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Applied Neuropsychology: Child

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A Neuropsychological Profile of Childhood

Maltreatment Within an Adolescent Inpatient Sample
a b b
Brian Kavanaugh , Karen Holler & Gregg Selke
a
Department of Clinical Psychology , Antioch University New England , Keene , New
Hampshire
b
Department of Psychiatry and Human Behavior , Alpert Medical School of Brown
University , Providence , Rhode Island
Published online: 24 Oct 2013.

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Childhood Maltreatment Within an Adolescent Inpatient Sample, Applied Neuropsychology: Child, 4:1, 9-19, DOI:
10.1080/21622965.2013.789964

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 APPLIED NEUROPSYCHOLOGY: CHILD, 4: 9–19, 2015
Copyright © Taylor & Francis Group, LLC
ISSN: 2162-2965 print/2162-2973 online
DOI: 10.1080/21622965.2013.789964

A Neuropsychological Profile of Childhood Maltreatment

Within an Adolescent Inpatient Sample
Brian Kavanaugh
Department of Clinical Psychology, Antioch University New England, Keene, New Hampshire

Karen Holler and Gregg Selke

Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University,
Providence, Rhode Island
Downloaded by [Wayne State University] at 08:25 09 April 2015

Recent research has begun to identify the neurocognitive and psychological effects of
childhood maltreatment, although information is limited on the neuropsychological
presentation of maltreatment in psychiatrically hospitalized adolescents. This study
examined the executive-functioning and language abilities as well as psychopathological
presentation of childhood maltreatment victims in an adolescent psychiatric inpatient
setting. The sample consisted of adolescent inpatients (ages 13–19 years old) who
completed a neuropsychological/psychological assessment during hospitalization
(n = 122). The sample was grouped based on childhood maltreatment history, with one
group categorized by maltreatment history (n = 49) and the other group characterized by
no maltreatment history (n = 73). Analyses revealed statistically significant differences
(p < .01) between maltreatment groups on executive functioning, as well as on measures
of self-reported depression and anxiety symptoms. No group differences remained after
controlling for posttraumatic stress disorder. Further, distinct neuropsychological profiles
were identified for specific types of maltreatment experienced. These findings suggest
that while childhood maltreatment is associated with a range of neuropsychological
impairments, the specific type of maltreatment experienced may have a significant
influence on the type and severity of impairments. These findings contribute to the
growing body of research on the significant consequences of childhood maltreatment.

Key words:  adolescence, inpatient, maltreatment, neurocognitive, psychopathology

