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Post-Traumatic Stress Disorder in Physically Abused Adolescents
Post-Traumatic Stress Disorder in Physically Abused Adolescents DAVID PELCOVITZ, PH.D., SANDRA KAPLAN, M.D., BARBARA GOLDENBERG, B.A., FRAN MANDEL, PH.D., JULIE LEHANE, PH.D., AND JAMES GUARRERA, B.A.
ABSTRACT Objective: In an investigation of the prevalence of post-traumatic stress disorder (PTSD), other Axis I psychiatric
disorders, and social and behavioral difficulties, 27 physically abused adolescents were compared with 27 nonabused controls who were recruited through random-digit dialing procedures. Method: The Structured Clinical Interview for Diagnosis (PTSD module), Kiddie-Schedule for Affective Disorders and Schizophrenia, and Youth Self-Report were administered to all subjects; mothers were interviewed regarding their adolescent's behavior using the Kiddie-Schedule for Affective Disorders and Schizophrenia for School-Age Children and Child Behavior Checklist. Results: The three physically abused adolescents who received a diagnosis of PTSD on the PTSD module of the Structured Clinical Interview for Diagnosis reported their PTSD symptoms were in reaction to extrafamilial sexual assaults and not to physical abuse. In contrast, the abused adolescents showed significantly higher prevalence rates of depression, conduct disorder, internalizing and externalizing behavior problems, and social deficits. Conclusions: Findings suggest that physically abused adolescents may be more at risk for behavioral and social difficulties than for PTSD. J. Am. Acad. Child Ado/esc. Psychiatry, 1994, 33, 3:305-312. Key Words: post-traumatic stress disorder, adolescent physical child
abuse, psychopathology.
This study provides a preliminary report of the findings of an investigation of the prevalence of post-traumatic stress disorder (PTSD) in a sample of physically abused adolescents who were recruited from the New York State central register for abuse and in a communityrecruited nonabused comparison group. The subjects
Accepted June 1, 1993. Dr. Pelcovitz is ChiefPsychologist, Dr. Kaplan is Associate Chairman, Ms. Goldenberg is Psychology Extern, Dr. Lehane is Research Psychologist, and Mr. Guarrera wasResearch Assistant, Department ofPsychiatry, Division ofChild and Adolescent Psychiatry, and Dr. Mandel is Research Statistician, Division of Biostatistics, Department of Research, North Shore University HospitalCornell University Medical College, Manhasset, NY. Also, Dr. Pelcovitz is Clinical Associate Professor of Psychology in Psychiatry, and Dr. Kaplan is Associate Professor of Clinical Psychiatry, Cornell University Medical College. Dr. Mandel is also Assistant Professor ofBiostatistics, School ofPublic Health, Cornell University Medical College. Reprintrequests to Dr. Pelcovitz, Division ofChild Psychiatry, Department ofPsychiatry, North Shore University Hospital, 400 Community Drive, Manhasset, NY 11030. Thisresearch wassupported in part through NIMHgrant 1R01MH4377204 and theNIMH-jUndedDSM-IV PTSD FieldTrials. Theopinions expressed in this article are those of the authors and do not necessarily represent the position oftheAmerican Psychiatric Association or its TaskForce on DSM-IV. 0890-8567/94/3303-0305$03.00/0©1994 by the American Academy of Child and Adolescent Psychiatry.
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were interviewed as part of the DSM-IV PTSD field trials and an ongoing National Institute of Mental Health-funded study of adolescent physical abuse. In addition, the subjects and their mothers were administered behavior problem checklists to determine whether they manifested behavioral disturbance not reflected in the PTSD diagnosis. There is a surprising lack of systematic investigation of the prevalence of PTSD physically abused children and adolescents. Although PTSD is a frequently used diagnosis for victims of intrafamilial sexual abuse (Deblinger et al., 1989; Goodwin, 1985), few investigators have empirically investigated the prevalence of PTSD in victims of physical child abuse. In one of the only published studies investigating PTSD symptoms in victims of physical child abuse, Deblinger et al. (1989) reported that 2 of 29 physically abused children, 20 of 29 sexually abused children (most of whom also were physically abused), and 3 of 29 nonabused comparison children met the DSMIII-R criteria for PTSD as diagnosed by a symptom checklist. This study had several limitations including use of a referred sample of abused children, reliance
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on a checklist rather than structured interviews, and the overlap between physical and sexual abuse in the sex abuse sample. Furthermore, both the physical abuse and sex abuse samples contained subjects who were victimized by family members as well as victims who were assaulted by nonrelatives. The findings, however, are intriguing in that they suggest a relatively lower rate of PTSD in physical abuse, even in comparison with the nonabused group. Kiser et al. (1991) srudied 49 victims of sexual and/ or physical abuse who had symptoms characteristic of PTSD based primarily on clinician ratings and 40 victims of sexual and/or physical abuse who did not show evidence of PTSD symptoms. Findings suggested that two distinct symptom pictures emerged. One was consistent with the reexperiencing, arousal, and avoidance criteria seen in patients with PTSD; the other was that those without PTSD were characterized by higher levels of behavioral difficulties (as measured by the Child Behavior Checklist and the Youth SelfReport), including delinquency, aggression, anxiety, and depression. The generalizability of this study is limited because the researchers combined physical and sexual abuse victims, and they did not rely on structured interviews for diagnosis of PTSD. However, the findings suggest the possibility that a significant percentage of abuse victims may respond by exhibiting symptoms not explained by a PTSD diagnosis. As noted earlier, in contrast to physical abuse, there are far more studies that systematicallyassess the prevalence ofPTSD in sexual abuse victims. In investigations ofPTSD in victims of sexual assaults (including extrafamilial), this diagnosis has been found to be twice as prevalent as that found in victims of other crimes (Kilpatrick et al., 1987). When researchers relied on referred samples, very high rates ofPTSD were generally found in incest victims. Lindberg and Distad (1985) found PTSD in all 17 patients who were survivors of incest, and Donaldson and Gardner (1985) reported PTSD in 96% of 26 women who were receiving therapy for the sequelae of sexual abuse. Similarly, in a referred sample of 31 sexually abused children , McLeer er al. (1988) reported a 48.4% incidence of PTSD, ranging from 75% in children abused by their fathers to 25% in those abused by trusted adults. However, when the relative prevalence of PTSD in victims of incest is looked at more systematically using
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nonclinical samples, it is clear that a significant proportion of victims do not meet the criteria for this disorder. Greenwald and Leitenberg (1990) found that 4% of 54 women in a nonclinical sample of sexual abuse victims report moderate PTSD symptomatology currently, and only 17% might have met criteria in the past. Kilpatrick et al. (1987), who studied 126 adult survivors of child sexual abuse, found the current incidence was 10% and the lifetime history of PTSD was 36%. These data suggest that an accurate understanding of the relative prevalence of PTSD in physically abused children and adolescents needs to be based on studies of abused children who are not recruited from samples of victims referred for treatment. Finkelhor (1988) criticized exclusive reliance on the PTSD diagnosis for sexual abuse victims. He noted that PTSD is a more appropriate diagnosis for "events" like crimes or combat and may be a less relevant diagnosis for incest, which is more of a process that frequently is not accompanied by violence or threats. Furthermore, symptoms frequently reported in the literature on sequelae of child abuse such as selfblame, revictimization, and sexual difficulties are not addressed. As with sexual abuse, victims of intrafamilial physical abuse grow up in a situation that may not be directly analogous to the high-magnitude stressors usually associated with PTSD . Victims of adolescent physical abuse often live in an environment that is so dominated by violence that they are exposed to an ongoing process rather than a discrete "event. " Even more than is the case with survivors of incest, physical abuse victims may grow up in a situation in which the violence they encounter is viewed as part of their parents' childrearing style rather than as a traumatic event that is outside the range of normal human expenence. This study ofPTSD in victims oflegally documented physical child abuse differs from previous research in its use of a sample that was not referred for treatment and not confounded by inclusion of subjects who were also incest victims. Unlike previous researchers, we used a comparison sample recruited through use of random-digit dialing procedures. Our study was designed to test two hypotheses that were guided by previous research regarding the psychological sequelae of abuse (e.g., Cole and Putnam, 1992): (1) There will be a higher proportion of PTSD in a group of physically abused adolescents than in controls. (2)
