Maltrato Review 2005 PDF

17 Feb 2005 9:58 AR AR240-CP01-15.tex AR240-CP01-15.
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10.1146/annurev.clinpsy.1.102803.144029
Annu. Rev. Clin. Psychol. 2005. 1:409–38

doi: 10.1146/annurev.clinpsy.1.102803.144029
Copyright c 2005 by Annual Reviews. All rights reserved
First published online as a Review in Advance on October 5, 2004
CHILD MALTREATMENT
Dante Cicchetti and Sheree L. Toth
Mt. Hope Family Center, Rochester, New York 14608; email: MHFC@netacc.net;
s.toth@att.net
Annu. Rev. Clin. Psychol. 2005.1:409-438. Downloaded from arjournals.annualreviews.org
by University of Kanas-Lawrence & Edwards on 09/14/05. For personal use only.
Key Words definition, etiology, sequelae, intervention, policy

■ Abstract Child maltreatment exemplifies a toxic relational environment that
poses significant risks for maladaptation across biological and psychological domains
of development. Research on child maltreatment can inform developmental theory,
but more importantly, it can enhance the quality of clinical, legal, and policy-making
decisions for maltreated children. This chapter addresses definitional, epidemiologi-
cal, and etiological aspects of child maltreatment. A developmental psychopathology
perspective is directed toward the discussion of the psychological and neurobiological
sequelae of child maltreatment. Implications for prevention, intervention, and social
policy are discussed, and recommendations for future research are proffered.
CONTENTS
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410
DEFINITIONAL CONSIDERATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410
EPIDEMIOLOGY AND ETIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412
MALTREATING FAMILIES AS A PATHOGENIC RELATIONAL
ENVIRONMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414
THE DEVELOPMENTAL PSYCHOPATHOLOGY PERSPECTIVE . . . . . . . . . . . . 414
THE EFFECTS OF CHILD MALTREATMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
PSYCHOLOGICAL SEQUELAE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416
Affect Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416
Development of Attachment Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419
The Development of Self-System Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419
Peer Relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Adaptation to School . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
NEUROBIOLOGICAL SEQUELAE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
Acoustic Startle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
Neuroendocrine Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
Cognitive Event-Related Potentials to Emotional Facial Displays . . . . . . . . . . . . . . 425
Neuroimaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426
PSYCHOPATHOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426
RESILIENCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
PREVENTION AND INTERVENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428
SOCIAL POLICY IMPLICATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430
CONCLUSION AND FUTURE PERSPECTIVE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431
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410 CICCHETTI TOTH
INTRODUCTION
Research on maltreated children provides an opportunity to examine contextual ex-
periences that far exceed normative experiences of caregiving. Child maltreatment
exemplifies a toxic relational environment that poses considerable risk for mal-
adaptation across diverse biological and psychological domains of development
(Cicchetti 2002). Beyond the contributions that research on child maltreatment can
make to inform developmental theory, it also is extremely important for enhancing
the quality of clinical, legal, and policy-making decisions for maltreated children
(Cicchetti & Toth 1993, Toth & Cicchetti 1993).
In this chapter, we provide a selective review of theory and research in the

area of child maltreatment. We begin by addressing definitional, epidemiologi-

cal, and etiological aspects of child maltreatment. Our discussion is guided by
a developmental psychopathology perspective, which we describe. We then di-
rect our attention toward the extant research on the effects of child maltreatment
on the developmental process, addressing both psychological and neurobiological
sequelae. In the penultimate section of the chapter, implications for prevention,
intervention, and social policy are explored. We conclude with recommendations
for future research to continue to advance the understanding of, and intervention
for, this societal problem.
DEFINITIONAL CONSIDERATIONS
In the last decade, the maltreatment literature has profited from methodological
advances devoted to the operationalization of child maltreatment. In general, four
categories of child maltreatment have been distinguished: (a) physical abuse, which
involves the infliction of bodily injury on a child by nonaccidental means; (b) sex-
ual abuse, which includes sexual contact or attempted contact between a child and a
caregiver or other adult for purposes of the caregiver’s sexual gratification or finan-
cial gain; (c) neglect, which pertains to both the failure to provide minimum care
and the lack of supervision; and (d) emotional maltreatment, which involves persis-
tent and extreme thwarting of a child’s basic emotional needs (Barnett et al. 1993).
Despite some definitional advances, however, more than a decade since the
National Research Council (1993) highlighted the need for improved operational
definitions of child maltreatment, debate continues. Therefore, it becomes impor-
tant to examine why a consensus on the definition of child maltreatment has been so
elusive. First, the fact that maltreatment is a legal matter defined by social service
systems and not by researchers or mental health providers must be recognized.
Furthermore, there are no clear, agreed upon standards to differentiate between
acceptable parental disciplinary practices and those that cross the line into child
maltreatment (Cicchetti & Lynch 1995). This situation has been further compli-
cated by variations across periods of history and cultures regarding acceptable
versus maltreating parenting (Barnett et al. 1993).
CHILD MALTREATMENT 411
Issues regarding whether child maltreatment should be defined based on the

actions of the perpetrator, the effects on the child, or on a combination of the
two (Barnett et al. 1993, McGee & Wolfe 1991) have contributed to ongoing
disagreement about the parameters of child maltreatment. Whether or not parental
intent should be considered when determining if an act of maltreatment occurs also
has been hotly debated. Controversy also has accompanied decisions regarding the
purpose of a given definition. For example, a definition of maltreatment that was
acceptable for research purposes might not be viable in a legal setting. Similarly, a
medical model focuses on overt signs of maltreatment, typically physical in nature,
and, although effective for informing medical practice, such a definition is likely
to miss more subtle forms of maltreatment.

Finally, for purposes of research, the methodological strategies utilized to ascer-

tain the presence of maltreatment have varied. Typically, methods have included
self-report (of either perpetrator or victim), observational paradigms, or utiliza-
tion of official child protective services (CPS) records (e.g., Dodge et al. 1997,
Egeland & Sroufe 1981, Manly et al. 1994). Each method has positive as well as
negative aspects. Reliance on self-report may be clouded by limitations associated
with the willingness of the perpetrator or victim to report honestly. Observational
methods may not result in the full portrayal of nonobserved experiences. Reliance
on records is limited by the “gatekeepers” of the system and not all acts of mal-
treatment eventuate in official records. In general, multipronged approaches to
delimiting the occurrence and type of maltreatment experienced are likely to yield
the most accurate account of experiences.
In response to the challenges accompanying the measurement of child mal-
treatment, a number of classification systems have been developed to increase the
accuracy and comparability of determinations of child maltreatment in research
investigations. One such system, the Maltreatment Classification System (MCS;
Barnett et al. 1993), provides operational definitions of maltreatment subtypes, with
inclusion and exclusion criteria and exemplars for each of five levels of severity for
each subtype. The MCS also includes measurement of onset, frequency, chronicity
of each subtype, the developmental period(s) during which each subtype occurred,
the severity of each subtype, and the perpetrator(s) of each subtype. The MCS
was devised to provide an objective and comprehensive portrayal of information
contained in official records of maltreatment and it has been effectively utilized
in more than 40 research laboratories across the United States. McGee & Wolfe
(1994) also emphasized the importance of coding official reports of maltreatment
in order to capture the diversity and complexities of children’s experiences. The
Record of Maltreatment Experiences (ROME; McGee et al. 1990) that was utilized
to code CPS record data demonstrated the role of the interplay among the dimen-
sions of developmental period, subtype, and gender in contributing to behavior
problems in maltreated youngsters.
Systems such as MCS and ROME, which provide independent coding of mal-
treatment records, possess a number of advantages. Because all maltreatment
filings in official records are legally substantiated, determinations are made by
412 CICCHETTI TOTH
individuals not directly involved with a given research investigation. This mini-
mizes the risk that families participating in research will need to be reported to
authorities by researchers. Moreover, utilization of legally identified occurrences
of child maltreatment are representative of actual cases that are considered to be
sufficiently severe to warrant intervention by authorities.
Although systems such as these possess many advantages, they have not gone
uncriticized. Gelles (1982) argued that reliance by researchers on official reports
of maltreatment results in a study of factors leading to being “caught” as much as,
if not more than, the study of maltreatment itself. Others have criticized utilization
of official reports for resulting in a biased sample of maltreated children who
may come to the attention of authorities due to limited family resources, severe
maltreatment, or child behavior problems (Dodge et al. 1997).

