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Childhood maltreatment is an important psychiatric risk factor. Research has focused primarily on the effects of physical abuse, sexual abuse, or witnessing domestic violence. Parental verbal aggression has received little attention as a specific form of abuse. This study was designed to delineate the impact of parental verbal aggression, witnessing domestic violence, physical abuse, and sexual abuse, by themselves and in combination, on psychiatric symptoms. Symptoms and exposure ratings were collected from 554 subjects 18-22 years of age (68% female) who responded to advertisements. The Verbal Abuse Questionnaire was used to assess exposure to parental verbal aggression. Outcome measures included dissociation and symptoms of "limbic irritability," depression, anxiety, and anger-hostility. Comparisons were made by using effect sizes. Verbal aggression was associated with moderate to large effects, comparable to those associated with witnessing domestic violence or nonfamilial sexual abuse and larger than those associated with familial physical abuse. Exposure to multiple forms of maltreatment had an effect size that was often greater than the component sum. Combined exposure to verbal abuse and witnessing domestic violence had a greater negative effect on some measures than exposure to familial sexual abuse. Parental verbal aggression was a potent form of maltreatment. Exposure to multiple forms of abuse was associated with very large effect sizes. Most maltreated children had been exposed to multiple types of abuse, and the number of different types is a critically important factor.
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Am J Psychiatry 163:6, June 2006 993
Sticks, Stones, and Hurtful Words: Relative Effects
of Various Forms of Childhood Maltreatment
Martin H. Teicher, M.D., Ph.D.
Jacqueline A. Samson, Ph.D.
Ann Polcari, R.N., C.S., Ph.D.
Cynthia E. McGreenery
Objective: Childhood maltreatment is
an important psychiatric risk factor. Re-
search has focused primarily on the ef-
fects of physical abuse, sexual abuse, or
witnessing domestic violence. Parental
verbal aggression has received little atten-
tion as a specific form of abuse. This study
was designed to delineate the impact of
parental verbal aggression, witnessing do-
mestic violence, physical abuse, and sex-
ual abuse, by themselves and in combina-
tion, on psychiatric symptoms.
Method: Symptoms and exposure ratings
were collected from 554 subjects 18–22
years of age (68% female) who responded
to advertisements. The Verbal Abuse
Questionnaire was used to assess expo-
sure to parental verbal aggression. Out-
come measures included dissociation and
symptoms of “limbic irritability,” depres-
sion, anxiety, and anger-hostility. Compar-
isons were made by using effect sizes.
Results: Verbal aggression was associ-
ated with moderate to large effects, com-
parable to those associated with witness-
ing domestic violence or nonfamilial
sexual abuse and larger than those associ-
ated with familial physical abuse. Expo-
sure to multiple forms of maltreatment
had an effect size that was often greater
than the component sum. Combined ex-
posure to verbal abuse and witnessing
domestic violence had a greater negative
effect on some measures than exposure
to familial sexual abuse.
Conclusions: Parental verbal aggression
was a potent form of maltreatment. Ex-
posure to multiple forms of abuse was
associated with very large effect sizes.
Most maltreated children had been ex-
posed to multiple types of abuse, and
the number of different types is a criti-
cally important factor.
(Am J Psychiatry 2006; 163:993–1000)
Childhood abuse has been the focus of increasing
concern, particularly when it is sexual or severely physical.
This has been further reinforced by studies that suggest
that abuse produces enduring effects on brain develop-
ment (1). While sexual abuse has come under intense
scrutiny as a psychiatric risk factor, emotional maltreat-
ment may be a more elusive and insidious problem. Emo-
tional abuse encompasses several forms of childhood
maltreatment, such as the witnessing of domestic violence
and exposure to verbal aggression (2). Generally, exposure
to verbal aggression has received little attention as a spe-
cific form of abuse, although it may be at least as impor-
tant as witnessing domestic violence. In one large national
study, Vissing et al. (3) found that 63% of American parents
reported one or more instances of verbal aggression, such
as swearing at and insulting their child. Children who were
the target of frequent verbal aggression exhibited higher
rates of physical aggression, delinquency, and interper-
sonal problems than other children (3).
Maternal verbal abuse during childhood has been asso-
ciated with a markedly higher risk for development of bor-
derline, narcissistic, obsessive-compulsive, and paranoid
personality disorders (4). These associations remained
significant after control for temperament, physical abuse,
sexual abuse, neglect, parental psychopathology, and co-
occurring psychiatric disorders (4). Verbal abuse may also
have more lasting consequences than other forms of
abuse (5) and, in combination with physical abuse and ne-
glect, produce the most dire outcome (6). However, child
protective service agencies, doctors, and lawyers are most
concerned about the impact and prevention of physical or
sexual abuse (7, 8).
Co-occurrence of multiple types of childhood abuse is
known to be common, with reported rates of co-occur-
rence ranging from 3% to 55% (9). When the effects of ex-
posure to multiple forms of adversity are considered, it ap-
pears that the greater the number of forms experienced,
the more severe the subsequent pathology (9, 10).
We sought to answer two questions. First, is there a dis-
cernible impact of exposure to childhood verbal aggres-
sion in the absence of physical abuse, sexual abuse, or ex-
posure to domestic violence? Second, what are the relative
psychiatric consequences of childhood exposure to verbal
aggression, witnessing domestic violence, physical abuse,
and sexual abuse, experienced either alone or in combina-
tion? Dissociation and “limbic irritability” were selected as
two primary variables for analysis, as previous research
had shown robust correlations between dissociation and
hippocampal size (11) and between limbic irritability and
blood flow to the cerebellar vermis as assessed with func-
994 Am J Psychiatry 163:6, June 2006
tional magnetic resonance imaging (12). We also assessed
the effects of exposure on symptoms of depression, anxi-
ety, and anger-hostility.
Detailed ratings of symptoms and exposure history were col-
lected from 554 young adults who responded to advertisements
requesting healthy subjects or individuals with a history of an un-
happy childhood. They ranged in age from 18 to 22 years (mean=
19.8, SD=1.4 years); 378 were women, and 176 were men. After
complete description of the study to the subjects, written in-
formed consent was obtained. Most of the study subjects (73%)
were white, 6% were black, 6% were Hispanic, 10% were Asian, 1%
were Native American, and 4% were from other ethnic groups.
Exposure to verbal aggression. The Verbal Abuse Question-
naire consists of 15 items that cover the key components of verbal
abuse—scolding, yelling, swearing, blaming, insulting, threaten-
ing, demeaning, ridiculing, criticizing, belittling, etc. In a separate
group of 48 college students, the questionnaire showed high in-
ternal consistency as applied to both maternal and paternal be-
haviors (Cronbach alphas, 0.98 and 0.94, respectively). Scores
from the questionnaires for maternal and paternal verbal abuse
were averaged as a measure of childhood verbal abuse. More de-
tailed discussion of scale development and psychometric proper-
ties is available from the authors.
