Child Dissociative Checklist Packet-1

CHILD DISSOCIATIVE CHECKLIST
(V3.0 – 2/90)
Frank W. Putnam, M.D.
Unit on Dissociative Disorders, LDP, NIMH
Date: ________ Age: ________ Sex: M F Identification: ________
Below is a list of behaviors that describe children. For each item that describes your child NOW
or WITHIN THE PAST 12 MONTHS, please circle 2 if the item is VERY TRUE of your
child. Circle 1 if the time is SOMEWHAT or SOMETIMES TRUE of your child. If the item
is NOT TRUE of your child, circle 0.
0 1 2 1. Child does not remember or denies traumatic or painful experiences that are
known to have occurred.
0 1 2 2. Child goes into a daze or trance-like state at times or often appears “spaced-
out”. Teachers may report that he or she ‘daydreams’ frequently in school.
0 1 2 3. Child shows rapid changes in personality. He or she may go from being shy to
being outgoing, from feminine to masculine, from timid too aggressive.
0 1 2 4. Child is unusually forgetful or confused about things that he or she should

know, e.g. may forget the names of friends, teachers or other important people,
loses possessions or gets lost easily.
0 1 2 5. Child has a very poor sense of time. He or she loses track of time, many think
that it is morning when it is actually afternoon, gets confused about what day it is,
or becomes confused about when something happened.
0 1 2 6. Child shows marked day-to-day or even hour-to-hour variations in his or her

skills, knowledge, food preferences, athletic abilities, e.g. changes in handwriting,
memory for previously learned information such as multiplication tables, spelling,
use of tools or artistic ability.
0 1 2 7. Child shows rapid regressions in age-level of behavior, e.g. a twelve year-old

starts to use baby-talk, sucks thumb or draws like a four year-old.
0 1 2 8. Child has a difficult time learning from experience, e.g. explanations, normal
discipline or punishment do not change his or her behavior.
0 1 2 9. Child continues to lie or deny misbehavior even when the evidence is obvious.
0 1 2 10. Child refers to him or herself in the third person (e.g. as she or her) when
talking about self, or at times insists on being called by a different name. He or
she may also claim that things that he or she did actually happened to another
person.
0 1 2 11. Child has rapidly changing physical complaints such as headache or upset
stomach. For example, he or she may complain of a headache one minute and
seem to forget all about it the next.
0 1 2 12. Child is unusually sexually precocious and may attempt age-inappropriate

sexual behavior with other children or adults.
0 1 2 13. Child suffers from unexplained injuries or may even deliberately injure self at
times.
0 1 2 14. Child reports hearing voices that talk to him or her. The voices may be
friendly or angry and may come from “imaginary companions” or sound like the
voices of parents, friends or teachers.
0 1 2 15. Child has a vivid imaginary companion or companions. Child may insist
that the imaginary companion(s) is responsible for things that he or she has done.
0 1 2 16. Child has intense outbursts of anger, often without apparent cause and may
display unusual physical strength during these episodes.
0 1 2 17. Child sleepwalks frequently.
0 1 2 18. Child has unusual nighttime experiences, e.g. may report seeing “ghosts” or
that things happen at night that he or she can’t account for (e.g. broken toys,
unexplained injuries.)
0 1 2 19. Child frequently talks to him or herself, may use a different voice or argue
with self at times.
0 1 2 20. Child has two or more distinct and separate personalities that take control
over the child’s behavior.
Journal of Child Sexual Abuse, 18:93–102, 2009
Copyright © Taylor & Francis Group, LLC
ISSN: 1053-8712 print/1547-0679 online
DOI: 10.1080/10538710802584643
MEASUREMENT ISSUES
1547-0679
1053-8712
WCSA
Journal of Child Sexual Abuse,
Abuse Vol. 18, No. 1, December 2008: pp. 1–16
Pathological Dissociation as Measured

by the Child Dissociative Checklist
JEFFREY N. WHERRY, DEBRA A. NEIL, and TAMARA N. TAYLOR

Pathological
J. Dissociation
N. Wherry et al.
Abilene Christian University, Abilene, Texas, USA

Downloaded By: [EBSCOHost EJS Content Distribution] At: 19:23 8 June 2009
The component structure of the Child Dissociative Checklist was

examined among abused children. A factor described as patholog-
ical dissociation emerged that was predicted by participants being
male. There also were differences in pathological dissociation
between groups of sexually abused and physically abused chil-
dren. Replication of this factor and the establishment of base rates
for various groups of children are recommended so that the Child
Dissociative Checklist might be used to more effectively eliminate
false positives and increase true positives in the screening and
ultimate treatment of dissociative children.
KEYWORDS child abuse, dissociation, assessment, diagnosis
Dissociation has been described by Putnam, Helmers, and Trickett (1993) as

a psychophysiological process occurring along a continuum from minor
normative dissociations (e.g., daydreaming) to psychiatric conditions such
as dissociative identity disorder (DID). Studies of patients with dissociative
disorders yield a high percentage of cases (85–100%) with reported
traumatic childhoods (Coons, Bowman, & Milstein, 1988; Putnam, Guroff,
Silberman, Barban, & Post, 1986) and child abuse (Chu & Dill, 1990). More-
over, dissociation is significantly correlated with severity of trauma, with the
magnitude of correlations ranging from approximately .25 to .45 (Anderson,
Received 26 September 2006; revised 17 January 2007; accepted 6 May 2008.

This research was supported by grant number 5-R01-MH48784-04 awarded to Roscoe
Dykman, PhD, from the National Institute of Mental Health.
Address correspondence to Jeffrey N. Wherry, Human Development and Family Studies,
Box 41230, Texas Tech University, Lubbock, TX 79409-1230. E-mail: [email protected]
93
94 J. N. Wherry et al.
Yasenik, & Ross, 1993; Branscomb, 1991; Carlson & Rosser-Hogan, 1991;
Chu & Dill, 1990; Kirby, Chu, & Dill, 1993; Sandberg & Lynn, 1992).
As noted, dissociation appears related to the severity of trauma, but it
also is predicted by age, gender, duration, and the nature of the sexual
abuse. That is, dissociation as measured by the Child Dissociative Checklist
(CDC; Bernstein & Putnam, 1986) and the Trauma Symptom Checklist for
Children (TSCC; Briere, 1996) was predicted by being older, being female,
by abuse occurring over a longer period of time, and the nature/severity of
sexual abuse (Friedrich, Jaworski, Huxsahl, & Bengston, 1997). Confirma-
tion of dissociative symptomatology in a child client is relatively uncommon
(Kluft, 1984, 1985; Putnam, 1991; Vincent & Pickering, 1988) despite
acknowledgement that multiple personality disorder (MPD) or DID often
originate in childhood. In fact, less than 3% of the diagnoses of a dissocia-
tive disorder are made in children under 12, and less than 8% are made in
adolescents between the ages of 12 and 19 (Kluft, 1984).
Putnam (1997) reviewed two models for understanding both normal
and pathological dissociation. The continuum model holds that dissociation
is a normally distributed spectrum of experiences and behaviors. In
contrast, the taxon model posits that normal and pathological dissociation
are of a different type. Specifically, pathological dissociation involves expe-
riences rarely or never experienced by normal people. Putnam also
suggested that normal and pathological dissociation predict developmental
trajectories that are fundamentally different.
Pathological dissociation is characterized by disruptions in the sense of
identity and disturbances of memory (Nemiah, 1980). Similarly, Putnam
(1997) describes pathological dissociation as a disturbance in the integrative
functions of identity, memory, and consciousness. Dorahy, Lewis, Millar,
and Gee (2003) also note that pathological or nonnormative dissociation
includes amnesia and depersonalization, where nonpathological dissocia-
tion is represented by constructs like imaginative involvement and absorp-
tion. Waller and Ross (1997) studied the prevalence of pathological
dissociation in a large random sample of 1,055 adults and found that 3.3%
of the sample experienced pathological dissociation. Similarly, Maaranen
et al. (2005) found that 3.4% of a large stratified sample of adults in Finland
experienced pathological dissociation. Maaranen et al. also found that there
was a relationship between pathological dissociation and depression,
suicidality, and alexithymia.
Although pathological dissociation has received some attention in the
adult literature, its measurement among children is virtually nonexistent.
Measurement and recognition of pathological dissociation early in life
would be important because treatment of dissociation is much more
successful in childhood (Kluft, 1984). The CDC (Bernstein & Putnam, 1986)
has been developed as a screening measure to assess dissociative symptoms
in children according to parent reports. The purpose of the study was to
Pathological Dissociation 95
determine if children assessed by the CDC could be described as evidencing

a taxon described as pathological dissociation similar to that described for
and applied to adults. Moreover, this study aimed to examine whether
groups of abused children would differ in pathological dissociation based
on abuse status and whether pathological dissociation would be predicted
by variables described in the adult literature as related to pathological disso-
ciation (e.g., gender, duration, severity).
METHOD
Participants
Participants were parents of 232 physically and sexually abused children
between the ages of 6 and 13. They were recruited primarily from a chil-
dren’s hospital serving a largely rural state. Sixty-one percent of the abused
children were girls and 39% were boys; 69% were Caucasian and 31% were
African American. The mean age of the children was 9.96 (SD = 1.69).
Demographic data for the parents were not collected.
Participants were included if their children provided a clear disclosure
of physical or sexual abuse, if the child’s report was acknowledged as
credible by the nonoffending caretaker, and at least one of the following
external supportive factors was met: (a) official substantiation by the state
child protective services agency, (b) abuser admission of abuse, (c) physical
evidence strongly consistent with abuse, or (d) trained interviewer conclu-
sion that physical or sexual abuse was likely.
Parents completed informed consent and children provided assent. The
measures were collected as part of a larger study supported by the National
Institute of Mental Health. Only 16% of all participants screened were
recruited. Many caregivers refused to participate, and some children did not
endorse abuse despite confirmation by another source.
Children and parents were interviewed separately. For many, multiple
sessions were required to complete the measures. Children were screened
to assure an overall IQ of at least 75 on the Slosson Intelligence Test-
Revised (SIT-R; Slosson, Nicholson, & Hibpshman, 1990) or Kaufman Brief
Intelligence Test (KBIT; Kaufman & Kaufman, 1990). IQ scores averaged
98.09 (SD = 16.16).
Instruments
ABUSE DIMENSIONS INVENTORY
The Abuse Dimensions Inventory (ADI; Chaffin, Wherry, Newlin, Crutchfield, &
Dykman, 1997) is a 15-scale instrument designed to measure the severity of
physical and sexual abuse. The sexual abuse section, which was the only
section utilized in the present study, has scales measuring sexual behavior
severity, duration of abuse, number of most severely rated incidents, num-
ber of total incidents, abuser reaction to disclosure, use of force or coer-
cion to gain submission or compliance, use of force or coercion to gain
secrecy, and relationship of the abuser to the victim. The ordering of items
in terms of severity was obtained by surveying a national sample of mental
health professionals belonging to a national abuse organization. Coeffi-
cients of concordance for orderings averaged .87. Interrater reliability of
the scales based upon a semistructured interview with non-accused
parents ranged from .84 to .99, and factor analysis of the instrument pro-
duced a four-factor solution with separate factors for physical abuse
behaviors, sexual abuse behaviors, number and duration of physical abuse
events, and number and duration of sexual abuse events (Chaffin et al.,
1997).
CHILD DISSOCIATIVE CHECKLIST, VERSION 3.0

The CDC is a screening measure developed by Putman and colleagues
(1993) to access dissociative symptoms based on ratings by caregivers for
children and adolescents. The CDC is comprised of 20 items rated on a
scale ranging from 0 (not true) to 2 (very true). These ratings are summed,
and a cutoff score equal to or greater than 12 is considered abnormal, par-
ticularly in older children. It has a one-year test-retest reliability coefficient
of rho = .69 (N = 73, p = .0001) in a sample of normal and sexually abused
girls. Putman and colleagues (1993) report good discriminant validity for
the CDC.
RESULTS
Principal Components of the CDC with Physically and Sexually
Abused Children
In order to explore the principal components of the CDC, a principal com-
ponents analysis of the 20 CDC items was undertaken. The sample included
both physically and sexually abused children (N = 232). The Kaiser-Meyer-
Olkin measure of sampling adequacy was .857, indicating that the data were
appropriate for principal components analysis. A varimax rotation was
performed. Based on examination of the scree plot, a three-factor solution
resulted and accounted for 46% of the variance. The factors included items
describing variability in a number of behaviors, general externalizing prob-
lems, and pathological dissociation (see Table 1). The variability component
accounted for 19.09% of the variance, the pathological dissociation compo-
nent accounted for 14.12%, and the externalizing behavior component
accounted for 12.88%.
TABLE 1 Rotated Component Matrix of the CDC
Rotated Component Matrix
CDC Items Variability Pathological Externalizing
6. Child shows marked variations in skills, .721 .186 .015

knowledge, food preferences, etc.
3. Child shows rapid changes in personality. .690 .051 .255
4. Child unusually forgetful or confused about .670 .151 .219
things that he/she should know.
11. Child has rapidly changing physical complaints. .639 .001 .070
7. Child shows rapid regressions in age level .607 .329 .151
of behavior.
2. Child goes into daze or trancelike state; spaced .592 .016 .303
out/daydreams.
5. Child has poor sense of time; loses track of time. .588 .273 .159
18. Child has unusual nighttime experiences. .560 .381 .025

1. Child doesn’t remember/denies traumatic .402 .313 .361
experiences.
15. Child has a vivid imaginary companion(s). .029 .749 .086
20. Child has two or more distinct and separate .328 .648 .036
personalities that take control.
17. Child sleepwalks frequently. .072 .574 .080
14. Child reports hearing voices that talk to him/her. .072 .548 .242
10. Child refers to himself/herself in third person; .270 .548 .017
insists on being called a different name.
19. Child frequently talks to himself/herself .150 .541 .148
(may use different voice or argue with self).
9. Child continues to lie or deny misbehavior .161 .015 .803
when evidence is obvious.
8. Child has difficult time learning from .272 .074 .768
experience.
12. Child is unusually sexually precocious. .041 .127 .608
16. Child has intense outbursts of anger often .262 .188 .596
without apparent cause (may display
unusual physical strength).
13. Child suffers from unexplained injuries or may .199 .279 .364
deliberately injure self.
Note: Highlighted items represent the factor items.
Table 2 reports the distribution of scores for the items of the pathologi-
cal dissociation factor. A score of 1 indicates that for one item the behavior
was “sometimes true,” while a score of 2 indicates that either two items
were “sometimes true,” or one item was “very true.” If a score of 2 is set as
a threshold for pathological dissociation, then 85.8% of the sexually abused
sample did not evidence pathological dissociation and 14.2% did evidence
pathological dissociation.
Reliability
Reliability was calculated for each of the three scales derived from factor
analysis. In ascending order, alpha coefficients for the CDC principal
TABLE 2 Distribution of Pathological Dissociation Raw Scores
Distribution
Score Frequency Percent Cumulative Percent
.00 or more 157 67.4 100.0

.00 or more 43 18.5 32.7
.00 or more 16 6.9 14.2
.00 or more 5 2.1 7.3
.00 or more 6 3.6 5.2
.00 or more 2 .9 2.6
.00 or more 2 .9 1.7
.00 or more 1 .4 .8
.00 or more 1 .4 .4
components were .834 for variability in behavior, .696 for pathological

dissociation, and .721 for externalizing behavior. The Cronbach’s alpha for
all items was .873. The item mean was .865.
Predicting Pathological Dissociation

Next, the scores for the six items of the pathological dissociation factor were
weighted based on their individual factor loadings relative to the overall
factor loading. The weighted pathological dissociation score was then used
as the dependent variable in a series of hierarchical regression analyses
involving abuse characteristics and demographic variables. These analyses
were done using hierarchical multiple regression as outlined in SPSS (soft-
ware). Each independent variable was entered into the regression equation
according to a specific hierarchy. The adjusted R2 (explained variance) was
then analyzed by increments as to the proportion of variance explained
after adding each additional variable (Cohen & Cohen, 1975). Predictor vari-
ables were entered in the following order: (a) gender, (b) duration, and (c)
severity. Only gender was a significant predictor of weighted pathological
dissociation, overall F(1, 134) = 11.47, p < .01, accounting for .08 of the total
adjusted R2. Male children were more likely to experience pathological
dissociation.
Differences between Groups

An independent-samples t-test was performed and yielded significant differ-
ences in weighted pathological dissociation between those children who
were sexually abused and those who were not. The mean and standard
deviations were 5.74 (SD = 12.39) for non–sexually abused children and
14.15 (SD = 28.81) for sexually abused children. Levene’s test of equality of
variance indicated that the variance between the groups was not equal,
based on an F of 11.68 (p < .01). Thus, the resulting t-score was 3.08
(df = 217.51, p < .01). The results of an independent t-test of the weighted
pathological dissociation score performed on groups of physically abused
and non–physically abused children was nonsignificant.
Weighted item scores were calculated for the variability and externaliz-
ing items based on their individual item loadings relative to the overall
factor loading. There were significant differences between physically
abused children and non–physically abused children on the weighted exter-
nalizing factor, t(231) = 6.52, p <.001 with physically abused children scoring
higher (M = 85.22, SD = 45.34) than non–physically abused children (M = 40.93,
SD = 48.73). On the variability factor, children who were sexually abused
(M = 46.07, SD = 45.25) scored higher than non–sexually abused children
(M = 30.55, SD = 37.17), t(203.50) = 2.83, p < .01 (Levene’s F = 5.59, p < .05).
DISCUSSION
For this sample, the CDC can be reduced into three components: pathologi-
cal dissociation, variability, and externalizing. One of the components,
pathological dissociation, appears to assess more serious symptoms of dis-
sociation. Unfortunately, there is no measure that serves as a “gold stan-
dard” for the systematic diagnosis of dissociation in young children.
However, Kluft (1984) reports that less than 3% of dissociative disorder
diagnoses are made in children under age 12. Similarly, Waller and Ross
(1997) report that only 3.3% of adults report pathological dissociation. In
this sample, 14.2% of sexually abused children evidenced pathological dis-
sociation according to parent reports when a score of 2 was used as the
threshold on the pathological dissociation factor. This higher rate of patho-
logical dissociation is to be expected because the participants are drawn
from a clinical population rather than a general population.
Differences in weighted pathological dissociation scores were exam-
ined between those in the sample who experienced sexual abuse and those
who experienced physical abuse. The sexually abused children were rated
by their parents as evidencing more pathological dissociation than the phys-
ically abused children. Since the physical abuse itself might have been per-
petrated by the parent rater, one explanation might be that the physically
abusive parent raters were less sensitive and attuned to their child’s prob-
lems. However, another interpretation is that sexual abuse leads to more
pathological dissociation as a traumatic event that is difficult to integrate
into one’s experience. This is contrary to some findings in the adult litera-
ture where physical abuse is related to pathological dissociation more than
sexual abuse (e.g., Macfie, Cicchetti, & Toth, 2001).
The finding that pathological dissociation was predicted by being male
was partially in contrast to Friedrich and colleague’s (1997) finding that
being female was related to dissociation in general. This may be due to
higher rates of pathological dissociation among boys or to differences

between this sample and the one used by Friedrich and colleagues. Ulti-
mately, the value of the pathological dissociation factor will be fully demon-
strated when differences in scores differentiate between groups of normal
controls, sexually abused children, and children with a DSM-IV (Diagnostic
and Statistical Manual of Mental Disorder, Fourth Edition) diagnosis of a
dissociative disorder.
As suggested, one of the limitations of the study was the lack of a nor-
mal control group. The establishment of base rates of dissociative symp-
toms, especially pathological dissociation, among normal children would
assist in the interpretation of pathological dissociation in abused and clinical
populations. Another limitation of the study was the likely bias created
because of voluntary nonparticipation by 86% of all potential children
screened. This may have resulted in less severe ratings of child behavior
and abuse, especially among those children who were physically abused.
That is, an undetermined portion of the physically abused children had par-
ents who retained custody of their children and provided the ratings for
their children.
Future studies would be beneficial to replicate the pathological dissocia-
tion factor and to establish base rates of pathological dissociation scores
among normal children, abused groups, children traumatized by other
events, and clinical populations. By refining our screening of dissociation
through the specific assessment of pathological dissociation, clinicians might
improve on the accurate identification of those with dissociative symptoms
versus those who represent false positives in the screening process. Ulti-
mately, this may lead to more timely and appropriate treatment of children.
REFERENCES
Anderson, G., Yasenik, L., & Ross, C. A. (1993). Dissociative experiences and disor-
ders among women who identify themselves as sexual abuse survivors. Child
Abuse & Neglect, 17, 677–686.
Bernstein, E. M., & Putnam, F. W. (1986). Development, reliability, and validity of a
dissociation scale. The Journal of Nervous and Mental Disease, 174, 727–735.
Branscomb, L. (1991). Dissociation in combat-related post-traumatic stress disorder.
Dissociation, 4, 13–20.
Briere, J. (1996). Trauma symptom checklist for children (TSCC) professional man-
ual. Odessa, FL: Psychological Assessment Resources.
Carlson, E.B., & Rosser-Hogan, R. (1991). Trauma experiences, posttraumatic stress,
dissociation, and depression in Cambodian refugees. The American Journal of
Psychiatry, 148(11), 1548–1551.
Chaffin, M., Wherry, J. N., Newlin, C., Crutchfield, A., & Dykman, R. (1997). The
abuse dimensions inventory: Initial data on a research measure of abuse severity.
Journal of Interpersonal Violence, 12, 569–589.
Chu, J. A., & Dill, D. L. (1990). Dissociative symptoms in relation to childhood

physical and sexual abuse. American Journal of Psychiatry, 147, 887–892.
Cohen, J., & Cohen, P. (1975). Applied multiple regression/correlational analyses for
the behavioral sciences. New York: John Wiley.
Coons, P. M., Bowman, E. S., & Milstein, V. (1988). Multiple personality disorder: A
clinical investigation of 50 cases. Journal of Nervous and Mental Disease, 176,
519–527.
Dorahy, M. J., Lewis, C. A., Millar, R. G., & Gee, T. L. (2003). Predictors of
nonpathological dissociation in Northern Ireland: The affects of trauma and
exposure to political violence. Journal of Traumatic Stress, 16, 611–615.
Friedrich, W. N., Jaworski, T. M., Huxsahl, J. E., & Bengston, B. S. (1997). Dissocia-
tive and sexual behaviors in children and adolescents with sexual abuse and
psychiatric histories. Journal of Interpersonal Violence, 12, 155–173.
Kaufman, A. S., & Kaufman, N. L. (1990). Manual for the Kaufman brief intelligence
test. Circle Pines, MN: American Guidance Service.

