Child maltreatment is an urgent public health problem. Maltreatment is defined as failing to meet physical, emotional, or medical needs (neglect), purposefully causing physical harm (physical abuse), engaging in sexual activity to which a child cannot understand and consent (sexual abuse), or making statements or behaving in a way that causes emotional or psychological harm (emotional abuse).
The Third National Incidence Study reported approximately 1.5 million children were maltreated in 1993.1 This number represented a 67% increase from 1986 estimates, with all forms of maltreatment increasing in incidence. In the 1993 study, more children were seriously injured as a result of maltreatment than in the previous studies, but child protective services formally investigated a smaller percentage of alleged maltreatment man during any previous study period.1
Childhood maltreatment is a significant risk factor for developing emotional and behavioral problems later in life. The psychiatric sequelae of child maltreatment can be chronic and devastating. Children and adolescents may demonstrate specific psychiatric disorders and nonspecific behavioral and emotional problems associated with their traumatic experiences.25 Investigators have linked childhood maltreatment to the development of personality disorders in adulthood,6 to depression in adults,7 and to the differences in me course of psychiatric disorders in adults.8
Pediatricians play a critical role in recognizing and reporting acute maltreatment in me course of responding to child protective services referrals, parents' concerns about maltreatment, or a child's direct disclosure of maltreatment. Primary care professional organizations have formulated practice guidelines to strengmen the ability of primary care physicians to perform this important role.9·10 Although there are no practice guidelines to assist pediatricians in recognizing and managing the long-term psychiatric sequelae of maltreatment, pediatricians are likely to be the first to be confronted wim these sequelae.
This article provides guidelines to assist pediatricians in recognizing and managing long-term psychiatric disorders associated with maltreatment. The clinical presentation of the psychiatric disorders associated wim maltreatment are discussed as well as the factors that mediate me risk of developing psychiatric disorders after maltreatment and emerging neurobiological evidence linking maltreatment to psychiatric sequelae. Finally, the challenges inherent in screening and managing psychiatric consequences of maltreatment in primary care are examined, and strategies for successful collaborative management are offered.
CLINICAL PRESENTATION OF PSYCHIATRIC SEQUELAE OF MALTREATMENT
Posttraumatic Stress Disorder
Studies have demonstrated children and adolescents can develop posttraumatic stress disorder (PTSD) following maltreatment.11 Posttraumatic stress disorder typically presents with some combination of intrusive recall of the trauma (nightmares, flashbacks), changes in emotion (feeling numb, irritability), and changes in arousal level (insomnia, more likely to startle, feeling "on edge"). Individuals also may describe losing meir sense of having a future.
Young children may not be able to describe intrusive memories, but instead demonstrate themes of the maltreatment in their play. Unfortunately, mere is a dearth of formal measurement tools for trauma and PTSD symptoms geared toward children and adolescents.12·13 Although several tools have recently been devised by investigators, mese tools have limitations. In some cases, there are few data on validity and reliability, and some of the tools are cumbersome to administer in a clinical setting. Therefore, pediatricians need to screen for PTSD by asking about a history of trauma and asking about me core symptoms associated wim the disorder.
Reactive Attachment Disorder
Reactive attachment disorder (RAD) of infancy and early childhood was first identified as a specific diagnostic entity in me third edition of me Diagnostic and Statistical Manual of Mental Disorders (DSM-III).14 Children with dus disorder demonstrate abnormalities in relationships; for example, they may seem indifferent to their caregivers or may be too friendly even to strangers. Young children may present with failure to thrive.
Studies have correlated childhood maltreatment and attachment styles in children.15 Reactive attachment disorder typically is diagnosed in very young children (infants, toddlers, and young school-aged children) and is considered to be rare.
Less is known about the extent to which disordered patterns of attachment persist into later childhood and adolescence and the ways that such disordered attachment patterns present in these age groups.16·17 However, mere seems to be a tendency for teenagers to demonstrate lack of empathy, trust, conscience, and connection to family and school.
