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Trajectories of internalizing problems among maltreated girls and boys: differences by maltreatment type and developmental timing

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Trajectories of internalizing problems among maltreated girls and boys: differences by maltreatment type and developmental timing

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TRAJECTORIES OF INTERNALIZING PROBLEMS AMONG MALTREATED
GIRLS AND BOYS: DIFFERENCES BY MALTREATMENT TYPE AND
DEVELOPMENTAL TIMING

by

Cara Pohle

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(SOCIAL WORK)

August 2012

Copyright 2012 Cara Pohle
ii

TABLE OF CONTENTS
List of Tables iii
List of Figures iv
Abstract v
Chapter One: Introduction and Literature Review 1
Introduction 1
Internalizing Problems 5
Maltreatment 11
Characteristics of Maltreatment as Predictors of Internalizing Problems 14
Developmental Psychopathology and Maltreatment 21
The Current Study 24
Chapter Two: Research Methods 26
Statistical Plan 35
Statistical Plan by Aim 42

Chapter Three: Results 45
Preliminary Analyses 45
Substantive Analyses 50
Specific Aim 1 51
Specific Aim 2 56
Specific Aim 3 64

Chapter Four: Discussion 67
References 78

iii

LIST OF TABLES
Table 1: Definitions of Repeated Measures ANOVA Equation Components 37
Table 2: Demographic Characteristics by Maltreatment Status 45
Table 3: Demographic Characteristics by Gender 46
Table 4: Frequencies of Maltreatment Types 47
Table 5: Frequency of Developmental Timing of Maltreatment for Boys
and Girls 47
Table 6: Descriptive Statistics for Depression, Anxiety, and Internalizing
Problems by Gender 48
Table 7: Correlations between T1, T2, & T3 Outcomes for Analytic Sample 50

iv

LIST OF FIGURES
Figure 1: Baron & Kenny’s Moderator Model 40
Figure 2: Mean Differences in Internalizing Problems by Maltreatment Status 52
Figure 3: Mean Differences in Anxiety by Maltreatment Status 52
Figure 4: Trajectory of Mean CDI Depression Scores 54
Figure 5: Trajectory of Mean CBCL Internalizing Problems 54
Figure 6: Trajectory of Mean MASC Anxiety Scores 56
Figure 7: Trajectory of Mean Anxiety Scores for Time x Gender Interaction 60
Figure 8: Trajectory of Mean Anxiety Scores for Time x Emotional Abuse
Interaction 61
Figure 9: Trajectory of Mean Internalizing Problems for Time x Emotional
Abuse x Gender Interaction 62
Figure 10: Trajectory of Mean Anxiety Scores for Time x Sexual Abuse
Interaction 63
Figure 11: Trajectory of Mean Internalizing Problems for Time x Sexual
Abuse Interaction 63
v

ABSTRACT
The purpose of the current study was to examine the relationship between
maltreatment characteristics and the change in internalizing outcomes over time in a
sample of maltreated and non-maltreated adolescents. The sample (n=311) was drawn
from a larger, federally-funded longitudinal study of the psychological and biological
effects of maltreatment. A largely African American and Latino sample was measured at
three time points, roughly one year apart. At the first assessment the age of the sample
ranged from 9 to 13 years. Aim 1 examined the effect of maltreatment status (maltreated
or not) on the trajectory of internalizing outcomes over time, and whether gender
moderated this relationship. Aim 2 examined the effect of specific types of maltreatment
on the trajectory of internalizing problems, and whether gender moderated this
relationship. Aim 3 examined the relationship between developmental timing of
maltreatment and the trajectories of internalizing outcomes and tested whether gender
moderated this relationship. Internalizing outcomes included self-reported depression and
anxiety, along with caregiver-reported internalizing problems. A repeated measures
MANOVA was used to study the change in outcomes over time. Results indicate that the
internalizing outcomes change significantly over time, but neither maltreatment status nor
developmental timing significantly contributed to this change. Testing for the moderation
of gender produced significant effects for the type of maltreatment. Emotionally abused
youth showed less decline in anxiety scores over time compared to non-emotionally
abused youth. Gender moderated the relationship between emotional abuse and
internalizing problems where emotionally abused boys began with the fewest problems
vi

but showed the most problems at the final assessment. Sexual abuse was also a
significant predictor; sexually abused youth showed more change in anxiety and
internalizing scores over time compared to those who were maltreated but not sexually
abused. These findings provide evidence that certain characteristics of maltreatment may
impact how internalizing outcomes change over time. Future research should continue to
longitudinally explore the contributions of maltreatment characteristics on the trajectories
of internalizing outcomes.

1

CHAPTER ONE: INTRODUCTION AND LITERATURE REVIEW
Introduction
Child abuse and neglect affects the entire nation, changing the lives of over one
million children and youth annually (Sedlak, Mettenburg, Basena, Petta, McPherson,
Greene, & Li, 2010). Maltreated youth are more likely to experience internalizing and
externalizing problems, depression, anxiety, and symptoms of PTSD (Avery, Rippey
Massat, & Lundy, 2000; Kaplow, Dodge, Amaya-Jackson, & Saxe, 2005; Lansford,
Dodge, Pettit, Bates, Crozier, & Kaplow, 2002; Trickett & McBride-Chang, 1995). A
long-term effect is evident, whereby maladaptive coping skills and poor psychological
functioning are apparent in adults maltreated as youth (Copeland, Shanahan, Costello, &
Angold, 2009; Kaplow & Widom, 2007; Mullen, Martin, Anderson, Romans, &
Herbison, 1996; Widom, DuMont, & Czaja, 2007). The relationship between child
maltreatment and the development of internalizing outcomes such as depression and
anxiety is undisputed. In fact, decades of research provide evidence of the relationship
between child maltreatment and the development of subsequent internalizing problems
(see Cicchetti, Rogosch, Gunnar, & Toth, 2010; Kaplow & Widom, 2007; Kaufman,
1991; Keiley, Howe, Dodge, Bates, & Pettit, 2001; Kim & Cicchetti, 2006; Manly, Kim,
Rogosch, & Cicchetti, 2001; Toth, Manly, & Cicchetti, 1992; Widom, et al., 2007).
Despite the resounding number of studies on this topic, the research is not without
limitations. Some of the limitations include the lack of prospective longitudinal studies,
infrequent use of methodologically stringent classification systems to parcel out the
unique contribution of characteristics of maltreatment experiences, and few studies that
2

investigate how internalizing problems change over time. These gaps in the research
inhibit the bridging of information to clearly understand the relationship between
maltreatment and internalizing outcomes.
A continued need exists for prospective longitudinal studies, especially considering
that onset of depression and anxiety, inclusive of internalizing problems, often occurs in
childhood (Kessler, Avenevoli, Costello, Georgiades, Green, & Gruber et al, 2012). Thus,
cohort studies cannot adequately capture the trajectory of internalizing problems across
development. Even epidemiologists specify the importance of understanding the
progression of psychological problems among youth (Costello, Mustillo, Erkanli, Keeler,
& Angold, 2003; Kessler, et al, 2012; Zahn-Waxler, Klimes-Dougan, & Slattery, 2000).
Just knowing the prevalence rates and onset of internalizing problems is insufficient.
There is still a need to understand how problems change over time (Zahn-Waxler, et al.,
2000) to better understand mechanisms that maintain the problems and those that inhibit
their development. The present study focuses on internalizing outcomes of childhood and
adolescence; left untreated, internalizing problems in childhood and adolescence can
negatively impact mental health functioning in adulthood (Copeland, et al., 2009).
The identification of maltreatment as a precursor to internalizing problems highlights
the importance of understanding how maltreatment experiences may have differential
effects on mental health functioning. Critical to building this knowledge base is to study
how specific maltreatment characteristics such as type of abuse or neglect experienced,
and the developmental timing when maltreatment commenced contribute to subsequent
symptoms of internalizing problems among boys and girls. Defining maltreatment
3

experiences is a difficult task due to the multitude of factors associated with maltreatment
(reporting, interpreting case records, inaccurate recollection of information, deciding how
to qualify and quantify experiences), not to mention the co-occurence of maltreatment
experiences. However, it is a necessary task in order to systematically assess the
relationship between various maltreatment experiences and internalizing outcomes.
The study of specific types of maltreatment and mental health outcomes is common.
Extant literature has compared outcomes based on differing experiences of child abuse
and neglect (e.g. Gibb, Wheeler, Alloy, & Abramson, 2001; Higgins, & McCabe, 2000,
Higgins, & McCabe, 2003; Horwitz, Widom, McLaughlin, & White, 2001; Mullen, et al.,
1996; Trickett & McBride-Chang, 1995; Widom, et al., 2007), or has focused on a
particular type of abuse within one study (e.g. Avery, et al., 2000; Banyard, Williams, &
Siegel, 2001; Nash, Zivney, & Hulsey, 1993; Kaplow, et al., 2005; Kendall-Tackett,
Williams, & Finkelhor, 1993; Toth, et al., 1992; Trickett, Noll & Putnam, 2011). As a
result, research demonstrates that different experiences of maltreatment do contribute to
varying outcomes. However, the lack of prospective longitudinal studies and imprecise
definition of maltreatment experiences, require a reevaluation of findings. Additionally,
among longitudinal studies, few address how type of abuse impacts the change in
depression, anxiety and other internalizing symptoms over time.
The developmental timing of maltreatment, or the age at when the maltreatment
began, is a characteristic of maltreatment that is gaining more attention in the literature.
While researchers have suggested considering its contribution to outcomes for years
(Toth, et al., 1992), the available literature is still limited. Maltreatment spans childhood,
4

with the youngest experiencing the greatest rates of maltreatment (US Department of
Health and Human Services, 2010). The exposure to maltreatment at different time points
can influence mental health functioning at a later time. Considering the importance of
childhood experiences on future development, investigating the relevance of the
developmental timing of maltreatment is essential to understanding the trajectory of
internalizing problems of maltreated girls and boys (Cicchetti, et al., 2010; English,
Graham, Litrownik, Everson, & Bangdiwala, 2005; Kaplow & Widom, 2007; Keiley, et
al., 2001; Lansford, et al., 2002; Manly, et al., 2001; Thornberry, Ireland, & Smith,
2001).
Prospective, longitudinal community-based studies investigating mental health
functioning from childhood to adolescence are rare (Bittner, Egger, Erkanli, Costello,
Foley, & Angold, 2007; English, Bangdiwala & Runyon, 2005), thus, the prospective
study of how internalizing problems change over time is even less common. By focusing
on internalizing outcomes, this study will address the need for more longitudinal
prospective studies of child maltreatment that use better classifications of maltreatment
experiences to determine how maltreatment characteristics influence the trajectory of
internalizing problems among adolescents. Because boys and girls may differ in how they
respond to the experience of maltreatment, and because they exhibit internalizing
problems at different points along their development (Ge, Conger, & Elder, 2001; Ge,
Conger, & Elder, 2011; Ge, Kim, Brody, Conger, Simons, Gibbons, & Cutrona, 2003;
Hofstra, van der Ende, Verhulst, 2002), gender will be included as moderating variable
between maltreatment characteristics and change in internalizing problems over time.
5

Internalizing Problems
Definition
Internalizing problems refer to symptomology related to the disregulation of
mood and/or emotion (Kovacs, & Devlin, 1998) while broader definitions may also
include social withdrawal and somatic symptoms (Bolger & Patterson, 2001).
Internalizing problems are said to consist of symptoms related to both depression and
anxiety. Symptoms of depression in childhood and adolescence mimic symptoms seen in
adult mood disorders. Symptoms associated with depression include depressed or sad
mood, irritability, difficulty concentrating, social withdrawal, and problems with eating
or sleeping (see DSM-IV TR for complete diagnostic criteria, American Psychiatric
Association (APA), 2000). Epidemiological reports show previous 12 month and 30 day
prevalence of any mood disorder among 13-17 year olds was 10 percent and 3 percent,
respectively (Kessler, et al., 2012).
Unlike depressive disorders, anxiety disorders in children and youth are grounded
in development, and present differently in childhood than they do in adulthood.
Symptoms of anxiety disorders in children and adolescents may include pervasive worry,
difficulty concentrating, irritability, restlessness, easily fatigued, and problems with sleep
(APA, 2000). The presence of anxiety disorders of childhood and adolescence were not
formally recognized until the release of the Diagnostic and Statistical Manual III, in 1980
(APA). As such, the study of anxiety disorders is relatively new for child/adolescent
populations (Zahn-Waxler, et al., 2000). As studies of childhood anxiety problems grew,
information regarding prevalence rates emerged. The epidemiological, National
6

Comorbidity Survey Replication Adolescent Supplement (NCS-A) includes information
on over 10,000 13-17 year olds. Reports estimate that almost 25 percent of youth met the
criteria for any anxiety disorder within the previous 12 months. Thirty day prevalence
was 14.9 percent (Kessler, et al., 2012).
Although depression and anxiety are jointly considered to be internalizing
problems, there is a debate as to whether depressive disorders and anxiety disorders can
be considered under the single construct of internalizing problems or whether they are in
fact, distinct disorders erroneously lumped into one construct. Evidence supporting the
use of one construct refers to the high comorbidity of the two disorders. In their report on
anxiety disorders among youth, Angold and colleagues (1999) showed that anywhere
from 20 to 50 percent of youth had a diagnosis of both a mood disorder and anxiety
disorder. Based on findings such as this, it is arguable that they share similar etiologies
(Kraemer, Krueger, & Hicks, 2007). Other support for a single construct of internalizing
problems rely on findings showing that anxiety syndromes typically precede depressive
symptoms and the development of major depressive disorder (Zahn-Waxler, et al, 2000).
On the other hand, a counter argument to the use of one construct indicate that sequential
and cumulative comorbidity between generalized anxiety disorder (GAD) and major
depressive disorder (MDD) was more balanced, suggesting that the two are distinct
(Moffit, Harrington, Caspi, Kim-Cohen, Goldberg, Gregory, & Poulton, 2007).
Ultimately, this author does not purport to take a side in this debate. Rather, it is believed
that depression and anxiety do share similar typologies of symptoms and therefore, for
ease of discussion, use of the term internalizing outcomes or internalizing problems
7

within the literature review is inclusive of symptoms of depression, anxiety, and general
internalizing symptoms.

