476458
8Violence Against WomenLevendosky et al.
© The Author(s) 2011
VAWXXX10.1177/107780121347645
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Article
PTSD Symptoms in Young
Children Exposed to Intimate
Partner Violence
Violence Against Women
19(2) 187–201
© The Author(s) 2013
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DOI: 10.1177/1077801213476458
vaw.sagepub.com
Alytia A. Levendosky1, G. Anne Bogat1,
and Cecilia Martinez-Torteya2
Abstract
Intimate partner violence (IPV) places infants and young children at risk for development
of trauma symptoms. However, this is an understudied consequence of IPV because young
children pose particular difficulties for assessment of trauma symptoms. The authors
collected maternal reports on mothers’ and children’s posttraumatic stress disorder
(PTSD) symptoms and IPV yearly, from ages 1 to 7. Approximately half of the children
exposed to IPV at each time period developed some trauma symptoms, and frequency of
IPV witnessed was associated with PTSD symptoms. Maternal and child PTSD symptoms
were correlated, suggesting that young children may be particularly vulnerable to relational
PTSD due to their close physical and emotional relationship with their parents.
Keywords
childhood exposure, intimate partner violence, PTSD, trauma
There is a dearth of research on posttraumatic stress disorder (PTSD) in young children
that occurs as a result of exposure to intimate partner violence (IPV; defined here as male
violence against a female romantic partner). This is unfortunate, as young children are at
high risk for exposure to IPV. Families in which IPV occurs are more likely than the general population to have children under the age of 5 (Fantuzzo, Boruch, Beriama, Atkins, &
Marcus, 1997). Also, young children are likely to witness the violence directly (i.e., see or
hear it) because they are often in the presence of their mothers (DeJonghe, von Eye, Bogat,
& Levendosky, 2006; Fantuzzo et al., 1997). Between 20% and 25% of school-age children
1
Michigan State University, East Lansing, MI, USA
DePaul University, Chicago, USA
2
Corresponding Author:
Alytia A. Levendosky, Department of Psychology, Michigan State University, East Lansing, MI 48824, USA.
Email: levendo1@msu.edu
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Violence Against Women 19(2)
living in homes with IPV report that they directly witness it (McCloskey, Figueredo, &
Koss, 1995; McCloskey & Walker, 2000; O’Brien, John, Margolin, & Erel, 1994). When
IPV episodes involve law enforcement, the rate of child witnessing at all ages increases to
95% (Fusco & Fantuzzo, 2009).
Exposure to IPV results in an increased risk of behavioral and emotional problems among
children, as demonstrated by recent meta-analyses (e.g., Chan & Yeung, 2009; Evans, Davies,
& DiLillo, 2008; Sternberg, Baradaran, Abbott, Lamb, & Guterman, 2006). The problems
include externalizing (e.g., Davis & Carlson, 1987; Fantuzzo et al., 1991; Hughes, 1988;
Graham-Bermann & Levendosky, 1998a) and internalizing symptoms (e.g., Grych, Jouriles,
Swank, McDonald, & Norwood, 2000; Hughes, 1988), such as PTSD and dissociative symptoms (Bogat, DeJonghe, Levendosky, Davidson, & von Eye, 2006; Graham-Bermann &
Levendosky, 1998b; Levendosky, Huth-Bocks, Semel, & Shapiro, 2002).
The extant literature provides only a broad, generic understanding of the effects of IPV
on children’s PTSD symptoms. The current research focused on children exposed to IPV
during the time they were aged 1 to 7 years. The number of children exposed to IPV varied
from 29 to 48 across these ages. Our unique, longitudinal data set allowed us to elucidate
developmental differences in the symptom picture of these children. In addition, we examined why, because IPV is a unique interpersonal stressor, it is important to understand the
child’s trauma symptoms in the context of the mother’s traumatic response as well as the
severity of the IPV she experiences.
Problems Diagnosing PTSD in Young Children
A significant difficulty in accurately diagnosing very young children stems from their
inability to report on their psychological symptoms (Scheeringa, Zeanah, Myers, &
Putnam, 2003; Stover & Berkowitz, 2005); thus, children’s symptoms are generally
assessed through parental report. However, because PTSD symptoms are more likely to be
on the internalizing rather than the externalizing spectrum (e.g., feeling confused about the
event) and, thus, not “visible” to the parent, there are inevitably problems with reliability.