Kirby, J. S., Chu, J. A., & Dill, D. L. (1993). Correlates of dissociative symptomatol-
ogy in patients with physical and sexual abuse histories. Comprehensive
Psychiatry, 34, 258–263.
Kluft, R. P. (1984). Multiple personality in childhood. Psychiatric Clinics of North
America, 7, 121–134.
Kluft, R. P. (1985). Hypnotherapy of childhood multiple personality disorder. American
Journal of Clinical Hypnosis, 27, 201–210.
Maaranen, P., Tanskanen, A., Honkalampi,, K., Haatainen, J. H., Hintikka, J., &
Viinamaki, H. (2005). Factors associated with pathological dissociation in the
general population. Australian and New Zealand Journal of Psychiatry, 39,
387–394.
Macfie, J., Cicchetti, D., & Toth, S. L. (2001). The development of dissociation in
maltreated preschool-aged children. Development and Psychopathology, 13,
233–253.
Nemiah, J. C. (1980). Dissociative disorders. In A. M. Freedman & H. I. Kaplan
(Eds.), Comprehensive textbook of psychiatry (3rd ed., pp. 1544–1561).
Baltimore: Williams & Wilkins.
Putnam, F. W. (1991). Dissociative disorders in children and adolescents. Psychiat-
ric Clinics of North America, 14, 519–531.
Putnam, F. W. (1997). Dissociation in children and adolescents. New York: Guilford.
Putnam, F. W., Guroff, J. J., Silberman, E. K., Barban, L., & Post, R. M. (1986). The
clinical phenomenology of multiple personality disorder: Review of 100 recent
cases. Journal of Clinical Psychiatry, 47, 285–293.
Putnam, F. W., Helmers, K., & Trickett, P. K. (1993). Development, reliability, and
validity of a child dissociation scale. Child Abuse & Neglect, 17, 731–741.
Sandberg, D. A., & Lynn, S. J. (1992). Dissociative experiences, psychopathology
and adjustment, and child and adolescent maltreatment in female college
students. Journal of Abnormal Psychology, 101(4), 717–723.
Slosson, R., Nicholson, C., & Hibpshman (1990). The Slosson Intelligence Test—
Revised. East Aurora, NY: Slosson Educational Publications.
Vincent, M., & Pickering, M. R. (1988). Multiple personality disorder in childhood.
Canadian Journal of Psychiatry, 33, 524–529.
Waller, N. G., & Ross, C. A. (1997). The prevalence and biometric structure of
pathological dissociation in the general population: Taxometric and behavior
genetic findings. Journal of Abnormal Psychology, 106, 499–510.
AUTHOR NOTE
At the time this research was conducted, Jeffrey N. Wherry was a Professor
of Psychology at Abilene Christian University. He is now Rockwell Professor,
Rockwell Professor of Human Development and Family Studies and Director
of the Institute for Child and Family Studies at Texas Tech University,
Lubbock, Texas.
Debra A. Neil and Tamara N. Taylor are undergraduate students in the
Accelerated Professional Career Track Psychology Program at Abilene Christian

University, Abilene, Texas.
Article
Dissociation as a Mediator of Psychopathology

Among Sexually Abused Children and Adolescents
Cassandra L. Kisiel, Ph.D. Objective: This study investigated the turbance, including risk-taking behavior
role of dissociation as a mediator of men- (suicidality, self-mutilation, and sexual ag-
tal health outcomes in children with a his- gression). Severity of sexual abuse was not
John S. Lyons, Ph.D.
tory of sexual abuse. associated with dissociation or psycho-
Method: The study group consisted of pathology. Analysis of covariance indi-
114 children and adolescents (ages 10–18 cated that dissociation had an important
years) who were wards of the Illinois De- mediating role between sexual abuse and
partment of Children and Family Services psychiatric disturbance. These results
and were living in residential treatment were replicated across several assessment
centers. Interviews, provider ratings, and sources and varied perspectives.
chart reviews were used to assess the rela-
tionship of childhood abuse history, disso- Conclusions: Th e fin ding s s ug ge s t a
ciative responses, and psychopathology. unique relationship between sexual abuse
and dissociation. Dissociation may be a
Results: Sexual abuse history was sig-
nificantly associated with dissociation, critical mediator of psychiatric symptoms
whereas a history of physical abuse was and risk-taking behavior among sexually
not. Both sexual abuse and dissociation abused children. The assessment of disso-
were independently associated with ciation among children may be an impor-
several indicators of mental health distant aspect of treatment.
(Am J Psychiatry 2001; 158:1034–1039)
C hildhood sexual abuse may be related to more dele-

terious long-term outcomes than physical abuse (1–4).
ated with differences in defining abuse or its severity as
well as with difficulties substantiating reports of sexual
However, no psychiatric profile or course of adjustment abuse (16).
unique to the sexual abuse survivor has been identified. A natural, protective response to overwhelming trau-
Depression, anxiety, and somatic and sexualized responses matic experiences, dissociation can become an automatic
are frequently documented (5, 6). Risk-taking behaviors response to stress. This can impair functioning and in-
(e.g., suicidality, self-mutilation, physical and sexual crease susceptibility to serious psychopathology (17, 18).
aggression, substance abuse, and sexual revictimization)
Putnam (12) has suggested that aggressive, risk-taking be-
have also been noted (7–10). Yet symptoms can wax and
havior often occurs in the context of dissociative experi-
wane or shift over the course of development (5, 11),
ences, when individuals feel out of control and compelled
making it difficult to interpret the “real” effect of sexual
to do something against their will. A hierarchical model of
trauma (12).
dissociation proposes that primary dissociation (e.g., for-
While the symptomatic effects of sexual abuse are well-
getfulness, fragmentation, emotional numbing) often co-
studied (6, 11), the possible mediators of the complex rela-
occurs with several symptom constellations (e.g., mood
tionship between childhood abuse and psychopathology
swings, aggressive behavior, substance abuse). These
are currently a focus (11–14). Included is an emphasis on
symptoms are considered secondary or tertiary responses
the coping responses of abuse survivors.
to dissociation in which dissociation serves as a mediator
A number of studies have assessed the relationship be-
(12). These observable symptoms or risks may not mani-
tween childhood abuse and dissociation among adult sur-
fest until adolescence or early adulthood (18).
vivors (1–4, 10, 15–17), but this relationship has been less
studied among children. The majority of studies suggest Dissociation and development appear related. Norma-
that sexual abuse, particularly severe sexual abuse, com- tive dissociation peaks during latency years (age 10) and
pared to physical abuse, has the predominant effect on declines through adolescence and adulthood (17). While
dissociation (2–4, 10, 16). However, other studies have some consider pathological dissociation to exist only in
pointed to higher levels of dissociation among subjects adults, adolescence may be a transition period critical to
with physical abuse or combined sexual and physical understanding the development of pathological dis-
abuse (1, 15). Some of this inconsistency may be associ- sociation (18). The early identification of dissociative re-
1034 Am J Psychiatry 158:7, July 2001

CASSANDRA L. KISIEL AND JOHN S. LYONS
sponses, particularly in relation to risk-taking behavior, evidence of pathological dissociation. The Child Dissociative
may provide important avenues for prevention. Checklist shows good 1-year test-retest stability (r=0.65) and in-
ternal consistency (Cronbach’s alpha=0.86) (20). Good conver-
The present study assessed the role of dissociation in gent and discriminant validity have been indicated (20).
the presence of psychiatric symptoms among a group of
Traumatic experiences. The History of Abuse Form was com-
adolescents and pre-adolescent children with experiences pleted by caregivers. The History of Abuse Form included items
of sexual and physical abuse. It was hypothesized that dis- abbreviated from another measure (23) and incorporated vari-
sociation would have a mediating role between sexual ables associated with severity of sexual abuse in the literature (5,
abuse and mental health outcomes, particularly increas- 6), including type of sexual abuse, age at onset, frequency and du-
ration, relationship and emotional closeness of the perpetrator,
ing the likelihood of behaviors that are harmful to self or
and use of force. These data were reported secondhand by the
others. primary caseworker and, therefore, must be interpreted with cau-
tion. Asking the youth directly was seen as too intrusive. File re-
Method view was seen as insufficiently detailed. Information on physical
abuse and neglect was also collected.
Study Group and Procedure Mental health outcomes. The Child Behavior Checklist (21) is
One hundred fourteen subjects, ages 10 to 18, were recruited a 113-item, 0–2 point, observer-report measure. The items com-
from a group of children who were wards of the State of Illinois prise several factor-analytically derived problem scales, compe-
Department of Children and Family Services. The group was re- tence scales, two broadband groupings (internalizing and exter-
cruited on the basis of the following five criteria: 1) removal from nalizing problems), and a total problem scale. The Child Behavior
family and placement into Department of Children and Family Checklist is widely used, with excellent reliability and validity
Services custody, 2) current placement in residential treatment, (21). The counterpart to the Child Behavior Checklist, the Youth
3) age, 4) proximity to Chicago, and 5) agreement to participate. Self-Report (19), is a child self-report measure with the same scale
Each child lived in one of five state-supervised residential treat- format and content. The Youth Self-Report exhibits adequate reli-
ment centers. Two of the residential treatment centers included ability and validity (19).
groups of children treated specifically for sexual aggression. The The Child Acuity of Psychiatric Illness scale (22) is a 21-item, 4-
child’s primary residential treatment caseworker was asked to point measure designed to rate acute mental health symptoms,
participate in the study as the caregiver, i.e., an informant who subject to change on the basis of interventions. The Child Acuity
knew the child well. Subjects were not recruited on the basis of of Psychiatric Illness scale includes dimensions of risks, symp-
any specific abuse history. Children were screened for their ability toms, functioning, and systems support. The Child Severity of
to participate by staff at each site and were then selected for the Psychiatric Illness scale (22) is a 25-item, 4-point measure, similar
study if they agreed to participate. Written informed consent was in nature and format to the Child Acuity of Psychiatric Illness
obtained from both the child and the Public Guardian in Illinois. scale. It is a chart review measure used to gather recent and his-
torical information on psychiatric functioning.
The study group included 59 male (52%) and 55 female (48%)
subjects. The majority were African American (69%), with 24%
Caucasian and 5% Hispanic. The average length of stay in the res- Results
idential treatment center was 15.2 months (SD=12.2). The mean
full-scale IQ was 82 (SD=15), but the range of IQ scores (range= Eight of the 114 subjects were missing data because of
50–125) suggests that the mean score likely was not reflective of either the child’s unwillingness to complete certain mea-
the overall study group. sures or the caregiver’s failure to return the questionnaires
Children were administered the Adolescent Dissociative Expe- (despite multiple requests). This accounts for the varia-
riences Scale (18) by a clinically trained interviewer and were
tion in number of subjects across measures.
asked to complete the Youth Self-Report (19). Caregivers were
asked to complete the Child Dissociative Checklist (20), the Child Types of Childhood Abuse Experiences
Behavior Checklist (21), the Child Acuity of Psychiatric Illness
scale (22), and the History of Abuse Form. Trained raters used the According to the chart review, 97% of the study group
Child Severity of Psychiatric Illness scale (22) to review residential had a history of any type of abuse (sexual, physical, ne-
charts. glect), and 84% of the subjects had an abuse history that
Measures was considered moderate to severe. According to the His-
tory of Abuse Form, most of the group (92%) experienced
Dissociation. Two measures of dissociation were used. The Ado-
lescent Dissociative Experiences Scale (18) is a 30-item self-report some neglect, with 42% experiencing severe neglect or
measure developed as a screening tool for serious dissociative and abandonment. Sixty-one percent had a history of sexual
posttraumatic disorders. Each item is rated on a scale of 0 (never) abuse, 47% experienced physical abuse, and 39% had
to 10 (always) on the basis of adolescents’ self-report of symptoms. both. Children who experienced only sexual abuse with-
The total score for the scale is the average of all item scores. Psy-
out physical abuse made up 22%, while 16% had a history
chometric data on the Adolescent Dissociative Experiences Scale
indicate excellent reliability (Cronbach’s alpha=0.93; split-half= of physical abuse alone, and 49% witnessed the physical
0.92). A mean score of 4 or above on the Adolescent Dissociative abuse of family members.
Experiences Scale signifies pathological dissociation. Among those who reported a history of sexual abuse,
The Child Dissociative Checklist (20) is a 20-item observer-re- the following types of sexual contact were reported: sexual
port checklist with a 3-point scale (0=not true, 1=sometimes true, kissing or fondling (11%), touching genitals/digital pene-
2=frequently true). The Child Dissociative Checklist is a clinical
screening instrument that assesses dissociation on the basis of
tration (16%), oral sex (9%), and genital or anal intercourse
ratings given by caregivers or adults in close contact with the (64%). The age at onset of sexual abuse fell into one of four
child. A score of 12 or higher on the Child Dissociative Checklist is ranges: 0–2 years (4%), 3–6 years (46%), 7–11 years (43%),
Am J Psychiatry 158:7, July 2001 1035

DISSOCIATION AND SEXUAL ABUSE
TABLE 1. Dissociation and Psychopathology in 114 Children and Adolescents Living in State-Supervised Residential Treat-
ment Centers, by Abuse History
Abuse History
Sexual Abuse Physical Abuse Sexual/Physical
No Abuse (N=27) (N=25) (N=18) Abuse (N=44)
Measure Mean SD Mean SD Mean SD Mean SD
Dissociation
Adolescent Dissociative Experiences Scale score 2.4 2.0 3.4 2.6 2.4 1.8 3.7 2.1
Child Dissociative Checklist score 4.7 3.4 6.0 4.8 6.2 6.1 10.4 6.9
Psychopathology
Child Behavior Checklist scores
Total 56.2 10.5 62.2 10.5 60.1 13.1 67.2 10.2
Internalizing problemsa 53.6 10.6 59.6 12.0 55.5 12.8 64.6 10.5
Externalizing problemsb 58.4 10.7 62.3 8.7 61.8 13.3 66.9 10.4
Youth Self-Report scores
Total 58.8 14.1 63.0 14.7 56.0 15.0 64.4 11.4
Externalizing problemsb 60.8 13.2 62.0 13.5 56.6 15.2 66.3 12.6
Child Acuity of Psychiatric Illness scores
Total 9.0 5.8 13.3 8.8 10.9 10.4 18.8 10.5
Symptoms 3.9 3.6 5.1 3.8 4.7 5.2 7.8 4.8
Risks 1.3 1.3 1.8 2.6 1.2 2.0 2.7 2.2
Child Severity of Psychiatric Illness scores
Sexual aggression 0.6 0.9 1.0 1.2 0.1 0.3 1.4 1.1
Suicide 0.3 0.5 0.6 0.8 0.3 0.5 0.6 0.6
a Items from the withdrawal, somatic complaints, and anxious/depressed syndromes within the scale.
b Items from the delinquent and aggressive behavior syndromes within the scale.
or 12 years and above (7%). The length of abuse varied: 0– female subjects reported significantly higher levels of ex-
1 year (29%), 1–3 years (36%), 3–5 years (19%), 5 years or perienced dissociation (t=1.95, df=105, p<0.05).
more (16%). The frequency of the abuse ranged from ei-
ther one occasion (8%) or rarely but more than once (26%) Abuse and Dissociation
to monthly (15%), weekly (38%), and daily (13%). The ma- In order to identify the differential effects of sexual and
jority of victims were related to their abuser (who was ei- physical abuse experiences, a two-by-two analysis of vari-
ther an immediate family member [44%] or extended fam- ance (ANOVA) was used. Main effects were tested for sex-
ily member [29%]); 4% of the abusers were strangers to the ual abuse (yes versus no) and physical abuse (yes versus
victim, and 23% were unrelated but known. The degree of no). Statistical interactions between sexual and physical
emotional closeness to the perpetrator was described as abuse were also tested to determine whether the co-oc-
follows: no relationship (16%), distant relationship (23%), currence of sexual abuse and physical abuse had differen-
moderately close (41%), and extremely close (20%). The tial effects greater than the occurrence of either sexual
prototypical picture of sexual abuse was weekly genital or abuse or physical abuse alone. Mean scores on the dissoci-
anal intercourse by a family member to whom the child ation measures for the 114 subjects grouped by abuse his-
was at least moderately emotionally close, lasting between tory (no abuse, sexual abuse only, physical abuse only,
1 and 3 years. When multiple types of sexual abuse were both sexual and physical abuse) are presented in Table 1.
reported for a given child, the most severe type was used. For experienced dissociation (i.e., scores on the Adoles-
cent Dissociative Experiences Scale), there was only a
Dissociation
main effect for sexual abuse: children with sexual abuse
The scores from the Adolescent Dissociative Experi- histories reported significantly higher levels of dissocia-
ences Scale (mean=3.2, SD=2.2) and Child Dissociative tion (F=6.88, df=1, 103, p<0.01). There was no effect for
Checklist (mean=7.6, SD=6.2) were positively correlated physical abuse and no interaction effect. For perceived
with each other (r=0.28, df=100, p<0.01). The magnitude of dissociation (i.e., scores on the Child Dissociative Check-
this correlation suggests that these constructs may not be list), both main effects were significant: higher levels of
highly related. It is unclear whether these two measures perceived dissociation were seen in children with a history
assess the same phenomenon: children’s report of their of either physical abuse (F=6.40, df=1, 103, p<0.05) or sex-
own internal experience versus adults’ perception of this ual abuse (F=5.54, df=1, 103, p<0.05). There was no inter-
experience. Therefore, for the purposes of distinction, we action effect. There was also no relationship between cir-
refer to the Adolescent Dissociative Experiences Scale cumstances or severity of sexual abuse and dissociation.
score as “experienced dissociation” and the Child Disso-
ciative Checklist score as “perceived dissociation.” Abuse and Psychiatric Status
There were no significant findings for age and dissocia- Again, two-by-two ANOVAs were conducted across the
tion. There were some gender differences in dissociation: measures of symptomatic functioning, with physical