The Verbal Abuse Questionnaire provides a continuous mea-
sure of exposure, which correlated strongly with all of our symp-
tom measures. However, for comparison with other forms of mal-
treatment that were dichotomized into “presence or “absence,
we selected a cutoff score to identify subjects exposed to a sub-
stantial degree of verbal aggression. From the subjects with no
history of physical or sexual abuse a cutoff score was selected that
designated the top 10% of scores. We used this score (>40) to de-
lineate a level of verbal aggression that was unusually high but
not rare. This upper 10% criterion had face validity, as this also
corresponded in this group to the percentage of subjects who en-
dorsed a history of exposure to domestic violence. The effect sizes
for the Verbal Abuse Questionnaire as a continuous measure were
always greater than the effect sizes for the dichotomous variable,
but cutoff scores greater than 40 provided effect sizes that were in
close agreement (70%–80% as large).
Exposure to other abuse and trauma. History of exposure to
physical abuse was obtained by self-report in response to the fol-
lowing question: “Have you ever been physically hurt or attacked
by someone such as husband, parent, another family member, or
friend (for example, have you ever been struck, kicked, bitten,
pushed, or otherwise physically hurt)?” If so, the subjects were
asked to provide information on their relationship to this individ-
ual, the number of times they were hurt, ages at initiation and ter-
mination of these episodes, whether the abuse received or should
have received medical attention, and whether the abuse resulted
in permanent injuries or scars. An individual was classified as
having experienced physical abuse if he or she reported any epi-
sode of inflicted physical injury that received or should have re-
ceived medical treatment or resulted in permanent injury or if
there were at least four reported episodes of what he or she felt
were less serious attacks.
Individuals were classified as having experienced sexual abuse if
they responded affirmatively to the following question: “Have you
ever been forced into doing more sexually than you wanted to do or
were too young to understand? (By “sexually” we mean being forced
against your will into contact with the sexual parts of your body or
his or her body.)” They were also asked to provide information on
their relationship to this individual, the number of times they were
forced, ages at first and last abuse, and whether or not they felt terri-
fied or had their life or another persons life threatened.
History of exposure to domestic violence was assessed by using
the question “Have you ever witnessed serious domestic violence?”
Limbic irritability. The Limbic System Checklist-33 (13) was
created to evaluate the frequency with which subjects experience
symptoms often encountered as phenomena of ictal temporal
lobe epilepsy, as described by Spiers et al. (14). These items consist
of paroxysmal somatic disturbances, brief hallucinatory events,
visual phenomena, automatism, and dissociative experiences.
Psychometric studies showed that the Limbic System Checklist-33
has high test-retest reliability (r=0.92, N=16) (13). Scores were low
in normal comparison subjects (<10) and higher in patients with
documented temporal lobe epilepsy (>23). Scores on the Limbic
System Checklist-33 are dramatically influenced by abuse history
(13), more so than any other variable we have examined (12).
Psychiatric symptoms. The Dissociative Experience Scale (15)
consists of 28 questions that assess the frequency of various dis-
sociative experiences. Scores on each item range from 0 to 100,
and they are averaged to provide an index score. Total scores un-
der 20 capture most healthy subjects and patient groups with no
appreciable dissociative symptoms.
Self-ratings of other psychiatric symptoms were obtained by
using Kellners Symptom Questionnaire (16). This is a 92-item
yes/no questionnaire used to elicit ratings of depression, anxiety,
anger-hostility, and somatic complaints. It was developed to de-
tect response to psychotropic medications and is sensitive to sub-
tle differences from normal.
Data Analysis
The strength of the association between maltreatment history
and self-report symptom scores was assessed by calculating the
effect sizes and 95% confidence intervals (CIs) for the differences
between subjects who had no exposure to maltreatment and sub-
jects exposed to the different maltreatment categories. Effect size
is a more valuable measure for assessing the impact of an experi-
ence than the p value, which is strongly affected by group size.
Cohens d values of 0.2, 0.5, and 0.8 are usually interpreted to rep-
resent small, medium, and large effects, respectively (17).
Effect size was used to highlight the differences between sub-
jects exposed to different forms of abuse and healthy comparison
subjects. Analysis of variance provided a single statistical mea-
sure for the effect of exposure to the various categories of mal-
treatment on the dependent variables. Finally, a few planned sta-
tistical comparisons germane to the main focus of the study were
made in order to understand the significant omnibus F values.
These tests were done to address different specific types of expo-
sure: 1) emotional abuse versus sexual abuse, 2) emotional abuse
versus physical abuse, 3) verbal abuse versus witnessing domestic
violence, 4) the combination of verbal abuse and witnessing do-
mestic violence versus familial sexual abuse, and 5) multiple cat-
egories of abuse.
Effects on Limbic Irritability
As seen in Figure 1, there were robust effects of each of
the five broad abuse categories (emotional only, sexual
only, physical only, any two, all three) on ratings on the
Limbic System Checklist-33 (F=21.46, df=5, 542, p<10
=0.149). There was no effect of gender on this measure
(F=1.13, df=5, 542, p>0.30). Subjects in all of the broad
Am J Psychiatry 163:6, June 2006 995
abuse categories had ratings that were higher than those of
subjects who had never experienced maltreatment. Emo-
tional abuse had a moderately large effect on the rating of
limbic irritability (d=0.703, 95% CI=0.548–0.858; t=4.95,
df=300, p<10
). Subjects who were exposed only to emo-
tional abuse had ratings that were as high as those of sub-
jects who were exposed only to physical abuse (t=0.72, df=
85, p>0.40) or only to sexual abuse (t=–0.83, df=102,
Subjects who were exposed to two different categories
of abuse had higher scores for limbic irritability than sub-
jects exposed to emotional abuse only (t=2.65, df=161,
p<0.01) or physical abuse only (t=3.07, df=144, p<0.003).
Subjects who reported exposure to all three categories of
abuse had significantly higher scores than those exposed
to any single category of abuse.
Limbic irritability was also significantly affected by ex-
posure to any of the more specific types of abusive experi-
ence within each broad abuse category (verbal, nonfamil-
ial sexual, etc.) (F=4.44, df=8, 372, p<10
). Exposure to
verbal abuse had a relatively large effect size (d=0.876,
95% CI=0.641–1.111), whereas witnessing domestic vio-
lence had a moderate effect size (d=0.403, 95% CI=0.189
0.617), although this difference could have occurred by
chance (t=1.49, df=42, p=0.15). It is interesting that com-
bined exposure to verbal abuse and witnessing domestic
violence had a very large effect size (d=1.428, 95% CI=
1.063–1.793), which was essentially equal to the effect size
of familial sexual abuse (d=1.333, 95% CI=1.043–1.623).
