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516681 research-article2013 ANP0010.1177/0004867413516681ANZJP ArticlesWatson et al. Research Australian &

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New Zealand Journal of Psychiatry 2014, Vol. 48(6) 564­–570 DOI: 10.1177/0004867413516681 Childhood trauma in bipolar disorder © The Royal Australian and New Zealand College of Psychiatrists 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com Stuart Watson1, Peter Gallagher1, Dominic Dougall2, Richard Porter3, Joanna Moncrieff2, I Nicol Ferrier1 and Allan H Young4 Editor’s Choice Abstract Objective: There has been little investigation of early trauma in bipolar disorder despite evidence that stress impacts on the course of this illness. We aimed to compare the rates of childhood trauma in adults with bipolar disorder to a healthy control group, and to investigate the impact of childhood trauma on the clinical course of bipolar disorder. Methods: Retrospective assessment of childhood trauma was conducted using the Childhood Trauma Questionnaire (CTQ) in 60 outpatients with bipolar disorder being treated for a depressive episode and 55 control participants across two centres in north-east England and New Zealand. Results: Significantly higher rates of childhood trauma were observed in patients with bipolar I and bipolar II disorder compared to controls. Logistic regression, controlling for age and sex, identified emotional neglect to be the only significant CTQ subscale associated with a diagnosis of bipolar disorder. Childhood history of sexual abuse was not a significant predictor. Associations with clinical severity or course were less clear. Conclusions: Childhood emotional neglect appears to be significantly associated with bipolar disorder. Limitations include the relatively small sample size, which potentially increases the risk of type II errors. Replication of this study is required, with further investigation into the neurobiological consequences of childhood trauma, particularly emotional neglect. Keywords Bipolar disorder, childhood trauma, depression, emotional neglect Introduction The high prevalence and incidence (Merikangas et al., 2011), chronicity of symptoms (Judd et al., 2002, 2003), and psychosocial impairment (Judd et al., 2005) of bipolar disorder underlines the need to establish its aetiological and risk factors. Bipolar disorder is highly heritable (McGuffin et al., 2003); psychosocial stress also appears to increase the likelihood of first and possibly subsequent episodes (Etain et al., 2008; Post, 1992). Childhood trauma is a recognised indicator of poor prognosis in major depressive disorder (Douglas and Porter, 2012; Nanni et al., 2012) but, in bipolar disorder, whilst the impact of stressors in adulthood on the course of illness has been investigated (Cohen et al., 2004; Paykel, 2003), the impact of early trauma has been relatively neglected. One study has shown that early parental loss is more common (Agid et al., 1999), whilst others have shown that childhood stressful life events are less common (Horesh et al., 2011) or as common (Horesh Australian & New Zealand Journal of Psychiatry, 48(6) and Iancu, 2010) in bipolar disorder compared with healthy controls. Children and adolescents with bipolar disorder have been shown to be exposed to more negative life events and less positive events compared to controls (Romero et al., 2009), although interestingly, a recent paper suggested that the link between stressful events and bipolar disorder may be a consequence of the illness (Hosang et al., 1The Institute for Neuroscience, Newcastle University, Newcastle, UK of Brain Sciences, University College London, London, UK 3Department of Psychological Medicine, University of Otago, Christchurch, New Zealand 4Centre for Affective Disorders, Institute of Psychiatry, Kings College London, London, UK 2Faculty Corresponding author: Stuart Watson, The Wolfson Unit, Campus for Aging and Vitality, The Institute for Neuroscience, Newcastle University, Newcastle NE4 6BE, UK. Email: stuart.watson@newcastle.ac.uk 565 Watson et al. 2012). Studies using the Childhood Trauma Questionnaire (CTQ) (Bernstein et al., 2003) have reported a higher rate of childhood trauma (Fowke et al., 2012), particularly emotional abuse (Etain et al., 2010), in bipolar disorder. Retrospectively reported childhood abuse has been associated with an adverse illness course (Garno et al., 2005; Leverich et al., 2002), more depressive episodes (Garno et al., 2005), greater severity of mania (Garno et al., 2005; Leverich et al., 2002), with earlier onset (Carballo et al., 2008; Garno et al., 2005; Leverich et al., 2002), suicidal ideation (Carballo et al., 2008; Leverich et al., 2002), substance abuse (Brown et al., 2005; Carballo et al., 2008), and with impaired performance on tests of neuropsychological function (Savitz et al., 2008). However, interpretation of these findings is limited by the clinical and methodological heterogeneity of these studies (Daruy-Filho et al., 2011). In this study, childhood trauma, as measured by the CTQ, was compared in a sample of people with bipolar disorder recruited for a randomised trial (Watson et al., 2012) and in a healthy control group. It was predicted that higher CTQ scores would be associated with a diagnosis of bipolar disorder and secondly, that childhood trauma would be associated with measures of clinical severity. Methods Sample This analysis uses baseline assessment data from a randomised placebo-controlled trial of mifepristone treatment in bipolar depression (Watson et al., 2012). The study was carried out in two centres, Newcastle University in the north-east of England and Otago University in Christchurch, New Zealand. The main inclusion criterion was a diagnosis of bipolar disorder current episode depressed, confirmed with the Structured Clinical Interview for DSM-IV (SCID) (First et al., 1997). Additional inclusion criteria were: age between 18 and 65 years, stable medication for a minimum of 4 weeks, the ability to provide informed consent and the ability to adequately understand both written and verbal English. Both men and women were eligible. Potential participants were excluded if they fulfilled criteria for substance abuse or dependence (First et al., 1997), were pregnant, suffered significant medical illness which would render recruitment into the clinical trial unsafe (such as: suffered head trauma with persistent loss of consciousness, a neurological disorder or uncompensated endocrine disorder). A co-morbid axis II diagnosis was not an exclusion criterion. After a complete description of the study, written informed consent was obtained from all participants. The study received full approval from the local ethics committee. Participants were recruited from outpatient clinics allied to the respective centres. Sixty patients were randomized over a 5-year period from October 2004, of which 31 patients met SCID criteria for bipolar I and 25 the criteria for bipolar II. A cohort of 55 age- and sex-matched comparators, who were SCID confirmed as having no current or past history of an axis I disorder, was concurrently locally recruited. Assessment After an initial screening visit, baseline data was collected by