For example, all of the reexperiencing symptoms cannot be assessed by an external
observer (parent or otherwise) in children below the age of 1 (e.g., bad dreams [with or
without clear content] or flashbacks about the traumatic event) as, without significant
language skills, the child cannot describe the content of his or her dreams. It is really only
at age 3 that clinicians and researchers can begin to have more confidence in parental
assessment of PTSD reexperiencing symptoms.
There are two current sets of diagnostic criteria for PTSD in young children: the DSMIV-TR (Diagnostic and Statistical Manual of Mental Disorders, text rev., American
Psychiatric Association, 2000) and DC: 0-3R (Diagnostic Classification of Mental Health
and Developmental Disorders of Infancy and Early Childhood, rev. ed.; Zero to Three,
2005). The DSM-IV-TR criteria require A1 (exposure to trauma) and A2 (reaction of fear,
helplessness, or horror) as well as one reexperiencing symptom, three avoidance symptoms, and two arousal symptoms (same as for adults). Some guidance is given for modifications of symptoms that are useful when diagnosing children. The major difference in the
Levendosky et al.
189
two diagnostic systems is that the DC: 0-3R diagnosis of PTSD excludes the A2 criteria
and reduces the number of criteria needed for the avoidance/numbing symptom cluster to
one symptom. In addition, it eliminates some criteria that are clearly inappropriate for
young children (“intense psychological distress at exposure to internal or external cues that
symbolize or resemble the trauma” and “inability to recall an important aspect of the
trauma”) and adds one new avoidance/numbing symptom (i.e., “social withdrawal”). The
DC: 0-3R diagnosis shows predictive validity of children’s problems in functioning and is
reliable over time (Meiser-Stedman, Smith, Glucksman, Yule, & Dalgleish, 2008;
Scheeringa, Zeanah, Myers, & Putnam, 2005).
However, some research indicates that very young children may experience additional/
different trauma symptoms that are not contained within either the DSM-IV-TR or the DC:
0-3R (Scheeringa & Zeanah, 1995, 2001). These include constriction of play, regression to
earlier functioning (such as loss of toilet training), aggression, separation anxiety, and
development of new fears (Scheeringa & Zeanah, 1995). This symptom cluster, called
“New Symptoms,” was included in the diagnosis of Traumatic Stress Disorder (TSD) in
the original DC: 0-3 (Diagnostic Classification of Mental Health and Developmental
Disorders of Infancy and Early Childhood, Zero to Three, 1994). Thus, if using the DSMIV-TR or the DC: 0-3R, the more constricted range of symptoms that exclude those most
applicable to young children may limit the clinician and researcher from diagnosing PTSD
symptoms in young children.
Assessment of PTSD symptoms needs to be developmentally sensitive. Recent studies
suggest that the DC: 0-3R is the superior system for children aged 0 to 6 (Meiser-Stedman
et al., 2008; Scheeringa, 2008); however, in our opinion, children under the age of 1 year
cannot be reliably diagnosed. The data are unclear whether the criteria for the DC: 0-3R
diagnosis of PTSD is the superior diagnostic system for childhood through adolescence
(Scheeringa, Wright, Hunt, & Zeanah, 2006) or whether current DSM-IV-TR criteria are
better (see Kearney, Wechsler, Kaur, & Lemos-Miller, 2010, for a review).
It is difficult to ascertain the most accurate diagnostic system for specific age groups
because most research is cross-sectional and thus it aggregates data from children of a wide
variety of ages. A recent meta-analysis that examined 96 studies of children aged 3 to 18
found that exposure to traumatic events was significantly associated with both posttraumatic symptoms and PTSD and that there were no age effects in this association (Furr,
Comer, Edmunds, & Kendall, 2010). However, the data were analyzed by comparing those
children aged 3 to 12 with children older than age 12. This procedure did not allow for
examination of the potential developmental differences between infants, preschoolers, and
school-age children. Our longitudinal data provided a unique opportunity to examine these
differences.
There are few studies solely focused on trauma symptoms of very young children.