TABLE 2. Correlations Between Dissociation and Mental Health Outcome Measures in 114 Children and Adolescents Living
in State-Supervised Residential Treatment Centers
Dissociation Measure
Adolescent Dissociative Experiences Scale Child Dissociative Checklist
Mental Health Outcome Measure r (df=88–106) p r (df=88–106) p
Psychiatric symptoms
Child Behavior Checklist scores
Total 0.27 0.01 0.83 0.01
Internalizing problemsa 0.22 0.01 0.70 0.01
Externalizing problemsb 0.16 0.72 0.01
Youth Self-Report scores
Total 0.58 0.01 0.22 0.05
Internalizing problemsa 0.53 0.01 0.15
Externalizing problemsb 0.48 0.01 0.24 0.05
Child Acuity of Psychiatric Illness: total score 0.25 0.05 0.72 0.01
Risk-taking behavior
Child Severity of Psychiatric Illness scores
Risks 0.13 0.34 0.01
Suicide risk 0.37 0.01 0.10
Sexual aggression 0.15 0.36 0.01
Child Acuity of Psychiatric Illness scores
Risks 0.07 0.60 0.01
Suicidal gesture 0.17 0.41 0.01
Self-mutilation 0.21 0.05 0.46 0.01
Aggression
People –0.07 0.42 0.01
Objects –0.01 0.50 0.01
a Items from the withdrawal, somatic complaints, and anxious/depressed syndromes within the scale.
b Items from the delinquent and aggressive behavior syndromes within the scale.
abuse and sexual abuse as main effects. Mean scores on physical abuse and no interaction effect. No associations
the symptom measures for the 114 subjects grouped by between sexual abuse severity and any measure of psychi-
abuse history are presented in Table 1. atric status were seen.
Most of the significant main effects for the Child Behav- Finally, a multivariate ANOVA was run across all depen-
ior Checklist were related to sexual abuse. Higher total dent variables to test the overall significance of physical
scores were seen in children with histories of physical and sexual abuse. There was a significant multivariate
abuse (F=4.13, df=1, 105, p<0.05) and sexual abuse (F=9.0, main effect for sexual abuse (Wilks’s lambda=3.82, df=
df=1, 105, p<0.01). Children with a history of sexual abuse 13.0, p<0.0001) but not for physical abuse or the sexual/
also had higher scores for internalizing problems (F=10.8, physical abuse interaction.
df=1, 105, p<0.01) and externalizing problems (F=4.32, df=
Dissociation and Psychiatric Status
1, 105, p<0.05), whereas there was no main effect for phys-
ical abuse and no interaction effect for either subscale. On Several significant relationships were found between
the measures of dissociation and mental health outcome
the Youth Self-Report, there were only main effects for sex-
(Table 2). There were significant inverse correlations be-
ual abuse: children with a history of sexual abuse had
tween perceived dissociation (Child Dissociative Checklist
higher total scores (F=4.81, df=1, 106, p<0.05) and exter-
score) and several of the competence scales from the Child
nalizing problem scores (F=4.11, df=1, 106, p<0.05).
Behavior Checklist, such as activities (r=–0.30, df=106,
On the Child Acuity of Psychiatric Illness scale, there
p<0.01), social functioning (r=–0.38, df=106, p<0.01), and
was a main effect for sexual abuse: children with a history
school performance (r=–0.29, df=106, p<0.01). The activi-
of sexual abuse had higher total scores (F=9.26, df=1, 91,
ties score was also inversely correlated with experienced
p<0.01), indicating more acute problems, and higher dissociation (Adolescent Dissociative Experiences Scale
symptom (F=5.48, df=1, 100, p<0.05) and risk (F=5.18, df= score) (r=–0.25, df=106, p<0.05).
1, 104, p<0.05) scores. There were no main effects for phys-
ical abuse or interaction effects for these scores. Dissociation as a Mediator
On the Child Severity of Psychiatric Illness scale, there Analyses of covariance were performed to determine
was a main effect for sexual abuse and an interaction ef- whether the relationship between sexual abuse and men-
fect for sexual aggression scores: higher scores were seen tal health outcomes was mediated by dissociation. Sexual
in children with a history of sexual abuse (F=17.51, df=1, and physical abuse were used as factors, with experienced
105, p<0.001) and both sexual and physical abuse (F=4.64, and perceived dissociation as covariates.
df=1, 105, p<0.05). There was no main effect for physical For the Child Behavior Checklist total score, perceived
abuse. There was also a main effect for sexual abuse on dissociation was significant as a covariate (F=153.4, df=1,
suicide scores (F=6.16, df=1, 107, p<0.05) but no effect for 95, p<0.001). Previously significant main effects for sexual

DISSOCIATION AND SEXUAL ABUSE
and physical abuse were no longer significant. Perceived the Adolescent Dissociative Experiences Scale, referred to
dissociation was a significant covariate for the internaliz- as “experienced dissociation,” and the Child Dissociative
ing (F=66.7, df=1, 95, p<0.001) and externalizing (F=80.2, Checklist, a “perceived dissociation” measure. While asso-
df=1, 95, p<0.001) problem scores. The main effect for sex- ciated with each other, these variables were not highly
ual abuse on these scores was eliminated after we con- correlated, perhaps reflecting separate constructs. The
trolled for dissociation. dissociation measures were primarily associated with out-
Experienced dissociation was a significant covariate for comes of the same informant (e.g., child-reported dissoci-
both total score (F=40.9, df=1, 93, p<0.001) and the exter- ation to child-reported symptoms), yet some significant
nalizing problems score (F=18.8, df=1, 93, p<0.001) from cross-informant relationships still existed. Thus, the find-
the Youth Self-Report. Previously significant main effects ings cannot be attributed solely to method variance.
for sexual abuse on both scores disappeared after we con- It is possible that children, particularly adolescents, are
trolled for dissociation. better able to describe their internal experience; adult ob-
For scores on the Child Acuity of Psychiatric Illness servations of dissociation may reflect external behaviors
scale, perceived dissociation was a significant covariate related to dissociation. This could represent a central diffi-
(total: F=86.6, df=1, 83, p<0.001; risks: F=49.4, df=1, 95, culty in measuring dissociation in children. Pathological
p<0.001; symptoms: F=74.6, df=1, 92, p<0.001). The previ- dissociation may be clinically inferred by the degree of
ously significant main effect for sexual abuse on all three problematic (e.g., destructive or harmful) behavior that is
indices disappeared. present. Alternately, if a child’s behavior is sufficiently dis-
For scores on the Child Severity of Psychiatric Illness ruptive and dissociation is not assessed in a particular set-
scale, experienced dissociation was a significant covariate ting, it may be overlooked. In fact, the Child Dissociative
for suicide risk (F=7.36, df=1, 94, p<0.01). The previously Checklist, the adult-report measure, includes an item on
significant main effect for sexual abuse was again not sexual behavior in its rating of dissociation. This could
present. However, a slightly different pattern emerged for have presented a confound for this study as dissociation
sexual aggression: while perceived dissociation was again was hypothesized to mediate risk behaviors.
a significant covariate (F=5.0, df=1, 93, p<0.05), a signifi- In this study, dissociation was measured on a contin-
cant main effect remained for sexual abuse (F=8.64, df=1, uum as it relates to abuse history and mental health out-
93, p<0.01) and the physical and sexual abuse interaction come. While the dissociation scores for this group were
(F=4.43, df=1, 93, p<0.05). similar to those of other samples of abused children, the
average scores were not within the pathological or diag-
Discussion nostic range for dissociation (18, 20).
Evidence for a relationship among abuse history, disso-
The primary finding of this study is that dissociation ap- ciation, and psychopathology was quite compelling, but
pears to have a mediating role between sexual abuse and a the data only suggest that these variables are associated at
variety of mental health outcomes. Higher levels of disso- the present time. Causal effects and directional relation-
ciation were found among sexually abused children than ships cannot be inferred given the cross-sectional design
among physically abused children. Dissociation was asso- of this study.
ciated with more symptoms, more frequent risk-taking This was an extreme sample of the child psychiatric
behaviors, and less competent functioning. Consistent population. All of the subjects were in state protective cus-
with other research, sexually abused children exhibited tody and receiving long-term psychiatric services. There-
more symptoms and acute disturbance, including suicid- fore, direct responses to abuse were not assessed, and
ality, sexual aggression, and self-mutilation (6–9). Associa- symptoms may have shifted over time as a result of other
tions between severity of sexual abuse, dissociation, and experiences. With a significant subset of children exhibit-
outcomes were not found, likely because of the consis- ing some history of sexual aggression, the generalizability
tently severe abuse histories within this study group. Over- of these findings to other populations may be limited.
all, these findings suggest a unique relationship between
sexual abuse and dissociation (1, 9) and the potential im-
portance of dissociation as a mediator of symptoms, par-
Conclusions
ticularly destructive and harmful behaviors, among sexu- Dissociation has been considered a mediator of psycho-
ally abused children (14). These findings are compelling pathology and risk-taking behavior in previous studies of
and may have clinical implications for work with trauma- childhood sexual abuse (2, 3, 12, 14) and adult sexual
tized children. trauma (24). This study supports these findings and may
This study has a number of strengths, including its have implications for treatment. Assessing dissociation
multimethod design, mixed gender sample, and replica- may be an important aspect of clinical care among trau-
tion of findings across several measures and perspectives. matized children. However, fully understanding these re-
There are also limitations and questions to consider. One lationships requires further empirical studies with multi-
important issue concerns the measures of dissociation: ple and varied methods and measurement among

individuals at different developmental stages. It would be 8. Gladstone G, Parker G, Wilhelm K, Mitchell P, Austin M-P: Char-
useful to assess children and their dissociative responses acteristics of depressed patients who report childhood sexual
abuse. Am J Psychiatry 1999; 156:431–437
closer to the time of abuse and across development to un-
9. Singer MI, Petchers MK, Hussey D: The relationship between
derstand how dissociation relates to psychiatric outcomes sexual abuse and substance abuse among psychiatrically hos-
over time. It is also important to consider how pathologi- pitalized adolescents. Child Abuse Negl 1989; 13:319–325
cal levels of dissociation relate to symptoms and risk. Lon- 10. Draijer N, Langeland W: Childhood trauma and perceived pa-
gitudinal studies are critical for assessing how dissociation rental dysfunction in the etiology of dissociative symptoms in
is adaptive in the short term and when and how it be- psychiatric inpatients. Am J Psychiatry 1999; 156:379–385
11. Pynoos RS, Steinberg AM, Wraith R: A developmental model of
comes maladaptive. Future research is needed in these ar-
childhood traumatic stress, in Developmental Psychopathol-
eas to better understand these complex phenomena, fore- ogy, vol 2: Risk, Disorder, and Adaptation. Edited by Cicchetti D,
stall inappropriate diagnosis and treatment, and prevent Cohen DJ. New York, Wiley & Sons, 1995, pp 72–95
further trauma in the lives of abused children. 12. Putnam FW: Dissociation in Children and Adolescents: A Devel-
opmental Perspective. New York, Guilford Press, 1997
Received July 12, 1999; revisions received March 2 and Nov. 13, 13. Finkelhor D, Browne A: The traumatic impact of child sexual
2000; accepted Jan. 9, 2001. From the Wellesley Centers for Women, abuse: a conceptualization. Am J Orthopsychiatry 1985; 55:
Wellesley College; and the Mental Health Services and Policy Pro- 530–541
gram, Northwestern University Medical School, Chicago. Address re- 14. Long PJ, Jackson JL: Childhood coping strategies and the adult
print requests to Dr. Kisiel, The Wellesley Centers for Women, Welles- adjustment of female sexual abuse victims. J Child Sex Abuse
ley College, 756 Washington St., Waban House, Wellesley, MA 02481.
1993; 2:23–39
Supported in part by a grant from the Philanthropic Educational
Organization. 15. Sanders B, Giolas MH: Dissociation and childhood trauma in
The authors thank Drs. Richard Carroll, Geri Donenberg, and Karen psychologically disturbed adolescents. Am J Psychiatry 1991;
Gouze for their help in the conceptualization and design of this study 148:50–54
and Dr. Drew Westen for his editorial comments on an earlier draft 16. McElroy LP: Early indicators of pathological dissociation in sex-
of this article. ually abused children. Child Abuse Negl 1992; 16:833–846
17. Putnam FW: Dissociative disorders in children: behavioral pro-
files and problems. Child Abuse Negl 1993; 17:39–45
References 18. Armstrong J, Putnam FW, Carlson EB, Libero DZ, Smith SR: De-
velopment and validation of a measure of adolescent dissocia-
1. Chu JA, Dill DL: Dissociative symptoms in relation to childhood
tion: the Adolescent Dissociative Experiences Scale (A-DES). J
physical and sexual abuse. Am J Psychiatry 1990; 147:887–892
Nerv Ment Dis 1997; 185:491–497
2. Waldinger RJ, Swett C, Frank A, Miller K: Levels of dissociation
and histories of reported abuse among women outpatients. J 19. Achenbach TM: Manual for the Youth Self-Report and 1991
Nerv Ment Dis 1994; 182:625–630 Profile. Burlington, University of Vermont, Department of Psy-
chiatry, 1991
3. Zlotnick C, Begin A, Shea MT, Pearlstein T, Simpson E, Costello
E: The relationship between characteristics of sexual abuse 20. Putnam FW, Helmers K, Horowitz LA, Trickett PK: Develop-
and dissociative experiences. Compr Psychiatry 1994; 35:465– ment, reliability, and validity of a child dissociation scale. Child
470 Abuse Negl 1993; 17:731–741
4. Chu JA, Frey LM, Ganzel BL, Matthews JA: Memories of child- 21. Achenbach TM, Edelbrock C: Manual for the Child Behavior
hood abuse: dissociation, amnesia, and corroboration. Am J Checklist and Revised Child Behavior Profile. Burlington, Uni-
Psychiatry 1999; 156:749–755 versity of Vermont, Department of Psychiatry, 1983
5. Beitchman JH, Zucker KJ, Hood JE, DaCosta GA, Akman D: A re- 22. Lyons JS: The Severity and Acuity of Psychiatric Illness, Child
view of the short-term effects of child sexual abuse. Child and Adolescent Version. San Antonio, Tex, Psychological Corp
Abuse Negl 1991; 15:537–556 (Harcourt), 1998
6. Kendall-Tackett KA, Williams LM, Finkelhor D: Impact of sexual 23. Wolfe VV, Gentile C, Bourdeau P: History of Victimization Ques-
abuse on children: a review and synthesis of recent empirical tionnaire. London, Ont., Canada, Children’s Hospital of West-
studies. Psychol Bull 1993; 113:164–180 ern Ont., 1986
7. Kaplan ML, Asnis GM, Lipschitz DS, Chorney P: Suicidal behav- 24. Feeny NC, Zoellner LA, Foa EB: Anger, dissociation, and post-
ior and abuse in psychiatric outpatients. Compr Psychiatry traumatic stress disorder among female assault victims. J
1995; 36:229–235 Trauma Stress 2000; 13:89–100

Blackwell Publishing AsiaMelbourne, AustraliaPCNPsychiatry and Clinical Neurosciences1323-13162006 Folia Publishing Society2006604434438Original ArticleADHD and dissociation in abused childrenT. Endo et al.
Psychiatry and Clinical Neurosciences (2006), 60, 434–438 doi:10.1111/j.1440-1819.2006.01528.x
Regular Article
Attention-deficit/hyperactivity disorder and dissociative
disorder among abused children
TARO ENDO, md,1 TOSHIRO SUGIYAMA, md, phd2 AND TOSHIYUKI SOMEYA, md, phd1
1
Department of Psychiatry, Niigata University Graduate School of Medical and Dental Science, Niigata, and
2
Division of Child Psychiatry, Aichi Children’s Health and Medical Center, Aichi, Japan
Abstract The aim of this study was to investigate the psychiatric problems and characteristics among chil-
dren of child abuse (CA). Specifically, the authors investigated whether attention-deficit/hyperac-
tivity disorder (ADHD) symptoms were exhibited before or after CA. A total of 39 abused child
inpatients who were treated at Aichi Children’s Health and Medical Center, Aichi, Japan, (mean
age, 10.7 ± 2.6; mean IQ scores, 84.1 ± 19.3) were included in the study. The most frequent diagno-
sis was dissociative disorder in 59% of abused subjects. ADHD was diagnosed in 18% of abused
subjects, and 71% of ADHD children had comorbid dissociative disorder. A total of 67% of all CA
subjects fulfilled the ADHD criteria A according to DSM-IV-TR, however, only 27% of those ful-
filled the criteria before CA. The subjects of dissociative disorder fulfilled ADHD criteria A more
frequently than those of non-dissociative disorder (P = 0.013), and this result led to an increase in
the frequency of the apparent ADHD. The rate of ADHD-suspected parents in the subjects who
fulfilled ADHD criteria A after CA was significantly lower than those who fulfilled it before CA
(P = 0.005). While it is difficult to distinguish ADHD from dissociative disorder, abused children
may have increased apparent ADHD due to dissociative disorder. Further studies should be con-
ducted in order to explore the distinct biological differences between ADHD before CA and the
subjects who fulfilled ADHD criteria A after CA.
Key words attention-deficit/hyperactivity disorder, child abuse, dissociative disorder.
INTRODUCTION abused children, however, abused children without

ADHD before CA also exhibit hyperactivity similar to
Child abuse (CA) is one of the most important prob-
ADHD after CA.
lems of child psychiatry. Developmental disorders
Recent neuroimaging studies suggested that abused
such as pervasive developmental disorder (PDD),
children exhibited increased volumes of superior tem-
attention-deficit/hyperactivity disorder (ADHD) and
poral gyrus6 and pituitary,7 decreased volumes of
learning disorder are regarded as psychiatric risk
hippocampus8,9 and corpus callosum,10,11 increased
factors of CA.1 ADHD was reportedly observed in
regional cerebral blood flow (CBF) in the orbitofrontal
14–46% of abused children,2–4 suggesting that ADHD
cortex and anterior temporal pole,12 decreased activa-
is more common in abused children than in the general
tion in hippocampus,8 and low N-acetylaspartate in the
population (3–7%5). However, Glod and Teicher2
anterior cingulate.13 It was reported that ADHD chil-
reported that children who had not met ADHD crite-
dren have cerebellar-prefrontal-striatal dysfunction.14
ria before CA expressed hyperactivity due to a hyper-
These previous reports suggest an etiological differ-
vigilant state after CA. ADHD is often diagnosed in
ence between hyperactivity of abused children and that
associated with ADHD.
The aim of this study was to investigate the psychi-
Correspondence address: Taro Endo, MD, Department of Psy-
atric problems and characteristics of abused children.
chiatry, Niigata University Graduate School of Medical and Dental
Sciences, 1-757 Asahimachi, Niigata 951–8510, Japan. Email:
Specifically, the authors investigated whether ADHD
[email protected] symptoms were exhibited before or after CA, and they
Received 9 June 2005; revised 2 February 2006; accepted 19 also examined the relationship between ADHD symp-
February 2006. toms and dissociative disorder.
© 2006 The Authors

Journal compilation © 2006 Folia Publishing Society
ADHD and dissociation in abused children 435
METHODS given in Table 1. As Table 1 shows, the most frequent

diagnosis was dissociative disorder (dissociative disor-
Subjects der not otherwise specified; NOS and dissociative iden-
A total of 39 child inpatients treated at Aichi Chil- tity disorder) in 59% (n = 23/39) of abused subjects. All
dren’s Health and Medical Center, a foundation hos- dissociative disorder NOS subjects were clinical pre-
pital for CA treatment in Aichi prefecture, Japan, were sentations similar to dissociative identity disorder that
included in the study. These subjects were all abused failed to meet full criteria for this disorder. PDD
patients treated at the Center from April 2004 to (Asperger’s disorder and PDD not otherwise speci-
November 2004. Screening was performed on all fied) and ADHD were diagnosed before CA in 23%
patients entering treatment by a psychiatrist and a clin- (n = 9/39) and 18% (n = 7/39) of abused subjects,
ical psychotherapist, and children who had a history of respectively. Moreover, 71% of ADHD children
CA, such as physical, psychological, sexual abuse, and (n = 5/7) had comorbid dissociative disorder.
neglect, participated in this study.
Attention-deficit/hyperactivity
Procedure disorder symptoms
All subjects were diagnosed according to the DSM-IV- All subjects were screened to determine if they met
TR5 and tested using the Wechsler Intelligence Scale ADHD-A. A total of 67% of all CA subjects (n = 26/
for Children–third edition (WISC-III) for intelligence 39) fulfilled ADHD-A. However, only 27% of these
assessment. Further screening was done using the subjects were determined to have ADHD-A before
Child Dissociative Checklist, Version 3.0 (CDC)15,16 by CA (n = 7/26), whereas the other 73% (n = 19/26) were
child psychiatrists. For further analysis, the authors determined to have ADHD-A after CA. Of the
confirmed with all CA subjects whether they fulfilled patients diagnosed with ADHD-A after CA, 12 were
DSM-IV-TR ADHD criteria A (ADHD-A; excluding diagnosed with dissociative disorder (two with disso-
ADHD criteria B–E) and from when they had fulfilled ciative identity disorder and 10 with dissociative disor-
it. The authors defined CA subjects who fulfilled der not otherwise specified) and seven with PDD (six
ADHD-A before CA as ‘ADHD-A before CA’ sub- Asperger’s disorder and one PDD-NOS).
jects and those who fulfilled it after CA as ‘ADHD-A
after CA’ subjects. Furthermore, the authors confirmed Dissociative disorder
whether the subjects’ parents (either the father or
mother) had ADHD-A symptoms in their childhood Child abuse subjects were most frequently diagnosed
based on the information obtained from the grandpar- with dissociative disorders (Table 1). Some type of dis-
ents. The authors defined parents who fulfilled ADHD- sociative disorder was found in 59% of total subjects
A in their childhood as ‘ADHD-suspected parents’. (n = 23/39). None of the PDD subjects (n = 9) showed
This study was approved by the ethical committee of dissociative disorder. The development of dissociative
the Aichi Children’s Medical Center.
Table 1. Psychiatric diagnoses of abused children
Statistical analyses
n (%)
Frequency analysis was performed with the χ2-test and
Fisher’s exact test. Continuous data, such as CDC DD-NOS 12 (30.8)
scores, was explored using the Student’s t-test. Differ- Asperger’s disorder 8 (20.5)
ences between groups for age, IQ scores, and CDC DD-NOS + ADHD 5 (12.8)
Dissociative identity disorder 4 (10.3)
scores were tested by anova. Post hoc comparisons
Borderline personality disorder 2 (5.1)
were performed using the Tukey test to identify differ- DD-NOS + conversion disorder 2 (5.1)
ences between groups. Statistical significance was set at ADHD 2 (5.1)
the 5% level. Pervasive developmental disorder 1 (2.6)
not otherwise specified
Major depressive disorder 1 (2.6)
RESULTS Adjustment disorder 1 (2.6)
Psychiatric diagnosis Obsessive–compulsive disorder 1 (2.6)
The subjects were 39 abused children (16 boys and 23 ADHD, attention-deficit/hyperactivity disorder; DD-NOS,
girls; mean age, 10.7 ± 0.6). Psychiatric diagnoses are dissociative disorder not otherwise specified.
© 2006 The Authors

