Psychiatric Diagnoses of Maltreated Children: Preliminary Findings RICHARD FAMULARO, M.D., ROBERT KINSCHERFF, PH.D., AND TERENCE FENTON, ED.D.
Abstract. The study sample consists of 96 children (61 maltreated, 35 controls) between 5 and 10 years of age. The two groups of subjects were compared on diagnoses as determined by the administration of the Diagnostic Interview for Children and Adolescents, Revised 6th Version (DICA-6-R) as well as clinical DSM-llI-R diagnoses. Children who had suffered maltreatment exhibited significantly greater incidences of attention deficit hyperactivity disorder, oppositional disorder and post-traumatic stress disorder diagnoses than did controls, on both child and parent DICA interviews. The children's interviews revealed that maltreated children present with a significant incidence of psychotic symptomatology as well as personality and adjustment disorders. Conversely, conduct and mood disorders emerged as significant factors in the parent interviews, with the maltreated group showing significantly greater incidence of these diagnoses. J. Am. Acad. Child Adolesc. Psychiatry, 1992,31, 5:863-867. Key Words: child abuse, post-traumatic stress disorder (PTSD), trauma, Diagnostic Interview for Children and Adolescents (DICA). Numerous papers have described the psychiatric symptoms exhibited by children who have suffered abuse. Oates et al. (1985) reported that, compared with nonabused children, those who had been maltreated exhibited lower selfconcept, perceived themselves as having fewer friends, played with friends less often, and were less ambitious. Affective disorders among children have been found to be related to parental abuse (Kashani et aI., 1987), and depressive symptomatology among child psychiatric patients has been shown to be associated with physical maltreatment (Kazdin et aI., 1985). Kaufman (1991) recently examined the prevalence of depressive disorders in a sample of 56 7 to 12 year-old maltreated children. Overall, 18% ofthe sample met the diagnostic criteria for major depression and 25% met the criteria for dysthymia, with the majority of the children who met the criteria for major depression also meeting the criteria for dysthymia. In sexually maltreated children, the incidence of DSM-III Axis I diagnoses proves to be associated with the duration and frequency of maltreatment, as well as factors such as the offender's relationship to the child and family history of alcohol abuse (Sirles et aI., 1989). Leifer et al. (1991) used several standardized scoring methods with the Rorschach to assess psychological functioning among 79 maltreated black females aged 5 to 16 and a comparison group of nonabused females. The sexually abused group showed more disturbed thinking, a higher level of stress experienced relative to
Accepted September 18, 1991. Dr. Famularo is Assistant Professor of Child Psychiatry and Dr. Kinscherff is Instructor in Psychology, Harvard Medical School. They are also with the Boston Juvenile Court, Massachusetts Department of Mental Health, and the Children's Hospital, Boston. Dr. Fenton is with the Department ofBiostatistics, Harvard School ofPublic Health, Boston. This research was funded by the National Center on Child Abuse and Neglect, Department of Health and Human Services grant 90CA-1408. Reprint requests to Dr. Famularo, Boston Juvenile Court Clinic, New Court House, Room 210, 17 Somerset Street, Boston, MA 02108. 0890-8567/92/3105-Q863$03.00/0©1992 by the American Academy of Child and Adolescent Psychiatry. J. Am. Acad. Child Adolesc. Psychiatry, 31:5, September 1992
their adaptive abilities, more negative descriptions of human relationships, and greater preoccupation with sexuality. This study also found that emotionally and cognitively active abused females experienced more distress than did psychologically constricted abused females. Recent studies have revealed that many cases of child maltreatment lead to the symptomatology associated with a diagnosis of post-traumatic stress disorder (PTSD). McLeer et al. (1988) found that 48% of the 31 sexually abused children they evaluated met the DSM-III-R (American Psychiatric Association, 1987) criteria for such a diagnosis. Famularo et al. (1989) reported that these criteria described 21% of a sample of 115 maltreated children presenting to a juvenile court, with sexual abuse representing a greater risk than physical abuse for the development of PTSD. It is possible, moreover, that a clinical presentation of borderline personality disorder (BPD) may represent chronic PTSD. Both Byrne et al. (1990) and Coon et al. (1989) found relatively high levels of childhood maltreatment among adults diagnosed as BPD, and Brown and Anderson (1991) discovered higher levels of maltreatment among patients with a BPD diagnosis than among other psychiatric patients. Looking at a child sample, one recent study (Famularo et aI., 1991) revealed that 79% of a group of 19 children diagnosed as BPD reported significant traumatic experiences, with 37% meeting the Diagnostic Interview for Children and Adolescents (DICA) criteria for PTSD. Finally, Zanarini et al. (1989) found that childhood histories of 50 adult outpatients who met criteria for borderline personality on the DSM-III and Interview for Borderlines were significantly more likely than those in either of two comparison groups to report a history of maltreatment.
