The British Journal of Psychiatry (2008)

193, 378382. doi: 10.1192/bjp.bp.108.049536

Associations between childhood trauma, bullying

and psychotic symptoms among a school-based
adolescent sample
Ian Kelleher, Michelle Harley, Fionnuala Lynch, Louise Arseneault, Carol Fitzpatrick and Mary Cannon
Background
Children and adolescents who report psychotic symptoms
appear to be at increased risk for psychotic disorders in
adulthood a putative symptomatic high-risk group.
However, little research has investigated whether those in
this high-risk population have increased rates of exposure to
traumatic events in childhood, as seen in patients who have
a psychotic illness.
Aims
To examine whether adolescents with psychotic symptoms
have an increased rate of traumatic experiences.
Method
Psychiatric interviews were carried out with 211 adolescents
aged between 12 and 15 years and their parents as part of a
population-based study. The interview enquired about a
number of early traumatic events including physical and
sexual abuse, exposure to domestic violence and bullying.

A proposed causal association between childhood trauma and

later psychosis has raised much debate within the psychiatric
literature over recent years.16 With some notable exceptions,5,6
the literature to date has been open to the risk of recall bias as most
studies were based on treatment samples and used retrospective
assessment of trauma. Although a number of studies indicate that
individuals with psychotic disorders are no less likely to be
accurate in recalling abusive experiences than the general
population,7,8 some researchers still voice reliability concerns.2
One solution to this methodological problem is to examine the
association between childhood trauma and psychosis in a
population-based sample of people who have not yet had contact
with the mental health services. The account of trauma is therefore
unbiased by diagnosed outcome. We analysed data from a
population-based sample of adolescents recruited from schools
in Dublin, Ireland, to investigate whether there was an association
between childhood traumatic experiences and the presence of
psychotic symptoms. Research on long-term outcomes suggests
there are increased rates of adult psychotic illness among
adolescents reporting psychotic symptoms.9 Therefore,
adolescents who report psychotic symptoms can be conceptualised
as a high-risk group for psychotic illness and this paradigm can
be used to explore early risk factors for psychosis vulnerability. We
wished to examine a range of traumatic experiences among such a
cohort to investigate the relationship between psychotic symptoms
in adolescence and childhood trauma.

Method
Participants
The Challenging Times study10,11 was established to investigate the
prevalence of psychiatric disorders among Irish adolescents aged

378

Results
Fourteen adolescents (6.6% of those interviewed) reported
experiencing at least one psychotic symptom. Adolescents
who reported psychotic symptoms were significantly more
likely to have been physically abused in childhood, to have
been exposed to domestic violence and to be identified as a
bully/victim (that is, both a perpetrator and victim of bullying)
than those who did not report such symptoms. These
findings were not confounded by comorbid psychiatric illness
or family history of psychiatric history.
Conclusions
Our findings suggest that childhood trauma may increase the
risk of psychotic experiences. The characteristics of bully/
victims deserve further study.
Declaration of interest
None. Funding detailed in Acknowledgements.

1215 years. The study was carried out in the geographical

catchment area of a child and adolescent mental health team in
North Dublin with a population of 137 000. After describing the
study to participants, written informed consent was obtained
from their parent or guardian. In brief, 743 pupils (52% of the
total school population in that area) were screened for psychiatric
symptoms using the Strengths and Difficulties Questionnaire12,13
and the Childrens Depression Inventory.14 Eight primary schools
were selected using a stratified random sampling technique,
stratified in order to approximate the socio-economic profile of
the geographical area population. Overall, 140 adolescents scored
above threshold on these instruments, indicating high risk of
having mental health problems. Of these, 117 (84%) agreed to
attend a full psychiatric interview. A comparison group of 173
adolescents, matched for gender and school were also invited to
attend, of whom 94 (54%) agreed.
Ethical approval for the study was granted by the medical
ethics committee of the Mater Misericordiae University Hospital,
Dublin, Ireland. The study was supported by the multidisciplinary
child and adolescent mental health team covering the geographical
area. The protocol ensured that any child who was deemed to be
in need of a clinical service could be referred to the team.
Interview instrument
The interview schedule used in this study was the Schedule for
Affective Disorders and Schizophrenia for School-Aged Children,
Present and Lifetime Versions (KSADS).15 The KSADS is a wellvalidated, semi-structured research diagnostic interview for the
assessment of all Axis 1 psychiatric disorders in children and
adolescents. Children and parents were interviewed separately,
both answering the same questions. Interviews were conducted
by two psychologists and one psychiatrist who were trained in