Childhood maltreatment is defined as sexual abuse, phys-
ical abuse, emotional abuse, or neglect toward a child (De
Bellis et al., 1999; Mash & Barkley, 2007). Childhood
maltreatment is a significant national health concern,
with recent statistics estimating that approximately 5.9
million children in the United States were maltreated in
2010, indicated by referrals to Child Protective Services
(U.S. Department of Health and Human Services,
Administration on Children, Youth, and Families, 2012).
Address correspondence to Brian Kavanaugh, Department of
Clinical Psychology, Antioch University New England, 40 Avon Street,
Keene, NH 03431. E-mail: BKavanaugh@antioch.edu
Many victims of childhood maltreatment do not experi-
ence significant developmental consequences, with some
even experiencing select positive outcomes, such as post-
traumatic growth (Alisic, van der Schoot, van Ginkel, &
Kleber, 2008; Wilson, Hansen, & Li, 2011). Despite this,
childhood maltreatment is a significant risk factor for
various developmental, neurocognitive, and psychiatric
conditions and is characterized by severe and long-term
consequences (De Bellis, Spratt, & Hooper, 2011;
Kendall-Tackett, 2000; Mash & Barkley, 2007; Pechtel &
Pizzagalli, 2011; Wilson et al., 2011).
While enriching environments enhance typical brain
development, executed through neurogenesis and selective
 10    KAVANAUGH, HOLLER, & SELKE
neuronal pruning, brain development can be significantly
restricted by negative experiences such as stress (Taber,
Salpekar, Wong, & Hurley, 2011; Teicher, Tomada, &
Andersen, 2006). When the body’s major biological stress
systems (e.g., hypothalamic-pituitary-adrenal axis, sym-
pathetic nervous system, and serotonin system) are acti-
vated to manage elevated and prolonged exposure to
stress, a shift occurs from a process of development and
growth to one of preservation and survival. The neurobio-
logical consequences of extreme childhood stress include
the elevated presence of catecholamines (e.g., epinephrine,
norepinephrine, and dopamine), corticotropin-releasing
hormones, cortisol, and serotonin in the circulatory
system (De Bellis, Keshavan, Spencer, & Hall, 2000; De
Bellis et al., 2011; Kirsch, Wilhelm, & Goldbeck, 2011;
Lupien et al., 2005; Teicher et al., 2003; Twardosz &
Lutzker, 2010; Wilson et al., 2011). Especially in child-
hood and adolescence, critical periods of postnatal brain
Downloaded by [Wayne State University] at 08:25 09 April 2015
development, the lack of healthy opportunity for growth
can negatively influence the development of critical neural
mechanisms (De Bellis et al., 2000, 2011; Heim, Shugart,
Craighead, & Nemeroff, 2010; Kearney, Wechsler, Kaur,
& Lemos-Miller, 2010; Lupien et al., 2005; Pechtel &
Pizzagalli, 2011; Taber et al., 2011; Teicher et al., 2003;
Twardosz & Lutzker, 2010; Wilson et al., 2011).
Childhood maltreatment has been associated with
reduced volume of the cerebral cortex and subcortical
structures, such as the prefrontal cortex, right temporal
lobe, corpus callosum, and hippocampus (Andersen
et al., 2008; De Bellis et al., 1999, 2002; Teicher et al.,
2004). In addition, neuroimaging studies have shown
decreased neural connectivity in frontal, central, tem-
poral, and parietal areas of the brain associated with
childhood trauma in adult brains, as well as diminished
left-hemisphere differentiation and left-sided electroen-
cephalography abnormalities in children and adolescent
abuse victims (Cook, Ciorciari, Varker, & Devilly, 2009;
Teicher et al., 1997). Further, it appears that certain areas
of the brain may be particularly vulnerable to the neuro-
biological consequences of childhood maltreatment,
notably those areas with protracted postnatal develop-
ment well into adolescence (e.g., prefrontal cortex, corpus
callosum, cerebellum, and hippocampus; De Bellis et al.,
2011; Pechtel & Pizzagalli, 2011; Wilson et al., 2011). The
dysregulation of the neurobiological system and subse-
quent neuroanatomical changes can result in direct neural-
functioning dysregulation, contributing to the development
of various psychiatric, neurodevelopmental, and neuro-
cognitive impairments (Andersen et al., 2008; De Bellis
et al., 2011; Hedges & Woon, 2011; Heim et al., 2010;
Kearney et al., 2010; Pechtel & Pizzagalli, 2011; Teicher
et al., 2003; Wilson et al., 2011).
It has been suggested that certain higher-order cogni-
tive functions are at increased risk for maltreatment-
related dysfunction due to extreme stress exposure during
critical developmental periods (De Bellis et al., 2011;
Pechtel & Pizzagalli, 2011; Wilson et al., 2011). Two of
these neurocognitive domains include executive func-
tions, predominantly correlated with the prefrontal
cortex, and language, primarily correlated with the left
cerebral cortex, along with the posterior corpus callosum
and cerebellum (De Bellis et al., 2011; Pechtel & Pizzagalli,
2011; Wilson et al., 2011). Executive functions are self-
regulatory actions to achieve goals, such as those actions
of planning and problem solving, cognitive flexibility,
response inhibition, working memory, processing flu-
ency, and attention (Anderson, 2002; Barkley, 2012;
Baron, 2004; Henry & Bettenay, 2010; Luria, 1965;
Mahone & Slomine, 2007; Willcutt, 2010). Further, these
theoretical hypotheses have been proven in human stud-
ies, which have identified executive and language impair-
ments in child and adolescent victims of maltreatment
(Allen & Oliver, 1982; Beers & De Bellis, 2002; De Bellis,
Hooper, Spratt, & Woolley, 2009; DePrince, Weinzierl, &
Combs, 2009; Fishbein et al., 2009; Kocovska et al., 2012;
Nolin & Ethier, 2007; Samuelson, Krueger, Burnett, &
Wilson, 2010; Spann et al., 2012; Stacks, Beeghly,
Partridge, & Dexter, 2011; Sylvestre & Merette, 2010).
Two studies by De Bellis and colleagues have been par-
ticularly influential. Beers and De Bellis (2002) found
that compared with nonmaltreated children, children
with maltreatment-related posttraumatic stress disorder
(PTSD) displayed significantly lower levels of attention
and executive functioning, although domains such as lan-
guage were not significantly lower in these maltreated
children. De Bellis and colleagues (2009) compared the
neuropsychological functioning of neglected children
with related PTSD, neglected children without PTSD,
and healthy children. Results indicated that both groups
of neglected children displayed significantly lower levels
of intelligence, attention/executive functioning, language,
and memory. Lower levels of attention/executive func-
tioning, language, and memory remained a statistically
significant impairment when controlling for intelligence.