In response to this concern, some researchers have advocated for the identifica-
tion of community-based samples of maltreated children who have not necessarily
come to the attention of authorities (Dodge et al. 1997). Such approaches typically
query parents about their disciplinary methods or ask children to report on their
experiences of caregiving and devise an index of positive versus severe parenting
practices. Although not plagued by the identification of only cases brought to the
attention of authorities, this approach may not capture more severely maltreated
children, thereby resulting in a bias of a different nature. Similar limitations can
accompany reliance on rating parent-child interaction to configure a “maltreating”
sample of parents.
The resulting conundrum is not without a resolution. By combining parental
report with the coding of official CPS records, it is possible to optimize positive
and minimize negative method components associated with the identification of a
population of maltreated children. Specifically, a semistructured interview can be
given to parents and used in conjunction with official records to provide a more
comprehensive portrayal of parenting.
EPIDEMIOLOGY AND ETIOLOGY

Now that the complexities associated with defining and identifying acts of child
maltreatment have been addressed, it is possible to better ascertain the extent of
the problem while simultaneously recognizing the limitations embodied in official
records. According to recent published U.S. government statistics (U.S. Dept. of
Health and Human Services 2002), an estimated 2.6 million referrals concern-
ing the welfare of approximately 4.5 million children were made to CPS agen-
cies throughout the United States in 2002. Of these, approximately two-thirds, or
1.8 million, were accepted for investigation. Of cases investigated, an estimated
896,000 children were determined by the CPS agencies to have been victims of
child abuse or neglect. The rate of victimization per 1000 children in the national
population is 12.3, with children younger than age three having the highest rates
of victimization—16.0 per 1000 children.
Importantly, these statistics reflect only those cases that came to the attention
of authorities and, therefore, the actual numbers of children who are victims of
child abuse and neglect are far greater. Moreover, the fact that one third of all
cases reported to authorities were not investigated further increases the likelihood
that the prevalence of maltreatment far exceeds official numbers. Reasons for
noninvestigation vary, and can include issues such as a determination that a clear
perpetrator cannot be identified or that a young child cannot provide sufficiently
specific information to warrant further action. Unfortunately, limited financial
resources and overburdened CPS staff also can contribute to decisions to investigate
only the most severe instances of maltreatment.
There is no doubt that child maltreatment is an enormous problem that exerts a

toll, not only on its victims, but also on society more broadly (Cicchetti & Rogosch
1994). In a National Institute of Justice report (Miller et al. 1996), the direct costs
(e.g., medical expenses, lost earnings, and public programs for victims) as well as
indirect costs (e.g., pain and diminished quality of life) of child abuse and neglect
were estimated at $56 billion annually. Furthermore, a 2001 study conducted by
Prevent Child Abuse America estimated that the total cost (i.e., direct and indirect
costs combined) of child abuse in the United States is over $94 billion per year
(Administration for Children & Families 2003). Annual direct costs, estimated
at $24,384,347,302, include hospitalization, chronic physical health problems,
mental health care, welfare costs, law enforcement, and court action. Yearly in-
direct costs (i.e., long-term costs), estimated at $69,692,535,227, include special
education, mental and physical health care, delinquency, criminality, and lost pro-
ductivity to society.
With respect to the etiology of child maltreatment, we now know that single-
risk-factor models that identify main effect influences such as parental psychopathol-
ogy, a history of maltreatment in one’s own childhood, poverty, and tempera-
mentally difficult children are insufficient to account for the complex processes
eventuating in maltreatment. Because no single risk factor or set of risk factors
have emerged as providing a necessary or sufficient cause of maltreatment, a num-
ber of interactive etiological models have evolved that consider a combination of
individual, familial, and environmental factors that may contribute to the occur-
rence of child maltreatment (see Belsky 1980 and Cicchetti & Rizley 1981 for
reviews).
Cicchetti & Lynch (1993) developed an ecological-transactional model that has
been used to examine the processes by which maltreatment occurs and development
is shaped as a result of potentiating and compensatory factors that are present at
each level of the social ecology (i.e., culture, community, and family). In the
model, a balance among risk and protective factors and processes is viewed both
as determining the likelihood of maltreatment occurring and as influencing the
course of subsequent development. Potentiating factors and processes increase the
probability of maltreatment, whereas compensatory factors and processes decrease
the likelihood that maltreatment will occur. Similarly, negative developmental
consequences eventuate when vulnerabilities outweigh protective factors.
414 CICCHETTI TOTH
Risk factors within a given level of the social ecology can affect outcomes and
processes in surrounding levels of the environment. These transactions are mu-
tually influencing and determine the amount of risk that the individual faces. At
more distal levels of the ecology (e.g., community, culture), potentiating factors
increase the potential conditions that promote maltreatment, whereas compensat-
ing factors decrease the potential of such conditions. Risk factors within the child’s
immediate environment (e.g., family) also contribute to the presence or absence of
maltreatment and to the adaptiveness of family functioning (Azar 2002, Rogosch
et al. 1995).
MALTREATING FAMILIES AS A PATHOGENIC

RELATIONAL ENVIRONMENT
Child maltreatment represents one of the most profound failures of the environ-
ment to present opportunities to foster normal developmental processes. Maltreat-
ing families do not provide many of the experiences that the existing theories of
normal development postulate are necessary for facilitating competent adaptation.
Accordingly, child maltreatment exemplifies a pathogenic relational environment
that poses substantial risk for undermining biological and psychological develop-
ment across a broad spectrum of domains of functioning.
In contrast to what is anticipated in response to an average expectable envi-
ronment, the social, biological, and psychological conditions that are associated
with maltreatment set in motion a probabilistic path of epigenesis for maltreated
children that is characterized by an increased likelihood of failure and disruption
in the successful resolution of major stage-salient issues of development, resulting
in grave implications for functioning across the life span. These repeated develop-
mental disruptions create a profile of relatively enduring vulnerability factors that
increase the probability of the emergence of maladaptation and psychopathology
as negative transactions between the child and the environment continue. Impor-
tantly, despite the fact that there is documented risk for maladaptation associated
with maltreatment, the absence of a caregiving environment that provides sufficient
opportunities for normal development does not necessarily condemn all maltreated
children to negative outcomes.
THE DEVELOPMENTAL PSYCHOPATHOLOGY

PERSPECTIVE
The emergence of the field of developmental psychopathology as a coherent in-
terdisciplinary science for conceptualizing and examining the links between the
study of normal and atypical development has taken place predominantly over the
course of the past several decades (Cicchetti & Sroufe 2000). Whereas traditional
viewpoints portray maladaptation and mental disorder as inherent to the individ-
ual, the developmental psychopathology framework places them in the dynamic
relation between the individual and his/her internal and external contexts (Sameroff
2000).
The field of developmental psychopathology emphasizes the argument put forth
by many of the great synthetic thinkers in the psychological and biological sciences
that one can learn more about the normal functioning of an organism by studying
its pathology and, likewise, more about its pathology by studying its normal con-
dition (Cicchetti 1984, 1990). By virtue of its interdisciplinary nature, the field of
developmental psychopathology requires that multiple domains of development be
investigated, including cognitive, socioemotional, linguistic, representational, ge-
netic, and neurobiological processes (Cicchetti 1990, Cicchetti & Dawson 2002).
Indeed, the application of the developmental psychopathology perspective has

contributed greatly to the advances that have been made in the understanding of the
causes and consequences of child maltreatment (Cicchetti & Toth 1995, National
Research Council 1993). A developmental scheme has proven to be essential for
tracing the roots, etiology, and nature of maladaptation in maltreated children so
that treatment interventions can be appropriately timed and guided. Moreover, a
developmental psychopathology approach has helped researchers to discover the
processes whereby some maltreated children develop and utilize compensatory
mechanisms that enable them to function adaptively despite experiencing great
adversity (Cicchetti & Rogosch 1997, Luthar et al. 2000).
THE EFFECTS OF CHILD MALTREATMENT