Childhood trauma and psychotic symptoms

the use of the KSADS. Interrater reliability for the KSADS was
estimated as 490% in this study.11
Exposure measurement
As part of the KSADS interview the following childhood
traumatic experiences were assessed. Interviews were conducted
with parents and children separately.
Childhood abuse

Both child physical and sexual abuse were assessed as part of the
KSADS interview. Children were asked the following questions in
relation to physical abuse: When your parents got mad at you, did
they hit you? Have you ever been hit so that you had bruises or
marks on your body, or were hurt in some way? What happened?
They were asked the following questions in relation to sexual
abuse: Did anyone ever touch you in your private parts when they
shouldnt have? What happened? Has someone ever touched you
in a way that made you feel bad?.
Parents were asked the same questions appropriately modified.
A disclosure of physical or sexual abuse from the parent was taken
as evidence of a history of child abuse, regardless of whether it was
also disclosed by the child. There were no cases where the parent
disputed the occurrence of abuse that had been disclosed by the
child.
Domestic violence

Exposure to domestic violence was assessed in the post-traumatic

stress disorder section: Some kids parents have a lot of nasty
fights. They call each other bad names, throw things, and threaten
to do bad things to each other. Did your parents ever get in really
bad fights? Tell me about the worst fight you remember your
parents having. What happened?. Again, parents were asked the
same questions, appropriately modified. A disclosure of physical
violence between parents/step-parents from the parent was taken
as evidence of a history of domestic violence. There were no cases
where the parent disputed the occurrence of domestic violence
that had been disclosed by the child.
Bullying

Bullying was assessed as part of the KSADS Social Relations

section; parents and children were specifically asked: Have you
ever been bullied? and Have you ever been accused of being a
bully?. A positive response from either the parent or child was
taken as evidence of a history of being a bully or being a victim
of bullying. The victim of bullying group included all those
who responded positively to being bullied (regardless of whether
they were also perpetrators of bullying). The perpetrator of
bullying group included all those who responded positively to
being bullies (regardless of whether they were also victims of
bullying).
Outcome measures
The Psychosis section of the KSADS asks about the childs
experience of hallucinations and delusions. Screen questions are
detailed in the Appendix. Responses to these questions were
recorded on the interview sheet. Three psychiatrists (M.H., F.L.
and M.C.) and one psychologist (I.K.) examined these responses
and concurred that the symptoms seemed genuine in content.
All psychotic experiences were reported by the child. In no case
did the parents report such symptoms in their child.

Socio-economic status and family history

of psychiatric illness
Socio-economic status of each participant was determined using
parental occupation assessed according to the Irish Social Class
Scale.16 We divided the sample into two major groups according
to social class: the first group contained socio-economic status
groups 1 and 2 (professional/managerial) and the second group
contained groups 37: (non-manual skilled, skilled manual,
semi-skilled manual, unskilled manual and unemployed). The
KSADS interview includes a routine screening section for family
history of psychiatric illness, which was used in the present study.
Statistical analysis
First, we used chi-squared tests to compare the socio-demographic
and clinical characteristics of adolescents reporting psychotic
symptoms with adolescents who did not report such symptoms.
Second, we used logistic regression analyses to examine the
association between the outcome measure, experiencing psychotic
symptoms, and the exposures: child physical and sexual abuse,
exposure to domestic violence and bullying (victimisation or
perpetration). We report univariate associations in terms of odds
ratios, along with 95% confidence intervals (95% CI) and
P-values, adjusted for gender and socio-economic status. Third,
in order to control for the effect of comorbid psychiatric illness,
we used a regression analysis stratified by the presence of
psychiatric disorder. All analyses were carried out using STATA
version 8.2 for Windows.
Results
Of the 211 children interviewed, 83 (39%) received a DSMIV17
Axis 1 diagnosis following KSADS interview. The most common
disorders diagnosed were depressive disorders. No participants
received a formal diagnosis of a psychotic illness. Fourteen
participants (6.6%) reported experiencing psychotic symptoms,
primarily auditory and visual hallucinatory experiences.
Adolescents who reported psychotic symptoms were significantly
more likely to receive an Axis 1 psychiatric diagnosis than were
adolescents who reported no such symptoms (71.4% v. 37.1%;
w2=5.4, d.f.=1, P=0.02). Specifically, the diagnoses of the 14
adolescents who reported psychotic symptoms included eight
depressive disorders, two conduct disorders, two phobic disorders,
two attention-deficit hyperactivity disorders, and one each of
post-traumatic stress disorder, overanxious disorder, oppositional
defiant disorder, tic disorder and separation anxiety disorder.
Adolescents who reported psychotic symptoms were more
likely to be male (71.4%, psychotic symptoms group v. 45.2%,
comparison group; w2=3.3, d.f.=1, P=0.07), and from high
socio-economic groups (professional/managerial) (64.3% v.
38.1%; w2=3.5, d.f.=1, P=0.06) than the adolescents who did not
report any symptoms. There were no differences between the
groups for family history of psychiatric illness (w2=0.12, d.f.=1,
P=0.73).
Table 1 shows that adolescents reporting psychotic symptoms
were six times more likely to have experienced child physical abuse
than adolescents who did not report such symptoms and were ten
times more likely to have witnessed domestic violence in their
homes. These findings were statistically significant. Adolescents
who reported psychotic symptoms were four-times more likely
to have experienced child sexual abuse but, given the low absolute
numbers of those who reported sexual abuse (n=4), this difference
was not statistically significant. Adolescents with psychotic
symptoms were not significantly more likely to have been victims