Effects on Dissociative Experiences
As seen in Figure 2, there were robust effects of the
broad abuse categories on dissociation (F=13.63, df=5,
540, p<10
, n
=0.105), and they did not differ between
genders (F=1.88, df=5, 540, p<0.10). Emotional abuse had
a large effect on Dissociative Experience Scale ratings (d=
0.910, 95% CI=0.753–1.067). Exposure to physical abuse
and sexual abuse had moderate effects (d=0.533, 95% CI=
0.351–0.715, and d=0.659, 95% CI=0.505–0.813, respec-
tively). Exposure to two different broad categories of
abuse was associated with a large effect size (d=0.902,
95% CI=0.783–1.021) that was similar to the effect size for
FIGURE 1. Effects of Childhood Maltreatment on Limbic Ir-
ritability Scores of 554 Young Adults
Based on comparison of subjects with each category of maltreat-
ment and a comparison group (N=250) with no history of exposure
to abuse or other form of early adversity. The Limbic System Check-
list-33 (13) was created to evaluate the frequency with which sub-
jects experience symptoms often encountered as phenomena of ic-
tal temporal lobe epilepsy.
Only (N=52)
violence (N=24)
abuse (N=20)
Both (N=8)
Only (N=35)
Nonfamilial (N=7)
Familial (N=18)
Both (N=10)
Only (N=53)
Nonfamilial (N=40)
Familial (N=13)
Any Two
Categories (N=111)
All Three
Categories (N=53)
Size of Effect (Cohen's d)
on Composite Score on Limbic
System Checklist-33 (±95% CI)
0.5 1.5
Type of Childhood
2.00.0 1.0
FIGURE 2. Effects of Childhood Maltreatment on Dissocia-
tive Experience Scale Scores of 554 Young Adults
Based on comparison of subjects with each category of maltreat-
ment and a comparison group (N=249) with no history of exposure
to abuse or other form of early adversity.
Only (N=52)
violence (N=24)
abuse (N=20)
Both (N=8)
Only (N=35)
Nonfamilial (N=7)
Familial (N=18)
Both (N=10)
Only (N=53)
Nonfamilial (N=40)
Familial (N=13)
Any Two
Categories (N=111)
All Three
Categories (N=53)
Size of Effect (Cohen's d)
on Score on Dissociative
Experience Scale (±95% CI)
1.0 4.00.0 2.00.5 3.51.5
Type of Childhood
996 Am J Psychiatry 163:6, June 2006
emotional abuse. Exposure to all three categories was as-
sociated with a very large effect size (d=1.431, 95% CI=
1.269–3.024) that was greater than the effect of exposure to
physical abuse (t=2.97, df=86, p<0.005) or sexual abuse (t=
2.55, df=104, p<0.02) and marginally greater than the ef-
fect of emotional abuse alone (t=1.92, df=103, p=0.06).
Exposure to verbal abuse alone and witnessing of do-
mestic violence had moderately strong effects on dissoci-
ation ratings (d=0.690, 95% CI=0.456–0.924, and d=0.564,
95% CI=0.349–1.343, respectively). Subjects exposed to
both verbal abuse and domestic violence (but no other
form of maltreatment) had Dissociative Experience Scale
scores 4.5 times as high as those of the nonabused sub-
jects (d=3.719, 95% CI=3.324–4.114). In this limited study
group, the effect of combined exposure to verbal abuse
and witnessing domestic violence had more impact on
dissociation ratings than exposure to familial sexual abuse
(t=2.42, df=19, p=0.02).
Effects on Anxiety Symptoms
As seen in Figure 3, there were robust effects of the
broad abuse categories on anxiety (F=14.36, df=5, 541,
, n
=0.109), which did not differ between genders
(F=1.53, df=5, 541, p<0.20). Emotional abuse alone and
sexual abuse alone had moderate effects (d=0.510, 95%
CI=0.356–0.664, and d=0.684, 95% CI=0.530–0.838, re-
spectively). Exposure to physical abuse alone exerted only
a small and nonsignificant effect (d=0.158, 95% CI=–
0.023–0.339; t=0.81, df=283, p=0.16). Exposure to two dif-
ferent broad categories of abuse was associated with a
large effect size (d=0.832, 95% CI=0.714–0.950), and expo-
sure to all three abuse categories was associated with a
very large effect size (d=1.429, 95% CI=1.267–1.591) that
was significantly greater than the effect of exposure to any
single category of abuse.
Exposure to verbal abuse alone and witnessing do-
mestic violence had relatively weak effects on anxiety
ratings (d=0.422, 95% CI=0.189–0.655, and d=0.158,
95% CI=–0.056–0.372, respectively). Combined exposure
to verbal abuse and witnessing domestic violence had a
greater than additive effect (d=1.718, 95% CI=1.351–
2.085). Subjects exposed to both verbal abuse and do-
mestic violence (but no other forms) had anxiety scores
that were 2.2 times as high as those of the nonabused
subjects (t=4.76, df=256, p<10
). The effect of combined
exposure to verbal abuse and witnessing of domestic vi-
olence was as great as the effect of exposure to familial
sexual abuse (d=1.204, 95% CI=0.915–1.493).
FIGURE 3. Effects of Childhood Maltreatment on Ratings of Anxiety, Depression, and Anger-Hostility of 554 Young Adults
Based on comparison of subjects with each category of maltreatment and a comparison group (N=250) with no history of exposure to abuse
or other form of early adversity. Kellner’s Symptom Questionnaire (16) is a yes/no self-report questionnaire that is sensitive to subtle differ-
ences from normal.
Only (N=52)
violence (N=24)
abuse (N=20)
Both (N=8)
Only (N=35)
Nonfamilial (N=7)
Familial (N=18)
Both (N=10)
Only (N=53)
Nonfamilial (N=40)
Familial (N=13)
Any Two
Categories (N=111)
All Three
Categories (N=53)
–0.5 0.5 1.5
Size of Effect (Cohen's d) on Score on Measure From Kellner's Symptom Questionnaire (±95% CI)
Anxiety Depression Anger-Hostility
2.50.0 1.0 2.0
–0.5 0.5 1.5 2.50.0 1.0 2.0 –0.5 0.5 1.5 2.50.0 1.0 2.0
Type of Childhood
Am J Psychiatry 163:6, June 2006 997
Effects on Depression Symptoms
There were robust effects of the broad abuse categories
on depression (F=15.91, df=5, 541, p<10
, n
=0.121), and
they were consistent across genders (F=0.58, df=5, 541,
p>0.70). Emotional abuse alone and sexual abuse alone
had large effects (d=0.804, 95% CI=0.648–0.960, and d=
0.971, 95% CI=0.815–1.127, respectively). Exposure to
physical abuse alone exerted a moderate effect (d=0.452,
95% CI=0.271–0.633). Exposure to all three categories ex-
erted a very large effect (d=1.696, 95% CI=1.530–1.862),
which was significantly greater than the effect of exposure
to any single category of abuse.