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There will be higher prevalence rates of internalizing . and externalizing behavior in the abuse group, with a particularly high prevalence rate of affective disorder, substance abuse, and conduct disorder. METHOD To determine the presence of PTSD symptoms, 27 adolescents, found by a child protective services investigation to have been physically abused, were administered structured interviews eliciting a history of exposure to traumatic events. Subjects were recruited from a list ofconsecutively indicated cases ofphysical abuse reported to the New York State register for child abuse. Subjects who had a history of intrafamilial sexual abuse discovered either by child protective services report or by self-report, were excluded. The rationale for this was that because previous studies combined sexual abuse (a trauma that places one at high risk for PTSD) with physical abuse, it was possible that high prevalence rates of PTSD in those studies were the result of the sexual abuse and not the physical abuse. Therefore, we aimed at interviewing victims of int rafam ilial physical abuse alone . A community control sample , demographically comparable with the abuse sample and living in the same neighborhood as the abused subjects, were recruited through use of a random-digit dialing procedure. Table 1 presents the demographic characteristics ofrhe abuse and comparison groups. The abuse and control groups were composed entirely of white, suburban adolescents ofcomparable age, gender, and socioeconomic status (SES) (Hollingshead, 1975). The PTSD module of the Structured Clinical Interview for Diagnosis (SCID) (Spitzer er al., 1987) was administered to all subjects. Dr. Robert Spitzer, the senior author of the SCID, has found this instrument suitable for use with adolescents (personal communication) . The choice of the SCID instead of structured or semistructured interviews normally used with adolescents was based on the lack of availability of a DSM-III-R-based PTSD module for the Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS) at the time our study began. Furthermore, the reliability of use of parents as informants on a diagnosis that specifically addresses the emotional impact of abuse on their child is questionable because the parent either perpetrated the abuse or may have been complicitous in maintaining an abusive home environment. Interviewers were graduate students in doctoral programs in clinical psychology. Training of interviewers consisted of reading a SCID-PTSD training manual, which clearly delineated the stan dards necessary to meet the criteria for DSM-III-R diagnosis of PTSD. In addition, training sessions were held for the interviewers to listen to audiotapes of previous SCID-PTSD interviews. As
TABLE 1 Demographic Variables (Means) Abused Adolescents
Comparison
Age (yr)
15.1 ± 1.7 55.6 44.4 2.7 ± 0.9
15.1 ± 1.7 59.3 40.7 2.4 ± 0.9
Note: N = 27 in each group .
Procedure Subjects were administered the SCID-PTSD structured interview, Potential Stressful Events Interview, and Achenbach scales as part of a wider study of psychopathology and suicidal behavior in physically abused adolescents . The families involved in the study were paid $250 for their participation, which involved 5 hours of interv iewing for each subject , divided between two visits. The measures used in this study were administered in the first of the two visits. Several other interviews, which were part of the DSMN PTSD field trials, were also administered to the physically abused subjects. These measures added approximately an additional half-hour to the test battery.
Statistical Methods
Variable Females (%) Males (%) Socioeconomic status
noted earlier, the abuse sample was interviewed as part of the DSM-NPTSD field trials, which recruited subjects from five sites. Interrater K: coefficients measuring the reliability of interviewers from the authors' site compared with the other four sites was .72 for current and lifetime interviews (Kilpatrick et al., 1992) . The Potential Stressful Events Interview (Kilpatrick er al., 1992) was administered to subjects in both groups. This measure is a structured interview designed to assess systematically whether the subject has been exposed to any traumatic incidents that would meet the DSM-III-R criterion A guidelines for PTSD. The adolescents were systematically asked whether they had been exposed to high-magnitude traumas such as natural disasters, sexual abuse, and extrafamilial physical assaults. Current level of behavioral difficulty was measured using both the mother (Achenbach and Edelbrock, 1983) and adolescent (Youth Self-Report [YSR]; Achenbach and Edelbrock, 1987) as informants. These measures were used to provide a profile of behavioral adjustment that may not have been reflected through the assessment of PTSD symptomatology. The Child Behavior Checklist (CBCL) (Achenbach and Edelbrock, 1983) is a 118item checklist designed to obtain parental ratings of their children's behavior problems. A factor analysis of the instrument, carried out separately for girls and boys, yields nine behavior problem scales. Test-retest reliability ranges from .82 to .90. Interparenr correlations are .67 for girls and .74 for boys. The YSR (Achenbach and Edelbrock, 1987), which is filled out by the child, closely parallels the parent form . The YSR is designed for children with reading skills at least at fifth grade level. The measure can be read aloud to respondents who have reading skills below fifth grade level. Achenbach and Edelbrock report a test-retest correlation of .69 over a 6-month interval. The K-SADS-E (Epidemiologic Version) Modified for DSMIII (Orvaschel et al., 1982) is a semistructured diagnostic interview for children aged 6 through 17. Acceptable interrater reliability for this interview was reported by Gammon et al. (1984) . Interviewers for this study were trained by one of the developers of the instrument. Periodic training meetings were held with the raters to compare interviewing and diagnostic habits and to minimize interviewer "drift."
Data analyses of K-SADS and SCID diagnoses used X2 tests for proportions or Fisher's exact rests, as indicated by sample size. A X2 tests was used to compare the proportions of male and female adolescents in each group. Mann-Whitney tests were used to compare the distribution of CBCL and YSR scores for the physically abused group and the distribution of scores for the comparison group. Because of the large number of comparisons being made ,
]. AM. ACAD. CHILD ADOLESC . PSYCHIATRY, 33:3, MARCH/APRIL 1994
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PELCOVITZ ET AL. a significance level of .01 was used to attempt to avoid spurious results. A X2 test for proportions was used to compare the proportions of male and female adolescents in each group. We decided to use nonparametric statistics in our analyses because the measure did not meet the assumptions of the T test; i.e., the scores did not appear to be normally distributed and the residuals also were not normally distributed.
