Sexually Abused Children at High Risk for Post-traumatic Stress Disorder SUSAN V. McLEER, M.D., ESTHER DEBLINGER, PH.D., DELMINA HENRY, PH.D., AND HELEN ORVASCHEL, PH.D.
Abstract. Ninety-two sexually abused children were studied using structured interviews and standardized instruments to determine the frequency of post-traumatic stress disorder (PTSD) and associated symptoms. Of these sexually abused children, 43.9% met DSM-lII-R PTSD criteria; 53.8% of children abused by fathers, 42.4% abused by trusted adults, and 10% of those abused by strangers met criteria as opposed to none of the children abused by an older child. No relationship was observed between the time lapsed since last abusive episode and the presence ofPTSD. Many children not meeting full criteria exhibited partial PTSD symptoms. Only one standardized instrument (Child Behavior Checklist) detected group differences with PTSD children exhibiting more symptoms. This study replicates an earlier pilot study and underscores the need for further PTSD research. J. Am. Acad. Child Adolesc. Psychiatry, 1992,31,5:875-879. Key Words: sex abuse, sexually abused children, post-traumatic stress disorder, high-risk study. Post-traumatic stress disorder (PTSD) is a major anxiety disorder that has been reported in children after natural and man-made disasters (Blaufarb and Levine, 1972; Galante and Foa, 1982; GIeser et al., 1981; Lacey, 1972; Malmquist, in press; Pynoos et al., 1981; Pynoos and Eth, in press; Terr, 1979, 1981, 1983), with disabling symptoms that appear to have stability across time (Armsworth, 1984; Fox and Scherl, 1972; McFarlane, 1987; Terr, 1983). Major disasters are fortunately relatively infrequent. Consequently, the total number of affected children has remained small. However, recently, reports have appeared in the literature suggesting that PTSD is not limited to the sequelae of major disasters, but may well follow events that are all too frequent in our society, mainly child physical and sexual abuse (Deblinger et al., 1989; Green, 1983; McLeer et al., 1988) and the witnessing of domestic violence (Pynoos and Eth, 1984). McLeer et al. (1988) have previously reported the findings of a small pilot study of 31 sexually abused outpatient children, 48.4% of whom met full DSM-III-R (American Psychiatric Association, 1987) criteria for PTSD. Additionally, it was found that 75% of those abused by natural fathers and 25% of those abused by trusted adults met criteria, as opposed to none of the children abused by older children (X2 = 10.64, p < 0.005). No correlation was found between the presence of PTSD and the length of time that had lapsed since the last abusive episode. That study, although limited by its small sample size, suggested that PTSD is common
Accepted October 4, 1991. Drs. McLeer, Henry and Orvaschel are from the Division of Child and Adolescent Psychiatry, Medical College of Pennsylvania/Eastern Pennsylvania Psychiatric 1nstitute, Philadelphia, Pennsylvania. Dr. Deblinger is from the Department of Pediatrics, University of Medicine and Dentistry of New Jersey, Stratford, New Jersey. Presented at the Annual Meeting of the Academy of Child and Adolescent Psychiatry, New York, New York, October 11-15, 1989. Requests for reprints to Dr. McLeer, Division of Child and Adolescent Psychiatry, Medical College ofPennsylvania/Eastern Pennsylvania Psychiatric 1nstitute, 3200 Henry Avenue, Philadelphia, PA 19129. 0890-8567/92/3l05-0875$03.00/0©1992 by the American Academy of Child and Adolescent Psychiatry. J. Am. Acad. Child Adolesc. Psychiatry, 31:5, September 1992
among sexually abused children and that variables can be identified that are correlated with increased risk for the development of PTSD as a sequelae of child sexual abuse. These findings have now been replicated in a larger prospective study and are reported here.
Methods Subjects
Ninety-two sexually abused children were recruited from the Child Sexual Abuse: Diagnostic and Treatment Center in the Division of Child Psychiatry at the Medical College of Pennsylvania, with referrals coming from two code R (rape and sex abuse) centers, the Department of Human Services, Women Organized Against Rape, and from private practitioners in the community. All subjects had been sexually abused on at least one occasion. There was no upper limit to the number of abusive episodes. Children were referred to the Center for evaluation subsequent to sexual abuse for determination of the clinical impact of the abuse and provision of treatment as needed. All cases were either judged to be "indicated" cases of sexual abuse by the Philadelphia Department of Human Services, or the allegations were viewed as sufficiently credible by the Philadelphia Police Sex Crimes Unit to refer the case for prosecution. Sexual abuse was defined as sexual touching, with or without force, by anyone five or more years older than the child (contact sexual abuse). Russell's (1983) criteria were used for classifying the degree of seriousness of sexual abuse: (1) least serious-inappropriate kissing or sexual touching while the child was clothed; sexual touching (nongenital) under the clothes or when the child was undressed; (2) serious-direct genital touching and/or digital penetra-
tion of vagina or anus; simulated intercourse; (3) very serious-cunnilingus, fellatio, anilingus, and penile penetration of vagina, anus, or mouth. The average time lapse since the last abusive episode was 4.4 months, with a median of 5 months. Seventy-one girls and 21 boys were included in the study with ages ranging from 3 years to 16 years. The mean age was 8.9 years. Thirty-nine children (42.4%) had been abused by their father or stepfather. Thirty-three (35.9%) were
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abused by a trusted adult, nine (9.8%) were abused by an older child, and 10 (19.9%) by a stranger. The perpetrator was unidentified for one child. Using Russell's criteria for seriousness of abuse, seven children were in category 1 (least serious), 26 in category 2 (serious), and 50 in category 3 (very serious). Procedures
The subjects and their custodial guardians were interviewed according to a structured interview developed by the investigators for evaluating the child's sexual abuse. A subgroup of 27 children, additionally, were evaluated using the Kiddie Schedule for Affective Disorders and Schizophrenia for School Age Children-Epidemiologic Version (K-SADS-E) (Orvaschel et aI., 1981, 1982) with a newly developed PTSD section for determination of DSM-III-R, Axis I diagnoses. In addition, the Harter Perceived Competence Scale (HPCS) (Harter, 1985), the Harter Social Support Scale (HSSS) (Harter, 1985), the Revised Children's Manifest Anxiety Scale (R-CMAS) (Reynolds and Richmond, 1978), the State-Trait Anxiety Inventory for Children (STAIC) (Speilberger, 1973), the Children's Depression Inventory (CDI) (M. Kovacs, unpublished manuscript), and the Child Behavior Checklist (CBCL) (Achenbach and Edelbrook, 1983) were administered. The initial interviews were scored according to a PTSD symptom checklist. The checklist was developed from DSMIII-R criteria for PTSD (American Psychiatric Association, 1987). The scoring was dichotomized and symptoms noted to be either present or absent. To fulfill DSM-III-R criteria for PTSD, a child had to demonstrate concurrence of at least one symptom of reexperiencing behavior, three or more symptoms of avoidant behaviors, and two or more symptoms of autonomic hyperarousal. A subsample of 22 subjects who were administered the