General Emotional and Behavioral Disorders
Posttraumatic stress disorder and RAD are clearly associated with maltreatment, and children and adolescents sometimes present with symptoms that meet diagnostic criteria for these disorders. However, many children present with symptoms that do not meet formal diagnostic criteria for PTSD or RAD.
To make diagnosis even more difficult, children also present wim many otfier symptoms or disorders.3 Mood disturbances, including depression and mood instability, and anxiety symptoms, including separation anxiety, specific fears, social phobia, and panic attacks, have been associated wim maltreatment. It is not uncommon for children to display oppositional and defiant behavior and a disregard for omers consistent with conduct disorder. Substance use disorders are more prevalent in adolescents who suffered maltreatment in childhood.
In any of these instances, symptoms or a discrete disorder may be me result of, related to, or separate from maltreatment. Flashbacks associated wim PTSD can be difficult to differentiate from auditory or visual hallucinations that may be indicative of psychosis.18 Also, children wim PTSD symptoms can demonstrate hyperactivity and inattention, which might be mistaken for attentiondeficit/hyperactivity disorder (ADHD).19
FACTORSTHAT MEDIATE RISK OF PSYCHIATRIC PROBLEMS AFTER MALTREATMENT
There are multiple lines of evidence to support die notion mat some component of psychiatric disorders is inherited. Among the most convincing are twin studies showing monozygotic twins have a higher concordance for many psychiatric disorders, including depression20 and autism,21 man do dizygotic twins. There also is evidence that parents who engage in maltreatment are more likely to have psychiatric disorders themselves.22 These data raise the possibility mat psychiatric disorders might be the result of inherited vulnerability rather tiian the result of maltreatment. However, parental psychopamology probably increases the risk of psychiatric problems in maltreated children and adolescents.
Prenatal and Postnatal Environment
Prenatal risk factors are likely to coexist in individuals who are at risk for maltreatment. Sedlak et al. reported epidemiologic relationships between maltreatment and substance use, poverty, and availability of prenatal care.1 Because all of these factors also increase me risk of developmental and psychiatric disorders, any of these complicating factors may increase the risk of psychiatric problems in children and adolescents who have been maltreated.
Postnatal environment also may play an important role in emotional and behavioral problems associated with maltreatment. Toxin exposure in early childhood affects neurological development. One specific example is the impact of low level lead exposure on IQ.23 Both lead exposure and maltreatment are more likely in poor families.
Family characteristics also impact the development of psychiatric disorders. For example, paternal substance use increases the risk of psychopamology in boys.24 Punitive parenting style, among other factors, is associated with the development and persistence of conduct disorder in boys.25
A number of parental risk factors (eg, educational achievement, history of psychiatric illness) increase me risk of maltreatment directly.26 Certain maternal factors (eg, discontinuities and history of sexual abuse in childhood, and current maltreatment and substance abuse) predict how well children adjust after sexual maltreatment.27
Neurobiological consequences of maltreatment also add to the risk of developing psychiatric disorders. Early primate studies showed infant monkeys who only had a wire mesh structure rather than their mother or even a softer, terry-cloth covered structure demonstrated abnormal social behaviors into adulthood.28
More recent data in humans indicate children who are exposed to maltreatment demonstrate differences in a number of neuroendocrine and neurotransmitter systems. For example, the hypothalamic-pituitary-adrenal axis is abnormal in children with PTSD compared to that of normal children.7·29·30
Imaging studies are beginning to clarify the connection between childhood maltreatment and the volume and activity of specific areas of the brain.31"34 However, drawing conclusions from imaging studies is complicated. There are limited data on the normal development of me brain over the life span, including the degree of individual variation and gender-based variation.35 Studies have focused on the correlation between brain structures and specific disorders associated with maltreatment (eg, PTSD), but far less is known about the brain structure volumes in individuals with less specific emotional and behavioral problems associated with maltreatment.