Research finds that young children exposed to single event or chronic traumatic events
(e.g., IPV) exhibit symptoms that fit the three DSM-IV-TR clusters (see Coates &
Gaensbauer, 2009, for a review). However, the rates of PTSD diagnosis in traumaexposed young children are only consistent with rates of older children when developmentally sensitive versus DSM-IV-TR criteria are used (25%-69% vs. 0%-20%,
190
Violence Against Women 19(2)
respectively; Ghosh-Ippen, Briscoe-Smith, & Lieberman, 2004; Levendosky et al., 2002;
Meiser-Stedman et al., 2008; Ohmi et al., 2002; Scheeringa, Peebles, Cook, & Zeanah,
2001; Scheeringa, Zeanah, Drell, & Larrieu, 1995; Scheeringa & Zeanah, 2008; Scheeringa
et al., 2003). A similar pattern of results is found in the few studies that have specifically
examined PTSD symptoms and diagnoses in children exposed to IPV.
Research on PTSD in Young Children Exposed to IPV
Extant studies find that, among young children, witnessing IPV is associated with PTSD
symptoms (e.g., Jarvis, Gordon, & Novaco, 2005; Kilpatrick & Williams, 1997). However,
while these studies generally find that mothers and/or children report high rates of symptoms, low rates of PTSD diagnosis are reported for children, particularly when DSM-IV
(American Psychiatric Association, 1994) criteria are used. Across studies of young children (including studies that assessed PTSD symptoms in both younger and older children
exposed to IPV), the rates of children who endorsed symptoms in each of the criteria sets
were as follows: 52% to 85% for reexperiencing, 3% to 98% for avoidance, and 31% to
73% for arousal, while the rates of DSM-IV-TR PTSD reported were between 3% and 25%
(Graham-Bermann, DeVoe, Mattis, Lynch, & Thomas, 2006; Graham-Bermann &
Levendosky, 1998; Levendosky et al., 2002; Mertin & Mohr, 2002; Rossman, Bingham,
& Emde, 1997). The large discrepancies in percentages of symptoms in each of the PTSD
clusters that different researchers find are probably due to the cross-sectional nature of the
research methods that assessed children from a wide age range (e.g., young childhood to
middle childhood or adolescence; Graham-Bermann et al., 2006; Mertin & Mohr, 2002;
Rossman et al., 1997). Across ages, reexperiencing symptoms seem to be most prevalent,
with avoidant symptoms least prevalent. In addition, the discrepancy between the large
percentages of children who have symptoms of PTSD and the much lower percentages of
children who meet diagnostic criteria for PTSD suggests that PTSD criteria as defined by
the DSM-IV-TR are not as valid for young children as they are for adolescents and adults.
Finally, when examining PTSD diagnoses or symptoms in young children, it is important to also examine the mother’s symptoms in order to understand fully the child’s symptom picture. For example, prior research with infants in the current study revealed that
while mothers reported that more than one third of the infants who witnessed IPV had at
least one symptom of PTSD, these symptoms of PTSD were associated with maternal
PTSD symptoms, especially when mothers had been exposed to severe IPV (Bogat et al.,
2006).
IPV and PTSD in Mothers
In very young children there is some evidence that the mother’s trauma symptoms are
associated with those of her child (e.g., Bogat et al., 2006; Scheeringa & Zeanah, 2001).
This is significant because rates of PTSD across studies of women experiencing IPV typically range from 31% to 84% (Golding, 1999). Scheeringa and Zeenah propose that in
situations where mothers experience trauma, relational PTSD can result—a situation in
Levendosky et al.
191
which the emotional relationship between the mother and child causes an enhancement of
the trauma symptoms of each of them. Young children, compared to older children, are
considered to be particularly vulnerable to the effects of the mother’s trauma response due
to their increased physical proximity to and more significant emotional dependence on the
mother. Thus, for young children, trauma symptoms may be more highly related to the
severity of the mother’s trauma symptoms, rather than the frequency of witnessing IPV (or
other traumas), compared with older children and adults. Current research has not examined developmental changes in relational PTSD, nor has it examined whether specific
symptom clusters of mothers and children are more likely than others to be related. Again,
longitudinal data allowed us to examine changes in relational PTSD over time.
The Current Study
The data from the current longitudinal study allowed for a fine-grained description of the
PTSD symptom clusters at six different ages. At each age, we measured PTSD symptoms
using developmentally appropriate criteria. In contrast to most studies, we chose to examine symptoms for each of the six age groups separately because of the significant developmental changes that occur over the course of 1 year during early childhood. This
allowed us to examine variation in symptom picture across age groups. We addressed the
following research questions. First, does age influence the types of symptoms and symptom clusters that children exhibit? Second, do the three different diagnostic schemes
(DSM-IV-TR, DC: 0-3R, and DC: 0-3) show age differences in rates of diagnosis? Third,
is the frequency of witnessed IPV related to children’s PTSD symptoms? Fourth, controlling for frequency of witnessed IPV, is there a significant relationship between maternal
and child PTSD symptoms, and does this change as a function of the child’s age?