379

Kelleher et al

Table 1 Associations between psychotic symptoms in adolescence and early life traumatic experiences in (A) the whole
sample ( n =211) and (B) just adolescents with a history of psychiatric disorder ( n =84) a
(A) Adolescents with (n=14) v. without (n=197)
psychotic symptoms
Trauma type

Odds ratio (95% CI)

(B) Adolescents with psychiatric disorder with (n=10)

v. without (n=74) psychotic symptoms
Odds ratio (95% CI)

Child physical abuse

5.96 (1.2727.97)

0.023

6.19 (1.0536.29)

0.040

Child sexual abuse

4.16 (0.3450.51)

0.260

5.39 (0.26111.17)

0.280

Exposure to domestic violence

10.06 (2.2046.01)

0.003

7.78 (1.4741.28)

0.016

History of being bullied (victim)

1.23 (0.403.83)

0.720

1.51 (0.385.92)

0.560

History of being a bully

9.90 (2.5139.05)

0.001

12.32 (2.4063.35)

0.003

a. All findings adjusted for gender and socio-economic status.

of bullying but were significantly more likely to be bullies than

adolescents who did not report such symptoms. Figure 1 shows
the percentages of participants in each group who experienced
the given traumatic events.
There was a high level of comorbidity between reported
psychotic symptoms and other childhood psychiatric disorder in
this sample. Therefore, we considered that the traumatic
experiences identified could be associated with general psychopathology rather than showing any specificity to psychotic
symptoms. To test this hypothesis, we carried out a further
analysis confined to those adolescents who received psychiatric
diagnoses following interview. The prevalence of childhood
traumatic experiences among adolescents with a diagnosed
psychiatric disorder who also displayed psychotic symptoms
(n=10) was compared with the prevalence among adolescents with
diagnosed psychiatric disorder who did not display psychotic
symptoms (n=73). Table 1 shows that the association between
psychotic symptoms and traumatic experiences remained statistically significant after controlling for psychiatric disorders.

Discussion
Our results show significant associations between psychotic
symptoms in early adolescence and reports of child physical abuse,
exposure to domestic violence and involvement in bullying. We
did not find a significant association with child sexual abuse but
the reported rate of sexual abuse in our sample as a whole was
No psychotic symptoms
Psychotic symptoms
Percentage reporting
traumatic experiences

40
35

*
*

30
25

Traumatic experiences and mechanisms of risk

for psychosis
Theories proposed to explain how exposure to childhood abuse
may increase the risk of psychotic symptoms have drawn on
findings that severe stress at a young age appears to result in
catecholamine deregulation and hypothalamicpituitaryadrenal
axis dysfunction.18 It has been shown that adult female victims
of child physical and sexual abuse demonstrate persistent sensitisation of the pituitaryadrenal and autonomic stress response.19
This process may create a diathesis that renders the individuals
mental health vulnerable to stress and may place them at greater
risk of future psychiatric illness, including psychosis.20,21
Although direct evidence is lacking, witnessing domestic
(interparental) violence may well invoke similar stress-induced
neurodevelopmental changes as those evidenced in victims of
childhood physical and sexual abuse. It is known that multiple
behavioural, emotional, social and psychological effects are
associated with childhood exposure to domestic violence.22,23 A
correlation between marital discord and child urinary dopamine
levels has also been reported,24 which may indicate a process of
dopamine sensitisation.25
Complementary theories suggest that the cognitive schema
formed as a result of traumatic experiences increase risk of
psychosis1. These are characterised by negative schematic models
of the self and the world. Abusive experiences, for example, may
teach the victim that people are dangerous, ultimately leading
to paranoid ideation and the appraisal of normal events as
threatening.2628

