significant
proportion (4.2%) of these cases (US Department of Health
and Human Services Administration on Children Youth and
Families 2009). In Australia, there were 55,120 substanti-
ated cases of child abuse and neglect between 2007–08,
with psychological maltreatment accounting for 38% of
these cases (Australian Institute for Health and Welfare:
Whilst there is no doubt that childhood psychological
maltreatment often leads to negative outcomes, research
has lagged behind that of other forms of maltreatment.
Specifically, research of the outcomes secondary to
psychological maltreatment, or the mechanisms that
mediate this type of maltreatment and psychopathology
is still in its infancy. This is despite suggestions that
psychological maltreatment could be considered the core
component of all forms of child abuse (Hart et al. 2002).
In contrast, the corresponding literature with other
subtypes of maltreatment, in particular sexual abuse, is
well developed and has substantially contributed to the
formulation of evidence-based treatment programs. There-
fore, a central goal of the present study was to examine
whether certain cognitive styles in children who have
experienced psychological maltreatment play a unique role
in its association with problematic symptomatology once
other maltreatment types are controlled.
Numerous studies have demonstrated that maltreatment
increases a child’s risk of developing both internalizing
F. J. Leeson:R. D. V. Nixon (*)
School of Psychology, Flinders University,
GPO Box 2100, Adelaide, SA 5001, Australia
J Abnorm Child Psychol (2011) 39:759–771
(Bolger et al. 1998; Kim and Cicchetti 2004; Manly et al.
2001) and externalizing (Briere and Runtz 1990; Kim and
Cicchetti 2004; Manly et al. 2001) problems. Whilst studies
have documented the impact of this form of maltreatment,
findings need to be qualified in relation to certain
limitations. Many are adult retrospective studies, and they
are often restricted to a single form of maltreatment, rather
than examining the combination of abuse types (Briere and
Runtz 1988, 1990). Studies of psychological maltreatment
have been particularly prone to these problems and this
type of maltreatment is more often than not excluded in
research that examines multiple maltreatment subtypes.
This is in part due to some of the challenges in researching
this area, such as the difficulty in identifying psychological
maltreatment due to the lack of physical injuries, and the
fact that it is arguably the most underreported form of
maltreatment (Tomison and Tucci 1997). There is also a
lack of consensus on the definition of psychological
maltreatment amongst professionals (Thompson and
Kaplan 1996). In this paper, this subtype of maltreatment
will be referred to as psychological maltreatment. This term
encompasses both perpetrator acts of commission and
omission, as well as the cognitive and affective meanings
of maltreatment (Hart et al. 2002). We use the definition
adapted by the American Professional Society on the Abuse
of Children (APSAC):
“Psychological maltreatment” means a repeated pattern
ofcaregiver behaviororextreme incident(s) thatconvey
to children that they are worthless, flawed, unloved,
unwanted, endangered, or only of value in meeting
another’sneeds(APSAC1995,p. 2) (cited in Hart et al.
It is worth noting such a definition includes acts such
as spurning, terrorizing, isolating, exploiting/corrupting,
denying responsiveness, as well as certain forms of
neglect (e.g., mental health, medical, educational) (Hart
et al. 2002).
The Role of Cognitions
Not only has there been a modest amount of empirically
sound research into the consequences of child psycholog-
ical maltreatment, there has also been little evaluation of
what differentiates individuals who develop internalizing or
externalizing problems from those who adjust well, despite
evidence that there are individual differences in children’s
ability to cope after experiencing maltreatment (Edmond et
al. 2006). Although at present there is no universal theory
to explain the specific consequences of psychological
maltreatment, it intuitively makes sense that theories that
place an emphasis on appraisals and cognitions are likely to
have utility in explaining maladaptive outcomes following
maltreatment. Advocates for cognitive perspectives of the
development and maintenance of emotional disorders
have long argued that it is a person’s way of interpreting
situations that can lead to or prevent psychological
disturbances (Beck 1976; Rose and Abramson 1992),
and a number of these cover domains that are highly
relevant to the negative outcomes associated with child
maltreatment. For example, Abramson et al.’s (1989)
hopelessness theory of depression, Beck’s (1976) model
of anxiety, and cognitive models of PTSD, such as that of
Ehlers and Clark (2000), and Brewin et al. (1996) dual
representation theory all have a central theme that
maladaptive appraisals are responsible for the onset and
maintenance of psychopathology.
Many of these theories have been well-tested and
supported with non-maltreated samples, the evidence of
which spans the past 20 years. For example, in a large
sample comprising both clinical and non-clinical children
(aged 7–16), Schniering and Rapee (2004) found that
different types of thinking patterns predicted different
symptoms. In the child aggression literature, it has been
well documented that children and adolescents with a
hostile attributional style are at an increased risk of
aggressive behaviour (for reviews see de Castro et al.
2002; Dodge 2006). Further evidence for the role of
cognitive styles can be found in the trauma literature
(Ehlers et al. 2003; Stallard and Smith 2007).