trained psychiatrists with full history, case note and medication review. The data included demographic and clinical characteristics of sex, age, body mass index (BMI), pre-morbid IQ measured by the National Adult Reading Test (NART) (Nelson and Willison, 1991) and number of years of education. Measures which may indicate clinical severity included: the 17-item version of the Hamilton Depression Rating Scale (HDRS-17) (Hamilton, 1960); diagnosis of DSM-IV melancholia; length of the current depressive episode (weeks); number of previous hospitalisations; current alcohol intake (standard UK alcohol units per week); diagnosis of rapid cycling bipolar disorder; history of attempted suicide; any form of current suicidal ideation reported to the assessor. The childhood trauma questionnaire (CTQ) was also completed. The CTQ is a validated 28-item self-report questionnaire used to provide a retrospective measure of childhood trauma (Bernstein et al., 2003). It uses a fivepoint Likert-type scale. Twenty-five of the CTQ questions are split into five subscales of maltreatment: emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect. The other three questions are used for detecting ‘false-negative’ answers involving a minimisation/denial scale. Statistical analyses Distributions of CTQ scores did not meet the assumption required for parametric analysis. Where appropriate, the bipolar group was divided into SCID (First et al., 1997) determined bipolar I and bipolar II subgroups. Chi-squared (χ2) test was used to compare sex distribution across bipolar and control groups. Age and BMI were normally distributed and were compared across bipolar and control groups using the independent samples t-test. The Mann–Whitney U-test and Spearman’s rank order correlations were used for all other comparisons of continuous variables. CTQ subscales for pooled bipolar and control data were examined using Spearman’s rho to identify significant correlations between subscales to determine suitability for inclusion in a regression analysis. Spearman’s rho was also used to examine relationships between CTQ subscale scores and the demographic variables, age, pre-morbid IQ (NART score) and years of education. CTQ subscale scores were compared between males and females. Step forward logistic regression of CTQ total scores and relevant demographic Australian & New Zealand Journal of Psychiatry, 48(6) 566 ANZJP Articles variables was performed to examine the overall relationship between trauma and bipolar disorder, with the binary outcome variable of bipolar or control group. A separate step forward logistic regression of the relevant CTQ subscales and demographic variables was performed to explore for relationships according to types of trauma. Results Patients and controls were matched for age, sex, pre-morbid IQ (NART score) and years of education, as reported in Table 1. A diagnosis of bipolar disorder was found to be significantly associated with a greater total CTQ score (Table 2). All subscale scores were significantly higher in the bipolar group, apart from sexual abuse. Similar results were found when the analysis was restricted to those with a diagnosis of bipolar I. In participants diagnosed with bipolar II, CTQ total, emotional abuse, emotional neglect and physical neglect scores were significantly greater than controls. Table 3 shows that in bipolar patients, CTQ scores did not differ between those with and those without suicidal ideation, although scores for the emotional neglect subscale showed a trend towards significance. Participants with a diagnosis of DSM-IV melancholia had significantly higher CTQ total scores, and significantly higher emotional neglect and emotional abuse scores than those without. Participants with a diagnosis of rapid cycling bipolar disorder had higher sexual abuse subscale scores than those who were not rapid cycling. In bipolar patients who reported one Table 1. Demographic and clinical characteristics of the bipolar group and control group. Bipolar patients % or mean (SD) Controls % or mean (SD) Comparison (p) Male (%) 53.3 54.5 χ2 = 0.02 (0.896) Age (mean years) 47.9 (9.4) 45.1 (13.1) t = 1.3 (0.193) BMI 29.8 (6.2) 26.0 (3.7) t = 3.0 (0.004) 110.6 (10.5) 113.3 (11.3) U = 1152.5 (0.089) 14.7 (3.3) 14.8 (4.3) U = 917.0 (0.554) NART IQ Years of education BMI: body mass index; NART IQ: National Adult Reading Test IQ. Table 2. CTQ scores in bipolar groups compared to controls.a All bipolar N = 60b Bipolar I N = 31b,c Comparison CTQ (SD) U p Bipolar II N = 25b,c Control N = 55% Comparison Comparison CTQ (SD) U p CTQ (SD) U p CTQ (SD) CTQ total 44.4 (19.1) 490.0 < 0.001 43.6 (20.6) 280.5 0.004 41.1 (13.1) 203.0 0.003 31.2 (8.0) Emotional abuse 10.4 (5.4) 780.0 < 0.001 10.2 (5.8) 470.0 0.012 9.7 (4.3) 294.0 0.005 6.8 (2.8) Physical abuse 7.5 (4.4) 903.0 0.005 7.9 (4.9) 461.0 0.005 6.0 (2.1) 439.5 0.387 5.4 (1.3) Sexual abuse 7.7 (5.4) 1092.5 0.131 7.9 (4.9) 584.5 0.182 7.1 (4.1) 428.5 0.224 6.2 (3.1) 12.4 (6.0) 767.0 < 0.001 12.7 (7.0) 459.5 0.011 11.1 (4.2) 299.0 0.008 8.2 (3.5) 7.9 (3.8) 787.5 < 0.001 8.1 (4.2) 446.0 0.002 7.2 (3.0) 306.5 0.003 5.7 (1.7) Emotional neglect Physical neglect aTable showing mean and SD of CTQ scores in different subject groups with a comparison using Mann–Whitney U-test of CTQ scores between the bipolar groups (all bipolar patients and those with a diagnosis of bipolar I or bipolar II) with controls. bNumbers vary due to the incomplete return of CTQs: all bipolar, N = 49–57; bipolar I, N = 25–31; bipolar II, N = 20–22; control, N = 39–45. cFour participants with bipolar disorder were not sub-classified as either bipolar I or II. CTQ: Childhood Trauma Questionnaire. Australian & New Zealand Journal of Psychiatry, 48(6) 567 vary due to the incomplete return of CTQs: history of attempted suicide, yes N = 23–29, no N = 21–23; current suicidal ideation, yes N = 11–13, no N = 34–40; rapid cycling, yes N = 6, no N = 38–46; DSM-IV melancholia, yes N = 21–24, no N = 23–27. CTQ: Childhood Trauma Questionnaire. aNumbers 0.046 222.0 (3.8) 6.9 (3.7) 8.9 137.0 0.976 (3.5) 7.8 9.3 9.2 Physical neglect (4.3) 6.6 (2.7) 218.5 0.029 6.8 (2.2) 8.2 (4.3) 235.0 0.597 (6.5) 0.031 210.0 (5.2) 10.9 (6.0) 129.5 0.807 14.3 (5.9) 12.6 12.5 13.7 Emotional neglect (6.4) 11.4 (5.4) 255.0 0.146 9.7 (5.9) 13.1 (6.0) 169.0 0.058 (6.7) 0.907 319.0 (5.3) 7.6 (6.0) 8.2 75.5 0.038 (5.0) 7.4 12.7 9.0 Sexual abuse (6.2) 6.7 (4.6) 265.0 0.198 8.4 (4.9) 7.7 (5.8) 190.0 0.184 (7.9) 0.227 264.5 (3.5) 7.0 (4.3) 7.8 116.0 0.503 (3.9) 7.2 10.2 8.3 Physical abuse (5.6) 6.9 (2.8) 322.5 0.831 6.8 (3.2) 7.9 (4.9) 234.0 0.569 (7.7) 0.216 259.0 (4.2) 8.9 (6.2) 113.5 0.479 11.6 (5.3) 10.1 12.3 11.5 Emotional abuse (5.9) 9.2 (5.0) 260.5 0.174 10.1 (5.6) 10.4 (5.6) 256.0 0.933 (6.4) 0.023 p U (14.9) 145.0 CTQ (SD) (20.8) 37.7 CTQ (SD) p U 92.0 0.451 49.8 (16.3) (SD) CTQ (32.6) 42.9 56.8 CTQ (SD) p U (20.3) 176.5 0.781 (SD) CTQ (19.4) 44.7 (SD) CTQ 42.8 0.051 p U Comparison (12.8) 158.5 CTQ (SD) (23.1) 38.3 CTQ (SD) No N = 42a Yes N = 14a No N = 24a Yes N = 31a 51.6 No N = 48a Yes N = 7a Comparison Rapid cycling Current suicidal ideation History of attempted suicide Table 3. Analyses of bipolar group clinical severity and clinical characteristics. CTQ total No N = 29a Yes N = 25a Comparison