Neurobiological research, however promising, has not yet provided physicians with new means to assess and treat psychiatric disorders associated with maltreatment in clinical settings. However, physicians working with individual children, adolescents, and families should be aware of new information in this area to use as a guide when approaching assessment, differential diagnosis, and treatment.
BARRIERS TO ASSESSMENT AND TREATMENT OF PSYCHIATRIC SEQUELAE
All physicians rely on establishing and maintaining a collaborative relationship with parents and caregivers to provide the best care for children and adolescents. Disclosure of maltreatment entails a great degree of risk for parents. Parents who are ashamed, who fear authorities may remove their children, or who fear the consequences of disclosing information about their spouse may not provide accurate information.
Given the social stigma attached to spousal violence, substance use disorders, and child maltreatment, parents are unlikely to volunteer such information unless asked directly, and mere may be reluctance on the part of medical professionals to inquire about these issues. Data indicate physicians are less likely to inquire about domestic violence.36 It would not be surprising if this were also true of child maltreatment.
The demands of a pediatric practice are also a barrier to screening and recognizing emotional and behavioral problems in general.37 Typically, appointments for an acute complaint are brief and focused, and during well-child visits, pediatricians must obtain an interim history, ascertain developmental progress, perform a physical examination, and provide anticipatory guidance, which makes it difficult for pediatricians to do more man briefly screen for emotional and behavioral problems.
Furthermore, because emotional problems sometimes present with physical symptoms, it is often difficult to connect symptoms with an underlying cause. Under such circumstances, there is an increased risk of initiating treatment for the most obvious problem, eg, somatic complaints,38 which may not address any underlying issues. Thus, such children are at increased risk of enduring invasive tests and treatments without successfully addressing meir symptoms.
Children who have been maltreated often become the responsibility of the child welfare system. Children may be placed with extended family members or in foster care, shelters, or group homes. Children who demonstrate emotional and behavioral problems often move from placement to placement. Such children may demonstrate poor self-care, enuresis, encopresis, aggression, and inappropriate sexual behaviors. Any of fJhese behaviors might result in a request that the child be removed.
Under such circumstances, it can be difficult for any physician, whetfier in primary care or in mental health services, to obtain adequate information needed to establish a diagnosis, begin treatment, and provide ongoing care. The situation is complicated further because there are inadequate systems to share clinical data.
Once die family system has been disrupted, it can be difficult for physicians to find individuals who are empowered to provide consent for sharing assessment and treatment records. Moreover, when providers take time to communicate in person wim other individuals involved in a patient's care, frequently their efforts are not consistently reimbursed or rewarded. All of these factors add to me complications of providing services to children who have suffered maltreatment.
In many communities, there are not enough mental health care providers to meet the needs of children and adolescents. In addition, there are disparities in the care available to individuals with fewer financial resources as well as limitations in the kind of services mat insurance providers reimburse.
Therefore, it frequently is necessary for professionals from different areas of social services to provide comprehensive services to children and families. For example, children may be involved in special education services in school, child protective services, the juvenile justice system, and mental health care services as well as medical care. Each agency has its own mandate, procedures, and philosophy. Because these procedures and goals may conflict, there is a risk of miscommunication between providers and with families.
OVERCOMING BARRIERS TO COLLABORATIVECARE
Primary Care Interventions
Family factors. When a pediatrician becomes aware of recent maltreatment, die initial priority is to address acute medical problems, initiate reports to child protective services, and ensure die child's safety. Once mese immediate needs have been addressed, me pediatrician should screen for mood and anxiety symptoms, and behavioral changes. Acute stress disorder presents with symptoms similar to PTSD, but wimin a shorter time frame (within the first month after the trauma). If there is any indication of emotional distress, early intervention may prevent me progression to PTSD.39
Practice factors. Pediatricians also must be alert for emotional and behavioral problems related to past maltreatment. During well-child visits, it is critical to review family composition, changes in parents' marital status, and new parental relationships. These changes increase the risk for maltreatment.1 Parents should be asked about significant changes in behavior, alterations in sleep patterns, new difficulty wim separation, new behavior problems such as aggression or defiance, loss of previously acquired developmental skills, statements about self-harm or suicide, and any changes in sexual behavior.