Sanders and Giolas (1991) found that dissociation in adolescence is positively correlated with the degree of stress or abuse experienced earlier in childhood. Dissociative symptoms correlated significantly with self-reported physical abuse or punishment, sexual abuse, psychological abuse, neglect, and negative home atmosphere, although not with abuse ratings made from hospital records. The authors concluded that dissociation represents a reaction to early negative experience and placed multiple personality disorder at
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FAMULARO ET AL.
the extreme end of a continuum of dissociative sequelae of childhood trauma. The behavioral consequences of maltreatment appear to be related to the type of abuse and can have profound effects upon society as well as the victim. In a study of adolescents with documented histories of having been maltreated (Famularo et al., 1990) a history of physical abuse was significantly associated with acts of aggression against persons, whereas a history of sexual maltreatment increased the probability of presenting as a runaway. A review of the literature by Terr (1991) led her to conclude that psychic trauma in childhood acts as a crucial etiological factor in the development of a number of serious disorders in both childhood and adulthood. She likened such trauma to a childhood "rheumatic fever" in that it could set into motion anyone of a number of different problems, any of which could result in one of a variety of psychiatric disturbances. The authors concur with Terr's (1991) position that childhood psychic trauma results in a complex developmental unfolding of possible psychiatric disturbance. Experiences of maltreatment generate complex dynamics that will manifest and impact differently depending upon such factors as the nature of the maltreatment and the age of the child (Mrazek and Mrazek, 1985). We hypothesize that whereas symptom profiles and developmental alterations will be related to type, duration, and frequency of maltreatment, a diagnosis ofPTSD will be correlated with a history of severe maltreatment in a sample of children ages 5 to 10, regardless of the age of onset of the maltreatment. One purpose of this article is to assess what psychiatric diagnoses might be characteristic of severely maltreated children of that age range. This study provides a comprehensive examination of the formal psychiatric diagnoses of chil-
The two groups of subjects, maltreated children and controls, were compared on the basis of DSM-III-R diagnoses, determined by the administration of the DICA-C structured
dren with documented histories of maltreatment, basing the
interview of the children, and the DICA-P interview of their
children's diagnoses primarily upon structured interviews of both the children (DICA-Child) (Reich and Welner, 1988) and their parents (DICA-Parent) with supplemental DSMIII-R clinical diagnoses. An additional aim is to compare maltreated children with a control group in terms of the relative incidence of all other DSM-III-R diagnoses. In view of the broad range of symptoms described in the literature, one might assume that maltreatment leads to a great many forms of "mental illness"; the goal here is to delineate the diagnoses that might be most specifically associated with experiences of maltreatment.
parents. The maltreated group was compared with the controls in terms of the incidence of each diagnosis to determine which, if any, revealed significant differences between the two groups. In addition to the structured interview, a clinical interview of each child (and parent regarding the child) was performed leading to a clinical DSM-III-R diagnoses for all those categories not covered by the Diagnostic Interview for Children and Adolescents (Reich and Welner, 1988), Revised 6th Version (DICA-6-R). The DICA diagnosis and clinical diagnosis were assigned by the same person. All DICA-6-R diagnoses reported are current diagnoses as provided by the child and the parent. After the clinical interview with the child, DSM-III-R diagnoses were assigned for those diagnoses not covered by DICA-6-R.
Methods
cases met the legal requirement that "clear and convincing" evidence of child maltreatment be presented. The children were involved in civil and not criminal proceedings stemming from the child maltreatment. The experience of severe maltreatment is the common factor among all child subjects. In the case of the hospital sample, maltreatment was defined by the presence of two recent substantiated child abuse/neglect reports filed with the state Department of Social Services. The members of the control group were children receiving treatment at the same hospital who had no history of abuse. Any control case presenting with either current or past evidence of maltreatment during the administration of the DICA and clinical interviews (parent or child) was eliminated from the study. The children were matched to the maltreated group on the basis of age, gender, race, and family income. The researchers received parental permission to review all pertinent records and to interview both parents and abused children. The subjects were informed that the information gathered would not become part of the court or hospital record, and could not be released, except where the State's General Laws required disclosure. Of those recruited for the study, 14% of the maltreatment group and 10% of the control group declined to participate. Subjects from both groups were commensurately, financially compensated for participation and travel. The research was performed under a confidentiality certificate, and permission for child evaluation was obtained from both the parent and the State. Experimental Design
Sample
Measures
The sample consisted of 96 children between 5 and 10 years of age, 61 of whom had been maltreated, and 35 of whom served as controls. The maltreated sample was drawn from an urban juvenile court, and an outpatient department of pediatrics located within the court's jurisdiction. The court sample included children whose parents were before the court on petitions of child abuse significant enough to warrant removal of the children from their parents; these
The DICA-6-R is a structured psychiatric interview for children including questions initially patterned after the National Institute of Mental Health Diagnostic Interview Schedule (DIS) and based on DSM-III. A child version for ages 5 to 12 years old and an adolescent version including ages 13 to 17 have been developed. The DICA-6-R has both a child version and a parallel parent version leading to the same diagnoses.
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PSYCHIATRIC DIAGNOSIS OF MALTREATED CHILDREN TABLE
1. Comparison of Demographic Data between Maltreated Children and Controls
Group Maltreated (N = 61) Mean age (months) Age range (years) Age SD (months) Medicaid (0/0) Female (0/0) Ethnic group White (0/0) Black (0/0) Hispanic (0/0) Other (0/0)
Control = 35)
93.2 5-10 18.3 44 56
93.5 5-10 18.4 43 57
48 35 8 8
40 43 II 6
The DICA-6-R includes 275 questions and is organized into demographic, diagnostic, and symptom profiles (for adjustment and stressor symptoms, psychotic symptoms, and mental status). No DSM-III-R Axis II (developmental, personality) or Axis III (physical disorders and conditions) diagnoses are possible except menstruation symptoms in females. Most, but not all Axis I diagnoses are possible. Notable absences include tic and movement disorders, panic disorder, and obsessive compulsive disorder. Although many questions address psychotic symptoms or disturbances in reality testing, no formal psychotic diagnoses are offered. As described, clinical DSM-III-R diagnoses for these conditions are offered.