Only one individual score in visual memory differentiated
the neglected groups from one another, suggesting that
neglected children may possess similar neuropsychologi-
cal profiles, regardless of PTSD diagnosis.
Research has suggested that childhood maltreatment
may contribute to the presence of severe psychopathol-
ogy (e.g., anxiety, depression, personality differences,
impulsivity, violence, suicidality; Cloitre et al., 2009;
Kearney et al., 2010; Kendall-Tackett, 2000; Wilson
et al., 2011). The psychiatric adolescent inpatient popula-
tion is one group with high rates of childhood maltreat-
ment (ranging from 31% to 61% depending on type of
maltreatment), with maltreatment suggested as a signifi-
cant risk factor for psychiatric hospitalization during
childhood (Boxer & Terranova, 2008; Fehon, Grilo, &
Lipschitz, 2001). Generally, maltreatment is associated
 NEUROPSYCHOLOGICAL PROFILE OF MALTREATMENT    11
with significant psychopathological symptoms and
impaired functioning in the child and adolescent inpa-
tient setting and contributes to long-term psychological
struggles beyond that of acute emotional distress (Boxer
& Terranova, 2008; Grilo, Sanislow, Fehon, Martino, &
McGlashan, 1999; Sullivan, Fehon, Andres-Hyman,
Lipschitz, & Grilo, 2006).
Increasingly, research is examining the neurocognitive
and psychological presentation of those young victims
of childhood maltreatment. However, few studies have
simultaneously examined the neurocognitive and psy-
chological components of maltreatment, which has lim-
ited the comprehensive profile we can identify in this
population. Further, fewer studies have examined the
neurocognitive and psychological components of child-
hood maltreatment within the adolescent psychiatric
inpatient setting. To contribute to the growing neuropsy-
chological literature on childhood maltreatment, the
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present study examined the neurocognitive (e.g., execu-
tive functions and language) and psychological (e.g.,
anxious and depressive symptoms) presentation of a
group of adolescent psychiatric inpatient victims of
childhood maltreatment. It was hypothesized that com-
pared with those adolescent inpatients without a history
of childhood maltreatment, maltreatment victims would
display lower scores on measures of executive function-
ing and language, while reporting elevated symptoms of
anxiety and depression.
METHOD
Participants and Procedure
The present study received institutional review board
(IRB) approval from Butler Hospital/Alpert Medical
School of Brown University and followed the ethical prin-
ciples set forth by the American Psychological Association.
It is part of a research project at Butler Hospital, an inpa-
tient psychiatric hospital. Specifically, the research project
is examining the neuropsychological correlates of psychi-
atric conditions based on retrospective chart review of
adolescents admitted to the hospital who received a neu-
ropsychological/psychological evaluation during the years
from 2002 to 2012. Of note, there was one change in the
version of the tests administered in the neuropsychologi-
cal inpatient battery during these noted years (such as
transitioning from the first edition to the second edition
of a given instrument). As noted in later sections, a small
portion of participants completed the first edition of the
Revised Children’s Manifest Anxiety Scale (RCMAS).
Due to similar clinical subscale categorization, individuals
who completed the RCMAS-First Edition (RCMAS-1)
and RCMAS-Second Edition (RCMAS-2) were included
in this sample. Each individual admitted to the hospital
received a discharge diagnosis by the attending psychia-
trist (or psychiatry resident under direct supervision of
the psychiatrist) based on the Diagnostic and Statistical
Manual of Mental Disorders-Fourth Edition, Text Revision
(American Psychiatric Association, 2000). A clinical
child neuropsychologist, a professional psychometrist, or
a doctoral student in clinical psychology under direct
supervision of a child neuropsychologist conducted the
neuropsychological/psychological evaluations. Reasons for
evaluation were based on parent/guardian concerns and/
or a request for additional information by the attending
psychiatrists. Evaluations were typically completed within
a few days of hospital admission.
The present study examined the neuropsychological
profile (i.e., executive functions, language, anxiety, and
depression) of childhood maltreatment within an ado-
lescent inpatient sample. Given the nature of the hospital
in relation to the other medical school-affiliated hospitals,
those patients treated at the current hospital primarily
present with a psychiatric presentation in the absence of
comorbid medical or neurological conditions. While rep-
resenting a minority component of the overall popula-
tion served, those patients with a comorbid medical or
neurological condition were not included in the present
study (e.g., traumatic brain injury, seizure disorders,
cerebral palsy, spina bifida). Inpatients diagnosed with
bipolar disorder, a pervasive developmental disorder
(e.g., autistic disorder, Asperger syndrome, Rett syn-
drome, childhood disintegrative disorder, and pervasive
developmental disorder-not otherwise specified), or a
psychotic disorder were also excluded from the current
sample. However, those patients with a diagnosis of
attention-deficit hyperactivity disorder (ADHD) were
included in the current sample. As noted in Table 1, there
were no significant differences between groups regarding
the presence of ADHD. One notable weakness of the
current study is that intellectual and academic assess-
ment was not available to researchers due to limited use
of these instruments in the neuropsychological inpatient
battery at the hospital. Although intellectual functioning
was not typically assessed formally in these evaluations,
those individuals who received the described evaluation
were deemed intellectually competent and capable of
testing, as assessed by the absence of a history of intel-
lectual disability or borderline intelligence. This limita-
tion will be discussed elsewhere, but it is important to
note that information regarding the presence of learning
and intellectual disabilities was not available. A total of
122 adolescent inpatients were included in the present
study, with 49 participants included in the maltreatment
group and 73 participants included in the no maltreat-
ment group based on chart review. Demographics and
comorbidities were examined either using chi-squared or
analyses of variance (ANOVAs). Results are provided in
Table 1.
 12    KAVANAUGH, HOLLER, & SELKE