Method
Participants
The participants were drawn from the Mother-Infant Study (Bogat, Levendosky, &
Davidson, 1999; Levendosky, Bogat, Davidson, & von Eye, 2000). Two hundred and six
women were interviewed during the last trimester of their pregnancy. After the child was
born, they were assessed yearly at the child’s birthday through age 7. In the current study,
we are presenting data from ages 1, 2, 3, 4, 5 and 7. We did not collect data on the children’s
PTSD symptoms at age 6. The demographics for the full sample are shown in Table 1. The
children in the current research are those whose mothers reported that they witnessed IPV
at any age. For each data collection, if the mother reported that her child had witnessed IPV
(note, the mother may have experienced IPV but the child did not witness it), then she was
asked to report on her child’s symptoms of PTSD. Because in any given year the women
may not have experienced IPV or the child may not have witnessed what occurred, the data
at each time point are not necessarily for the same children (see Table 1 for the children
witnessing IPV each year and the percentage with any PTSD symptoms and full diagnosis).
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Violence Against Women 19(2)
Table 1. Children Who Witnessed IPV With PTSD Symptoms at Ages 1 to 7.
Age of Child
IPV, n
Witness, n
PTSD symptoms, n
Percentage of witnessing with any
symptoms
Percentage of witnessing with DSMIV-TR diagnosis
Percentage of witnessing with DC:
0-3R diagnosis
Percentage of witnessing with DC:
0-3 diagnosis
1
2
3
4
5
7
77
48
18
38
83
43
26
60
55
29
23
79
65
38
29
76
51
33
16
48
47
29
17
86
N/A
0
0
2
2
4
N/A
1
9
14
6
21
N/A
4%
12%
17
N/A
N/A
Note: DSM-IV-TR = Diagnostic and Statistical Manual of Mental Disorders (text rev.); DC: 0-3R = Diagnostic
Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (rev. ed.).
Measures
IPV. IPV was assessed with the Severity of Violence Against Women Scales (SVAWS:
Marshall, 1992), a 46-item questionnaire that measures the frequency of threats of violence, actual physical violence, and sexual violence during the past year. A total frequency
score at each time point was used. Mothers also indicated whether their children witnessed
the violence. Marshall reported coefficient alphas among a community sample ranging
from .86 to .96 for the subscales.
Maternal PTSD. This was assessed using the Posttraumatic Stress Disorder Scale for Battered Women (Saunders, 1994). This self-report questionnaire asks women to endorse how
often they experience 17 symptoms that are consistent with the DSM-IV-TR symptom list
(Criteria B-D) for PTSD. A total score as well as scores for the individual cluster symptoms
were used in these analyses. Saunders reported a .94 reliability coefficient, and a high correlation (r = .58) with other PTSD scales.
Child PTSD. This was assessed with maternal report on three different measures, based
on the appropriateness of the measure for the developmental level of the child. The
infants were assessed with a measure developed for this study based on the DC: 0-3 criteria (Zero to Three, 1994)—the Infant Traumatic Stress Questionnaire (ITSQ: Bogat,
1999). The preschool children (ages 2-4) were assessed with a measure based on the
DSM-IV-TR and DC: 0-3 (Zero to Three, 1994) criteria—the Child Traumatic Stress
Questionnaire (CTSQ: Bogat & Levendosky, 2002). The 5- and 7-year-old children were
assessed with the Child Domestic Violence PTSD scale (Pynoos, Rodriguez, Steinberg,
Stuber, & Frederick, 1998), a measure based on the DSM-IV (American Psychiatric
Association, 1994) criteria. All of these measures yielded symptoms for the three clusters
Levendosky et al.
193
of reexperiencing, avoidance, and arousal, with the exception of the ITSQ, which did not
assess reexperiencing. The ITSQ and the CTSQ also assessed symptoms in the new fears
category from the DC: 0-3R.
Procedures
Women were recruited into this study during their pregnancy. We oversampled for
women who had experienced IPV so that more than half of them had experienced IPV
during the pregnancy (see Huth-Bocks, Levendosky, Bogat, & von Eye, 2004) for a
detailed description of recruitment and screening. The current study analyzes data collected when the children were ages 1, 2, 3, 4, 5 and 7. At each wave, data include only
those children whose mothers indicated that they witnessed IPV during the past year.