In the depression literature, hopelessness theory
(Abramson et al. 1989) explains that a person’s risk of
developing depression increases when an individual
makes inferences about the cause of a negative event
being stable and global, when they catastrophize about the
consequences of the event, and when they view them-
selves as deficient following the event (Abela et al. 2007;
Gibb et al. 2006). Extending this theory, it has been
suggested that certain factors, such as verbal victimization
may lead individuals to develop a negative attributional
style, which heightens their sense of hopelessness and in
turn makes them more susceptible to depression (Gibb et
al. 2006). Expanding on this further is the weakest link
hypothesis (Abela et al. 2007; Abela and Sarin 2002). This
is based upon the analogy, ‘a chain is only as strong as its
weakest link’, and posits that an individual’s vulnerability
to hopelessness depression is dependent on the individual’s
most depressogenic inferential style (Abela and Sarin
2002). This is particularly useful when considering child
maltreatment, since the outcomes for children who have
experienced maltreatment are so varied. It may be that
there is not simply one cognitive style that leads to
problems, but potentially multiple pathways that can lead
to the same problem, or that can lead to different
pathological outcomes for different children who have
experienced similar negative experiences. Whilst all
760J Abnorm Child Psychol (2011) 39:759–771
cognitions may be relevant, they may not be equal, with
some being more problematic than others in different
Whilst hopelessness theory is supported by a large body
of evidence, the bulk of the literature in this area is confined
to the adult population (e.g., Alloy et al. 2000). It should
not be assumed that cognitive theories related to adults are
automatically relevant to children and thus these theories
must be tested in child samples (Abela et al. 2007). It is
worth noting that the literature that has examined hopeless-
ness theory in children and adolescents has produced
inconsistent results (Abela et al. 2007), and is often limited
to non-clinical samples (e.g., Gibb et al. 2006).
It is plausible that the cognitive pathways found to be
associated with disorders such as depression and anxiety
in non-maltreated children may be similar to that of
maltreated children. In fact, there has been some
indication that cognitive styles may mediate between
child psychological maltreatment and psychopathology
into adulthood. A number of studies support the
relationship between psychological maltreatment, cognitive
styles and adult outcomes, including depression and anxiety
(Gibb et al. 2007; van Harmelen et al. 2010), and adult
interpersonal conflict (Crawford and Wright 2007;
Messman-Moore and Coates 2007). However, only a few
studies have addressed cognitive processes in maltreated
child samples, and almost all of these focus on children’s
For example, Gibb (2002) conducted a review of 11
studies, including both adults and children, examining the
attributional styles related to childhood sexual, physical and
emotional abuse. The review reported a small but significant
relationship between emotional abuse and attributional style
as well as a small but significant relationship between sexual
abuse and attributional style for studies including relatively
older participants. The report did not, however, find evidence
for a link between childhood physical maltreatment and
attributional style, and only four of the studies examined
emotional and physical abuse. Further, they did not examine
the relationship between attributional style and resulting
Valle and Silovsky (2002), however, did examine the
relationship of abuse and attributions on outcome in child
survivors of physical and sexual abuse in a review article.
They reported that abuse-specific internal attributions, such
as self-blame, was related to increased risk of interpersonal
and internalizing problems, such as depression and anxiety.
Abuse-specific external attributions, on the other hand,
were associated with higher rates of externalising and
interpersonal problems. Whilst this review indicates that
children’s attributions play a role in the development of
internalizing and externalising problems following abuse,
there were inconsistencies between the findings of the
included studies, particularly with regards to the role of
attributions on the development of PTSD symptoms (Valle
and Silovsky 2002). Further, these findings are limited by
the fact that most of the research focused on sexual abuse,
with only few physical abuse studies, and no emotional
abuse or neglect studies.
More recently, Keil and Price (2009) examined the social
information-processing theory on aggressive behaviour in
physically abused and neglected children (n=100; all had
experienced neglect, 35 also experienced physical abuse)
and a control group (n=88). They found that children in the
abuse group made more hostile attributions than those in
the control group, and generated more aggressive
responses. Further, children who had experienced both
physical abuse and neglect demonstrated the most hostile
orientation and aggressive responses when faced with
situations involving provocations and threats from peers.
In contrast, children who had experienced neglect alone had
more difficulties in situations in which they were attempting
to engage in social activities with peers.
Limitations of Cognitive Studies with Regards
to Psychological Maltreatment
Whilst these studies lend support for the role of cognitions
in the development of psychopathology following maltreat-
ment, they are limited by their failure to include or
adequately assess all maltreatment subtypes. This is critical
for two reasons. First, it is uncommon for a child to
experience just one type of maltreatment alone (Crittenden
et al. 1994; Manly et al. 2001). Most maltreated children
are likely to be subject to multiple combinations of
maltreatment subtypes (Higgins 2004). Thus, failure to
assess the co-existence of maltreatment experiences not
only reduces the representativeness of a study’s sample, but
it also may lead researchers to draw incorrect associations
between one type of maltreatment experience and psycho-
logical adjustment (Higgins 2004), and mask the impact of
other forms of maltreatment (Farrall 2005).