TABLE 1
Clinical and Demographic Characteristics for Maltreatment Groups

Total Sample History of Maltreatment No History of Maltreatment

Variable (N = 122) (n = 49) (n = 73) Pearson X2 F

% Male 60% 49% 34% 2.65

Age 15.31 (1.31) 15.48 (1.25) 15.19 (1.34) 1.45
Beery VMI Total 40.09 (9.47) 37.00 (9.68) 41.99 (8.89) 7.83*
% With Comorbidity 77% 84% 73% 2.03
# of Diagnoses 2.01 (0.76) 2.14 (0.68) 1.92 (0.80) 2.64
Diagnoses
Mood NOS 45% 49% 42% 0.50
Depression 41% 39% 42% 0.17
Anxiety 24% 29% 21% 1.04
PTSD 10% 25% 0% 19.83**
Behavioral 35% 29% 40% 1.60
ADHD 46% 45% 47% 0.03

Beery VMI Total = Beery Visual-Motor Integration Test (Fourth Edition, representing an intellectual proxy); % With Comorbidity = percentage
of participants who had more than one psychiatric diagnosis; Diagnoses = psychiatric diagnoses at hospital discharge; Anxiety = anxiety disorders;
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PTSD = posttraumatic stress disorder; Behavioral = disruptive behavioral disorders; ADHD = attention deficit/hyperactivity disorder.

*p < .01. **p < .001.