Interviews were scheduled near the child’s birthday. Women were paid for their time, and
children were given a small gift.
Results
The children who witnessed IPV at each of the six ages were assessed for their PTSD
symptoms and whether they met criteria for PTSD. There was no linear developmental
pattern to the number of children who lived in homes where IPV occurred or to the number of children who witnessed the IPV (see Table 1). At ages 1 and 2, children were more
likely to have IPV in their homes and to witness it compared to children at other ages.
Across the different ages, there was a general rise in the percentage of children witnessing
IPV who experienced symptoms, with the exception of age 5 when there was a decline.
The percentage of children diagnosed with PTSD based on the DC: 0-3 or DC: 0-3R
criteria was higher at all ages compared to when the DSM-IV-TR diagnostic criteria were
used (see Table 1).
There were developmental patterns in the three PTSD clusters of symptoms: reexperiencing, avoidance, and arousal (see Figure 1). Arousal was the most frequently endorsed
at all ages, except age 4. At age 4 reexperiencing was the most highly endorsed symptom.
The percentage of children with reexperiencing symptoms peaked at age 4 and then
declined. The percentage of children who experienced avoidance rose from ages 1 to 3
and then stayed fairly stable, with mild fluctuation between ages 4 and 7. The percentage
of children who experienced arousal symptoms increased from ages 1 to 3, dropped at
ages 4 and 5, and was then fairly stable until age 7, when it increased dramatically. In
addition, the percentage of new symptoms (a category of symptoms unique to DC: 0-3
diagnostic criteria) also showed a nonlinear pattern (see Figure 1). The percentage of
children with these symptoms was similar at ages 1 and 2, more than doubled at age 3, and
then declined at age 4, but to levels higher than ages 1 and 2. These symptoms were not
measured at ages 5 and 7.
Frequency of IPV witnessed by the children influenced the relationship between symptoms and the age at which they were expressed (see Table 2). Again, though, the results
were not consistent. Frequency of IPV was significantly related to total PTSD symptoms at
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Violence Against Women 19(2)
80
% with Symptoms
70
60
Avoidance
50
Re-experiencing
40
Arousal
30
New Fears
20
10
0
1
2
3
4
Age
5
7
Figure 1. Percentage of Children Experiencing the Four Types of Symptoms at Each Age.
Note: Figure is available in full color in the online version at vaw.sagepub.com
Table 2. Relationship Between Frequency of IPV Witnessed and Child PTSD Symptoms.
Age of Child
Total PTSD
Reexperiencing
Avoidance
Arousal
New symptoms
1
2
3
4
5
7
.46*
N/A
.28*
.30*
.09
.24*
–.15
–.02
.17
.17
.70*
.04
.08
.36*
.44*
.48*
.16
.21
.29*
.35*
.72*
.34*
.36
.52*
N/A
.48*
.41*
.36*
.23
N/A
Note: IPV = intimate partner violence; PTSD = posttraumatic stress disorder.
*p < .05.
all ages. None of the symptom clusters follows this pattern. Reexperiencing was only associated with severity of IPV at age 7. Avoidance was only associated with frequency of IPV
at ages 1, 5, and 7. Arousal was associated with frequency of IPV at ages 1, 3, 4, and 5. The
new symptoms cluster from the DC: 0-3 (Zero to Three, 1994) was associated with frequency of witnessing IPV at ages 3 and 4.
Finally, we examined the relationship between mothers’ and children’s PTSD symptoms, controlling for frequency of witnessed IPV (see Table 3). These revealed inconsistent
significant relationships across ages without a clear developmental pattern. In fact, the
patterns that existed seemed to be related to symptom clusters rather than to age. The most
consistent relationships were found for arousal symptoms across ages, showing significance for ages 1, 2, 4, and 7. In contrast, there were no significant relationships between
reexperiencing symptoms for mothers and children.
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Levendosky et al.
Table 3. Relationship Between Child and Maternal PTSD Symptoms Controlling for
Frequency of IPV Witnessed.
Age of Child
Total PTSD
Reexperiencing
Avoidance
Arousal
1
2
3
4
5
7
.47*
N/A
.44*
.39*
.19
.15
.18
.32*
.25
.01
.04
.21
.43*
.17
.45*
.44*
.44*
–.02
.44*
.19
.13
.28
.07
.31*
Note: IPV = intimate partner violence; PTSD = posttraumatic stress disorder.