Second, it is argued that psychological maltreatment
should be conceptualised as a core component of all
maltreatment subtypes (Hart et al. 2002). In other words,
psychological maltreatment exists in almost all other cases
of maltreatment. For example, by physically maltreating a
child, an adult is communicating to the child that they are
unworthy of protection. If psychological maltreatment is
the unifying component of all maltreatment subtypes, then
excluding this from empirical research reduces our ability
to understand the mechanisms between maltreatment and
its consequences. Further, there is some evidence that
psychological maltreatment may contribute to greater
negative outcomes than the other subtypes of maltreatment
(Crittenden et al. 1994), although this issue remains
J Abnorm Child Psychol (2011) 39:759–771761
contested, with other researchers arguing that it is the
chronicity and severity of maltreatment that is important,
rather than the type of maltreatment per se (Higgins 2004;
Manly et al. 2001). We do not suggest that psychological
maltreatment is a more important indicator of outcome than
the other maltreatment subtypes. Rather we have chosen to
focus on psychological maltreatment because, if it is in fact
the core component of all types of maltreatment, then it is
important tounderstandboththe uniqueand combinedeffects
of psychological maltreatment as this will assist in a better
understanding of the different pathways and outcomes that
children experience, and will help to better guide treatment
programs for maltreated children.
Therefore, whilst there is an established literature on the
role of cognitions in the development of general anxiety
and depressive disorders in children, and whilst there is an
increasing body of literature on the role of cognitions in the
development of psychopathology following some types of
maltreatment, there is little clinical research examining the
cognitions that may play a role in determining the outcomes
of children who have experienced psychological maltreat-
ment. Developing a greater understanding of these processes
the effects of psychological maltreatment because the current
community focus lies heavily on the consequences of other
If it is found that psychological maltreatment is as detrimental
as other maltreatment types, then this will indicate a need for
greater community awareness of the problem and a greater
focus by organizations in addressing the problem. Second,
understanding the cognitive mechanisms that lead to such
detrimental outcomes may lead to better understanding of the
reasons why some children develop psychopathology
whilst others do not. This knowledge will aid clinicians
to better identify children most at risk of adverse
outcomes. Third, improved understanding of the way
that disorders such as depression and PTSD develop
following maltreatment may lead to the development of
improved treatments for such children.
Insummary,ourgoalwas toidentifythe possiblecognitive
mechanisms associated with externalising and internalising
problems, such as depression, PTSD symptoms, low self-
esteem and behavioural problems following psychological
maltreatment. We were particularly interested in whether the
known cognition-symptom relationships for other types
of traumatic experiences and general negative events
would be present in children who had suffered psychological
maltreatment. Level of child maltreatment experiences and
the cognitive processes of interest, together with depression,
PTSD symptoms, self-esteem and externalizing behaviours
were examined. Based on the literature reviewed earlier, we
made the following predictions. First, we anticipated that
relative to non-abused control children, children who
experienced maltreatment would demonstrate significantly
higher levels of emotional disturbance and unhelpful
cognitions. Second, if psychological maltreatment is a core
feature of all maltreatment, we expected it to demonstrate a
unique role in contributing to child psychopathology (over
and beyond the impact of other types of abuse). Third, given
the cognitive modelsofemotional adjustmentoutlinedearlier,
we hypothesised that unhelpful beliefs would account for
symptoms even after total severity of maltreatment was
Participants were 50 children (aged 6–17 years, M=
11.18 years). Children in the maltreatment group consisted
of 24 children who had experienced maltreatment, 15 of
whom were recruited from child protection and mental
health services, with the remaining nine coming from
community advertising. The control group consisted of 26
children who had never been psychologically maltreated (as
far as the researchers were aware). Children in the control
group were recruited from schools in areas that matched the
socioeconomic status of children in the maltreatment sample.
The short form of the Childhood Trauma Questionnaire
(CTQ-SF: Bernstein et al. 2003) is a 28-item self-report
scale that measures the frequency of sexual abuse (e.g.,
‘someone tried to touch me in a sexual way, or tried to
make me touch them’), physical abuse (e.g., ‘I was
punished with a belt, a board, a cord, or some other hard
object’), physical neglect (e.g., ‘I didn’t have enough to
eat’), emotional abuse (e.g., ‘people in my family called me
things like “stupid”, “lazy,” or “ugly”’) and emotional neglect
(e.g., ‘I felt loved’ (item reverse scored) experiences.
Three additional items were added to the scale to include
witnessing domestic violence (DV) (e.g., ‘I saw or heard
one of my parents/caregivers hitting, pushing or threat-
ening my other parent/caregiver’). Items were summed to
obtain a total maltreatments score, as well as total scores
for the individual maltreatment subtypes. This measure
was originally used as an adult retrospective measure of
abuse, but has more recently been used with children and
youth (Bernstein et al. 1997; Wekerle et al. 2009) where it
has been found to have acceptable psychometric properties
(Bernstein et al. 1997). Cronbach’s alpha for the current
study was 0.77 for the total maltreatment score and 0.50–
762 J Abnorm Child Psychol (2011) 39:759–771
0.92 for the subscales. Total Psychological Maltreatment
consisted of the combination of the emotional abuse and
emotional neglect subscales, and had acceptable internal
reliability, α=0.72. Scores on the CTQ were used to verify
the absence of maltreatment in the control group.