Statistical Test
(N
t = 0.06, p = 0.95
x2 = 0.02, p = 0.89 X2 = 0.02, P = 0.89
x= 2
1.13, p = 0.77
personality and adjustment disorders (p :::; 0.05). These child findings were not confirmed by parent interviews. Despite child reports of disturbances of reality-testing, there were no diagnoses of schizophrenia or other psychotic disorder. Conduct and mood disorders emerged as significant factors in the parent interviews, with the maltreated group showing significantly greater number of these diagnoses (p < 0.05). These results were not replicated in data from the child interviews. Clinical Axis I diagnoses not covered by the DICA (tic and movement disorders, panic disorder, obsessive compulsive disorder) were uncommon. Children with mental retardation, pervasive developmental disorder, and autism were excluded from the study. Discussion
Statistical Analysis Analyses of demographic data consisted of t-tests to examine group differences in age and chi-squared tests to compare the groups in terms of sex, ethnicity, and Medicaid status. Because some of the DSM-III-R diagnoses were relatively rare events, resulting in cells with expected frequencies of fewer than five subjects, Fisher's exact probability tests (two-tailed) were used to examine the statistical significance of group differences in the incidence of each of the psychiatric diagnoses. Whenever possible, the results were also presented in terms of odds ratios, with 95% confidence intervals. Results Table 1 shows that the maltreated and control samples were well matched in terms of age, sex, ethnic group, and Medicaid status. Table 2 compares the incidence of psychiatric diagnoses from the maltreated and control samples, based on DICA interviews of the children. Table 3 presents the same comparisons, based on DICA interviews of the parents. Both tables show that children who had suffered maltreatment exhibited significantly greater incidences of attention deficit hyperactivity disorder (ADHD), oppositional disorder, and PTSD diagnoses than did controls (p :::; 0.002)1 The children's interviews revealed a further tendency for maltreated children to exceed controls in the incidence of psychotic symptomatology (9.38% versus 0% control group; Fischer's Exact = 0.020; odds ratio = 12.85), as well as J. Am. Acad. Child Adolesc. Psychiatry, 31:5, September 1992
These results confirm the hypothesis of a strong association between maltreatment and the incidence of a PTSD diagnosis. Based on structured interviews of the children, 39% of the maltreated sample were given a diagnosis of PTSD; parental interviews resulted in 21 % receiving such a diagnosis. Neither child (DICA-Child) nor parental (DICAParent) structured interviews resulted in any of the children in the control group being diagnosed as PTSD. Because specific personality disorders proved to be relatively rare events, all forms of such disorders were combined for the purposes of statistical analysis. This analysis revealed that, on the basis of child interviews, 11% of the maltreated children were diagnosed with some form of personality disorder, whereas none of the controls had been so diagnosed (p < 0.05). The parental clinical interviews yielded a 7% incidence of personality disorders among maltreated children, with none among controls (p = 0.29). Therefore, although maltreated children may not significantly meet criteria for anyone specific personality disorder such as schizotypal, borderline, avoidant, etc., they do report patterns of general dysfunction consistent with the emergence of personality disorders. Careful clinical evaluation is necessary to differentiate between those disturbances of conduct, interpersonal relationships, and cognition that are characteristic of PTSD symptomatology and personality disturbances that are characteristic of nontraumatic etiologies. In addition to PTSD, two other diagnoses, ADHD and oppositional disorder, provided strong discriminations be865
FAMULARO ET AL. TABLE 2. Differences in Psychiatric Diagnoses between Maltreated Children and Controls (Based on DICA Interview of the Child)
Diagnosis ADHD Oppositional Conduct disorder Substance abuse Mood disorder Anxiety Personality PTSD Enuresis or encopresis Psychosis Adjustment disorder Simple phobia Other
Percent with Diagnosis Control Maltreated (N = 35) (N = 61) 2.86 0.00 0.00 0.00 8.57 11.43 0.00 0.00 8.57 0.00 2.86 22.86 2.86
24.59 22.95 3.28 1.64 22.95 19.67 11.48 39.34 16.39 9.38 18.03 9.84 14.75
Fischer 's Exact 2-tailed Test: (p values) 0.005 0.002 0.532 1.000 0.098 0.398 0.045 0.000 0.363 0.020 0.051 0.131 0.088
Odds Ratio 11.09
21.67a 2.98'
1.76a 3.18 1.90 9.77'
46.39a 2.09 12.85a 7.48 0.37 5.89
95% CI Lower
Upper
1.40 1.25 0.14 0.07 0.84 0.56 0.54 2.72 0.54 0.72 0.92 0.12 0.71
88.06 375.64 63.92 44.38 11.96 6.41 176.47 791.82 8.18 227.85 60.66 1.17 48.57
"The logit estimators use a correction of 0.5 in every cell of those tables that contain a zero.