The ecological-transactional model possesses significant implications for how mal-
treatment affects development. An increased presence of risk factors associated
with the occurrence of maltreatment at any or at all ecological levels represents a
deviation from the conditions that promote normal development. As such, children
who have been maltreated have a greater likelihood of manifesting negative devel-
opmental outcomes and psychopathology (Cicchetti & Toth 1995). Conversely, an
ecological-transactional model also can explain the fact that not all children who
have been maltreated are similarly affected and, in fact, that despite maltreatment
some children do not succumb to negative developmental consequences. The most
critical contributor to eventual competence or incompetence is the negotiation of
the central tasks of each developmental period.
In accord with an organizational perspective (Cicchetti 1993, Sroufe & Rut-
ter 1984), at each juncture of developmental reorganization prior developmental
structures are incorporated into later ones by means of hierarchical integration. In
this way, early experiences and their effects on the individual are carried forward
within the individual’s organization of systems through subsequent developmental
stages and across the life span. Based on this hierarchical depiction of adaptation,
the successful resolution of early-stage-salient issues increases the probability of
subsequent successful adjustment (Sroufe & Rutter 1984). Conversely, failure on
early issues increases the likelihood of continued difficulties. However, continuity
416 CICCHETTI TOTH
of development is not certain, as factors in the internal and external environment

can alter subsequent adaptational capacities. Thus, an ever-changing model of de-
velopment wherein newly formed competencies or maladaptations may emerge
across the life course is proffered (Cicchetti & Tucker 1994).
Although certain issues of development may be central at particular periods
in time and subsequently decrease in importance, each issue must be coordinated
and integrated with the environment, as well as with subsequently emerging issues
across the life span (Cicchetti & Lynch 1993). Accordingly, each new develop-
ment builds on and incorporates previous developments (i.e., these stage-salient
tasks are hierarchically organized and integrated). The way in which these issues
are handled plays a pivotal role in determining subsequent adaptation. In order

to understand the consequences of child maltreatment, psychological as well as

neurobiological domains of development must be examined. Increasingly, inves-
tigations have moved beyond the articulation of main effects of maltreatment to
ascertain mediators and moderators of outcome. Therefore, when available, we
present investigations that have examined the mechanisms and processes whereby
some maltreated children avert negative developmental trajectories.
PSYCHOLOGICAL SEQUELAE
Affect Regulation
An early stage-salient developmental issue of infancy involves the ability to regu-
late and differentiate affective experience. Affect regulation is defined as the intra-
and extraorganismic factors by which emotional arousal is redirected, controlled,
modulated, and modified so that an individual can function adaptively in emotion-
ally challenging situations (Cicchetti et al. 1991). Child maltreatment represents
a significant threat to the optimal development of affective processing abilities.
Maltreated children evidence numerous deficits in the recognition, expression,
and understanding of emotions (for a review, see Camras et al. 1996). In the early
months of life, distortions in affect differentiation have been noted (Gaensbauer
& Hiatt 1984). Specifically, either excessive amounts of negative affect or blunted
patterns of affect have been observed long before they occur in normal
development.
The early maladaptive processing of stimuli that contributes to affective regu-
latory problems may lay the foundation for future difficulties in modulating affect.
For example, physically abused preschool boys who witnessed an angry simulated
interaction directed at their mothers evinced greater aggressiveness and more cop-
ing directed toward the alleviation of maternal distress than did nonabused boys
(Cummings et al. 1994). In a related inquiry, abused boys who viewed videotaped
vignettes of angry and friendly interactions reported experiencing more distress
than did nonabused boys in response to interadult hostility. Physically abused
boys also reported more fear in response to angry interactions between adults,
especially when the interactions were unresolved (Hennessy et al. 1994). Finally,
in an investigation of 4- to 6-year-old children, approximately 80% of maltreated
preschoolers exhibited patterns of emotion dysregulation in response to witness-
ing interadult anger. Undercontrolled/ambivalent emotion regulation patterns were
associated with maternal reports of child behavior problems and were found to
mediate the link between maltreatment and children’s symptoms of anxiety or
depression (Maughan & Cicchetti 2002). Findings such as these support a sensiti-
zation model whereby repeated exposure to anger and familial violence results in
greater emotional reactivity.
Difficulties in mentally representing and processing social information also
have been noted in children with histories of maltreatment. Children with histo-
ries of neglect have difficulty discriminating emotional expressions, while physi-

cally abused children demonstrate a response bias to angry emotional expressions
(Pollak et al. 2000). Pollak & Sinha (2002) demonstrated that physically abused
children required less sensory input than did comparison children in order to accu-
rately identify facial displays of anger. Pollak & Sinha utilized a gradual evolution
of images depicting facial expressions of various emotions. Physically abused
children detected angry emotions at lower steps of the sequence but did not ex-
hibit increased sensitivity for the other facial displays. The authors concluded that
physically abused children have facilitated access to representations of anger. Sim-
ilarly, in a task in which pairs of photographs of emotional expressions were mor-
phed into each other (Pollak & Kistler 2002), physically abused children detected
anger with lower signal strength than did controls. In combination, these stud-
ies suggest that physically abused children can detect facial expressions of anger
more accurately and at lower levels of perceptual intensity in comparison to other
emotions.
In an investigation of the attentional mechanisms underlying the finding that
physically abused children overattend to angry experiences, Pollak & Tolley-Schell
(2003) found that children who had experienced physical abuse demonstrated
delayed disengagement when angry faces served as invalid cues and exhibited
increased attention on valid angry trials. These results suggest that early adverse
experiences influence maltreated children’s selective attention to threat-related
signals.
For the physically abused child, displays of anger may be the strongest pre-
dictor of threat; however, increased sensitivity to anger could result in decreased
attention to other emotional cues. Conversely, the neglected child may suffer from
an extremely limited emotional learning environment. A solution to the problem
created for maltreated children by aberrant emotional signals from parents may
be general constraints imposed on children in the form of immature or limited re-
sources, which require young children to filter or select some environmental cues
over others (Bjorklund 1997). This developmentally normal aspect of selective
attention suggests that irrespective of the initial state of the organism, emotional
development is contingent on the nature of the input or experiences made available
to the child.
418 CICCHETTI TOTH
Deviations in understanding negative affect and in affective processing also

have been identified in maltreated children, and these difficulties have been
shown to relate to undercontrolled and aggressive behavior in the school setting
(Rogosch et al. 1995). Affective processing also was found to partially mediate
the effect of maltreatment on later social effectiveness. In an investigation of at-
tributional processes, Toth et al. (2002a) found that attributional style moderated
externalizing behavior problems and perceptions of mothers mediated both inter-
nalizing and externalizing symptoms. In a prospective longitudinal study, Bolger &
Patterson (2001) reported that higher levels of perceived external control mediated
the associations between specific subtypes of maltreatment and children’s inter-
nalizing behavior problems. Moreover, moderator analyses revealed that, among

maltreated children, greater perceived internal control predicted fewer internaliz-

ing problems, suggesting that perceived internal control acts as a protective factor.
Findings such as these have advanced knowledge of how cognitive processes con-
tribute to behavior problems, as well as to the avoidance of such problems, in
maltreated children.
Drawing upon previously developed models of social information processing,
Dodge and his colleagues (Dodge et al. 1995) hypothesized that children who
had experienced harsh discipline or who had been physically abused in their first
five years of life would develop deviant patterns of information processing in the
school-age years. Specifically, abused children were found to be defensively hy-
pervigilant to hostile cues and to fail to adequately attend to relevant nonhostile
cues. In essence, maltreated children were found to attribute hostility to others in
situations where most people would not make such an attribution. In addition, phys-
ically abused children were found to acquire large repertoires of highly accessible
aggressive responses to interpersonal problems so that, when provoked, aggres-
sive retaliatory responses were likely. Finally, physically abused children appear
to learn that aggressive behavior can have positive consequences for the aggressor.
Evidence from cross-sectional investigations suggests specific developmental
trajectories from affect-regulatory problems to behavioral dysregulation among
maltreated children. Maltreated preschool- and school-age children exhibit a range
of dysregulated behaviors that are often characterized by disruptive and aggressive
actions. Maltreated toddlers also have been shown to react to peer distress with
poorly regulated and situationally inappropriate affect and behavior, including
anger, fear, and aggression, as opposed to the more normatively expected response
of empathy and concern (Klimes-Dougan & Kistner 1990). Shields & Cicchetti
(1998) found that maltreated children were more likely than nonmaltreated children
to be aggressive, with physically abused children at heightened risk for reactive
aggression. Maltreated children also evidenced attention deficits, and subclinical
or nonpathological dissociation was more likely among children with histories of
physical or sexual abuse. A history of abuse also predicted emotion dysregulation,
affective lability/negativity, and socially inappropriate emotion expressions. The
emotion dysregulation was a mechanism whereby maltreatment resulted in reactive
aggression.
Development of Attachment Relationships

The establishment of a secure attachment relationship between an infant and his
or her caregiver represents a primary task during the first year of life. As de-
velopment proceeds, attachment theorists have posited that a secure attachment
relationship provides a base from which to explore and, ultimately, contributes
to the integration of cognitive, affective, and behavioral capacities that influence
ongoing and future relationships, as well as the understanding of the self (Bowlby
1969/1982, Sroufe 1979). Not surprisingly, maltreated children are at considerable
risk for the development of insecure attachment relationships. In fact, investiga-
tions have found that maltreated infants evidence insecure attachment rates as high
as 95% (Carlson et al. 1989; D Cicchetti, SL Toth, & FA Rogosch, in preparation;