K-SADS-E were studied to determine interrater reliability for DSM-III-R, Axis I diagnoses. The percentage of agreement was 82.9% for current diagnoses and 73.3% for past and current diagnoses combined. There was an 85.7% agreement for current PTSD and 73.3% for all current anxiety disorders. The CBCL was scored and compared with standardized population norms (T = 70). The CDI was scored on the basis of a score of 9 being the average for the nonpsychiatric population with 12 and above being indicative of clinical depression. The STAIC, HPCS, HSSS, and R-CMAS were compared with standardized population norms for each of their subscales. Children whose ages were not within the limits defined for normative data on specific instruments were not included in the analysis. Results
Almost half of the sexually abused children (43.9%) met DSM-III-R criteria for PTSD: 53.8% of the children abused
by natural fathers, 42.4% of those abused by trusted adults, and 10% of those abused by strangers met the criteria as opposed to none of the children abused by an older child (X2 = 12.99, p < 0.0047) (Table 1). Chi square analyses revealed no significant difference in the frequency of PTSD 876
amongst children abused by father versus trusted adults. However, significance was reached with father versus stranger (X2 = 4.54, p < 0.03) and fathers versus older children (X2 = 6.57, p < 0.01), with children abused by fathers being more likely to exhibit PTSD. No relationship was observed between the time lapsed since the last abusive episode and the evaluation and the development of PTSD, and no significant relationship was found between the age of the child, seriousness of the abuse, or duration of the abuse and the development of PTSD. Many children who did not meet full criteria met partial criteria for PTSD. Of the entire sample, 86.5% demonstrated one or more symptoms or reexperiencing behaviors, 52.4% demonstrated three or more avoidant behaviors, and 72.0% demonstrated two or more symptoms of autonomic hyperarousal. Standardized instruments were useful in identifying non-PTSD related symptoms. Forty of the 68 children (58.8%) evaluated by the CDI scored 12 or higher, a score indicative of clinical depression. Twenty-nine of the 88 children who were given the CBCL (33.0%) had a T score above 70 on the internalizing scale, whereas 25 (28.4%) scored above 70 on the externalizing scale of the CBCL, and 16.7% of the children were one standard deviation above the normative mean of the R-CMAS. The two Harter scales had 21.4% of the total sample on the HPCS, 23.1% on the HSSS Parent and Friend subscales, and 11.5% on the HSSS classmate and teacher subscale who scored one standard deviation below the normative means. Only one instrument, the CBCL, was useful in differentiating PTSD children from the others with significant differences found between groups on the mean T scores for the internalizing (t76 = -2.61, p < 0.011) and externalizing t76 -2.85, P < 0.006) subscales of the CBCL (PTSD children exhibiting higher externalizing and internalizing scores). A trend was found on the CDI (t59 = -1.74, p < 0.087) with children suffering from PTSD having higher depression scores. PTSD and non-PTSD childrens' scores on the self-report measures of anxiety, selfesteem, perceived competency, and social support did not differ significantly. Utilizing the Duncan Post-hoc Procedure, the mean scores for the study population of sexually abused children were compared with the published mean scores for the standardized rating scales for both clinical and nonclinical populations. Again, only those children whose ages were appropriate for the individual scales were included in the analysis. On the CBCL, it was necessary to compare published norms for sexually abused boys independent of the sexually abused girls. Sexually abused boys, both with and without PTSD, were found to differ significantly (p < 0.05) from the nonclinical population on both the internalizing and externalizing subscales. Additionally, the sexually abused boys with PTSD had significantly higher mean scores than all other groups on the externalizing subscale. This included both the nonclinical and clinical populations as well as the non-PTSD group of sexually abused boys (p < 0.05). Among girls, sexually abused girls differed significantly on both the externalizing and internalizing subscales from the nonclinical population (p < 0.05). Sexually abused girls with PTSD J. Am. Acad. Child Adolesc. Psychiatry, 31:5, September 1992
POST-TRAUMATIC STRESS AFTER SEX ABUSE TABLE
1. Relationship between Abuser Characteristics and Frequency of PTSD in Sexually Abused Children Abuser N
Non-PTSD PTSD Total
18 21 39
Stranger
Trusted Adult
Father %
46.2 53.8 100
N
19 14 33
additionally had significantly higher means than both sexually abused girls without PTSD and the total population of sexually abused children (p < 0.05). There was no significant difference between sexually abused children with PTSD and the norms for the clinical population on both the internalizing and externalizing subscale of CBCL; however, the clinical population means were significantly higher than that for the total population of sexually abused children and the nonPTSD population (p < 0.05). On the cm, both the sexually abused children with and without PTSD had higher mean scores than that published for normative population with the PTSD group having higher mean scores than the non-PTSD group (p < 0.05). No significant differences were found between the published means for the normative populations and the study population on both the RCMAS scale and the STAIC scale. Among the 27 children who were administered the K-SADS-E, the predominant current diagnosis was PTSD (44.4%; 12/27) followed by attention deficit disorder with hyperactivity (33.3%; 9/27), conduct disorder (25.9%; 7/27), simple phobias and oppositional disorders (7.4%; 2/ 27 for each), and dysthymia and overanxious disorders (3.7%; 1/27 for each). Three children had no diagnosis. Several met criteria for more than one diagnosis. Discussion Although this study replicates our earlier finding that PTSD is common among clinically referred children who have been sexually abused, and all children in this study were referred for evaluation subsequent to being sexually abused, it is still possible, and, in fact probable, that the subjects reflect a subpopulation of sexually abused children who may be more symptomatic than others since the Diagnostic and Treatment Center is viewed as a facility within the community that can help with difficult cases. Consequently, because of the probable subject recruitment bias of this study we still do not know how prevalent the disorder is among nonclinically referred sexually abused children and adult survivors of child sexual abuse. Additionally, no studies have been done to date that delineate the natural history of PTSD in childhood and so, we do not know how many of the children who develop PTSD acutely after a trauma will spontaneously remit or how will develop a more chronic clinical pattern. The finding that 53.8% of children abused by natural fathers and 42.4% of those abused by trusted adults suffer from PTSD irrespective of the time lapse since the last abusive episode, underscores the need for further research on risk factors for the development and persistence of PTSD J. Am. Acad. Child Adolesc. Psychiatry, 31:5, September 1992