*p < .05.
Discussion
Overall, our findings indicate that children are affected by the IPV they witness and often
show a traumatic response. The likelihood of traumatic symptoms increases as children
age; this is consistent with the trajectory of other anxiety disorders and internalizing disorders generally (Kovacs, Feinberg, Crouse-Novak, Paulauskas, & Finkelstein, 1984;
Leve, Kim, & Pears, 2005). In addition, maternal report of child PTSD symptoms changes
across development such that some symptoms are more likely to be endorsed in infancy
and others during preschool. The “new symptoms” category in the original DC: 0-3 (Zero
to Three, 1994) was relatively highly endorsed by the mothers in our sample, and the correlations with frequency of witnessing IPV were in the same direction and generally of the
same strength as the other three groups of symptoms. In addition, these symptoms contributed to several additional cases of diagnosed TSD in ages 2 to 4. One possible interpretation is that these symptoms are in fact other ways of responding to trauma and a
comprehensive assessment of early childhood traumatic responses should include these
symptoms.
Rates of diagnosed PTSD were low in this study, compared with studies of older children exposed to trauma (Graham-Bermann et al., 2006; Lehmann, 1997). Only the PTSD
diagnosis rate of 21% in the 7-year-olds (using the DC: 0-3R criteria) approaches rates
typical of older children reported in the literature (i.e., 25%-69%; Ghosh-Ippen et al., 2004;
Levendosky et al., 2002; Meiser-Stedman et al., 2008; Ohmi et al., 2002; Scheeringa et al.,
2001, 1995; Scheeringa & Zeanah, 2008; Scheeringa et al., 2003). It may be that young
children rarely meet all criteria for a PTSD diagnosis, similar to the low rates for other
anxiety and internalizing disorders. The low rates of PTSD diagnosis, even using the DC:
0-3R or DC: 0-3 criteria suggest that young children witnessing IPV do not fit the same
profile of responses to IPV as older children and adults. Their high rates of symptoms suggest that they do experience affective and behavioral dysregulation but that it is not adequately captured with the various instruments that assess PTSD diagnoses. Our findings
suggest that alternative conceptions of posttraumatic consequences for young children are
important to consider, such as the Developmental Trauma Disorder (DTD), currently under
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Violence Against Women 19(2)
development by van der Kolk and colleagues (see van der Kolk, Roth, Oelcovitz, Sunday,
& Spinazzola, 2005).
Another explanation for the low rates of PTSD diagnosis among the young children in
our sample may relate to the difficulty mothers have reliably reporting internalizing symptoms. At this stage of development, mothers may have underestimated the symptoms, thus
depressing the rates of PTSD. Consistent with this hypothesis is the finding that arousal
symptoms were generally the most frequently endorsed by mothers. Arousal symptoms are
more amenable to external observation than are reexperiencing and avoidance symptoms.
The total number of children’s symptoms was related to the frequency of IPV that they
witnessed. This is consistent with previous findings (e.g., Graham-Bermann et al., 2006;
Levendosky et al., 2002; Rossman et al., 1997) and suggests that young children are
directly affected by witnessing violence, even if most of them do not meet criteria for
PTSD. Arousal was significantly associated with witnessing IPV for ages 1 to 5 (with the
exception of age 2). In contrast, avoidance was only associated with witnessing IPV at ages
5 and 7, and reexperiencing was only associated at age 7. This may indicate a developmental shift such that in the youngest children, affective dysregulation is the most dominant
response to witnessing IPV, but as children get older, more cognitive and behavioral dysregulation as a response to witnessing IPV become prominent, as seen in reexperiencing
and avoidance. This may reflect the increasing differentiation of symptoms of emotional
distress that occur with development and are associated with particular psychopathologies
(Carter, Briggs-Gowan, Jones, & Little, 2003; Eisenberg et al., 2001). Age 2 was an exception to the trend, with no specific symptom clusters related to witnessing IPV. The inconsistency of the age 2 data may be a valid finding. This is the age when children first attempt
to separate and develop independence; this may be a particularly trying and conflictual
experience in families where IPV takes place. A mother may be unable to distinguish her
toddler’s traumatic response from other difficult behaviors.