It is also important to speak directly to the child in a neutral and nonthreatening way about discipline at home and about die child's interactions with older children or adults. Such conversations can use language about "good" and "bad" touch. These conversations should take place wim the child alone once he or she can tolerate time separate from parents.
Parents and caregivers also should be asked similar questions to determine if there is any concern about unsafe relationships. Any information that increases concern about maltreatment should be investigated in more depth and addressed appropriately.
When a child or adolescent is transitioning to a new living situation such as a group home or a new foster home, the pediatrician may be the newest member of the team. In such cases, a high degree of vigilance should be maintained for emotional and behavioral problems. Foster and pre-adoptive parents may receive little information about the prior life experience of the child who is now in their care. Few foster and adoptive parents receive the training and support they need to cope with the kinds of problems that these children can exhibit.
Often, die pediatrician may be the first medical professional with whom the child or adolescent and his or her new family have contact. Whenever possible, the pediatrician should be prepared to provide basic information about the impact of maltreatment on development and behavior. In addition, pediatricians should be able to provide referral information for mental health services and community support systems. Obtaining prior medical and mental healtii records as quickly as possible facilitates continuity of care.
Symptoms such as depressed mood, insomnia, anxiety, panic, and hyperactivity may be identified and could be addressed wim psychotropic medication. Pediatricians wim the expertise to assess mese symptoms, determine the diagnosis, and prescribe psychotropic medication may provide such treatment in collaboration with a psychotherapist.
To date, few psychotropic medications have received approval by the Food and Drug Administration (FDA) for use in children and adolescents. These include fluoxetine for depression, fluvoxamine for obsessive compulsive disorder, and psychostimulants for ADHD. Other selective serotonin reuptake inhibitors (SSRIs), including paroxetine and sertraline, have been approved for depression and anxiety disorders, including PTSD, in adults. All SSRIs are generally well tolerated and are commonly prescribed for children and adolescents wim mood and anxiety symptoms.
Referrals to Mental Health Care Systems
Family factors. When children and adolescents present with recurrent, poorly defined physical complaints accompanied by symptoms of depression or anxiety, regardless of a history of maltreatment, me pediatrician may want to approach the family about incorporating mental health treatment into the treatment plan. Families refuse mental health treatment for a number of reasons such as a desire to avoid die stigma attached to mental disorders, the belief that meir concerns are being dismissed, or concern mat the pediatrician is distancing him- or herself from care.
Such concerns should be addressed by reassuring the family that physical symptoms associated with emotional distress cannot be addressed by physical interventions alone. It may be helpful to use an example of a physical symptom with more than one potential medical explanation, eg, chest pain from either indigestion or a heart attack, and explain the importance of treating the right problem. The physician also should reassure the family that he or she is not relinquishing care or giving up on the child and family.
There are times when the family may seek the opinion of a psychiatrist even when the pediatrician has been die primary mental heath care provider. Under such circumstances, the family may not communicate they have initiated a second opinion. Furthermore, the psychiatrist may not be aware that another physician has been providing care.
To some extent, such circumstances can be avoided by actively communicating to families that they have the option to seek additional opinions and support at the outset of treatment. Although active collaboration between psychiatry and primary care specialties has not been the rule,40 primary care physicians can initiate contact and communicate their desire to collaborate with the psychiatric provider.