Although standardized scores do not exist to definitively
determine absence or presence of abuse, all children in the
control group scored within the ‘none or minimal’ range
of each subscale, with these scores being comparable to
normative data obtained from adult samples (Bernstein
and Fink 1998).
The following established measures were used to assess
children’s unhelpful cognitions. The Child Posttraumatic
Cognitions Inventory (Meiser-Stedman et al. 2009) is a
25-item self-report of children’s appraisals after a
traumatic or frightening event and its consequences.
Children in the maltreatment groups were asked to
complete the questionnaire with regards to their worst
maltreatment experience, whilst children in the control
group completed the questionnaire with regards to their
most frightening life event. Total scores were used for
the present study and internal reliability was high, Cronbach’s
The Children’s Automatic Thoughts Scale (CATS:
Schniering and Rapee 2002) is a 40-item self-report
measure that assesses negative self-statements in children
and adolescents and was used to index non-trauma specific
beliefs. Total scores were used for the present study, and
The Childhood Attributions Style Questionnaire—
Revised (CASQ-R: Thompson et al. 1998) is a 24-item
self-report measure designed to assess children’s causal
explanations for positive and negative events. Higher
scores indicate a less depressive attribution style. Summed
scores were used and Cronbach’s Alpha=0.28.
The following established measures were used to index
psychological adjustment: The Short Form Children’s
Depression Inventory (CDI: Kovacs 1992) with T scores
reported. Cronbach’s alpha for the present study was 0.75;
The Child PTSD Symptom Scale (CPSS: Foa et al. 2001).
In the present study, Cronbach’s alpha was 0.88; The
Child Behavior Checklist (CBLC: Achenbach 2001), with
scores reported as T scores. Cronbach’s alpha for Total
Problems was 0.97, Internalizing=0.95, and Externalizing=
0.93. The short form of the Self-Esteem Inventory (SEI:
Coopersmith 1981). In the present study, Cronbach’s
Two questions were included in order to gain qualitative
information about what helps children to cope following
abuse. The first question was, ‘We would like to know what
helps children after something bad or frightening happens.
Tell us something about yourself that has helped you’.
Answers were coded into the following categories: ‘Support
from others’; ‘Distraction; ‘Positive thinking’; and ‘Prob-
lem-solving skills’. The second qualitative question was,
‘Tell us what you would say to help another boy or girl who
is going through something bad or frightening’. Answers
were coded into the following categories: ‘Talk through
experiences’; ‘Positive growth; ‘Help seeking; ‘Distraction;
and ‘Providing reassurance’. These questions also ensured
that the interview ended on a positive note for children.
Following informed consent, the interviewer spoke with
parents/caregivers for approximately 5 min to obtain
demographic information (Table 1) and then parents were
asked to complete the CBCL. Separately, children were
administered the child measures in an interview format
which took approximately 40–60 min, depending on the
level of assistance and clarification required by the child.
Maltreatment Classification System ratings were obtained
by the first author by coding of the children’s CPS records.
Examination of demographic background revealed no signif-
icant differences between the abuse and control group on any
of the demographic variables except for living situation, with
children in the control group more likely to live with both
parents than those in the abuse group. A series of
independent-samples t-tests were conducted to examine the
differences between the maltreatment and no-maltreatment
control group on the main dependent variables of interest.
As expected, there was a significant difference between
groups in terms of children’s self-reported maltreatment
experiences and all symptom measures (see Table 2 for
details). Effect sizes (Hedge’s unbiased g) ranged from
medium (e.g., self-esteem, g=0.65) to very large (e.g., self-
reported maltreatment severity, g=2.50).
On the cognitive measures, analyses similarly demon-
strated significant differences between the maltreatment
and no-maltreatment groups on children’s automatic
thoughts and post-trauma cognitions, but not attributional
style (see Table 2).
J Abnorm Child Psychol (2011) 39:759–771 763
Controlling for the Severity of Other Types
of Maltreatment, Does Psychological Maltreatment
Uniquely Predict Poor Adjustment?
Due to the small sample size and adopting the position that
abuse and adjustment outcomes fall on a continuum, the
multiple regression was used to examine the unique
contribution of psychological maltreatment on emotional
and behavioural adjustment, when controlling for other
types of maltreatment. Physical Abuse, Physical Neglect,
Sexual Abuse and Witnessing DV were entered in the
first step of a hierarchical multiple regression. Total
Psychological Maltreatment was entered in the second
step. The findings were as follows.
Depression Physical and sexual abuse, physical neglect and
witnessing DV together were significant contributors to
children’s depression, accounting for 24% of the variance
explained, F(4, 45)=3.60, p=0.01. Total psychological
maltreatment explained an additional significant 10% of
the variance, F(1, 44)=6.94, p=0.01. While the overall
model was significant, F(5, 44)=4.65, p=0.002, total
psychological maltreatment (β=0.39, p=0.01) and sexual
abuse (β=0.28, p=0.04) were the only variables that
remained significant in the final step of the model.