Materials The RCMAS-2 is a self-report measure of symptoms

History of Maltreatment
Information regarding the history of maltreatment
was gathered directly from the patient’s chart. At the time
of hospital admission, detailed information was obtained
by primary clinicians regarding the recent behaviors
exhibited by patients, recent stressors to patient and
family, and the child’s developmental history. Specific
examination of potential maltreatment history was stan-
dard in the admission/interview protocol with parents.
Any history of maltreatment was recorded by clinicians,
including maltreatment occurring immediately prior to
hospitalization and maltreatment occurring years prior,
such as in early childhood. Due to the nature of the clini-
cal hospital admission process, specific maltreatment
history including duration and time since maltreatment
were not consistently included in patient medical charts.
However, the specific types of maltreatment were obtained
by researchers. Maltreatment history was defined by the
experience of physical abuse, sexual abuse, emotional/
verbal abuse, or neglect. Any history of these maltreat-
ment experiences resulted in a positive identification of
maltreatment history.
Self-Reported Anxiety/Depressive Symptoms
The Childhood Depression Inventory (CDI) is a self-
report measure of depressive symptoms, specifically in
the domains of negative mood, interpersonal problems,
ineffectiveness, anhedonia, and negative self-esteem. The
CDI contains 27 items and can be used for children and
adolescents aged 7 to 17 years old (Kovacs, 1992). The
total score and subdomain scores on the CDI were used
for the present study.
of childhood anxiety, specifically physiological anxiety,
worry, and social anxiety (Reynolds & Richmond, 2008).
It also contains scales that assess defensiveness and
inconsistent reporting. The RCMAS-2 contains 49 items
and can be used for children and adolescents aged 6 to 19
years old. Of note, some of the older participants com-
pleted the RCMAS-1. Because the scoring criteria
remained consistent in the transition from RCMAS-1 to
RCMAS-2, along with same clinical subscales, it was
deemed appropriate to include these cases.
Task of Intellectual Estimation
No information on participant intelligence (IQ) was
available. The Beery Visual Motor Integration Test-
Fourth Edition (Beery VMI-4) was used as an intellectual
proxy to provide information on overall functioning. The
Beery VMI is a task of visual-motor integration, where
the participant copies increasingly complex figures as
correctly as possible (Beery, 1997). The Beery VMI has
been highly correlated with intelligence in children and
adolescents (r = .62 with Full-Scale IQ) and has been cat-
egorized as possessing predictive intellectual utility
(Campbell, Brown, Cavanagh, Vess, & Segall, 2008). The
Beery VMI was used in the present study as a proxy for
intelligence.
Tasks of Executive Functioning
Based on a review of pediatric neuropsychological litera-
ture (Anderson, 2002; Baron, 2004; Henry & Bettenay, 2010;
Willcutt, 2010), five executive-functioning subdomains were
constructed: (a) planning/problem solving, (b) set shifting/
cognitive flexibility, (c) response inhibition/interference
 NEUROPSYCHOLOGICAL PROFILE OF MALTREATMENT    13
control, (d) fluency, and (e) working memory/simple
attention.
Planning/problem solving.  The Wisconsin Card-Sorting
Test (WCST) is a test of executive function that assesses
skills in abstraction, shifting and maintaining focus, goal
orientation, and impulse control (Baron, 2004; Henry &
Bettenay, 2010; Strauss, Sherman, & Strauss, 2006; Willcutt,
2010). This study used the following WCST scores: amount
of categories achieved (WCST Categories), failures to
maintain set (WCST FMS), and perseverative errors
(WCST Perseverative Errors). The WCST Categories
score was used as a measure of planning/problem solving
(Baron, 2004; Strauss et al., 2006). The Rey Osterreith
Complex Figure (ROCF) is a neuropsychological task
designed to assess visual-spatial, perceptual, planning,
integration, and organizational abilities (Strauss et al.,
2006). The ROCF requires the participant to copy a
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picture of a complex geometric design as accurately as
possible. The ROCF was used in the present study to
assess planning.
Set shifting/cognitive flexibility.  The Trail-Making Test
(TMT) is a neuropsychological instrument that assesses
attention, speed, and cognitive flexibility (Baron, 2004;
Henry & Bettenay, 2010; Strauss et al., 2006). It consists
of two versions that are administered consecutively to