RESULTS
As can be seen by reviewing the description of the sample in Table 1, subjects in the two groups are comparable in age, gender, and SES (Hollingshead, 1975). The distribution of ages and SES for the two groups was approximately equal (Mann-Whitney tests, p > .05). The proportions of male and female adolescents were approximately equal in the two groups (X2 test, p > .05). Data from the SCID, CBCL, and YSR were analyzed for 27 abuse and 27 comparison subjects. However, for the K-SADS data were analyzed for only 25 abuse and 25 comparison subjects. On the K-SADS the proportion of adolescents reporting major depression (lifetime) (p < .001), conduct disorder (lifetime (p < .05), oppositional disorder (current) (p < .05), and lifetime and current cigarette use (p < .03) was significantly greater in the abuse group than in the control group. Mothers' reports resulted in a finding that there was a significantly greater proportion of abused children reporting current major depression (p < .05) and current cigarette use (p < .05) than in the comparison group. Percentages of significant DSM-III-R diagnoses in the abuse and comparison groups are presented in Table 2; all other diagnoses, including PTSD (as measured by the SCID), were reported in approximately the same proportion for the two groups, i.e., they were not significantly different. The three physicallyabused adolescents who received a diagnosis of PTSD all reported that their PTSD symptoms were in reaction to extrafamilial sexual assaults and not to physical abuse. The 24 subjects who did not receive a PTSD diagnosis did not report histories of sexual abuse. None of the subjects in the comparison group received a full diagnosis of PTSD. Two subjects showed some symptoms of this disorder (one as a result of being physically assaulted by a gang in his school, and another who saw her brother's body after a suicide by hanging). A third subject, who reported some PTSD symptoms as a result of a sexual assault, refused to fully answer questions regarding the
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TABLE 2 Results from the Kiddie-Schedule for Affective Disorders and Schizophrenia: Percentage Meeting Criteria for DSM-III-R Diagnosis
Child report Major depression (L) Conduct disorder (L) Oppositional defiant (C) Cigarette use (L) Cigarette use (C) Mother report Major depression (C) Cigarette use (C)
Abuse
Control
40
3.7 0 0 3.7 7.4
16 20 12
32
16 24
0 3.7
Note: C = current, L = lifetime; N = 27 in each group.
presence of PTSD symptoms. It is possible this subject would have met criteria for PTSD had she answered all of the SCID-PTSD items. Scales on which the two groups differed significantly on the adolescent self-report of social competence and behavioral difficulties (YSR) are presented in Table 3. Significant differences between the two groups in parental reports of social and behavioral difficulties, as indicated on the CBCL, are presented in Table 4. Only raw scores and not normalized t scores are presented because of concerns reported in the literature regarding the validity of relying on the normative population used in the Achenbach scales (Sandberg et al., 1991). The meanings of significant scores are as follows: the total social score is obtained from the ratings regarding the child's number and frequency of contacts with friends and level of activities in organizations outside of school. Total competence scores are obtained by assessing the adolescent's level of activity in sports and jobs as well as overall level of competence in school and social areas. The "Sum" score is a measure of the total severity of specific problem items. Achenbach and Edelbrock (1983) differentiate between internalizing problem behaviors (reflected in the "Sum Internal" score), manifested through fearful, inhibited, and overcontrolled behavior, arid externalizing behaviors (reflected in the "Sum External" score), manifested by aggressive, antisocial, and undercontrolled behavior. Regardless of whether the adolescent or the parent was the informant, the physically abused adolescents showed significantly more behavioral and social deficits compared with the control group. The types of behavior
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difficulties appeared to be both internalizing and externalizing in nature. DISCUSSION
Findings of this study do not support hypothesis 1, i.e., PTSD was not present in significantly higher proportions in the abuse group. However, the K-SADS data and problem checklist results do substantially support hypothesis 2. This study is, to the best of our knowledge, the first to assess systematicallythe presence of PTSD in a group of unreferred victims of physical abuse in which intrafamilial sexual abuse was ruled out. The finding that there was little evidence in our sample of adolescents that physical abuse results in PTSD is surprising in light of previous reports that this population is at risk for this disorder (Green, 1985). The presence of significant levels of behavioral and social problems in our abuse sample is consistent with previous reports concerning physically abused children and suggests the possibility that, in contrast to those sexually abused, physically abused adolescents may "enact" the results of their victimization rather than express their reactions to the abuse via the more trauma-specific avenue of PTSD. The failure of subjects in both groups to meet criteria for PTSD does not appear to be related to a general tendency on the part of adolescents to deny PTSD symptoms. An identical protocol recently was used in a sample of adolescent cancer survivors,and a significant percentage of them met criteria for PTSD (Pelcovitz, 1991). There is evidence that adolescence is a time when one may be particularly likely to have PTSD symptoms in response to external stress. van der Kolk (1985) reported that fighting in Vietnam during adolescence, compared with being in combat as an adult, was a greater risk factor for developing PTSD.
All three abused adolescents who received a PTSD diagnosis reported these symptoms in response to extrafamilial sexual assaults. There are a number of ways in which sexual assault differs from physical abuse. Sexual abuse is, by its very nature, difficult to integrate. Summit and Kryso (1978) attribute this to the high level of secrecy and shame that accompanies sexual abuse, thereby making this type of trauma particularly difficult to deal with in a direct way. In contrast, physical abuse is less likely to be accompanied by a high level of secrecyand shame. As Straus et al. (1980) note in their national study, physical child abuse often occurs as an extension of child discipline that relies on the use of corporal punishment. In a culture that often condones such disciplinary practices, the adolescent may not view more severe physical punishments as something unique and out of the "ordinary." Our experience in interviewing physicallyabused adolescents is that, in contrast to sexual abuse survivors, they showed little embarrassment and/or secrecy in their discussions regarding the beatings they received at the hands of their parents. In fact, they often appeared surprised that we were making such an issue of a process they considered "normal" and not worthy of our interest. This attitude lies in sharp contrast to the great reluctance that typically attends the disclosure and frequent retraction of intrafamilial sexual abuse. Qualitative impressions of our interviewers regarding the three subjects who were extrafamilial sexual abuse survivors was that they shared their feelings and memories regarding those traumatic incidents with a higher level of reluctance and upset than that which attended their descriptions of physical abuse. Another difference between the process of physical and sexual abuse is the frequently public nature of physical sequelae of physical abuse. Bruises, fractures,
TABLE 3 Behavioral and Social Difficulties: Adolescent Report (Youth Self-Report) Physically Abused Scale Social Score Total Social Total Competence Thought Disorder Delinquent
Median Interquartile Range
6 6 16 6 9
5-8.5 5-9 14-19 3-10 4-16
Note: Sum is the total problem raw score. All raw score scales with
j, AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:3, MARCH/APRIL 1994
Comparison Group Median
Interquartile Range
p
8.5 9 18 2 5
7.5-9.5 8-10 17-21 1-4 3-9
<.001 <.001 <.005 <.003 <.014
p less than .01 are reported. N
= 27 in each group.
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TABLE 4 Behavioral and Social Difficulties: Parent Report (Child Behavior Checklist) Physically Abused Scale General (boys and girls combined, N = 27 in each group) Social Score Sum Competence Sum Internal Sum External Boys alone (N = 15 in each group) Somatic Delinquent Girls alone (N = 12 in each group) Delinquent Aggressive
Comparison Group
Median
Interquarrile Range
Median
Interquarrile Range
p
5.25 32 12.5 19.5
4.5-7 16-54 6-21 6-27
8 11 4 4
6.5-9.5 4-26 1-13 2-14
<.001 <.004 <.011 <.001
0 6
1-6 2-9
3 1
0-1 0-3
<.005 <.001
4 9
2-10 4-20
0.5 2
0-3 1-7.5
<.003 <.007
Note: Sum is the total problem raw score. All raw score scales with p less than .01 are reported .