Exposure to verbal abuse alone and witnessing of do-
mestic violence had moderately strong effects on depres-
sion (d=0.730, 95% CI=0.496–0.964, and d=0.463, 95% CI=
0.249–0.677, respectively). Combined exposure to verbal
abuse and witnessing domestic violence had a greater
than additive deleterious effect (d=2.042, 95% CI=1.672–
2.412). Subjects who were exposed to this combined type
of emotional abuse had depression scores that were 2.8
times as high as those of the nonabused subjects (t=5.66,
df=256, p<10
). The effect of combined exposure to verbal
abuse and witnessing domestic violence was greater than
or equal to the effect of exposure to familial sexual abuse
(d=1.494, 95% CI=1.202–1.786) or exposure to all three
categories of abuse (d=1.696, 95% CI=1.530–1.862).
Effects on Symptoms of Anger-Hostility
There were robust effects of the broad abuse categories
on anger-hostility (F=15.18, df=5, 541, p<10
, n
Emotional abuse alone and sexual abuse alone exerted
moderate effects (d=0.630, 95% CI=0.475–0.785, and d=
0.520, 95% CI=0.367–0.673, respectively). Physical abuse
alone exerted only a weak and not statistically significant
effect (d=0.131, 95% CI=–0.049–0.311; t=0.73, df=283,
p>0.40) and was eclipsed by the effects of exposure to
emotional abuse (t=2.08, df=85, p=0.04). Combined expo-
sure to any two categories of abuse had a large effect size
(d=0.851, 95% CI=0.733–0.969), and exposure to all three
categories had an even larger effect size (d=1.121, 95% CI=
Exposure to verbal abuse alone had a moderately strong
effect on anger-hostility (d=0.758, 95% CI=0.523–0.993),
and these subjects had scores that were 58% greater than
those of the nonabused individuals (t=3.25, df=268,
p<0.002). Witnessing domestic violence had a relatively
weak effect on these symptoms (d=0.327, 95% CI=0.113–
0.541), and the scores of subjects with this childhood ex-
perience were only 25% higher than those of the compari-
son subjects (t=1.53, df=272, p=0.13). Combined exposure
to verbal abuse and witnessing domestic violence had an
additive deleterious effect (d=1.156, 95% CI=0.793–1.519).
The effect of combined exposure to verbal abuse and do-
mestic violence was at least as great as the effect of expo-
sure to familial sexual abuse (d=0.427, 95% CI=0.142–
0.712) and was comparable to the effect of exposure to all
three types of abuse (d=1.121, 95% CI=0.963–1.279).
History of Treatment
The impact of multiple exposures to different forms of
maltreatment was also mirrored in the percentage of sub-
jects reporting a past history of psychiatric treatment (χ
40.4, df=5, p<10
). Previous psychiatric care was reported
by 3% of the subjects with no history of maltreatment, 0%
of those with a history of physical abuse alone, 8% of those
who were exposed to emotional maltreatment, and 9% of
those who were exposed to sexual abuse. In contrast, 18%
of the subjects exposed to any two types of maltreatment
and 25% of those exposed to all three categories reported a
past history of psychiatric care.
Childhood exposure to parental verbal aggression was
associated, by itself, with moderate to large effects on
measures of dissociation, limbic irritability, depression,
and anger-hostility. Exposure to verbal aggression was as-
sociated with numerically larger effects on scores on the
Limbic System Checklist-33 and Kellner Symptom Ques-
tionnaire than was exposure to domestic violence, al-
though these differences could have occurred by chance.
Combined exposure to verbal abuse and witnessing of do-
mestic violence was associated with extraordinarily large
adverse effects, particularly on dissociation. This finding
is consonant with studies that suggest that emotional
abuse may be a more important precursor of dissociation
than is sexual abuse (18).
These findings raise the possibility that exposure to verbal
aggression may be a stressor that affects the development of
certain vulnerable brain regions in susceptible individuals,
resulting in psychiatric sequelae (1). Alternatively, exposure
to verbal aggression in childhood may put into force a pow-
erful negative model for interpersonal communication,
which is then incorporated as a behavioral response in fu-
ture relationships. Toth and Cicchetti (19) proposed a cas-
cade of interpersonal events in maltreated children that be-
gins with insecure attachment relationships, moves to
negative representational models of the self and of the self in
relation to others, and eventuates in impaired perceived
competence, poorer social functioning, and lowered self-es-
teem. Similarly, Crittenden (20) found that exposure to
abuse and neglect affects attachment patterns and coping
strategies. These possibilities are not mutually exclusive,
and each could contribute in important ways.
In the present study group, with our definitions of abuse
it appeared that emotional maltreatment was more closely
associated with psychiatric sequelae than was physical
abuse. It is possible that we would have observed a more
deleterious effect of physical abuse if we had adopted a
stricter definition. We are conducting further studies with
additional measures to test this possibility.
998 Am J Psychiatry 163:6, June 2006
Combined exposure to different categories of abusive
experiences often equaled or exceeded the impact of ex-
posure to familial sexual abuse. This is of great importance
as it suggests that combined exposure to less blatant
forms of abuse may be just as deleterious as the most egre-
gious acts we confront. Fifty-nine percent of the subjects
in the present study with a history of maltreatment had
been exposed to more than one type of abuse.
These findings are concordant with the results of a large-
scale epidemiological study designed to assess the preva-
lence and health impact of early trauma experiences, the
Adverse Childhood Experiences Study (21). All of the publi-
cations resulting from this work point to a relationship be-
tween self-reported early exposure to adversity and subse-
quent problems, including depression (9), attempted
suicide (10), substance abuse, and an array of medical dis-
orders. A dose-response relationship was observed such
that the greater the number of childhood adverse experi-
ences, the greater the risk for a negative health outcome in
adulthood. Macfie et al. (22) also reported that exposure to
multiple forms of trauma, along with severity and chronic-
ity, was predictive of subsequent psychopathology.
The mechanisms underlying the additive or synergistic
effects of exposure to different types of abuse are un-
known. It is possible that an additive or greater effect may
emerge because abuse at home could prevent a child from
seeking help or reassurance from his or her parents when
confronted with abuse outside the home. Alternatively, in-
dividuals exposed to different types of abuse may experi-
ence them at different developmental stages, which would
increase the likelihood that abuse occurred during key
sensitive periods. A third hypothesis is that exposure to
multiple types of abuse increases the frequency of expo-
sure and that, in addition to genetic factors, a certain min-
imal number of exposures is necessary for the develop-
ment of an adverse outcome (23).