tween the maltreated and control groups on both the child (DICA-Child) and the parental interviews (DICA-Parent). Both ADHD and oppositional disorder were awarded more frequently among the maltreated children. The etiology of these relation ships cannot be ascertained on the basis of the data in the current study . It is possible that the symptoms resulting in the diagnoses of ADHD and oppositional disorder may have been cau sed by maltreatment, as in cases where the difficulties reported with attention/concentration and hyperactivity that contributed to an ADHD diagnosis actually represent anxiety symptoms associated with PTSD . However, it is also possible that the "difficult" behav iors associated with these diagnoses may have played a role in provoking maltreatment, and that any similar symptoms stemming from the PTSD were an overlap upon a preexisting condition. Approximately 9 1/ 3 % of maltreated children reported psychotic symptomatology, although none met criteria for a formal thought disorder. With only one exception, all children reporting at least one current psychotic symptom also
carried a PTSD diagnosis. Content of the reported visual and/or auditory hallucinations or illusions tended to be strongly reminiscent of concrete details of episodes of traumatic victimization. The psychotic symptoms were not related to any other symptoms suggestive of schizophrenia such as flat or blunted affect , bizarre delu sions, or oddities of interpersonal relating. Rather, they appeared to represent manifestations of post-traumatic flashback, hallucination, or illusion such as those referred to by Terr ( 199 1). These psychotic symptoms may also be the manifestations of dissociative responses to maltreatment. Although there are too few cases in this sample to fully analyze, it doe s suggest that PTSD can be a significantly virulent and pervasively pathological outcome of child maltreatment. The findings of this study have several implications for clinical practice. First, very careful consideration of the diagnosis of PTSD and its clinical manifestations should occur when there is a history of maltreatment. Furthermore, since maltreated children do report indications of a variety of personality diagnoses, evaluators should consider the devel-
TABLE 3. Differences in Psychiatric Diagnoses between Maltreated Children and Controls (Based on DICA Interview of the Parent) Percent with Diagnosis Diagnosi s ADHD Oppositional Conduct disorder Substance abuse Mood disorder Anxiety Personality PTSD Enuresis or encopresis Psychosis Adjustment disorder Simple phobia Other
Control (N = 35)
Maltre ated (N = 6 1)
Fischer 's Exact 2-Tailed Test (p values)
5.71 5.71 0.00 0.00 0.00 8.57 0.00 0.00 8.57 0.00 2.86 14.29 5.71
42.62 39.34 11.48 1.64 14.75 2 1.31 6.56 2 1.31 22.95 4.92 8.20 22.95 8.20
0.000 0.000 0.046 1.000 0.024 0.156 0.293 0.002 0.098 0.298 0.411 0.426 1.000
Odds Ratio 12.26 10.70 9.77 a
1.76a 12.85a 2.89
5.56a 19.76a 3.18
4.25a 3.04 1.79 1.47
95% CI Lower
Upper
2.70 2.35 0.54 0.07 0.72 0.76 0.29 1.14 0.84 0.21 0.34 0.58 0.27
55.75 48.78 176.47 44.38 227.85 10.95 106.33 343.60 11.96 84.67 27.10 5.47 8.03
"The logit estimators use a correction of 0.5 in every cell of those tables that contain a zero.
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PSYCHIATRIC DIAGNOSIS OF MALTREATED CHILDREN
opmental impact of PTSD symptoms as a chronic process distorting subsequent development. As a corollary, children initially presenting with possible personality disorder should be evaluated for a history of trauma, including maltreatment. The cases of children with personality disorder diagnoses seen on follow-up or institutional transfer should be reviewed for evidence that earlier evaluations considered possible histories of maltreatment. Second, initial evidence also suggests that children presenting with hallucinations or illusions in the absence of other indications of formal thought disorder or schizophrenia should also be specifically evaluated for histories of maltreatment or other trauma . Because the parent interviews often fail to yield reports of the psychotic symptoms of the maltreated children, evaluators must interview the children themselves about these experiences . Similarly, parents may report more symptoms related to conduct and mood. That parents and children report different observations and experiences strongly suggests that especially in cases of child maltreatment both the parent and the child must be interviewed. Third, the overlap of ADHD , oppositional disorder, and PTSD among maltreated children calls for evaluation of the preexisting or comorbid presentation of these conditions in maltreated children. A known or suspected history of maltreatment should prompt detailed history-taking and differential diagnosis. The diagnostic and intervention challenge is further complicated by the fact that the manifestations of these disorders may closely resemble each other. For example, difficulties in a child 's attention/concentration and conduct may be manifestations of an anxiety disorder (PTSD), or a presumed neurocognitive developmental delay (ADHD), or both. However, careful differential diagnosis will permit appropriate selection of psychopharmacological, psychotherapeutic, and environmental interventions.
References Ame rican Psychiatric Association. ( 1987), Diagnostic and Statistical Manual ofMental Disorders, Third Edition-Revised. Washington, DC , American Psychiatric Association. Brown , G. & Anderson, B. (1991), Psychiatric morbidity in adult
J. Am. Acad. Child Adolesc. Psy chiatry, 3 J: 5, September J992
inpatients with childhood histori es of sexual and phy sical abuse. Am. J. Psychiatry , 148:55-61. Byrne, C., Velamoor, V., Cernovsky, Z., Cortese, L. & Losztyn, S. (1990), A comparison of borderline and schizophrenic patients for childhood life events and parent-child relationships. Can. J. Psych iatry, 35:590-595. Coons, P. M., Bowman, E. S., Pellow , T. A. & Schneider, P. (1989 ), Post-traumatic aspects of the treatment of victims of sexual abu se and incest. Psychiatr. Clin. North Am., 12:325-335. Famularo, R., Kinscherff, R. & Fenton, T. ( 1989), Posttraumatic stress disorder among maltreated children presenting to a juvenile court. Am. J. Forensic Psychiatry, 10:33-39. - - - - - - Bolduc, S . (1 990), Child maltreatment hi stories among runaway and delinquent children. CUn. Pediatr . (Phila.) 