Self-esteem Physical and sexual abuse, physical neglect
and witnessing DV together were also significant
contributors to children’s self-esteem, accounting for
24% of the variance explained, F(4, 45)=3.5, p=0.01.
Total psychological maltreatment explained an additional
significant 10% of the variance, F(1, 44)=6.45, p=0.02.
The model as a whole was significant F(5, 44)=4.43,
p=0.002. Again, sexual abuse (β=−0.37, p=0.006) and
total psychological maltreatment (β=−0.38, p=0.02) were
the only variables that remained significant in the final
step of the model.
PTSD As with depressive and esteem, other maltreatment
types significantly predicted PTSD severity, R2=0.32, F(4,
45)=5.26, p=0.001. However, total psychological maltreat-
ment did not make a unique contribution to the second step.
The model as a whole was significant, F(5, 44)=4.51,
p=0.002, with physical abuse (β=0.35, p=0.03) and sexual
abuse (β=0.29, p=0.03) remaining as significant predictors
on the final step.
Parent-reported externalizing behaviour Other maltreat-
ment types together were not significant contributors to
children’s parent-reported externalizing symptoms, R2=
0.18, F(4, 45)=2.38, p=0.07. However, after adding total
psychological maltreatment, the model as a whole was
Demographic variablesAbuse group n=24 Control group n=26p value
Mean (SD) age (years)
Socio-economic status (Mean
(SD) suburb percentile)
Parental/caregiver income per annum (%)
Less than $10,000
Previous traumas (%)
At least one previous trauma
No previous traumas
Living situation (%)
Other (e.g., foster care, grandparents)
11.42 (2.62) 10.96 (3.08)0.58
Table 1 Comparison between
abuse and control group
participants on demographic
aFisher’s exact test
764J Abnorm Child Psychol (2011) 39:759–771
significant F(5, 44)=3.47, p=0.01, with total psychological
maltreatment explaining an additional significant 11% of
the variance. Psychological maltreatment was the only
variable that remained significant in the final step of the
model (β=0.40, p=0.01).
Parent-reported internalizing behaviour In contrast, inter-
nalising symptoms were predicted by the other maltreat-
ment types, R2=0.24, F(4, 45)=3.6, p=0.01. Nevertheless,
psychological maltreatment continued to uniquely account
for adjustment, explaining an additional7%ofthevariance,
F(5, 44)=4.04, p=0.004. Only sexual abuse (β=0.34,
p=0.01) and psychological maltreatment (β=0.33,
p=0.04) were significant predictors in the final step of
Is the Core Component Status of Psychological
played a unique role in predicting children’s adjustment,
reversing the order of entry generally demonstrated the
sizeable impact this type of abuse had on children’s well-
being. Accordingly, total psychological maltreatment was a
significant contributor to all outcome measures when entered
for depression, 19% for self-esteem, 11% for PTSD, 21% for
parent-reported externalizing, and 18% for parent-reported
internalizing problems. Interestingly, the addition of the other
subtypes of abuse and neglect in step 2 did not add a
significant variance for depression, or any of the parent-
reported difficulties (internalizing or externalising problems).
The addition of these other subtypes did lead to a significant
14% of variance explained for self-esteem and a significant
23% of variance explained for PTSD symptoms.
The Role of Cognitions on Psychological Adjustment
As can be seen in Table 3, children’s thinking styles were
generally highly correlated with abuse severity and symp-
toms. We conducted regressions to test our third hypothesis
that unhelpful beliefs uniquely account for children’s
Table 2 Descriptive data and inferential statistics on symptom measures
VariableGroupM SDt dfUnbiased gp
CTQ Total MaltreatmentMaltreatment
8.64 32.94 2.50<0.001
CTQ Psyc Maltreatment 7.2748 2.03 <0.001
CDI 2.79 35.340.80 0.008
SEI2.2948 0.64 0.03
CBCL Internalizing5.0348 1.40 <0.001
CBCL Externalizing 3.43480.95 0.001
CBCL Total5.30 48 1.50<0.001
2.4932.89 0.71 0.02
CPTCI3.06 480.85 0.004
CASQ-R1.47 48 0.41 0.15
CTQ Total Maltreatment Childhood Trauma Questionnaire total score; CTQ Psyc Maltreatment Childhood Trauma Questionnaire sum of
emotional abuse and emotional neglect; CDI Children’s Depression Inventory; CPSS Child PTSD Symptom Scale; SEI Self-Esteem Inventory;
CBCL Internalizing Child Behaviour Checklist T score sum of internalizing subscales; CBCL Externalizing Child Behaviour Checklist T score
sum of externalizing subscales; CBCL Total Child Behaviour Checklist T score total; CATS Children’s Automatic Thoughts Scale; CPTCI Child
Post-trauma Cognitions Inventory; CASQ-R Children’s Attribution Style Questionnaire—Revised
aSquare root/log transformed score
** p<0.01 (two-tailed)
J Abnorm Child Psychol (2011) 39:759–771 765
adjustment after controlling maltreatment severity. Children’s
automatic thoughts (CATS), post-trauma cognitions (CPTCI)
and attributional styles (CASQ-R) were examined separately.