The present study is limited by our reliance on self-re-
ports. How do we know if the participants’ abuse histories
are valid? We are sensitized to this issue by the debate sur-
rounding false or repressed memories. However, the issue
of repressed memories is unlikely to be a significant factor
in this research protocol as the events reported were cur-
rent memories and the study provided no incentive for the
subjects to fabricate a history of abuse, as they were never
informed of our screening criteria. While we are con-
cerned about potential fabrications, research suggests
that the overall bias is in the opposite direction—individu-
als are more likely to minimize or deny their adverse child-
hood experiences (24). Positive reports of maltreatment
can be corroborated (25). While retrospective self-report
studies constitute the vast bulk of the literature on the ef-
fects of early abuse on adults, prospective studies that
confirm its impact are emerging (23, 26).
We cannot exclude the possibility that individuals who
have a relatively high degree of current psychiatric symp-
toms may report aspects of their childhood in a more neg-
ative light than do individuals who are free of such symp-
toms (27). It is also possible that exposure to familial
emotional, physical, or sexual abuse is highest in families
with mental illness, and thus, genetic factors could con-
tribute to the higher symptom scores we observed in our
subjects with exposure to familial abuse. Studies of twins
discordant for childhood sexual abuse provide a poten-
tially powerful means of assessing the respective contribu-
tion of childhood sexual abuse while controlling for ge-
netic vulnerabilities and shared environment. Kendler et
al. (28) reported that the twins with childhood sexual
abuse had an overall increased risk for major depression
and a substantially increased sensitivity to the depres-
sogenic effects of other stressful life events.
We have used the term “association” to describe the re-
lationship between symptom ratings and retrospective
self-reports of abuse. While we hypothesize that there may
be a causal relationship, there are other legitimate ways to
interpret the data. Indeed, it may be the case that the rela-
tionship between abuse reports and symptoms is due to a
combination of direct effects of early stress, recall bias,
and increased genetic load.
Another limitation is that our probe question for expo-
sure to domestic violence was very broad, and so the defi-
nition of domestic violence may not be comparable to def-
initions in studies that specifically focused on observations
of mothers being battered. We know from more detailed
assessment of 54 individuals (16 men and 38 women,
mean age=20.8 years, SD=1.1) who responded positively to
this general probe question on the witnessing of serious
domestic violence that 65% had witnessed their mothers
being threatened or assaulted, 43% had witnessed siblings
Patient Perspectives
Angela was an 18-year-old college freshman who en-
rolled in this study after spotting our advertisement on a
subway car. Following a thorough telephone intake inter-
view, she was mailed a study booklet for completion. The
booklet contained questions concerning sociodemo-
graphic status, as well as standardized scales and ques-
tions concerning physical abuse, sexual abuse, domestic
violence, verbal aggression, psychiatric symptoms, and
parenting behaviors. The booklet concluded with a com-
ments section, in which she wrote, “This survey took a lot
longer to fill out than I thought it would. This is the first
time I have thought about these things in years and the
first time I have talked about it.”
We followed up with a personal contact to explore her
history further. We suggested to Angela that her ability to
reveal these events in her responses might be an indica-
tor that she was ready now to talk about them, and we
gave her the contact information for counseling services
at her university, as well as an invitation to be connected
with one of our clinicians.
Am J Psychiatry 163:6, June 2006 999
being threatened or assaulted, and 17% had witnessed
threats or assaults of their fathers. Further, 24% had wit-
nessed the severe beating of the person involved. The ef-
fect of exposure to domestic violence might have been
greater had we used a more specific and limited definition.
Finally, representative sampling techniques were not
used. This means that the impact of maltreatment ob-
served may not generalize to other groups. Sixty-five sub-
jects from the group were recruited for additional studies
and went through structured diagnostic interviews, neu-
ropsychological testing, and imaging protocols. They had
an average Hollingshead two-factor socioeconomic status
of 4.0 (SD=0.8) (upper middle class).
In all likelihood, the overall degree of psychopathology
was probably lower in our healthy, predominantly colle-
giate study group than would be found in a representative
sample, although the relative effects of exposure to differ-
ent forms of abuse should generalize to other populations.
Verbal abuse was associated with effect sizes that were
numerically greater than those associated with witnessing
domestic violence or familial physical abuse. However, wit-
nessing domestic violence and physical abuse can qualify
as a category A(1) traumatic event necessary for the DSM-
IV diagnosis of posttraumatic stress disorder (PTSD), while
exposure to verbal abuse cannot. We wonder, particularly
in children, if threats to ones mental integrity and sense of
self can also be traumatizing. Bremner et al. (29) made an
interesting observation: “Surprisingly, emotional abuse
items, such as being often shouted at, appeared to have se-
vere consequences in terms of risk for PTSD.” The specific
role of verbal abuse in the development of PTSD has yet to
be determined. Research is needed to evaluate whether
such exposure is causative or whether it contributes to the
development of PTSD by amplifying the effects of exposure
to traumatic events.
It will likely come as no surprise to clinicians that paren-
tal verbal aggression is associated with psychiatric symp-
toms. The potential effects of exposure to verbal abuse, by
itself and in combination with other forms of abuse, need
to be carefully considered in research studies focusing on
the effects of early experience. Individuals interested in
the welfare of maltreated children should not underesti-
mate the consequences of verbal abuse. Finally, careful at-
tention should be given to the number of different types of
traumatic experiences a child was exposed to, as this may
be even more critical than the specific type of abuse.
Received Feb. 21, 2005; revision received Oct. 6, 2005; accepted
Jan. 27, 2006. From the Department of Psychiatry, Harvard Medical
School, Boston; and the Developmental Biopsychiatry Research Pro-
gram, McLean Hospital. Address correspondence and reprint re-
quests to Dr. Teicher, Developmental Biopsychiatry Research Pro-
gram. McLean Hospital, 115 Mill St., Belmont, MA 02478; (e-mail).
Supported by RO1 grants to Dr. Teicher from NIMH (MH-53636, MH-
66222) and the National Institute on Drug Abuse (DA-016934, DA-
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... In addition to the phenomenological similarities enumerated above, evidence is accumulating for a strong correlation between meeting diagnostic criteria for BPD and, on the other hand, childhood history of entrapment in mistrusted caretaking relationships (Briere & Rickards, 2007;Hyland et al., 2017). It seems that the correlation gets stronger in studies that include childhood history of grave neglect and betrayal, even if without violence and exploitation (Lyons-Ruth, 2008;Teicher, Samson, Polcari, & McGreenery, 2006 For lack of sufficient research findings, the American Psychiatric Association (2001) guidelines for treatment of patients with BPD relied mostly on expert opinion of senior clinicians and made recommendations in levels of "clinical confidence" (p. 8). ...