29:713-718. - - - - - - (1991), Posttraumatic stress disorder among children clinically diagnosed as borderline personality disorder. J. Nerv. Ment. Dis., 42:41-53. Kashani, J., Shekim, W., Burk , J. & Beck, N. (1987), Abuse as a predictor of psychopathology in children and adolescents. J. CUn. Child Psychol., 16:43-50. Kaufman, J. (1991), Depressive disorders in maltreated children. J. Am. Acad. Child Adolesc. Psychiatry, 30:257-265. Kazdin , A., Moser, J., Colbus, D. & Bell, R. ( 1985), Depressive symptoms among physically abused and psychiatrically disturbed children. J. Abnorm . Psychol., 94:298-307. Leifer, M., Shapiro, J. P., Martone, M. & Kassem, L. (1991), Rorschach assessment of psychological functioning in sexually abused girls. J. Pers. Assess. , 56:14-28. Mcl.eer, S., Deblinger, E., Atkins, M. et al. (1988 ), Post-traumatic stress disorder in sexually abused children. J. Am. Acad. Child Adolesc . Psychiatry , 27:650-654. Mrazek, D. & Mrazek, P. (1985), Child maltreatment. In: eds . M. Rutter & L. Hersov. Child and Adolescent Psychiatry: Modern Approaches, 2nd ed., Oxford: Blackwell Scientific Publications, pp. 679-697. Oate s, R., Forrest, D. & Peacock, A. (1985 ), Self-esteem of abused children: Special Issue : C. Henry Kempe Memorial Research Issue. Child Abuse Negl., 9:159-163. Reich, W. & WeIner, Z. (1988), OICA-R-C (DSM-IlI-R version ), revised version 5-R. St. Louis : Washington University. Sanders, B. & Giolas, M. (1991) , Dissociation and childhood trauma in psychologically disturbed adolescents. Am. J. Psychiatry, 148:50-54. Sirles, E. A., Smith, J. A. & Kusama, H. (1989), Psychiatric status of intrafamilial child sexual abus e victims. J. Am. Acad. Child Adolesc. Psychiatry, 28:225-229. Terr, L. C. (1991), Childhood traumas: an outline and overview. Am. J. Psychiatry, 148: 10-20. Zanarini, M., Gunderson, J., Marino , M. , Schwartz, E. & Frankenburg, F. (1989) , Childhood experiences of borderline patients. Compr. Psychiatry, 30 : 18-25.
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Abstract. The study sample consists of 96 children (61 maltreated, 35 controls) between 5 and 10 years of age. The two groups of subjects were compared on diagnoses as determined by the administration of the Diagnostic Interview for Children and Adolescents, Revised 6th Version (DICA-6-R) as well as clinical DSM-llI-R diagnoses. Children who had suffered maltreatment exhibited significantly greater incidences of attention deficit hyperactivity disorder, oppositional disorder and post-traumatic stress disorder diagnoses than did controls, on both child and parent DICA interviews. The children's interviews revealed that maltreated children present with a significant incidence of psychotic symptomatology as well as personality and adjustment disorders. Conversely, conduct and mood disorders emerged as significant factors in the parent interviews, with the maltreated group showing significantly greater incidence of these diagnoses. J. Am. Acad. Child Adolesc. Psychiatry, 1992,31, 5:863-867. Key Words: child abuse, post-traumatic stress disorder (PTSD), trauma, Diagnostic Interview for Children and Adolescents (DICA). Numerous papers have described the psychiatric symptoms exhibited by children who have suffered abuse. Oates et al. (1985) reported that, compared with nonabused children, those who had been maltreated exhibited lower selfconcept, perceived themselves as having fewer friends, played with friends less often, and were less ambitious. Affective disorders among children have been found to be related to parental abuse (Kashani et aI., 1987), and depressive symptomatology among child psychiatric patients has been shown to be associated with physical maltreatment (Kazdin et aI., 1985). Kaufman (1991) recently examined the prevalence of depressive disorders in a sample of 56 7 to 12 year-old maltreated children. Overall, 18% ofthe sample met the diagnostic criteria for major depression and 25% met the criteria for dysthymia, with the majority of the children who met the criteria for major depression also meeting the criteria for dysthymia. In sexually maltreated children, the incidence of DSM-III Axis I diagnoses proves to be associated with the duration and frequency of maltreatment, as well as factors such as the offender's relationship to the child and family history of alcohol abuse (Sirles et aI., 1989). Leifer et al. (1991) used several standardized scoring methods with the Rorschach to assess psychological functioning among 79 maltreated black females aged 5 to 16 and a comparison group of nonabused females. The sexually abused group showed more disturbed thinking, a higher level of stress experienced relative to
Accepted September 18, 1991. Dr. Famularo is Assistant Professor of Child Psychiatry and Dr. Kinscherff is Instructor in Psychology, Harvard Medical School. They are also with the Boston Juvenile Court, Massachusetts Department of Mental Health, and the Children's Hospital, Boston. Dr. Fenton is with the Department ofBiostatistics, Harvard School ofPublic Health, Boston. This research was funded by the National Center on Child Abuse and Neglect, Department of Health and Human Services grant 90CA-1408. Reprint requests to Dr. Famularo, Boston Juvenile Court Clinic, New Court House, Room 210, 17 Somerset Street, Boston, MA 02108. 0890-8567/92/3105-Q863$03.00/0©1992 by the American Academy of Child and Adolescent Psychiatry. J. Am. Acad. Child Adolesc. Psychiatry, 31:5, September 1992
their adaptive abilities, more negative descriptions of human relationships, and greater preoccupation with sexuality. This study also found that emotionally and cognitively active abused females experienced more distress than did psychologically constricted abused females. Recent studies have revealed that many cases of child maltreatment lead to the symptomatology associated with a diagnosis of post-traumatic stress disorder (PTSD). McLeer et al. (1988) found that 48% of the 31 sexually abused children they evaluated met the DSM-III-R (American Psychiatric Association, 1987) criteria for such a diagnosis. Famularo et al. (1989) reported that these criteria described 21% of a sample of 115 maltreated children presenting to a juvenile court, with sexual abuse representing a greater risk than physical abuse for the development of PTSD. It is possible, moreover, that a clinical presentation of borderline personality disorder (BPD) may represent chronic PTSD. Both Byrne et al. (1990) and Coon et al. (1989) found relatively high levels of childhood maltreatment among adults diagnosed as BPD, and Brown and Anderson (1991) discovered higher levels of maltreatment among patients with a BPD diagnosis than among other psychiatric patients. Looking at a child sample, one recent study (Famularo et aI., 1991) revealed that 79% of a group of 19 children diagnosed as BPD reported significant traumatic experiences, with 37% meeting the Diagnostic Interview for Children and Adolescents (DICA) criteria for PTSD. Finally, Zanarini et al. (1989) found that childhood histories of 50 adult outpatients who met criteria for borderline personality on the DSM-III and Interview for Borderlines were significantly more likely than those in either of two comparison groups to report a history of maltreatment.