Physical and sexual abuse, physical neglect and witnessing
DV were entered in the first step of a hierarchical multiple
regression. Total psychological maltreatment was entered in
the second step and the respective cognitive styles were
was largely supported.
Automatic Thoughts Controllingforallmaltreatmentseverity,
children’s automatic thoughts contributed an additional 7% of
the variance to children’s depression symptomatology,
F(1, 43)=5.38, p=0.03. Similarly, it contributed an additional
9% of the variance to self-esteem, F(1, 43)=6.72, p=0.01,
and 20% of the variance to PTSD symptoms, F(1, 43)=
18.73, p<0.001. It was also the only variable that remained
significant in the final step of the model for depression (β=
0.44, p=0.03), self-esteem (β=−0.49, p=0.01) and PTSD
(β=0.74, p<0.001). Children’s automatic thoughts did not
add in a statistically significant manner to any of the parent-
reported problem scores (internalising p=0.81, externalizing
Post-trauma Cognitions Children’s post-trauma cogni-
tions contributed an additional 7% of the variance to
children’s depression symptomatology, F(1, 43)=5.01,
p=0.03. It contributed an additional 12% of the variance
to self-esteem F(1, 43)=9.27, p=0.004), and 39% of the
variance to PTSD symptoms, F(1, 43)=62.18, p=<0.001.
As with the CATS, it was also the only variable that
remained significant in the final step of the model for
depression (β=0.37, p=0.03), self-esteem (β=−0.49, p=
0.004) and PTSD (β=0.89, p<0.001). Again, it did not add
in a statistically significant manner to any of the parent-
reported problem scores (internalising p=0.46, externalizing
Attributional Style Children’s attributional style contributed
an additional 7% of the variance to children’s depression
symptomatology, F(1, 43)=4.84, p=0.03, and an additional
10% of the variance to self-esteem F(1, 43)=7.56, p=0.009.
In the final step of the model, CASQ-R (β=−0.29, p=0.03)
and total psychological maltreatment (β=0.33, p=0.02) were
the only variables that remained significant for depression.
For self-esteem, total psychological maltreatment (β=−0.31,
p=0.04) and sexual abuse (β=−0.33, p=0.01) both remained
significant, as well as CASQ-R scores (β=0.36, p<0.009).
Children’s attributional style did not add in a statistically
significant manner to PTSD symptoms (p=0.19) or any of
the parent-reported problem scores (internalising p=0.85,
Both the maltreatment and control group’s responses (N=38)
were included in the analyses. The response percentages are
illustrated in Table 4. Regarding what has been most helpful
for them (Question 1), most children cited support from
friends and family to have contributed most to their recovery
following negative life events, followed by distracting
oneself from memories of the event/s, and positive thinking.
With regards to what they would say to another child
Table 3 Correlations between maltreatment severity, thinking styles and outcome variables
1. Total Maltreatment
2. Psyc Maltreatment
9. CBCL Int
10. CBCL Ext
11. CBCL Total
1. Total Maltreatment Childhood Trauma Questionnaire total score; 2. Psyc Maltreatment Childhood Trauma Questionnaire sum of emotional
abuse and emotional neglect; 3. CATS Children’s Automatic Thoughts Scale; 4. CPTCI Child Post-trauma Cognitions Inventory; 5. CASQ-R
Children’s Attribution Style Questionnaire—Revised; 6. CDI Children’s Depression Inventory; 7. CPSS Child PTSD Symptom Scale; 8. SEI Self-
Esteem Inventory; 9. CBCL Int Child Behaviour Checklist T score sum of internalizing subscales; 10. CBCL Ext Child Behaviour Checklist T
score sum of externalizing subscales; 11. CBCL Total Child Behaviour Checklist T score total
** p<0.01 (two-tailed); * p<0.05 (two-tailed)
766J Abnorm Child Psychol (2011) 39:759–771
experiencing something scary (Question 2), most children
stated that they would provide reassurance to the child,
followed by seeking help, doing something to forget about it,
and talking to someone trusted.
This study examined the role of psychological maltreatment
in the development of externalising and internalising
problems, such as depression, PTSD symptoms, low self-
esteem and behavioural problems, as well as possible
associated mechanisms. As predicted, children in the abuse
group reported more symptoms of depression, PTSD and
lower self-esteem. Parents of children who had experienced
abuse also reported more internalising and externalising
problems for their children. Whilst children in the abuse
group reported more negative automatic thoughts and
post-trauma cognitions, they did not significantly differ
in relation to attributional style. This may have been due
to the fact that the CASQ-R is a measure of every day
attributions, as opposed to abuse-specific attributions.
Previous authors have highlighted the difficulties of
drawing conclusions about attributional styles in maltreated
children using general attribution measures (Kolko and
Feiring 2002; Valle and Silovsky 2002) and our nonsig-
nificant results are consistent with this research (e.g.,
Gross and Keller 1992). The poor internal reliability of the
CASQ-R in the present sample is also likely to have
contributed to our findings.