and other bodily evidence of physical abuse may lead to this type of abuse becoming more of a public event which, in turn, may facilitate integration of the trauma to a greater extent. The element of surprise and unpredictability have been noted to be risk factors for PTSD (Cella et al., 1990). Physical abuse is generally more predictable than sexual abuse. Physically abused adolescents often are perceived by themselves and by others as more actively involved as "triggers" to abusive incidents than are sexually abused adolescents. This perception is particularly evident in situations in which their behavior is viewed as provocative, and it may play a role in provoking physically abusive responses from their parents. The literature on adolescent physical abuse (Pelcovitz et al., 1984) makes clear that incidents that result in abusive responses from parents of adolescents often are related to family conflicts such as curfews, clothing, and dating. The predictable course of such recurring conflicts includes the adolescent's knowledge regarding which of his or her behaviors may provoke an abusive response. In contrast, intrafamilial sexual abuse often is described as taking place in a manner that is neither predictable nor in any way contingent on the victim's behavior. In addition to the ways in which the process of physical abuse differs from that of sexual abuse, child physical abuse differs from other types of trauma that are associated with PTSD. Unlike many high-magnitude stressors such as combat, acute extrafamilial physical assaults, and natural disasters, intrafamilial physical
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abuse often presents as part of the fabric of the child's everyday life. Although the children in our abuse sample were at times abused so severely they required hospitalization, they expressed surprise regarding our interest in a series of events that they viewed as essentially a normal component of their lives. Many of the risk factors associated with PTSD were not present in the abusive incidents, including life threat. The abuse often was viewed as painful but generally was not seen as life threatening. In contrast to what is seen in adolescent adaptation to other types of trauma, the process of adaptation to physical abuse did not seem to require an alteration in preexisting schemas. For example, unlike adolescent cancer survivors, who manifest a relatively high prevalence rate of PTSD as a result of the illness conflicting with their assumptions regarding their invulnerability (Pelcovitz, 1991), our physical abuse sample appeared to view the beatings as consistent with their life view and not as "outside the range of normal human experience." This is consistent with a number of studies, which have found that individuals who have a history of frequent traumatic experiences may be less likely to develop PTSD in response to trauma. Ironically, those who have histories characterized by a family atmosphere that fosters a belief that the world is benevolent and predictable and that they are worthy individuals may be at greater risk for developing PTSD (janoff-Bulrnan, 1991; Janoff-Bulman and Marshall, 1982). In contrast , if a child grows up in an atmosphere characterized by a view of the world as malevolent and unpredictable,
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the assaults at the hands of their parents are not as likely to lead to a reassessment of their life view. Thus, such a child may be able to integrate these experiences in a manner that reduces the likelihood of developing PTSD symptoms. However, they remain at risk for behavioral and social difficulties as well as generalized emotional disturbances. An alternative hypothesis is that the physicallyabused children in our sample do not currently manifest PTSD symptoms because they remain in the abusive environment. It is possible that a "sleeper effect" is present and that PTSD may not manifest itself until the adolescent leaves home. A delay in onset of PTSD until the trauma has ended is seen in reaction other types of traumatic events. For example, Krystal (1968) reported that holocaust survivors frequently did not manifest PTSD symptomatology until years after they left the concentration camps. Although the abuse has ostensibly stopped (because of child protective services intervention), the correlates of the abuse, including a critical and nonsupportive home atmosphere, may remain. One can hypothesize that while the adolescent remains home, it is difficult to develop PTSD symptoms. This is particularly true in meeting PTSD criteria for avoidance. By definition , an abuse victim cannot easily avoid an abusive parent when they continue to live in the same home. Our findings are consistent with those of Kiser et al. (1991), who described a subtype of abuse victims who manifest general behavioral difficulties instead of PTSD. As noted earlier, it is possible that adolescent physical abuse victims process the trauma associated with the abuse in a manner different from that typically seen in response to acute traumatic events. T err (1991) has described such a process in children who are subjected to chronic victimization. According to Terr, traumatic stress conditions can be divided into twO categories. Type I trauma produces the usual PTSD symptom picture and typically occurs after a child experiences a one-time , sudden traumatic event. Type II trauma, however, is the result of repeated exposure to long-standing trauma (such as that suffered by the adolescents in this study) and may be more likely to result in reliance on coping mechanisms such as denial and dissociation rather than the symptom cluster seen in PTSD. Terr's findings that the disorders commonly diagnosed in type II trauma are conduct disorders, attention-deficit hyperactivity disorder, depression, and
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dissociative disorders are consistent with our findings indicating higher prevalence rates of depression, conduct disorder, oppositional-defiant disorder, and cigarette use. Recent research in developmental psychopathology supports the notion that physically abused children may process the trauma in a different manner than do victims of other types of trauma. Cicchetti (1989) studied the use of language in abused toddlers. He reports that whereas there were no significant differences in measures of receptive language, the abused children showed more difficulty than did a comparison group in expression of affect. In particular, they had more difficulty expressing negative emotions such as hate, disgust, and anger. A related dysfunction was noted by Kropp and Haynes (1987), who found that abusive mothers were more likely to mislabel "negative" emotions in their children as "positive." Although these studies focused on younger abuse victims, there is evidence that adolescents are even more likely to deny the impact of trauma . It is possible that the tendency of the physical abuse victims in our sample to manifest the sequelae of the abuse via behavioral difficulties rather than PTSD symptoms may be related to this finding. Our findings suggest that physically abused adolescents may be more at risk for emotional, behavioral, and social difficulties than for PTSD. Child mental health professionals, in designing accurate assessment and treatment strategies for physically abused adolescents, need to screen carefully for depression, conduct disorder, and social difficulties. Clinicians need to be aware that even when adolescents show no traumaspecific symptomatology and deny that the abuse had any impact on their functioning, these disorders may be present. The finding that the only subjects with PTSD developed those symptoms in response to extrafamilial sexual assault highlights the need for particular attention to PTSD symptoms in sexual assault survivors. Forensic mental health professionals also need to be aware that the absence of PTSD in adolescence does not rule out the possibility that the adolescent was physically abused. Some of the questions raised by this study suggest the need for additional research to compare childhoodonset adolescent abuse victims and adolescent-onset abuse victims. In addition, comparison with a sample of intrafamilial sexual abuse victims would help clarify
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the relative impact of sexual abuse as a risk factor for PTSD. Retrospective study of adult victims of childhood physical abuse and longitudinal designs ultimately would help clarify whether there is a sleeper effect, in which PTSD in physicallyabused adolescents emerges in adulthood. We are investigating some of these questions in an investigation of psychopathology in a larger sample of physically abused adolescents. These data should allow comparisons of PTSD prevalence in physical abuse as a function of the severity of abuse, as well as a comparison of childhood-onset compared with adolescent-onset abuse.
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Bulletin 8:691-698 Kilpatrick DG, ResnickHS, FreedyJR (1992), Post-traumatic stressdisorder field trial repott: a comprehensive review of initial results. Presented at Annual Meeting of the American Psychiatric Association, Washington, DC Kilpatrick DG, Saunders BE, Vernon LJ, Best CL, Von JM (1987), Criminal victimization: lifetime prevalence, reporting to police, and psychological impact. Crime and Delinquency 33:479-489 Kiser LJ, Heston J, Millsap PA, Pruitt DB (1991), Physical and sexual abuse in childhood: relationship with post-traumatic stress disorder.