the client. TMT Part A (TMT-A) requires the client to
use a pencil and connect encircled numbers in numerical
order. TMT Part B (TMT-B) requires the client to use a
pencil and connect encircled numbers and letters in
numerical and alphabetical order, alternating between
numbers and letters until completed. The adult form is
for ages 15 to 89 years old and the child form is for ages
9 to 14 years old. The child form is very similar to the
adult form, although it contains fewer numbers and
letters. TMT-B was used in the present study to assess
set shifting/cognitive flexibility (Strauss et al., 2006). In
addition, the WCST Perseverative Errors score was
used to assess set shifting/cognitive flexibility (Baron,
2004).
Response inhibition/interference control.  The Stroop
Test is a verbal task of executive function that assesses
processing speed, attention, cognitive flexibility, resistance
to distraction, and response inhibition (Baron, 2004;
Henry & Bettenay, 2010; Strauss et al., 2006; Willcutt,
2010). It consists of three conditions, which require the
client to read increasingly difficult patterns of words and
colors. The third condition, called Color-Word (Stroop
C-W), presents a word list of colors, with each color
name printed in the ink of another color. For example,
the word “RED” would be printed in blue ink, with the
participant required to say the color of the ink, not the
written word. The increasingly difficult conditions
challenge the executive functions of the client. The Stroop
C-W score was the only Stroop score used for this study,
and it was used to assess response inhibition/interference
control. In addition, the WCST FMS score was used to
assess response inhibition/interference control (Strauss
et al., 2006).
Fluency.  The Controlled Oral Word Association Test
(COWAT) is a verbal task that requires the individual to
produce words based on clinician-delivered characteristics
and is typically viewed as a task assessing executive
functioning, specifically verbal fluency (Baron, 2004;
Henry & Bettenay, 2010; Strauss et al., 2006). Two
conditions were used in this administration, phonemic and
semantic. The phonemic condition, FAS, asks the client to
produce words starting with the letters F, A, and S for 1
min per letter. The semantic condition, Animals, asks the
client to say the names of various animals for 1 min.
Although the COWAT has been used as a language
measure, for the present study, it was used to assess verbal
fluency, identified as a subdomain of executive functioning.
Working memory/simple attention.  The Wide Range
Assessment of Memory and Learning (WRAML) is a set
of tasks that assesses the learning and memory abilities
of children and adolescents (Sheslow & Adams, 1990).
One subtest, Sentence Repetition, involves the clinician
verbally presenting increasingly difficult sentences to the
client and asking the client to repeat the sentence. This
subtest, similar to other verbally presented digit span and
sentence repetition tasks, is believed to assess working
memory and simple attention/concentration (Burton,
Donders, & Mittenberg, 1996). Therefore, WRAML
Sentence Repetition was used in this study to assess
working memory. TMT-A was also used in the present
study to assess simple attention (Baron, 2004; Strauss
et al., 2006).
Tasks of Language
T scores were used for all language measures.
The Boston Naming Test is a test of visual naming
that requires the individual to produce the word descrip-
tions of a series of black-and-white drawings (Strauss
et al., 2006). The picture drawings range from frequently
seen words to words that are rarely seen. The total score
on the Boston Naming Test was used in the present
study and was used to indicate express language. The
Peabody Picture Vocabulary Test-Third Edition (PPVT-
III) is a task of receptive vocabulary (Strauss et al.,
2006). The PPVT-III is used for ages 2 to 90+ years and
has been recommended as an intellectual screening and/
or academic achievement tool. For the present study, the
PPVT-III was used as a language measure, specifically
receptive language.
 14    KAVANAUGH, HOLLER, & SELKE
RESULTS
Maltreatment History and Executive
Functioning/Language/Psychopathology
Composite scores were calculated for each executive-
functioning/language subdomain based on the mean
performance of administered executive-functioning and
language measures: cognitive flexibility/set shifting (TMT-B
and WCST Perseverative Errors), interference control/
response inhibition (Stroop C-W and WCST FMS), plan-
ning/problem solving (ROCF and WCST Categories),
working memory/simple attention (WRAML Sentence