20
15

Bullying and psychosis

10
5

ic
tim

/v
lly
bu
or
lly

Bu

Vi
ct

es
m
Do

im

tic

of

vio

la
ua
se
x
ild
Ch

bu
lly
in

le
n

se
bu

us
e
ab
al
ic
ys
ph
ild
Ch

ce

Type of trauma

Fig. 1 Percentage of adolescents with and without psychotic

symptoms reporting traumatic experiences.
*P50.05.

380

low. There is an emerging literature on the association between

adverse childhood experiences and positive psychotic symptoms,
and this literature has focused mainly on child physical and sexual
abuse.1,2 We have extended these findings to exposure to domestic
violence and bullying, which have been rarely studied to date.4

In the context of our findings on child physical abuse and

exposure to domestic violence, our findings regarding bullying
were somewhat counterintuitive. We found that adolescents who
reported psychotic symptoms were not significantly more likely
to have been victims of bullying than the remainder of the sample.
This finding is contradictory to a number of studies that reported
a significant association between psychotic symptoms and being a
victim of bullying.29,30 There are a number of possible explanations for this discrepancy. First, there were high reported baseline
rates of bullying victimisation in our whole sample (34%), which
is likely to have reduced our ability to find an effect of victimisation. We did not have sufficient information on the nature of the

Childhood trauma and psychotic symptoms

victimisation experiences to allow subdivision by severity of victimisation. It is worth noting that, of those identified as bullies in
the psychotic symptom group, the majority (80%) were also
victims of bullying and would fit the definition of bully/victim
rather than the typical bully profile. In fact, children who fit the
definition of bully/victim appear to be at particularly high risk
of psychotic experiences, as 50% of the bully/victims in the study
reported psychotic symptoms. Research is beginning to address
the factors associated with bully/victim status.31,32 Compared with
pure victims, they tend to develop more pervasive and more
severe psychological and behavioural outcomes, even after
controlling for adjustment problems existing prior to the bully/
victim behaviours.32 Studies suggest that bully/victims come from
homes where the parents are less involved and more likely to be
hostile and rejecting.33
Physical abuse and exposure to domestic violence may be
common risk factors for both the development of psychotic
symptoms and the development of bullying behaviour. Children
who have witnessed domestic violence or who have been victims
of physical abuse may model their own behaviour on such acts
of aggression. It could also be hypothesised that underlying
genetic factors may influence antisocial and violent behaviour
both in the parents and in the child. However, we found no
significant relationship between being a bully and experiencing
physical abuse and/or domestic violence. More research is needed
to clarify what role bullying behaviour may play in the
development of psychotic symptoms.
Strengths and limitations
This study has a number of strengths. First, it was populationbased and all participants were attending mainstream schools.
The detailed clinical interviews provided a comprehensive
evaluation of the prevalence of experiences of trauma. Second,
parents were interviewed in every instance and this collateral
information was particularly valuable regarding child abuse and
exposure to domestic violence. Parents, when reporting traumas,
were unaware that their offspring had reported psychotic
symptoms. Furthermore, most studies on psychosis that have
investigated child abuse have been conducted with adults. There
is, therefore, a significant intervening time period between the
abuse events and assessment of these events. In our study the
assessment is much closer to the time of abuse events. All of these
factors reduce the possibility of recall bias, which has been
identified as a significant problem in the literature to date.2
One limitation is that the Challenging Times study was not
designed specifically to identify psychotic symptoms. This may
have resulted in less sensitivity in detecting weaker symptoms with
an underestimation of symptom prevalence in this sample.
Another important limitation is the cross-sectional nature of the
study. Our ability to draw causal conclusions between traumatic
experiences and psychotic symptoms is limited by a lack of clear
temporal information. If psychotic symptoms preceded trauma
in only a couple of the cases this would have serious implications
since the numbers with psychotic symptoms is small. However,
our data from parental interviews show that exposure to domestic
violence, at least, occurred from a very young age, typically less
than 5 years old.
The questions on sexual abuse in the interview instrument
involve a somewhat narrow definition of abuse and the ambiguity
of these questions may partially explain the low sexual abuse rates
reported in this study. One study, based on self-report questionnaires, has suggested that sexual abuse (or, more specifically,
unwanted sexual experiences) is, in fact, more common among
adolescents who report having experienced psychotic symptoms.30