DSM-IV melancholia Comparison Watson et al. or more previous suicide attempts, CTQ total score was higher (p = 0.051), and scores significantly higher in the emotional abuse subscale. No significant correlations between CTQ total or CTQ subscale scores and length of current episode, number of previous hospitalizations, current severity of depression (HDRS-17 score), current alcohol intake were found (rs < 0.3, p > 0.1). Bivariate correlations between pooled bipolar and control scores of the five trauma subscales found significant correlations between all subscales (0.33 < rs < 0.64, p < 0.002), apart from between physical and sexual abuse (rs = 0.12, p = 0.17). All correlations were below 0.8 and therefore could be entered into a regression model without risk of multi-colinearity. Differences or associations with CTQ subscale scores and demographic characteristics were limited to age, which was significantly, but weakly, correlated with emotional neglect (rs = 0.14, p = 0.046) and sexual abuse scores which were significantly higher in females (U = 873.0, p < 0.001). NART scores or years of education were not significantly correlated with the CTQ subscales (rs < 0.2, p > 0.1). The factors considered to be plausible independent causal risk factors, i.e. CTQ total score, age and sex, were entered into step forward logistic regression, with the dependent variable of group (bipolar or control). This confirmed CTQ total score was the only significant predictor (β = 0.08, p = 0.001). The five subscale scores, age and sex, were then entered into a second step forward logistic regression, also with the dependent variable of group. Emotional neglect (β = 0.185, p < 0.001) remained the only significant predictor in the model (Table 4). Emotional abuse approached significance (p = 0.082). Discussion This paper demonstrates significant associations between childhood trauma and bipolar disorder. Higher CTQ scores were found in patients diagnosed with both bipolar I and bipolar II disorder compared to controls. Sexual abuse was the only subscale measure that was not higher in bipolar patients compared with controls. In bipolar patients with a diagnosis of DSM-IV melancholia, emotional neglect and physical neglect scores were higher. CTQ subscale scores were higher in those with a past history of attempted suicide or a diagnosis of rapid cycling bipolar disorder. Logistic regression showed CTQ total scores to differentiate bipolar patients from controls, and separately identified emotional neglect to be the only significant subscale of the CTQ to differentiate bipolar patients from controls. Emotional abuse approached significance and may therefore be considered as a potential contributor to the model. Our study is in line with the findings of two previous studies which also found that patients with a diagnosis of bipolar disorder reported higher rates of childhood trauma compared to healthy controls (Etain et al., 2010; Fowke et al., 2012). Exploring the subscales, we did not find Australian & New Zealand Journal of Psychiatry, 48(6) 568 ANZJP Articles Table 4. Logistic regression of CTQ subtypes predicting a diagnosis of bipolar disorder (I and II). Step 1 Age Gender Emotional abuse Physical abuse Sexual abuse Physical neglect Step 1a Emotional neglect Constant Score df 0.324 0.119 3.030 1.790 0.017 1.865 1 1 1 1 1 1 p 0.569 0.730 0.082 0.181 0.896 0.172 β Wald p 0.185 1.651 14.393 10.246 < 0.001 0.001 CTQ: Childhood Trauma Questionnaire. significant differences in the sexual abuse scale, which is in accord with one previous report (Etain et al., 2010) and is supported by a recent paper that found sexual abuse to be the least reported form of abuse by bipolar patients (Larsson et al., 2013), although other studies did find this association (Fowke et al., 2012; Hyun et al., 2000). Our findings differed in identifying emotional neglect, as opposed to an earlier finding of emotional abuse, to be the single significant subscale associated with bipolar disorder (Etain et al., 2010; Fowke et al., 2012). Methodological differences with the previous studies utilising the CTQ (Etain et al., 2010; Fowke et al., 2012) relate to the presence or absence of current episode and to the sample size. Our finding that a history of childhood trauma is related to a history of suicide attempts in bipolar patients is also in line with other studies (Alvarez et al., 2011; Carballo et al., 2008; Garno et al., 2005; Leverich et al., 2002), although two of these studies did not use a validated measure to retrospectively assess for childhood trauma (Carballo et al., 2008; Leverich et al., 2002). The allostatic impact of childhood trauma may be mediated through a range of biological systems with the hypothalamic–pituitary–adrenal (HPA) axis appearing to have a central role (Grande et al., 2012). It can also be argued that childhood trauma, at sensitive periods, may trigger an altered developmental pathway (Bateson et al., 2004), mediated in part by epigenetic processes (McGowan et al., 2009). For example, the regulation of hippocampal GR expression (McGowan et al., 2009) may induce ‘evolutionary appropriate’ responses such as increased vigilance, alertness to danger, responsivity to novel stressors and a willingness to explore new environments (Glover, 2011). The trade-off for such responses may be an increased risk of behavioural problems in childhood (Ramchandani et al., 2012) and of adult psychopathology including bipolar disorder (Watson et al., 2007) and suicidality (McGowan Australian & New Zealand Journal of Psychiatry, 48(6) et al., 2009). It is of interest that emotional neglect was the only subscale which significantly differentiated patients from controls. Emotional neglect suggests a pervasive deficiency in the parent–child relationship (Glaser, 2002), has been repeatedly linked with HPA axis dysregulation in adults (Gerra et al., 2008, 2010; Watson et al., 2007) and has been previously shown to be differentially related to depression (Spinhoven et al., 2010). It has been suggested that retrospective assessment of childhood trauma may be liable to recall bias in depressed patients (Lewinsohn and Rosenbaum, 1987). However, it should be noted that autobiographical recall of events (as measured using CTQ scores) in our study did not significantly correlate with severity of depression. CTQ scores have also been demonstrated to remain stable over time and to be independent of the current degree of abuse-related psychopathology (Paivio, 2001). Although there have been concerns that retrospective reporting overestimates associations between abuse and adult psychopathology compared to prospective assessment (Gilbert et al., 2009), a recent study found retrospective, compared to prospective, assessment of maltreatment predicted similar rates of mental disorder (Scott et al., 2012). A previous study has shown that recall bias accounted for less than 1% of reporting variance for measures of childhood abuse (Fergusson et al., 2011). However, emotional neglect is arguably the most subjective and difficult to define among forms of abuse, and hence further examination of the relationship between abuse and neglect and bipolar disorder in prospective studies which exclude recall bias would be useful. Investigations