Psychological maltreatment was strongly related to
children’s self-reported depression and low self-esteem
and parent reported internalizing and externalizing problems,
even after controlling for other abusive experiences. This
underscores the impact of this type of abuse on a child’s
emotional and behavioural functioning, and highlights the
need for greater community awareness of the magnitude of its
effects. Despite the fact that psychological maltreatment
accounts for a large proportion of substantiated cases of abuse
and neglect in Australia (AIHW 2009), this type of abuse
currently appears to attract less attention from researchers
and policy makers than the other subtypes (Farrall 2005).
While cross-sectional in design, the current findings provide
preliminary justification of the need for more effort and
resources to be invested into the identification and interven-
tion of this type of maltreatment.
The findings support the core component status of
psychological maltreatment with regards to outcomes of
depression, low self-esteem and externalizing behaviours,
suggesting that psychological maltreatment is highly
correlated with these difficulties, even after controlling for
other types of abuse. These findings are consistent with
previous research into the unique impact of psychological
maltreatment on depression and self-esteem (e.g., Briere
and Runtz 1990; Gross and Keller 1992). However, this
was not the case for children’s PTSD symptoms. Previous
large-scale studies (e.g., Schneider et al. 2005; Wekerle et al.
2009) have supported the association between psychological
maltreatment and PTSD, and research in the area of adult
intimate partner violence has also indicated support for the
unique contribution of psychological maltreatment on PTSD,
with several studies finding that it plays a significant role,
even after controlling for physical abuse (e.g., Pico-Alfonso
et al. 2006; Street and Arias 2001). The failure to observe
this relationship in the current study may be explained by a
number of reasons. First, both of the large-scale child studies
(Schneider et al. 2005; Wekerle et al. 2009) consisted of
children recruited from high risk families, or through CPS.
Therefore, it may be that these children’s psychological
maltreatment experiences were more severe and chronic than
those in the current study that included both abused and
non-abused children. A study by Spitzer et al. (2006)
also failed to find a significant relationship between
psychological maltreatment and PTSD in a sample of
adult forensic inpatients. Like the current study, their
study also consisted of participants both with and without
a history of child maltreatment. Second, the small sample
size of the current study may have reduced the power to
detect the significant relationship that was found in the
two larger studies. Third, it is also plausible that particular
types of psychological maltreatment are associated with
PTSD symptoms. The study by Schneider et al. (2005)
included a greater range of psychological maltreatment
experiences in its definition, and thereby may have
identified behaviours not identified in the current study.
Finally, it should be noted that PTSD is a syndrome
Table 4 Percentages of responses to qualitative questions
Support from others (family, friends)
Talk through experiences
Positive thinking, growth
Distraction, try to forget
Question 1: ‘We would like to know what helps children after
something bad or frightening happens. Tell us something about
yourself that has helped you’. Question 2: ‘Tell us what you would
say to help another boy or girl who is going through something bad or
J Abnorm Child Psychol (2011) 39:759–771 767
elicited and defined by a significant threat (or potential
threat) to life and physical integrity (American Psychiatric
Association 2000). Whilst few would argue the harmful
effect of psychological maltreatment, it may not elicit the
immediate sense of threat associated with other subtypes
of maltreatment, such as physical and sexual abuse, and
thus whether it constitutes a Criterion A stressor in many
cases is debatable.
In addition to the above findings, this study also
demonstrated preliminary support for a cognitive model of
adjustment following psychological maltreatment. Not only
were unhelpful cognitions found to be associated with
problematic emotional and behavioural functioning, but in
some instances, these cognitions accounted for greater
variance in outcomes than the maltreatment itself. Both
automatic thoughts and post-trauma cognitions were pre-
dictive of self-reported depression, self-esteem and PTSD.
In fact, they were also the only variables that remained
significant after accounting for maltreatment severity.
Children’s attributional style was significantly predictive
of children’s self-reported depression symptomatology and
self-esteem after controlling for maltreatment severity,
although unlike the other cognitive styles, it was not
predictive of PTSD.
Despite this, none of the cognitive styles contributed to
the parent-reported problem scores. This was contrary to
expectations, especially given that parent-reported internaliz-
ing was significantly correlated with children’s self-reported
depression, PTSD and self-esteem. However, a measure of
child-reported externalising problems was not included in the
current study and therefore, at this stage, it cannot be
determined with any certainty whether children’s unhelpful
cognitions were unrelated to externalising problems, or
whether including a child self-report measure would have
provided some indication of correspondence with parent
report. Previous research has supported the role of cognitions
on externalizing problems, particularly hostile attributions on
aggressive behaviour (for review, see de Castro et al. 2002;
Dodge 2006). Further, there has been some support for the
relationship between child physical abuse and hostile
attributional tendencies (Price and Glad 2003). Despite this,
the current study’s findings lend support to the proposal that
unhelpful cognitions play a particularly important role in the
development of depression, low self-esteem and PTSD
symptoms in children who have experienced maltreatment.
These findings are consistent with recent adult studies (e.g.,
Gibb et al. 2007; van Harmelen et al. 2010).