Maltreatment and the Development of Internalizing Problems
Human growth and development is a dynamic process, influenced by innate
characteristics and life experiences. Therefore, although utility exists in knowing
prevalence rates of internalizing problems, this lacks specific information regarding the
nature of the problems – factors that contribute to etiological development, problem
maintenance, and/or how problems change throughout development, for example.
As already indicated, relatively little is known regarding how internalizing
problems change over time. However, it is apparent that differences in the prevalence of
psychological disorders in general are present across child development. For instance,
cross-sectional studies indicate that children aged 9-10 years present with the highest
prevalence of any psychiatric disorder. Prevalence rates dip to low levels among 12 year
olds before steadily rising throughout adolescence (Costello, et al., 2003). Thus, there is
evidence to support that trajectories of different problems such as internalizing problems
may differ across stages of a child’s development.
Attachment is a common theory used to frame the relationship between
maltreatment and internalizing problems. Regardless of whether a youth experiences
emotional abuse, physical abuse, sexual abuse, neglect, or a combination of maltreatment
types, a shared component influencing internalizing symptoms is the lack of adequate
caregiving (Zahn-Waxler, et al., 2000). The importance of the disrupted caregiving is best
8

framed within a developmental context. Throughout childhood children rely on
caregivers for attendance to basic needs. Attachment with a caregiver is a salient factor in
childhood. The weakening of this relationship due to the experience of maltreatment
leads to an increased chance of developing poor attachment patterns, not to mention
developing a poor sense of one’s sense of self related to significant others (Cicchetti,
1991; Crittenden & Ainsworth, 1989). Poor attachments with caregivers have been linked
with poor outcomes in later developmental periods. An association has been found
between unresponsive parenting of infants and increased rates of anxiety disorders in
adolescence (Warren, Huston, Egeland, & Stroufe, 1997). Similarly, increased depressive
symptoms are evident in adolescence for youth who had hostile parents and experienced
little parental warmth (Ge, Best, Conger, & Simons, 1996). Thus, it is suggested that the
experience of maltreatment by a caregiver or significant parental figure increases the risk
of developing maladaptive emotional functioning associated with internalizing problems.

Gender Differences in Internalizing Problems
Although the study of gender differences with respect to various developmental
and mental health outcomes is common in the research literature, findings vary regarding
how gender contributes to these differences. Regarding the study of the trajectories of
problems in functioning, the focus on gender differences is relatively new (Zahn-Waxler,
Crick, Shirtcliff, & Woods, 2006). Zahn-Waxler and colleagues mention that the bulk of
research in this area focuses on three themes: 1. gender differences in the prevalence of
disorders at different developmental periods; 2. differences in the manifestation of
9

problems; and 3. differences in the developmental trajectories. The first theme will
provide a platform to delineate the rationale for studying gender differences in
internalizing problems, but the current study will focus on the third theme, developmental
trajectories. From a developmental perspective, the presence of any psychiatric disorder
in childhood increases the likelihood of maintaining the diagnosis or experiencing a new
episode following remission. Further complicating the issue is the increased impairment
associated with psychiatric disorders in adolescence, when problems peak (Zahn-Waxler
et al., 2006), which is especially true for girls (Costello, et al, 2003).
Adolescence is a time of turmoil and adjustment. As such, it seems only natural
that psychological problems spike during this developmental period. Using the National
Comorbidity Survey Replication Adolescent Supplement, Kessler and colleagues (2012)
show that among 13 to 17 year olds, girls present with significantly higher 12-month
prevalence, 30-day prevalence, and prevalence ratios of mood and anxiety disorders.
Similarly, in cohort samples of 9 to 16 year olds, girls were significantly more likely than
boys to experience the onset of depression and anxiety disorders in later adolescence
(Costello, et al., 2003). Bittner and colleagues (2007) also found higher rates of anxiety
disorders and depression in girls during adolescence; a trend which continues into
adulthood (Kramer, Krueger, & Hicks, 2008; Moffitt, et al., 2007). Ge, Conger, and Elder
(2001) studied a rural sample of adolescents and found significant gender differences in
depressive symptoms beginning in 7
th
and 8
th
grade, or about 13 to 14 years of age. They
also found differences in the trajectory of problems, with girls showing a linear increase
in symptoms from 8
th
to 12
th
grade. Boys, on the other hand, showed a decline in
10

symptoms between 7
th
and 9
th
grade, but symptoms increased from 10
th
to 12
th
grade. In
another study of adolescent boys, the same authors found more internalizing distress in
8
th
and 10
th
grade among boys who matured earlier than other boys their age (Ge, et al.,
2011). Similarly, in a sample of pre- to early adolescent African American youth, boys
maturing early relative to their peers had more elevated levels of depression at the age of
11, although these symptoms declined by 13 years of age. The girls who matured early
showed consistent elevated levels of depression that did not subside over time (Ge, et al.,
2003). Thus it seems sufficient to conclude that the time around entry into, and during
adolescence is a critical time to study the change in symptoms.
Although internalizing problems peak in adolescence, differences in the display of
symptoms related to fear and anxiety are apparent even in the first years of life. From
early on, girls show a proclivity towards higher rates of internalizing problems (Carter,
Briggs-Gowan, Jones, & Little, 2003). Similarly, prospective longitudinal studies of the
developmental pathways of psychopathology suggest that the etiology of internalizing
problems is different for boys. Hofstra and colleagues (2002) followed a group of Dutch
children over 14 years. Their findings show the emergence of internalizing problems
(specifically depression) in adolescence for girls, yet for boys, the origin is earlier, in
childhood. This highlights the importance of longitudinal studies in understanding how
symptoms change and the factors that contribute to the change.
Gender differences among maltreated samples also emerge, with slight
differences from non-maltreated samples. For instance, Coohey (2010) found that among
a sample of 11-14 year old sexually abused boys and girls involved with Child Protective
11

Services, boys were more likely to present with clinical levels of internalizing problems.
Similarly, among a community sample of Australian youth up to the age of 12, maltreated
boys were more likely to have higher levels of internalizing problems than maltreated
girls (Higgins & McCabe, 2003). Conversely, in a sample of 9-13 year olds, maltreated
girls self-reported more internalizing problems than maltreated boys (Bolger & Patterson,
2001). Thus, it is evident that contextual factors such as maltreatment contribute to
differences in the onset and trajectory of internalizing outcomes for boys and girls.
Perhaps there are differences in how boys and girls make sense of the experience of
maltreatment, which contributes to the findings contrary to other reports of consistent
higher rates of internalizing problems among girls.

Maltreatment
Prevalence of Maltreatment
Several federal programs have been developed to document and report statistics
on the prevalence of child maltreatment in the U.S. The Fourth National Incidence Study
of Child Abuse and Neglect (NIS-4) is the fourth congressionally mandated effort by the
Department of Health and Human Services (DHHS) to accumulate information on the
incidence of child maltreatment in the United States. The NIS-4 results are based on data
collected in 2005 and 2006. Based on this comprehensive data collection, an estimated
1,256,600 children were victims of any type of child abuse or neglect (Sedlak, et al.,
2010). Prevalence rates do differ by age. The Federal Interagency Forum on Child and
Family Statistics (2011) compiled statistics summarizing maltreatment information on
12

children aged 0-17, collected in 2009. The findings show that younger children
commonly and consistently experience higher rates of maltreatment than older children.
The frequency of substantiated reports decreases with age. Girls had more substantiated
reports than boys and African American children had higher rates compared to other
racial/ethnic groups. These statistics/prevalence rates shed light on the heterogeneity
present among maltreated youth.

Classification of Maltreatment
The undertaking of properly defining child maltreatment is arduous. Several
investigators have demonstrated the inaccuracy of using Child Protective Service (CPS)
identifications of maltreatment (Barnett, Manly, & Cicchetti, 1993; Dubowitz, Pitts,
Litrownik, Cox, Runyon, & Black, 2005; Trickett, Mennen, Kim, & Sang, 2009). CPS
labels of maltreatment tend to identify the maltreatment allegation most likely to result in
the substantiation of abuse. This method has led to under-reporting of the co-occurrence
of other forms of maltreatment. Current approaches attempt to account for the overlap of
experiences and improve upon the methods used to define abuse type.
To address the lack of a clear definition and consensus of maltreatment
experiences, researchers abstracted information from CPS records to construct methods
for more clearly labeling abuse categories. Barnett and colleagues (1993) were among
the first to develop a systematic classification system, the Maltreatment Classification
System (MCS). Its purpose, to provide a detailed nosological system of classifying abuse,
is fundamentally based on developmental psychopathology. The MCS expands upon CPS
13

reports to include information regarding various characteristics of the abuse experience,
including subtype, age of onset, chronicity, severity of abuse, placement status, and
perpetrator. Such detailed data collection was designed to quantify unique and shared
experiences of maltreatment. Investigators from the Longitudinal Studies of Child Abuse
and Neglect (LONGSCAN) team built upon Barnett and colleague’s work to create the
Modified Maltreatment Classification System (MMCS; English, D. J. & the
LONGSCAN Investigators, 1997). This modification includes the addition of more
specific severity and neglect codes. However, although the MCS and MMCS vastly
improved the ability to obtain data about specific maltreatment experiences, these
classification systems failed to adequately describe the characteristics of child neglect
and emotional maltreatment (Mennen, Kim, Sang, & Trickett, 2010). To remedy this, the
Maltreatment Case Records Abstraction Instrument (MCRAI) was developed. Using the
major types of maltreatment (physical abuse, sexual abuse, emotional abuse and neglect)
and CPS categorizations of caretaker incapacity and substantial risk, the MCRAI system
focuses on the acts inflicted on the child instead of the resulting injury (see Mennen, et
al., 2010, and Trickett, et al., 2009). This approach is significant in that it provides a
detailed account of each separate experience of maltreatment, rather than just the
substantiated experience. More detailed information regarding this instrument can be
found in chapter 2.
The development of the above classification systems provides current researchers
the opportunity to investigate maltreatment experiences in more detail, to examine the
full range of experiences that may contribute to maladaptive functioning. As such, there
14

is a need for the research on child abuse and neglect to utilize these mechanisms of
defining maltreatment experiences in order to present findings based on more accurate
depiction of what the maltreated youth experienced.

Characteristics of Maltreatment as Predictors of Internalizing Problems
Direction of Maltreatment Research
A current trend of maltreatment research involves the investigation of unique
contributions of specific maltreatment experiences; particularly, the characteristics of
maltreatment such as abuse type, developmental onset, severity, and chronicity, to name a
few. The implied importance of these topics is such that an entire 2005 volume of the
journal Child Abuse & Neglect was dedicated to the longitudinal study of the effect of
maltreatment characteristics on various outcomes. The rationale for this pertained to the
imperative need of maltreatment research to focus on better operationalizations of
maltreatment experiences in relation to expected outcomes (English, et al., 2005). Even
outside of this journal, emphasis rests on the exploration of the unique contributions of
specific details of the maltreatment experience (Barnett, et al., 1993; Cicchetti, et al.,
2010; Cicchetti & Toth, 2000; Manly, et al., 2001; Trickett & McBride-Chang, 1995).
Although several characteristics are deemed important, this study focused on two – the
specific type of maltreatment, and the developmental timing of the onset of maltreatment.
Each will be discussed separately.

15

Type of Maltreatment
When deciphering the effects of maltreatment type on internalizing outcomes,
formulating a consensus of the literature presents difficulty due to different methods for
comparing samples. Frequently, selection of a specific sample of maltreated youth to
study the effects of that maltreatment experience occurs. This specific maltreated sample
may then be compared to a non-maltreated sample. Regardless of how the maltreatment
experience is defined, the prolific study of maltreatment types clearly demonstrates that
maltreated youth tend to function worse than samples of non-maltreated youth. To briefly
summarize research using one type of maltreatment compared to a non-maltreated
sample, more internalizing problems are found among youth who have been physically
abused (Kim & Cicchetti, 2006), sexually abused (Coohey, 2010; Kendall-Tackett, et al.,
1993; Trickett, Noll, Reiffman, & Putnam, 2001; Turner, Finkelhor, & Ormrod, 2010),
emotionally abused (McGee, Wolfe, & Wilson, 2007), and neglected (Dubowitz, Papas,
Black, & Starr, 2002; Hildyard, & Wolfe, 2002). Alternatively, an entire maltreated
sample can be compared against itself, grouped by differing experiences, distinguishing
the effects of the maltreatment type. It is this approach that is of relevance to the current
study. Considering that more often than not, maltreatment types co-occur, Higgins and
McCabe (2000; 2003) stress the importance of studying all types of maltreatment
simultaneously to determine the unique and shared effects of maltreatment types.
Manly and colleagues (2001) conducted a cohort study of 5 ½ to 11 ½ year olds
to investigate the contribution of maltreatment type, in addition to developmental timing,
on various measures of children’s adjustment. Using the Maltreatment Classification
16

System to define the type of maltreatment experienced, they compared physical abuse,
sexual abuse with physical abuse, sexual abuse without physical abuse, emotional
maltreatment - physical neglect, physical neglect, emotional maltreatment, and no
maltreatment. A multivariate analysis of variance detected a significant contribution of
maltreatment type on caregiver reported internalizing problems, among other variables of
interest to the researchers. Specifically, youth experiencing physical neglect, and
emotional maltreatment-physical neglect had more internalizing problems than youth
with other types of maltreatment and non-maltreated youth. Herrenkohl and Herrenkohl
(2007) detected a unique contribution of physical abuse and sexual abuse among a
longitudinal sample of Pennsylvania youth involved with child welfare. The study used
both prospective and retrospective reports of adversity and the researchers created a latent
maltreatment construct that consisted of physical abuse, neglect, sexual abuse, and
domestic violence. Using structural equation modeling, they analyzed the effects of a
maltreatment construct, along with a stress construct on child-reported internalizing and
externalizing problems. Other stressors, socioeconomic status and child’s gender served
as control variables. The researchers concluded that the latent construct of maltreatment
significantly predicted internalizing and externalizing problems. Subsequent follow-up
analyses of each type of adversity suggest a unique developmental effect of physical
abuse on externalizing problems and of sexual abuse on both internalizing and
externalizing problems. Bolger and Patterson (2001) also found sexual abuse to be a
significant predictor of self-reported internalizing problems, compared to those who
17

experienced neglect and harsh parenting. The generalization of this finding is limited by
the small sample, of only 59 maltreated 9 – 13 year olds.
Although there is evidence indicating that specific maltreatment experiences are
significant contributors of internalizing outcomes, there is also evidence to the contrary –
that it is only the experience of maltreatment, not the type, that predicts outcomes. Using
a self-selected Australian community sample, Higgins and McCabe (2003) observed that
although the experience of maltreatment significantly predicted caregiver reported
internalizing problems (using the child behavior checklist), no specific type of
maltreatment emerged as a significant predictor. However, results from this study are
impaired due to the caregiver-reported experiences of abuse, rather than any form of
official report.
Evidently, more research is needed to clarify these findings. Not to mention the
need to look at these outcomes over time to understand how internalizing problems
evolve across development. In doing so, it will shed light on the mechanisms that may
contribute to the maintenance of internalizing problems while simultaneously suggesting
reasons why some maltreated youth do fine.