%
57.6 42.4 100
Older Child
N
%
N
%
9 1 10
90 10 100
a
9
100
9
100
a
in childhood. The lack of correlation between PTSD and the seriousness of the abuse may well reflect the fact that most subjects were classified as having been seriously or very seriously abused; hence, recipients of a narrow spectrum of seriously abusive behaviors. Consequently, the range of abusive behaviors was not sufficiently large for differences to be detected. The relationship of the duration of abuse to PTSD requires a larger study since the relationship of the abuser to the child is confounded by duration. The number of children meeting partial criteria for PTSD was extremely high with 86.5% of the sample demonstrating one or more symptoms of reexperiencing behaviors, 52.4% with three or more avoidant behaviors, and 72.0% with two or more symptoms of autonomic hyperreactivity. These findings could be indicative of several possibilities all of which need exploration in a study of the natural history of PTSD. For example, (1) greater numbers of children may develop PTSD immediately following the abusive incident with a certain percentage remitting, or partially remitting, across time; (2) the stress response to sexual abuse may be reflective of a spectrum of clinical symptoms differing in severity and frequency with many children never developing full blown PTSD and some never developing post-traumatic stress symptoms at all; (3) the number and patterns of symptoms may vary across time, hence, shifting the ratio of reexperiencing symptoms, avoidant symptoms, and symptoms of autonomic arousal; and (4) some children for a variety of reasons, both psychological and biological, respond differently than others with some having more reexperiencing symptoms and other more avoidant symptoms. Hence, one would see a qualitatively different symptom picture emerging and remaining consistent or perhaps varying across time depending on the interaction of the stressor with premorbid factors. In comparing sexually abused children with PTSD with CBCL norms, both boys and girls on the externalizing and internalizing sub scale demonstrated no differences when compared to clinical populations of children with the one exception that for boys, the mean score on the externalizing subscale was significantly higher (p < 0.05). This is indicative of the severity of symptomatology in PTSD and underscores how behaviorally disruptive the disorder is, particularly among boys. On both the CBCL and cm, the total sample of sexually abused children were found to have higher means than the normative populations (nonclinical) and indistinguishable from clinical populations with the one exception noted above. The significance of these findings is unclear because it is highly likely that the clinically referred study population
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of sexually abused children reflects a sampling bias caused by agencies referring many of their most symptomatic and disturbed sexually abused children. Final determination of the unique contribution of sexual abuse to symptom development as well as the development of psychiatric disorder, must await a larger study with nonclinical populations of sexually abused children compared to appropriate groups of nonabused, nonclinically referred children as well as those referred for outpatient psychiatric evaluation. PTSD appears to be a serious psychiatric disorder fueled by both psychological and biological factors (Giller, 1990) with a full blown disorder being resistant to many of the treatments currently being utilized in many child sexual abuse programs. Therefore, it becomes important to understand what premorbid factors contribute to the development of severe and persistent symptoms; what factors are protective and contribute to a minimized stress response with either spontaneous remission or a lack of development of the fullblown picture of PTSD. Questions needing further study include: does PTSD have a natural history and pattern of evolution that is consistent across individuals or do individuals differ regarding the clinical form which the post-traumatic stress response takes? If the stress response differs across individuals, are different treatments indicated depending on the symptom patterns which evolve? Because of the psychobiological complexities of PTSD, in addition to the research that has already been directed toward the relationship between symptom severity and certain abuse related variables, attention also needs to be directed toward nonabused variables such as comorbid and premorbid psychiatric disorders, family psychiatric history, and temperament (including the reactivity of the autonomic nervous system). Obviously, psychological and social factors relating to family stability and parental support, other traumatic events that the child has experienced in his/her life such as domestic violence or death of a parent, and a variety of environmental changes that may occur subsequent to the disclosure of the abuse need to be examined as well. The finding among the subsample of 27 children who were administered the K-SADS-E also reflects that PTSD is a common finding, with 44.4% of the children meeting criteria for current PTSD. Both the PTSD rating scale and the K-SADS-E identified the same children as having this disorder, indicating that both instruments appear to be sensitive to identifying children suffering from this disorder. The advantage of using the K-SADS-E, however, is that it allows a semistructured format for detecting other Axis I disorders that may coexist with PTSD. While the distribution of the most prevalent disorders after PTSD is similar to that which we would expect in a psychiatric outpatient population, the sample of sexually abused children have a higher percentage of females presenting for care. Consequently, the finding that attention deficit disorder is the second most frequent diagnosis is an interesting finding since it is a disorder that tends to be more prevalent among boys. However, the examination of what diagnoses are most frequently found among sexually abused children as compared to an outpatient population of psychiatrically referred children and the relation-
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ship of comorbid disorders to PTSD symptom severity must await further study with adequate comparison groups. Summary
PTSD was once thought to be an outcome following only severe man-made or natural disasters, hence, affecting small numbers of children. With sexually abused children being at high risk for PTSD, it becomes clear that PTSD may, in fact, be a much more prevalent disorder of childhood than was once thought. Further research on children at risk and on the development of effective treatments is a matter of great urgency.