with euthymic bipolar patients would help to clarify the potential impact of current mood state. A weakness of this study is the relatively small sample size, which engenders the risk of type II errors. Further, the use of baseline data from a randomized controlled trial may have resulted in an under-sampling of more severe bipolar patients or those with comorbidities, which in turn may have resulted in an underestimation of the rates of childhood trauma in the bipolar group given the association between childhood trauma and poorer clinical outcomes (Garno et al., 2005; Leverich et al., 2002). Conclusions The association of perceived childhood trauma and depression is established (Nanni et al., 2012). This study adds to the literature suggesting a similar relationship in bipolar disorder, although confirmation in prospective studies is desirable. Emotional neglect may be particularly pernicious. Further consideration of its psychological and neurobiological mediation is warranted. Acknowledgements We are grateful to the participants who contributed to the research and to all those who helped in participant recruitment. Watson et al. Funding The study was funded by the Stanley Medical Research Institute (REF.: 03T-429) and the Medical Research Council (REF.: G0401207). Declaration of interest The authors declare that there is no conflict of interest. The funders did not influence the design or dissemination of the study. References Agid O, Shapira B, Zislin J, et al. (1999) Environment and vulnerability to major psychiatric illness: a case control study of early parental loss in major depression, bipolar disorder and schizophrenia. Molecular Psychiatry 4: 163–172. 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476458 8Violence Against WomenLevendosky et al. © The Author(s) 2011 VAWXXX10.1177/107780121347645

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Reprints and permission: http://www. sagepub.com/journalsPermissions.nav Article PTSD Symptoms in Young Children Exposed to Intimate Partner Violence Violence Against Women 19(2) 187­–201 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1077801213476458 vaw.sagepub.com Alytia A. Levendosky1, G. Anne Bogat1, and Cecilia Martinez-Torteya2 Abstract Intimate partner violence (IPV) places infants and young children at risk for development of trauma symptoms. However, this is an understudied consequence of IPV because young children pose particular difficulties for assessment of trauma symptoms. The authors collected maternal reports on mothers’ and children’s posttraumatic stress disorder (PTSD) symptoms and IPV yearly, from ages 1 to 7. Approximately half of the children exposed to IPV at each time period developed some trauma symptoms, and frequency of IPV witnessed was associated with PTSD symptoms. Maternal and child PTSD symptoms were correlated, suggesting that young children may be particularly vulnerable to relational PTSD due to their close physical and emotional relationship with their parents. Keywords childhood exposure, intimate partner violence, PTSD, trauma There is a dearth of research on posttraumatic stress disorder (PTSD) in young children that occurs as a result of exposure to intimate partner violence (IPV; defined here as male violence against a female romantic partner). This is unfortunate, as young children are at high risk for exposure to IPV. Families in which IPV occurs are more likely than the general population to have children under the age of 5 (Fantuzzo, Boruch, Beriama, Atkins, & Marcus, 1997). Also, young children are likely to witness the violence directly (i.e., see or hear it) because they are often in the presence of their mothers (DeJonghe, von Eye, Bogat, & Levendosky, 2006; Fantuzzo et al., 1997). Between 20% and 25% of school-age children 1 Michigan State University, East Lansing, MI, USA DePaul University, Chicago, USA 2 Corresponding Author: Alytia A. Levendosky, Department of Psychology, Michigan State University, East Lansing, MI 48824, USA. Email: levendo1@msu.edu 188 Violence Against Women 19(2) living in homes with IPV report that they directly witness it (McCloskey, Figueredo, & Koss, 1995; McCloskey & Walker, 2000; O’Brien, John, Margolin, & Erel, 1994). When IPV episodes involve law enforcement, the rate of child witnessing at all ages increases to 95% (Fusco & Fantuzzo, 2009). Exposure to IPV results in an increased risk of behavioral and emotional problems among children, as demonstrated by recent meta-analyses (e.g., Chan & Yeung, 2009; Evans, Davies, & DiLillo, 2008; Sternberg, Baradaran, Abbott, Lamb, & Guterman, 2006). The problems include externalizing (e.g., Davis & Carlson, 1987; Fantuzzo et al., 1991; Hughes, 1988; Graham-Bermann & Levendosky, 1998a) and internalizing symptoms (e.g., Grych, Jouriles, Swank, McDonald, & Norwood, 2000; Hughes, 1988), such as PTSD and dissociative symptoms (Bogat, DeJonghe, Levendosky, Davidson, & von Eye, 2006; Graham-Bermann & Levendosky, 1998b; Levendosky, Huth-Bocks, Semel, & Shapiro, 2002). The extant literature provides only a broad, generic understanding of the effects of IPV on children’s PTSD symptoms. The current research focused on children exposed to IPV during the time they were aged 1 to 7 years. The number of children exposed to IPV varied from 29 to 48 across these ages. Our unique, longitudinal data set allowed us to elucidate developmental differences in the symptom picture of these children. In addition, we examined why, because IPV is a unique interpersonal stressor, it is important to understand the child’s trauma symptoms in the context of the mother’s traumatic response as well as the severity of the IPV she experiences. Problems Diagnosing PTSD in Young Children A significant difficulty in accurately diagnosing very young children stems from their inability to report on their psychological symptoms (Scheeringa, Zeanah, Myers, & Putnam, 2003; Stover & Berkowitz, 2005); thus, children’s symptoms are generally assessed through parental report. However, because PTSD symptoms are more likely to be on the internalizing rather than the externalizing spectrum (e.g., feeling confused about the event) and, thus, not “visible” to the parent, there are inevitably problems with reliability. For example, all of the reexperiencing symptoms cannot be assessed by an external observer (parent or otherwise) in children below the age of 1 (e.g., bad dreams [with or without clear content] or flashbacks about the traumatic event) as, without significant language skills, the child cannot describe the content of his or her dreams. It is really only at age 3 that clinicians and researchers can begin to have more confidence in parental assessment of PTSD reexperiencing symptoms. There are two current sets of diagnostic criteria for PTSD in young children: the DSMIV-TR (Diagnostic and Statistical Manual of Mental Disorders, text rev., American Psychiatric Association, 2000) and DC: 0-3R (Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, rev. ed.; Zero to Three, 2005). The DSM-IV-TR criteria require A1 (exposure to trauma) and A2 (reaction of fear, helplessness, or horror) as well as one reexperiencing symptom, three avoidance symptoms, and two arousal symptoms (same as for adults). Some guidance is given for