Developmental Timing
Improved maltreatment classification methods enhance the ability to specify the
timing at which instances of maltreatment began. With this, there is an increase in the
number of studies aimed at evaluating the relationship of the developmental timing of
maltreatment on mental health outcomes. This increase, however, is not reflective of an
18

abundance of available research, and more research is needed in this area to build a solid
foundation from which to draw consistent conclusions.
Currently, two problems persist with the literature on developmental timing of
maltreatment. The first relates to the most appropriate method for classifying
developmental timing, where the inconsistent definitions impair the ability to compare
findings. The second problem relates to mixed findings, where maltreatment beginning
within the same developmental period is related to both better and worse functioning.
Regarding the classification of developmental timing, review of the literature
shows that studies typically use one of three developmental timing classifications: 1.
continuous, where developmental timing is measured from (hypothetically) birth to 18
years; 2. dichotomous, which is typically broken down into early versus late onset, or
before the age of 6 versus after the age of 6 (Kaplow & Widom, 1997; Keiley, et al.,
2001); and 3. developmental stages, where onset is separated by several developmental
periods spanning infancy/toddlerhood, early school years, school years, and adolescence.
Since distinct differences can be found across different developmental time frames, the
developmental stages classification produces the most useful interpretations of findings.
Developmental timing, measured continuously negates the ability to specify outcomes by
age. Thus, the results are hard to interpret; to compare early versus late onset relays less
meaning without a definitive age cutoff (Kaplow, et al., 1997). With the dichotomous
group differences between early versus late onset, with a defined age cutoff, provide
improved interpretation over a continuous classification, but are less informative when
compared to the developmental stages. Yet, the drawback to the study of developmental
19

stages pertains to the lack of standardization of the developmental stages utilized.
Additionally, methodological complications may arise when trying to obtain sufficient
sample sizes to enable interpretation of all developmental groups.
As mentioned, findings related to the impact of developmental timing are mixed.
On the one hand, there is a body of research which indicates that earlier maltreatment
greatly impacts functioning at later developmental periods. For example, results from a
cross-domain growth analysis of the impact of developmental timing on internalizing and
externalizing problems conclude that compared to youth maltreated after the age of 6 and
those never maltreated, the children maltreated earlier consistently present with more
internalizing and externalizing problems. These problems were also found to be stable
over time (Keiley, et al., 2001). Similarly, using pairwise comparisons of developmental
timing groups, Kaplow and Widom (2007) found that maltreatment beginning in infancy
or preschool –before the age of 5 - led to higher levels of depressive symptoms and
anxiety in adulthood, even when controlling for the effect of gender, ethnicity, current
age and subsequent maltreatment reports. They specifically found differences in
depressive symptoms when comparing maltreatment in preschool versus early school
age, infancy versus early school age, and preschool versus school age, whereby the
earlier maltreatment experience was indicative of more symptoms compared to the later
onset. Manly, Rogosch, and Cicchetti (2001) also compared differences based on onset
beginning during infancy-toddlerhood (0-2), preschool (3-5) and school age (6-11). They
also found that maltreatment beginning in infancy-toddlerhood, and/or preschool resulted
in worse functioning compared to the school age onset. Infancy-toddlerhood onset was
20

also associated with more externalizing problems and aggression compared to non-
maltreated youth. Nash, Zivney, and Hulsey (1993) also concluded that earlier
maltreatment, specifically sexual abuse, predicted greater psychopathology compared to
later sexual abuse. However, this study demonstrates methodological flaws associated
with early studies of timing. In their methods, the researchers state that a continuous
variable, age of onset, was used to predict rates of psychopathology among sexually
abused girls. Despite this, they conclude in the discussion, that earlier sexual abuse, onset
before age 7 or 8, predicts greater psychopathology. This is problematic in that the
analysis was not conducted with a dichotomized early versus late timing variable.
On the other hand, there is literature that suggests that maltreatment beginning in
later developmental periods has more negative effects on outcomes. For instance,
Thornberry and colleagues (2001) constructed a childhood only and any adolescent
maltreatment dichotomy. They found that compared to non-maltreated youth, caregivers
of youth who were maltreated before the age of 5 reported them as having higher rates of
internalizing problems. However, when compared to youth maltreated in adolescence,
those maltreated earlier in life fared better psychologically and behaviorally at 14-16
years of age. When maltreatment experienced only in adolescence, and/or persistent
maltreatment are considered, the authors argue that it at this stage that results in the most
psychological detriment.
Counter to the variability between findings of the effects of earlier versus later
maltreatment on outcomes, is the finding that developmental timing does not affect
outcomes. Using data from the first National Study of Child and Adolescent Well-Being
21

(NSCAW), Jaffe and Maikovich-Fong (2011) found that developmental timing was not
predictive of internalizing problems, externalizing problems, IQ, or prosocial behavior.
However, developmental timing did moderate the effect of maltreatment chronicity and
caregiver reported prosocial behavior. Youth who experienced chronic maltreatment
beginning between the ages of 6 and 9 had more social skills deficits than those only
experiencing situational maltreatment.
What these disparate studies of this topic do indicate is a dire need for more
research to clarify findings. The inconsistent findings related to the relationship between
the developmental timing of maltreatment and functioning at later developmental periods
do suggest that developmental timing is a significant factor, however, the relative
significance is not clear. An additional complication to consolidating research findings is
the variability in the comparison group, whereby some compared developmental timing
against non-maltreated youth (Manly, et al., 2001) and others compared onset within one
group with onset within other groups (i.e., Kaplow, & Widom, 2007; Thornberry, et al.,
2001).

Developmental Psychopathology and Maltreatment
Maltreatment is embedded within a developmental context. There is a pronounced
link between early stress inducing experiences during early development and mental
health outcomes later in life, demonstrating the permeating effect that child maltreatment
has on the trajectories of symptoms over time. There is also evidence indicating that
trauma, such as maltreatment, effects biological indicators, such as brain development,
22

where exposure to stressors early in life lead to an increased propensity for maladaptive
coping such as vulnerability towards depression and anxiety (Heim, & Nermeroff , 2001).
Developmental psychopathology, the study of psychopathology surrounding
significant changes and milestones that occur throughout one’s life cycle (Achenbach,
1990), focuses on developmental milestones, creating a multi-dimensional framework for
the operationalization and understanding of the influences of maltreatment. Rather than
being considered a stand-alone approach, Cicchetti (1991) defines developmental
psychopathology as originating from the study of medical (embryology and
neurosciences) and psychological frameworks (psychology, psychology, psychiatry). Due
to this, it provides an all-encompassing framework to understand the multitude of factors,
both internal and external, that influence adaptive and maladaptive outcomes related to
maltreatment. Essentially, it “transcends disciplinary boundaries and provides fertile
ground for moving beyond descriptive facts to a process-level understanding of normal
and abnormal developmental trajectories” (Cicchetti, & Toth, 1995, p. 542). A key
feature here relates to the ability of the developmental psychopathology framework to
account for both positive and negative outcomes. It is within this framework that Barnett
et al. (1993), developed their classification system, taking into consideration the multiple
environmental, developmental, and contextual factors related to the maltreatment
experience.
From an organizational perspective, each developmental period has certain
abilities associated with it, marked by the successful or unsuccessful mastery of expected
abilities, or tasks. Consequences of maltreatment manifest differently based on
23

successful/unsuccessful negotiation of stage-salient tasks at specific developmental levels
(Cicchetti & Toth, 1995) therefore it is useful to distinguish within which developmental
period the maltreatment was experienced (Cicchetti & Lynch, 1995; Manly, et al., 2001).
Additionally, understanding the developmental context has implications regarding how
the youth makes sense of the maltreatment experience (Cicchetti, & Toth, 1995). It is
theorized that the experience of maltreatment can impede the mastery of critical tasks,
thereby affecting the mastery of subsequent developmental milestones (English et al.,
2005). Therefore, it is argued that the earlier the maltreatment experience occurs, the
greater the likelihood for maladjustment and stunted skill mastery in subsequent
developmental stages (English, et al., 2005; Keiley et al, 2001; Manly, et al., 2001). Or,
in a positive tone, the more opportunity a child has to successfully negotiate stage-salient
tasks, the greater the potential for successfully negotiating subsequent tasks (Stroufe &
Rutter, 1984), despite adversity. A counter argument for the suggestion that maltreatment
later in life could indicate better outcomes states that maltreatment earlier in life could be
buffered by the lack of developmental mastery. Either way, it is evident that the
experience of maltreatment impacts developmental functioning. The particular aspects of
maltreatment that attenuate or assist the development of problems are less clear,
especially when considering outcomes associated with internalizing problems. As such,
the study of characteristics of maltreatment such as abuse type and developmental timing
provides a means to investigate the multiple contexts that effect changes in mental health
functioning over time.

24

The Current Study
The purpose of the present study was to contribute to the growing body of
research focusing on the contribution that specific characteristics of maltreatment have on
internalizing problems, including depression and anxiety. It adds to the current
maltreatment literature by its utilization of a stringent classification system that better
captured information regarding multiple incidences of maltreatment. The more clearly the
maltreatment experience is defined, the greater the ability to distinguish unique
contributions of specific experiences and the greater the ability to compare with other
findings.
A prospective, longitudinal, demographically matched sample of urban girls and
boys was used to explore the relationship between three maltreatment variables and
internalizing problems. It considered the contribution of the overall effect of experiencing
maltreatment, the unique effect of abuse type, and the effect of developmental timing of
maltreatment. The intent was to determine the contribution of these variables on the
trajectories of self-reported depression and anxiety, and caregiver-reported internalizing
problems (collectively referred to as internalizing outcomes since one of the scales is a
measure of internalizing problems). Due to the variability of internalizing problems by
gender, it was included in a model for moderation.
The specific aims and related research questions of this study are as follows:

Specific Aim #1: Model the longitudinal trajectory of internalizing outcomes
predicted by maltreatment status.

1A. How are the trajectories of internalizing outcomes different between
maltreated and non-maltreated youth?
25

1B. Does gender moderate the relationship between maltreatment status
and internalizing outcomes?

Specific Aim #2: Model the longitudinal trajectory of internalizing outcomes
predicted by abuse type.

2A. Among the sample of maltreated youth, how are the trajectories of
internalizing outcomes different based on type of abuse?

2B. Does gender moderate the relationship between the type of abuse and
internalizing outcomes among the sample of maltreated youth?

Specific Aim #3: Model the longitudinal trajectory of internalizing outcomes
predicted by the developmental timing of maltreatment.

3A. How does the developmental timing of maltreatment impact the
trajectory of internalizing outcomes among the sample of maltreated
youth?