References Achenbach, T. M. & Edelbrock, C. (1983), Manual for the Child Behavior Checklist and Revised Child Behavior Profile, Burlington, Vermont: University of Vermont, Department of Psychiatry. American Psychiatric Association (1987), Diagnostic and Statistical Manual ofMental Disorders, 3rd edition-revised DSM-IIl-R. Washington, DC: American Psychiatric Association. Armsworth, M. W. (1984), Post Traumatic Stress Responses in Women Who Experienced Incest as Children or Adolescents. Ann Arbor, Michigan: University Microfilms International. Blaufarb, H. & Levine, J. (1972), Crisis intervention in an earthquake. Social Work, 17:16-19. Deblinger, E. B., McLeer, S. V., Atkins, M., Ralphe, D. & Foa, E. (1989), Post-traumatic stress disorder in sexually abused, physically abused and non-abused children. International Journal of Child Abuse and Neglect. 13(3):403-408. Fox, S. S. & Scherl, D. 1. (1972), Crisis intervention with victims of rape. Social Work, 17:37-42. Galante, R. & Foa, D. (1982), Epidemiological Study of Psychic
Trauma and Treatment Plan for Children After a Natural Disaster. Presented at the 10th International Congress for the International Association for Child and Adolescent Psychiatry and Allied Profession. Dublin, Ireland (July). Giller, E. L. (1990), Biological Assessment and Treatment of PostTraumatic Stress Disorder. Washington, DC: American Psychiattic Association. GIeser, G. C., Green, B. L. & Winget, C. (1981), Prolonged Psychosocial Effects of Disaster: A Study of Buffalo Creek. New York: Academic Press. Green, A. H. (1983). Child abuse: dimension of psychological trauma in abused children. J. Am. Acad. Child Psychiatry, 22(3):231-237. Harter, S. (1985), Manualfor the Self-Perception Profile for Children. Denver, Colorado: University of Denver Press. Lacey, G. N. (1972), Observations on Aberfam. J. Psychosom. Res., 16:257-260. Malmquist, C. P. (1986), Children who witnessed parental murder: post-traumatic and legal issues. J. Am. Acad. Child Psychiatry, 25:320-325. McFarlane, A. C. (1987), Post-traumatic phenomena in a longitudinal study of children following a natural disaster. J. Am. Acad. Child Adolesc. Psychiatry, 26(5):764-769. McLeer, S. V., Deblinger, E., Atkins, M. S., et al. (1988), Posttraumatic stress disorder in sexually abused children. J. Am. Acad. Child Adolesc. Psychiatry, 27(5):650-654. Orvaschel, H., Weisman, M. M., Padier, W. & Lowe, T. (1981). Assessing psychopathology in children of psychiatrically disturbed parents: a pilot study. J. Am. Acad. Child Adolesc. Psychiatry, 20:112-122. Orvaschel, H., Puig-Antich, J., Chambers, W., Tabrizi, M. A. & Johnson, R. (1982), Retrospective assessment of child psychopathology with the Kiddie-SADS-E. J. Am. Acad. Child Adolesc. Psychiatry, 21 :392-397. Pynoos, R. S. & Eth, S. (1984), The child as witness to homicide. Journal of Social Issues, 40:87-108. Pynoos, R. S., Gilman, K. & Shapiro, T. (1981), Children's response to parental suicide behavior. Presented at the Annual Meeting of
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the American Academy of Child Psychiatry, October 14-18, Dallas, Texas. Reynolds, C. R. & Richmond, B. O. (1978), What I think and feel: a revised measure of children's manifest anxiety. J. Abnorm. Child Psychol., 6:271-280. Russell, D. (1983), The incidence and prevalence of intrafamilial and extrafamilial sexual abuse of female children. Child Abuse and Neglect, 7: 133-146. Speilberger, C. D. (1973), Preliminary Manual for the State-Trait Anxiety Inventory for Children. Palo Alto, CA: Consulting Psychologists.
Terr, L. C. (1979), Children of Chowchilla: a study of psychic trauma. Psychoanal. Study Child, 34:552-623. Terr, L. C. (1981), Psychic trauma in children: observations following the Chowchilla school bus kidnapping. Am. J. Psychiatry, 138:1419. Terr, L. C. (1983), Chowchilla revisited: the effects of psychic trauma four years after a school bus kidnapping. Am. J. Psychiatry, 140:1543-1550.
From Pediatrics Identification and Management of Psychosocial and Developmental Problems in Community-Based, Primary Care Pediatric Practices. Sarah McCue Horwitz, Ph.D., Philip 1. Leaf, Ph.D., John M. Leventhal, M.D., Brian Forsyth, M.B.Ch.B., and Kathy Nixon Speechley, Ph.D. Abstract. The importance of psychological and social issues for children's well-being has long been recognized and their importance in the practice of pediatrics is well documented. However, many of the studies looking at this issue have emphasized psychiatric problems rather than issues commonly referred to as the new morbidity. The goal of this research was to refocus interest on the problems of the new morbidity. The study examined the rates and predictors of psychological problems in 19 of 23 randomly chose pediatric practices in the greater New Haven area. Families of all 4- to 8-year-old children were invited to partricipate and to complete the Child Behavior Checklist prior to seeing a clinician. Clinicians completed a 13-category checklist of psychosocial and developmental problems based on a World Health Organizationsponsored primary care, child-oriented classification system. Of the 2006 eligible families, 1886 (94%) participated. Clinicians identified at least one psychosocial or developmental problem in 515 children (27.3%). Thirty-one percent of the children with problems received no active intervention, 40% received intervention by the clinician, and 16% were referred to specialty services. Not surprisingly, children whose problems were rated as moderate or severe were twice as likely to be referred compared with children with mild problems. Recognition of a problem was related to four characteristics: if the visit was for well child rather than acute care; if the clinician felt he or she knew a child well; if the child was male; and if the child had unmarried parents (all p ::; .05). The data suggest that, when asked to use a taxonomy appropriate for primary care, clinicians recognize problems in many 4- to 8-year-old children (515/1886; 27.3%). This rate is considerably higher than the rates previously reported. Further, many children with identified problems (56%) were reported by their clinicians to receive some form of active intervention. Characteristics of the visit (type of visit, clinician's knowledge of a child) that influence the recognition of problems were also identified. These results suggest that investigators must define what types of problems they are interested in and under what circumstances to determine accurately what pediatric practitioners know about psychosocial and developmental problems in their young patients and families. Pediatrics 1992;89480-485.