436 T. Endo et al.
Table 2. Comorbidity of dissociative disorder and attention-deficit/hyperactivity disorder symptoms
Subjects who did not fulfil Subjects who fulfilled

ADHD-A before CA ADHD-A before CA
† †
ADHD-A symptoms (–) before and (–) after CA (–) before and (+) after CA (+) before and (+) after CA Total
Dissociative disorder (+) 6 12 5 23

Dissociative disorder (–) 5 0 2 7
Total 11 12 7 30
†
χ2 = 6.97, d.f. = 1, P = 0.013.
CA, child abuse; ADHD-A, attention-deficit/hyperactivity disorder criteria A according to the DSM-IV-TR.
disorder in PDD subjects may be different from other *

individuals, therefore, PDD subjects were excluded **
from the following analysis of dissociative disorder. 100%
100%
As Table 2 shows, dissociative disorder was equally
Rate of ADHD-suspected parents

comorbid among both the subjects who fulfilled
ADHD-A before CA (n = 5/7, 71%) and those who did
not fulfil ADHD-A before CA (n = 18/23, 78%). How- 50%
ever, 12 of the dissociative disorder subjects who did 31.3%
not fulfil ADHD-A before CA were determined to 18.2%
have ADHD-A after CA when they were screened
0%
after CA (Table 2). Among the subjects who did not ADHD-A (+) before CA ADHD-A (-) before CA ADHD-A (-) before
fulfil ADHD-A before CA, the subjects with dissocia- but (+) after CA and after CA
tive disorder fulfilled ADHD-A after CA more fre-

Figure 1. Rate of attention-deficit/hyperactivity disorder
quently (n = 12/18) than those without dissociative (ADHD)-suspected parents of abused children. ADHD-A
disorder (n = 0/5). Although only seven of 30 subjects (+) before child abuse (CA; n = 7): Subjects who have ful-
fulfilled ADHD-A when they were screened before filled the ADHD criteria A according to the DSM-IV-TR
CA, an additional 12 subjects fulfilled ADHD-A after before child abuse. ADHD-A (–) before CA but (+) after CA
CA. This result lead to a significant increase of appar- (n = 16): subjects who did not fulfil DSM-IV-TR ADHD cri-
ent ADHD compared to before CA (n = 7/30 vs 12 + teria A before child abuse but fulfilled it after child abuse.
7/30, χ2 = 9.77, d.f. = 1, P = 0.004). ADHD-A (–) before and after CA (n = 11): subjects who did
In a comparison of CDC scores, there was a signifi- not fulfil DSM-IV-TR ADHD criteria A both before and
cant group effects for CDC scores among six groups as after child abuse. *P = 0.002; **P = 0.005.
seen in Table 2 (F = 2.86, P = 0.045). Understandably,
CDC scores of the subjects with dissociative disorder
were significantly higher than those without dissocia- and subjects who did not have ADHD-A symptoms
tive disorder (20.4 ± 7.3 vs 11.3 ± 4.4, t = −4.05, both before and after CA, and there was a significant
d.f. = 17.1, P = 0.001). In post hoc analysis, no signifi- difference between these three groups (χ2 = 13.05,
cant differences were detected for CDC scores d.f. = 2, P = 0.001). The rate of ADHD-suspected par-
between the six groups. There was no significant group ents in ADHD-A before CA subjects was significantly
effects for age and IQ scores (F = 2.33, P = 0.117, and higher than that in ADHD-A after CA subjects and in
F = 1.77, P = 0.194, respectively). the subjects who did not have ADHD-A both before
and after CA (100% vs 31.3% and 18.2%; χ2 = 9.22,
Comparison between attention-deficit/ d.f. = 1, P = 0.005, and χ2 = 11.45, d.f. = 1, P = 0.002,
hyperactivity disorder before child abuse and respectively; Fig. 1). There was no significant group
effects for age, IQ scores, and CDC scores between
attention-deficit/hyperactivity disorder after child
ADHD-A before CA, ADHD-A after CA subjects,
abuse subjects
and the subjects who did not fulfil ADHD-A both
The data of parents were obtained from 34 subjects. before and after CA (F = 1.70, P = 0.198 for age;
The rate of ADHD-suspected parents was compared F = 2.28, P = 0.12 for IQ scores; F = 0.68, P = 0.52 for
between ADHD-A before CA, ADHD-A after CA, CDC scores; respectively).
© 2006 The Authors

ADHD and dissociation in abused children 437
DISCUSSION ation scale should be established in Japan as soon as

possible.
The abused children in this study had a high preva- This study suggests that there are a large number of
lence of ADHD (18%), which is similar to previous abused children with ADHD and that abused children
studies,2–4 and many of the abused children examined frequently present ADHD-A symptoms after CA.
exhibited ADHD criteria A symptoms after CA. The Additionally, the present results also suggest that the
question remains of why abused children fulfil the rate of ADHD-suspected parents between ADHD-A
ADHD criteria A after CA. before CA and ADHD-A after CA subjects is differ-
Previous neurophysiological studies have suggested ent. After CA, the subjects who had dissociative disor-
that traumatized children have an abnormal concentra- der fulfilled ADHD-A more frequently than those who
tion of attention and discrimination of relevant stim- did not, and dissociative disorder was frequently
uli,17 such as abnormal habituation18,19 or abnormal comorbid with both ADHD-A before CA and ADHD-
event-related potential (ERP).20,21 Consequently, A after CA. While it is difficult to distinguish ADHD
abused children have posteriori abnormal concentra- from dissociative disorder, abused children may have
tion of attention and impulse control. These symptoms increased apparent ADHD due to dissociative disor-
might also be valid for ADHD-A in a cross-sectional der. Clinicians need to treat abused children taking
study. Furthermore, in this study, the subjects of disso- both ADHD and dissociative disorder into consider-
ciative disorder fulfilled ADHD-A more frequently ation, and it might be necessary to revise the diagnostic
than those of non-dissociative disorder, and this result criteria in the future. Further studies should explore
lead to an increase in the frequency of the apparent distinct biological differences between ADHD before
ADHD. These dissociative symptoms may be partially CA and ADHD after CA and how to treat ADHD
congruent with inattention symptoms of ADHD-A if comorbid dissociative disorder.
DSM criteria are applied in a cross-sectional manner.
Consequently, a large number of abused children
would be diagnosed with ADHD after CA. REFERENCES
The results of this study also suggest the inheritance
1. Asai T, Sugiyama T, Unno T et al. A clinical research of
differences between ADHD-A before CA and 79 children who visited ‘parental support clinic’. Psychi-
ADHD-A after CA. As mentioned above, previous atr. Neurol. Pediatr. Jpn 2002; 42: 293–299 (in Japanese).
neuroimaging studies have suggested an etiological dif- 2. Glod CA, Teicher MH. Relationship between early
ference between ADHD children and abused children. abuse, posttraumatic stress disorder, and activity levels in
Further genetic or biological studies might enable one prepubertal children. J. Am. Acad. Child Adolesc. Psy-
to more readily distinguish between ADHD before chiatry 1996; 34: 1384–1393.
and after CA. Additionally, the result of inheritance 3. McLeer SV, Callagham M, Henry D, Wallen J. Psychiat-
also indicated some other possibilities. One possibility ric disorder in sexually abused children. J. Am. Acad.
is that ADHD-suspected parents were more likely to Child Adolesc. Psychiatry 1994; 33: 313–319.
abuse their children, and the other is that ADHD-sus- 4. Merry SN, Andrews LK. Psychiatric status of sexually
abused children 12 months after disclosure of abuse. J.
pected parents have been abused by their parents and
Am. Acad. Child Adolesc. Psychiatry 1994; 33: 939–944.
they have become ADHD-A after CA. However, it 5. American Psychiatric Association. Diagnostic and Statis-
was uncertain whether the parents of subjects have tical Manual of Mental Disorder, 4th edn. Text Revision.
been abused in their childhoods based on the informa- Author, Washington, DC, 2000.
tion obtained from the grandparents. 6. De Bellis MD, Keshavan MS, Frustaci K et al. Superior
This study has some limitations. For example, no temporal gyrus volumes in maltreated children and ado-
control subjects, nonabused children, were included. lescents with PTSD. Biol. Psychiatry 2002; 51: 544–552.
This study examined psychiatric inpatients, and it was 7. Thomas LA, De Bellis MD. Pituitary volumes in pediat-
difficult to include children who had no psychiatric ric maltreatment-related posttraumatic stress disorder.
problems. Furthermore, the sample size of this study Biol. Psychiatry 2004; 55: 752–758.
was not very large. Further research with a larger sam- 8. Bremner JD, Vythilingam M, Vermetten E et al. MRI
and PET study of deficits in hippocampal structure and
ple size should be conducted. In this study, the authors
function in women with childhood sexual abuse and post-
used CDC for assessment of dissociation. Although traumatic stress disorder. Am. J. Psychiatry 2003; 160:
CDC was translated into Japanese,16 reliability and 924–932.
validity of it was not confirmed among the Japanese 9. Vythilingam M, Heim C, Newport J et al. Childhood
population. It might not be appropriate to use CDC for trauma associated with smaller hippocampal volume in
assessment of dissociation among Japanese abused women with major depression. Am. J. Psychiatry 2002;
children. The reliability and validity of a child dissoci- 159: 2072–2080.
© 2006 The Authors

438 T. Endo et al.
10. De Bellis MD, Keshavan MS, Shifflett H et al. Brain ability, and validity of a child dissociation scale. Child
structures in pediatric maltreatment-related posttrau- Abuse Negl. 1993; 17: 731–741.
matic stress disorder: a sociodemographically matched 16. Shirakawa M. Appendix: the child dissociative checklist
study. Biol. Psychiatry 2002; 52: 1066–1078. (CDC), Version 3.0. In: Kim Y (ed.). Understanding and
11. Teicher MH, Dumont NL, Ito Y, Vaituzis C, Giedd JN, Treatment of Traumatic Stress. Jiho, Tokyo, 2001; 246–
Andersen SL. Childhood neglect is associated with 248.
reduced corpus callosum area. Biol. Psychiatry 2004; 56: 17. Shalev AY, Orr SP, Peri T, Schreiber S, Pitman RK.
80–85. Physiologic responses to loud tones in Israeli patients
12. Shin LM, McNally RJ, Kosslyn SM et al. Regional cere- with post-traumatic stress disorder. Arch. Gen. Psychia-
bral blood flow during script-driven imagery in childhood try 1992; 49: 870–875.
sexual abuse-related PTSD: a PET investigation. Am. J. 18. Ornitz EM, Pynoos RS. Startle modulation in children
Psychiatry 1999; 156: 575–584. with post traumatic stress disorder. Am. J. Psychiatry
13. De Bellis MD, Keshavan MS, Spencer S, Hall J. N- 1989; 146: 866–870.
Acetylaspartate concentration in the anterior cingulate 19. Shalev AY, Rogel-Fuchs Y. Psychophysiology of PTSD:
of maltreated children and adolescents with PTSD. Am. from sulfur fumes to behavioral genetics. Psychosom.
J. Psychiatry 2000; 157: 1175–1177. Med. 1993; 55: 413–423.
14. Bush G, Valera EM, Seidman LJ. Functional neuroimag- 20. McFarlane AC, Weber DL, Clark CR. Abnormal stimu-
ing of attention-deficit/hyperactivity disorder: a review lus processing in PTSD. Biol. Psychiatry 1993, 34: 311–
and suggested future directions. Biol. Psychiatry 2005; 320.
57: 1273–1284. 21. Paige S, Reid G, Allen M et al. Psychophysiological cor-
15. Putnam FW, Helmers K, Trickett PK. Development, reli- relates of PTSD. Biol. Psychiatry 1990; 58: 329–335.
© 2006 The Authors

Child Abuse & Neglect 32 (2008) 732–737
Contents lists available at ScienceDirect
Child Abuse & Neglect
Brief communication
Trauma-related predictors of deontic reasoning: A pilot study in a

community sample of children夽
Anne P. DePrince ∗ , Ann T. Chu, Melody D. Combs
Department of Psychology, University of Denver, 2155 S. Race Street, Denver, CO 80208, USA
a r t i c l e i n f o a b s t r a c t
Article history: Objective: Deontic reasoning (i.e., reasoning about duties and obligations) is essential
Received 25 January 2007 to navigating interpersonal relationships. Though previous research demonstrates links
Received in revised form 24 August 2007
between deontic reasoning abilities and trauma-related factors (i.e., dissociation, expo-
Accepted 15 October 2007
sure to multiple victimizations) in adults, studies have yet to examine deontic reasoning
Available online 9 July 2008
abilities in children exposed to trauma. Given that social and safety rules (exemplars of
deontic reasoning rules) may appear arbitrary for children in the face of trauma exposure,
Keywords:
Maltreatment particularly interpersonal violence perpetrated by adults (i.e., caregivers, close relatives),
Child abuse we predicted that the ability to detect violations of these rules would vary as a function of
Reasoning trauma exposure type (no, non-interpersonal, and interpersonal). Additionally, given previ-
Wason Selection Task ous research linking dissociation and deontic reasoning in adults, we predicted that higher
levels of dissociation would be associated with more errors in deontic problems.
Methods: Children exposed to interpersonal violence (e.g., sexual abuse by an adult family
member, witnessing domestic violence, or physical abuse in the home) were compared to
children exposed to non-interpersonal trauma (e.g., motor vehicle accident, natural disas-
ter) or no trauma on their ability to detect violations of deontic and descriptive rules in a
Wason Selection Task and assessed for their level of dissociative symptoms.
Results: Dissociation (but not trauma exposure type) predicted errors in deontic (but not
descriptive) reasoning problems after controlling for estimated IQ, socio-economic status,
and children’s ages.
Conclusions: The current study provides preliminary evidence that deontic reasoning is
associated with dissociation in children. This pilot study points to the need for future
research on trauma-related predictors of deontic reasoning.
Practice implications: Deontic rules are essential to navigating interpersonal relationships;
errors detecting violations of deontic rules have been associated with multiple victim-
izations in adulthood. Future research on violence exposure, dissociation, and deontic
reasoning in children may have important implications for intervention and prevention
around interpersonal functioning and later interpersonal risk.
© 2008 Elsevier Ltd. All rights reserved.
Introduction
Deontic reasoning involves reasoning about “what one may, ought, or may not do in a given set of circumstances”
(Cummins, 1996a, p. 161), whereas descriptive reasoning involves reasoning about descriptions of some aspect of the world
(Ermer, Guerin, Cosmides, Tooby, & Miller, 2006). For example, a deontic rule states, “If it is cold outside, then you must wear
夽 This research was supported by start-up funds at the University of Denver.