Although the present study was population based, it does not

represent a true population cohort since one of the two groups
was selected for being at risk of psychiatric problems, based on
screening measures. However, we have controlled for psychiatric
disorders in our analysis. There was also a higher than expected
refusal rate among the comparison group. Although the overall
sample size was large, there were small numbers with the
symptoms of interest and with the experiences of interest
(particularly sexual abuse). For these reasons, replication of our
findings is warranted.
Early life traumatic events and psychosis
Clearly not all individuals who experience severely traumatic
events in childhood go on to develop a psychotic disorder. Disease
causation is a dynamic process and should be considered in terms
of a pathway over a life course rather than in terms of a certain set
of risk factors at a point in time.34 Other environmental risk
factors for schizophrenia, such as obstetric complications,35
urbanicity36 or cannabis use,37 may have cumulative or interactive
effects on psychosis risk. None the less, this paper adds to the
evidence that traumatic childhood events may be part of a cascade
that leads to the development of psychotic symptoms and may
ultimately contribute to the onset of psychotic illness.
Ian Kelleher, MSc, Department of Psychiatry, Royal College of Surgeons in Ireland,
Dublin, Ireland; Michelle Harley, MB, MRCPsych, Department of Psychiatry, Royal
College of Surgeons in Ireland, and Child and Adolescent Mental Health Service,
Mater Misericordiae University Hospital, Dublin, Ireland; Fionnuala Lynch, MB, MD,
MRCPsych, MSc, Child and Adolescent Mental Health Service, Mater Misericordiae
University Hospital, and University College Dublin, Ireland; Louise Arseneault, PhD,
Medical Research Council Social, Genetic and Developmental Psychiatry Centre,
Institute of Psychiatry, Kings College London, UK; Carol Fitzpatrick, MD, FRCPI,
FRCPsych, Child and Adolescent Mental Health Service, Mater Misericordiae
University Hospital, The Childrens University Hospital Temple St, and University
College Dublin, Ireland; Mary Cannon, MB, PhD, MRCPsych, Department of
Psychiatry, Royal College of Surgeons in Ireland and Beaumont Hospital, Dublin,
Ireland.
Correspondence: Professor Mary Cannon, Department of Psychiatry, Royal
College of Surgeons in Ireland, Education and Research Centre, Beaumont
Hospital, Dublin 9, Ireland. Email: [email protected]
First received 9 Jan 2008, final revision 4 Jul 2008, accepted 24 Jul 2008

Acknowledgements
This work was supported by a Clinician Scientist Award to M.C. (CSA/2004/1) from the
Health Research Board (Ireland). L.A. is supported by a Career Scientist Award from the
Department of Health (UK). We thank Ms Carla Mills and Ms Irene Daly for their roles in
conducting clinical interviews for this study. The original Challenging Times study was
funded by Friends of the Childrens University Hospital (Dublin), the American Foundation
for Suicide Prevention, HSE Northern Area and the Mater Misericordiae University Hospital.

Appendix
KSADS Psychosis section15 (reprinted with
permission)
Hallucinations:
Sometimes children, when they are alone, hear voices or see things, or
smell things and they dont quite know where they come from. Has this
ever happened to you? Tell me about it.
Has there ever been a time you heard voices when you were alone? What
did you hear?
Have you ever heard someone call your name when there was no one
around?
What kind of things did you hear?
Did you ever hear music which other people could not?
Has there ever been a time when you saw things that were not there?
What about shadows or other objects moving?
Did you ever see ghosts? When?

381

Kelleher et al

Did this only happen at night while you were trying to sleep, or did it
happen in the daytime too? What did you see?
Has there ever been a time when you had an unusual smell about
yourself?

Delusions
Do you know what imagination is? Tell me.
Has there ever been a time your imagination played tricks on you?
What kinds of tricks? Tell me more about them.
Did you have any ideas about things that you didnt tell anyone because
you are afraid they might not understand? What were they?
Did you believe in things that other people didnt believe in? Like what?

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Associations between childhood trauma, bullying and psychotic

symptoms among a school-based adolescent sample

Ian Kelleher, Michelle Harley, Fionnuala Lynch, Louise Arseneault, Carol Fitzpatrick and Mary Cannon
BJP 2008, 193:378-382.
Access the most recent version at DOI: 10.1192/bjp.bp.108.049536

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