Sanders and Giolas (1991) found that dissociation in adolescence is positively correlated with the degree of stress or abuse experienced earlier in childhood. Dissociative symptoms correlated significantly with self-reported physical abuse or punishment, sexual abuse, psychological abuse, neglect, and negative home atmosphere, although not with abuse ratings made from hospital records. The authors concluded that dissociation represents a reaction to early negative experience and placed multiple personality disorder at
863
FAMULARO ET AL.
the extreme end of a continuum of dissociative sequelae of childhood trauma. The behavioral consequences of maltreatment appear to be related to the type of abuse and can have profound effects upon society as well as the victim. In a study of adolescents with documented histories of having been maltreated (Famularo et al., 1990) a history of physical abuse was significantly associated with acts of aggression against persons, whereas a history of sexual maltreatment increased the probability of presenting as a runaway. A review of the literature by Terr (1991) led her to conclude that psychic trauma in childhood acts as a crucial etiological factor in the development of a number of serious disorders in both childhood and adulthood. She likened such trauma to a childhood "rheumatic fever" in that it could set into motion anyone of a number of different problems, any of which could result in one of a variety of psychiatric disturbances. The authors concur with Terr's (1991) position that childhood psychic trauma results in a complex developmental unfolding of possible psychiatric disturbance. Experiences of maltreatment generate complex dynamics that will manifest and impact differently depending upon such factors as the nature of the maltreatment and the age of the child (Mrazek and Mrazek, 1985). We hypothesize that whereas symptom profiles and developmental alterations will be related to type, duration, and frequency of maltreatment, a diagnosis ofPTSD will be correlated with a history of severe maltreatment in a sample of children ages 5 to 10, regardless of the age of onset of the maltreatment. One purpose of this article is to assess what psychiatric diagnoses might be characteristic of severely maltreated children of that age range. This study provides a comprehensive examination of the formal psychiatric diagnoses of chil-
The two groups of subjects, maltreated children and controls, were compared on the basis of DSM-III-R diagnoses, determined by the administration of the DICA-C structured
dren with documented histories of maltreatment, basing the
interview of the children, and the DICA-P interview of their
children's diagnoses primarily upon structured interviews of both the children (DICA-Child) (Reich and Welner, 1988) and their parents (DICA-Parent) with supplemental DSMIII-R clinical diagnoses. An additional aim is to compare maltreated children with a control group in terms of the relative incidence of all other DSM-III-R diagnoses. In view of the broad range of symptoms described in the literature, one might assume that maltreatment leads to a great many forms of "mental illness"; the goal here is to delineate the diagnoses that might be most specifically associated with experiences of maltreatment.
parents. The maltreated group was compared with the controls in terms of the incidence of each diagnosis to determine which, if any, revealed significant differences between the two groups. In addition to the structured interview, a clinical interview of each child (and parent regarding the child) was performed leading to a clinical DSM-III-R diagnoses for all those categories not covered by the Diagnostic Interview for Children and Adolescents (Reich and Welner, 1988), Revised 6th Version (DICA-6-R). The DICA diagnosis and clinical diagnosis were assigned by the same person. All DICA-6-R diagnoses reported are current diagnoses as provided by the child and the parent. After the clinical interview with the child, DSM-III-R diagnoses were assigned for those diagnoses not covered by DICA-6-R.
Methods
cases met the legal requirement that "clear and convincing" evidence of child maltreatment be presented. The children were involved in civil and not criminal proceedings stemming from the child maltreatment. The experience of severe maltreatment is the common factor among all child subjects. In the case of the hospital sample, maltreatment was defined by the presence of two recent substantiated child abuse/neglect reports filed with the state Department of Social Services. The members of the control group were children receiving treatment at the same hospital who had no history of abuse. Any control case presenting with either current or past evidence of maltreatment during the administration of the DICA and clinical interviews (parent or child) was eliminated from the study. The children were matched to the maltreated group on the basis of age, gender, race, and family income. The researchers received parental permission to review all pertinent records and to interview both parents and abused children. The subjects were informed that the information gathered would not become part of the court or hospital record, and could not be released, except where the State's General Laws required disclosure. Of those recruited for the study, 14% of the maltreatment group and 10% of the control group declined to participate. Subjects from both groups were commensurately, financially compensated for participation and travel. The research was performed under a confidentiality certificate, and permission for child evaluation was obtained from both the parent and the State. Experimental Design
Sample
Measures
The sample consisted of 96 children between 5 and 10 years of age, 61 of whom had been maltreated, and 35 of whom served as controls. The maltreated sample was drawn from an urban juvenile court, and an outpatient department of pediatrics located within the court's jurisdiction. The court sample included children whose parents were before the court on petitions of child abuse significant enough to warrant removal of the children from their parents; these
The DICA-6-R is a structured psychiatric interview for children including questions initially patterned after the National Institute of Mental Health Diagnostic Interview Schedule (DIS) and based on DSM-III. A child version for ages 5 to 12 years old and an adolescent version including ages 13 to 17 have been developed. The DICA-6-R has both a child version and a parallel parent version leading to the same diagnoses.