∗ Corresponding author.
0145-2134/$ – see front matter © 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.chiabu.2007.10.006
A.P. DePrince et al. / Child Abuse & Neglect 32 (2008) 732–737 733
a coat.” A descriptive rule, on the other hand, states “If you play soccer, then you take the red water bottle.” Typically devel-
oping children and adults are more likely to detect violations of deontic rules compared to descriptive rules (e.g., Cosmides,
1989; Cosmides & Tooby, 1992, 1997; Ermer et al., 2006; Klaczynski, 1993; Light, Blaye, Gilly, & Girotto, 1989), even as young
as 3–4 years of age (Cummins, 1996b; Núnez & Harris, 1998).
Deontic reasoning is critical to navigating social relationships and institutions (Cummins, 1996b). Impoverished deon-
tic reasoning abilities are likely to place individuals at high risk for being taken advantage of in relationships or failing
to protect against harm (Stone, Cosmides, Tooby, Kroll, & Knight, 2002). Thus, deontic reasoning performance may be
particularly relevant to the deleterious interpersonal consequences associated with child victimization, such as peer vic-
timization in childhood (e.g., Shields & Cicchetti, 2001; Schwartz, Dodge, Pettit, & Bates, 1997; Schwartz, Dodge, Pettit,
& Bates, 2000) and physical and/or sexual revictimization in adolescence and young adulthood (for review, see Arata,
2002).
To date, we are aware of only one study that has examined deontic reasoning and trauma-related factors. DePrince (2005)
reported that young adults who reported histories of victimizations both before and after age 18 made significantly more
errors detecting violations of deontic rules (both social contract – rules involving a social exchange; and precautionary – rules
involving safety) than their peers; the groups did not differ in descriptive reasoning. Importantly, pathological dissociation
explained unique variance in deontic reasoning performance after controlling for other trauma-related factors (DePrince,
2005). Dissociation is associated with a host of information processing difficulties (e.g., memory problems; see Putnam,
1997), including disruptions in working memory and processing speed (DePrince & Weinzierl, 2006). Working memory
and processing speed have, in turn, been implicated in deontic reasoning (Klaczynski, Schuneman, & Daniel, 2004). In the
current study, we evaluated whether dissociation was linked with deontic (and not descriptive) reasoning errors in school-
aged children. Specifically, we predicted that higher levels of dissociation would be associated with more errors in deontic
(but not descriptive) reasoning problems.
In addition to dissociation, we also examined trauma exposure history in relation to deontic reasoning. While DePrince
(2005) argued that poorer deontic reasoning may increase risk of multiple victimizations in young adulthood, certain types
of trauma exposure in childhood may be associated with deficits in deontic reasoning. To the extent that traumatic events
generally challenge fundamental assumptions regarding predictability, safety, and trust (e.g., Janoff-Bulman, 1992), deontic
rules may seem arbitrary and unreliable to children who grow up in environments that include exposure to potentially trau-
matizing events. Therefore, trauma-exposed children may generally show problems detecting violations of safety and social
relationship rules. Thus, we predicted that any trauma exposure (non-interpersonal or interpersonal) would be associated
with worse deontic performance than no exposure.
To further qualify this prediction, we also hypothesized that interpersonal trauma exposure would be associated with
worse deontic performance than non-interpersonal trauma exposure. In the face of interpersonal violence, deontic rules
about safety and social exchange may seem particularly arbitrary and, therefore, be associated with worse performance.
Indeed, Freyd (1996) has argued that the close nature of victim–perpetrator relationships (e.g., in familial violence) may
decrease children’s motivation to develop accurate reasoning about social relationships because the abusive caregiving rela-
tionship violates a fundamental social contract. In addition, violent family environments, in particular, may fail to provide the
structure or social learning environment required to develop these reasoning abilities. Thus, we predicted that interpersonal
trauma exposure would be associated with poorer deontic (but not descriptive) than non-interpersonal trauma exposure,
which would be associated with worse performance than no trauma exposure.
Current study
The current study provides the first examination of trauma-related predictors of children’s deontic reasoning perfor-
mance. Drawing on theory (e.g., Janoff-Bulman, 1992; Freyd, 1996) and previous research (DePrince, 2005), we tested the
contributions of trauma exposure type and dissociation to deontic reasoning performance in school-aged children. A priori
contrast weights for trauma exposure groups that corresponded to the predicted pattern of means were assigned (weights:
interpersonal trauma = 1, non-interpersonal trauma = 0, no trauma = −1). The use of planned contrast weights is justified
given a priori predictions (Loftus, 1996; Furr, 2004) and minimizes Type II errors that would be associated with post hoc
comparisons between multiple groups in a small pilot sample.
Method
Participants
Prior to data collection, all procedures were approved by the University of Denver Institutional Review Board. Partic-
ipants were recruited in the Denver, Colorado, metro area through flyers in social service and mental health agencies,
community centers, and local businesses as part of a larger study on parenting and stress that involved additional lab
tasks not reported here. Female guardians and their school-aged children were paid for their participation; children
received several small prizes throughout the testing session. All participants completed an extensive informed consent
process. Of the 72 children who participated in the larger study, we report here on the 63 children for whom we had
complete reasoning data. Of these 63 children (Age M = 8.89; S.D. = 1.36), 43 were female. Five female guardians did
734 A.P. DePrince et al. / Child Abuse & Neglect 32 (2008) 732–737
Table 1
Descriptive statistics for variables used in hierarchical regression analyses
No traumaa (n = 22) Non-interpersonal traumab (n = 14) Interpersonal traumac (n = 27) Differences between groups
Mean S.D. Mean S.D. Mean S.D.
Predictors
IQ estimate 106.09 17.78 99.36 14.27 92.67 12.83 a, c
Child age 8.82 1.22 8.79 1.37 9.07 1.47
SES composite 0.07 0.89 0.16 0.71 −0.15 0.79
Dissociation 0.18 0.17 0.21 0.14 0.4 0.38 a, c
Outcomes
Descriptive errors (range 0–12) 5.14 1.78 6.21 1.97 5.63 1.82
Deontic errors (range 0–24) 4.55 3.88 6.14 3.88 6.33 5.06
Note: Letters indicate differences between groups revealed by Tukey’s Honest Significant Difference (HSD) test (p < .05).
not provide racial/ethnic information about their children; the remaining children were reported to be of the following
racial and ethnic backgrounds: 40% Euro-American, 19% African-American, 19% Hispanic/Latino, 3% Native Hawaiian/Pacific
Islander, and 11% other race or bi/multiracial. Mothers reported the following income levels: 33.3% below $10,000; 14.3%
$10,000–20,000; 14.3% $20,001–30,000; 7.9% $30,001–40,000; 7.9% $40,001–50,000; and 22.2% above $50,000. An SES
composite score was created by transforming the following variables to z-scores and calculating the average: income
(ranging from 1 = $10,000 or below to 6 = $50,000 or above), maternal occupational status (Hollingshead, 1975), and mater-
nal years of education (see Table 1). The SES composite did not differ across the trauma exposure groups (F(2, 60) = .82,
p = .44).
Materials
Replicating methods from previous studies of deontic reasoning (e.g., Cosmides & Tooby, 1992, 1997; Stone et al., 2002;
Núnez & Harris, 1998), participants were presented with a series of conditional (if p, then q) rules using the Wason Selection
Task (WST). Consistent with WST methods previously used with children (Núnez & Harris, 1998), response sets developed for
this study included four cards with pictorial representations of p, not-p, q, and not-q options. Children were instructed to pick
which cards must be turned over to check if anyone was breaking the ‘if p-then q’ rule (see Section “Procedure” for additional
task administration details). For each rule, a child could make up to four errors (two commission and two omission). Deontic
rules included three social contract and three precautionary rules. As detailed by Ermer et al. (2006), social contract rules
took the form “If you [take the benefit P], then you must [satisfy the requirement Q]”. For example, “If you go outside to play,
then you must have a clean room.” Precautionary rules took the form “If you [engage in the hazardous activity P], then you
must [take the precaution Q]”. For example, “If it is cold outside, then you must wear a coat.” Descriptive rules took the form
“If you are [in category P], then you [have the preference, habit or trait Q]”. For example, “If you are reading a book, then you
sit in a green chair.” Total errors for the six deontic (possible range: 0–24) and three descriptive (possible range: 0–12) rules
were tallied.
In order to help rule out the possibility that any differences in WST performance were due to overall intelligence, children
also completed the Block Design and Vocabulary scales of the Wechsler Intelligence Scales for Children (WISC; either 3rd or
4th edition; Wechsler, 1991a, 2003a). Full Scale IQ was estimated from scaled scores (Wechsler, 1991b, 2003b) and used as
a covariate in regression models.
Guardians reported on children’s trauma history using behaviourally defined questions from the UCLA PTSD Index (Pynoos,
Rodriguez, Steinberg, Stuber, & Frederick, 1998). The measure has been shown to have good test–retest reliability and inter-
nal consistency (e.g., Roussos et al., 2005) as well as validity (e.g., correspondence with well-established PTSD interviews;
Rodriguez, Steinberg, Saltzman, & Pynoos, 2001). While this measure also assesses PTSD symptoms, we only used the reports
of the child’s trauma exposure here. Dissociation was assessed using the Child Dissociative Checklist (CDC; Putnam, 1997),
a 20-item guardian-report measure that assesses multiple types of observable, dissociative behaviors. The CDC has been
shown to have good test–retest reliability and internal consistency, as well as discriminant validity in distinguishing children
with and without pathological levels of dissociation (for review see Putnam, 1997). Internal consistency was excellent in this
sample (Cronbach’s alpha = 0.89).
Procedure
After the consent process, mothers were seated in a private room and asked to complete questionnaires. Children
were tested by a graduate research assistant in a separate, private room. WISC scales were administered first, followed
by the WST. WST rules were read out loud to children, who were asked to make responses using pictures; this proce-
dure has been used successfully by other researchers with young children (e.g., Núnez & Harris, 1998). Children were
asked to play a detective game in which they had to decide when rules might be broken. The experimenter told chil-
dren that they would hear a rule and see four cards with information on only one side. Using these cards, children
were asked to decide when the rule might be broken and an investigation should be started. Children were instructed
to pick (by pointing at pictures) only those cards to investigate that were the most important. Children did not receive
accuracy feedback, as such feedback could have guided performance on the test rules (e.g., children would know that
there were always two correct responses). After three sample rules to familiarize children with the task, test rules were
presented in random order for each participant. Upon completion of the study tasks, child and adult participants were
debriefed.
Results
Table 1 provides descriptive statistics for study variables by trauma-exposure group, as well as differences between the
groups. Notably, neither predictor nor outcome variables differed as a function of gender; therefore gender is not included
in the reported analyses.
WST psychometrics
Cronbach’s alphas were calculated for errors on the six deontic rules; internal consistency was excellent (alpha = .82). Task
validity was assessed by comparing deontic and descriptive performance. Convergent with previous findings using the WST,
children made significantly more errors (as a proportion of errors possible) on descriptive than deontic rules [t(62) = 9.41,
p < .001]; the effect size was large (Cohen’s d = 1.35).
Predictors of WST performance
Using hierarchical multiple regression analyses, we tested models predicting both descriptive and deontic errors. Cor-
relations among predictor variables for the hierarchical regressions are reported in Table 2. Child age, IQ estimate, and SES
composite were entered on the first step; trauma exposure status and dissociation scores were entered on the second step.
The model predicting descriptive errors failed to reach significance at either the first (F(3, 59) = 2.13, p = .11) or second (F(5,
57) = 1.63, p = .17) step.
The model predicting deontic errors was significant at Step 1 (F(3, 59) = 2.97, p < .05; R2 = .13). The change in R2 was
significant (F-change(2, 57) = 3.95, p < .05) at Step 2, with the full model reaching significance (F(5, 57) = 3.54, p < .01; R2 = .24).
As seen in Table 3, only dissociation scores explained unique variance in deontic errors, though estimated IQ approached
conventional significance levels.
Discussion
This pilot study is the first to examine trauma-related predictors of deontic reasoning in children. Dissociation explained
unique variance in deontic errors (beta = .35), even after controlling for estimated IQ, socio-economic status, and child age.
This finding contributes to the larger literature on dissociation and disruptions in information processing, replicating a recent
finding with young adults. Specifically, DePrince (2005) reported that dissociation predicted unique variance in deontic (e.g.,
beta = .30), but not descriptive reasoning errors. Thus, in both children and young adults, dissociation is associated with a
specific type of reasoning error, but not global reasoning deficits (as illustrated by the lack of relationship to descriptive
reasoning errors). As working memory and processing speed are implicated in both dissociation (e.g., DePrince & Weinzierl,
2006) and deontic reasoning (e.g., Klaczynski et al., 2004), future research should evaluate whether links between dissociation
and deontic reasoning are mediated by deficits in working memory and/or processing speed.
Because of the importance of deontic reasoning to social relationships, the dissociation–deontic reasoning findings
reported here may have implications for understanding some of the interpersonal correlates of dissociation, including revic-
timization. Several researchers have reported associations between dissociation and revictimization (see Classen, Palesh,
& Aggarwal, 2005); however, the mechanisms by which dissociation might mediate later victimization have been unclear.
In the current study, dissociation is associated with more errors in deontic reasoning fairly early in child development. By
Table 2
Zero-order correlations among predictor variables used in hierarchical regression analyses
Dissociation SES composite Child age Trauma exposure group
IQ estimate −0.10 0.40** 0.01 −0.37**

Dissociation 0.09 0.23 0.34**
SES composite −0.09 −0.13
Child age 0.09
Note: The trauma exposure group variable was coded using a priori contrast weights: no trauma (−1), non-interpersonal trauma (0), interpersonal trauma
(1).
**
p < .01.
736 A.P. DePrince et al. / Child Abuse & Neglect 32 (2008) 732–737
Table 3
Regression coefficients for hierarchical regression model predicting deontic errors
Beta S.E. (B) t
Step 1
Estimated IQ −0.28 0.04 −2.09*
SES composite −0.14 0.73 −1.07
Child age −0.06 0.40 −0.50
Step 2
Estimated IQ −0.24 0.04 −1.74†
SES composite −0.20 0.71 −1.57
Child age −0.14 0.40 −1.19
Trauma exposure group −0.05 0.66 −0.35
Dissociation 0.35 1.95 2.75**
†
p < .10.
*
p < .05.
**
p < .01.
young adulthood, participants reporting experiences of revictimization both make more errors in deontic reasoning prob-
lems; and report higher levels of dissociation (DePrince, 2005). Therefore, future longitudinal research should test whether
disruptions in deontic reasoning early in development might mediate links between dissociation and later victimization
risk.
In contrast to our prediction, trauma-exposure was not associated with deontic reasoning errors. It may indeed be
the case that these variables are simply unrelated; however, several methodological issues should be taken into account
in future research. First, given that we used a screener (rather than interview) for trauma exposure, we had relatively
limited information about the details of the trauma exposure. Nineteen of the 27 children in the interpersonal trauma
group were reported to have been exposed to violence in the family environment (e.g., sexual abuse by an adult family
member, witnessing domestic violence, or physical abuse in the home); the remaining 8 were exposed to interpersonal
violence in their communities or sexual abuse by an adult whose relationship to the child was not specified. Among
those exposed to violence in the family, the degree of closeness with the perpetrator may have varied greatly. It may
be that trauma exposure is associated with deontic reasoning disruptions in cases of close-other abuse; and not in more
general cases of interpersonal violence (e.g., see Freyd, 1996). We were unable to examine this closely in the current
data.
Second, we relied on parent-report of trauma exposure. Parents may have failed to report fully on interpersonal violence
exposure because of social desirability, fears of consequences of reporting, or lack of knowledge about such events. Thus,
some children may have been mis-categorized in terms of the trauma exposure group. As noted by one anonymous reviewer
of this manuscript, in the case of under-reporting of familial violence, dissociation may actually be a better indicator of level
of trauma than the form of trauma reported by parents. Thus, extending this research to samples with confirmed abuse or
where children also report on trauma-exposure will be important.
Interpretation of these findings must be cautious for many reasons. Small sample size, low power, and potential self-
selection biases inherent in community-based recruiting create challenges in generalizing these findings to other groups,
therefore requiring replication in other samples. Further, participants in this sample reported low income levels, suggesting
further research is needed to evaluate how findings generalize to other socio-economic groups. As noted previously, the
current study depended on guardian-reported trauma history and child symptoms. Given various pressures (e.g., social
desirability), some guardians may have failed to accurately report on their children’s trauma histories or symptoms, thus
adding error variance. Finally, the questionnaire used to assess trauma exposure did not allow us to examine contextual
factors, such as age of onset or frequency of exposure to potentially traumatic events that may be important contributors to
deontic reasoning abilities.
In summary, these findings contribute to the growing literature on information processing alterations associated with
maltreatment (e.g., Pollak, Cicchetti, Hornung, & Reed, 2000) and dissociation (e.g., Cromer, Stevens, DePrince, & Pears, 2006;
DePrince & Weinzierl, 2006).
Given the importance of deontic reasoning to navigating the social world and the serious interpersonal consequences
associated with child maltreatment, future research of reasoning abilities in relation to trauma exposure and trauma-related
symptoms is warranted.
Acknowledgements
We wish to acknowledge Drs. Megan Saylor and Jackie Rea for project assistance; community agencies for assistance with
recruitment; Drs. Daniel McIntosh, Kathy Becker-Blease, Jennifer J. Freyd, and anonymous reviewers for helpful comments
on earlier versions of this manuscript.
References
Arata, C. M. (2002). Child sexual abuse and sexual revictimization. Clinical Psychology: Science and Practice, 9, 135–164.
Classen, C. C., Palesh, O. G., & Aggarwal, R. (2005). Sexual revictimization: A review of the empirical literature. Trauma, Violence, and Abuse, 6,
103–129.
Cosmides, L. (1989). The logic of social exchange: Has natural selection shaped how humans reason? Studies with the Wason selection task. Cognition, 31,
187–276.
Cosmides, L., & Tooby, J. (1997). Dissecting the computational architecture of social inference mechanisms. In G. R. Bock & G. Cardew (Eds.), Characterizing
human psychological adaptations (pp. 132–156). Chichester, NY: Wiley & Sons.
Cosmides, L., & Tooby, J. (1992). Cognitive adaptations for social exchange. In J. Barkow, L. Cosmides, & J. Tooby (Eds.), The adapted mind: Evolutionary
psychology and the generation of culture (pp. 163–228). New York: Oxford University Press.
Cromer, L. D., Stevens, C., DePrince, A. P., & Pears, K. (2006). The relationship between executive attention and dissociation in children. Journal of Trauma and
Dissociation, 7(4), 135–154.
Cummins, D. D. (1996a). Evidence for the innateness of deontic reasoning. Mind & Language, 11, 160–190.
Cummins, D. D. (1996b). Evidence of deontic reasoning in 3- and 4-year old children. Memory & Cognition, 24, 823–829.
DePrince, A. P. (2005). Social cognition and revictimization risk. Journal of Trauma and Dissociation, 6, 125–141.
DePrince, A. P., & Weinzierl, K. W. (2006). Trauma context, dissociation, and executive function in children. Annual Meeting, International Society for Traumatic
Stress Studies. Hollywood, CA.
Ermer, E., Guerin, S., Cosmides, L., Tooby, J., & Miller, M. (2006). Theory of mind broad and narrow: Reasoning about social exchange engages ToM areas,
precautionary reasoning does not. Social Neuroscience, 1, 196–219.
Freyd, J. J. (1996). Betrayal trauma: The logic of forgetting childhood abuse. Cambridge: Harvard University Press.
Furr, R. M. (2004). Interpreting effect sizes in contrast analysis. Understanding Statistics, 3, 1–25.
Hollingshead, A. B. (1975). Four factor index of social status. Unpublished manuscript. Yale University, Department of Sociology.
Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. New York: Free Press.
Klaczynski, P. A. (1993). Reasoning schema effects on adolescent rule acquisition transfer. Journal of Educational Psychology, 4, 679–692.
Klaczynski, P. A., Schuneman, M. J., & Daniel, D. B. (2004). Theories of conditional reasoning: A developmental examination of competing hypotheses.
Developmental Psychology, 40, 559–571.
Light, P., Blaye, A., Gilly, M., & Girotto, V. (1989). Pragmatic schemas and logical reasoning in 6- to 8-year old children. Cognitive Development, 4, 49–64.
Loftus, G. R. (1996). Psychology will be a much better science when we change the way we analyze data. Current Directions in Psychological Science, 1996,
161–171.
Núnez, M., & Harris, P. (1998). Psychological and deontic concepts: Separate domains or intimate connection? Mind & Language, 13, 153–170.
Pollak, S. D., Cicchetti, D., Hornung, K., & Reed, A. (2000). Recognizing emotion in faces: Developmental effects of child abuse and neglect. Developmental
Psychology, 36, 679–688.
Putnam, F. (1997). Dissociation in children and adolescents: A developmental perspective. New York: Guilford Press.
Pynoos, R., Rodriguez, N., Steinberg, A., Stuber, M., & Frederick, C. (1998). UCLA PTSD index for DSM IV. Los Angeles: Trauma Psychiatric Services.
Rodriguez, N., Steinberg, A. S., Saltzman, W. S., & Pynoos, R. S. (2001). PTSD Index: Preliminary psychometric analyses of child and parent versions. In
Symposium conducted at the Annual Meeting of the International Society for Traumatic Stress Studies.
Roussos, A., Goenjian, A. K., Steinberg, A. M., Sotiropoulou, C., Kakaki, M., Kabakos, C., Karagianni, S., & Manouras, V. (2005). Posttraumatic stress
and depressive reactions among children and adolescents after the 1999 earthquake in Ano Liosia, Greece. American Journal of Psychiatry, 162,
530–537.
Schwartz, D., Dodge, K. A., Pettit, G. S., & Bates, J. E. (1997). The early socialization of aggressive victims of bullying. Child Development, 68, 665–675.
Schwartz, D., Dodge, K. A., Pettit, G. S., & Bates, J. E. (2000). Friendship as a moderating factor in the pathway between early harsh home environment and
later victimization in the peer group. Developmental Psychology, 36, 646–662.
Shields, A., & Cicchetti, D. (2001). Parental maltreatment and emotion dysregulation as risk factors for bullying and victimization in middle childhood.
Journal of Clinical Child Psychology, 30, 349–363.
Stone, V. E., Cosmides, L., Tooby, J., Kroll, N., & Knight, R. (2002). Selective impairment of reasoning about social exchange in a patient with bilateral limbic
system damage. Proceedings of the National Academy of Sciences of the United States of America, 99, 11531–11536.
Wechsler, D. (1991a). Wechsler Intelligence Scale for Children-Third edition. San Antonio: The Psychological Corporation.
Wechsler, D. (1991b). Wechsler Intelligence Scale for Children-3rd edition Administration and scoring manual. San Antonio: The Psychological Corporation.
Wechsler, D. (2003a). Wechsler Intelligence Scale for Children-Fourth edition. San Antonio: The Psychological Corporation.
Wechsler, D. (2003b). Wechsler Intelligence Scale for Children-Fourth edition. Administration and Scoring Manual. San Antonio: The Psychological Corporation.
Child Abuse & Neglect 32 (2008) 1026–1036
Contents lists available at ScienceDirect
Child Abuse & Neglect
Children’s expressed emotions when disclosing maltreatment夽