3B. Does gender moderate the relationship between developmental timing
of maltreatment and internalizing outcomes among the sample of
maltreated youth?
26

CHAPTER TWO: RESEARCH METHODS

The Parent Study

Procedure
Data for the current study come from a larger, federally funded study of the
developmental and psychological effects of maltreatment. The original study gained
approval from the Institutional Review Board of the University of Southern California.
Along with the Los Angeles County Juvenile Court, a partnership with the Los Angeles
County Department of Child and Family Services (DCFS) was undertaken to obtain a
sample of maltreated children and youth. Letters were mailed to caretakers (birth parents,
kin caretakers, and foster parents) informing them of the study. Unless a request not to be
contacted was returned to the project office, the informational letter was followed up by a
phone call detailing the purpose of the study. Participants came to the study location
where trained research assistants interviewed the child and caregiver separately, in
different rooms. The interview took 3 to 5 hours to complete. It gathered information
about various aspects of development, including developmental, psychological and
biological functioning. Caregivers reported on their own behaviors, parenting and
functioning, in addition to caregiver report of child’s functioning. At the conclusion of
the interview participants received a debriefing and compensation for their participation.
Participant recruitment for the larger study began in 2002 and ended in 2004.
Inclusion criteria for the maltreated sample included: (1) an open Los Angeles County
Department of Child and Family Services (LACDCFS) case due to a substantiated report
of maltreatment, (2) aged 9-12 years, (3) youth identifies as Latino, African American or
27

Caucasian, and, (4) reside in one of ten zip codes within a specified proximity to the
study site in downtown Los Angeles. The specified zip codes were chosen based on
concentration of reports of maltreatment and racial/ethnic composition to include African
American, Latino and Caucasian youth. Recruitment efforts obtained 303 maltreated
youth.
A demographically similar comparison sample was selected from the same zip
codes using a list of names provided by a marketing firm. Caretakers were contacted via
postcard. Upon indication of interest in participating, a follow-up phone call was made.
The final comparison sample consisted of 151 non-maltreated youth.
A second wave of data collection occurred 12 months after the initial assessment.
At Time 2, 87 percent (393) of the total sample returned. This included 83 percent
(N=250) of the maltreated and 94 percent (N=142) of the comparison sample. Fifteen
participants (3%) dropped out of the study after only completing measurement at T1.
Another wave of data collection took place 18 months following assessment at Time 2.
Seventy one percent of the sample participated at Time 3, retaining 64 percent (N=195)
of the maltreated sample and 94 percent (n=142) of the comparison sample. Six
participants (1%) declined further participation in the study at T3. Attempts were made to
reach families by phone, mail, alternate contacts provided by family, and online searches.
Binomial logistic regression analyses were conducted to assess characteristics
predictive of participation at T2 and T3. Dichotomous variables were created indicating
participation at T2 and/or T3 (0 = did not participate, 1 = participated). Demographic
variables, along with T1 outcome measures (T1 depression, T1 anxiety, T1 internalizing
28

problems) were entered into the model to predict participation at later measurement
points. Maltreatment status was predictive of participation at T2, such that comparison
youth were more likely than maltreated youth to participate at T2 (OR = 3.82, p<.01).
Maltreated youth who were not neglected were more likely to participate at T2 than those
who were neglected (OR=3.46, p<.05). Developmental timing of maltreatment also
predicted participation at T2. Using developmental timing during school years as the
reference group, maltreated youth whose maltreatment began in infancy-preschool and
early school years were more likely to participate at T2 (OR=3.90, p<.05 and OR=2.68,
p<.05, respectively). Maltreatment status was also predictive of participation at T3, where
again, comparison youth were more likely to participate (OR=4.23, p<.01). Caucasian
and Latino youth were less likely than African American youth to participate at T3
(OR=.32, p<.05 and OR=.46, p<.05, respectively).

The Current Study
Sample
For the current analysis, only youth that participated in all three study waves were
included, resulting in a sample of 311 youth. This included 185 maltreated youth and 126
comparison youth. Similar to the analysis to predict participation at subsequent
measurement points, a binary logistic regression was also conducted to determine
participation at all three measurement times to gain a better picture of the study sample.
Results show that maltreatment status, ethnicity and developmental timing significantly
predicted participation at all three assessments. Specifically, comparison youth were
29

more likely than maltreated youth to participate (OR=4.24, p<.001). Latino (OR=.44,
p<.001) and Caucasian youth (OR=.48, p<.05) were less likely than African American
youth to participate, and youth maltreated during infancy-toddlerhood were more likely
to participate across time than those maltreated during early school years (OR=2.25,
p<.05).

Maltreatment Type.
Maltreatment type was determined by the Maltreatment Case Records Abstraction
Instrument (MCRAI), as will be described later. Categories of maltreatment included
emotional abuse, physical abuse, sexual abuse, and neglect. Each maltreatment type was
dichotomized to indicate the presence or absence of that particular type of maltreatment
(i.e., physical abuse, yes or no). Almost 40 percent of the maltreated sample experienced
more than 1 type of maltreatment therefore, within each analysis of maltreatment type it
is likely that a participant had experienced other types of maltreatment on top of the
particular type referenced. When a particular type of maltreatment was indicated, the
analysis investigated the effect of that type of maltreatment, holding the other
experience(s) constant.
The maltreatment categorizations were obtained by case record abstraction. A
detailed account of the procedure can be found in two prior studies (Mennen et al., 2010;
Trickett et al., 2009); an abbreviated account follows. Two retired DCFS supervisors
were hired to access agency records. They provided a summary of each case after
reviewing case records, maltreatment investigation documents, court reports, and child’s
30

placement history. Upon receipt of the information for each incidence of maltreatment,
study personnel constructed the MCRAI data base using SPSS Data Entry Builder 3.0.
DCFS consults were utilized to determine what information to enter into the system,
which, as mentioned in the literature review, built upon the MCS (Barnett et al., 1993)
and MMCS (English and the LONGSCAN investigators, 1997). Each report of
maltreatment was entered as a separate record. Although siblings participated in the
study, individual children were the unit of analysis, based on the understanding that
sibling experiences of maltreatment are unique. The MCRAI includes reports of the
original DCFS maltreatment categories (physical abuse, sexual abuse, neglect, emotional
maltreatment, substantial risk, and caretaker incapacity), the informant and disposition.
Then, for each instance of abuse, more specific information was collected, including
perpetrator, age of onset, frequency, duration, information regarding CPS investigation
status, and specific information regarding the abuse experience (i.e. whether marks were
left, if hospitalization was necessary/occurred). Each instance of abuse was entered
separately so that each participant may have more than one record of abuse in the system.
The project PI, co-PI and doctoral social work research assistants trained masters
level social work and psychology students in data entry procedures. They were closely
supervised until 90% inter-rater agreement occurred. Individual case record review and
data matching was used with the entered abstracted data. When inconsistencies were
found, the original DCFS case records were consulted and/or the researchers met to
discuss appropriate modifications of the case record. Eighty reports were randomly
chosen and tested for inter-rater agreement on the four major types of maltreatment,
31

which are the focus of this study. Good reliability was indicated by good Kappa statistics:
.82, .82, .79 and .75 for physical, sexual, emotional abuse and neglect respectively
(Mennen et al., 2010; Trickett et al., 2009).

Developmental Timing
As part of the case record abstraction, the case record reviewers documented the
date of CPS referral for every instance of reported maltreatment. The referral indicates
the date of the referral to CPS for alleged maltreatment. The referral date was then used
to construct the developmental timing variable. MCRAI system calculates developmental
timing by subtracting the child’s birth date from the maltreatment referral date. This
value is then divided by 365.25, resulting in a continuous age variable. This age variable
was then recoded from a continuous variable into three groups, indicating a proxy for the
age at which the first episode of maltreatment occurred: infancy-preschool (ages 0–5.99
years), early school age (ages 6–8.99 years), and school age (ages 9–12.99 years).
Although the age cutoff points were meant to produce four developmental timing groups,
as identified by previous research (English, Graham, et al., 2005; English, Upadhyaya,
Litrownik, Marshall, Runyon, Graham, & Duboqwitz, 2005), to permit comparisons with
previous findings, the groups corresponding to infancy/toddlerhood and preschool were
combined due to cell sizes less than 10. However, the combining of infancy/toddlerhood
and preschool years is consistent with work by other researchers who did find that even
when measured separately, these developmental groups were similar in terms of
outcomes (Manly, et al., 2001).
32

It is important to note that the first documented account of maltreatment may not
be the actual first instance of abuse. This is the risk of using a proxy of maltreatment
onset. Yet, outside of actual CPS involvement and documentation of the occurrence, a
proxy is the best measure and can still contribute to the understanding of maltreatment
experiences.

Mental Health Measures
Depression. The Children’s Depression Inventory (CDI; Kovacs, 1989, 1992) is a
widely used 27 item self-report measure on the presence and severity of depressive
symptoms. It requires respondents to indicate the frequency of behavior within the last 2
weeks. It utilizes a 3-point scale ranging from 0 to 2, where a 2 indicates greater
frequency of occurrence. It has been normed by age and gender (Kovacs, 1985). Myers
and Winters (2002) assessed studies using the CDI and report good psychometric
properties and support its utility in detecting depressive symptoms in youth. The CDI
consists of five subscales (negative mood, ineffectiveness, negative self-esteem,
anhedonia, and interpersonal problems) and a total score. Ranging from 0-54 the total
score was used to determine depressive symptoms in this study.

Anxiety. The Multidimensional Anxiety Scale for Children (MASC; March,
Parker, Sullivan, Stallings, & Conners, 1997) is a 39 item self-report questionnaire that
assesses pediatric dimensions of anxiety. Responses are rated on a 4-point scale ranging
from 0 = never true about me to 3= often true about me. This study used the total score,
33

ranging from 0 to 117. It includes four basic scales - physical symptoms (tense; somatic);
harm avoidance (perfectionism, anxious coping); social anxiety (humiliation fears;
performance fears) and separation anxiety. The four-factor structure has been cross-
validated in clinical and community samples (March, Conners, Arnold, Epstein, Parker,
& Hinshaw et al., 1999; March, et al., 1997; Rynn, Barber, Khalid-Khan, Siqueland,
Dembiski, McCarthy, & Gallop., 2006; Baldwin & Dadds, 2007) and is invariant across
age (March et al., 1997; Rynn et al., 2006) and gender (March et al., 1997; Rynn, et al.,
2006; Baldwin, et al., 2007). March et al., (1999) has demonstrated good test-retest
reliability (March et al., 1999). It has good discriminate validity in that it has the ability
to discriminate between anxious youth with ADHD and depression (Rynn et al., 2006).

Internalizing problems. The Child Behavior Checklist/6-18 (CBCL, Achenbach,
1991) is a standardized caregiver report of child’s social competence and emotional
problems. One hundred and twelve items assess caregiver’s observation of behavior
within the last six months. Items are rated on a 3-point scale indicating the frequency of
behavior occurrence (0 - not true; 1 – somewhat or sometimes true; 2 – very or often
true). It provides two broadband scales (internalizing and externalizing), eight narrow-
band scales (anxious/depressed, withdrawn/depressed, somatic complaints, social
problems, thought problems, attention problems, rule-breaking behavior, and aggressive
behavior), a total problems scale and a total competence scale. This study used the
broadband internalizing scale which is computed by summing the anxious/depressed,
withdrawn/depressed, and somatic complaints subscales. The raw score for the
34

internalizing scale was used in this study. Scores ranged from 0-64. The CBCL/6-18 has
been nationally normed on clinical and nonclinical populations. Achenbach and Rescorla
(2001) have reported on the high test-retest reliability, construct validity, and criterion
validity. Both broadband scales and the total problems scales have good internal
consistency (alpha >.90). The CBCL also demonstrates good inter-observer agreement
(Achenbach, McConaughey, & Howell, 1987) and provides an un-biased assessment
related to racial/ethnic differences (Achenbach & Rescorla, 2001).

Control variables. Consistent with other research, the following demographic
variables were considered as control variables: age, race/ethnicity, income, living
arrangement, and number of maltreatment reports. When not entered into the analysis as
a moderator, gender was also a control variable. Consistent with a developmental
approach, this study will also consider pubertal development. Research identifies puberty
as a documented stressor that is linked to internalizing outcomes in adolescence (Ge, et
al., 2001; Ge, et al., 2003; Ge, Lorenz, Conger, Elder, & Simons, 1994); therefore its
potential contribution towards psychological problems will be controlled for. The
Pubertal Development Scale (PDS; Petersen, Crockett, Richards, & Boxer, 1988) is a
self-report, 4-item measure of the physical changes associated with pubertal
development – growth spurt in height, development of pubic hair, and changes in skin for
both genders; breast growth and menarche for girls, and growth of facial hair and
deepening of voice for boys. Subjects indicate their level of pubertal development based
on a 4-point scale ranging from 1 – development has not yet started, to 4 – development
35

has completed. The items are averaged and a higher score indicates completion of more
aspects of pubertal development compared to peers. This measure has been shown to
have adequate reliability and validity (Petersen et al., 1988).

Moderating variable. Gender (male/female) will be studied as a moderating
variable due to the reported differences in the outcome variables previously presented.

Statistical Plan
Preliminary Analyses
Prior to conducting the substantive analyses related to the study aims, the data
was subjected to preliminary analyses to determine demographic characteristics and
group differences between maltreated and comparison youth. Group differenced were
assessed using a t-test (age) and chi square (gender, ethnicity, living arrangement).

Substantive Analysis
Multivariate, repeated measures analysis of variance (MANOVA) in SPSS
Version 20 was used to conduct the substantive analyses. A type of General Linear
Model (GLM), repeated measures MANOVA is considered an adequate statistical
approach for longitudinal research interested in change in functioning over time due to its
less restrictive assumptions without sacrificing power (Hertzog, & Rovine, 1985; McCall
& Appelbaum, 1973; O’Brien, & Kaiser, 1985). Given that the repeated measures
MANOVA is an extension of univariate repeated measures ANOVA models (Keselman,
36

1998; McCall, & Appelbaum, 1973), a discussion of this will precede that of the repeated
measures MANOVA model, but first, a primer of basic analysis of variance (see
Kachigan, 1989; Blalock, 1979, or any basic statistics text for a more detailed
description): ANOVA is a statistical approach designed to partition the variance into
component parts. It rests on the assumptions of normal distribution of the dependent
variable, independent random samples, and homogeneity of population variances.
Although ANOVA is typically robust to violations of the assumptions, repeated
measurements introduce potential problems related to intercorrelations of means (Vasey
& Thayer, 1987). The null hypothesis of an ANOVA tests for equal population means.
The total variation (the sum of the squared deviations from the mean) is partitioned into a
within sum of squares and a between sum of squares, also referred to as the explained and
unexplained variation. Within sum of squares refers to the sum of squared deviations of
individual scores from their respective category means while the between sum of squares
relates to the sum of squares of the deviations of group means from the grand mean.
Population estimates are calculated by dividing by the associated degrees of freedom.
The two estimates of the population variance form an F ratio, which is the ratio of
between groups variance to within groups variance. There are two degrees of freedom
associated with this ratio, which account for the within groups variance (k - 1 where k
equals the number of groups) and between groups variance (N - k where N is the total
sample).
The multivariate analysis of variance (MANOVA) is similar to an ANOVA, but
instead of testing mean differences in the independent variable based on the grouping
37

variable, it tests the difference in the vector of means of multiple dependent variables
(Keselman, 1998; McCall, & Appelbaum, 1973). The utilization of repeated measures is
conceptually similar, although statistically more complicated than an ANOVA. As
before, a discussion univariate repeated measures will precede that of multivariate
approaches. This is due to the fact that the multivariate approach relies on the
interpretation of univariate findings when significant multivariate findings emerge.
Univariate repeated measures ANOVA. A simple repeated measure ANOVA with
one factor is written as:

= +

+

+

+

,
where
Table 1
Definitions of Repeated Measures ANOVA Equation Components
Value Definition

Response of subject i at time j with the level of predictor k
Grand mean of all measurements

Effect of level j of the within subjects factor

Effect of level k of the between subjects factor

Interaction term between within subjects factor and between subjects factor

Random error associated with subject i, at factor level k, at time j

Like a basic ANOVA, a repeated measures analysis involves separating the components
into explained and unexplained variance; the F ratio is used to determine significance. A
univariate repeated measures ANOVA assumes that error terms are normally distributed
with a mean of 0 (Bagiella, Sloan, & Heitjan, 2000). It also relies on the often untested,
and arguably not necessary, assumption of compound symmetry, which refers to the need
for equality of variance and covariance between all pairs of measured independent
variables (Bagiella, et al., 2000; Girden, 1992; O’Brien & Kaiser, 1985). Huynh (1978)
38

advises that there are 2

−1 circularity assumptions per repeated measures design, where
T refers to the number of repeated factors. Sphericity is also an assumption of univariate
repeated measures ANOVA. This assumption refers to the variance-covariance matrix,
and assumes constant variance of the contrasts between the repeated measures and that
the differences between pairs of scores are not correlated (Girden, 1992; Vasey &
Thayer, 1987). Like the compound symmetry assumption, sphericity is frequently
violated. However, if sphericity is assumed, then compound symmetry is also assumed,
but the reverse is not true (e.g. Girden, 1992; Keselman, & Rogan, 1980; Vasey &
Thayer). Violation of the sphericity assumption is related to an increase in Type I errors,
or a greater likelihood of falsely rejecting the null hypothesis. In response to this Box
(1954), proposed an adjustment for the degrees of freedom for both the numerator and
denominator in the F distribution, called epsilon (ε). The adjustment works by
multiplying the degrees of freedom by the estimated ε. Criticisms of the conservative
nature of Box’s ε resulted in several approaches for correcting the degrees of freedom.
Use of ε to correct the degrees of freedom has been deemed a statistically reasonable
method, although the choice of correction should be justified (McCall & Appelbaum,
1973). This study utilized the Huynh and Feldt (1976) ε correction since it is reported to
produce unbiased estimates, even for smaller samples. The correction works by
computing the adjustment factor, ε, based on the heterogeneity of variance. This
adjustment is applied to both degrees of freedom, which raises the critical F.
Unlike a univariate repeated measures ANOVA, a repeated measures MANOVA
does not assume sphericity. Because of the lack of the sphericity requirement and its
39

ability to link contrasts with their specific error term, the use of repeated measures
MANOVA is the recommended analysis for repeated measures designs with multiple
dependent variables (see O’Brien & Kaiser, 1985; Vasey & Thayer, 1987). As described
by Keselman (1998), M – 1 difference (D) variables are created to test the repeated
measures main effect. The null hypothesis of this multivariate test is that the vector of
the population means of the difference variable is equal to the null vector. The within-
subjects interaction effect tests whether the vectors of population means of the difference
variables are equal across levels of a between-subjects grouping variable.
A repeated measures MANOVA depends on the following assumptions; that
vectors of each dependent variable follows a normal distribution, and that the within-
group covariance matrices are equal. The likelihood of violating the equality of the
covariance matrices increases with unequal groups. It is tested using Box’s M tests. Use
of Pillai’s trace criterion is recommended for testing the significance of multivariate
analysis because it is robust even when homogeneity of covariance matrices assumption
is violated (Keselman, 1998; O’Brien, & Kaiser, 1985). Outside of testing the distribution
for normality, assumption testing occurs simultaneously with multivariate tests. Success
or failure to reject the null hypotheses for each assumption is indicative of which test
statistic to report. As mentioned in the previous section, significant findings are followed
by univariate ANOVAs to delineate the significance of the differences.
Step by step details of the analysis are discussed later. Use of this statistical
method requires that data be available for each measurement period, and therefore, only
40

complete cases are used (listwise deletion), resulting in reduced sample size. This is a
limitation of this statistical approach.

Testing for Moderating Effects of Gender
A moderating variable is a variable that impacts the relationship between the
independent and dependent variable(s) by affecting its direction and/or strength. The test
of moderation is a test of the interaction between the moderating variable and the
predictor variable of interest. If the interaction is significant, it is said that the effect that
the predictor variable has on the outcome(s) is dependent on the value of the moderating
variable (Aiken, & West, 1991), or in this case, gender. Figure 1 shows the three possible
paths leading to the outcome variable. Path a is the direct effect of the predictor, path b is
the direct effect of the moderator, and path c is the interaction of the predictor and the
moderator. Moderation is supported if path c is significant.

Figure 1. Baron & Kenny’s (1989, p. 1174) Moderator Model

Predictor

Moderator Outcome
Variable

Predictor
X
Moderator

b
a
c
42

Tests for moderation prefer that the moderating variable not be correlated with
either the independent or dependent variables and that the moderating variable is
exogenous to the dependent variable. Other researchers also recommend that a
moderating variable temporally precedes the variable that it moderates (Kraemer,
Kiernan, Essex, & Kupfer, 2008). Considering that gender is a fixed variable (Kraemer,
Kazdin, Offord, Kessler, Jensen & Kupfer, 1997) – unchanging over time – it naturally
precedes any of the independent variables of interest in this study.

Statistical Plan by Aim
Several variables were originally entered as possible control variables. The
control variables that did not contribute significantly to the model were removed from the
analysis in order to preserve power and increase model parsimony. Those removed
included child’s age, race/ethnicity, number of maltreatment reports, living arrangement,
and income. Gender and pubertal development were retained as control variables.

Specific Aim #1: Model the longitudinal trajectory of internalizing outcomes
predicted by maltreatment status.

1A. How are the trajectories of internalizing outcomes different between
maltreated and non-maltreated youth?

Specific Aim #2: Model the longitudinal trajectory of internalizing outcomes
predicted by the developmental timing of maltreatment.

2A. Among the sample of maltreated youth, how are the trajectories of
internalizing outcomes different based on type of abuse?

43

Specific Aim #3: Model the longitudinal trajectory of internalizing outcomes
predicted by the developmental timing of maltreatment.

3A. How does the developmental timing of maltreatment impact the
trajectory of internalizing outcomes among the sample of maltreated
youth?

All aims included above were analyzed using repeated measures MANOVA. Aim
1A and 2A both consisted of a 2 (group) X 3 (measurements) design. The between
subjects groups for 1A included maltreated v. comparison. Groups for 2A included a
comparison of each type of maltreatment (yes/no), so that four 2 X 3 models were
simultaneously entered as predictors. The groups included emotional abuse (yes/no);
physical abuse (yes/no); sexual abuse (yes/no); and neglect (yes/no). Aim 3A used a 3 X
3 design, with the following developmental timing groups: infancy-toddlerhood, early
school age, and school age. Gender and pubertal development were controlled for in all
analyses.
Each analysis proceeded with a review of Box’s test for the equality of covariance
matrices. Violation of this assumption required interpretation of Pillai’s trace criterion
instead of Wilk’s lambda for significance. Upon finding significant multivariate results,
the follow up univariate results were inspected as appropriate. Inspection of the
assumption of sphericity via Mauchly’s test of sphericity occurred for each measured
outcome. If sphericity was violated, the Huyhn-Feldt correction for degrees of freedom
was utilized. Analyses were concluded by reporting significant linear or quadratic
contrasts. Marginal means were plotted to create a visual display of the significant
trajectories.
44

Specific Aim #1: Model the longitudinal trajectory of internalizing outcomes
predicted by maltreatment status.

1B. Does gender moderate the relationship between maltreatment status
and internalizing outcomes?

Specific Aim #2: Model the longitudinal trajectory of internalizing outcomes
predicted by the developmental timing of maltreatment.

2B. Does gender moderate the relationship between the type of abuse and
internalizing outcomes among the sample of maltreated youth?

Specific Aim #3: Model the longitudinal trajectory of internalizing outcomes
predicted by the developmental timing of maltreatment.

3B. Does gender moderate the relationship between developmental timing
of maltreatment and internalizing outcomes among the sample of
maltreated youth?

There were three analyses for the moderation of gender; however, all were 2 X 3
repeated measures MANOVA where moderation was defined as the interaction between
the independent variable of interest and gender (boy/girl). All analysis proceeded as
described in the previous section.
45

CHAPTER THREE: RESULTS
Preliminary Analyses
Demographic Characteristics
The demographic characteristics are presented in Table 2. Maltreated and
comparison youth were similar ages at T1 (t(309) = 1.91, p=.06), T2 (t(309) = 1.90,
p=.06), and T3 (t(309) = 1.70, p=.09). Group differences were present across all other
demographic characteristics. The maltreated sample was more likely than comparison
youth to be female (χ
2
(1) = 3.93, p<.05), African American (χ
2
(3) = 8.11, p<.05), and to
reside in an out-of-home placement (χ
2
(1)=68.69, p<.001).

Table 2.
Demographic Characteristics by Maltreatment Status
Total Maltreated Comparison
N 311 185 126

Age in years (SD)
T1 10.92 10.82 (1.07) 11.06 (1.14)
T2 12.06 11.96 (1.12) 12.22 (1.22)
T3 13.64 13.54 (1.32) 13.80 (1.42)

Gender (%)*
Male 51 46 58
Female 49 54 42

Ethnicity (%)*
African American 41 46 33
Latino 35 29 43
Caucasian 10 9 11
Biracial 14 16 13

Living Arrangement
(%)***

In-Home 68 50 94
Out-of-Home 32 50 6
Note: *p<.05; ***p<.001

46

Demographic characteristics are also presented by gender in Table 3. Boys and
girls showed no significant age differences at T1 (t(309) = -.480, p=.63), T2 (t(309) = -
.02, p=.99), or T3 (t(309) = -.56, p=.58), nor were there demographic differences between
boys and girls in terms of ethnicity (χ
2
(3) = 1.34, p=.72) or type of living arrangement
(χ
2
(1) = .001, p=1.0).

Table 3.
Demographic Characteristics by Gender
Boys Girls
N 159 152

Age in years (SD)
T1 10.9 (1.11) 10.95 (1.10)
T2 12.06 (1.19) 12.07 (1.14)
T3 13.60 (1.47) 13.69 (1.26)

Ethnicity (%)
African American 42 41
Latino 33 37
Caucasian 11 8
Biracial 14 14

Living Arrangement (%)
In-Home 68 68
Out-of-Home 32 32

Maltreatment Type
Maltreated youth (N=181) experienced an average of 2 types of maltreatment
(SD=1.0), with a range of 1 to 4 types; 65% experienced two or more types of
maltreatment. As shown in Table 4, among the maltreated youth, 74% experienced some
47

form of neglect, 48% were physically abused, half were emotionally abused, and 21%
were sexually abused.

Table 4
Frequencies of Maltreatment Types
N %
Emotional Abuse 93 50.3
Physical Abuse 89 48.1
Sexual Abuse 38 20.5
Neglect 136 73.5
Two or More Types 120 64.8

Developmental Timing
Table 5 displays the frequency of developmental timing of maltreatment for the
maltreated sample and the frequency of onset by gender. The maltreated sample includes
170 maltreated youth due to missing information for 15 of the maltreated youth. There
were no significant gender differences with respect to developmental timing of
maltreatment (χ
2
(2) = .67, p=.72).

Table 5
Frequency of Developmental Timing of Maltreatment for Boys and Girls
Infancy-
Preschool Early School Age School Age Total N
N 52 65 53 170

Gender (%)
Boys 29 42 30 77
Girls 32 35 32 93
Note: Numbers may not add up to 100 due to rounding.

48

Descriptive Analyses of Outcome Variables
The means, standard deviations, range, and skewness of each outcome variable
are displayed in Table 6. The descriptive statistics are displayed by gender across each
measurement period. Inspection of mean values suggests relative stability across time.
The mean scores show positive skewness. A skewness statistic ranging between -.5 and .5
is more or less indicative of a symmetric distribution. MASC anxiety scores fall within
this range at T1 and T2. At T3, anxiety scores show moderate skewness (range from .5-
1.0). CDI depression and CBCL internalizing problems are skewed, with scores greater
than 1, suggesting that scores tend to be higher than the mean.
Table 6
Descriptive Statistics for Depression, Anxiety, and Internalizing Problems by Gender
Time 1 Time 2 Time 3
Boys Girls Boys Girls Boys Girls
CDI Depression
N 239 206 200 183 158 156
Mean 9.09 9.6 7.60 8.36 7.48 8.71
Std Deviation 7.23 7.26 5.67 6.77 5.71 6.78
Range 0-45 0-38 0-25 0-34 0-28 0-35
Skewness 1.37 1.41 .94 1.03 1.02 1.0

MASC Anxiety
N 236 205 201 178 161 155
Mean 45.74 51.64 39.88 44.46 34.34 41.37
Std Deviation 20.55 20.02 18.9 17.65 18.25 19.06
Range 5-103 6-111 0-94 5-106 0-97 4-102
Skewness .25 .34 .42 .54 .95 .85

CBCL
Internalizing

N 222 199 205 184 166 157
Mean 7.35 7.90 6.56 8.42 14.21 14.38
Std Deviation 7.22 6.98 6.73 8.34 8.12 7.17
Range 0-44 0-40 0-37 0-46 7-43 7-39
Skewness 1.62 1.67 1.62 1.63 1.62 1.19
Note. CDI = Child Depression Inventory, MASC = Multidimensional Anxiety Scale for Children,
CBCL = Child Behavior Checklist Internalizing Problems.
49

Due to the skewness of the outcome variables, the data were inspected for
outliers. For CDI depression, there were 9 outliers at T1 with scores ranging from 27-38.
There were also 9 outliers at T2, with scores ranging from 24-30 and 6 outliers at T3
ranging from 25-35 on the CDI. MASC anxiety had 1 outlier at T1 (score of 111), 4 at T2
(scores ranged from 89-96) and 10 at T3 (scores ranged from 97-102). There were 11
outliers for T1 CBCL internalizing problems, with scores ranging from 28-40. At T2
there were 14 outliers on the CBCL with scores ranging from 36-46, and at T3, there
were 9 outliers with scores ranging from 39-43. After considering the outliers, it was
determined that they would remain in the analysis as they were distributed across the
predictors. Additionally, although the scores are higher, they do indicate valid scores
representative of more distress.