Our findings also indicated a high co-occurrence of maternal and child PTSD symptoms, controlling for frequency of IPV witnessed, across all the ages. One interpretation of
these findings is support for relational PTSD. Young children who are likely to be in close
physical and emotional proximity to their mothers are likely to influence and be influenced
by her traumatic response to the IPV. In particular, maternal symptoms of arousal were
associated with children’s arousal symptoms. This suggests young children are responding
directly to their mothers’ affective dysregulation in reaction to IPV as well as demonstrating similar affective dysregulation. In contrast, maternal reexperiencing symptoms were
not related to those of the children. This may be due to children’s lack of awareness of
maternal reexperiencing symptoms or that these symptoms in their mothers may be less
distressing to children than their mother’s arousal symptoms. Finally, the lack of a significant relationship also may be due to the difficulty mothers have in ascertaining children’s
reexperiencing symptoms, as noted above.
There are several limitations to this study. The first is the reliance on the mother as the
sole reporter of her experiences of IPV as well as her and her child’s trauma symptoms.
Mothers may underreport witnessing of IPV because, at the time it is occurring, their
involvement in the episode may have distracted them from attending to whether or not their
Levendosky et al.
197
child heard or saw the IPV. In addition, they may defensively imagine that they protect
their children from exposure to IPV. The second limitation is related to the size of the
sample. Our sample was sufficient to allow for examination of symptoms at each age,
rather than aggregating different age children as prior studies have done. However, our
study method was to assess PTSD symptoms at each age only for those children whose
mothers reported that they witnessed IPV. Thus, we could not examine whether and how
PTSD symptoms change throughout an individual child’s development. Unfortunately,
because women’s experiences of IPV are rarely consistent (e.g., overall rates of IPV
decrease as women and men age, women often leave and return to abusive partners multiple times) an enormous epidemiological sample would be necessary to track children’s
trauma symptoms over time.
In summary, similar to other studies, the ratio between children who had symptoms of
PTSD in response to witnessing IPV, compared with those who met criteria for PTSD
under any of the diagnostic schemes, was low. This adds evidence to the growing movement to include DTD in the DSM-5 (van der Kolk et al., 2005). This disorder is designed
to address the very significant problem that most children exposed to traumatic events,
including witnessing IPV, do not meet criteria for PTSD, even the modified criteria by
Scheeringa et al. (2003) for younger children. Van der Kolk et al. argue that many children
who have a posttraumatic disorder are not currently diagnosed, with the implication that
children often do not get services they need. Many of these children, instead, may be
receiving treatment for other disorders, such as ADHD (attention-deficit hyperactive disorder) or depression, rather than the treatment they need. Among children who witness IPV,
DTD may better capture the posttraumatic problems than current diagnostic schemas.
Future studies should continue to examine the trajectories of symptoms of PTSD in
response to trauma across children’s ages. Our study suggests that children may exhibit different PTSD symptom clusters across development in response to witnessing IPV. Finally,
there are some clinical implications from the current study. It is critical that assessment
instruments used by clinicians and researchers with young children exposed to IPV include
developmentally sensitive symptom items. Physicians and mental health professionals should
assess young children exposed to IPV for trauma symptoms and consider the consequences
for children’s functioning and development, even when children do not fit criteria for the
DSM-IV PTSD diagnosis. Finally, this study highlights the importance of clinicians being
aware of the differences in the types of posttraumatic symptoms across early childhood.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship,
and/or publication of this article: This study was supported by grants from the National Institute
of Justice (8–7958-MI-IJ) and the Centers for Disease Control (RO1/CCR518519–01) to the
first and second authors.
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Violence Against Women 19(2)
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Author Biographies
Alytia A. Levendosky is a professor of clinical psychology and director of clinical training at
Michigan State University. Her research focuses on the intergenerational transmission of intimate partner violence. She is particularly interested in the perinatal period and the psychological and biological mechanisms through which intimate partner violence influences the
mother–child relationship and child behavior.
G. Anne Bogat is a professor of clinical psychology at Michigan State University. Her research
focuses on risk and resilience factors related to women and children living with intimate partner
violence, including social, psychological, and biological correlates related to psychological
outcomes. She is particularly interested in understanding the longitudinal trajectory of the
effects of intimate partner violence.
Cecilia Martinez-Torteya is a postdoctoral fellow at the Department of Psychiatry of the
University of Michigan. She studies the effects of prenatal and early traumatic stress on children’s development. Using a developmental psychopathology framework, her research
addresses the biological, psychological, and environmental mechanisms that promote resilience
or increase risk for psychopathology in the context of early adversity.
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