Practice factors. Patients who demonstrate an unsatisfactory or unusual response to initial treatment modalities should be referred to a child and adolescent psychiatrist. The American Academy of Pediatrics (AAP) and the American Family Practice Association have both expressed a commitment on the part of pediatricians and primary care providers to deliver mental health care, including assessment and treatment, when possible.41 Both professional organizations also recognize the need for pediatricians and primary care providers to collaborate with mental health professionals when attempts to treat in the primary care setting are not successful or when complications arise in treatment.42
Managing the long-term sequelae of maltreatment requires collaboration between primary care providers and mental health providers. The AAP endorses policies recommending timely and comprehensive mental health evaluations for all children and adolescents in out-of-home placements.43·44
The pediatrician should discuss a potential referral for child and adolescent psychiatrist or other mental health care provider with me child and family. It is important to focus on the target problems, the goals for consultation, and the roles that other providers might take in the child's care. The best collaborative relationships occur when the pediatrician contacts the referral source and provides brief historical information and the clinical question to be addressed. Psychiatrists also like to know if they are expected to assume care of psychiatric conditions or provide recommendations to the pediatrician. This degree of clarity will afford the patient and family the best chance of well-coordinated care.
System factors. Primary care physicians should know what mental health services are available in their communities. It is beyond the scope of this article to provide a full discussion of these matters. This summary will provide a starting point. The physician should maintain up-to-date lists of local mental health providers and other local resources such as educational advocates that the parent can access. Prior good working relationships with child welfare agencies, eg, child protective services, and with mental health providers in the community facilitates good care and timely access to services.
Mental health providers. Master's and doctoral level clinicians such as psychologists, marriage counselors, and family therapists are trained in assessment and merapeutic techniques, although the use of the DSM disorder classification system is far from universal. Individual therapists will have varying levels of experience and skill in therapeutic modalities. Some will have experience in family therapy and group therapy.
In addition, some master's and doctoral level clinicians are skilled in psychological, psychoeducational, and neuropsychological testing. Formal testing of cognitive abilities, information processing, and reasoning may be warranted as part of a comprehensive evaluation and treatment plan because maltreatment can impact cognition, perception, emotion, and behavior.
Child and adolescent psychiatrists can provide comprehensive psychiatric evaluations and recommendations for medication and psychotherapeutic interventions. Psychiatrists can provide ongoing medication treatment, and some psychiatrists offer both individual and family psychotherapy.
Level of Care
Each individual and family is unique and requires a treatment plan focused on their strengths and needs. One way of providing an array of services is to organize care by level of intensity. The lowest intensity of service focuses on helping families organize and manage the services that are available to them. Such case management services are usually part of community mental health (CMH) programs and focus more on helping families provide for their immediate needs and helping families coordinate care rather than providing specific therapy or counseling. Case managers typically have a bachelor's degree and limited treatment experience.
Outpatient therapy is office-based, occurs on a regular basis, and can include individual, family, and group therapy. An outpatient therapist is more likely to have a master's or doctoral level education, although it is possible to obtain certification for certain kinds of counseling (eg, substance use treatment) with a bachelor's degree or less formal education.
When more intensive treatment is needed, several types of in-home services might be available. Programs such as wraparound services or family-based services provide an added level of therapy and support, and are typically provided by a team of individuals who have different levels of formal training and expertise. These programs are also more likely to be provided by community mental health or other social service agencies. After-school or day treatment programs also provide a combination of individual, group, and family therapy for those who require more intensive treatment.
The most intensive levels of care are inpatient and residential treatment. Most inpatient treatment programs are short term and focus on providing an initial diagnosis or providing acute management when there is no way to ensure safety at a lower level of care. Residential treatment is typically longer term (3 months to 6 months) and is reserved for individuals who have failed attempts at more intensive treatment within their family and community.
Because of the complexities involved in working with children and adolescents who have been maltreated, it is common for these individuals to become involved in several intensity levels during the course of their treatment. Children and adolescents may only be able to access certain types of services if they are eligible for Medicaid insurance or are uninsured because most standard insurance programs will not reimburse for services that are more intensive than outpatient treatment.
Posttraumatic Stress Disorder
The evidence base for treatments specific to sequelae of maltreatment varies greatly. For PTSD, open-ended, exploratory therapy does not appear to be effective. However, cognitive behavioral therapy (CBT)45 does appear to be effective. This technique involves the patient recalling aspects of the trauma and learning to change thoughts associated with trauma. For example, a patient may learn that he or she is not responsible for the maltreatment.