Crittenden 1988; Lyons-Ruth et al. 1987). In a longitudinal investigation of 12-,
18-, and 24-month-old maltreated and nonmaltreated comparison infants, Barnett
et al. (1999) found that maltreated infants were significantly less likely than are
nonmaltreated infants to be securely attached (86%, 61%, and 75%, respectively)
and to have disorganized/disoriented types of attachments to their caregivers.
Children construct “internal working models” of their attachment figures out
of their interactions with their caregivers, their own actions, and the feedback they
receive from these interactions. Once organized, these internal working models
tend to operate outside of conscious awareness and to be relatively resistant to
change. Children formulate their conceptions of how acceptable or unacceptable
they are in the eyes of their attachment figures (i.e., their self-image) based on their
interactional history with their primary caregiver.
Although particularly salient during infancy and toddlerhood, attachment con-
tinues to be important beyond the early years of life as internal working models
are carried forward. Consistent with attachment patterns identified in infancy, mal-
treated children are more likely than nonmaltreated children to exhibit insecure
attachments throughout the preschool years (Cicchetti & Barnett 1991, Crittenden
1988). Moreover, insecure attachment has been found to be present in school-age
children when self-report measures have been utilized. For example, Lynch &
Cicchetti (1991) found a preponderance of insecure patterns of relatedness among
maltreated children. Such insecure patterns of relatedness also have been linked
with the presence of depressive symptoms (Toth & Cicchetti 1996a).
The Development of Self-System Processes

Following the consolidation of the attachment relationship, the succeeding stage-
salient issue for children involves the establishment of a sense of self as separate
from the caregiver and as capable of autonomous functioning (Sroufe 1979). In-
creasingly during this period, responsibility for self-regulation and the regulation
of affect is transferred from the caregiver-child dyad to the child alone. In order to
make this transition successfully, caregiver sensitivity to and tolerance of toddler
strivings for autonomy are needed.
420 CICCHETTI TOTH
As self-capacities emerge, children raised in maltreating environments are at

heightened risk for maladaptive self-development. Investigations on visual self-
recognition in maltreated children provide information on their emerging self-
system processes. Although maltreated and nonmaltreated toddlers do not dif-
fer with respect to their capacities to recognize themselves (Schneider-Rosen &
Cicchetti 1991), differences have been observed with respect to affective respon-
sivity. Specifically, maltreated toddlers are more likely than comparison children
to display either neutral or negative affect upon seeing their rouge-marked images
in a mirror, possibly suggesting an early precursor of low self-esteem.
Similar delays in the self-system of maltreated toddlers have been noted with re-
spect to their ability to talk about the internal states and feelings of self and other.
Because socialization exerts a significant role in a child’s expression of affect,

caregivers can influence a child’s ability to express various emotions. Maltreated
toddlers, although not differing from nonmaltreated children in receptive vocabu-
lary, have been found to exhibit proportionally fewer internal-state words, to show
less differentiation in their attributional focus, and to be more context-bound in
their use of internal-state language than were their nonmaltreated peers (Beeghly &
Cicchetti 1994). Specifically, maltreated toddlers produced fewer utterances about
physiological states and fewer utterances about negative affect, which suggests
that the use of negative emotion words, or references to the self and the self’s de-
sires, may provoke negative responses in the caregiver and, ultimately, contribute
to modifications in the use of such verbalizations. Further evidence about the effect
of communication styles in maltreating homes emerges with respect to the devel-
opment of theory-of-mind abilities. Delays in theory of mind, considered an index
of the ability to attribute beliefs, desires, emotions, and intentions to others, have
been found in maltreated children. Maltreatment during the toddler period and a
history of physical abuse both were related to delays in the development of theory
of mind (Cicchetti et al. 2003). Thus, it appears that aberrations in internal state
language may be an early precursor of theory of mind. Within a maltreating envi-
ronment, children may learn that it is unacceptable, threatening, or even dangerous
to discuss feelings and emotions, particularly negative ones. As such, the internal
state language deficits of maltreated children may reflect inhibited development in
understanding the experience of self and other, thereby contributing to difficulty
in acquiring theory-of-mind abilities (Cicchetti et al. 2003).
Aberrations in the self-systems of maltreated children continue to be evident
during the preschool period. Alessandri & Lewis (1996) found differences be-
tween maltreated and nonmaltreated preschoolers in the expression of pride and
shame. Maltreated girls evidenced less pride and more shame as compared to
both maltreated and comparison boys. A considerable body of work utilizing story
stem narratives also has revealed self-system deficits in maltreated preschool-
ers. For example, maltreated preschoolers tell stories that contain more negative
self-representations than do the stories told by nonmaltreated preschoolers (Toth
et al. 1997, 2000). Negative representations of caregivers also have been associ-
ated with emotion dysregulation, aggression, and peer rejection, whereas positive
representations have been related to prosocial behavior and peer preferences

(Shields et al. 2001). These negative representations mediate maltreatment’s ef-
fects on peer rejection, in part by undermining emotion regulation. The narratives
of these preschoolers also contain more negative representations of caregivers, sug-
gesting a trajectory from negative caregiving experiences and resultant negative
representations of caregivers to negative self-representations. Moreover, evidence
shows that preschool-age maltreated children, especially those with histories of
physical and sexual abuse, demonstrate more dissociation during a storytelling
task than do nonmaltreated children (Macfie et al. 2001). These findings suggest
that as early as the preschool years, fragmentation in the self-system of maltreated
youngsters may be present.

Importantly, aberrations in the self-systems of young maltreated children also

may be reflected in their moral judgment and reasoning. Although research has
shown that maltreated children do not differ from nonmaltreated children in their
moral judgment or reasoning (Smetana et al. 1999), evidence does support the
presence of behavioral and affective differences in domains related to moral rea-
soning. Deficits also have been found in areas involving the internalization of
moral standards and socialization. In an observational study, physically abused
children engaged in more stealing behaviors and neglected children exhibited more
cheating behaviors and less rule-compatible behavior than did nonmaltreated chil-
dren (Koenig et al. 2004). Furthermore, maltreated children exhibit less empathy
(Macfie et al. 1999), fewer prosocial and more aggressive behaviors (Shields et al.
1994), less internalization of compliance (Koenig et al. 2000) and higher rates of
delinquency (Smith & Thornberry 1995, Widom 1989) than do their nonmaltreated
peers.
Abnormalities in the self-systems of maltreated children continue to be seen in
their self-concepts. However, different patterns of findings emerge for children of
varying ages. Young maltreated children overrate their level of competence and
peer acceptance, whereas by the age of 8 or 9 years, maltreated children evidence
lower rates of self-esteem and perceive themselves as being less competent than do
nonmaltreated children (Vondra et al. 1989). Fragmentations in self-organization
also have been found in sexually abused adolescent girls, who demonstrate deviant
splitting between both positive and negative self-references (Calverley et al. 1994).
Peer Relations
Given the preponderance of difficulties evidenced by maltreated children on the
early stage-salient issues of development, difficulties in the peer arena are not
unexpected. In general, maltreated youngsters evidence elevated aggression toward
or withdrawal from peers. Among the most salient findings are: (a) maltreated
children evidence more antisocial behaviors, including aggressiveness, meanness,
and disruptiveness, and fewer prosocial behaviors such as leadership and sharing
(Salzinger et al. 1993); and (b) maltreated preschoolers are more likely to cause
distress in their peers than are nonabused children (Klimes-Dougan & Kistner
422 CICCHETTI TOTH
1990). Dodge and his colleagues (Dodge et al. 1994) found that maltreated children
were rated by peers, teachers, and mothers as more disliked, less popular, and more
socially withdrawn than were nonmaltreated children. Additionally, rejection of
maltreated children by their peers was found to increase over a five-year period.
In some maltreated children, a combination of aggressive and withdrawn behav-
ior has been rated by peers and, when present, such children evidence much lower
social effectiveness (Rogosch & Cicchetti 1994). Finally, difficulties in developing
and maintaining friendships have been noted in physically abused children (Parker
& Herrera 1996). Preadolescent and adolescent physically abused children display
less intimacy in their friendships than do nonabused children. Moreover, the friend-
ships of physically abused children are marked by more conflict, especially during
competitive activities where emotion-regulation skills are particularly stressed.