Bivariate Relationships
Bivariate correlations are useful in determining the pattern of intercorrelations
between variables. The closer the correlation coefficient is to 1/-1, the stronger the
relationship between the two variables. Pearson correlations were computed for the
outcome variables at all time points. The correlation coefficients are displayed in Table 7.
All outcomes were positively correlated with each other, providing evidence that the
measures of depression, anxiety, and internalizing problems are related to each other over
time. This indicates that someone who shows symptoms of depression at one time is also
likely to show signs of anxiety or internalizing problems at the same time, or at other
50

time points. The strongest correlations were found between T1 and T2 depression (r =
.50, p<.01), T2 and T3 depression (r = .59, p<.01), and T2 and T3 internalizing problems
(r = .65, p<.01).

Table 7
Correlations between T1, T2 & T3 Outcomes for Analytic Sample
T1
CDI
T1
MASC
T1
CBCL
T2
CDI
T2
MASC
T2
CBCL
T3
CDI
T3
MASC
T3
CBCL
T1 CDI 1.00
T1 MASC .27** 1.00
T1 CBCL .19** .23** 1.00
T2 CDI .50** .13* .20** 1.00
T2 MASC .21** .41** .18** .30** 1.00
T2 CBCL .14* .15** .46** .15** .14* 1.00
T3 CDI .43* .14* .17** .59** .25** .16** 1.00
T3 MASC .28** .31** .18** .24** .38** .16** .36** 1.00
T3 CBCL .21** .17** .42** .17** .13* .65** .24** .16** 1.00
Note: CDI = Child’s Depression Inventory; MASC= Multidimensional Anxiety Scale for Children; CBCL
= Child Behavior Checklist Internalizing Problems; *p<.05, **p<.01.

Substantive Analyses
All analyses were initially conducted with demographic variables included in the
model. At no point did age, ethnicity, living arrangement, income, or additional
maltreatment reports account significantly for any of the variance in any outcome. Based
on this, they were removed from the analyses reported below as a method to preserve
statistical power and obtain parsimony.
Specific Aim #1: Model the longitudinal trajectory of internalizing outcomes
predicted by maltreatment type.

1A. How are the trajectories of internalizing outcomes different between
maltreated and non-maltreated youth?
51

A repeated measures MANOVA was run to determine whether the trajectories of
anxiety, depression and internalizing problems differed over time based on maltreatment
status. This analysis (N=257) controlled for gender and pubertal development. The
assumption of homogeneity of covariance matrices was violated as Box’s test of the
equality of covariance matrices was significant (Box’s M=318.28, p<.001), indicating
that the within-group covariance matrices were not equal. Thus, Pillai’s Trace criterion
was used to inspect multivariate significance as it is a correction to this violation that
reduces the reporting of biased results.
Multivariate analysis showed a significant between-subjects main effect for the
predictor of interest, maltreatment status (F(3, 250) = 3.48, p<.05, partial η

=.04). The
control variable, pubertal development (F(3, 250) = 5.27, p<.01, partial η

=.06), was
also significant. Gender approached, but did not reach significance (F(3, 250) = 2.48,
p=.06, partial η

=.03). Time was the only significant within-subjects main effect (F(6,
247) = 64.17, p<.001, partial η

=.61). No significant interaction between time and
maltreatment status was present (F(6, 247) =1.48, p = .19, partial η

=.04). Thus, although
the mean scores may differ significantly based on maltreatment status, the change in
functioning over time does not.
Inspection of follow-up results to determine the specific impact of between-
subjects effects proceeded. As displayed in Figure 2, a significant effect of maltreatment
status was found for caregiver-reported internalizing problems (F(1, 252) = 9.03, p<.01,
partial η

=.04) where caregivers reported more internalizing problems for maltreated

52

youth compared to non-maltreated youth. Although not significant, the group effect for
self-reported anxiety did approach significance (F(1, 252) = 3.67, p=.06, partial η

=.01),
also suggesting higher mean scores of anxiety among maltreated youth. The marginal
means for anxiety are displayed in Figure 3. There was no significant effect of
maltreatment status on depression (F(1, 252) = 1.95, p=.16, partial η

=.01).

0
5
10
15
Maltreated Comparison
Figure 2.Mean Differences in Internalizing Problems by
Maltreatment Status
CBCL Internalizing Problems
38
40
42
44
46
Maltreated Comparison
Figure 3. Mean Differences in Anxiety by Maltreatment
Status
MASC Anxiety
53

Although the between subjects effect of gender on internalizing outcomes only
approached significance, inspection of between-subjects effects show a significant effect
of gender on anxiety (F(1, 252) = 6.95, p<.01, partial η

=.03), with girls reporting higher
rates of anxiety compared to boys. The significant effect of the pubertal development
control was found for self-reported depression (F(1, 252) = 15.71, p<.001, partial η

=.06).
Analyses then proceeded with the inspection of univariate results. The purpose of
this was to determine the specific within-subjects effects of time. Prior to interpreting
these findings, however, it was necessary to evaluate the assumption of sphericity for
each outcome variable. Mauchly’s test of sphericity was used to test for the equivalence
of hypothesized and observed variance/covariance patterns. The measures for
internalizing problems (Mauchly’s W=.93, χ
2
(2) =19.05, p<.001) and depression
(Mauchly’s W=.89, χ
2
(2) = 29.80, p<.001) violated the sphericity assumption and
therefore required the use of the Huynh-Feldt correction to determine significance. Since
the test of sphericity was not significant for the measure of anxiety (Mauchly’s W=.99, χ
2
(2) = 3.50, p=.17), sphericity was assumed and a correction to the degrees of freedom
was not necessary. Univariate results indicated a significant effect of time for self-
reported depression (F(1.84, 463.54) = 4.98, p<.05, partial η

=.02), self-reported
anxiety (F(2, 504) = 31.23, p<.001, partial η

=.11), and caregiver-reported internalizing
problems (F(1.91, 480.54) = 140.10, p<.001, partial η

=.36). The marginal means were
plotted to visually show the trajectory of change over time in outcome scores. Self-
reported depression had both a significant linear (F(1, 252) = 5.05, p<.05, partial η

=.02)
54

and quadratic trend (F(1, 252) = 4.84, p<.05, partial η

=.02). As shown in figure 4, self-
reported depression declined from T1 to T2 but mean scores increased from T2

to T3. Internalizing problems also showed significant linear (F(1, 252) = 170.90, p<.001,
partial η

=.40) and quadratic trends (F(1, 252) = 93.39, p<.001, partial η

=.27). As
shown in Figure 5, the mean CBCL internalizing problems scores were relatively stable
from T1 to T2 but increased significantly from T2 to T3. The change in marginal

7.5
8
8.5
9
9.5
T1 T2 T3
Figure 4. Trajectory of Mean CDI Depression Scores
6
8
10
12
14
16
T1 T2 T3
Figure 5. Trajectory of Mean CBCL Internalizing Problems
55

means over time for anxiety is display in Figure 6. The trajectory exhibited a steady
linear decline in mean scores over time (F(1, 252) = 55.86, p<.001, partial η

=.18).

These analyses demonstrate that among this sample, the maltreated youth have
more symptoms of self-reported anxiety and caregiver-reported internalizing problems
than non-maltreated youth. While overall symptoms of depression, anxiety, and
internalizing problems change significantly over time, the change in scores is not
dependent on whether or not the youth was maltreated.

1B. Does gender moderate the relationship between maltreatment status
and internalizing outcomes?

A repeated measures MANOVA was conducted to determine whether gender
moderated the relationship between maltreatment status and the internalizing outcomes of
depression, anxiety, and internalizing problems (N=257). A significant Box’s test (Box’s
M=318.28, p<.001) required use of the Pillai’s Trace criterion to determine significant
findings. Gender did not emerge as a significant moderator of maltreatment status and
30
35
40
45
50
T1 T2 T3
Figure 6. Trajectory of Mean MASC Anxiety Scores

internalizing outcomes (F
significant between-subjects main effect (
consistent with findings in 1A
(F(3, 250) = 3.48, p<.05, partial
p<.01, partial η

=.06) had a significant between
anxiety, and internalizing problems.
for time (F(6, 247) = 64.17
replication of that in 1A, with the addition of the group x gender interac
up analysis duplicate those found in the previous section.

Specific Aim #2: Model the longitudinal trajectory of
predicted by maltreatment type.

2A. Among the
internalizing outcomes different based on type of abuse?

As in the previous analysis, the analysis based on type of abuse (N=143) also
included gender and pubertal development
MANOVA. Testing for the equality of covariance matrices indicated that the assumption
of equality of the covariance matrices was violated as Box’s
243.18, p<.05). As such, it was necessary to report Pillai’s Trace criterion. No significant
main effect for emotional abuse (
(F(3, 135) = .62, p=.60, partial
η

=.01), or neglect (F(3, 135) = 1.55, p=.20, partial
tests showed a significant main effect of
F(3, 250) = .24, p=.87, partial =.00), nor did it contribute a
subjects main effect (F(3, 250) = 2.48, p=.06, partial
consistent with findings in 1A. As found in the analysis of aim 1A, maltreatment status
(3, 250) = 3.48, p<.05, partial η

=.04) and pubertal development (F(3, 250) = 5.23,
had a significant between-subjects main effect on depression,
anxiety, and internalizing problems. A significant within-subjects main effect was found
(6, 247) = 64.17, p<.001, partial η

=.61). Because the analysis was a
that in 1A, with the addition of the group x gender interaction, the follow
licate those found in the previous section.
: Model the longitudinal trajectory of internalizing outcome
predicted by maltreatment type.
Among the sample of maltreated youth, how are the trajectories
internalizing outcomes different based on type of abuse?
As in the previous analysis, the analysis based on type of abuse (N=143) also
luded gender and pubertal development as control variables in the repeated measures
MANOVA. Testing for the equality of covariance matrices indicated that the assumption
of equality of the covariance matrices was violated as Box’s M was significant (
3.18, p<.05). As such, it was necessary to report Pillai’s Trace criterion. No significant
main effect for emotional abuse (F(3, 135) = .50, p=.68, partial η

=.01), physical abuse
(3, 135) = .62, p=.60, partial η

=.01), sexual abuse (F(3, 135) = .45, p=.72, partial
(3, 135) = 1.55, p=.20, partial η

=.03) emerged. Within
ed a significant main effect of time (F(6, 132) =17.05, p<.001, partial
56

), nor did it contribute a
, p=.06, partial η

=.03),
maltreatment status
(3, 250) = 5.23,
on depression,
subjects main effect was found
ause the analysis was a
tion, the follow-
ing outcomes
the trajectories of

As in the previous analysis, the analysis based on type of abuse (N=143) also
as control variables in the repeated measures
MANOVA. Testing for the equality of covariance matrices indicated that the assumption
was significant (M =
3.18, p<.05). As such, it was necessary to report Pillai’s Trace criterion. No significant
=.01), physical abuse
(3, 135) = .45, p=.72, partial
=.03) emerged. Within-subjects
, partial η

=.44),
57

indicating that the scores on the outcome measures changed over time, but the change
was not dependent on the specific type of abuse experienced. The lack of significance for
the between-subjects variables is central to the interpretation of the findings. Thus, a
post-hoc power analysis using G*Power (Erdfelder, Faul, & Buchner, 1996) was
conducted to determine whether there was enough power to detect differences based on
maltreatment type. With a sample size of 143 and α=.05, the power to detect at least a
medium-sized effect (f=0.25), for between-subjects differences was 0.97, and in fact the
minimum detectable effect size with adequate power (0.80) in this design was f=.10, a
relatively small effect size. Results from this power analysis indicated that there was
sufficient power to detect between-subjects differences in the present analysis. Lack of
significant between-subjects effects precluded the interpretation of the respective
univariate follow-up analysis. However, follow-up univariate findings were reviewed for
the significant within-subjects main effect of time.
Prior to examining the univariate effects of time, the assumption of sphericity was
assessed. Mauchly’s test of sphericity showed that sphericity had been violated for the
scales of depression (Mauchly’s W=.85, χ
2
(2) =17.76, p<.001) and internalizing
problems (Mauchly’s W=.88, χ
2
(2)=21.63, p<.001), thus indicating the need to use the
Huynh-Feldt correction. Sphericity was assumed for the MASC measure of anxiety
(Mauchly’s W=.98, χ
2
(2)=2.63, p>.10). As plotted previously in Figures 5 and 6, there
was a significant effect of time for symptoms of anxiety (F(2, 274) = 14.62, p<.001 ,
partial η

=.10), which showed a steady linear decline in symptoms over time (F(1, 137)
= 25.67, p<.001, partial η

=.16) and parent reported internalizing problems (F (1.87,
58

256.14) = 24.21, p<.001 , partial η

=.15), which evidenced a slight linear decline in
symptoms from T1 to T2 (F(1, 137) = 19.28, p<.001, partial η

=.12) and then increased
between T2 and T3 (F(1, 137) = 32.58, p<.001, partial η

=.19). There was not a
significant effect of time on depressive symptoms (F (1.83, 250.53) = .10, p = .36, partial
η

=.01).

2B. Does gender moderate the relationship between maltreatment type
and internalizing outcomes among the sample of maltreated youth?