JAm Acad Child Adolesc Psychiatry 30:776-783 Kropp J, Haynes OM (1987), Abusive and nonabusive mothers' ability to identify general and specific emotion signals of infants. Child
Dev 58:187-190 Krystal H (1968), Massive Psychic Trauma. New York: International Universities Press Lindberg FH, Distad LJ (1985), Post-traumatic stress disorders in women who experienced childhood incest. Child Abuse Negl 9:329-334 McLeer SV, Deblinger E, Atkins MS, Foa EB, Ralphe DL (1988), Post-traumatic stress disorder in sexually abused children. JAm Acad
Child Adolesc Psychiatry 27:650-654 Orvaschel H, Puig-Antich P, Chambers W, Abrizi M (1982), Retrospective assessment of prepubertal major depression with the Kiddie SADS. J Am Acad Child Adolesc Psychiatry 21 :392-397 Pelcovitz D (1991), DSM-IV PTSD field trials update: PTSD in physically abused adolescents, adolescent cancer survivors, and their mothers. Paper presented at the International Society for Traumatic Stress Studies Annual Convention, Washington, DC, October 1991 Pelcovitz D, Kaplan S, Samit C, Krieger R, Ganeles D (1984), Adolescent abuse: family structure and implications for treatment. J Am Acad
Child Psychiatry 23:85-90 Sandberg DE, Meyer- Bahlburg HF, Yager TJ (1991), The child behavior checklist nonclinical standardization samples: should they be utilized as norms? JAm Acad Child Adolesc Psychiatry 30:124-134 Spitzer RL, Williams JB, Gibbon M (1987), StructuredClinicalInterview for DSM-III-R. New York State Psychiatric Institute Straus M, Gelles R, Steinmetz S (1980), Behind Closed Doors: Violence in the American Family. New York: Anchor, Doubleday Summit R, Kryso J (1978), Sexual abuse of children: a clinical spectrum.
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Terr LC (1991), Childhood traumas: an outline and overview. Am J Psychiatry 148: 10-20 van der Kolk BA (1985), Adolescent vulnerabiliry to posttraumatic stress disorder. Psychiatry 48:365-370
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ABSTRACT Objective: In an investigation of the prevalence of post-traumatic stress disorder (PTSD), other Axis I psychiatric
disorders, and social and behavioral difficulties, 27 physically abused adolescents were compared with 27 nonabused controls who were recruited through random-digit dialing procedures. Method: The Structured Clinical Interview for Diagnosis (PTSD module), Kiddie-Schedule for Affective Disorders and Schizophrenia, and Youth Self-Report were administered to all subjects; mothers were interviewed regarding their adolescent's behavior using the Kiddie-Schedule for Affective Disorders and Schizophrenia for School-Age Children and Child Behavior Checklist. Results: The three physically abused adolescents who received a diagnosis of PTSD on the PTSD module of the Structured Clinical Interview for Diagnosis reported their PTSD symptoms were in reaction to extrafamilial sexual assaults and not to physical abuse. In contrast, the abused adolescents showed significantly higher prevalence rates of depression, conduct disorder, internalizing and externalizing behavior problems, and social deficits. Conclusions: Findings suggest that physically abused adolescents may be more at risk for behavioral and social difficulties than for PTSD. J. Am. Acad. Child Ado/esc. Psychiatry, 1994, 33, 3:305-312. Key Words: post-traumatic stress disorder, adolescent physical child
abuse, psychopathology.
This study provides a preliminary report of the findings of an investigation of the prevalence of post-traumatic stress disorder (PTSD) in a sample of physically abused adolescents who were recruited from the New York State central register for abuse and in a communityrecruited nonabused comparison group. The subjects
Accepted June 1, 1993. Dr. Pelcovitz is ChiefPsychologist, Dr. Kaplan is Associate Chairman, Ms. Goldenberg is Psychology Extern, Dr. Lehane is Research Psychologist, and Mr. Guarrera wasResearch Assistant, Department ofPsychiatry, Division ofChild and Adolescent Psychiatry, and Dr. Mandel is Research Statistician, Division of Biostatistics, Department of Research, North Shore University HospitalCornell University Medical College, Manhasset, NY. Also, Dr. Pelcovitz is Clinical Associate Professor of Psychology in Psychiatry, and Dr. Kaplan is Associate Professor of Clinical Psychiatry, Cornell University Medical College. Dr. Mandel is also Assistant Professor ofBiostatistics, School ofPublic Health, Cornell University Medical College. Reprintrequests to Dr. Pelcovitz, Division ofChild Psychiatry, Department ofPsychiatry, North Shore University Hospital, 400 Community Drive, Manhasset, NY 11030. Thisresearch wassupported in part through NIMHgrant 1R01MH4377204 and theNIMH-jUndedDSM-IV PTSD FieldTrials. Theopinions expressed in this article are those of the authors and do not necessarily represent the position oftheAmerican Psychiatric Association or its TaskForce on DSM-IV. 0890-8567/94/3303-0305$03.00/0©1994 by the American Academy of Child and Adolescent Psychiatry.
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were interviewed as part of the DSM-IV PTSD field trials and an ongoing National Institute of Mental Health-funded study of adolescent physical abuse. In addition, the subjects and their mothers were administered behavior problem checklists to determine whether they manifested behavioral disturbance not reflected in the PTSD diagnosis. There is a surprising lack of systematic investigation of the prevalence of PTSD physically abused children and adolescents. Although PTSD is a frequently used diagnosis for victims of intrafamilial sexual abuse (Deblinger et al., 1989; Goodwin, 1985), few investigators have empirically investigated the prevalence of PTSD in victims of physical child abuse. In one of the only published studies investigating PTSD symptoms in victims of physical child abuse, Deblinger et al. (1989) reported that 2 of 29 physically abused children, 20 of 29 sexually abused children (most of whom also were physically abused), and 3 of 29 nonabused comparison children met the DSMIII-R criteria for PTSD as diagnosed by a symptom checklist. This study had several limitations including use of a referred sample of abused children, reliance
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on a checklist rather than structured interviews, and the overlap between physical and sexual abuse in the sex abuse sample. Furthermore, both the physical abuse and sex abuse samples contained subjects who were victimized by family members as well as victims who were assaulted by nonrelatives. The findings, however, are intriguing in that they suggest a relatively lower rate of PTSD in physical abuse, even in comparison with the nonabused group. Kiser et al. (1991) srudied 49 victims of sexual and/ or physical abuse who had symptoms characteristic of PTSD based primarily on clinician ratings and 40 victims of sexual and/or physical abuse who did not show evidence of PTSD symptoms. Findings suggested that two distinct symptom pictures emerged. One was consistent with the reexperiencing, arousal, and avoidance criteria seen in patients with PTSD; the other was that those without PTSD were characterized by higher levels of behavioral difficulties (as measured by the Child Behavior Checklist and the Youth SelfReport), including delinquency, aggression, anxiety, and depression. The generalizability of this study is limited because the researchers combined physical and sexual abuse victims, and they did not rely on structured interviews for diagnosis of PTSD. However, the findings suggest the possibility that a significant percentage of abuse victims may respond by exhibiting symptoms not explained by a PTSD diagnosis. As noted earlier, in contrast to physical abuse, there are far more studies that systematicallyassess the prevalence ofPTSD in sexual abuse victims. In investigations ofPTSD in victims of sexual assaults (including extrafamilial), this diagnosis has been found to be twice as prevalent as that found in victims of other crimes (Kilpatrick et al., 1987). When researchers relied on referred samples, very high rates ofPTSD were generally found in incest victims. Lindberg and Distad (1985) found PTSD in all 17 patients who were survivors of incest, and Donaldson and Gardner (1985) reported PTSD in 96% of 26 women who were receiving therapy for the sequelae of sexual abuse. Similarly, in a referred sample of 31 sexually abused children , McLeer er al. (1988) reported a 48.4% incidence of PTSD, ranging from 75% in children abused by their fathers to 25% in those abused by trusted adults. However, when the relative prevalence of PTSD in victims of incest is looked at more systematically using