Maltreated children also are more likely than nonmaltreated children to bully
others. Shields & Cicchetti (2001) found that bullying behaviors were particularly
prevalent among children with histories of physical or sexual abuse. Histories of
maltreatment also place children at risk for victimization by peers. Both bullies
and victims evidenced problems with emotion regulation, and emotion dysregula-
tion made a unique contribution toward the differentiation of bullies and victims
from those without such problems. In addition, emotion dysregulation mediated
maltreatment’s effects on children’s risk for bullying and victimization.
Adaptation to School
Adaptation to school represents the major extrafamilial environment in which
children are exposed to a novel group of unfamiliar peers and adults. As such,
it presents both a challenge to functioning and an opportunity to break free of
patterns that have been established within a maltreating home. However, because
an organizational perspective suggests that children’s experiences in the home
provide a foundation on which future transitions are built, probabilistically children
who have been maltreated are at risk for failure in the school environment.
Abused and neglected children are at considerable risk for academic failure
(Eckenrode et al. 1993). In efforts to identify those factors that might mitigate
against the impact of abuse on school performance, Trickett et al. (1994) con-
ducted an investigation with adolescent girls who had been sexually abused. Pre-
vious abuse was found to predict poorer social competence, impaired competence
in learning, and lower overall academic performance. Higher levels of anxious de-
pression, bizarre destructiveness, and dissociation also were present in victims of
sexual abuse. Importantly, cognitive ability and perceived competence emerged as
mediators of overall academic performance and achievement, whereas dissociative
and destructive behaviors exacerbated the child’s level of school success. Okun and
colleagues (1994) also sought to examine the independent and interactive effects
of physical abuse, recent exposure to additional life events such as death or illness,
and social disadvantage on children’s social, cognitive, and affective adjustment
during middle childhood. Abused children were found to evidence difficulties in
three areas: peer adjustment, self-perception, and depression. Further analyses

identified unique effects of negative events and socioeconomic disadvantage on
children’s adjustment. Additive contributions of abuse status and socioeconomic
disadvantage also predicted behavior problems at school and in the home.
In yet another investigation of links between relationship patterns and school
adaptation, Toth & Cicchetti (1996b) found that the security that a child expe-
rienced in relation to his or her mother, in interaction with maltreatment status,
significantly affected school functioning. Nonmaltreated children who reported se-
cure patterns of relatedness to their mothers exhibited less externalizing behavior
problems, more ego resilience, and fewer school risk factors (e.g., poor attendance,
poor achievement test performance, suspensions, failure in 50% of courses, and

grade retention) than did maltreated children who reported insecure patterns of
relatedness. Moreover, nonmaltreated children with secure patterns of relatedness
to their mothers exhibited more positive school adaptation than did nonmaltreated
children who reported insecure patterns of relatedness.
Finally, in an investigation of more than 200 low-income children, impairments
in academic engagement, social skills, and ego resiliency were found to be present
in children with histories of maltreatment (Shonk & Cicchetti 2001). Maltreated
children manifested multiple forms of academic risk and exhibited more externaliz-
ing and internalizing behavior problems. The effects of maltreatment on academic
adjustment were partially mediated by academic engagements, while maltreat-
ment’s effects on behavior problems were fully mediated by social competencies
and ego resiliency.
NEUROBIOLOGICAL SEQUELAE
Although neurobiological development is guided and controlled to some extent
by genetic information, a significant portion of brain structuration and neural pat-
terning is thought to occur through interaction with the environment (Greenough
et al. 1987). Moreover, because the mechanisms of experience-expectant and
experience-dependent plasticity cause the brain’s anatomical differentiation to be
dependent upon stimulation from the environment, it is now acknowledged that
the cytoarchitecture of the cerebral cortex is shaped by input from the social en-
vironment (Cicchetti & Tucker 1994). Thus, to comprehend neuropsychological
development, one must understand that the brain is malleable and that its structural
organization reflects both the history of the organism and what is most important
to the organism at that particular time (Luu & Tucker 1996).
Even children who are born with normal brains may encounter a number of
experiences, such as child maltreatment, that can exert a negative impact upon de-
veloping brain structure, function, and organization and can contribute to distorting
their experiences of the world. During the past several decades, the examination
of the neurobiological correlates and sequelae of child maltreatment have begun
to receive more emphasis from researchers. Such work holds great promise for
424 CICCHETTI TOTH
contributing to an understanding of the mechanisms underlying maladaptive de-

velopment in maltreated children.
Research examining different components of brain functioning, each represent-
ing fairly distinct neural systems, has been conducted. The methodologies utilized
have been diverse, ranging from acoustic startle, to neuroendocrine regulation, to
event related potentials (ERPs), to magnetic resonance imaging.
Acoustic Startle
Klorman et al. (2003) examined acoustic startle to white noise burst probes in
a large sample of school-aged maltreated and nonmaltreated children. Maltreated

boy’s startle responses exhibited smaller startle amplitude and earlier onset latency
and were less affected by increasing probe loudness than were those of compar-
ison boys. Among maltreatment subtypes, this pattern was most salient for boys
who had been physically abused. These results for maltreated boys are consis-
tent with the literature documenting diminished startle responses among children
with post-traumatic stress disorder (PTSD). The diminution in startle in physically
abused boys may reflect structural brain stem anomalies in these maltreated chil-
dren. Repetitive social challenges in a child’s environment, such as engendered
by child maltreatment, can cause disruptions in basic homeostatic and regulatory
processes that are essential to the maintenance of optimal physical and mental
health. Physically abused children often are exposed to threat and danger and their
smaller responses to startle may reflect allostatic load, the cumulative long-term
effect of physiologic responses to stress (McEwen 1998). Accumulated allostatic
load may eventuate in a number of deleterious biological consequences for mal-
treated children, including impairments in sympathetic and parasympathetic ner-
vous system functioning, hypercortisolism or hypocortisolism, and dysregulation
in catecholaminergic and serotonergic functioning (Kaufman & Charney 2001,
McEwen 1998, Repetti et al. 2002).
Neuroendocrine Regulation
Incidents of maltreatment, such as sexual, physical, and emotional abuse, as well
as neglect, may engender massive stress in vulnerable children. The functioning
of one physiological system, the hypothalamic-pituitary-adrenal (HPA) axis, has
been the subject of a number of investigations in the area of child maltreatment.
The capacity to elevate the stress hormone cortisol in response to acute trauma
is critical for survival. Brief elevations in corticosteroids following acute stres-
sors appear to enhance the individual’s ability to manage stressful experiences
competently, both physiologically and behaviorally. However, chronic hyperactiv-
ity of the HPA axis (i.e., hypercortisolism) may eventuate in the accelerated loss
or metabolism of hippocampal neurons, the inhibition of neurogenesis, lags in
the development of myelination, abnormalities in synaptic pruning, and impaired
affective and cognitive ability (Sapolsky 1992). Moreover, hypocortisolism, in
which individuals who are experiencing chronic stressors such as ongoing mal-
treatment may manifest reduced adrenocortical secretion, reduced adrenocortical
reactivity, or enhanced negative feedback inhibition of the HPA axis (Gunnar &
Vasquez 2001), also can damage neurons, as well as contribute to the development
of stress-related bodily disorders (Heim et al. 2000).
A number of studies indicate atypical HPA-axis regulation in maltreated chil-
dren. Children who have experienced both physical and sexual abuse exhibit hyper-
cortisolism, whereas children who have been physically abused display hypocor-
tisolism (Cicchetti & Rogosch 2001a). Maltreated children with PTSD excrete
greater concentrations of 24-hour urinary free cortisol than do nonmaltreated con-
trol children (DeBellis 2001). Furthermore, maltreated children with clinical-level
internalizing problems manifest higher morning, afternoon, and average daily cor-
tisol levels across a one-week period. Maltreated children with comorbid clinical-
level internalizing and externalizing problems were more likely not to display
the expected diurnal decrease in cortisol. In contrast, nonmaltreated boys with
clinical-level externalizing problems exhibited low levels of morning and average
daily levels of cortisol (Cicchetti & Rogosch 2001b).
Thus, differential patterns of cortisol regulation have been observed in investi-
gations of maltreated children. However, a number of methodological issues in the
extant investigations may have contributed to this variability, including inconsis-
tency in the operationalization of maltreatment; divergence in the array, severity,
and chronicity of traumatic experiences to which children have been exposed; dif-
ferences in ascertainment of samples (e.g., community versus hospitalized); and
differences in the context in which neuroendocrine assessments have occurred.
Regardless, it seems that the neuroendocrine functioning of all maltreated chil-
dren is not affected in a similar fashion. In fact, in the extant investigations not
all maltreated children exhibited dysregulated cortisol regulation. The children
who experience physical and/or sexual abuse appear to be most at risk for neu-
roendocrine dysregulation. These children, who generally experience severe and
chronic maltreatment, most likely have accumulated a large allostatic load that
may ultimately render the hippocampal region more vulnerable.
Cognitive Event-Related Potentials to