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Abstract. Ninety-two sexually abused children were studied using structured interviews and standardized instruments to determine the frequency of post-traumatic stress disorder (PTSD) and associated symptoms. Of these sexually abused children, 43.9% met DSM-lII-R PTSD criteria; 53.8% of children abused by fathers, 42.4% abused by trusted adults, and 10% of those abused by strangers met criteria as opposed to none of the children abused by an older child. No relationship was observed between the time lapsed since last abusive episode and the presence ofPTSD. Many children not meeting full criteria exhibited partial PTSD symptoms. Only one standardized instrument (Child Behavior Checklist) detected group differences with PTSD children exhibiting more symptoms. This study replicates an earlier pilot study and underscores the need for further PTSD research. J. Am. Acad. Child Adolesc. Psychiatry, 1992,31,5:875-879. Key Words: sex abuse, sexually abused children, post-traumatic stress disorder, high-risk study. Post-traumatic stress disorder (PTSD) is a major anxiety disorder that has been reported in children after natural and man-made disasters (Blaufarb and Levine, 1972; Galante and Foa, 1982; GIeser et al., 1981; Lacey, 1972; Malmquist, in press; Pynoos et al., 1981; Pynoos and Eth, in press; Terr, 1979, 1981, 1983), with disabling symptoms that appear to have stability across time (Armsworth, 1984; Fox and Scherl, 1972; McFarlane, 1987; Terr, 1983). Major disasters are fortunately relatively infrequent. Consequently, the total number of affected children has remained small. However, recently, reports have appeared in the literature suggesting that PTSD is not limited to the sequelae of major disasters, but may well follow events that are all too frequent in our society, mainly child physical and sexual abuse (Deblinger et al., 1989; Green, 1983; McLeer et al., 1988) and the witnessing of domestic violence (Pynoos and Eth, 1984). McLeer et al. (1988) have previously reported the findings of a small pilot study of 31 sexually abused outpatient children, 48.4% of whom met full DSM-III-R (American Psychiatric Association, 1987) criteria for PTSD. Additionally, it was found that 75% of those abused by natural fathers and 25% of those abused by trusted adults met criteria, as opposed to none of the children abused by older children (X2 = 10.64, p < 0.005). No correlation was found between the presence of PTSD and the length of time that had lapsed since the last abusive episode. That study, although limited by its small sample size, suggested that PTSD is common
Accepted October 4, 1991. Drs. McLeer, Henry and Orvaschel are from the Division of Child and Adolescent Psychiatry, Medical College of Pennsylvania/Eastern Pennsylvania Psychiatric 1nstitute, Philadelphia, Pennsylvania. Dr. Deblinger is from the Department of Pediatrics, University of Medicine and Dentistry of New Jersey, Stratford, New Jersey. Presented at the Annual Meeting of the Academy of Child and Adolescent Psychiatry, New York, New York, October 11-15, 1989. Requests for reprints to Dr. McLeer, Division of Child and Adolescent Psychiatry, Medical College ofPennsylvania/Eastern Pennsylvania Psychiatric 1nstitute, 3200 Henry Avenue, Philadelphia, PA 19129. 0890-8567/92/3l05-0875$03.00/0©1992 by the American Academy of Child and Adolescent Psychiatry. J. Am. Acad. Child Adolesc. Psychiatry, 31:5, September 1992
among sexually abused children and that variables can be identified that are correlated with increased risk for the development of PTSD as a sequelae of child sexual abuse. These findings have now been replicated in a larger prospective study and are reported here.
Methods Subjects
Ninety-two sexually abused children were recruited from the Child Sexual Abuse: Diagnostic and Treatment Center in the Division of Child Psychiatry at the Medical College of Pennsylvania, with referrals coming from two code R (rape and sex abuse) centers, the Department of Human Services, Women Organized Against Rape, and from private practitioners in the community. All subjects had been sexually abused on at least one occasion. There was no upper limit to the number of abusive episodes. Children were referred to the Center for evaluation subsequent to sexual abuse for determination of the clinical impact of the abuse and provision of treatment as needed. All cases were either judged to be "indicated" cases of sexual abuse by the Philadelphia Department of Human Services, or the allegations were viewed as sufficiently credible by the Philadelphia Police Sex Crimes Unit to refer the case for prosecution. Sexual abuse was defined as sexual touching, with or without force, by anyone five or more years older than the child (contact sexual abuse). Russell's (1983) criteria were used for classifying the degree of seriousness of sexual abuse: (1) least serious-inappropriate kissing or sexual touching while the child was clothed; sexual touching (nongenital) under the clothes or when the child was undressed; (2) serious-direct genital touching and/or digital penetra-
tion of vagina or anus; simulated intercourse; (3) very serious-cunnilingus, fellatio, anilingus, and penile penetration of vagina, anus, or mouth. The average time lapse since the last abusive episode was 4.4 months, with a median of 5 months. Seventy-one girls and 21 boys were included in the study with ages ranging from 3 years to 16 years. The mean age was 8.9 years. Thirty-nine children (42.4%) had been abused by their father or stepfather. Thirty-three (35.9%) were
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abused by a trusted adult, nine (9.8%) were abused by an older child, and 10 (19.9%) by a stranger. The perpetrator was unidentified for one child. Using Russell's criteria for seriousness of abuse, seven children were in category 1 (least serious), 26 in category 2 (serious), and 50 in category 3 (very serious). Procedures
The subjects and their custodial guardians were interviewed according to a structured interview developed by the investigators for evaluating the child's sexual abuse. A subgroup of 27 children, additionally, were evaluated using the Kiddie Schedule for Affective Disorders and Schizophrenia for School Age Children-Epidemiologic Version (K-SADS-E) (Orvaschel et aI., 1981, 1982) with a newly developed PTSD section for determination of DSM-III-R, Axis I diagnoses. In addition, the Harter Perceived Competence Scale (HPCS) (Harter, 1985), the Harter Social Support Scale (HSSS) (Harter, 1985), the Revised Children's Manifest Anxiety Scale (R-CMAS) (Reynolds and Richmond, 1978), the State-Trait Anxiety Inventory for Children (STAIC) (Speilberger, 1973), the Children's Depression Inventory (CDI) (M. Kovacs, unpublished manuscript), and the Child Behavior Checklist (CBCL) (Achenbach and Edelbrook, 1983) were administered. The initial interviews were scored according to a PTSD symptom checklist. The checklist was developed from DSMIII-R criteria for PTSD (American Psychiatric Association, 1987). The scoring was dichotomized and symptoms noted to be either present or absent. To fulfill DSM-III-R criteria for PTSD, a child had to demonstrate concurrence of at least one symptom of reexperiencing behavior, three or more symptoms of avoidant behaviors, and two or more symptoms of autonomic hyperarousal. A subsample of 22 subjects who were administered the