Reactive Attachment Disorder
There are limited studies investigating the treatment of RAD. In infancy, treatment typically involves removing the child from the neglectful environment and providing good care. Treatment data are limited and in some cases controversial17 for children with RAD.
Some research demonstrates young children may benefit from a situation in which a primary caretaker establishes a highly supervised environment that limits the child's degree of control. The child should simultaneously engage in therapy in which he or she learns to express feelings associated with maltreatment.46 The reasoning behind this is that these children have lived in chaotic conditions and have not learned the basics of trust or cause and effect. In this regard, their emotional development is more likely to be at the stage of an infant or toddler.
There are no studies that address treatment strategies to reduce disruptive behavior in late childhood and adolescence with RAD; anecdotal reports document problems associated with using standard behavioral management techniques that rely on systems of positive and negative reinforcement.17 Again, such techniques are effective for children and adolescents who have achieved the ability to enter into trusting relationships with others and who are capable of understanding cause and effect, both of which are typically lacking or are not reliable in children who have been maltreated.46
Mood and Anxiety Disorders
There are also few data on the psychotherapeutic treatment of mood disorders and other anxiety disorders that occur in the aftermath of maltreatment. Typically, treatment for these disorders is approached in the same manner as when maltreatment is not associated. However, there is some evidence that adults with a history of maltreatment do not respond as well to standard treatment measures.8
At present, the evidence for pharmacologic interventions for children and adolescents is limited. To date, the FDA has approved the use of psychostimulants for ADHD and the SSRIs fluoxetine and fluvoxamine for certain mood and anxiety disorders in children. Although off-label uses of other SSRIs, atypical antidepressants (ie, venlafaxine, bupropion, mirtazapine, and trazodone), lithium, and anticonvulsant mood-stabilizing medication and neuroleptics are common, their use is supported by limited scientific evidence.
Child psychiatrists typically determine whedier a specific disorder wim established treatment parameters is present and men treat accordingly. In the absence of a clear disorder, specific target symptoms (eg, anxiety, mood instability, and anger outbursts) are identified and medication is prescribed to address me symptoms. The psychiatrist will then assess the impact of medication on the intensity of the target symptoms balanced against any adverse reaction. It is rare for medications alone to address target symptoms; most children and adolescents require multidisciplinary treatment.
Pediatricians should inquire about the specific treatment modalities used by any mental health care provider to whom they might refer a patient and refer only to those providers who have skill in evidence-based treatments such as CBT. Pediatricians whose practices include a high percentage of children involved in child welfare systems should obtain more training in the sequelae of maltreatment to optimize the well-being of die children and families in meir care.
The case example summarized in the Sidebar on pages 26 and 27 illustrates several of the points outlined in this article and offers some insights into the difficulties encountered when treating children and adolescents with long-term psychiatric disorders associated with maltreatment.
Childhood maltreatment is a serious public health problem and represents a significant challenge to pediatricians. Maltreated children present with a variety of emotional and behavioral problems. Pediatricians should screen for risk factors associated with maltreatment and psychiatric sequelae associated with maltreatment.
Because of the complexity of psychiatric sequelae in childhood maltreatment, children who have been maltreated will likely require multidisciplinary treatment in mental health care settings. Therefore, pediatricians need to be knowledgeable about mental health services in their communities and actively assist die family in obtaining services.
Although we are gaining a more sophisticated understanding of me impact that maltreatment has on the mental health of children and adolescents, much remains to be done. It is critical for pediatricians to work wimin meir professional organizations and meir individual communities to address me systemic issues that create barriers to care for patients who have suffered maltreatment. It is also critical for pediatricians to encourage meir professional organizations to establish good working relationships with omer organizations in areas where tiiey share interest, need, and commitment.
Such collaborative relationships at local, state, and national levels can facilitate governmental policy changes diat are needed to protect and care for children and adolescents. Only through such efforts can we bring about lasting changes that will support the healtfi and well-being of children and adolescents.
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