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nonclinical samples, it is clear that a significant proportion of victims do not meet the criteria for this disorder. Greenwald and Leitenberg (1990) found that 4% of 54 women in a nonclinical sample of sexual abuse victims report moderate PTSD symptomatology currently, and only 17% might have met criteria in the past. Kilpatrick et al. (1987), who studied 126 adult survivors of child sexual abuse, found the current incidence was 10% and the lifetime history of PTSD was 36%. These data suggest that an accurate understanding of the relative prevalence of PTSD in physically abused children and adolescents needs to be based on studies of abused children who are not recruited from samples of victims referred for treatment. Finkelhor (1988) criticized exclusive reliance on the PTSD diagnosis for sexual abuse victims. He noted that PTSD is a more appropriate diagnosis for "events" like crimes or combat and may be a less relevant diagnosis for incest, which is more of a process that frequently is not accompanied by violence or threats. Furthermore, symptoms frequently reported in the literature on sequelae of child abuse such as selfblame, revictimization, and sexual difficulties are not addressed. As with sexual abuse, victims of intrafamilial physical abuse grow up in a situation that may not be directly analogous to the high-magnitude stressors usually associated with PTSD . Victims of adolescent physical abuse often live in an environment that is so dominated by violence that they are exposed to an ongoing process rather than a discrete "event. " Even more than is the case with survivors of incest, physical abuse victims may grow up in a situation in which the violence they encounter is viewed as part of their parents' childrearing style rather than as a traumatic event that is outside the range of normal human expenence. This study ofPTSD in victims oflegally documented physical child abuse differs from previous research in its use of a sample that was not referred for treatment and not confounded by inclusion of subjects who were also incest victims. Unlike previous researchers, we used a comparison sample recruited through use of random-digit dialing procedures. Our study was designed to test two hypotheses that were guided by previous research regarding the psychological sequelae of abuse (e.g., Cole and Putnam, 1992): (1) There will be a higher proportion of PTSD in a group of physically abused adolescents than in controls. (2)
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There will be higher prevalence rates of internalizing . and externalizing behavior in the abuse group, with a particularly high prevalence rate of affective disorder, substance abuse, and conduct disorder. METHOD To determine the presence of PTSD symptoms, 27 adolescents, found by a child protective services investigation to have been physically abused, were administered structured interviews eliciting a history of exposure to traumatic events. Subjects were recruited from a list ofconsecutively indicated cases ofphysical abuse reported to the New York State register for child abuse. Subjects who had a history of intrafamilial sexual abuse discovered either by child protective services report or by self-report, were excluded. The rationale for this was that because previous studies combined sexual abuse (a trauma that places one at high risk for PTSD) with physical abuse, it was possible that high prevalence rates of PTSD in those studies were the result of the sexual abuse and not the physical abuse. Therefore, we aimed at interviewing victims of int rafam ilial physical abuse alone . A community control sample , demographically comparable with the abuse sample and living in the same neighborhood as the abused subjects, were recruited through use of a random-digit dialing procedure. Table 1 presents the demographic characteristics ofrhe abuse and comparison groups. The abuse and control groups were composed entirely of white, suburban adolescents ofcomparable age, gender, and socioeconomic status (SES) (Hollingshead, 1975). The PTSD module of the Structured Clinical Interview for Diagnosis (SCID) (Spitzer er al., 1987) was administered to all subjects. Dr. Robert Spitzer, the senior author of the SCID, has found this instrument suitable for use with adolescents (personal communication) . The choice of the SCID instead of structured or semistructured interviews normally used with adolescents was based on the lack of availability of a DSM-III-R-based PTSD module for the Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS) at the time our study began. Furthermore, the reliability of use of parents as informants on a diagnosis that specifically addresses the emotional impact of abuse on their child is questionable because the parent either perpetrated the abuse or may have been complicitous in maintaining an abusive home environment. Interviewers were graduate students in doctoral programs in clinical psychology. Training of interviewers consisted of reading a SCID-PTSD training manual, which clearly delineated the stan dards necessary to meet the criteria for DSM-III-R diagnosis of PTSD. In addition, training sessions were held for the interviewers to listen to audiotapes of previous SCID-PTSD interviews. As
TABLE 1 Demographic Variables (Means) Abused Adolescents
Comparison
Age (yr)
15.1 ± 1.7 55.6 44.4 2.7 ± 0.9
15.1 ± 1.7 59.3 40.7 2.4 ± 0.9
Note: N = 27 in each group .
Procedure Subjects were administered the SCID-PTSD structured interview, Potential Stressful Events Interview, and Achenbach scales as part of a wider study of psychopathology and suicidal behavior in physically abused adolescents . The families involved in the study were paid $250 for their participation, which involved 5 hours of interv iewing for each subject , divided between two visits. The measures used in this study were administered in the first of the two visits. Several other interviews, which were part of the DSMN PTSD field trials, were also administered to the physically abused subjects. These measures added approximately an additional half-hour to the test battery.
Statistical Methods
Variable Females (%) Males (%) Socioeconomic status
noted earlier, the abuse sample was interviewed as part of the DSM-NPTSD field trials, which recruited subjects from five sites. Interrater K: coefficients measuring the reliability of interviewers from the authors' site compared with the other four sites was .72 for current and lifetime interviews (Kilpatrick et al., 1992) . The Potential Stressful Events Interview (Kilpatrick er al., 1992) was administered to subjects in both groups. This measure is a structured interview designed to assess systematically whether the subject has been exposed to any traumatic incidents that would meet the DSM-III-R criterion A guidelines for PTSD. The adolescents were systematically asked whether they had been exposed to high-magnitude traumas such as natural disasters, sexual abuse, and extrafamilial physical assaults. Current level of behavioral difficulty was measured using both the mother (Achenbach and Edelbrock, 1983) and adolescent (Youth Self-Report [YSR]; Achenbach and Edelbrock, 1987) as informants. These measures were used to provide a profile of behavioral adjustment that may not have been reflected through the assessment of PTSD symptomatology. The Child Behavior Checklist (CBCL) (Achenbach and Edelbrock, 1983) is a 118item checklist designed to obtain parental ratings of their children's behavior problems. A factor analysis of the instrument, carried out separately for girls and boys, yields nine behavior problem scales. Test-retest reliability ranges from .82 to .90. Interparenr correlations are .67 for girls and .74 for boys. The YSR (Achenbach and Edelbrock, 1987), which is filled out by the child, closely parallels the parent form . The YSR is designed for children with reading skills at least at fifth grade level. The measure can be read aloud to respondents who have reading skills below fifth grade level. Achenbach and Edelbrock report a test-retest correlation of .69 over a 6-month interval. The K-SADS-E (Epidemiologic Version) Modified for DSMIII (Orvaschel et al., 1982) is a semistructured diagnostic interview for children aged 6 through 17. Acceptable interrater reliability for this interview was reported by Gammon et al. (1984) . Interviewers for this study were trained by one of the developers of the instrument. Periodic training meetings were held with the raters to compare interviewing and diagnostic habits and to minimize interviewer "drift."
Data analyses of K-SADS and SCID diagnoses used X2 tests for proportions or Fisher's exact rests, as indicated by sample size. A X2 tests was used to compare the proportions of male and female adolescents in each group. Mann-Whitney tests were used to compare the distribution of CBCL and YSR scores for the physically abused group and the distribution of scores for the comparison group. Because of the large number of comparisons being made ,
]. AM. ACAD. CHILD ADOLESC . PSYCHIATRY, 33:3, MARCH/APRIL 1994
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PELCOVITZ ET AL. a significance level of .01 was used to attempt to avoid spurious results. A X2 test for proportions was used to compare the proportions of male and female adolescents in each group. We decided to use nonparametric statistics in our analyses because the measure did not meet the assumptions of the T test; i.e., the scores did not appear to be normally distributed and the residuals also were not normally distributed.