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The benefit of various psychiatric drugs for mitigation of irrational fear, anger, anxiety and impulsivity during episodes of complex traumarelated disorder is well documented. Those episodes consist of frantically making unreasonable demands, alternating with just as frantic acts of repentance and ingratiation during a crisis of trust in a current relationship. They also include flashbacks that rehearse a similar scenario retrospectively, for past experiences of traumatic betrayal. In mitigating such emotions, medication expedites psychotherapy. It restores patients’ ability to discern good will and expertise in others’ offer to jointly reappraise a patient’s reasons to cope with danger of betrayal in that manner. Psychodynamic therapists then help patients retrieve and reappraise reasons that often are latent to patients themselves. This paper notes the similarity of episodic disorder, as well as the similarity of pharmacotherapy’s outcomes among patients diagnosed variously with Complex Posttraumatic Stress Disorder, Borderline Personality Disorder or Dissociative Identity Disorder. The author proposes that these three disorders are causally related, all variants of “complex trauma-related disorder.” Therefore, it is reasonable to cite findings from the treatment of patients with all three disorders interchangeably. In summary, it is intriguing that various psychiatric drugs, i.e., antianxiety drugs, antidepressants, antipsychotics and mood stabilizers, all selectively mitigate irrational anxiety, fear, anger and impulsivity, regardless of the family name that they earned in the treatment of other disorders. In contrast, for patients with complex trauma-related disorder, the evidence for benefit strictly according to a drug’s family name (except for antianxiety drugs) has been inconsistent beyond comprehension. This paper presents an algorithm that simplifies reasoning about the order in which we test drugs by relinquishing expectations for an effect by a drug’s family name, e.g., “antidepressant,” in addition to mitigating irrational anxiety, fear, anger and impulsivity, which all four families do, more or less. This algorithm simply chooses depending on a drug’s potency, speed and duration of action, and desired or undesirable side-effects. In addition to the algorithm, this paper clarifies the logic of comparing symptom changes with and without a certain medication, in order to continue it, change the dosage or replace it. To attribute symptom changes to medication changes, we must control for symptom changes in the disorder’s natural course. Symptoms wax and wane with bad and good turns in patients’ judgment of others’ trustworthiness, which often greatly mask the true effect of medication changes
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Internationally, various laws govern reporting of child abuse to child protection services by medical professionals. Whether mandatory reporting laws are in place or not, medical professionals need internal thresholds for suspicion of abuse to even consider a report (“reasonable suspicion” in US law, “gewichtige Anhaltspunkte” in German law). Objective: To compare internal thresholds for suspicion of abuse among US and German pediatricians, i.e., from two countries with and without mandatory reporting laws. Participants and Setting: In Germany, 1581 pediatricians participated in a nationwide survey among child health professionals. In the US, a survey was mailed to all Pennsylvania pediatricians, and 1249 participated. Methods: Both samples were asked how high in their rank order of differential diagnoses child abuse would have to be when confronted with a child’s injuries to qualify for reasonable suspicion / gewichtige Anhaltspunkte (differential diagnosis scale, DDS). In a second step, both had to mark a 10-point likelihood scale (0–100%) corresponding to reasonable suspicion / gewichtige Anhaltspunkte (estimated probability scale, EPS). Results: While for almost two-thirds of German pediatricians (62.4%), child abuse had to be among the top three differential diagnoses for gewichtige Anhaltspunkte, over half of the US respondents (48.1%) had a lower threshold for reasonable suspicion. On the estimated probability scale, over 65% in both samples indicated that the probability of abuse had to exceed 50% for reasonable suspicion / gewichtige Anhaltspunkte. There was great variability between the two countries. Conclusions: There are similar uncertainties in assessing cases of suspected child abuse in different legal systems. There is a need for debates on thresholds among medical professionals in both countries.
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Background: The situation in the world today, encompassing multiple armed conflicts, notably in Ukraine, the Coronavirus pandemic and the effects of climate change, increases the likelihood of childhood exposure to physical injury and pain. Other effects of these worldwide hardships include poverty, malnutrition and starvation, also bringing with them other forms of trauma, including emotional harm, neglect and deliberate maltreatment. Objective: To review the neurobiology of the systems in the developing brain that are most affected by physical and emotional trauma and neglect. Method: The review begins with those that mature first, such as the somatosensory system, progressing to structures that have a more protracted development, including those involved in cognition and emotional regulation. Explored next are developing stress response systems, especially the hypothalamic–pituitary–adrenal axis and its central regulator, corticotropin-releasing hormone. Also examined are reward and anti-reward systems and genetic versus environmental influences. The behavioural consequences of interpersonal childhood trauma, focusing on self-harm and suicide, are also surveyed briefly. Finally, pointers to effective treatment are proffered. Results: The low-threshold nature of circuitry in the developing brain and lack of inhibitory connections therein result in heightened excitability, making the consequences of both physical and emotional trauma more intense. Sensitive and critical periods in the development of structures such as the amygdala render the nervous system more vulnerable to insults occurring at those points, increasing the likelihood of psychiatric disorders, culminating in self-harm and even suicide. Conclusion: In view of the greater excitability of the developing nervous system, and its vulnerability to physical and psychological injuries, the review ends with an exhortation to consider the long-term consequences of childhood trauma, often underestimated or missed altogether when faced with adults suffering mental health problems.
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Objective The abuse and neglect of a child is a major public health problem with serious psychosocial, health and economic consequences. The aim of this study was to assess the relationship between various types of childhood trauma, selected long-term diseases and alcohol and nicotine use disorder in Czech and Slovak representative samples. Methods Data on retrospective reporting about selected long-term diseases, alcohol and nicotine use disorder (CAGE Questionnaire) and childhood maltreatment (Childhood Trauma Questionnaire; CTQ) in two representative samples (Czech sample: n = 1800, 48.7% men, mean age 46.61 ± 17.4; Slovak sample: n = 1018, 48.7% men, mean age: 46.2 ± 16.6) was collected. Multinomial logistic regression models were used to assess the relationships between childhood maltreatment and long-term diseases. Results There is a higher occurrence of some long-term diseases (such as diabetes, obesity, allergy, asthma) and alcohol and nicotine use disorder in the Czech sample; however, in the Slovak sample the associations between child maltreatment and long-term diseases are stronger overall. Emotional abuse predicts the occurrence of all the studied long-term diseases, and the concurrent occurrence of emotional abuse and neglect significantly predicts the reporting of most diseases. All types of childhood trauma were strong predictors of reporting the occurrence of three or more long-term diseases. Conclusion The extent of reporting childhood trauma and associations with long-term diseases in the Czech and Slovak population is a challenge for the strengthening of preventive and therapeutic programmes in psychosocial and psychiatric care for children and adolescents to prevent later negative consequences on health.