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PSYCHIATRIC DIAGNOSIS OF MALTREATED CHILDREN TABLE
1. Comparison of Demographic Data between Maltreated Children and Controls
Group Maltreated (N = 61) Mean age (months) Age range (years) Age SD (months) Medicaid (0/0) Female (0/0) Ethnic group White (0/0) Black (0/0) Hispanic (0/0) Other (0/0)
Control = 35)
93.2 5-10 18.3 44 56
93.5 5-10 18.4 43 57
48 35 8 8
40 43 II 6
The DICA-6-R includes 275 questions and is organized into demographic, diagnostic, and symptom profiles (for adjustment and stressor symptoms, psychotic symptoms, and mental status). No DSM-III-R Axis II (developmental, personality) or Axis III (physical disorders and conditions) diagnoses are possible except menstruation symptoms in females. Most, but not all Axis I diagnoses are possible. Notable absences include tic and movement disorders, panic disorder, and obsessive compulsive disorder. Although many questions address psychotic symptoms or disturbances in reality testing, no formal psychotic diagnoses are offered. As described, clinical DSM-III-R diagnoses for these conditions are offered.
Statistical Test
(N
t = 0.06, p = 0.95
x2 = 0.02, p = 0.89 X2 = 0.02, P = 0.89
x= 2
1.13, p = 0.77
personality and adjustment disorders (p :::; 0.05). These child findings were not confirmed by parent interviews. Despite child reports of disturbances of reality-testing, there were no diagnoses of schizophrenia or other psychotic disorder. Conduct and mood disorders emerged as significant factors in the parent interviews, with the maltreated group showing significantly greater number of these diagnoses (p < 0.05). These results were not replicated in data from the child interviews. Clinical Axis I diagnoses not covered by the DICA (tic and movement disorders, panic disorder, obsessive compulsive disorder) were uncommon. Children with mental retardation, pervasive developmental disorder, and autism were excluded from the study. Discussion
Statistical Analysis Analyses of demographic data consisted of t-tests to examine group differences in age and chi-squared tests to compare the groups in terms of sex, ethnicity, and Medicaid status. Because some of the DSM-III-R diagnoses were relatively rare events, resulting in cells with expected frequencies of fewer than five subjects, Fisher's exact probability tests (two-tailed) were used to examine the statistical significance of group differences in the incidence of each of the psychiatric diagnoses. Whenever possible, the results were also presented in terms of odds ratios, with 95% confidence intervals. Results Table 1 shows that the maltreated and control samples were well matched in terms of age, sex, ethnic group, and Medicaid status. Table 2 compares the incidence of psychiatric diagnoses from the maltreated and control samples, based on DICA interviews of the children. Table 3 presents the same comparisons, based on DICA interviews of the parents. Both tables show that children who had suffered maltreatment exhibited significantly greater incidences of attention deficit hyperactivity disorder (ADHD), oppositional disorder, and PTSD diagnoses than did controls (p :::; 0.002)1 The children's interviews revealed a further tendency for maltreated children to exceed controls in the incidence of psychotic symptomatology (9.38% versus 0% control group; Fischer's Exact = 0.020; odds ratio = 12.85), as well as J. Am. Acad. Child Adolesc. Psychiatry, 31:5, September 1992
These results confirm the hypothesis of a strong association between maltreatment and the incidence of a PTSD diagnosis. Based on structured interviews of the children, 39% of the maltreated sample were given a diagnosis of PTSD; parental interviews resulted in 21 % receiving such a diagnosis. Neither child (DICA-Child) nor parental (DICAParent) structured interviews resulted in any of the children in the control group being diagnosed as PTSD. Because specific personality disorders proved to be relatively rare events, all forms of such disorders were combined for the purposes of statistical analysis. This analysis revealed that, on the basis of child interviews, 11% of the maltreated children were diagnosed with some form of personality disorder, whereas none of the controls had been so diagnosed (p < 0.05). The parental clinical interviews yielded a 7% incidence of personality disorders among maltreated children, with none among controls (p = 0.29). Therefore, although maltreated children may not significantly meet criteria for anyone specific personality disorder such as schizotypal, borderline, avoidant, etc., they do report patterns of general dysfunction consistent with the emergence of personality disorders. Careful clinical evaluation is necessary to differentiate between those disturbances of conduct, interpersonal relationships, and cognition that are characteristic of PTSD symptomatology and personality disturbances that are characteristic of nontraumatic etiologies. In addition to PTSD, two other diagnoses, ADHD and oppositional disorder, provided strong discriminations be865
FAMULARO ET AL. TABLE 2. Differences in Psychiatric Diagnoses between Maltreated Children and Controls (Based on DICA Interview of the Child)
Diagnosis ADHD Oppositional Conduct disorder Substance abuse Mood disorder Anxiety Personality PTSD Enuresis or encopresis Psychosis Adjustment disorder Simple phobia Other
Percent with Diagnosis Control Maltreated (N = 35) (N = 61) 2.86 0.00 0.00 0.00 8.57 11.43 0.00 0.00 8.57 0.00 2.86 22.86 2.86
24.59 22.95 3.28 1.64 22.95 19.67 11.48 39.34 16.39 9.38 18.03 9.84 14.75
Fischer 's Exact 2-tailed Test: (p values) 0.005 0.002 0.532 1.000 0.098 0.398 0.045 0.000 0.363 0.020 0.051 0.131 0.088
Odds Ratio 11.09
21.67a 2.98'
1.76a 3.18 1.90 9.77'
46.39a 2.09 12.85a 7.48 0.37 5.89
95% CI Lower
Upper
1.40 1.25 0.14 0.07 0.84 0.56 0.54 2.72 0.54 0.72 0.92 0.12 0.71
88.06 375.64 63.92 44.38 11.96 6.41 176.47 791.82 8.18 227.85 60.66 1.17 48.57
"The logit estimators use a correction of 0.5 in every cell of those tables that contain a zero.