Emotional Facial Displays
Two studies have utilized cognitive ERPs to facial displays in a reaction-time task
to evaluate whether maltreated children overresponded to facial displays of anger.
The ERP is an index of central nervous system functioning thought to reflect the un-
derlying neurological processing of discrete stimuli. ERPs represent scalp-derived
changes in brain electrical activity over time, obtained by averaging time-locked
segments of the electroencephalogram that follow or precede the presentation of
a stimulus.
In the first study, maltreated and nonmaltreated children viewed photos of mod-
els displaying prototypically angry, happy, or neutral expressions (Ekman 1976).
In one condition, children pressed a button when the angry face was displayed,
and in the other condition, they responded to the happy face. Although the two
samples were comparable in their speed and accuracy to the two targets, they
426 CICCHETTI TOTH
differed in the amplitude of a positive parietally maximal ERP wave, identified as

the P3b component. Specifically, whereas comparison children exhibited compa-
rable amplitude of P3b to angry and happy targets, maltreated children displayed
larger P3b amplitude to the angry than to the happy target. Pollak et al.’s (1997)
results converge with the series of findings noted earlier concerning greater vig-
ilance to anger by maltreated children. A subsequent investigation (Pollak et al.
2001) in which ERPs were recorded to angry, happy, and fearful facial expres-
sions similarly supports specific sensitivity by maltreated children to angry facial
displays.
Taken together, the results of these ERP investigations suggest that the ex-
periences that maltreated children have encountered cause particular classes of

emotional stimuli to become personally meaningful based, in part, on the stored

mental representations (“working models”) that have been associated with that
stimulus over time. The chronic stress associated with maltreatment may enhance
the memory of salient stimuli in the environment (Toth & Cicchetti 1998).
Neuroimaging
DeBellis (2001) examined the magnetic resonance imaging brain scans of a large
group of maltreated children and adolescents with PTSD and a group of matched
nonmaltreated comparisons. The maltreated group with PTSD evinced 7% and
8% smaller intracranial and cerebral volumes, respectively. Moreover, the total
midsagittal area (the major interconnection between the two hemispheres that is
thought to facilitate intercortical communication) and the middle and posterior
regions of the corpus callosum also were smaller in the maltreated group. In
addition, the lateral ventricles were larger in the maltreated PTSD group. The
decreased hippocampal volumes found in maltreated adults with PTSD were not
found in the maltreated PTSD group of children and adolescents.
Teicher and colleagues (2004) measured the regional corpus callosum area
utilizing magnetic resonance imaging in a group of abused/neglected children
hospitalized in a psychiatric facility and a control group of nonmaltreated children
receiving psychiatric services. The total corpus callosum area was 17% smaller in
the abused/neglected group than in the control group. Child neglect was associ-
ated with the greatest reduction in the corpus callosum and sexual abuse was the
strongest factor associated with reduced corpus callosum size in girls. The findings
obtained in the DeBellis (2001) and Teicher et al. (2004) investigations suggest that
adverse social experiences such as child maltreatment exert deleterious influences
on neurobiological development.
PSYCHOPATHOLOGY
Although not all maltreated children will develop maladaptively, disruptions
in psychological and neurobiological development during the early years
of life may contribute to the emergence of psychopathology. In general, the
literature on maltreated children reveals a greater prevalence of psychiatric symp-

toms and diagnoses in these youngsters than in nonmaltreated children. Maltreated
children have evidenced elevated levels of disturbance across a wide range of areas.
Physical abuse has been linked consistently with higher levels of child depressive
symptomatology (Kaufman 1991, Toth & Cicchetti 1996a, Toth et al. 1992), as
well as to conduct disorder and delinquency (Smith & Thornberry 1995). Higher
rates of attention deficit hyperactivity disorder, oppositional disorder, and PTSD
also have been reported in maltreated children (Famularo et al. 1992). Childhood
maltreatment also has been linked to personality disorders, substance abuse, sui-
cidal and self-injurious behavior, somatization, anxiety, and dissociation (Johnson
et al. 1999, Luntz & Widom 1994, Malinosky-Rummell & Hansen 1993, McLeer
et al. 1994).
Two recent investigations shed light on how genetic vulnerabilities may mod-
erate the impact of child maltreatment on the development of antisocial behavior.
Twins at low genetic risk for conduct disorder who were maltreated had a 2%
increase in the probability of developing conduct disorder. In contrast, the experi-
ence of maltreatment was associated with an increase of 24% for conduct disorder
among twins at high genetic risk. Thus, the prediction of behavioral pathology is
made more accurate by including information on both pathogenic environments
and genetic risk (Jaffe et al. 2004).
Caspi and colleagues (2002) found that a functional polymorphism in the
monoamine oxidase A (MAOA) gene moderates the impact of early child mal-
treatment on the development of antisocial behavior in males. Located on the X
chromosome, the MAOA gene encodes the MAOA enzyme; genetic deficiencies
in MAOA activity have been linked with aggression in mice and humans and in
increased aggression and increased levels of brain norepinephrine, serotonin, and
dopamine in a transgenic mouse line in which the gene encoding MAOA was
detected. Maltreated children with a genotype conferring high levels of MAOA
expression have a lower probability of developing antisocial problems. In contrast,
maltreated children with a genotype that conferred a low level of MAOA activity
are significantly more likely to develop antisocial behaviors (Caspi et al. 2002).
These findings may explain why not all children who experience maltreatment go
on to victimize others.
RESILIENCE
Despite heightened risk for maladaptation and psychopathology in children with
histories of maltreatment, not all maltreated children evidence negative devel-
opmental trajectories. Unfortunately, much less effort has been directed toward
delimiting pathways to resilience in maltreated children than has been directed
toward elucidating problems. Resilience has been defined as the achievement of
positive adaptation despite the experience of extreme adversity (Luthar et al. 2000).
Investigators have identified certain personality characteristics as protective
428 CICCHETTI TOTH
factors. Moran & Eckenrode (1992) reported that an internal locus of control
and higher self-esteem mitigated against depression in adolescents who had been
maltreated. Resilience also emerges as a dynamic construct. In one investiga-
tion of maltreated and nonmaltreated children between 18 months and 6 years
of age, in elementary school, and during adolescence, only 61% of children who
had been resilient during the school-age years continued to evidence resilience
when assessed during adolescence (Herrenkohl et al. 1994). Interestingly, in-
vestigations have begun to delimit differential predictors of resilience in mal-
treated and nonmaltreated children. Specifically, Cicchetti & Rogosch (1997)
found that for maltreated children, positive self-system variables predicted re-
silience, whereas relationship features were more influential for nonmaltreated

children. These results are consistent with those of Moran & Eckenrode (1992)
and suggest that the self-systems of children with histories of maltreatment may be
an important arena in which to intervene to prevent psychopathology and to foster
resilience.
PREVENTION AND INTERVENTION

Research on the psychological and biological sequelae of child maltreatment is
particularly important for enhancing the quality of clinical services that can be di-
rected toward this serious social problem. By conducting research that elucidates
the developmental processes whereby maltreatment exerts its deleterious impact
on children, theoretically and empirically informed interventions for maltreated
children and their families can be developed, provided, and evaluated for effective-
ness. Although not all children who have been maltreated develop maladaptively,
the extant literature conveys the negative and often lifelong effects of child abuse
and neglect. Therefore, the provision of services designed to prevent the occurrence
of maltreatment and to treat its sequelae must be a priority. In recognition of the
criticality of preventing child maltreatment, in 2001 the Children’s Bureau initiated
the “Emerging Practices in the Prevention of Child Abuse and Neglect” project
(Administration for Children & Families 2003). The goal of this project was to
develop information on programs and initiatives throughout the United States and
to disseminate findings to the professional community. Current child maltreatment
prevention services typically fall within a number of broad areas, including public
awareness campaigns, skill-based curricula designed to teach children safe prac-
tices, parent education programs and support groups, home visitation programs,
respite and crisis care programs, and family resource centers.
With respect to information on the effectiveness of prevention services, research
has generally focused on home visitation programs, parent education programs,
and school-based programs for the prevention of sexual abuse. However, the most
compelling research that has demonstrated success at preventing child maltreat-
ment has been conducted in the area of home visitation services. Although not
all models of home visitation have been shown to be effective in preventing child
abuse and neglect (cf. Duggan et al. 2004), the work of David Olds and his col-
leagues emerges as an exemplary home visitation model (Olds et al. 1986, Olds &
Kitzman 1990). Home visitation was initially provided to 400 pregnant women and
continued through the first two years of their child’s life. Improvement on a num-
ber of maternal and child health outcomes was found as a result of the prevention
program. Moreover, women considered to be at high risk for child maltreatment
evidenced a 75% reduction in state-verified cases of child abuse and neglect during
the first two years of a child’s life. Follow-up data on these children continue to
reveal lower rates of child maltreatment through age 15 (Olds et al. 1998). Unfor-
tunately, the majority of home-visitation programs has not yielded such long-term
effects, most likely because they are less intensive and do not utilize theoretically
guided models or highly trained staff.