modifications of symptoms that are useful when diagnosing children. The major difference in the Levendosky et al. 189 two diagnostic systems is that the DC: 0-3R diagnosis of PTSD excludes the A2 criteria and reduces the number of criteria needed for the avoidance/numbing symptom cluster to one symptom. In addition, it eliminates some criteria that are clearly inappropriate for young children (“intense psychological distress at exposure to internal or external cues that symbolize or resemble the trauma” and “inability to recall an important aspect of the trauma”) and adds one new avoidance/numbing symptom (i.e., “social withdrawal”). The DC: 0-3R diagnosis shows predictive validity of children’s problems in functioning and is reliable over time (Meiser-Stedman, Smith, Glucksman, Yule, & Dalgleish, 2008; Scheeringa, Zeanah, Myers, & Putnam, 2005). However, some research indicates that very young children may experience additional/ different trauma symptoms that are not contained within either the DSM-IV-TR or the DC: 0-3R (Scheeringa & Zeanah, 1995, 2001). These include constriction of play, regression to earlier functioning (such as loss of toilet training), aggression, separation anxiety, and development of new fears (Scheeringa & Zeanah, 1995). This symptom cluster, called “New Symptoms,” was included in the diagnosis of Traumatic Stress Disorder (TSD) in the original DC: 0-3 (Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, Zero to Three, 1994). Thus, if using the DSMIV-TR or the DC: 0-3R, the more constricted range of symptoms that exclude those most applicable to young children may limit the clinician and researcher from diagnosing PTSD symptoms in young children. Assessment of PTSD symptoms needs to be developmentally sensitive. Recent studies suggest that the DC: 0-3R is the superior system for children aged 0 to 6 (Meiser-Stedman et al., 2008; Scheeringa, 2008); however, in our opinion, children under the age of 1 year cannot be reliably diagnosed. The data are unclear whether the criteria for the DC: 0-3R diagnosis of PTSD is the superior diagnostic system for childhood through adolescence (Scheeringa, Wright, Hunt, & Zeanah, 2006) or whether current DSM-IV-TR criteria are better (see Kearney, Wechsler, Kaur, & Lemos-Miller, 2010, for a review). It is difficult to ascertain the most accurate diagnostic system for specific age groups because most research is cross-sectional and thus it aggregates data from children of a wide variety of ages. A recent meta-analysis that examined 96 studies of children aged 3 to 18 found that exposure to traumatic events was significantly associated with both posttraumatic symptoms and PTSD and that there were no age effects in this association (Furr, Comer, Edmunds, & Kendall, 2010). However, the data were analyzed by comparing those children aged 3 to 12 with children older than age 12. This procedure did not allow for examination of the potential developmental differences between infants, preschoolers, and school-age children. Our longitudinal data provided a unique opportunity to examine these differences. There are few studies solely focused on trauma symptoms of very young children. Research finds that young children exposed to single event or chronic traumatic events (e.g., IPV) exhibit symptoms that fit the three DSM-IV-TR clusters (see Coates & Gaensbauer, 2009, for a review). However, the rates of PTSD diagnosis in traumaexposed young children are only consistent with rates of older children when developmentally sensitive versus DSM-IV-TR criteria are used (25%-69% vs. 0%-20%, 190 Violence Against Women 19(2) respectively; Ghosh-Ippen, Briscoe-Smith, & Lieberman, 2004; Levendosky et al., 2002; Meiser-Stedman et al., 2008; Ohmi et al., 2002; Scheeringa, Peebles, Cook, & Zeanah, 2001; Scheeringa, Zeanah, Drell, & Larrieu, 1995; Scheeringa & Zeanah, 2008; Scheeringa et al., 2003). A similar pattern of results is found in the few studies that have specifically examined PTSD symptoms and diagnoses in children exposed to IPV. Research on PTSD in Young Children Exposed to IPV Extant studies find that, among young children, witnessing IPV is associated with PTSD symptoms (e.g., Jarvis, Gordon, & Novaco, 2005; Kilpatrick & Williams, 1997). However, while these studies generally find that mothers and/or children report high rates of symptoms, low rates of PTSD diagnosis are reported for children, particularly when DSM-IV (American Psychiatric Association, 1994) criteria are used. Across studies of young children (including studies that assessed PTSD symptoms in both younger and older children exposed to IPV), the rates of children who endorsed symptoms in each of the criteria sets were as follows: 52% to 85% for reexperiencing, 3% to 98% for avoidance, and 31% to 73% for arousal, while the rates of DSM-IV-TR PTSD reported were between 3% and 25% (Graham-Bermann, DeVoe, Mattis, Lynch, & Thomas, 2006; Graham-Bermann & Levendosky, 1998; Levendosky et al., 2002; Mertin & Mohr, 2002; Rossman, Bingham, & Emde, 1997). The large discrepancies in percentages of symptoms in each of the PTSD clusters that different researchers find are probably due to the cross-sectional nature of the research methods that assessed children from a wide age range (e.g., young childhood to middle childhood or adolescence; Graham-Bermann et al., 2006; Mertin & Mohr, 2002; Rossman et al., 1997). Across ages, reexperiencing symptoms seem to be most prevalent, with avoidant symptoms least prevalent. In addition, the discrepancy between the large percentages of children who have symptoms of PTSD and the much lower percentages of children who meet diagnostic criteria for PTSD suggests that PTSD criteria as defined by the DSM-IV-TR are not as valid for young children as they are for adolescents and adults. Finally, when examining PTSD diagnoses or symptoms in young children, it is important to also examine the mother’s symptoms in order to understand fully the child’s symptom picture. For example, prior research with infants in the current study revealed that while mothers reported that more than one third of the infants who witnessed IPV had at least one symptom of PTSD, these symptoms of PTSD were associated with maternal PTSD symptoms, especially when mothers had been exposed to severe IPV (Bogat et al., 2006). IPV and PTSD in Mothers In very young children there is some evidence that the mother’s trauma symptoms are associated with those of her child (e.g., Bogat et al., 2006; Scheeringa & Zeanah, 2001). This is significant because rates of PTSD across studies of women experiencing IPV typically range from 31% to 84% (Golding, 1999). Scheeringa and Zeenah propose that in situations where mothers experience trauma, relational PTSD can result—a situation in Levendosky et al. 191 which the emotional relationship between the mother and child causes an enhancement of the trauma symptoms of each of them. Young children, compared to older children, are considered to be particularly vulnerable to the effects of the mother’s trauma response due to their increased physical proximity to and more significant emotional dependence on the mother. Thus, for young children, trauma symptoms may be more highly related to the severity of the mother’s trauma symptoms, rather