tween the maltreated and control groups on both the child (DICA-Child) and the parental interviews (DICA-Parent). Both ADHD and oppositional disorder were awarded more frequently among the maltreated children. The etiology of these relation ships cannot be ascertained on the basis of the data in the current study . It is possible that the symptoms resulting in the diagnoses of ADHD and oppositional disorder may have been cau sed by maltreatment, as in cases where the difficulties reported with attention/concentration and hyperactivity that contributed to an ADHD diagnosis actually represent anxiety symptoms associated with PTSD . However, it is also possible that the "difficult" behav iors associated with these diagnoses may have played a role in provoking maltreatment, and that any similar symptoms stemming from the PTSD were an overlap upon a preexisting condition. Approximately 9 1/ 3 % of maltreated children reported psychotic symptomatology, although none met criteria for a formal thought disorder. With only one exception, all children reporting at least one current psychotic symptom also
carried a PTSD diagnosis. Content of the reported visual and/or auditory hallucinations or illusions tended to be strongly reminiscent of concrete details of episodes of traumatic victimization. The psychotic symptoms were not related to any other symptoms suggestive of schizophrenia such as flat or blunted affect , bizarre delu sions, or oddities of interpersonal relating. Rather, they appeared to represent manifestations of post-traumatic flashback, hallucination, or illusion such as those referred to by Terr ( 199 1). These psychotic symptoms may also be the manifestations of dissociative responses to maltreatment. Although there are too few cases in this sample to fully analyze, it doe s suggest that PTSD can be a significantly virulent and pervasively pathological outcome of child maltreatment. The findings of this study have several implications for clinical practice. First, very careful consideration of the diagnosis of PTSD and its clinical manifestations should occur when there is a history of maltreatment. Furthermore, since maltreated children do report indications of a variety of personality diagnoses, evaluators should consider the devel-
TABLE 3. Differences in Psychiatric Diagnoses between Maltreated Children and Controls (Based on DICA Interview of the Parent) Percent with Diagnosis Diagnosi s ADHD Oppositional Conduct disorder Substance abuse Mood disorder Anxiety Personality PTSD Enuresis or encopresis Psychosis Adjustment disorder Simple phobia Other
Control (N = 35)
Maltre ated (N = 6 1)
Fischer 's Exact 2-Tailed Test (p values)
5.71 5.71 0.00 0.00 0.00 8.57 0.00 0.00 8.57 0.00 2.86 14.29 5.71
42.62 39.34 11.48 1.64 14.75 2 1.31 6.56 2 1.31 22.95 4.92 8.20 22.95 8.20
0.000 0.000 0.046 1.000 0.024 0.156 0.293 0.002 0.098 0.298 0.411 0.426 1.000
Odds Ratio 12.26 10.70 9.77 a
1.76a 12.85a 2.89
5.56a 19.76a 3.18
4.25a 3.04 1.79 1.47
95% CI Lower
Upper
2.70 2.35 0.54 0.07 0.72 0.76 0.29 1.14 0.84 0.21 0.34 0.58 0.27
55.75 48.78 176.47 44.38 227.85 10.95 106.33 343.60 11.96 84.67 27.10 5.47 8.03
"The logit estimators use a correction of 0.5 in every cell of those tables that contain a zero.
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PSYCHIATRIC DIAGNOSIS OF MALTREATED CHILDREN
opmental impact of PTSD symptoms as a chronic process distorting subsequent development. As a corollary, children initially presenting with possible personality disorder should be evaluated for a history of trauma, including maltreatment. The cases of children with personality disorder diagnoses seen on follow-up or institutional transfer should be reviewed for evidence that earlier evaluations considered possible histories of maltreatment. Second, initial evidence also suggests that children presenting with hallucinations or illusions in the absence of other indications of formal thought disorder or schizophrenia should also be specifically evaluated for histories of maltreatment or other trauma . Because the parent interviews often fail to yield reports of the psychotic symptoms of the maltreated children, evaluators must interview the children themselves about these experiences . Similarly, parents may report more symptoms related to conduct and mood. That parents and children report different observations and experiences strongly suggests that especially in cases of child maltreatment both the parent and the child must be interviewed. Third, the overlap of ADHD , oppositional disorder, and PTSD among maltreated children calls for evaluation of the preexisting or comorbid presentation of these conditions in maltreated children. A known or suspected history of maltreatment should prompt detailed history-taking and differential diagnosis. The diagnostic and intervention challenge is further complicated by the fact that the manifestations of these disorders may closely resemble each other. For example, difficulties in a child 's attention/concentration and conduct may be manifestations of an anxiety disorder (PTSD), or a presumed neurocognitive developmental delay (ADHD), or both. However, careful differential diagnosis will permit appropriate selection of psychopharmacological, psychotherapeutic, and environmental interventions.
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