K-SADS-E were studied to determine interrater reliability for DSM-III-R, Axis I diagnoses. The percentage of agreement was 82.9% for current diagnoses and 73.3% for past and current diagnoses combined. There was an 85.7% agreement for current PTSD and 73.3% for all current anxiety disorders. The CBCL was scored and compared with standardized population norms (T = 70). The CDI was scored on the basis of a score of 9 being the average for the nonpsychiatric population with 12 and above being indicative of clinical depression. The STAIC, HPCS, HSSS, and R-CMAS were compared with standardized population norms for each of their subscales. Children whose ages were not within the limits defined for normative data on specific instruments were not included in the analysis. Results
Almost half of the sexually abused children (43.9%) met DSM-III-R criteria for PTSD: 53.8% of the children abused
by natural fathers, 42.4% of those abused by trusted adults, and 10% of those abused by strangers met the criteria as opposed to none of the children abused by an older child (X2 = 12.99, p < 0.0047) (Table 1). Chi square analyses revealed no significant difference in the frequency of PTSD 876
amongst children abused by father versus trusted adults. However, significance was reached with father versus stranger (X2 = 4.54, p < 0.03) and fathers versus older children (X2 = 6.57, p < 0.01), with children abused by fathers being more likely to exhibit PTSD. No relationship was observed between the time lapsed since the last abusive episode and the evaluation and the development of PTSD, and no significant relationship was found between the age of the child, seriousness of the abuse, or duration of the abuse and the development of PTSD. Many children who did not meet full criteria met partial criteria for PTSD. Of the entire sample, 86.5% demonstrated one or more symptoms or reexperiencing behaviors, 52.4% demonstrated three or more avoidant behaviors, and 72.0% demonstrated two or more symptoms of autonomic hyperarousal. Standardized instruments were useful in identifying non-PTSD related symptoms. Forty of the 68 children (58.8%) evaluated by the CDI scored 12 or higher, a score indicative of clinical depression. Twenty-nine of the 88 children who were given the CBCL (33.0%) had a T score above 70 on the internalizing scale, whereas 25 (28.4%) scored above 70 on the externalizing scale of the CBCL, and 16.7% of the children were one standard deviation above the normative mean of the R-CMAS. The two Harter scales had 21.4% of the total sample on the HPCS, 23.1% on the HSSS Parent and Friend subscales, and 11.5% on the HSSS classmate and teacher subscale who scored one standard deviation below the normative means. Only one instrument, the CBCL, was useful in differentiating PTSD children from the others with significant differences found between groups on the mean T scores for the internalizing (t76 = -2.61, p < 0.011) and externalizing t76 -2.85, P < 0.006) subscales of the CBCL (PTSD children exhibiting higher externalizing and internalizing scores). A trend was found on the CDI (t59 = -1.74, p < 0.087) with children suffering from PTSD having higher depression scores. PTSD and non-PTSD childrens' scores on the self-report measures of anxiety, selfesteem, perceived competency, and social support did not differ significantly. Utilizing the Duncan Post-hoc Procedure, the mean scores for the study population of sexually abused children were compared with the published mean scores for the standardized rating scales for both clinical and nonclinical populations. Again, only those children whose ages were appropriate for the individual scales were included in the analysis. On the CBCL, it was necessary to compare published norms for sexually abused boys independent of the sexually abused girls. Sexually abused boys, both with and without PTSD, were found to differ significantly (p < 0.05) from the nonclinical population on both the internalizing and externalizing subscales. Additionally, the sexually abused boys with PTSD had significantly higher mean scores than all other groups on the externalizing subscale. This included both the nonclinical and clinical populations as well as the non-PTSD group of sexually abused boys (p < 0.05). Among girls, sexually abused girls differed significantly on both the externalizing and internalizing subscales from the nonclinical population (p < 0.05). Sexually abused girls with PTSD J. Am. Acad. Child Adolesc. Psychiatry, 31:5, September 1992
POST-TRAUMATIC STRESS AFTER SEX ABUSE TABLE
1. Relationship between Abuser Characteristics and Frequency of PTSD in Sexually Abused Children Abuser N
Non-PTSD PTSD Total
18 21 39
Stranger
Trusted Adult
Father %
46.2 53.8 100
N
19 14 33
additionally had significantly higher means than both sexually abused girls without PTSD and the total population of sexually abused children (p < 0.05). There was no significant difference between sexually abused children with PTSD and the norms for the clinical population on both the internalizing and externalizing subscale of CBCL; however, the clinical population means were significantly higher than that for the total population of sexually abused children and the nonPTSD population (p < 0.05). On the cm, both the sexually abused children with and without PTSD had higher mean scores than that published for normative population with the PTSD group having higher mean scores than the non-PTSD group (p < 0.05). No significant differences were found between the published means for the normative populations and the study population on both the RCMAS scale and the STAIC scale. Among the 27 children who were administered the K-SADS-E, the predominant current diagnosis was PTSD (44.4%; 12/27) followed by attention deficit disorder with hyperactivity (33.3%; 9/27), conduct disorder (25.9%; 7/27), simple phobias and oppositional disorders (7.4%; 2/ 27 for each), and dysthymia and overanxious disorders (3.7%; 1/27 for each). Three children had no diagnosis. Several met criteria for more than one diagnosis. Discussion Although this study replicates our earlier finding that PTSD is common among clinically referred children who have been sexually abused, and all children in this study were referred for evaluation subsequent to being sexually abused, it is still possible, and, in fact probable, that the subjects reflect a subpopulation of sexually abused children who may be more symptomatic than others since the Diagnostic and Treatment Center is viewed as a facility within the community that can help with difficult cases. Consequently, because of the probable subject recruitment bias of this study we still do not know how prevalent the disorder is among nonclinically referred sexually abused children and adult survivors of child sexual abuse. Additionally, no studies have been done to date that delineate the natural history of PTSD in childhood and so, we do not know how many of the children who develop PTSD acutely after a trauma will spontaneously remit or how will develop a more chronic clinical pattern. The finding that 53.8% of children abused by natural fathers and 42.4% of those abused by trusted adults suffer from PTSD irrespective of the time lapse since the last abusive episode, underscores the need for further research on risk factors for the development and persistence of PTSD J. Am. Acad. Child Adolesc. Psychiatry, 31:5, September 1992