Liat Sayfan a , Emilie B. Mitchell a , Gail S. Goodman a,∗ ,
Mitchell L. Eisen b , Jianjian Qin b
a
Department of Psychology, University of California, One Shields Avenue, Davis, CA 95616, USA
b
Department of Psychology, California State University, Los Angeles, CA, USA
a r t i c l e i n f o a b s t r a c t
Article history: Objective: Our goal was to examine children’s expressed emotions when they disclose
Received 3 September 2005 maltreatment. Little scientific research exists on this topic, and yet children’s emotional
Received in revised form 29 February 2008
expressions at disclosure may inform psychological theory and play a crucial role in legal
Accepted 4 March 2008
determinations.
Method: One hundred and twenty-four videotaped forensic interviews were coded for chil-
Keywords:
dren’s emotional displays. In addition, children’s trauma-related symptoms (depression,
Child maltreatment
Disclosure dissociation, and PTSD) and global adaptive functioning were assessed, and abuse type and
Emotion expression frequency were documented.
Children Results: Most children in the sample evinced neutral emotion during disclosure. However,
Trauma-related psychopathology stronger negative reactions were linked to indices of psychopathology. Number of abuse
experiences was inversely related to negative emotional displays.
Conclusion: Fact finders may profit from knowing that maltreated children do not necessar-
ily cry or display strong emotion when disclosing maltreatment experiences. Nevertheless,
predictors of greater negative affect at disclosure can be identified: fewer abuse expe-
riences; higher global adaptive functioning; and for sexually abused children, greater
dissociative tendencies.
Practice implications: Although further research is needed, practitioners should consider
that children who disclose abuse may display relatively neutral affect despite having expe-
rienced maltreatment.
© 2008 Elsevier Ltd. All rights reserved.
Introduction
“She was extremely timid, and I think there’s no way she’d put herself through this if she were lying. Became visibly upset
when she began recalling molestation incidents; I think that she really didn’t want to be there, but was, to testify” (Myers,
Goodman, Redlich, & Prizmich, 1999, p. 418). This quotation from a juror in a child sexual abuse trial attests to the importance
of children’s affect when disclosing abuse. It suggests that individuals have certain expectations about how children “should”
react if they were really abused.
The victim just referred to evinced negative emotions (anxiety, sadness, upset) expected of abuse victims (Regan & Baker,
1998). However, the one extant published study conducted in a forensic setting that concerned observed emotions in children
as they disclosed abuse found that the majority of children were more likely to display relaxed or neutral behaviors than
夽 This study was funded, in part, by a grant from the National Center on Child Abuse and Neglect to Drs. Mitchell L. Eisen and Gail S. Goodman.
We thank Niki Head for her assistance.
∗ Corresponding author.
0145-2134/$ – see front matter © 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.chiabu.2008.03.004
L. Sayfan et al. / Child Abuse & Neglect 32 (2008) 1026–1036 1027
shame, sadness, or anger (Wood, Orsak, Murphy, & Cross, 1996). Is it possible that although most individuals believe that
children should be upset when disclosing abuse, children are in fact more likely to seem relaxed or neutral? Can we identify
factors that predict children’s emotional expressions during disclosure of abuse?
The current study concerned children’s emotional expressions during forensic interviews of suspected child maltreatment
victims. Although emotional displays may or may not reflect actual emotional experience or feelings, emotional displays are
of substantial interest in their own right (Ekman & Friesen, 1975), perhaps especially in the forensic context (Kaufman,
Drevland, Wessel, Oversleid, & Magnussen, 2002; Kovera, Gresham, Borgida, Gray, & Regan, 1997). In the following sections,
to generate hypotheses for our study, we consider expression of emotions, particularly negative ones, in relation to child
maltreatment, age, and gender. We also address trauma-related psychopathology and abuse characteristics (e.g., frequency
of maltreatment) as they may relate to negative emotions children express at disclosure. We then describe our study and its
results.
Expression of negative emotions in maltreated children
It has been suggested that maltreated children learn that expression of negative emotions, like anger or distress, is
unacceptable in certain contexts and could cause harm to themselves or family members (Briere, 1992; Cole, Zahn-Waxler,
& Smith, 1994). Such children may employ strategies for managing negative emotions, such as hiding their emotional states
from others in situations potentially related to abuse. During forensic interviews, this suppression of negative emotional
display may contribute to stunted or neutral affect when children are discussing their abuse incidents with interviewers.
This possibility is congruent with studies showing that maltreated children are likely to be dissuaded from expressing their
feelings openly within the family and that they often use coping strategies to reduce emotional awareness (Briere, 1992;
Cole et al., 1994; Harter, 1998), both of which may result in a neutral emotional display.
Age and gender differences in emotion expression
The ability to use strategies to hide negative emotions is also a function of children’s age and gender. Preschoolers,
compared to school-age children, are less able to use efficient strategies to hide their emotions (Harris, 1985; Harris, Olthof,
& Meerum Terwogt, 1981; Saarni, 1989). Older children (ages 10-12 years) are more likely to report strategic suppression of
their experienced emotions, especially sadness, than are younger children (ages 5-9 years; Fuchs & Thelen, 1988; Weiner &
Handel, 1985).
However, older compared to younger children are more likely to understand the ramifications of child abuse allegations
and legal investigations, and thus to express more distress. Older children show greater understanding of the legal system
than do younger children (Block, Goodman, Oran, & Oran, 2005; Saywitz, 1989; Warren-Leubecker, Tate, Hinton, & Ozbek,
1989) and express more negative feelings about testifying (Goodman et al., 1992; Quas et al., 2005), which suggests that they
may evince greater negative emotion during forensic-interview disclosures as well. Moreover, older children are generally
more aware of society norms concerning sexual taboos and proper parental care (e.g., Goldman & Goldman, 1982), awareness
that may result in greater distress during a forensic interview. Thus, we expected an age increase in emotional display when
children disclose abuse in a legal context.
Gender may also be related to children’s negative affect at disclosure. Boys and girls express emotions differently, with
girls exhibiting less anger and more fear and sadness than boys (Belle, 1989; Belle, Burr, & Cooney, 1987; Fuchs & Thelen,
1988; Zeman & Garber, 1996), and boys being more successful at suppressing distress than girls (Alessandri & Lewis, 1996).
Thus, we expected a significant gender difference in maltreated children’s expressed distress during disclosure.
Trauma-related symptoms, psychological adjustment, and emotion expression
Child maltreatment is associated with adverse emotional reactions, such as depression, dissociation, and post-traumatic
stress disorder (PTSD: Egeland, Sroufe, & Erickson, 1983; Kendall-Tackett, Williams, & Finkelhor, 1993; Putnam, 1997; Toth,
Manly, & Cicchetti, 1992; Trickett & McBride-Chang, 1995). Emotional expressivity at disclosure may be affected by such
trauma-related symptoms (Bonnano, Noll, Putnam, O’Neill, & Trickett, 2003; Bonanno et al., 2007). Maltreated children often
evince symptoms of depression (e.g., Beitchman et al., 1992; Polusny & Follette, 1995), a potentially important predictor of
maltreated children’s expressed emotion during disclosure. Burnam et al. (1988) reported that 13% to 22% of abused children
met criteria for depression compared to only 4% to 6% of non-abused children. Andrews (1995) demonstrated an association
between depression symptoms and feelings of shame in adult female survivors of abuse. Shame is behaviorally manifested
by downward head movements and gaze aversion (Bonanno et al., 2002), displays likely to be interpreted as indices of upset.
In addition, dissociation could lead some children to display neutral or stunted emotional affect when discussing abuse.
Dissociation is a coping mechanism that enables an individual to deal with extreme stressors by psychologically escaping an
otherwise inescapable situation. It is believed that dissociation can become habitual, resulting in psychopathology (Putnam,
2000). Highly dissociative children are at risk of developing chronic feelings of depersonalization and derealization, which
may lead these children to appear emotionally stunted during a forensic interview (Bonnano et al., 2003). However, it is also
possible that such children will become openly upset when required to articulate their highly stressful experiences.
1028 L. Sayfan et al. / Child Abuse & Neglect 32 (2008) 1026–1036
Post-traumatic stress might also influence children’s expression of emotion. Sufferers of PTSD typically show three types of
symptoms: (a) re-experiencing the stressful event through flashbacks, nightmares, and daydreams; (b) avoidance behaviors,
such as numbness and avoidance of thoughts and reminders of the trauma; and (c) hyper-arousal including sleep prob-
lems, difficulties in concentration, heightened startle responses, and irritability (American Psychiatric Association, 1994).
These symptoms may affect children’s emotional expressions during a forensic interview. For example, children who have
repeated nightmares and flashbacks might be expected to become particularly distressed when discussing abuse. Putnam
(1997) asserts that exposure to trauma-related stimuli (e.g., direct questions about the abuse) can increase the traumatized
individual’s susceptibility to re-experiencing abuse-related emotions. Conversely, children who have become emotionally
withdrawn and numb as a part of their trauma response might be expected to evince less emotional upset.
It is also important to consider children’s overall psychological adjustment. Recent research suggests that expression
of positive emotion when discussing abuse is related to adjustment problems (Bonanno et al., 2007). To the extent that
adjustment problems generally and trauma-related psychopathology specifically are correlated, the independent contribu-
tion of each should be determined. This was accomplished in the present study by inclusion of a measure of global adaptive
functioning.
Child abuse characteristics and emotion expression
Child abuse characteristics, such as type and frequency of abuse, may play important roles in how children display
emotion when disclosing abuse. For example, child physical abuse might be associated with greater anger (e.g., Hoffman-
Plotkin & Twentyman, 1984), and child sexual abuse with greater shame (e.g., Bonanno et al., 2002). When adult females
with histories of sexual abuse were asked to report how they felt emotionally during the sexual activities, victims’ reactions
fell into three categories: Guilt/Fear, Anger/Disgust, and Positive. Individuals in the Guilt/Fear group reported feeling guilty,
afraid, ashamed, anxious, detached, and numb, and those in the Anger/Disgust category reported being angry, disgusted,
and curious. Individuals in the positive emotions category reported feeling, for example, interested, special, important, and
enjoyment (e.g., of the physical sensations). Of particular note was the finding that individuals in the Guilt/Fear group were
more likely to be involved in repeated abuse incidences. That is, the children who were abused repeatedly (e.g., by a family
member) were especially likely to report feeling ashamed, detached, and numb (Long & Jackson, 1993; see also Bonanno et
al., 2002). In regard to the current study, such research might indicate that in a forensic interview, children who have been
repeatedly abused might display stunted affect when disclosing abuse.
Overview
The present study focused on predictors of maltreated children’s affect when they discussed incidents of abuse. Videotaped
forensic interviews of abused children were coded, and indices of demographic information, abuse characteristics, and
psychological functioning served as predictors.
Based on prior research (Wood et al., 1996), it was expected that the majority of maltreated children in our sample would
evince neutral affect during disclosure. We considered neutral affect as an indifferent, flat, or calm expression, one that cannot
be identified as expressing obvious negative affect (e.g., sadness, irritation, or anger) or positive affect (e.g., joy, happiness).
Predictors of differences in children’s emotional expressivity were also hypothesized. Specifically, older compared to younger
children were expected to express greater emotional upset when they disclosed abuse. Males were expected to display
less emotion than females. Further, greater depression was expected to predict more negative affect expression. We also
tested the opposing hypothesis that children with more symptoms of dissociation would display less emotional expressivity
versus the hypothesis that children with more symptoms of dissociation would display more emotional expressivity. We
examined similar contrasting hypotheses for symptoms of PTSD. Finally, we expected that children who were repeatedly
abused (measured by number of prior reported allegations) would express less upset during disclosure.
Method
Participants
The 124 children, ranging from 3- to 16-years-old (M = 8.54, SD = 3.47), were those who disclosed some form of abuse
or neglect during a forensic interview conducted at an abuse-evaluation center. The sample was largely African American,
female, and allegedly physically abused, sexually abused, and/or neglected (see Table 1).
The children had been removed from home by child protective services due to suspicions of maltreatment, or in a relatively
few cases, brought to the center by caretakers. Caretakers who brought their children to the center received information
about the study upon their arrival, and a staff member obtained their consent. For children who were wards of the state,
consent was given by child protective services. Child assent was obtained as well. The study was reviewed and approved by
Internal Review Boards at the child protective services department, the maltreatment evaluation center, and the University
of California, Davis.
To be included, all children had a videotaped forensic interview and an affect rating provided by a forensic interviewer.
Videotapes were included if the child disclosed some form of abuse or neglect and had a determination of maltreatment
Table 1
Characteristics of the sample.
Variable Percentage N
Gender
Male 38% 47
Female 62% 77
Age
3-5 years old 24% 30
6-8 years old 31% 38
9-16 years old 45% 56
Ethnicity
African American 76% 94
Caucasian 13% 17
Hispanic 10% 12
Others 1% 1
Abuse type category

Sexual Abuse 36% 45
Physical Abuse 43% 53
Neglect 21% 26
as indicated by the clinical staff at the evaluation center and/or by child protective services. Some of the videotapes were
excluded due to poor sound or visual quality. Using these restrictions, a total of 124 tapes were coded for the present study.
Our sample did not differ significantly from the entire sample (n = 443) in age, gender, abuse type, or race, 2 s ≤ 1.99, ps ≥ .16.
Most of the children at the evaluation center did not experience a forensic interview, which was conducted only if a criminal
case was being considered. There were no known refusals to participate, but our previous research on forensic and clinical
interviews that encompassed the present sample indicated that approximately 18% of the larger sample did not disclose past
abuse experiences (Ghetti, Goodman, Eisen, Qin, & Davis, 2002).
Coding of emotional expression
Interviewer ratings. At the end of the interview, the interviewer rated the child’s upset and crying both for when the child
entered the room and during disclosure. The scale for the child’s negative affect ranged from 1 (very happy) to 6 (very upset),
with 3.5 considered as neutral. The scale for the child’s crying ranged from 1 (not crying) to 6 (hysterically crying), with 3.5
treated as moderately crying.
Researcher ratings. To establish inter-rater reliability, two researchers first jointly coded several tapes (not part of the current
sample) using the same scales as those used by the interviewers at the child-abuse assessment center. All disagreements
were resolved by discussion. After this practice period, the researchers independently coded 25% of the videotaped inter-
views, and these data were used to calculate reliability between coders and interviewers. Specifically, researchers rated the
child’s upset and crying upon entering the room and during disclosure, on the 6-point scales. The researchers were blind
to the interviewers’ and to each other’s ratings and to hypotheses. Reliabilities were calculated within one scale point as
an agreement. Proportions of agreement between the two raters, and between each rater and the interviewer, for negative
affect at the beginning of the interview, ranged from .90 to 1.0. The proportions of agreement between the two raters, and
between each rater and the interviewer, for negative affect when the child discussed/disclosed the abuse ranged from .75 to
.95. The proportion of agreement between the two raters, and between each rater and the interviewer, for the cry scale was
1.0.
Psychological measures
Dissociative Experiences Scale for Adolescents (A-DES; Armstrong & Carlson, 1993). The A-DES, for 11-year-olds and older, is
a downward extension of the DES (Bernstein & Putnam, 1986) that includes 30 items describing dissociative experiences
(e.g., “When I am somewhere that I don’t want to be, I can go away in my mind.”). Children are asked to rate how often
each experience happens to them on a 0-10 scale (0 = never and 10 = always). The A-DES has adequate reliability (alpha = .93),
internal validity, and discriminant validity (Armstrong, Putnam, Carlson, Libero, & Smith, 1997). Reliability within the current
sample was also adequate (alpha = .93). Higher scores indicate greater dissociative tendencies.
Child Dissociative Checklist (CDC). The CDC is an observer-report measure of dissociative behavior, ranging from normal to
pathological, in 4- to 19-year-olds. A 3-point scale (0 = not at all true to 2 = very true) is used to indicate whether behaviors
such as “Child frequently talks to him or herself, may use a different voice or argue with self at times” are characteristic of
the child. In the present study, the CDC was administered only to caretakers who had been caring for the child for at least 2
months at the time of the assessment. The instrument is temporally reliable, with test-retest reliability coefficients ranging
from .61 to .69, and test-retest reliabilities for individual subscales ranging from .57 to .92 (Putnam, Helmers, & Trickett,
1993). The CDC is internally consistent (alphas = .80 to .95) and has obtained a Spearman-Brown coefficient of .94 (Putnam
et al., 1993). In the current sample, alpha was .86.
Child Depression Inventory (CDI-S; Kovacs, 1983). The CDI-S is a widely used self-report measure of depression for 8- to 15-
year-olds (Kovacs, 1983). For each of 10 items, children are asked to point to one of three statements that best represents
how they felt in the past 2 weeks, for example “I feel sad: 0 (once in a while), 1 (many times), or 2 (all the time).” Higher
numbers indicate elevated depression. The CDI-S is internally consistent, with alpha coefficients ranging from .71 to .89
(Kovacs, 1992). In the current sample alpha was .75.
Trauma Symptom Checklist-Child Version (TSC-C; Briere & Runtz, 1993). The TSC-C, a downward extension of the TSC-40, is a
54-item questionnaire designed to assess post-traumatic stress, dissociation, anxiety, anger, sexual concerns, and depression
in 8- to 15-year-olds who have been abused and/or traumatized. Children indicate on a 4-point scale (0 = never to 3 = almost
all of the time) how often experiences such as “Feeling nervous or jumpy inside” happen to them. Higher scores designate a
greater number of symptoms. The inventory is psychometrically sound and predictive of maltreatment history (e.g., Briere,
1996; Briere & Runtz, 1993; Evans, Briere, Boggiano, & Barrett, 1994; Friedrich, 1993; Sadowski & Friedrich, 2000). The
reliability within the current sample was high (alpha = .94).
Post-Traumatic Symptom Inventory for Children (PT-SIC; Eisen, 1997). The PT-SIC is a 28-item self-report measure of symptoms
of posttraumatic stress in young children (4 years of age and up). The PT-SIC has excellent internal reliability (alpha = .91) and
adequate test-retest reliability, r = .88, when administered to a clinical sample of maltreated children (Eisen, 1997). Within
the current sample alpha was .89.
Global Assessment of Functioning (GAF; American Psychiatric Association, 1994). This measure is based on criteria described in
the DSM-IV manual. The child’s psychological, social, and educational functioning is rated on a 100-point scale. Higher ratings
indicate higher levels of adaptive functioning. The GAF scale is almost identical to the Global Assessment Scale, which has high
reliability, and good concurrent and predictive validity; it is among the most useful instruments for measuring psychological
functioning (Endicott, Spitzer, Fleiss, & Cohen, 1976; Sohlberg, 1989).
Composite measures. All measures were standardized, and composite measures of depression, dissociation, and PTSD were
created. The depression composite measure was the average of the CDI-S total score and the TSC-C depression subscale. A
principal components analysis with promax rotation revealed that the two measures of depression (CDI-S and TSC-C) loaded
on the same factor with 75% of the variance explained (alpha = .67). Similarly, the dissociation composite measure was the
average of four scores: the CDC total score, the A-DES total score, and the two TSC-C dissociation subscales. A principal
components analysis with promax rotation confirmed that the four measures of dissociation loaded on the same factor
with 66% of the variance explained (alpha = .79). A principal components analysis with promax rotation revealed that the
two measures of PTSD (PT-SIC and the TSC-C PTSD subscale) loaded on the same factor with 82% of the variance explained
(alpha = .77).
Abuse characteristics
Abuse type. Abuse type was determined in conjunction with the child abuse evaluation program based on current medical
and forensic evaluations, and previous history as reported by child protective services. Children were separated into three
abuse status categories. A child was classified into the sexually abused category if he or she had a known history of sexual
abuse based on child protective services reports, or if the current program investigation indicated that the child had been
sexually abused. Specifically, the sexually abused group included children with a known history of sexual abuse alone or
combined with other forms of maltreatment. A child was classified as physically abused if he or she had a known history of
physical abuse according to child protective services reports, or if the current program investigation indicated that the child
had been physically abused, but there was no history of child sexual abuse. A child was classified into the neglect category
if he or she had a previous history of neglect, but no known history or current incidents of abuse (sexual or physical).
Number of abuse allegations. The number of abuse allegations was calculated based on the frequency of former sexual abuse,
physical abuse, or neglect accusations indicated by child protective services.
Procedure
As a part of the child maltreatment assessment procedure, children individually received a forensic interview. During the
interview, one of five forensic interviewers (blind to the study hypotheses) questioned the child about possible maltreatment
using a semi-structured interview that minimized, but still included some, leading questions (“Has anybody ever hit or
whooped you?” “Do you have enough food at home?” “Has anyone ever touched you on your private parts?” [asked after
determining that the child understood the term “private parts”]). The interview often involved use of anatomical dolls and
Table 2
Means and standard deviations for key variables.
Variable Gender Abuse type Overall N
Males Females SAB PAB Neglected
Age 8.32 (3.59) 8.68 (3.42) 8.84 (3.56) 9.04 (2.85) 7.00 (4.09) 8.54 (3.47) 124
Negative affect at beginning of interview 2.74 (1.03) 2.52 (.90) 2.49 (.82) 2.87 (1.00) 2.27 (.96) 2.60 (.95) 124
Negative affect at disclosure 3.62 (.80) 3.73 (.97) 3.91 (.82) 3.64 (.90) 3.38 (.98) 3.69 (.90) 124
Frequency of abuse allegations 3.88 (.2.83) 5.04 (4.54) 4.80 (4.08) 4.65 (4.66) 4.14 (2.02) 4.60 (4.01) 112
Composite dissociationa .14 (.91) −.03 (.80) .05 (.63) .05 (.95) .06 (1.03) 0 (1.00) 93
Composite depressiona .11 (1.1) .19 (.98) .05 (.90) .24 (.102) −.10 (1.27) 0 (1.00) 78
Composite PTSDa −.05 (.95) .05 (.95) .06 (.93) −.04 (.85) .04 (1.33) 0 (1.00) 95
GAF 67.83 (9.29) 69.43 (8.04) 68.18 (7.80) 67.48 (9.42) 72.67 (6.85) 68.82 (8.54) 97
Note. SDs in parentheses. Dissociation, depression, and post-traumatic stress disorder (PTSD) composite measures were standardized (Z scored). GAF = Global
Assessment of Functioning. SAB = sexual abuse. PAB = physical abuse. The Ns reported are the original ones before imputing missing values.
a
z scores.
body charts. During this interview, or right after, the interviewer rated the child’s upset and crying in regard to when the
child had entered the room and when the child had discussed the abuse.
At the end of a (separate) psychological consultation interview, a licensed clinical psychologist (blind to the study
hypotheses) assessed the child’s GAF. The child-report dissociation, depression, and PTSD measures were administered to
age-appropriate participants within ±2 days of the forensic interview. Parents or caretakers who were available completed
the CDC.
Results
Means for key variables are presented in Table 2. To preview, descriptive data concerning the overall demeanor of children
at disclosure are presented first. Next, the relations among participant factors (age, gender, race), abuse factors (type of abuse,
frequency of abuse), and psychopathology measures (depression, dissociation, PTSD, GAF) are elucidated. Finally, results of a
multiple hierarchical regression analysis, conducted to detect the independent contribution of predictors of negative affect
at disclosure, are described.
Negative emotional expression in maltreated children
Congruent with our expectation to find high proportions of neutral emotional display, 75% of the children in our sample
evinced a neutral expression when disclosing abuse (their negative affect was coded at the midpoints, that is, at 3 or 4, of
the 6-point scale). A neutral expression corresponded to flat affect, lack of emotional expression, blank stares, or monotone
voice. Further, 98% of the children did not cry when disclosing the abuse; only three cried at that time.
Imputing missing data
Because of the complex nature of the study design and sample, it was not possible to obtain a complete data set on every
participant. Mainly, this happened because the child was released from the program before completing all questionnaires.
In a few cases, a negative affect at disclosure or a crying rating by the forensic interviewer was missing. In these cases, one of
the researchers who had established reliability with the forensic interviewers completed the rating. To account for missing
data, a linear regression interpolation method was used (see Elliot & Hawthorne, 2005, for review).
Predictors of negative emotional expression at disclosure
Type of abuse was recoded into two variables: SAB (child sexual abuse = 1, physical abuse or neglect = 0) and PAB (child
physical abuse = 1, child sexual abuse or neglect = 0). Gender was coded as males = 0 and females = 1. Race was coded as
African Americans = 1 and all other races = 2. As a first step, correlations were calculated. Significant associations were found
for a subset of predictors concerning the ratings of emotional distress at disclosure for maltreated children (see Table 3).
Specifically, number of abuse allegations was significantly but negatively correlated with negative affect at disclosure, indi-
cating that children with a greater number of prior alleged abuse incidences expressed less upset at disclosure. SAB was
significantly correlated with negative affect at disclosure, such that sexually abused children were rated as more upset at
disclosure than were the other children. Negative affect at the beginning of the interview was also significantly related to
negative affect at disclosure. In contrast to our prediction, psychopathology measures were not significantly correlated with
negative affect at disclosure. Finally, physically abused children were more upset at the beginning of the interview than were
the other children.
To control for interrelations among the variables, a multiple hierarchical regression was performed. First, we examined
the individual scatterplots of each variable and the dependent measure (i.e., negative affect at disclosure). Because no outliers
1032
Table 3
Correlation matrix for all maltreated children.
Gender Race Age SAB PAB Number of GAF Composite Composite Composite Negative affect Negative affect
L. Sayfan et al. / Child Abuse & Neglect 32 (2008) 1026–1036