Repetition and TMT-A), verbal fluency (COWAT FAS
and COWAT Animals), and language (Boston Naming
Test and PPVT-III).
As noted previously, information regarding IQ was
not available. To provide information on level of func-
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tioning at the time of evaluation, the Beery VMI was
used as an intelligence proxy.
Based on original ANOVA and chi-squared analysis
on diagnostic and demographic variables between
groups, PTSD diagnosis, X2 = 19.83, and Beery VMI (IQ
proxy), F(1, 111) = 7.83, p = .006, were identified as pos-
sessing significant differences between groups. Initial
analyses of group differences on clinical measures were
conducted without controlling for these variables
(ANOVA). Because Beery VMI served as an IQ proxy in
the current sample, analyses were then conducted while
controlling for Beery VMI (analysis of covariance
[ANCOVA]). Due to the relevance of PTSD within child-
hood maltreatment, analyses were also conducted while
controlling for PTSD diagnosis (ANCOVA). To protect
statistical integrity during multiple comparisons, statisti-
cal significance was set at p < .01 for all ANOVAs and
correlations.
Analysis of Variance Between Groups Without
Controlling for PTSD/VMI
ANOVAs were conducted to examine the differences
between maltreatment groups on executive functioning,
language, anxiety, and depression measures. The ANOVA
identified a statistically significant difference between
maltreatment groups on the executive function composite,
F(1, 119) = 16.31, p = .000, cognitive flexibility/set shifting,
F(1, 119) = 15.26, p = .000, problem solving/planning, F(1,
114) = 12.7, p = .001, CDI Mood, F(1, 113) = 7.08, p = .009,
CDI Anhedonia, F(1, 113) = 7.66, p = .007, RCMAS Total,
F(1, 107) = 7.28, p = .008, and RCMAS Physiological Anxiety,
F(1, 105) = 7.61, p = .007. No differences were observed in
the following domains: working memory/simple atten-
tion, response inhibition/interference control, fluency,
language, CDI Total, or RCMAS/CDI subdomains. The
results are provided in Table 2.
Analysis of Variance Between Groups When
Controlling for VMI (IQ Proxy)
ANCOVAs were conducted to examine the differ-
ences between maltreatment groups on executive func-
tioning, language, anxiety, and depression measures
while identifying Beery VMI (IQ proxy) as a covariate.
The ANCOVA identified a statistically significant dif-
ference between maltreatment groups on the executive
function composite, F(1, 112) = 10.24, p = .002, cogni-
tive flexibility/set shifting, F(1, 112) = 10.98, p = .001,
problem solving/planning, F(1, 108) = 11.16, p = .001,
CDI Total, F(1, 108) = 7.48, p = .007, and CDI Mood,
F(1, 107) = 7.12, p = .009. No differences were observed
in the following domains: working memory/simple atten-
tion, response inhibition/interference control, fluency,
language, and the RCMAS. The results are provided in
Table 2.
Analysis of Variance Between Groups When
Controlling for PTSD
ANCOVAs were conducted to examine the differences
between maltreatment groups on executive functioning,
language, anxiety, and depression measures while identi-
fying PTSD diagnosis as a covariate. The ANCOVA
identified no statistically significant difference between
maltreatment groups on any executive-functioning, lan-
guage, anxiety, or depression measures/domains. The results
are provided in Table 2.
Correlation Analysis
Pearson and Point biserial correlations between the
neuropsychological measures and the type of maltreat-
ment experienced are shown in Table 3. Results indicate
that a history of physical abuse was negatively correlated
with the executive-functioning composite, cognitive flex-
ibility/set shifting, and problem solving/planning, and
was positively correlated with the RCMAS. A history of
sexual abuse was negatively correlated with the executive-
functioning composite, cognitive flexibility/set shifting,
problem solving/planning, and language (primarily the
PPVT). A history of emotional abuse was negatively cor-
related with working memory/simple attention and posi-
tively correlated with the CDI. A history of neglect was
not correlated with any neuropsychological measures.
PTSD diagnosis was negatively correlated with the execu-
tive-functioning composite, cognitive flexibility/set shift-
ing, working memory/simple attention, problem solving/
planning, and language (primarily Boston). In addition,
age was negatively correlated with problem solving/plan-
ning, while sex (male = 1; female = 2) was negatively cor-
related with both self-report psychological measures
(CDI and RCMAS).
 NEUROPSYCHOLOGICAL PROFILE OF MALTREATMENT    15