A repeated measures MANOVA was conducted where gender was entered as a
moderator of the relationships between physical abuse, emotional abuse, sexual abuse,
and/or neglect and the internalizing outcomes. Because Box’s test for the equality of
covariance matrices was significant (Box’s M = 243.18, p<.05), it is assumed that the
observed covariance matrices of the dependent variables are not equal across groups and
Pillai’s trace was inspected. As indicated in the previous analysis, there were no
significant between-subjects main effects for emotional abuse, physical abuse, sexual
abuse, or neglect. Gender did not emerge as a significant between-subjects moderator of
the relationship between emotional abuse (F(3, 130) = .97, p=.41, partial η

=.02),
physical abuse (F(3, 130) = .1.06, p=.37, partial η

=.02), sexual abuse (F(3, 130) = .77,
p=.52, partial η

=.02), or neglect (F(3, 130) = .22, p=.88, partial η

=.01), and
internalizing outcomes. However, since significant within-subjects main effects and
moderation were present for time, emotional abuse, sexual abuse and gender, the model
was re-run, with only the significant predictors included. Thus, to improve model fit and
59

to preserve power, emotional abuse, and sexual abuse were included in the model, with
gender as a moderating variable, and pubertal development was controlled for.
As in the previously run model with all predictors, the equality of covariance
matrices was violated (Box’s M = 415.36, p<.001) and therefore Pillai’s Trace criterion
was interpreted. While no between-subjects main or interaction effects emerged, several
significant within-subjects effects did. A significant main effect for time was present
(F(6, 131) = 25.15, p<.001, partial η

=.54). The significant two-way within-subjects
interactions included time x gender (F(6, 131) = 2.22, p<.05, partial η

=.09), time x
emotional abuse (F(6, 131) = 2.18, p<.05, partial η

=.09), and time x sexual abuse (F(6,
131) = 2.42, p<.05, partial η

=.10). The interaction of time and pubertal development
(control variable) was not significant (F(6, 131) = 1.08, p=.38, partial η

=.05). A
significant 3-way interaction emerged for time x emotional abuse x gender (F(6, 131) =
2.43, p<.05, partial η

=.10), but the time x sexual abuse x gender interaction did not
reach significance (F(6, 131) = 1.59, p=.16, partial η

=.07)
To understand where the significance of the within-subjects effects occurred,
univariate results were investigated. Prior to interpreting univariate findings, it is noted
that the sphericity assumption was violated for both depression (Mauchly’s W=.85, χ
2
(2)
= 22.27, p<.001), and internalizing problems (Mauchly’s W=.87, χ
2
(2) = 18.60, p<.001),
requiring the Huynh-Feldt correction for epsilon. Sphericity was assumed for the measure
of anxiety (Mauchly’s W=.98, χ
2
(2) = 3.32, p =.19).
Although a significant interaction was present for time x gender, the univariate
effects on the outcome variables did not reach significance. This occurrence can be
60

understood by the fact that the interaction was significant with p right at .05 in the full
model. Therefore, the significance became marginal when the between-subjects effects
were no longer controlled for. With this in mind, it is worth describing the marginal
linear time x gender effect on anxiety (F(2, 272) = 2.61, p=.08, partial η

=.02), where,
unlike girls, boys show a consistent decline in symptoms over time (F(1, 136) = 3.29,
p=.08, partial η

=.02). The marginal means of anxiety are plotted in Figure 7 to show the
trajectory of the change in anxiety over time for maltreated boys and girls.
A specific effect of time was found for anxiety (F(2, 272) = 24.31, p<.001, partial
η

=.15) and internalizing problems (F(1.87, 254.71) = 31.98, p<.001, partial η

=.19).
Anxiety showed a significant linear decrease in symptoms over time (F(1, 136) = 39.53,

p<.001, partial η

=.23; see Figure 4). Internalizing problems presented significant linear
(F(1, 136) = 21.29, p<.001, partial η

= .14) and quadratic trends (F(1, 136) = 49.73,
30
35
40
45
50
55
T1 T2 T3
Anxiety
Figure 7. Trajectory of Mean Anxiety Scores for Time x
Gender Interaction
Boys
Girls
61

p<.001, partial η

=.27) over time. Overall parent-reported internalizing problems
decreased from T1 to T2 but then showed a steep increase in symptoms at T3 (see Figure
5).
The time x emotional abuse interaction significantly affected the trajectory of
anxiety (F(2, 272) = 3.58, p<.05, partial η

=.03), which showed a significant quadratic
trend (F(1, 136) = 8.22, p<.01, partial η

=.06). As shown in Figure 8, from T1 to T2 the
emotionally abused youth show a steeper decline in mean anxiety scores than maltreated,
but not emotionally abused youth. The levels decreased from T2 to T3 for the
emotionally abused youth, while the decline in mean anxiety scores is greater at this time
for those who were maltreated but not emotionally maltreated.

Internalizing problems were significantly affected by the time x emotional abuse
x gender interaction (F(1.87, 254.71) = 3.55, p<.05, partial η

=.03), which showed a

30
35
40
45
50
55
Time 1 Time 2 Time 3
Anxiety
Figure 8. Trajectory of of Mean Anxiety Scores for Time x
Emotional Abuse Interaction
Emotionally Abused
Not Emotionally
Abused
62

significant linear increase in problems over time (F(1, 136) = 5.63, p<.05, partial
η

=.04). The marginal means are plotted in Figure 9. Although caregivers of boys who
experienced emotional abuse rated them as having the lowest rates of internalizing
problems from T1 to T2, there is a steep significant increase in reported symptoms at T2
whereby they have the highest scores of internalizing problems at T3.
The time x sexual abuse interaction effected the trajectory of anxiety (F(2, 272) =
3.97, p<.05, partial η

=.03). As shown in Figure 10 the trend for anxiety was quadratic
(F(1, 136) = 4.44, p<.05, partial η

=.03), whereby the sexually abused youth had a
steeper decrease in symptoms from T1 to T2, and a flatter change from T2 to T3. The
linear trend approached significance (F(1, 136) = 3.62, p=.06, partial η

=.03).
Internalizing problems were also impacted by the time x sexual abuse interaction
(F(1.87) = 3.57, p<.05, partial η

=.03). As shown in Figure 11 there was a significant
quadratic trend (F(1, 136) = 4.20, p<.05, partial η

=.03). Scores for sexually abused
6
8
10
12
14
16
18
Time 1 Time 2 Time 3
CBCL Internalizing Problems
Figure 9. Trajectory of Mean Internalizing Problems for Time
x Emotional Abuse x Gender Interaction
Boys Not Emotionally
Abused
Boys Emotionally
Abused
Girls No Emotionally
Abused
Girls Emotionally
Abused
63

youth showed a steep decline between T1 and T2 that then increased at T3. Those
maltreated but not sexually abused had relative stability from T1 and T2, but also saw an
increase in internalizing symptoms at T3.

35
40
45
50
55
60
Time 1 Time 2 Time 3
Anxiety
Figure 10. Trajectory of Mean Anxiety Scores for Time x
Sexual Abuse Interaction
Sexually Abused
Not Sexually Abused
6
7
8
9
10
11
12
13
14
15
16
T1 T2 T3
Internalizing Problems
Figure 11. Trajectory of Mean Internalizing Problems for
Time x Sexual Abuse Interaction
Sexually Abused
Not Sexually Abused
64

Findings from specific aim 2 suggest that even though the type of maltreatment
does not predict between-group differences in depression, anxiety, and internalizing
problems, it does account for variance in how symptoms change over time. Both sexual
abuse and emotional abuse impacted the trajectories of self-reported anxiety and
caregiver reported internalizing problems. Differences in the trajectory of caregiver-
reported internalizing problems that were dependent on time, emotional abuse, and
gender, also emerged.

Specific Aim 3: Model the longitudinal trajectory of internalizing outcomes
predicted by the developmental timing of maltreatment.

3A. How does the developmental timing of maltreatment impact the
trajectory of internalizing outcomes among the sample of maltreated
youth?

A repeated measures MANOVA (N=133) was conducted to evaluate whether the
trajectories of depression, anxiety and internalizing problems differed significantly over
time with respect to the developmental stage at which maltreatment began, while
controlling for gender and pubertal development. With the assumption of equality of
covariance matrices violated (Box’s M =369.97, p<.001) Pillai’s trace criterion was used
to interpret significance. Developmental timing of maltreatment did not have a significant
main effect on the trajectory of internalizing outcomes (F(6, 256) = .40, p=.88, partial
η

=.01). A post-hoc power analysis using G*Power (Erdfelder, Faul, & Buchner, 1996)
was conducted to determine whether there was enough power to detect differences based
on the developmental timing of the maltreatment. With a sample size of 133 and α=.05,
the power to detect at least a medium-sized effect, f=.25, for between-subjects differences
65

was 0.88, suggesting adequate power to detect a significant effect were it present.
Consistent with earlier findings, there was a significant within-subjects main effect for
time (F(6, 124) = 29.32, p<.001, partial η

=. 59).
Also consistent with earlier findings, the sphericity assumption was violated for
both depression (Mauchly’s W=.86, χ
2
(2) = 19.17, p<.001) and internalizing problems
(Mauchly’s W=.87, χ
2
(2) = 17.89, p<.001), requiring the Huynh-Feldt correction.
Sphericity was assumed for the measure of anxiety (Mauchly’s W=.98, χ
2
(2) = 2.68,
p=.26). As graphed previously in Figures 5 and 6, subsequent univariate within-subject
follow-up analyses found that there were significant changes over time for anxiety (F(2,
258) = 20.14, p<.001, partial η

= .14) which evidenced a linear decrease over time (F(1,
129) = 34.92, p<.001, partial η

= .21), and internalizing problems (F(1.83, 236.56) =
46.23, p<.001, partial η

= .264), which were stable from T1 to T2 (F(1, 129) = 43.15,
p<.001, partial η

= .25) before increasing at T3 (F(1, 129) = 51.69, p<.001, partial η

=
.29). A significant effect for time was not present for depression (F(1.82, 234.71) = 1.44,
p = .24, partial η

= .01), meaning scores of depression did not change significantly over
time when accounting for developmental timing.

3B. Does gender moderate the relationship between developmental timing
of maltreatment and internalizing outcomes among the sample of
maltreated youth?

A repeated measures MANOVA was conducted to determine whether gender
moderated the relationship between the developmental timing of maltreatment and the
trajectory of internalizing outcomes, controlling for pubertal development. As in the
66

previous analysis, the assumption of equality of covariance matrices was violated (Box’s
M =370.0, p<.001), and therefore Pillai’s trace criterion was used to interpret
significance. Gender did not emerge as a significant moderator between the
developmental timing of maltreatment and subsequent internalizing problems (F(9, 378)
= 1.64, p = .10, partial η
2
=.04). As such, it was not appropriate to interpret univariate
findings and analyses concluded. As reported above in 3A, the within-subjects effect of
time was significant.
To summarize, there was neither a significant main effect of developmental
timing, nor was gender a significant moderator. Therefore, among this sample of
maltreated youth, it can be concluded that the developmental onset of maltreatment does
not account for significant differences in the trajectories of internalizing problems.

67

CHAPTER FOUR: DISCUSSION
This study explored the impact of child maltreatment, type of maltreatment, and
developmental onset of maltreatment on the trajectories of self-reported depression and
anxiety, and caregiver reported internalizing problems. It also explored whether gender
moderated these relationships. Findings showed that although the internalizing outcomes
changed significantly over time, the change in the trajectories were only dependent on
type of maltreatment. Neither maltreatment status nor developmental timing significantly
predicted the change in scores of depression, anxiety and internalizing problems over
time.
The first aim of the study compared the trajectories of internalizing outcomes for
maltreated and non-maltreated youth. Maltreatment status predicted overall group
differences in caregiver-reported internalizing problems, with caregivers indicating that
maltreated youth tend to have more internalizing problems compared to their non-
maltreated counterparts. However, the trajectory of change was not dependent on
maltreatment status, just time. It is interesting to note that for both maltreated and non-
maltreated youth, self-reported depression and anxiety declined over time. However, the
caregiver reported measure of internalizing problems depicted a steep increase in
symptoms from T2 to T3. It would be of interest to investigate characteristics of
caregivers in this sample to determine whether this finding is related to the caregiver,
rather than the child. Several studies have investigated bias in caregiver reported
problems of child’s functioning. It is commonly found that caregivers tend to over report
internalizing problems when compared against self-reported internalizing problems
68