than the frequency of witnessing IPV (or other traumas), compared with older children and adults. Current research has not examined developmental changes in relational PTSD, nor has it examined whether specific symptom clusters of mothers and children are more likely than others to be related. Again, longitudinal data allowed us to examine changes in relational PTSD over time. The Current Study The data from the current longitudinal study allowed for a fine-grained description of the PTSD symptom clusters at six different ages. At each age, we measured PTSD symptoms using developmentally appropriate criteria. In contrast to most studies, we chose to examine symptoms for each of the six age groups separately because of the significant developmental changes that occur over the course of 1 year during early childhood. This allowed us to examine variation in symptom picture across age groups. We addressed the following research questions. First, does age influence the types of symptoms and symptom clusters that children exhibit? Second, do the three different diagnostic schemes (DSM-IV-TR, DC: 0-3R, and DC: 0-3) show age differences in rates of diagnosis? Third, is the frequency of witnessed IPV related to children’s PTSD symptoms? Fourth, controlling for frequency of witnessed IPV, is there a significant relationship between maternal and child PTSD symptoms, and does this change as a function of the child’s age? Method Participants The participants were drawn from the Mother-Infant Study (Bogat, Levendosky, & Davidson, 1999; Levendosky, Bogat, Davidson, & von Eye, 2000). Two hundred and six women were interviewed during the last trimester of their pregnancy. After the child was born, they were assessed yearly at the child’s birthday through age 7. In the current study, we are presenting data from ages 1, 2, 3, 4, 5 and 7. We did not collect data on the children’s PTSD symptoms at age 6. The demographics for the full sample are shown in Table 1. The children in the current research are those whose mothers reported that they witnessed IPV at any age. For each data collection, if the mother reported that her child had witnessed IPV (note, the mother may have experienced IPV but the child did not witness it), then she was asked to report on her child’s symptoms of PTSD. Because in any given year the women may not have experienced IPV or the child may not have witnessed what occurred, the data at each time point are not necessarily for the same children (see Table 1 for the children witnessing IPV each year and the percentage with any PTSD symptoms and full diagnosis). 192 Violence Against Women 19(2) Table 1. Children Who Witnessed IPV With PTSD Symptoms at Ages 1 to 7. Age of Child IPV, n Witness, n PTSD symptoms, n Percentage of witnessing with any symptoms Percentage of witnessing with DSMIV-TR diagnosis Percentage of witnessing with DC: 0-3R diagnosis Percentage of witnessing with DC: 0-3 diagnosis 1 2 3 4 5 7 77 48 18 38 83 43 26 60 55 29 23 79 65 38 29 76 51 33 16 48 47 29 17 86 N/A 0 0 2 2 4 N/A 1 9 14 6 21 N/A 4% 12% 17 N/A N/A Note: DSM-IV-TR = Diagnostic and Statistical Manual of Mental Disorders (text rev.); DC: 0-3R = Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (rev. ed.). Measures IPV. IPV was assessed with the Severity of Violence Against Women Scales (SVAWS: Marshall, 1992), a 46-item questionnaire that measures the frequency of threats of violence, actual physical violence, and sexual violence during the past year. A total frequency score at each time point was used. Mothers also indicated whether their children witnessed the violence. Marshall reported coefficient alphas among a community sample ranging from .86 to .96 for the subscales. Maternal PTSD. This was assessed using the Posttraumatic Stress Disorder Scale for Battered Women (Saunders, 1994). This self-report questionnaire asks women to endorse how often they experience 17 symptoms that are consistent with the DSM-IV-TR symptom list (Criteria B-D) for PTSD. A total score as well as scores for the individual cluster symptoms were used in these analyses. Saunders reported a .94 reliability coefficient, and a high correlation (r = .58) with other PTSD scales. Child PTSD. This was assessed with maternal report on three different measures, based on the appropriateness of the measure for the developmental level of the child. The infants were assessed with a measure developed for this study based on the DC: 0-3 criteria (Zero to Three, 1994)—the Infant Traumatic Stress Questionnaire (ITSQ: Bogat, 1999). The preschool children (ages 2-4) were assessed with a measure based on the DSM-IV-TR and DC: 0-3 (Zero to Three, 1994) criteria—the Child Traumatic Stress Questionnaire (CTSQ: Bogat & Levendosky, 2002). The 5- and 7-year-old children were assessed with the Child Domestic Violence PTSD scale (Pynoos, Rodriguez, Steinberg, Stuber, & Frederick, 1998), a measure based on the DSM-IV (American Psychiatric Association, 1994) criteria. All of these measures yielded symptoms for the three clusters Levendosky et al. 193 of reexperiencing, avoidance, and arousal, with the exception of the ITSQ, which did not assess reexperiencing. The ITSQ and the CTSQ also assessed symptoms in the new fears category from the DC: 0-3R. Procedures Women were recruited into this study during their pregnancy. We oversampled for women who had experienced IPV so that more than half of them had experienced IPV during the pregnancy (see Huth-Bocks, Levendosky, Bogat, & von Eye, 2004) for a detailed description of recruitment and screening. The current study analyzes data collected when the children were ages 1, 2, 3, 4, 5 and 7. At each wave, data include only those children whose mothers indicated that they witnessed IPV during the past year. Interviews were scheduled near the child’s birthday. Women were paid for their time, and children were given a small gift. Results The children who witnessed IPV at each of the six ages were assessed for their PTSD symptoms and whether they met criteria for PTSD. There was no linear developmental pattern to the number of children who lived in homes where IPV occurred or to the number of children who witnessed the IPV (see Table 1). At ages 1 and 2, children were more likely to have IPV in their homes and to witness it compared to children at other ages. Across the different ages, there was a general rise in the percentage of children witnessing IPV who experienced symptoms, with the exception of age 5 when there was a decline. The percentage of children diagnosed with PTSD based on the DC: 0-3 or DC: 0-3R criteria was higher at all ages compared to when the DSM-IV-TR diagnostic criteria were used (see Table 1). There were developmental patterns in the three PTSD clusters of symptoms: reexperiencing, avoidance, and arousal (see Figure 1). Arousal was the most frequently endorsed at all ages, except age 4. At age 4 reexperiencing was the most highly endorsed symptom. The percentage of children with reexperiencing symptoms peaked at age 4 and then declined. The percentage of children who experienced avoidance rose from ages 1 to 3 and then stayed fairly stable, with mild fluctuation between ages 4 and 7. The percentage of children who experienced arousal symptoms increased from ages 1 to 