abuse PTSD depression dissociation at beginning at disclosure
allegations measure measure measure
Gender 1
Race 0.24** 1
Age 0.05 0.03 1
SAB 0.17* 0.06 0.07 1
PAB −0.23** −0.13 0.12 −0.65*** 1
Number of abuse 0.14 0.01 0.08 0.04 0.01 1
allegations
GAF 0.09 −0.06 −0.11 −0.06 −0.14 −0.08 1
Composite PTSD 0.03 −0.07 −0.08 0.05 −0.07 0.00 −0.18 1
measure
Composite depression −0.01 −0.04 −0.39*** −0.09 0.06 −0.04 −0.10 0.24** 1
measure
Composite dissociation −0.10 −0.07 −0.28** 0.01 −0.04 −0.06 −0.12 0.40*** 0.27** 1
measure
Negative affect at −0.12 −0.01 0.10 −0.09 0.24** −0.16 −0.14 −0.01 0.06 0.02 1
beginning
Negative affect at 0.06 0.07 0.09 0.19* −0.04 −0.22** 0.05 0.04 0.10 0.17 0.48*** 1
disclosure
Note. *p < .05, **p < .01, ***p < .001. Gender was coded as males = 0 and females = 1. Race was coded as African Americans = 1 and all other races = 2. GAF = Global Assessment of Functioning. PTSD = post-traumatic
stress disorder. SAB = sexual abuse. PAB = physical abuse.
Table 4
Multiple hierarchical regression analysis: Predicting negative affect at disclosure (N = 124).
Variable B SE B ˇ
Step 1
Negative affect at beginning of interview .46 .08 .49***
Gender .19 .15 10
Race .10 .18 .05
Age .01 .02 .03
Step 2
Gender .13 .15 .07
Race .09 .17 .04
Age .01 .02 .02
SAB .41 .19 .22*
PAB .00 .20 .00
Frequency of abuse allegations −.04 .02 −.20*
Step 3
Gender .16 .15 .09
Race .14 .17 .07
Age .04 .02 .14
SAB .50 .19 .27**
PAB .10 .20 .05
Depression .12 .09 .11
Dissociation .25 .11 .20*
PTSD −.03 .09 −.03
GAF .02 .01 .17*
Step 4
Gender .16 .15 .09
Race .08 .17 .04
Age .04 .02 .14
SAB 1.2 1.3 .64
PAB .10 .19 .06
Depression 08 .09 .7
Dissociation .14 .11 .12
PTSD −.02 .09 −.02
GAF .02 .01 .22*
SAB × Dissociation interaction .52 .23 .20*
SAB × Frequency of abuse interaction .03 .04 .10
SAB × GAF interaction −.01 .02 −.47
Note. R2 = .24 for Step 1 (p < .001); R2 = .05 for Step 2 (p < .05); R2 = .09 for Step 3 (p < .01); R2 = .04 for Step 4 (p = .07). *p < .05, **p < .01, ***p < .001.
Gender was coded as males = 0 and females = 1. Race was coded as African Americans = 1 and all other races = 2. GAF = Global Assessment of Functioning.
PTSD = post-traumatic stress disorder. SAB = sexual abuse. PAB = physical abuse.
were detected, we created the regression model using information on all 124 participants (with missing values imputed).
In each step of the model variables were entered simultaneously. The rationale for entering variables in each step was
conceptual. In the first step, the negative affect score from the beginning of the interview was entered as a covariate. All
participant factors (age, gender, and ethnicity) were entered at this stage. Abuse characteristics (abuse type and number of
abuse allegations) were entered in the second step. Next, the psychopathology measures (depression, dissociation, PTSD,
and GAF) were entered. In the final step, interactions between abuse type and the other significant factors (from the earlier
steps) were entered. Results of the regression analysis are reported in Table 4.
The first step in the regression accounted for 24% of the variance in negative affect at disclosure. This result was due to the
negative affect at the beginning of the interview which was positively related to negative affect at disclosure. Step 2 added 5%
to the shared variance explained in negative affect at disclosure, with SAB and the frequency of abuse allegation as significant
contributors. Accordingly, children who were sexually abused expressed more negative affect at disclosure compared to the
rest of the sample, and children who had more abuse incidents expressed less negative emotion at disclosure. At Step 3,
the dissociation and GAF psychopathology measures added 9% to the shared variance explained. Namely, higher dissociative
symptom scores predicted less negative emotion at disclose, and higher GAF scores were associated with more negative
emotion at disclosure. Note that although it is possible that the children who obtained higher scores on the GAF were more
intelligent, a measure of short-term memory, which correlates with full-scale IQ, was not a significant predictor of negative
affect at disclosure.
Finally, adding the interaction effects in Step 4 contributed 4% to the variance explained in the negative affect measure.
As can be seen in Table 4, although SAB and dissociation were no longer significant predictors on their own, a significant
interaction between SAB and dissociation emerged. This interaction indicated that for children who had been sexually abused,
a higher score on the dissociation measure predicted greater negative affect at disclosure.
Inspection of the distributions of all measures in the regression model suggested that none violated assumptions of
normality. That is, measures of skewness and kurtosis were within the acceptable two standard deviation ranges for the
psychopathology measures (depression, dissociation, PTSD, and GAF) as well as for the dependent variable (i.e., negative
affect at disclosure; .41 > sess > −.40, SEs = .22; .80 > seks > .37, SEs = .43). Further examination of the residuals plots revealed
that the linearity and homoscedasticity assumptions were not violated. Finally, measures of multicollinearity were also
within the acceptable range (1 < VIFs < 1.5); thus, adding the interaction terms did not affect the stability of the model.
To the extent that our sample might have included children who, despite their disclosure, actually had not experienced
maltreatment, we also examined the subset of cases in which corroborated evidence existed (i.e., cases that had the following
types of evidence: medical evidence, confession by perpetrator, or eyewitness). The same pattern of results emerged when
we analyzed only the corroborated cases.
Discussion
This study examined the characteristics of maltreated children’s emotional display at time of disclosure of abuse incidents,
as well as the unique predictors of these children’s negative affect. It is generally expected that during their disclosures, child
victims will be highly distressed, cry, and show other negative emotional reactions. This expected pattern of reaction seems
to make their story more credible to jurors (Myers et al., 1999). However, our findings cast doubt on the validity of these
expectations. Consistent with prior research (Wood et al., 1996), our study showed that most of the children displayed neutral
affect when they discussed abuse incidents, and most of them did not cry.
Nevertheless, in line with our expectations, maltreated children who had a greater number of prior abuse allegations
appeared less upset when discussing the abuse. It could be argued that abuse had become a regular part of these children’s
lives and therefore they had developed a stunted emotional reaction to the violence. Another possibility is that these children
simply had more previous interviews, and thus talking about the abuse was less upsetting for them.
For the sexually abused group, dissociation predicted children’s negative affect. Specifically, sexually abused children
who had more dissociative characteristics were more upset when discussing abuse. Previous studies indicate that highly
dissociative children are at risk of developing chronic feelings of depersonalization and derealization (Putnam, 2000). It
might have been expected that these characteristics would have led the maltreated children in the present study to appear
emotionally stunted during the forensic interview (Bonnano et al., 2003). Yet, sexually abused children who had more
dissociative characteristics seemed more upset. This finding is consistent with the argument that some sexually abused
children may become upset at time of disclosure because they are forced, in effect, to confront these stressful events.
Clinicians rated the children’s global adaptive functioning. The GAF measure provides an overall evaluation of children’s
mental health-related behavior. Children rated as better functioning expressed more emotion at disclosure. These children
may be more in touch with their negative emotions or more aware of the implications of the maltreatment. Taken together
with the present findings for dissociation, the results suggest that symptoms of certain forms of emotional problems are
important predictors of emotional expressivity at disclosure.
Contrary to expectation, age and gender were unrelated to negative affect at disclosure. This might have been influenced
by the fact that the number of children in certain age and/or gender groups did not afford sufficient statistical power. For
example, in the sexually abuse group most of the children were 9 years or over (50%), and in the physically abuse group,
there was a relatively small number of young children (13%). Further, in general there was a smaller number of males than
females in all the abuse groups. Nevertheless, the (nonsignificant) trends for the mean negative affect ratings were relatively
consistent with the stated hypotheses. Specifically, females tended to be somewhat more upset at disclosure than males,
and older children tended to be more upset than younger children.
Our findings must be viewed in light of the limitations of the study. First, the sample was relatively homogenous ethnically,
with 75% of the sample being African American, and all data were collected in one geographical area. Therefore, the results
may not generalize across other ethnicities and locales. Second, we had a limited number of children in certain maltreated
groups. Third, the possibility exists that some of the children had not in fact been maltreated; however, the results replicated
in corroborated cases. Nevertheless, the leading nature of the interview might have influenced emotional expression. Fourth,
because we had to rely on a composite measure of PTSD, we could not reliably separate intrusive, hyperarousal, and avoid-
ance/numbness symptoms. A fifth issue, mentioned earlier, is that children who were repeatedly abused might have been
repeatedly interviewed in the past. Sixth, interviewers’ preinterview knowledge about the case could have affected their
ratings, and the interviewers themselves were not trained to be reliable with each other in use of our negative affect scale.
However, the fact that researchers, who were naïve to the preinterview allegations, reached high inter-rater reliability with
the interviewers, and with each other, motivates greater confidence in the findings. Finally, co-occurrence of abuse types
may have negatively affected our results. In future studies, researchers should consider larger and more diverse samples,
coding for discrete emotions, assessing clusters of PTSD symptoms, relying on nonleading interviews, and carefully indexing
number of previous interviews.
Nevertheless, our findings are important for understanding how children react emotionally when they disclose abuse
in forensic interviews, and perhaps in clinical interviews as well. The results may also be relevant to court settings, when
abused children are required to testify (but see Quas et al., 2005). Although it is expected that during their disclosures, child
victims will be highly distressed, cry, and show other negative emotional reactions, we found, as did Wood et al. (1996)
previously, that children in forensic interviews often display neutral affect at disclosure, and most do not cry. Although
the abused children’s affect was often neutral, stronger negative reactions were linked to: fewer abuse experiences; global
adaptive functioning; and for sexually abused children, dissociation.
References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington DC: American Psychiatric Association.
Andrews, B. (1995). Bodily shame as a mediator between abusive experiences and depression. Journal of Abnormal Psychology, 104(2), 277–285.
Alessandri, S. M., & Lewis, M. (1996). Development of the self-conscious emotions in maltreated children. In M. Lewis & M. W. Sullivan (Eds.), Emotional
development in atypical children (pp. 185–201). Mahwah, NJ: Lawrence Erlbaum Associates.
Armstrong, J., & Carlson, E. (1993). The Adolescent Dissociative Experiences Scales (A-DES). Unpublished document.
Armstrong, J., Putnam, F., Carlson, E., Libero, D., & Smith, S. (1997). Development and validation of a measure of adolescent dissociation: The Adolescent
Dissociative Experiences Scale. Journal of Nervous and Mental Disease, 185(8), 491–497.
Beitchman, J. H., Zucker, K. J., Hood, J. E., DaCosta, G. A., Akman, D., & Cassavia, E. (1992). A review of the long-term effects of child sexual abuse. Child Abuse
& Neglect, 16(1), 101–118.
Belle, D. (1989). Children’s social networks and social supports. Oxford, England: John Wiley & Sons.
Belle, D., Burr, R., & Cooney, J. (1987). Boys and girls as social support theorists. Sex Roles, 17(11–12), 657–665.
Bernstein, E. M., & Putnam, F. W. (1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174, 727–735.
Block, S. D., Goodman, G. S., Oran, H. S., & Oran, D. (2005). Abused and neglected children in dependency court. Paper presented at the American Psychology-Law
Society Meetings, La Jolla, CA.
Bonanno, G. A., Colak, D. M., Keltner, D., Shiota, M. N., Papa, A., Noll, J. G., Putnam, F. W., & Trickett, P. K. (2007). Context matters: The benefits and costs of
expressing positive emotion among survivors of childhood sexual abuse. Emotion, 7(4), 824–837.
Bonanno, G. A., Keltner, D., Noll, J. G., Putnam, F. W., Trickett, P. K., LeJeune, J., & Anderson, C. (2002). When the face reveals what words do not: Facial
expressions on emotion, smiling, and willingness to disclose childhood sexual abuse. Journal of Personality and Social Psychology, 83, 94–110.
Bonnano, G. A., Noll, J. G., Putnam, F. W., O’Neill, M., & Trickett, P. K. (2003). Predicting willingness to disclose childhood sexual abuse from measures of
repressive coping and dissociative tendencies. Child Maltreatment, 8, 302–318.
Briere, J. (1992). Child abuse trauma: Theory and treatment of the lasting effects. Interpersonal violence: The practice series, No. 2. Thousand Oaks, CA: Sage
Publications.
Briere, J. (1996). Trauma Symptoms Checklist for Children: Professional manual. Odessa, FL: Psychological Assessment Resources.
Briere, J., & Runtz, M. (1993). Childhood sexual abuse: Long-term sequelae and implications for psychological assessment. Journal of Interpersonal Violence,
8, 312–330.
Burnam, M. A., Stein, J. A., Golding, J. M., Siegel, J. M., Judith, M., Sorenson, S. B., Forsythe, A. B., & TeUes, C. A. (1988). Sexual assault and mental disorders in
a community population. Journal of Consulting & Clinical Psychology, 56(6), 843–850.
Cole, P. M., Zahn-Waxler, C., & Smith, K. D. (1994). Expressive control during a disappointment: Variations related to preschoolers’ behavior problems.
Developmental Psychology, 30(6), 835–846.
Egeland, B., Sroufe, A., & Erickson, M. (1983). The developmental consequence of different patterns of maltreatment. Child Abuse & Neglect, 7(4), 459–469.
Eisen, M. L. (1997). Assessing post-traumatic stress in children: A new measure. Unpublished manuscript.
Ekman, P., & Friesen, W. V. (1975). Unmasking the face: A guide to recognizing emotions from facial clues. Oxford, England: Prentice-Hall.
Elliot, P., & Hawthorne, G. (2005). Imputing missing repeated measures data: How should we proceed? Mental health research. Australian & New Zealand
Journal of Psychiatry, 39(7), 575–582.
Endicott, J., Spitzer, R., Fleiss, J., & Cohen, J. (1976). The Global Assessment Scale: A procedure for measuring overall severity of psychiatric disturbance.
Archives of General Psychiatry, 33, 766–771.
Evans, J. J., Briere, J., Boggiano, A. K., & Barrett, M. (1994). Reliability and validity of the Trauma Symptom Checklist for Children in a normal sample. Poster
session at the San Diego Conference on Responding to Child Maltreatment, San Diego, CA.
Fuchs, D., & Thelen, M. H. (1988). Children’s expected interpersonal consequences of communicating their affective state and reported likelihood of
expression. Child Development, 59(5), 1314–1322.
Friedrich, W. N. (1993). Sexual victimization and sexual behavior in children: A review of recent literature. Child Abuse & Neglect, 17, 59–66.
Ghetti, S., Goodman, G. S., Eisen, M., Qin, J. J., & Davis, S. (2002). Consistency in children’s reports of sexual and physical abuse. Child Abuse & Neglect, 26,
977–995.
Goldman, R., & Goldman, J. (1982). Children’s sexual thinking. London: Routledge & Kegan Paul.
Goodman, G. S., Taub, E. P., Jones, D. P. H., England, P., Port, L. K., Rudy, L., & Prado, L. (1992). Testifying in criminal court: Emotional effects on child sexual
assault victims. Monographs of the Society for Research in Child Development, 57(5 serial no. 229), v-142.
Harris, P. L. (1985). What children know about the situations that provoke emotion. In M. Lewis & C. Saarni (Eds.), The socialization of emotions (pp. 161–185).
New York, NY: Plenum Press.
Harris, P. L., Olthof, T., & Meerum Terwogt, M. (1981). Children’s knowledge of emotions. Journal of Child Psychology and Psychiatry, 22, 247–261.
Harter, S. (1998). The effects of child abuse on the self-system. Journal of Aggression, Maltreatment & Trauma, 2, 147–169.
Hoffman-Plotkin, D., & Twentyman, C. T. (1984). A multimodal assessment of behavioral and cognitive deficits in abused and neglected preschoolers. Child
Development, 55, 794–802.
Kaufman, G., Drevland, G., Wessel, E., Oversleid, G., & Magnussen, S. (2002). The importance of being earnest: Displayed emotions and witness credibility.
Applied Cognitive Psychology, 19, 21–34.
Kendall-Tackett, K. A., Williams, L. M., & Finkelhor, D. (1993). Impact of sexual abuse on children: A review and synthesis of recent empirical studies.
Psychological Bulletin, 113, 164–180.
Kovacs, M. (1983). The Children’s Depression Inventory: A self-rated depression scale for school aged youngsters. Unpublished manuscript, University of Pittsburgh
School of Medicine.
Kovacs, M. (1992). Manual for the Children’s Depression Inventory. North Tonawanda, NY: Multi-Health Systems, Inc.
Kovera, M., Gresham, A., Borgida, E., Gray, E., & Regan, P. (1997). Does expert witness testimony inform or influence jury decision making? A social cognitive
analysis. Journal of Applied Psychology, 82, 178–191.
Long, P., & Jackson, J. L. (1993). Initial emotional response to childhood sexual abuse: Emotion profiles of victims and relationship to later adjustment. Journal
of Family Violence, 8, 167–181.
Myers, J. E. B., Goodman, G. S., Redlich, A., & Prizmich, L. (1999). Jurors’ reactions to hearsay in child sexual abuse cases. Psychology, Public Policy, and Law, 5,
388–419.
Polusny, M. A., & Follette, V. M. (1995). Long-term correlates of child sexual abuse: Theory and review of the empirical literature. Applied & Preventive
Psychology, 4(3), 143–166.
Putnam, F. W. (1997). Dissociation in children and adolescents. NY: Guilford Press.
Putnam, F. W. (2000). Dissociative disorders. In A. J. Sameroff & M. Lewis (Eds.), Handbook of developmental psychopathology (2nd ed., pp. 739–754). Dordrecht
Netherlands: Kluwer Academic Publishers.
Putnam, F. W., Helmers, K., & Trickett, P. K. (1993). Development, reliability, and validity of a child dissociation scale. Child Abuse & Neglect, 17, 731–740.
Quas, J. A., Goodman, G. S., Ghetti, S., Alexander, A., Edelstein, R., Redlich, A., Cordon, I., & Jones, D. P. H. (2005). Childhood sexual assault victims: Long-term
outcomes after testifying in criminal court. Monographs of the Society for Research in Child Development, 70, (Serial No. 280).
Regan, P. C., & Baker, S. J. (1998). The impact of child witness demeanor on perceived credibility and trial outcome in sexual abuse cases. Journal of Family
Violence, 13, 187–195.
Saarni, C. (1989). Children’s beliefs about emotion. In M. Luszez & T. Nettelbeck (Eds.), Psychological development: Perspectives across the life-span (pp. 69–78).
North-Holland: Elsevier Science Publishers.
Sadowski, C. M., & Friedrich, W. N. (2000). Psychometric properties of the Trauma Symptom Checklist for Children (TSCC) with psychiatrically hospitalized
adolescents. Child Maltreatment, 5(4), 364–372.
Saywitz, K. (1989). Children’s conceptions of the legal system: “Court is a place to play basketball”. In S. J. Ceci, M. Toglia, & D. Ross (Eds.), Perspectives on
children’s testimony (pp. 131–157). New York: Springer.
Sohlberg, S. (1989). There’s more in a number than you think: Validity data for the Global Assessment scores. Psychological Reports, 64, 455–461.
Toth, S. L., Manly, J. T., & Cicchetti, D. (1992). Child maltreatment and vulnerability to depression. Development & Psychopathology, 4(1), 97–112.
Trickett, P. K., & McBride-Chang, C. (1995). The developmental impact of different forms of child abuse and neglect. Developmental Review, 15(3), 311–337.
Warren-Leubecker, A., Tate, C., Hinton, I., & Ozbek, N. (1989). What do children know about the legal system and when do they know it? First steps down a
less traveled path in child witness research. In S. Ceci, M. Toglia, & D. Ross (Eds.), Perspectives on Children’s testimony (pp. 131–157). New York: Springer.
Weiner, B., & Handel, S. J. (1985). A cognition-emotion-action sequence: Anticipated emotional consequences of causal attributions and reported commu-
nication strategy. Developmental Psychology, 21(1), 102–107.
Wood, B., Orsak, C., Murphy, M., & Cross, H. J. (1996). Semistructured child sexual abuse interviews: Interview and child characteristics related to credibility
of disclosure. Child Abuse & Neglect, 20, 81–92.
Zeman, J., & Garber, J. (1996). Display rules for anger, sadness, and pain: It depends on who is watching. Child Development, 67(3), 957–973.
Child Dissociative Checklist (CDC)
Reference list of articles using the CDC
9-30-10
1. Blake, M. & Weinberger, J. (2006). The impact of childhood sexual abuse upon implicit
processing of intimacy-related stimuli. Stress, Trauma and Crisis: An International Journal, 9(1),
29-44.
2. Cardena, E., (2008). Dissociative disorders measures, in Handbook of psychiatric measures (2nd
ed.). 2008, American Psychiatric Publishing, Inc., Arlington, VA, US. 587-599.
3. Carlson, S.M., Tahiroglu, D., & Taylor, M. (2008). Links between dissociation and role play in a
nonclinical sample of preschool children. Journal of Trauma & Dissociation, 9(2), 149-171.
4. Chaffin, M., et al. (1997). False negatives in sexual abuse interviews: preliminary investigation of
a relationship to dissociation. Journal of Child Sexual Abuse, 6(3), 15-29.
5. Chu, A. & DePrince, A.P. (2006). Development of Dissociation: Examining the Relationship
Between Parenting, Maternal Trauma and Child Dissociation. Journal of Trauma & Dissociation,
7(4), 75-89.
6. Chu, A.T., DePrince, A.P., & Weinzierl, K.M. (2008). Children's perception of research
participation: Examining trauma exposure and distress. Journal of Empirical Research on Human
Research Ethics, 3(1), 49-58.
7. Collin-Vezina, D. & Hebert, M. (2005). Comparing Dissociation and PTSD in Sexually Abused
School-Aged Girls. Journal of Nervous and Mental Disease, 193(1), 47-52.
8. Collopy, M.-J.C. & B., 2000. The fantasy-reality distinction in children: Implications for
eyewitness testimony, in Dissertation Abstracts International: Section B: The Sciences and
Engineering. 2000, ProQuest Information & Learning, US. p. 2194.
9. Coons, P.M. (1996). Clinical phenomenology of 25 children and adolescents with dissociative
disorders. Child and Adolescent Psychiatric Clinics of North America, 5(2), 361.
10. Cromer, L.D., et al. (2006). The Relationship Between Executive Attention and Dissociation in
Children. Journal of Trauma & Dissociation, 7(4), 135-153.
11. Daignault, I.V. & Hebert, M. (2009). Profiles of school adaptation: Social, behavioral and
academic functioning in sexually abused girls. Child Abuse & Neglect, 33(2), 102-115.
12. De Bellis, M.D., et al. (1999). Developmental traumatology part I: biological stress systems.
Biological Psychiatry, 45(10), 1259-1270.
13. De Bellis, M.D., et al. (1997). Urinary catecholamine excretion in childhood overanxious and
posttraumatic stress disorders. Annals of the New York Academy of Sciences, 821, 451-455.
14. De Bellis, M.D., et al. (1999). Developmental traumatology part II: brain development.
Biological Psychiatry, 45(10), 1271-1284.
15. De Bellis, M.D., et al. (2002). Superior temporal gyrus volumes in maltreated children and
adolescents with PTSD. Biological Psychiatry, 51(7), 544-552.
16. De Bellis, M.D., et al. (2002). Brain structures in pediatric maltreatment-related posttraumatic
stress disorder: a sociodemographically matched study. Biological Psychiatry, 52(7), 1066-1078.
17. De Bellis, M.D. & Kuchibhatla, M. (2006). Cerebellar Volumes in Pediatric Maltreatment-
Related Posttraumatic Stress Disorder. Biological Psychiatry, 60(7), 697-703.
18. DePrince, A.P., Chu, A.T., & Combs, M.D. (2008). Trauma-related predictors of deontic
reasoning: A pilot study in a community sample of children. Child Abuse & Neglect, 32, 732-737.
19. DePrince, A.P., Weinzierl, K.M., & Combs, M.D. (2008). Stroop performance, dissociation, and
trauma exposure in a community sample of children. Journal of Trauma & Dissociation, 9(2),
209-223.
20. Diamanduros, T.D., 2004. Traumatic stress symptomatology in sexually abused boys
[dissertation]. 2004, New York University. p. 219 pp.
21. Diseth, T.H. & Christie, H.J. (2005). Trauma-related dissociative (conversion) disorders in
children and adolescents - an overview of assessment tools and treatment principles. Nordic
Journal of Psychiatry, 59(4), 278-292.
22. Eisen, M.L., et al., (1999). Individual differences in maltreated children's memory and
suggestibility., in Trauma and Memory, L.M. Williams and V.L. Banyard, Editors. 1999, Sage
Publications: Thousand Oaks, California. 31-46.
23. Eisen, M.L., et al. (2007). Maltreated children's memory: Accuracy, suggestibility, and
psychopathology. Developmental Psychology, 43(6), 1275-1294.
24. Endo, T., Sugiyama, T., & Someya, T. (2006). Attention-deficit/hyperactivity disorder and
dissociative disorder among abused children. Psychiatry and Clinical Neurosciences, 60, 434-
438.
25. Feindler, E.L., Rathus, J.H., & Silver, L.B., (2003). Self-report inventories for the assessment of
children, in Assessment of family violence: A handbook for researchers and practitioners. 2003,
American Psychological Association, Washington, DC, US. 125-227.
26. Friedrich, W.N. (2002). Psychological assessment of sexually abused children and their families.
2002, Thousand Oaks, California: Sage Publications, xvi, 368.
27. Friedrich, W.N., et al. (2001). Multimodal assessment of dissociation in adolescents: inpatients
and juvenile sex offenders. Sex Abuse, 13(3), 167-77.
28. Friedrich, W.N., et al. (1997). Dissociative and sexual behaviors in children and adolescents with
sexual abuse and psychiatric histories. Journal of Interpersonal Violence, 12(2), 155-171.
29. Friedrich, W.N., et al. (1997). Dissociative and sexual behaviors in children and adolescents with
sexual abuse and psychiatric histories. Journal of Interpersonal Violence, 12(2), 155-171.
30. Friedrich, W.N., Olafson, E., & Connelly, L., (2004). Child Abuse and Family Assessment:
Strategies and Inventories, in Assessment of couples and families: Contemporary and cutting-
edge strategies. 2004, Brunner-Routledge, New York, NY, US. 207-247.
31. Gilbert, A.M., 2004. Psychometric properties of the Trauma Symptom Checklist for Young
Children (TSCYC) [dissertation]. 2004, Alliant International University, San Diego. p. 152 p.
32. Goodman, J.R. & B., 1996. Symptoms of dissociative disorder in children and adolescents, in
Dissertation Abstracts International: Section B: The Sciences and Engineering. 1996, ProQuest
Information & Learning, US. p. 1465.
33. Graham, D.B., (1996). The pediatric management of the dissociative child, in The dissociative
child: Diagnosis, treatment, and management (2nd ed.). 1996, The Sidran Press, Baltimore, MD,
US. 297-314.
34. Haraldsson, E. (2003). Children who speak of past-life experiences: is there a psychological
explanation?. Psychology and Psychotherapy: Therapy, Research and Practice, 76(1), 55-67.
35. Haralsson, E., Fowler, P.C., & Periyannanpillai, V. (2000). Psychological Characteristics of
Children Who Speak of a Previous Life: A Further Field Study in Sri Lanka. Transcultural
Psychiatry, 37(4), 525.
36. Hoffman, T.L., 1999. Latino children, child abuse, symptoms of posttraumatic stress disorder
and psychiatric difficulties [dissertation]. 1999, University of Southern California.
37. Hoier, T.S. (1991). The course of treatment of a sexually abused child: a single-case study.
Behavioral Assessment, 13(4), 385-398.
38. Jareb, H.O. & B., 1999. Dissociation and memory for venipuncture in female adolescents and
young adults with and without a history of childhood sexual abuse, in Dissertation Abstracts
International: Section B: The Sciences and Engineering. 1999, ProQuest Information & Learning,
US. p. 0368.
39. Kaplow, J.B., et al. (2006). The Long-Term Consequences of Early Childhood Trauma: A Case
Study and Discussion. Psychiatry: Interpersonal and Biological Processes, 69(4), 362-375.
40. Kasiraj, J.M., 1993. Predicting residual trauma symptoms in child and adolescent cancer
survivors [dissertation]. 1993, California School of Professional Psychology: Fresno.
41. Kisiel, C.L. & Lyons, J.S. (2001). Dissociation as a mediator of psychopathology among sexually
abused children and adolescents. American Journal of Psychiatry, 158(7), 1034-1039.
42. London, M.D. & B., 1997. Comparing levels of dissociation and levels of depression, anxiety and
trauma sequelae in a non-clinical sample of elementary and middle school children aged 8 to 12
years, in Dissertation Abstracts International: Section B: The Sciences and Engineering. 1997,
ProQuest Information & Learning, US. p. 5333.
43. Macfie, J., Cicchetti, D., & Toth, S.L. (2001). Dissociation in maltreated versus nonmaltreated
preschool-aged children. Child Abuse & Neglect, 25(9), 1253-67.
44. Macfie, J.A. & B., 1999. The development of dissociation in maltreated preschoolers. (child
maltreatment, dissociative disorders, narratives), in Dissertation Abstracts International: Section
B: The Sciences and Engineering. 1999, ProQuest Information & Learning, US. p. 1861.
45. Malinosky-Rummell, R.R. & Hoier, T.S. (1997). Validating measures of dissociation in sexually
abused and nonabused children. Behavioral Assessment, 13(4), 341-357.
46. Marzo, D.C. & B., 1996. The relation between sexual abuse and dissociative symptomatology in
children and adolescents, in Dissertation Abstracts International: Section B: The Sciences and
Engineering. 1996, ProQuest Information & Learning, US. p. 1448.
47. Mennen, F.E. (2004). PTSD Symptoms in Abused Latino Children. Child & Adolescent Social
Work Journal, 21(5), 477-493.
48. Murphy, A.E., 2002. Congruence of symptomology in adult and child posttraumatic stress
disorder [dissertation]. 2002, Hofstra University.
49. Nader, K.O., (1997). Assessing traumatic experiences in children, in Assessing psychological
trauma and PTSD. 1997, Guilford Press, New York, NY, US. 291-348.
50. Ogawa, J.R., et al. (1997). Development and the fragmented self: longitudinal study of
dissociative symptomatology in a nonclinical sample. Development and Psychopathology, 9(4),
855-879.
51. Putnam, F.W. (1997). Dissociation in children and adolescents: a developmental perspective. Vol.
viii. 1997, New York: Guilford Press, 423.
52. Putnam, F.W., et al. (1995). Hypnotizability and dissociativity in sexually abused girls. Child
Abuse & Neglect, 19(5), 645-55.
53. Putnam, F.W., Helmers, K., & Trickett, P.K. (1993). Development, reliability, and validity of a
child dissociation scale. Child Abuse & Neglect, 17(6), 731-41.
54. Putnam, F.W. & Peterson, G. (1994). Further validation of the Child Dissociative Checklist.
Dissociation, 7(4), 204-211.
55. Putnam, F.W. & Trickett, P.K. (1997). Psychobiological effects of sexual abuse: a longitudinal
study. Annals of the New York Academy of Sciences, 821, 150-159.
56. Reyes-Perez, C.D., Mart¡nez-Taboas, A., & Ledesma-Amador, D. (2005). Dissociative
experiences in children with abuse histories: a replication in Puerto Rico. Journal of Trauma and
Dissociation, 6(1), 99-112.
57. Rossman, B.R., Bingham, R.D., & Emde, R.N. (1997). Symptomatology and adaptive
functioning for children exposed to normative stressors, dog attack, and parental violence.
Journal of the American Academy of Child & Adolescent Psychiatry, 36(8), 1089-97.
58. Sayfan, L., et al. (2008 ). Children's expressed emotions when disclosing maltreatment. Child
Abuse & Neglect, 32, 1026-1036.
59. Schechter, D.S., et al. (2007). Caregiver traumatization adversely impacts young children's
mental representations on the MacArthur Story Stem Battery. Attachment & Human
Development, 9(3), 187-205.
60. Schechter, D.S., et al. (2007). Child mental representations of attachment when mothers are
traumatized: The relationship of family-drawings to story-stem completion. Journal of Early
Childhood and Infant Psychology, 3, 119-140.
61. Schober, J.M., et al. (2004). The impact of monosymptomatic nocturnal enuresis on attachment
parameters. Scandinavian Journal of Urology & Nephrology, 38(1), 47-52.
62. Shapiro, L.R. & Purdy, T.L. (2005). Suggestibility and Source Monitoring Errors: Blame the
Interview Style, Interviewer Consistency, and the Child's Personality. Applied Cognitive
Psychology, 19(4), 489-506.
63. Silberg, J.L., (1996). Appendix A: Assessment Instruments., in The dissociative child: diagnosis,
treatment, and management. 1996, Sidran Press: Lutherville, Maryland. 331-340.
64. Steinberg, M. (1996). Diagnostic Tools for Assessing Dissociation in Children and Adolescents.
Child and Adolescent Psychiatric Clinics of North America, 5(2), 333-349.
65. Stolbach, B.C. (2005). Psychotherapy of a dissociative 8-year-old boy burned at age 3.
Psychiatric Annals, 35(8), 685-694.
66. Tupler, L.A. & De Bellis, M.D. (2006). Segmented hippocampal volume in children and
adolescents with posttraumatic stress disorder. Biological Psychiatry, 59(6), 523-529.
67. Walker, A.M., et al. (1999). Post-traumatic stress responses following liver transplantation in
older children. Journal of Child Psychology and Psychiatry and Allied Disciplines, 40(3), 363-
374.
68. Waters, F.S. (2005). When treatment fails with traumatized children...why? [editorial]. Journal of
Trauma and Dissociation, 6(1), 1-8.
69. Wherry, J.N., et al. (1994). The Child Dissociative Checklist: preliminary findings of a screening
measure. Journal of Child Sexual Abuse, 3(3), 51-66.
70. Wherry, J.N., Neil, D.A., & Taylor, T.N. (2009). Pathological dissociation as measured by the
child dissociative checklist. Journal of Child Sexual Abuse: Research, Treatment, & Program
Innovations for Victims, Survivors, & Offenders, 18(1), 93-102.
71. Wherry, J.N., Neil, D.A., & Taylor, T.N. (2010). Corrigendum of Pathological dissociation as
measured by the Child Dissociative Checklist. Journal of Child Sexual Abuse: Research,
Treatment, & Program Innovations for Victims, Survivors, & Offenders, 19(3), 365.
72. Yeager, C.A. & Lewis, D.O. (1996). The intergenerational transmission of violence and
dissociation. Child and Adolescent Psychiatric Clinics of North America, 5(2), 393-430.
73. Zoroglu, S.S., et al. (2002). Reliability and validity of the Turkish version of the Child
Dissociative Checklist. Journal of Trauma and Dissociation, 3(1), 37-49.

