are consistent with earlier research linking psychological
maltreatment to a range of internalizing symptoms, relational
insecurity and negative self-perceptions (e.g., Trickett, Kim, &
Psychological maltreatment also exhibited a strong
prediction of externalizing problems, such as behavioral
problems, self-injury and criminal activity, comparable to that
of physical abuse and greater than that of sexual abuse.
Exacerbating effect of psychological maltreatment
upon other maltreatment groups
Consistent with prior studies suggesting that psychological
maltreatment may increase the likelihood of the detrimental
effects of sexual or physical abuse, the co-occurrence of
psychological maltreatment with sexual or physical abuse was
associated with higher PTSD symptoms, as well as CBCL-Int.
and CBCL-Ext. behavior problem scores compared with sexual
or physical abuse alone. These findings add to a growing body
of research demonstrating that exposure to multiple forms of
trauma (Cloitre et al., 2009; Higgins, 2004) is associated with an
exacerbation of psychosocial impairment.
Interestingly, the co-occurrence of physical abuse with sexual
abuse rarely predicted greater outcome severity. Indeed, for a
number of study indicators, the predictive effect of physical
abuse and sexual abuse was significantly lower than that of
psychological maltreatment alone. As gauged by its incremental
predictive potency, psychological maltreatment may represent
a disproportionately more potent predictor to the risk for a
broad array of trauma-related adverse outcomes in childhood
and adolescence compared with other more extensively studied
forms of maltreatment.
These findings suggest that, in evaluating risk for PTSD
and other adverse behavioral and psychosocial outcomes, the
accumulation of multiple maltreatment types may not follow
a simple equally weighted additive pattern. Consistent with
the role of a vulnerability factor (Layne et al., 2009), the co-occurrence of psychological maltreatment in this study was
associated with a significant increase in the prevalence and
severity of a range of internalizing and externalizing problems
for children exposed to either physical or sexual abuse.
Our findings carry important implications for public policy
and the development, adaptation and implementation of child
First, given its predictive potency and widespread prevalence,
efforts to increase recognition of psychological maltreatment
as a potentially formidable type of maltreatment in its own
right should be at the forefront of mental health and social
service training efforts, including incorporation of education
on psychological maltreatment into graduate training curricula
and continuing education of child service professionals
(Courtois & Gold, 2009). This need is especially apparent in
the child welfare system considering the low rates at which
psychological maltreatment is detected. Enhancement of
training initiatives for protective services personnel focused
on screening and assessment of psychological maltreatment,
as well as linking children to appropriate services, is critical.
Also, mental health outreach, consumer resource development
and public awareness initiatives are needed to achieve more
widespread understanding of the detrimental consequences of
psychological maltreatment for children and adolescents.
Second, psychometrically sound, clinically useful
instruments are needed to help providers identify psychological
maltreatment, categorize and appreciate various forms of
emotional abuse and emotional neglect, and assess their
associated effects on a range of adverse youth outcomes.
Third, effective, theoretically grounded interventions for
the sizable subpopulation of traumatized youth exposed to
psychological maltreatment are clearly needed. For example,
few child trauma treatment models directly target psychological
maltreatment, and no intervention has been developed to focus
specifically on this widely prevalent form of trauma exposure.
The extent to which prevailing child trauma treatment
models are applicable to, and sufficiently address the needs of,
psychologically maltreated youth remains an open question.
Future research should explore whether existing models
are sufficient or can be adapted to accommodate the needs
of psychologically maltreated children and adolescents; or
alternatively, whether new models or interventions are required.
Finally, greater attention should be dedicated toward
understanding the complex manner in which co-occurring
forms of childhood trauma may intersect to influence traumatic
stress reactions, attachment and self-image problems, affective
and physiological dysregulation, risk behaviors, and functional
impairment across development (D’Andrea et al., 2012).
Guiding theory, assessment tools, interventions and clinical
training methods are needed to support accurate risk screening
and case identification, effective intervention, workforce
development and public policy.
If we are to heal the full spectrum of wounds inflicted
by childhood trauma — both the visible and the unseen —
such efforts must be guided by a clear appreciation for the
variability in occurrence, intersection, etiology, developmental
context, clinical course and causal consequences of all forms of
This article is adapted from “Unseen Wounds:
The Contribution of Psychological Maltreatment
to Child and Adolescent Mental Health and Risk
Outcomes,” published in the Vol. 6, 2014, issue
of Psychological Trauma: Theory, Research,
Practice, and Policy. Go to www.apa.org/pubs/