%
57.6 42.4 100
Older Child
N
%
N
%
9 1 10
90 10 100
a
9
100
9
100
a
in childhood. The lack of correlation between PTSD and the seriousness of the abuse may well reflect the fact that most subjects were classified as having been seriously or very seriously abused; hence, recipients of a narrow spectrum of seriously abusive behaviors. Consequently, the range of abusive behaviors was not sufficiently large for differences to be detected. The relationship of the duration of abuse to PTSD requires a larger study since the relationship of the abuser to the child is confounded by duration. The number of children meeting partial criteria for PTSD was extremely high with 86.5% of the sample demonstrating one or more symptoms of reexperiencing behaviors, 52.4% with three or more avoidant behaviors, and 72.0% with two or more symptoms of autonomic hyperreactivity. These findings could be indicative of several possibilities all of which need exploration in a study of the natural history of PTSD. For example, (1) greater numbers of children may develop PTSD immediately following the abusive incident with a certain percentage remitting, or partially remitting, across time; (2) the stress response to sexual abuse may be reflective of a spectrum of clinical symptoms differing in severity and frequency with many children never developing full blown PTSD and some never developing post-traumatic stress symptoms at all; (3) the number and patterns of symptoms may vary across time, hence, shifting the ratio of reexperiencing symptoms, avoidant symptoms, and symptoms of autonomic arousal; and (4) some children for a variety of reasons, both psychological and biological, respond differently than others with some having more reexperiencing symptoms and other more avoidant symptoms. Hence, one would see a qualitatively different symptom picture emerging and remaining consistent or perhaps varying across time depending on the interaction of the stressor with premorbid factors. In comparing sexually abused children with PTSD with CBCL norms, both boys and girls on the externalizing and internalizing sub scale demonstrated no differences when compared to clinical populations of children with the one exception that for boys, the mean score on the externalizing subscale was significantly higher (p < 0.05). This is indicative of the severity of symptomatology in PTSD and underscores how behaviorally disruptive the disorder is, particularly among boys. On both the CBCL and cm, the total sample of sexually abused children were found to have higher means than the normative populations (nonclinical) and indistinguishable from clinical populations with the one exception noted above. The significance of these findings is unclear because it is highly likely that the clinically referred study population
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MCLEER ET AL.
of sexually abused children reflects a sampling bias caused by agencies referring many of their most symptomatic and disturbed sexually abused children. Final determination of the unique contribution of sexual abuse to symptom development as well as the development of psychiatric disorder, must await a larger study with nonclinical populations of sexually abused children compared to appropriate groups of nonabused, nonclinically referred children as well as those referred for outpatient psychiatric evaluation. PTSD appears to be a serious psychiatric disorder fueled by both psychological and biological factors (Giller, 1990) with a full blown disorder being resistant to many of the treatments currently being utilized in many child sexual abuse programs. Therefore, it becomes important to understand what premorbid factors contribute to the development of severe and persistent symptoms; what factors are protective and contribute to a minimized stress response with either spontaneous remission or a lack of development of the fullblown picture of PTSD. Questions needing further study include: does PTSD have a natural history and pattern of evolution that is consistent across individuals or do individuals differ regarding the clinical form which the post-traumatic stress response takes? If the stress response differs across individuals, are different treatments indicated depending on the symptom patterns which evolve? Because of the psychobiological complexities of PTSD, in addition to the research that has already been directed toward the relationship between symptom severity and certain abuse related variables, attention also needs to be directed toward nonabused variables such as comorbid and premorbid psychiatric disorders, family psychiatric history, and temperament (including the reactivity of the autonomic nervous system). Obviously, psychological and social factors relating to family stability and parental support, other traumatic events that the child has experienced in his/her life such as domestic violence or death of a parent, and a variety of environmental changes that may occur subsequent to the disclosure of the abuse need to be examined as well. The finding among the subsample of 27 children who were administered the K-SADS-E also reflects that PTSD is a common finding, with 44.4% of the children meeting criteria for current PTSD. Both the PTSD rating scale and the K-SADS-E identified the same children as having this disorder, indicating that both instruments appear to be sensitive to identifying children suffering from this disorder. The advantage of using the K-SADS-E, however, is that it allows a semistructured format for detecting other Axis I disorders that may coexist with PTSD. While the distribution of the most prevalent disorders after PTSD is similar to that which we would expect in a psychiatric outpatient population, the sample of sexually abused children have a higher percentage of females presenting for care. Consequently, the finding that attention deficit disorder is the second most frequent diagnosis is an interesting finding since it is a disorder that tends to be more prevalent among boys. However, the examination of what diagnoses are most frequently found among sexually abused children as compared to an outpatient population of psychiatrically referred children and the relation-
878
ship of comorbid disorders to PTSD symptom severity must await further study with adequate comparison groups. Summary
PTSD was once thought to be an outcome following only severe man-made or natural disasters, hence, affecting small numbers of children. With sexually abused children being at high risk for PTSD, it becomes clear that PTSD may, in fact, be a much more prevalent disorder of childhood than was once thought. Further research on children at risk and on the development of effective treatments is a matter of great urgency.