RESULTS
As can be seen by reviewing the description of the sample in Table 1, subjects in the two groups are comparable in age, gender, and SES (Hollingshead, 1975). The distribution of ages and SES for the two groups was approximately equal (Mann-Whitney tests, p > .05). The proportions of male and female adolescents were approximately equal in the two groups (X2 test, p > .05). Data from the SCID, CBCL, and YSR were analyzed for 27 abuse and 27 comparison subjects. However, for the K-SADS data were analyzed for only 25 abuse and 25 comparison subjects. On the K-SADS the proportion of adolescents reporting major depression (lifetime) (p < .001), conduct disorder (lifetime (p < .05), oppositional disorder (current) (p < .05), and lifetime and current cigarette use (p < .03) was significantly greater in the abuse group than in the control group. Mothers' reports resulted in a finding that there was a significantly greater proportion of abused children reporting current major depression (p < .05) and current cigarette use (p < .05) than in the comparison group. Percentages of significant DSM-III-R diagnoses in the abuse and comparison groups are presented in Table 2; all other diagnoses, including PTSD (as measured by the SCID), were reported in approximately the same proportion for the two groups, i.e., they were not significantly different. The three physicallyabused adolescents who received a diagnosis of PTSD all reported that their PTSD symptoms were in reaction to extrafamilial sexual assaults and not to physical abuse. The 24 subjects who did not receive a PTSD diagnosis did not report histories of sexual abuse. None of the subjects in the comparison group received a full diagnosis of PTSD. Two subjects showed some symptoms of this disorder (one as a result of being physically assaulted by a gang in his school, and another who saw her brother's body after a suicide by hanging). A third subject, who reported some PTSD symptoms as a result of a sexual assault, refused to fully answer questions regarding the
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TABLE 2 Results from the Kiddie-Schedule for Affective Disorders and Schizophrenia: Percentage Meeting Criteria for DSM-III-R Diagnosis
Child report Major depression (L) Conduct disorder (L) Oppositional defiant (C) Cigarette use (L) Cigarette use (C) Mother report Major depression (C) Cigarette use (C)
Abuse
Control
40
3.7 0 0 3.7 7.4
16 20 12
32
16 24
0 3.7
Note: C = current, L = lifetime; N = 27 in each group.
presence of PTSD symptoms. It is possible this subject would have met criteria for PTSD had she answered all of the SCID-PTSD items. Scales on which the two groups differed significantly on the adolescent self-report of social competence and behavioral difficulties (YSR) are presented in Table 3. Significant differences between the two groups in parental reports of social and behavioral difficulties, as indicated on the CBCL, are presented in Table 4. Only raw scores and not normalized t scores are presented because of concerns reported in the literature regarding the validity of relying on the normative population used in the Achenbach scales (Sandberg et al., 1991). The meanings of significant scores are as follows: the total social score is obtained from the ratings regarding the child's number and frequency of contacts with friends and level of activities in organizations outside of school. Total competence scores are obtained by assessing the adolescent's level of activity in sports and jobs as well as overall level of competence in school and social areas. The "Sum" score is a measure of the total severity of specific problem items. Achenbach and Edelbrock (1983) differentiate between internalizing problem behaviors (reflected in the "Sum Internal" score), manifested through fearful, inhibited, and overcontrolled behavior, arid externalizing behaviors (reflected in the "Sum External" score), manifested by aggressive, antisocial, and undercontrolled behavior. Regardless of whether the adolescent or the parent was the informant, the physically abused adolescents showed significantly more behavioral and social deficits compared with the control group. The types of behavior
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difficulties appeared to be both internalizing and externalizing in nature. DISCUSSION
Findings of this study do not support hypothesis 1, i.e., PTSD was not present in significantly higher proportions in the abuse group. However, the K-SADS data and problem checklist results do substantially support hypothesis 2. This study is, to the best of our knowledge, the first to assess systematicallythe presence of PTSD in a group of unreferred victims of physical abuse in which intrafamilial sexual abuse was ruled out. The finding that there was little evidence in our sample of adolescents that physical abuse results in PTSD is surprising in light of previous reports that this population is at risk for this disorder (Green, 1985). The presence of significant levels of behavioral and social problems in our abuse sample is consistent with previous reports concerning physically abused children and suggests the possibility that, in contrast to those sexually abused, physically abused adolescents may "enact" the results of their victimization rather than express their reactions to the abuse via the more trauma-specific avenue of PTSD. The failure of subjects in both groups to meet criteria for PTSD does not appear to be related to a general tendency on the part of adolescents to deny PTSD symptoms. An identical protocol recently was used in a sample of adolescent cancer survivors,and a significant percentage of them met criteria for PTSD (Pelcovitz, 1991). There is evidence that adolescence is a time when one may be particularly likely to have PTSD symptoms in response to external stress. van der Kolk (1985) reported that fighting in Vietnam during adolescence, compared with being in combat as an adult, was a greater risk factor for developing PTSD.
All three abused adolescents who received a PTSD diagnosis reported these symptoms in response to extrafamilial sexual assaults. There are a number of ways in which sexual assault differs from physical abuse. Sexual abuse is, by its very nature, difficult to integrate. Summit and Kryso (1978) attribute this to the high level of secrecy and shame that accompanies sexual abuse, thereby making this type of trauma particularly difficult to deal with in a direct way. In contrast, physical abuse is less likely to be accompanied by a high level of secrecyand shame. As Straus et al. (1980) note in their national study, physical child abuse often occurs as an extension of child discipline that relies on the use of corporal punishment. In a culture that often condones such disciplinary practices, the adolescent may not view more severe physical punishments as something unique and out of the "ordinary." Our experience in interviewing physicallyabused adolescents is that, in contrast to sexual abuse survivors, they showed little embarrassment and/or secrecy in their discussions regarding the beatings they received at the hands of their parents. In fact, they often appeared surprised that we were making such an issue of a process they considered "normal" and not worthy of our interest. This attitude lies in sharp contrast to the great reluctance that typically attends the disclosure and frequent retraction of intrafamilial sexual abuse. Qualitative impressions of our interviewers regarding the three subjects who were extrafamilial sexual abuse survivors was that they shared their feelings and memories regarding those traumatic incidents with a higher level of reluctance and upset than that which attended their descriptions of physical abuse. Another difference between the process of physical and sexual abuse is the frequently public nature of physical sequelae of physical abuse. Bruises, fractures,
TABLE 3 Behavioral and Social Difficulties: Adolescent Report (Youth Self-Report) Physically Abused Scale Social Score Total Social Total Competence Thought Disorder Delinquent
Median Interquartile Range
6 6 16 6 9
5-8.5 5-9 14-19 3-10 4-16
Note: Sum is the total problem raw score. All raw score scales with
j, AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:3, MARCH/APRIL 1994
Comparison Group Median
Interquartile Range
p
8.5 9 18 2 5
7.5-9.5 8-10 17-21 1-4 3-9
<.001 <.001 <.005 <.003 <.014
p less than .01 are reported. N
= 27 in each group.