3, dropped at ages 4 and 5, and was then fairly stable until age 7, when it increased dramatically. In addition, the percentage of new symptoms (a category of symptoms unique to DC: 0-3 diagnostic criteria) also showed a nonlinear pattern (see Figure 1). The percentage of children with these symptoms was similar at ages 1 and 2, more than doubled at age 3, and then declined at age 4, but to levels higher than ages 1 and 2. These symptoms were not measured at ages 5 and 7. Frequency of IPV witnessed by the children influenced the relationship between symptoms and the age at which they were expressed (see Table 2). Again, though, the results were not consistent. Frequency of IPV was significantly related to total PTSD symptoms at 194 Violence Against Women 19(2) 80 % with Symptoms 70 60 Avoidance 50 Re-experiencing 40 Arousal 30 New Fears 20 10 0 1 2 3 4 Age 5 7 Figure 1. Percentage of Children Experiencing the Four Types of Symptoms at Each Age. Note: Figure is available in full color in the online version at vaw.sagepub.com Table 2. Relationship Between Frequency of IPV Witnessed and Child PTSD Symptoms. Age of Child Total PTSD Reexperiencing Avoidance Arousal New symptoms 1 2 3 4 5 7 .46* N/A .28* .30* .09 .24* –.15 –.02 .17 .17 .70* .04 .08 .36* .44* .48* .16 .21 .29* .35* .72* .34* .36 .52* N/A .48* .41* .36* .23 N/A Note: IPV = intimate partner violence; PTSD = posttraumatic stress disorder. *p < .05. all ages. None of the symptom clusters follows this pattern. Reexperiencing was only associated with severity of IPV at age 7. Avoidance was only associated with frequency of IPV at ages 1, 5, and 7. Arousal was associated with frequency of IPV at ages 1, 3, 4, and 5. The new symptoms cluster from the DC: 0-3 (Zero to Three, 1994) was associated with frequency of witnessing IPV at ages 3 and 4. Finally, we examined the relationship between mothers’ and children’s PTSD symptoms, controlling for frequency of witnessed IPV (see Table 3). These revealed inconsistent significant relationships across ages without a clear developmental pattern. In fact, the patterns that existed seemed to be related to symptom clusters rather than to age. The most consistent relationships were found for arousal symptoms across ages, showing significance for ages 1, 2, 4, and 7. In contrast, there were no significant relationships between reexperiencing symptoms for mothers and children. 195 Levendosky et al. Table 3. Relationship Between Child and Maternal PTSD Symptoms Controlling for Frequency of IPV Witnessed. Age of Child Total PTSD Reexperiencing Avoidance Arousal 1 2 3 4 5 7 .47* N/A .44* .39* .19 .15 .18 .32* .25 .01 .04 .21 .43* .17 .45* .44* .44* –.02 .44* .19 .13 .28 .07 .31* Note: IPV = intimate partner violence; PTSD = posttraumatic stress disorder. *p < .05. Discussion Overall, our findings indicate that children are affected by the IPV they witness and often show a traumatic response. The likelihood of traumatic symptoms increases as children age; this is consistent with the trajectory of other anxiety disorders and internalizing disorders generally (Kovacs, Feinberg, Crouse-Novak, Paulauskas, & Finkelstein, 1984; Leve, Kim, & Pears, 2005). In addition, maternal report of child PTSD symptoms changes across development such that some symptoms are more likely to be endorsed in infancy and others during preschool. The “new symptoms” category in the original DC: 0-3 (Zero to Three, 1994) was relatively highly endorsed by the mothers in our sample, and the correlations with frequency of witnessing IPV were in the same direction and generally of the same strength as the other three groups of symptoms. In addition, these symptoms contributed to several additional cases of diagnosed TSD in ages 2 to 4. One possible interpretation is that these symptoms are in fact other ways of responding to trauma and a comprehensive assessment of early childhood traumatic responses should include these symptoms. Rates of diagnosed PTSD were low in this study, compared with studies of older children exposed to trauma (Graham-Bermann et al., 2006; Lehmann, 1997). Only the PTSD diagnosis rate of 21% in the 7-year-olds (using the DC: 0-3R criteria) approaches rates typical of older children reported in the literature (i.e., 25%-69%; Ghosh-Ippen et al., 2004; Levendosky et al., 2002; Meiser-Stedman et al., 2008; Ohmi et al., 2002; Scheeringa et al., 2001, 1995; Scheeringa & Zeanah, 2008; Scheeringa et al., 2003). It may be that young children rarely meet all criteria for a PTSD diagnosis, similar to the low rates for other anxiety and internalizing disorders. The low rates of PTSD diagnosis, even using the DC: 0-3R or DC: 0-3 criteria suggest that young children witnessing IPV do not fit the same profile of responses to IPV as older children and adults. Their high rates of symptoms suggest that they do experience affective and behavioral dysregulation but that it is not adequately captured with the various instruments that assess PTSD diagnoses. Our findings suggest that alternative conceptions of posttraumatic consequences for young children are important to consider, such as the Developmental Trauma Disorder (DTD), currently under 196 Violence Against Women 19(2) development by van der Kolk and colleagues (see van der Kolk, Roth, Oelcovitz, Sunday, & Spinazzola, 2005). Another explanation for the low rates of PTSD diagnosis among the young children in our sample may relate to the difficulty mothers have reliably reporting internalizing symptoms. At this stage of development, mothers may have underestimated the symptoms, thus depressing the rates of PTSD. Consistent with this hypothesis is the finding that arousal symptoms were generally the most frequently endorsed by mothers. Arousal symptoms are more amenable to external observation than are reexperiencing and avoidance symptoms. The total number of children’s symptoms was related to the frequency of IPV that they witnessed. This is consistent with previous findings (e.g., Graham-Bermann et al., 2006; Levendosky et al., 2002; Rossman et al., 1997) and suggests that young children are directly affected by witnessing violence, even if most of them do not meet criteria for PTSD. Arousal was significantly associated with witnessing IPV for ages 1 to 5 (with the exception of age 2). In contrast, avoidance was only associated with witnessing IPV at ages 5 and 7, and reexperiencing was only associated at age 7. This may indicate a developmental shift such that in the youngest children, affective dysregulation is the most dominant response to witnessing IPV, but as children get older, more cognitive and behavioral dysregulation as a response to witnessing IPV become prominent, as seen in reexperiencing and avoidance. This may reflect the increasing differentiation of symptoms of emotional distress that occur with development and are associated with particular psychopathologies (Carter, Briggs-Gowan, Jones, & Little, 2003; Eisenberg et al., 2001). Age 2 was an exception to the trend, with no specific symptom clusters related to witnessing IPV. The inconsistency of the age 2 data may be a valid finding. This is the age when children first attempt to separate and develop independence; this may be a particularly trying and conflictual experience in families where