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CHILD DISSOCIATIVE CHECKLIST

Date: ________ Age: ________ Sex: M F Identification: ________

0 1 2 4. Child is unusually forgetful or confused about things that he or she should

0 1 2 6. Child shows marked day-to-day or even hour-to-hour variations in his or her

0 1 2 7. Child shows rapid regressions in age-level of behavior, e.g. a twelve year-old

0 1 2 12. Child is unusually sexually precocious and may attempt age-inappropriate

0 1 2 17. Child sleepwalks frequently.

Pathological Dissociation as Measured

JEFFREY N. WHERRY, DEBRA A. NEIL, and TAMARA N. TAYLOR

Abilene Christian University, Abilene, Texas, USA

The component structure of the Child Dissociative Checklist was

KEYWORDS child abuse, dissociation, assessment, diagnosis

Dissociation has been described by Putnam, Helmers, and Trickett (1993) as

Received 26 September 2006; revised 17 January 2007; accepted 6 May 2008.

determine if children assessed by the CDC could be described as evidencing

CHILD DISSOCIATIVE CHECKLIST, VERSION 3.0

TABLE 1 Rotated Component Matrix of the CDC

Rotated Component Matrix

CDC Items Variability Pathological Externalizing

6. Child shows marked variations in skills, .721 .186 .015

18. Child has unusual nighttime experiences. .560 .381 .025

TABLE 2 Distribution of Pathological Dissociation Raw Scores

Score Frequency Percent Cumulative Percent

.00 or more 157 67.4 100.0

components were .834 for variability in behavior, .696 for pathological

Predicting Pathological Dissociation

Differences between Groups

higher rates of pathological dissociation among boys or to differences

Chu, J. A., & Dill, D. L. (1990). Dissociative symptoms in relation to childhood

test. Circle Pines, MN: American Guidance Service.

Accelerated Professional Career Track Psychology Program at Abilene Christian

Dissociation as a Mediator of Psychopathology

(Am J Psychiatry 2001; 158:1034–1039)

C hildhood sexual abuse may be related to more dele-

1034 Am J Psychiatry 158:7, July 2001

Am J Psychiatry 158:7, July 2001 1035

1036 Am J Psychiatry 158:7, July 2001

Am J Psychiatry 158:7, July 2001 1037

1038 Am J Psychiatry 158:7, July 2001

Am J Psychiatry 158:7, July 2001 1039

Psychiatry and Clinical Neurosciences (2006), 60, 434–438 doi:10.1111/j.1440-1819.2006.01528.x

Key words attention-deficit/hyperactivity disorder, child abuse, dissociative disorder.

INTRODUCTION abused children, however, abused children without

© 2006 The Authors

METHODS given in Table 1. As Table 1 shows, the most frequent

© 2006 The Authors

Table 2. Comorbidity of dissociative disorder and attention-deficit/hyperactivity disorder symptoms

Subjects who did not fulfil Subjects who fulfilled

Dissociative disorder (+) 6 12 5 23

disorder in PDD subjects may be different from other *

Rate of ADHD-suspected parents

tive disorder fulfilled ADHD-A after CA more fre-

© 2006 The Authors

DISCUSSION ation scale should be established in Japan as soon as

© 2006 The Authors

© 2006 The Authors

Contents lists available at ScienceDirect

Date: Age: Sex: M F Identification:

IQ estimate −0.10 0.40 0.01 −0.37