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TABLE 4 Behavioral and Social Difficulties: Parent Report (Child Behavior Checklist) Physically Abused Scale General (boys and girls combined, N = 27 in each group) Social Score Sum Competence Sum Internal Sum External Boys alone (N = 15 in each group) Somatic Delinquent Girls alone (N = 12 in each group) Delinquent Aggressive
Comparison Group
Median
Interquarrile Range
Median
Interquarrile Range
p
5.25 32 12.5 19.5
4.5-7 16-54 6-21 6-27
8 11 4 4
6.5-9.5 4-26 1-13 2-14
<.001 <.004 <.011 <.001
0 6
1-6 2-9
3 1
0-1 0-3
<.005 <.001
4 9
2-10 4-20
0.5 2
0-3 1-7.5
<.003 <.007
Note: Sum is the total problem raw score. All raw score scales with p less than .01 are reported .
and other bodily evidence of physical abuse may lead to this type of abuse becoming more of a public event which, in turn, may facilitate integration of the trauma to a greater extent. The element of surprise and unpredictability have been noted to be risk factors for PTSD (Cella et al., 1990). Physical abuse is generally more predictable than sexual abuse. Physically abused adolescents often are perceived by themselves and by others as more actively involved as "triggers" to abusive incidents than are sexually abused adolescents. This perception is particularly evident in situations in which their behavior is viewed as provocative, and it may play a role in provoking physically abusive responses from their parents. The literature on adolescent physical abuse (Pelcovitz et al., 1984) makes clear that incidents that result in abusive responses from parents of adolescents often are related to family conflicts such as curfews, clothing, and dating. The predictable course of such recurring conflicts includes the adolescent's knowledge regarding which of his or her behaviors may provoke an abusive response. In contrast, intrafamilial sexual abuse often is described as taking place in a manner that is neither predictable nor in any way contingent on the victim's behavior. In addition to the ways in which the process of physical abuse differs from that of sexual abuse, child physical abuse differs from other types of trauma that are associated with PTSD. Unlike many high-magnitude stressors such as combat, acute extrafamilial physical assaults, and natural disasters, intrafamilial physical
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abuse often presents as part of the fabric of the child's everyday life. Although the children in our abuse sample were at times abused so severely they required hospitalization, they expressed surprise regarding our interest in a series of events that they viewed as essentially a normal component of their lives. Many of the risk factors associated with PTSD were not present in the abusive incidents, including life threat. The abuse often was viewed as painful but generally was not seen as life threatening. In contrast to what is seen in adolescent adaptation to other types of trauma, the process of adaptation to physical abuse did not seem to require an alteration in preexisting schemas. For example, unlike adolescent cancer survivors, who manifest a relatively high prevalence rate of PTSD as a result of the illness conflicting with their assumptions regarding their invulnerability (Pelcovitz, 1991), our physical abuse sample appeared to view the beatings as consistent with their life view and not as "outside the range of normal human experience." This is consistent with a number of studies, which have found that individuals who have a history of frequent traumatic experiences may be less likely to develop PTSD in response to trauma. Ironically, those who have histories characterized by a family atmosphere that fosters a belief that the world is benevolent and predictable and that they are worthy individuals may be at greater risk for developing PTSD (janoff-Bulrnan, 1991; Janoff-Bulman and Marshall, 1982). In contrast , if a child grows up in an atmosphere characterized by a view of the world as malevolent and unpredictable,
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the assaults at the hands of their parents are not as likely to lead to a reassessment of their life view. Thus, such a child may be able to integrate these experiences in a manner that reduces the likelihood of developing PTSD symptoms. However, they remain at risk for behavioral and social difficulties as well as generalized emotional disturbances. An alternative hypothesis is that the physicallyabused children in our sample do not currently manifest PTSD symptoms because they remain in the abusive environment. It is possible that a "sleeper effect" is present and that PTSD may not manifest itself until the adolescent leaves home. A delay in onset of PTSD until the trauma has ended is seen in reaction other types of traumatic events. For example, Krystal (1968) reported that holocaust survivors frequently did not manifest PTSD symptomatology until years after they left the concentration camps. Although the abuse has ostensibly stopped (because of child protective services intervention), the correlates of the abuse, including a critical and nonsupportive home atmosphere, may remain. One can hypothesize that while the adolescent remains home, it is difficult to develop PTSD symptoms. This is particularly true in meeting PTSD criteria for avoidance. By definition , an abuse victim cannot easily avoid an abusive parent when they continue to live in the same home. Our findings are consistent with those of Kiser et al. (1991), who described a subtype of abuse victims who manifest general behavioral difficulties instead of PTSD. As noted earlier, it is possible that adolescent physical abuse victims process the trauma associated with the abuse in a manner different from that typically seen in response to acute traumatic events. T err (1991) has described such a process in children who are subjected to chronic victimization. According to Terr, traumatic stress conditions can be divided into twO categories. Type I trauma produces the usual PTSD symptom picture and typically occurs after a child experiences a one-time , sudden traumatic event. Type II trauma, however, is the result of repeated exposure to long-standing trauma (such as that suffered by the adolescents in this study) and may be more likely to result in reliance on coping mechanisms such as denial and dissociation rather than the symptom cluster seen in PTSD. Terr's findings that the disorders commonly diagnosed in type II trauma are conduct disorders, attention-deficit hyperactivity disorder, depression, and
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dissociative disorders are consistent with our findings indicating higher prevalence rates of depression, conduct disorder, oppositional-defiant disorder, and cigarette use. Recent research in developmental psychopathology supports the notion that physically abused children may process the trauma in a different manner than do victims of other types of trauma. Cicchetti (1989) studied the use of language in abused toddlers. He reports that whereas there were no significant differences in measures of receptive language, the abused children showed more difficulty than did a comparison group in expression of affect. In particular, they had more difficulty expressing negative emotions such as hate, disgust, and anger. A related dysfunction was noted by Kropp and Haynes (1987), who found that abusive mothers were more likely to mislabel "negative" emotions in their children as "positive." Although these studies focused on younger abuse victims, there is evidence that adolescents are even more likely to deny the impact of trauma . It is possible that the tendency of the physical abuse victims in our sample to manifest the sequelae of the abuse via behavioral difficulties rather than PTSD symptoms may be related to this finding. Our findings suggest that physically abused adolescents may be more at risk for emotional, behavioral, and social difficulties than for PTSD. Child mental health professionals, in designing accurate assessment and treatment strategies for physically abused adolescents, need to screen carefully for depression, conduct disorder, and social difficulties. Clinicians need to be aware that even when adolescents show no traumaspecific symptomatology and deny that the abuse had any impact on their functioning, these disorders may be present. The finding that the only subjects with PTSD developed those symptoms in response to extrafamilial sexual assault highlights the need for particular attention to PTSD symptoms in sexual assault survivors. Forensic mental health professionals also need to be aware that the absence of PTSD in adolescence does not rule out the possibility that the adolescent was physically abused. Some of the questions raised by this study suggest the need for additional research to compare childhoodonset adolescent abuse victims and adolescent-onset abuse victims. In addition, comparison with a sample of intrafamilial sexual abuse victims would help clarify
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the relative impact of sexual abuse as a risk factor for PTSD. Retrospective study of adult victims of childhood physical abuse and longitudinal designs ultimately would help clarify whether there is a sleeper effect, in which PTSD in physicallyabused adolescents emerges in adulthood. We are investigating some of these questions in an investigation of psychopathology in a larger sample of physically abused adolescents. These data should allow comparisons of PTSD prevalence in physical abuse as a function of the severity of abuse, as well as a comparison of childhood-onset compared with adolescent-onset abuse.
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