(Martin, Ford, Friedman, Tang, & Huffman, 2004; Thornberry et al., 2003). Martin and
colleagues (2004) found that among an outpatient sample, that parents rated their children
as having more problems, than reported by the child. However, slightly more than half of
parents and children agreed on reports of clinical levels. Of those who disagreed, it was
more common for the parent to report more problems. Among this same sample, there
was a small group of youth who identified themselves in the clinical range when their
parents did not. Thus, it is still likely that there are characteristics related to the informant
that contribute to the recognition of internalizing problems. One such characteristic is
caregiver mental health. Higher levels of maternal depression and/or psychopathology are
associated with over-reporting adolescent’s internalizing problems (Berg-Nielsen, Vika
and Dahl; 2003; Kroes, Veerman, & Dr Bryn, 2003). Randazzo, Landsverk and Ganger
(2004) studied a group of foster children aged 5 to 16 and compared biological parent,
foster parent, and teacher rated CBCL problems. They found a significant relationship
between parent depressive symptoms and reports of internalizing problems. Treutler and
Epkins, (2003) also found that parent ratings of both internalizing and externalizing
problems were significantly related to parent’s psychological symptoms but also found
that characteristics of the parent-child relationship contributed to caregiver reports of
problems. Considering that the parent or caregiver-relationship might be strained due to
the experience of maltreatment, and the possibility that the youth resides in an out-of-
home placement, it is likely that caregiver characteristics could contribute to the reported
problems in functioning among the study sample. Other than the differences in reported
functioning that may be due to caregivers, another possible explanation for the significant
69

change in internalizing problems from T2 to T3 could be related to child factors. It is
unknown what occurred between T2 and T3 that could be contributing to this spike in
caregiver perceived problems. The youth went from an average 12.1 years to 13.6 years
between T2 and T3, thus it is possible that symptoms could be related to factors such as
puberty. Considering that depression was significantly related to the pubertal
development control variable, it is likely that developmental changes associated with
puberty could contribute to differences in functioning due to the associated stressors
related to puberty, although further exploration is required.
The second aim of the study was to investigate the contribution of maltreatment
type on the trajectory of internalizing outcomes and whether gender moderated this
relationship. A significant time x emotional abuse x gender interaction for internalizing
problems emerged. This finding is particularly interesting since emotional abuse is a type
of abuse that is understudied (Trickett, Kim, & Prindle, 2011). Among this sample,
emotionally maltreated boys have the lowest (T1-T2) and highest rates (T2-T3) of
caregiver reported internalizing problems. The fact that emotionally maltreated boys had
the highest rates of internalizing problems may seem contrary to the evidence that
suggests that maltreated boys are more likely to exhibit externalizing problems while
girls tend to exhibit more internalizing symptoms (McGee, Wolfe, & Wilson, 1997;
Trickett & McBride-Chang, 1996). However, Trickett, Kim, and Prindle (2011) also
found maltreated boys to have worse functioning than girls. Using the same sample of
maltreated youth, they conducted a cluster analysis to explore clusters of emotional
maltreatment and then compared functioning in various outcomes based on the cluster
70

profile of emotional maltreatment experiences. Boys who experienced emotional abuse
with physical abuse, and boys who experienced emotional abuse with physical abuse,
neglect, and sexual abuse, had higher scores of depression than girls experiencing the
same combinations of emotional abuse. Although the current study did not investigate the
different combinations of maltreatment experiences or the specific types of emotional
abuse, it is apparent that boys make sense of the experience of emotional maltreatment
differently from girls. Clearly, this finding supports the need for more studies of
emotional abuse and the differences in outcomes for boys and girls.
Sexual abuse was found to significantly predict the trajectories of self-reported
anxiety and caregiver-reported internalizing problems over time. Sexually abused youth
overall showed more variability in symptoms over time compared to other maltreated
youth. Specifically, sexually abused youth had higher rates of anxiety at the first
assessment that showed a steep decline in symptoms to the second assessment. The other
maltreated youth exhibited a steady decline in symptoms, but had slightly higher rates of
anxiety than sexually abused youth at the second and third assessment. Regarding the
difference found for internalizing problems, sexually abused youth have more
internalizing problems at T1, which again show a steep decline over time until T2. From
T2 to T3, both the sexually abused and other abused youth show an increase in problems
and look similar at T3. This suggests that something is happening between T1 and T2 for
the sexually abused youth leading to this decline in symptoms at this time. Gender was
not a significant moderator of these relationships. Much of the literature related to
childhood sexual abuse focuses on girls, as such, less is known about male child or
71

adolescent victims and few comparisons have been made across gender. A study from the
field of nursing does show that similar to girls, boys also respond to the abuse by
exhibiting behaviors related to anxiety, denial, and dissociation (Valente, 2005). The
finding that gender did not moderate the relationship between maltreatment type and any
of the internalizing outcomes is consistent with findings from a national study of child
well-being. Maikovich-Fong and Jaffee (2010) also found no gender differences in
caregiver-reported internalizing problems among sexually abused adolescent boys and
girls. Thus, it is possible that the experience of sexual abuse can be just as detrimental to
functioning in boys as it is to girls.
The third study aim considered the effect of developmental timing of
maltreatment on the change in the trajectory of internalizing problems over time. Despite
the evidence that suggests this is a significant contributor to subsequent functioning,
significant group differences based on developmental timing were not present for this
sample. However, an effect of developmental timing is still suggested considering that
the analysis of participation found that those maltreated during the school years were less
likely to return at later measurement periods. With this, it is possible that these particular
youth may have more mental health problems that contributed to them not participating
that are not accounted for in this study.

Limitations and Strengths
There are several limitations related to this study to consider when interpreting
results. First, the determination of maltreatment types and the timing of maltreatment
72

were abstracted from CPS/DCFS reports, which may be very inaccurate. Despite the
comprehensiveness of the MCRAI system, its dependence on case records is also a
limitation. A likelihood exists that specific maltreatment information may still be missing
from the case records due to circumstances such as lack of disclosure by the child or lack
of explicit documentation of event-related details by the case worker (Trickett, et al.,
2011). Similarly, regarding the onset of when the maltreatment began, it is quite possible
that maltreatment may have been going on for some time prior to CPS involvement,
and/or when the event was reported. Depending on the length of time between the
occurrence of the maltreatment and the report of it, recollection of actual details related to
timing and other factors such as duration may diminish, particularly among younger
children. Thus, it is possible that there is less variance in timing than CPS records
indicate.
Second, although self-reported measures of anxiety and depression were utilized,
broadband internalizing problems were caregiver reported. Considering that significant
caregiver-reported internalizing problems were found in this study, it is essential to
consider this. As previously discussed, there are issues related to bias present in
caregiver-reported levels of functioning. Typically caregivers over-report problems
(Kroes, Veerman, & Dr Bryn, 2003; Martin et al., 2004; Thornberry et al., 2001) and
their responses are dependent on their own levels of functioning (Berg-Nielsen, et al.,
2003; Randazzo, et al., 2004; Treutler et al., 2003). Ultimately, considering the nature of
inward focus of internalizing problems and the associated problems with detection,
careful consideration of the informant should occur when drawing conclusions. Along
73

similar lines, utility could be found in assessing the characteristics of caregivers to
determine how they contribute to the perception of mental health problems for youth.
Third, significant attrition occurred between T2 and T3. While this is problematic
in and of itself, it is more so in this study due to the requirement of repeated measures
MANOVA to have data available at each point. As such, the already reduced sample is
further reduced to include only those with data available at each time. Since maltreated
youth were less likely than comparison youth to return, it is possible that those who did
not return experienced more severe maltreatment and/or had more mental health
problems that factored into their attrition. As previously mentioned, the developmental
timing of maltreatment was a significant predictor of participation. Those whose
maltreatment began at an older age were less likely to participate at future study waves,
thus, it is possible that this group experienced more problems that were not measured by
the current study. All in all, the reduced sample size limits the ability to generalize
findings to other samples.
Fourth, there was significant skewness among outcome variables, particularly for
the CBCL and CDI. Although skewness can affect significance tests, the F test tends to
be robust to the deviations from normality whereby a skewed distribution does not have a
sizeable effect on it (Lindman, 1974). Similarly, in accordance with the central limit
theorem, as the sample size increases, deviations from normality have less impact.
Nonetheless, caution should be taken when interpreting and generalizing findings.
Despite the limitations mentioned above, there are several strengths associated
with this study that enhance its contribution to the existing literature. For instance, it
74

included a large number of Latino youth, which is not common in the research literature,
which tends to use predominantly Caucasian samples of youth. This promotes better
understanding of how ethnic minority youth experience maltreatment. Because ethnicity
was not a predictor of internalizing outcomes, this can be considered a study of a muti-
ethnic sample, rather than a study of ethnic differences. The inclusion of a control group
from the same neighborhoods as the maltreated youth is another strength. The first aim of
this study compared the maltreated sample with the non-maltreated control sample. The
fact that the samples are from similar geographic communities attempts to rule out
confounding environmental factors to better account for the effects of the maltreatment
experiences. Additionally, the sample was gender balanced, an important characteristic
when considering the moderation of gender. This study implemented the use of a
stringent classification system to define maltreatment and associated experiences. This is
a key feature considering that there is no standardized method for categorizing
maltreatment. As utilization of such classifications increases, it will better enable the
comparison of findings across maltreated samples and maltreatment types. A final
strength of this study is that is a prospective longitudinal study that incorporates both
self-reported and caregiver-reported measures of outcomes.

Future Directions and Implications
Although three time points are sufficient for longitudinal analysis, additional
assessments can provide more detail pertaining to how the trajectories change over time.
Data collection for a fourth wave of this data is currently taking place. Once data
75

collection is completed, the study can be replicated, including the fourth wave, to indicate
the trajectory of internalizing problems spanning from early adolescence to young
adulthood. Inclusion of this developmental period will be a unique contribution to the
current literature as research that spans childhood into early adulthood are limited, and
much like adolescence, this is a critical developmental period marked with stress as one
transitions into a period of independence associated with new responsibilities and
potentially stress inducing expectations. As such, it is hypothesized that the trajectories of
internalizing problems may differ at this time as the young adult makes sense of the new
role.
Future studies should consider employing more rigorous statistical techniques that
can use all data available, regardless of whether it was measured at that time. Analytic
techniques such as individual growth curve modeling are advantageous and more
dynamic due to the toleration of interindividual variability in assessment intervals, its
ability to use all data available, regardless of missing data (Curran, Obeidat, & Losardo,
2010; Lenzenweger, Johnson, & Willett, 2004), its precision in estimating individual
growth parameters (Singer, 2003; Speer & Greenbaum, 1995) and its robustness and
flexibility (Curran, et al., 2010; Lenzenweger,et al., 2004; Rogosa, 1988).
Future research should also consider the effect of other maltreatment characteristics
such as chronicity and severity. Using data from NSCAW I, Jaffe and Maikovich-Fong
(2011) also found that developmental timing alone was not a significant predictor of
outcomes. However, they did conclude that children who experienced maltreatment
across multiple developmental periods (compared to maltreatment in only one period)
76

had evidence of more family risk factors that contributed to higher rates of externalizing
and internalizing problems. Developmental timing was found to moderate the effect of
maltreatment chronicity on caregiver reported social competence (Jaffe, & Maikovich-
Fong). Developmental timing did predict study participation, with timing in the school
years predictive of drop-out. Thus, it is possible that timing does impact outcomes, but
may moderate relationships, rather than predict.
Developmental psychopathology places importance on the role of internal and
external factors, therefore future research should also consider other contributing factors
such as puberty, community violence, cognitive ability, as well as caregiver
characteristics that could speak to why caregivers of this sample of youth tend to indicate
more internalizing problems.
This study demonstrates that internalizing symptoms do change over time among
youth. The type of abuse was a significant predictor of this change and therefore this
should be considered when developing or implementing interventions. When decisions
are being made regarding the potential removal of maltreated youth from the home where
the maltreatment occurred, the type of maltreatment may contribute to this decision. For
instance, if more psychological harm is associated with emotional abuse and sexual
abuse, these types might take precedence in determining removal. Similarly, the type of
maltreatment speaks to the choice of therapeutic intervention; it appears as though more
attention may be needed to attend to the needs of emotionally abused boys. When
responding to maltreated youth, social workers should take into account the child’s
development. Consistent with a developmental psychopathology framework and stressors
77

associated with entry in adolescence, symptoms may fluctuate over time in accordance
with the youth’s developmental ability to understand and cope with problems associated
with the maltreatment experience.

Conclusions
The research on the effects of child maltreatment, specific types of maltreatment, and
the developmental timing of research is expanding. An improvement in classifications of
maltreatment experiences contributes to the clarification of findings related to different
predictors. Ultimately, the field still has a ways to go as it is difficult to coherently and
succinctly summarize the current state of knowledge. Findings from this study support
the need for more research to further determine whether it is the experience of
maltreatment, or specific characteristics of maltreatment that contribute to the change in
functioning over time. It is evident that boys and girls make sense of maltreatment
experiences differently and therefore gender should factor into research. Future studies
should particularly probe the unique effects of emotional abuse, a type of abuse that
receives scant attention. The evidence that emotional abuse may affect boys differently,
whereby emotionally abused boys exhibit more internalizing symptoms than emotionally
abused girls is mounting.
78

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Abstract (if available)

Abstract The purpose of the current study was to examine the relationship between maltreatment characteristics and the change in internalizing outcomes over time in a sample of maltreated and non-maltreated adolescents. The sample (n=311) was drawn from a larger, federally-funded longitudinal study of the psychological and biological effects of maltreatment. A largely African American and Latino sample was measured at three time points, roughly one year apart. At the first assessment the age of the sample ranged from 9 to 13 years. Aim 1 examined the effect of maltreatment status (maltreated or not) on the trajectory of internalizing outcomes over time, and whether gender moderated this relationship. Aim 2 examined the effect of specific types of maltreatment on the trajectory of internalizing problems, and whether gender moderated this relationship. Aim 3 examined the relationship between developmental timing of maltreatment and the trajectories of internalizing outcomes and tested whether gender moderated this relationship. Internalizing outcomes included self-reported depression and anxiety, along with caregiver-reported internalizing problems. A repeated measures MANOVA was used to study the change in outcomes over time. Results indicate that the internalizing outcomes change significantly over time, but neither maltreatment status nor developmental timing significantly contributed to this change. Testing for the moderation of gender produced significant effects for the type of maltreatment. Emotionally abused youth showed less decline in anxiety scores over time compared to non-emotionally abused youth. Gender moderated the relationship between emotional abuse and internalizing problems where emotionally abused boys began with the fewest problems but showed the most problems at the final assessment. Sexual abuse was also a significant predictor

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Creator Pohle, Cara (author)

Core Title Trajectories of internalizing problems among maltreated girls and boys: differences by maltreatment type and developmental timing

School School of Social Work

Degree Doctor of Philosophy

Degree Program Social Work

Publication Date 07/31/2012

Defense Date 06/21/2012

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Adolescents,anxiety,Depression,internalizing problems,maltreatment,Mental Health,OAI-PMH Harvest

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Mennen, Ferol, E. (committee chair), Huey, Stanley J., Jr. (committee member), Traube, Dorian E. (committee member), Trickett, Penelope (committee member)

Creator Email cara.pohle@gmail.com,caraelli@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-77285

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