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Background Common mental disorders are frequently experienced by refugees. This study evaluates the impact of a brief, lay provider delivered group-based psychological intervention [Group Problem Management Plus (gPM+)] on the mental health of refugees in a camp, as well as on parenting behavior and children’s mental health. Methods and findings In this single-blind, parallel, randomized controlled trial, 410 adult Syrian refugees (300 females, 110 males) in Azraq Refugee Camp (Jordan) were identified through screening of psychological distress (≥16 on the Kessler Psychological Distress Scale) and impaired functioning (≥17 on the WHO Disability Assessment Schedule). Participants were randomly allocated to gPM+ or enhanced usual care (EUC) involving referral information for psychosocial services on a 1:1 ratio. Participants were aware of treatment allocation, but assessors were blinded to treatment condition. Primary outcomes were scores on the Hopkins Symptom Checklist-25 (HSCL; depression and anxiety scales) assessed at baseline, 6 weeks, and 3 months follow-up as the primary outcome time point. It was hypothesized that gPM+ would result in greater reductions of scores on the HSCL than EUC. Secondary outcomes were disability, posttraumatic stress, personally identified problems, prolonged grief, prodromal psychotic symptoms, parenting behavior, and children’s mental health. Between October 15, 2019 and March 2, 2020, 624 refugees were screened for eligibility, 462 (74.0%) screened positive, of whom 204 were assigned to gPM+ and 206 to EUC. There were 168 (82.4%) participants in gPM+ and 189 (91.7%) in EUC assessed at follow-up. Intent-to-treat analyses indicated that at follow-up, participants in gPM+ showed greater reduction on HSCL depression scale than those receiving EUC (mean difference, 3.69 [95% CI 1.90 to 5.48], p = .001; effect size, 0.40). There was no difference between conditions in anxiety (mean difference −0.56, 95% CI −2.09 to 0.96; p = .47; effect size, −0.03). Relative to EUC, participants in gPM+ had greater reductions in severity of personally identified problems (mean difference 0.88, 95% CI 0.07 to 1.69; p = .03), and inconsistent disciplinary parenting (mean difference 1.54, 95% CI 1.03 to 2.05; p < .001). There were no significant differences between conditions for changes in PTSD, disability, grief, prodromal symptoms, or childhood mental health outcomes. Mediation analysis indicated the change in inconsistent disciplinary parenting was associated with reduced attentional (β = 0.11, SE .07; 95% CI .003 to .274) and internalizing (β = 0.08, SE .05; 95% CI .003 to 0.19) problems in children. No adverse events were attributable to the interventions or the trial. Major limitations included only one-quarter of participants being male, and measures of personally identified problems, grief, prodromal psychotic symptoms, inconsistent parenting behavior, and children’s mental health have not been validated with Syrians. Conclusions In camp-based Syrian refugees, a brief group behavioral intervention led to reduced depressive symptoms, personally identified problems, and disciplinary parenting compared to usual care, and this may have indirect benefits for refugees’ children. The limited capacity of the intervention to reduce PTSD, disability, or children’s psychological problems points to the need for development of more effective treatments for refugees in camp settings. Trial registration Prospectively registered at Australian and New Zealand Clinical Trials Registry: ACTRN12619001386123 .
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Background Prenatal stress influences brain development and mood disorder vulnerability. Brain structural covariance network (SCN) properties based on inter-regional volumetric correlations may reflect developmentally-mediated shared plasticity among regions. Childhood trauma is associated with amygdala-centric SCN reorganization patterns, however, the impact of prenatal stress on SCN properties remains unknown. Methods The study included participants from the European Longitudinal Study of Pregnancy and Childhood (ELSPAC) with archival prenatal stress data and structural MRI acquired in young adulthood (age 23-24). SCNs were constructed based on Freesurfer-extracted volumes of 7 subcortical and 34 cortical regions. We compared amygdala degree centrality, a measure of hubness, between those exposed to high vs. low (median split) prenatal stress, defined by maternal reports of stressful life events during the first (n=93, 57% female) and second (n=125, 54% female) half of pregnancy. Group differences were tested across network density thresholds (5-40%) using 10,000 permutations, with sex and intracranial volume as covariates, followed by sex-specific analyses. Finally, we sought to replicate our results in an independent all-male sample (n=450, age 18-20) from the Avon Longitudinal Study of Parents and Children (ALSPAC). Results The high-stress during the first half of pregnancy ELSPAC group showed lower amygdala degree particularly in men, who demonstrated this difference at 10 consecutive thresholds, with no significant differences in global network properties. At the lowest significant density threshold, amygdala volume was positively correlated with hippocampus, putamen, rostral anterior and posterior cingulate, transverse temporal, and pericalcarine cortex in the low-stress (p(FDR)<0.027), but not the high-stress (p(FDR)>0.882) group. Although amygdala degree was nominally lower across thresholds in the high-stress ALSPAC group, these results were not significant. Conclusion Unlike childhood trauma, prenatal stress may shift SCN towards a less amygdala-centric SCN pattern, particularly in men. These findings did not replicate in an all-male ALSPAC sample, possibly due to the sample’s younger age and lower prenatal stress exposure.
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This study examined differences in developmental problems between children who were victims of two child maltreatment dimensions: abuse versus neglect, and physical versus emotional maltreatment. Family demographics and developmental problems were examined in a clinical sample of 146 Dutch children from families involved in a Multisystemic Therapy – Child Abuse and Neglect treatment trajectory. No differences were found in child behavior problems within the dimension abuse versus neglect. However, more externalizing behavior problems (e.g., aggressive problems) were found in children who experienced physical maltreatment compared to children who experienced emotional maltreatment. Further, more behavior problems (e.g., social problems, attention problems, and trauma symptoms) were found in victims of multitype maltreatment compared to victims of any single-type maltreatment. The results of this study increase the understanding of the impact of child maltreatment poly-victimization, and highlight the value of classifying child maltreatment into physical and emotional maltreatment.
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Background: When assessing patients with depressive and anxiety disorders in psychiatric clinical practice, it is common to encounter children and adolescents who have experienced abuse and victimization. To date, it has been clarified that experiences of "childhood abuse" and "childhood victimization" lead to "neuroticism", and that neuroticism leads to "adult depressive symptoms". In this study, we analyzed how these four factors are interrelated. Subjects and methods: The following self-administered questionnaire surveys were conducted in 576 adult volunteers: Patient Health Questionnaire-9, Eysenck Personality Questionnaire-revised shortened version, Child Abuse and Trauma Scale, and Childhood Victimization Rating Scale. For statistical analysis, Pearson correlation coefficient analysis, t-test, multiple regression analysis, and covariance structure analysis (path analysis) were performed. Results: Path analysis showed that the indirect effects of childhood abuse and childhood victimization on depressive symptoms through neuroticism were statistically significant. In addition, the indirect effects of childhood abuse on neuroticism through childhood victimization were statistically significant. Finally, the indirect effects of childhood abuse on depressive symptoms through the combined paths of childhood victimization and neuroticism were statistically significant. Conclusion: Our results suggest that "childhood abuse (A)" induces changes in the personality trait of "neuroticism (C)" with "childhood victimization (B)" as a mediator, and that these adversities affect the expression of "depressive symptoms in adulthood (D)" through "neuroticism (C)" as a mediator. In other words, to our knowledge, this is the first study to clarify that these four factors are not only individually associated with each other but also cause a chain reaction of A to B to C to D.