Clearly, the prevention of child maltreatment emerges as an important strategy.
However, despite efforts in this arena, far too many youngsters continue to be vic-
timized by child maltreatment. Therefore, it also is clear that treatment initiatives
need to be brought to bear when a child has been maltreated. Despite calls for the
utilization of treatments based on our knowledge regarding the consequences of
maltreatment (Toth & Cicchetti 1993, 1999), a theoretically derived approach to
therapy for this population has been slow to emerge. Although writings on con-
siderations in the conduct of child therapy with maltreated children have become
more visible (Toth & Cicchetti 1993), developmentally based and empirically
validated approaches to addressing the sequelae of maltreatment are infrequent.
Diverse methods of evidence-based treatments might be applied successfully to
maltreated children; however, modifications are most likely to be needed based on
the maltreatment experiences of a given child.
One area in which research-based and theoretically informed treatments for
maltreated children have begun to emerge relates to the attachment relationship.
In a randomized clinical trial, 12-month-old infants and their maltreating mothers
were assigned to one of three intervention groups: (a) a psychoeducational home
visitation (PHV) that focused on improving parenting, reducing maternal stress,
increasing maternal social supports, and enhancing maternal knowledge of child
development; (b) an attachment-theory informed intervention, infant-parent psy-
chotherapy (IPP), focused on improving the mother-child attachment relationship;
and (c) the community standard (CS), consisting of treatment typically available in
the community for maltreating families. A fourth group of nonmaltreated compar-
ison (NC) infants was matched to the intervention groups on sociodemographic
indices. At the conclusion of the intervention approximately one year later, the
maltreated infants in the PHV and IPP interventions demonstrated a statistically
significant change in their attachment security from baseline and did not differ
in the percentages of attachment security from the babies in the NC group (D
Cicchetti, SL Toth, & FA Rogosch, in preparation). In contrast, infants in the CS
group manifested no improvements in their attachment security with their moth-
ers, suggesting that traditional services designed to ensure child safety do little
to foster positive developmental attainments. The fact that both the PHV and IPP
430 CICCHETTI TOTH
interventions were effective highlights the plasticity of development during in-

fancy and suggests that early interventions do not necessarily need to target at-
tachment during infancy to improve this developmental domain. Similar findings
on the utility of attachment-theory informed interventions in fostering positive
child adaptation have been obtained with maltreated preschool-age children (Toth
et al. 2002b). Interestingly, however, only the intervention that targeted attach-
ment was effective, suggesting that as development proceeds and the emerging
self becomes more consolidated, specific attachment-theory informed interven-
tions might be necessary to improve attachment security and to foster positive
self-system functioning.
SOCIAL POLICY IMPLICATIONS

As made clear by this selective review, child maltreatment exerts a significant toll
on individuals who have been victimized, on families confronted by maltreatment,
and on society more generally. There is no doubt that the burden of mental illness
accompanying child maltreatment is extensive. However, the picture is not without
hope. Not all children who have been maltreated manifest adverse developmental
sequelae. In fact, despite the risks that accompany the experience of maltreatment,
children can successfully avert a negative developmental trajectory. Moreover, we
now possess considerable knowledge about the effects of maltreatment, and this
knowledge can inform prevention and intervention strategies, thereby helping far
greater numbers of children escape maltreatment or its negative consequences.
Increasingly, the knowledge that has been gained from research initiatives has
been directed toward the development of prevention and intervention programs.
Emerging data suggest that maltreatment can be prevented and that, when it occurs,
its negative sequelae can be treated, particularly when intervention is theoretically
informed and provided early in development. Thus, we have come far from the
belief that maltreatment doomed a child to a life of suffering and would invariably
be perpetuated on any offspring through intergenerational transmission. Despite
the progress that has been made and the resultant guardedly optimistic view, many
challenges remain if maltreatment and all of its ramifications are to be banished
from society.
First, the judicial system continues to adhere to a focus on parental rights,
with an emphasis on maintaining family unity. Although a laudable goal, such an
approach is not necessarily in the best interests of children. Research into the foster
care system and examination of issues such as how multiple placement decisions
are made and how such decisions affect children must be conducted. In the absence
of research, we cannot know the advisability or impact of utilizing relative resource
placements rather than the formalized system of foster care.
Second, resources directed toward the prevention of child maltreatment must
be increased dramatically. The United States pales in comparison to other in-
dustrialized societies where home visitation following childbirth is provided to all
new mothers. Such universal preventive strategies avert stigmatization by avoiding
singling out high-risk mothers. Rather, providing support to facilitate a positive
transition to the stressful experience of parenthood should be made a national

priority.
It also is critical that we recognize the adverse trajectory toward mental illness,
delinquency, and criminal behavior in adulthood that increases each time a child is
maltreated. Maltreatment is not a diagnosable mental illness, but when it occurs,
data cogently demonstrate that a child’s risk for a range of serious mental disorders
becomes multiplied. In order to decrease the burden of mental illness, we cannot
underestimate the magnitude of contribution that child maltreatment makes to
serious psychopathology.
We must continue to build upon the foundation that has been established to fur-
ther develop and refine our prevention and intervention services. Efforts to export
efficacious services into community settings must become a priority. Moreover,

our systems of care must be sufficiently flexible to allow for nontraditional service
delivery. Home-based interventions require more time and therefore are likely to
be more costly than center-based programs. However, the investment is worth the
cost if it can avert missed appointments and the resultant failure to access services.
CONCLUSION AND FUTURE PERSPECTIVE

The experience of child maltreatment, and the concomitant poor quality parental
care received, exert a harmful impact on psychological and neurobiological de-
velopment. Multiple psychological and neurobiological systems are affected by
child maltreatment. However, to date most investigations of the consequences
of child maltreatment have examined psychological and neurobiological systems
separately. In the future, it will be essential to undertake investigations of mal-
treated children that examine multiple levels of psychological and neurobiological
functioning concurrently within the same individuals over developmental time
(Cicchetti & Dawson 2002, Curtis & Cicchetti 2003).
Additionally, great progress has been made in the field of molecular genetics
that provides exciting new opportunities for enhancing knowledge on not only
the genesis and epigenesis of maladaptive development and psychopathology in
maltreated children, but also on the pathways to resilient adaptation in abused and
neglected children. The integration of molecular genetics with the aforementioned
multiple levels of neurobiological and psychological analysis may facilitate the
elucidation of the mechanisms responsible for activating and inhibiting the expres-
sion of genes that are probabilistically associated with maladaptive developmental
outcomes and psychopathology in maltreated children. Likewise, these multidisci-
plinary approaches may proffer insights into the mechanisms that “turn on” genes
that may serve a protective function for individuals who have been maltreated.
Although groups of maltreated children differ from groups of nonmaltreated
children on the vast majority of the psychological and neurobiological domains
investigated to date, not all maltreated children are affected by their experiences in
the same fashion. Indeed, some maltreated children manifest resilient psychologi-
cal adaptation despite experiencing significant adversity. Furthermore, the neuro-
biology of some maltreated children appears not to be negatively affected, or may
432 CICCHETTI TOTH
be reflective of an enhanced neural plasticity in resilient individuals. Presently,

we do not know if the neurobiological difficulties displayed by some maltreated
children are irreversible, or whether there are particular sensitive periods when it is
more likely that neural plasticity will occur. Furthermore, it is not known whether
some neural systems may be more plastic than other neural systems or whether
particular neural systems may be more refractory to change or have a more time-
limited window when neural plasticity can occur. Thus, it is essential that future
research investigations on the determinants of resilient adaptation also incorporate
neurobiological and molecular genetic assessments (Curtis & Cicchetti 2003).
A recent randomized intervention trial has demonstrated that a major psycho-
logical issue, the development of attachment security, is modifiable (D Cicchetti,