References Achenbach, T. M. & Edelbrock, C. (1983), Manual for the Child Behavior Checklist and Revised Child Behavior Profile, Burlington, Vermont: University of Vermont, Department of Psychiatry. American Psychiatric Association (1987), Diagnostic and Statistical Manual ofMental Disorders, 3rd edition-revised DSM-IIl-R. Washington, DC: American Psychiatric Association. Armsworth, M. W. (1984), Post Traumatic Stress Responses in Women Who Experienced Incest as Children or Adolescents. Ann Arbor, Michigan: University Microfilms International. Blaufarb, H. & Levine, J. (1972), Crisis intervention in an earthquake. Social Work, 17:16-19. Deblinger, E. B., McLeer, S. V., Atkins, M., Ralphe, D. & Foa, E. (1989), Post-traumatic stress disorder in sexually abused, physically abused and non-abused children. International Journal of Child Abuse and Neglect. 13(3):403-408. Fox, S. S. & Scherl, D. 1. (1972), Crisis intervention with victims of rape. Social Work, 17:37-42. Galante, R. & Foa, D. (1982), Epidemiological Study of Psychic
Trauma and Treatment Plan for Children After a Natural Disaster. Presented at the 10th International Congress for the International Association for Child and Adolescent Psychiatry and Allied Profession. Dublin, Ireland (July). Giller, E. L. (1990), Biological Assessment and Treatment of PostTraumatic Stress Disorder. Washington, DC: American Psychiattic Association. GIeser, G. C., Green, B. L. & Winget, C. (1981), Prolonged Psychosocial Effects of Disaster: A Study of Buffalo Creek. New York: Academic Press. Green, A. H. (1983). Child abuse: dimension of psychological trauma in abused children. J. Am. Acad. Child Psychiatry, 22(3):231-237. Harter, S. (1985), Manualfor the Self-Perception Profile for Children. Denver, Colorado: University of Denver Press. Lacey, G. N. (1972), Observations on Aberfam. J. Psychosom. Res., 16:257-260. Malmquist, C. P. (1986), Children who witnessed parental murder: post-traumatic and legal issues. J. Am. Acad. Child Psychiatry, 25:320-325. McFarlane, A. C. (1987), Post-traumatic phenomena in a longitudinal study of children following a natural disaster. J. Am. Acad. Child Adolesc. Psychiatry, 26(5):764-769. McLeer, S. V., Deblinger, E., Atkins, M. S., et al. (1988), Posttraumatic stress disorder in sexually abused children. J. Am. Acad. Child Adolesc. Psychiatry, 27(5):650-654. Orvaschel, H., Weisman, M. M., Padier, W. & Lowe, T. (1981). Assessing psychopathology in children of psychiatrically disturbed parents: a pilot study. J. Am. Acad. Child Adolesc. Psychiatry, 20:112-122. Orvaschel, H., Puig-Antich, J., Chambers, W., Tabrizi, M. A. & Johnson, R. (1982), Retrospective assessment of child psychopathology with the Kiddie-SADS-E. J. Am. Acad. Child Adolesc. Psychiatry, 21 :392-397. Pynoos, R. S. & Eth, S. (1984), The child as witness to homicide. Journal of Social Issues, 40:87-108. Pynoos, R. S., Gilman, K. & Shapiro, T. (1981), Children's response to parental suicide behavior. Presented at the Annual Meeting of
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the American Academy of Child Psychiatry, October 14-18, Dallas, Texas. Reynolds, C. R. & Richmond, B. O. (1978), What I think and feel: a revised measure of children's manifest anxiety. J. Abnorm. Child Psychol., 6:271-280. Russell, D. (1983), The incidence and prevalence of intrafamilial and extrafamilial sexual abuse of female children. Child Abuse and Neglect, 7: 133-146. Speilberger, C. D. (1973), Preliminary Manual for the State-Trait Anxiety Inventory for Children. Palo Alto, CA: Consulting Psychologists.
Terr, L. C. (1979), Children of Chowchilla: a study of psychic trauma. Psychoanal. Study Child, 34:552-623. Terr, L. C. (1981), Psychic trauma in children: observations following the Chowchilla school bus kidnapping. Am. J. Psychiatry, 138:1419. Terr, L. C. (1983), Chowchilla revisited: the effects of psychic trauma four years after a school bus kidnapping. Am. J. Psychiatry, 140:1543-1550.
From Pediatrics Identification and Management of Psychosocial and Developmental Problems in Community-Based, Primary Care Pediatric Practices. Sarah McCue Horwitz, Ph.D., Philip 1. Leaf, Ph.D., John M. Leventhal, M.D., Brian Forsyth, M.B.Ch.B., and Kathy Nixon Speechley, Ph.D. Abstract. The importance of psychological and social issues for children's well-being has long been recognized and their importance in the practice of pediatrics is well documented. However, many of the studies looking at this issue have emphasized psychiatric problems rather than issues commonly referred to as the new morbidity. The goal of this research was to refocus interest on the problems of the new morbidity. The study examined the rates and predictors of psychological problems in 19 of 23 randomly chose pediatric practices in the greater New Haven area. Families of all 4- to 8-year-old children were invited to partricipate and to complete the Child Behavior Checklist prior to seeing a clinician. Clinicians completed a 13-category checklist of psychosocial and developmental problems based on a World Health Organizationsponsored primary care, child-oriented classification system. Of the 2006 eligible families, 1886 (94%) participated. Clinicians identified at least one psychosocial or developmental problem in 515 children (27.3%). Thirty-one percent of the children with problems received no active intervention, 40% received intervention by the clinician, and 16% were referred to specialty services. Not surprisingly, children whose problems were rated as moderate or severe were twice as likely to be referred compared with children with mild problems. Recognition of a problem was related to four characteristics: if the visit was for well child rather than acute care; if the clinician felt he or she knew a child well; if the child was male; and if the child had unmarried parents (all p ::; .05). The data suggest that, when asked to use a taxonomy appropriate for primary care, clinicians recognize problems in many 4- to 8-year-old children (515/1886; 27.3%). This rate is considerably higher than the rates previously reported. Further, many children with identified problems (56%) were reported by their clinicians to receive some form of active intervention. Characteristics of the visit (type of visit, clinician's knowledge of a child) that influence the recognition of problems were also identified. These results suggest that investigators must define what types of problems they are interested in and under what circumstances to determine accurately what pediatric practitioners know about psychosocial and developmental problems in their young patients and families. Pediatrics 1992;89480-485.
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