The current study adds to a body of research that
demonstrates unhelpful cognitions are strongly associated
with trauma response in children who have experienced
non-abuse trauma (e.g., Ehlers et al. 2003; Stallard and
Smith 2007). Given trauma-focused CBT is effective for
both non-abuse and abuse trauma (Cohen et al. 2004;
Deblinger et al. 2006), the present findings illustrate that
maladaptive appraisals are likely to be important targets for
intervention in children who have experienced psychological
abuse. While we cannot change the experiences that children
have already had, we can influence their thinking styles
ways that will aid in their recovery following maltreatment.
This will be an important pathway for future research in order
to determine whether targeting these unhelpful cognitions in
therapy reduces children’s negative symptomatology.
Qualitative responses from children indicated that a
number of adaptive appraisals, such as positive thinking,
may also be helpful for children’s recovery following
maltreatment. Previous research has found that positive
factors such as perceptions of good social support and
adaptive appraisals can be beneficial for children’s recovery
following single-incident traumas (Ellis et al. 2009), and
thus should be examined further.
We acknowledge several limitations. First, the cross-sectional
design precludes causal inferences regarding the relationships
between abuse, cognitions and adjustment. Second, the
sample size was modest. Third, many of the children in this
study, including those in the maltreatment group, only
demonstrated low level symptoms of psychopathology and
only one child had been completely removed from their
family of origin. It is likely that children who have been
removed from their parents will have experienced more
chronic and severe levels of abuse. They will have also had
the additional stress and trauma of this removal, as well as
facing the challenges of integrating into a new, or a number of
new, foster families. This said, as abuse, cognitions and
symptom severity can all be viewed as existing along a
continuum, it may be that the relationship between the
variables remains the same, but the magnitude is larger for
foster children. This is a question for further empirical study.
Fourth, for many participants, the children’s abuse
histories were provided only by means of self-report, with
no outside collaboration. Therefore, we must be cautious
about making firm conclusions about the actual level of
abuse that children had experienced. Finally, despite
using statistical methods to control for the impact of
other types of abuse, most of the children in this sample
experienced a range of maltreatment experiences. Therefore,
these findings should not be generalised to children who have
experienced psychological maltreatment alone. However, as
research shows that most children will have experienced
multiple abuse types (Crittenden et al. 1994; Higgins 2004;
Manly et al. 2001), this fact also increases the study’s
generalisability to a larger population of abused and
768 J Abnorm Child Psychol (2011) 39:759–771
cognitions can play on outcome following maltreatment, it is
critical to examine the effectiveness of addressing these
key cognitions within a therapeutic context. If there are
indeed certain cognitive styles that impact upon children’s
recovery, targeting these cognitions in therapy will likely
be of benefit. Thus, researchers should examine whether
interventions that specifically target these cognitions in
the context of psychological abuse have an additive
benefit for children’s outcomes.
It may also be of use to further dissect the cognitive
categories in order to create a more meaningful understanding
of their impact. For example, it has been argued that
different types of attributions may be related to different
outcomes for children. For example, internal attributions
are likely to lead to internalising problems such as low
self-esteem, anxiety and depression, whereas external
attributions are more likely to be related to externalizing
behaviour (Valle and Silovsky 2002). Future research
should also evaluate whether social, cultural and environ-
mental factors (e.g., family’s response to abuse, involvement
with child protection services, public disclosure of abuse)
influences the development of abuse-specific attributions
(Valle and Silovsky 2002).
Some researchers have argued that it is the chronicity
and severity of abuse that is important in determining
children’s outcomes, rather than the type of abuse per se (e.g.,
Higgins 2004). Whilst the current study provides evidence
that psychological maltreatment may be important for
children’s outcomes over and above that of other subtypes
of abuse, this may in fact be because psychological
maltreatment exists, in some form or another, within all types
of abuse. Therefore, it may be that it is the psychological
aspectof the abuse thatis mostcrucial in predicting children’s
outcomes. Further, it is possible that the chronicity and
severity of abuse, regardless of subtype, influences the
attributions or beliefs that children develop. In other words,
the longer a child is subjected to abuse or neglect, and the
more severe these experiences are, the more likely that they
are to develop unhelpful cognitive styles that then lead to the
development of problematic symptomatology. Therefore, this
is an area for further research.
Another potential area for research would be to examine
the possibility that children with a predisposition for
anxiety or depression may have a skewed perspective of
their life experiences. In other words, it is possible that
these children may be more likely to view ‘normal’
parenting or family difficulties as being maltreatment. The
use of corroborating reports (e.g., parent-, teacher-, carer-
reports) for children’s reported family experiences would
allow this testing of this proposal.
Finally, as recommended by Jacobs et al. (2008), it will be
important for future research to examine cognitive
vulnerability within a developmental framework. This will
allow a better understanding not only of what cognitive styles
may impact children at different ages and developmental
levels, but also how we may best tailor interventions to suit
children at these different stages of development and provide
them with the best chances of recovery.
staff from Child Protection Services, Department of Families and
Communities, and Department of Education and Children’s Services
for their involvement in the study.
The authors would like to thank families and
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