SL Toth, & FA Rogosch, in preparation). Future interventions should incorporate

theoretically informed multiple neurobiological and psychological measures. Suc-
cessful interventions should alter behavior and physiology by producing changes in
gene expression (transcription) that produce new structural and functional changes
in the brain (Kandel 1999).
In order to achieve the aforementioned goals, a number of methodological ad-
vances in research on the psychological and biological consequences of child mal-
treatment must be implemented. Longitudinal investigations must be conducted
that examine the neurobiological and psychological developmental trajectories of
maltreated children. Similarly, it is important to conduct longitudinal neuroimag-
ing studies of maltreated children. Notably absent are neuroimaging investiga-
tions that focus on brain function (i.e., functional magnetic resonance imaging and
magnetoencephalography). Moreover, neuroimaging studies of maltreated chil-
dren recruited from community samples are essential. Hospitalized psychiatric
patients present many challenges to disentangling the effects of maltreatment on
brain structure and function from other competing conditions. Because the brain is
a dynamic, self-organizing system that is mutable, future neuroimaging research
should strive to ascertain whether the brain structures and brain functioning of
resilient maltreated children differ from those of nonresilient maltreated children.
The knowledge base on the causes and consequences of child maltreatment
has increased exponentially in the last two decades. More recent technological
advances hold even greater promise for elucidating the mechanisms and processes
that contribute to the deleterious consequences associated with maltreatment, as
well as for shedding light on effective prevention and intervention strategies.
The Annual Review of Clinical Psychology is online at

http://clinpsy.annualreviews.org
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February 26, 2005 19:35 Annual Reviews AR240-FM
Annual Review of Clinical Psychology

Volume 1, 2005
CONTENTS
A HISTORY OF CLINICAL PSYCHOLOGY AS A PROFESSION IN AMERICA
(AND A GLIMPSE AT ITS FUTURE), Ludy T. Benjamin, Jr. 1

STRUCTURAL EQUATION MODELING: STRENGTHS, LIMITATIONS,
AND MISCONCEPTIONS, Andrew J. Tomarken and Niels G. Waller 31

CLINICAL JUDGMENT AND DECISION MAKING, Howard N. Garb 67
MOTIVATIONAL INTERVIEWING, Jennifer Hettema, Julie Steele,
and William R. Miller 91
STATE OF THE SCIENCE ON PSYCHOSOCIAL INTERVENTIONS FOR
ETHNIC MINORITIES, Jeanne Miranda, Guillermo Bernal, Anna Lau,
Laura Kohn, Wei-Chin Hwang, and Teresa La Fromboise 113
CULTURAL DIFFERENCES IN ACCESS TO CARE, Lonnie R. Snowden
and Ann-Marie Yamada 143
COGNITIVE VULNERABILITY TO EMOTIONAL DISORDERS,
Andrew Mathews and Colin MacLeod 167
PANIC DISORDER, PHOBIAS, AND GENERALIZED ANXIETY DISORDER,
Michelle G. Craske and Allison M. Waters 197
DISSOCIATIVE DISORDERS, John F. Kihlstrom 227
THE PSYCHOBIOLOGY OF DEPRESSION AND RESILIENCE TO STRESS:
IMPLICATIONS FOR PREVENTION AND TREATMENT,
Steven M. Southwick, Meena Vythilingam, and Dennis S. Charney 255
STRESS AND DEPRESSION, Constance Hammen 293
THE COGNITIVE NEUROSCIENCE OF SCHIZOPHRENIA, Deanna M. Barch 321
CATEGORICAL AND DIMENSIONAL MODELS OF PERSONALITY
DISORDER, Timothy J. Trull and Christine A. Durrett 355
THE DEVELOPMENT OF PSYCHOPATHY, Donald R. Lynam
and Lauren Gudonis 381
CHILD MALTREATMENT, Dante Cicchetti and Sheree L. Toth 409
PSYCHOLOGICAL TREATMENT OF EATING DISORDERS, G. Terence Wilson 439
GENDER IDENTITY DISORDER IN CHILDREN AND ADOLESCENTS,
Kenneth J. Zucker 467
vii
P1: JRX
February 26, 2005 19:35 Annual Reviews AR240-FM
viii CONTENTS
THE DEVELOPMENT OF ALCOHOL USE DISORDERS, Kenneth J. Sher,

Emily R. Grekin, and Natalie A. Williams 493
DECISION MAKING IN MEDICINE AND HEALTH CARE, Robert M. Kaplan
and Dominick L. Frosch 525
PSYCHOLOGY, PSYCHOLOGISTS, AND PUBLIC POLICY,
Katherine M. McKnight, Lee Sechrest, and Patrick E. McKnight 557
COGNITIVE APPROACHES TO SCHIZOPHRENIA: THEORY AND THERAPY,
Aaron T. Beck and Neil A. Rector 577
STRESS AND HEALTH: PSYCHOLOGICAL, BEHAVIORAL, AND
BIOLOGICAL DETERMINANTS, Neil Schneiderman, Gail Ironson,

and Scott D. Siegel 607

POSITIVE PSYCHOLOGY IN CLINICAL PRACTICE, Angela Lee Duckworth,
Tracy A. Steen, and Martin E. P. Seligman 629
INDEX
Subject Index 653

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17 Feb 2005 9:58 AR AR240-CP01-15.tex AR240-CP01-15.

sgm LaTeX2e(2002/01/18) P1: GCE

Annu. Rev. Clin. Psychol. 2005. 1:409–38

Key Words definition, etiology, sequelae, intervention, policy

410 CICCHETTI TOTH

In this chapter, we provide a selective review of theory and research in the

area of child maltreatment. We begin by addressing definitional, epidemiologi-

CHILD MALTREATMENT 411

Issues regarding whether child maltreatment should be defined based on the

to miss more subtle forms of maltreatment.

Finally, for purposes of research, the methodological strategies utilized to ascer-

412 CICCHETTI TOTH

maltreatment, or child behavior problems (Dodge et al. 1997).

EPIDEMIOLOGY AND ETIOLOGY

CHILD MALTREATMENT 413

There is no doubt that child maltreatment is an enormous problem that exerts a

414 CICCHETTI TOTH

MALTREATING FAMILIES AS A PATHOGENIC

THE DEVELOPMENTAL PSYCHOPATHOLOGY

CHILD MALTREATMENT 415

Indeed, the application of the developmental psychopathology perspective has

THE EFFECTS OF CHILD MALTREATMENT

416 CICCHETTI TOTH

of development is not certain, as factors in the internal and external environment

are handled plays a pivotal role in determining subsequent adaptation. In order

to understand the consequences of child maltreatment, psychological as well as

CHILD MALTREATMENT 417

ries of neglect have difficulty discriminating emotional expressions, while physi-

418 CICCHETTI TOTH

Deviations in understanding negative affect and in affective processing also

nalizing behavior problems. Moreover, moderator analyses revealed that, among

maltreated children, greater perceived internal control predicted fewer internaliz-

CHILD MALTREATMENT 419

Development of Attachment Relationships

as 95% (Carlson et al. 1989; D Cicchetti, SL Toth, & FA Rogosch, in preparation;

The Development of Self-System Processes

420 CICCHETTI TOTH

As self-capacities emerge, children raised in maltreating environments are at

Because socialization exerts a significant role in a child’s expression of affect,

CHILD MALTREATMENT 421

representations have been related to prosocial behavior and peer preferences

youngsters may be present.

Importantly, aberrations in the self-systems of young maltreated children also

422 CICCHETTI TOTH

competitive activities where emotion-regulation skills are particularly stressed.

CHILD MALTREATMENT 423

three areas: peer adjustment, self-perception, and depression. Further analyses

poor achievement test performance, suspensions, failure in 50% of courses, and

424 CICCHETTI TOTH

contributing to an understanding of the mechanisms underlying maladaptive de-

a large sample of school-aged maltreated and nonmaltreated children. Maltreated

CHILD MALTREATMENT 425

Cognitive Event-Related Potentials to

426 CICCHETTI TOTH

differed in the amplitude of a positive parietally maximal ERP wave, identified as

periences that maltreated children have encountered cause particular classes of

emotional stimuli to become personally meaningful based, in part, on the stored

CHILD MALTREATMENT 427

literature on maltreated children reveals a greater prevalence of psychiatric symp-

428 CICCHETTI TOTH

silience, whereas relationship features were more influential for nonmaltreated

PREVENTION AND INTERVENTION

CHILD MALTREATMENT 429