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The prevalence of traumatic events in South Africa is considerably high due to a history of political violence and the ongoing cycle of interpersonal, community-based, and socioeconomic violence. While conventional therapeutic techniques have been found to support trauma survivors in the local context, alternative approaches that focus on the mind–body connection have become increasingly popular. However, studies reporting on the use of these approaches remain scarce. This study aimed to add to the body of knowledge on yoga as a non-conventional therapy to support trauma survivors and foster posttraumatic growth. Semi-structured interviews were conducted with a sample of seven Kundalini yoga practitioners who had been exposed to trauma. A thematic analysis confirmed that Kundalini yoga was beneficial in fostering posttraumatic growth. Overall, the study findings, evidence a pocket of success in relation to value of such an intervention within a low socio economic black South African context.
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The coping strategies of four groups of maltreated children were compared with those of adequately reared children. The children were videotaped in a brief play session with their mothers, then in the Strange Situation, and finally during free play while the parent(s) were being interviewed. The coded videotapes of mother-child interaction yielded four scores for the children: cooperation, compulsive compliance, difficultness, and passivity. The coded videotapes of the Strange Situation yielded ten patterns of child attachment to the mother. The coded observations of play during the interview were analyzed in terms of seven child behaviors. The results indicated that abused, and abused-and-neglected children were difficult or compliant in interaction with their mothers, avoidant under stress, and aggressive with siblings; neglected children were cooperative in play with the mother, anxious under stress, and aggressive with siblings; adequately reared children were cooperative with both their mothers and siblings and secure under stress. Older children who had experienced abuse were less difficult and more compulsively compliant. Both marginally maltreated and adequately reared 1-year-olds were more difficult than either older or younger children from those groups but at all ages cooperation was the dominant pattern. The coherencies in the children's coping strategies were interpreted in terms of underlying internal representational models of relationships.
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Dissociation is a lack of the normal integration of thoughts, feelings, and experiences into the stream of consciousness and memory. Dissociation occurs to some degree in normal individuals and is thought to be more prevalent in persons with major mental illnesses. The Dissociative Experiences Scale (DES) has been developed to offer a means of reliably measuring dissociation in normal and clinical populations. Scale items were developed using clinical data and interviews, scales involving memory loss, and consultations with experts in dissociation. Pilot testing was performed to refine the wording and format of the scale. The scale is a 28-item self-report questionnaire. Subjects were asked to make slashes on 100-mm lines to indicate where they fall on a continuum for each question. In addition, demographic information (age, sex, occupation, and level of education) was collected so that the connection between these variables and scale scores could be examined. The mean of all item scores ranges from 0 to 100 and is called the DES score. The scale was administered to between 10 and 39 subjects in each of the following populations: normal adults, late adolescent college students, and persons suffering from alcoholism, agoraphobia, phobic-anxious disorders, posttraumatic stress disorder, schizophrenia, and multiple personality disorder. Reliability testing of the scale showed that the scale had good test-retest and good split-half reliability. Item-scale score correlations were all significant, indicating good internal consistency and construct validity. A Kruskal-Wallis test and post hoc comparisons of the scores of the eight populations provided evidence of the scale's criterion-referenced validity.(ABSTRACT TRUNCATED AT 250 WORDS)
An attachment theory framework is applied toward understanding the emergence of depressive symptomatology and lower perceived competence in maltreated and nonmaltreated children. Hypotheses that maltreated children with nonoptimal patterns of relatedness evidence elevated depressive symptomatology and lower competence, whereas nonmaltreated children with optimal or adequate patterns of relatedness exhibit the least depressive symptomatology and higher competence, were confirmed. Additionally, differentiations between maltreated children with and without optimal or adequate patterns of relatedness emerged, suggesting that relatedness may mitigate against the adverse effects of maltreatment. Moreover, sexually abused children with confused patterns of relatedness evidenced clinically significant depressive symptomatology. Results are discussed with regard to mechanisms that contribute to adaptation or maladaptation in children with negative caregiving histories.
Numerous recent studies have suggested a possible link between childhood sexual abuse and adult psychiatric disorders. However, these studies must be interpreted with careful attention to the problems of selection bias, information bias, and the effects of confounding variables. To our knowledge, no available studies in the scientific literature have adequately controlled for all three of these sources of error. Indeed, many published studies are so vulnerable to these forms of error that they are rendered almost valueless. Therefore at present we cannot reasonably conclude whether childhood sexual abuse is, or is not, an etiologic factor in adult psychiatric disorders.
Analyses of data on a nationally representative sample of 3,346 American parents with a child under 18 living at home found that 63% reported one or more instances of verbal aggression, such as swearing and insulting the child. Children who experienced frequent verbal aggression from parents (as measured by the Conflict Tactic Scales) exhibited higher rates of physical aggression, delinquency, and interpersonal problems than other children. This relationship is robust since it applies to preschool-, elementary school-, and high school-age children, to both boys and girls, and to children who were also physically punished as well as those who were not. Children who experienced both verbal aggression and severe physical violence exhibited the highest rates of aggression, delinquency, and interpersonal problems.
This study investigating the effects of verbal abuse on children and their abused parents, tends to support the clinical impression that verbal abuse may have a greater impact for a longer period of time. Although there are very few pure forms of verbal abuse, there are some parents who use verbal abuse but would hit their children, neglect them, or involve them in sex. Verbal abuse may become an increasingly frequent form of controlling and disciplining children because of the increased awareness of physical abuse and because of the possible declining value of children. Verbal abuse may have a greater impact because the abused child has greater difficulty defending himself from the attack. Because children tend to identify with their parents, the verbal abuse by their parents becomes a way in which they then abuse themselves.
There is little information concerning child abuse reporting by physicians. The present study, a questionnaire survey, was therefore designed to examine several aspects of child abuse reporting by practicing physicians in Virginia. Physicians diagnosed few abused or neglected children in their practices. More than 90% saw five or fewer cases, and 26% encountered no abuse or neglect at all during the preceding year. Most physicians were inclined to report all diagnosed cases of physical abuse (91%) and sexual abuse (92%), but fewer reported all cases of physical neglect (58%), emotional abuse (45%), or medical neglect (43%). The two most frequently cited reasons for not reporting were (1) reluctance to report before you are certain of the diagnosis of abuse or neglect; (2) the belief that you can work with the family to solve the problem without outside intervention.