IPV takes place. A mother may be unable to distinguish her toddler’s traumatic response from other difficult behaviors. Our findings also indicated a high co-occurrence of maternal and child PTSD symptoms, controlling for frequency of IPV witnessed, across all the ages. One interpretation of these findings is support for relational PTSD. Young children who are likely to be in close physical and emotional proximity to their mothers are likely to influence and be influenced by her traumatic response to the IPV. In particular, maternal symptoms of arousal were associated with children’s arousal symptoms. This suggests young children are responding directly to their mothers’ affective dysregulation in reaction to IPV as well as demonstrating similar affective dysregulation. In contrast, maternal reexperiencing symptoms were not related to those of the children. This may be due to children’s lack of awareness of maternal reexperiencing symptoms or that these symptoms in their mothers may be less distressing to children than their mother’s arousal symptoms. Finally, the lack of a significant relationship also may be due to the difficulty mothers have in ascertaining children’s reexperiencing symptoms, as noted above. There are several limitations to this study. The first is the reliance on the mother as the sole reporter of her experiences of IPV as well as her and her child’s trauma symptoms. Mothers may underreport witnessing of IPV because, at the time it is occurring, their involvement in the episode may have distracted them from attending to whether or not their Levendosky et al. 197 child heard or saw the IPV. In addition, they may defensively imagine that they protect their children from exposure to IPV. The second limitation is related to the size of the sample. Our sample was sufficient to allow for examination of symptoms at each age, rather than aggregating different age children as prior studies have done. However, our study method was to assess PTSD symptoms at each age only for those children whose mothers reported that they witnessed IPV. Thus, we could not examine whether and how PTSD symptoms change throughout an individual child’s development. Unfortunately, because women’s experiences of IPV are rarely consistent (e.g., overall rates of IPV decrease as women and men age, women often leave and return to abusive partners multiple times) an enormous epidemiological sample would be necessary to track children’s trauma symptoms over time. In summary, similar to other studies, the ratio between children who had symptoms of PTSD in response to witnessing IPV, compared with those who met criteria for PTSD under any of the diagnostic schemes, was low. This adds evidence to the growing movement to include DTD in the DSM-5 (van der Kolk et al., 2005). This disorder is designed to address the very significant problem that most children exposed to traumatic events, including witnessing IPV, do not meet criteria for PTSD, even the modified criteria by Scheeringa et al. (2003) for younger children. Van der Kolk et al. argue that many children who have a posttraumatic disorder are not currently diagnosed, with the implication that children often do not get services they need. Many of these children, instead, may be receiving treatment for other disorders, such as ADHD (attention-deficit hyperactive disorder) or depression, rather than the treatment they need. Among children who witness IPV, DTD may better capture the posttraumatic problems than current diagnostic schemas. Future studies should continue to examine the trajectories of symptoms of PTSD in response to trauma across children’s ages. Our study suggests that children may exhibit different PTSD symptom clusters across development in response to witnessing IPV. Finally, there are some clinical implications from the current study. It is critical that assessment instruments used by clinicians and researchers with young children exposed to IPV include developmentally sensitive symptom items. Physicians and mental health professionals should assess young children exposed to IPV for trauma symptoms and consider the consequences for children’s functioning and development, even when children do not fit criteria for the DSM-IV PTSD diagnosis. Finally, this study highlights the importance of clinicians being aware of the differences in the types of posttraumatic symptoms across early childhood. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by grants from the National Institute of Justice (8–7958-MI-IJ) and the Centers for Disease Control (RO1/CCR518519–01) to the first and second authors. 198 Violence Against Women 19(2) References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Bogat, G. A. (1999). Infant trauma symptom questionnaire. Unpublished measure. Bogat, G. A., DeJonghe, E. S., Levendosky, A. A., Davidson, W. S., & von Eye, A. (2006). Trauma symptoms among infants who witness domestic violence toward their mothers. Child Abuse & Neglect, 30, 109-125. Bogat, G. A., & Levendosky, A. A. (2002). 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E., & Guterman, E. (2006). Type of violence, age, and gender differences in the effects of family violence on children’s behavior problems: A mega-analysis. Developmental Review, 26, 89-112. Stover, C. S., & Berkowitz, S. (2005). Assessing violence exposure and trauma symptoms in young children: A critical review of measures. Journal of Traumatic Stress, 18, 707-717. van der Kolk, B., Roth, S., Pelcovitz, D., Sunday, S., & Spinazzola, J. (2005). Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma. Journal of Traumatic Stress, 18, 389-399. Zero to Three. (1994). The diagnostic classification of mental health and developmental disorders of infancy and early childhood. Washington, DC: Author. Zero to Three. (2005). Diagnostic classification of mental health and developmental disorders of infancy and early childhood (rev. ed.). Washington, DC: Author. Author Biographies Alytia A. Levendosky is a professor of clinical psychology and director of clinical training at Michigan State University. Her research focuses on the intergenerational transmission of intimate partner violence. She is particularly interested in the perinatal period and the psychological and biological mechanisms through which intimate partner violence influences the mother–child relationship and child behavior. G. Anne Bogat is a professor of clinical psychology at Michigan State University. Her research focuses on risk and resilience factors related to women and children living with intimate partner violence, including social, psychological, and biological correlates related to psychological outcomes. She is particularly interested in understanding the longitudinal trajectory of the effects of intimate partner violence. Cecilia Martinez-Torteya is a postdoctoral fellow at the Department of Psychiatry of the University of Michigan. She studies the effects of prenatal and early traumatic stress on children’s development. Using a developmental psychopathology framework, her research addresses the biological, psychological, and environmental mechanisms that promote resilience or increase risk for psychopathology in the context of early adversity.
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