TABLE 2
Analyses of Variance on Maltreatment and Executive-Functioning/Language Domains

Not Controlling for Controlling for VMI Controlling for

PTSD/VMI (IQ Proxy) PTSD
Maltreatment No Maltreatment
Domain Composites (n = 49) M (SD) (n = 73) M (SD) F Sig. F Sig. F Sig.

EF Composite 40.69 (8.96) 46.19 (6.04) 16.31 .000** 10.24 .002* 5.59 .020
CF/SS 39.96 (14.18) 48.82 (10.74) 15.26 .000** 10.98 .001* 6.02 .016
WM/SA 40.00 (11.53) 44.64 (10.21) 5.4 .022 2.25 .137 1.57 .213
RI/IC 49.05 (8.87) 46.80 (8.40) 1.78 .185 2.57 .112 2.64 .107
PS/P 36.68 (14.51) 44.85 (10.14) 12.70 .001* 11.16 .001* 2.54 .114
Fluency 42.67 (10.28) 46.87 (9.34) 4.95 .028 1.05 .308 1.61 .207
Language 37.43 (15.33) 44.25 (13.01) 6.44 .013 2.22 .139 1.90 .171
Boston 34.60 (18.17) 41.27 (17.14) 3.42 .067 0.458 .501 0.286 .594
PPVT-III 40.39 (13.72) 45.96 (12.08) 4.34 .040 2.17 .145 2.64 .108
CDI Total 62.17 (14.85) 55.07 (13.90) 6.94 .010 7.48 .007* 3.47 .065
CDI Mood 60.29 (14.46) 53.03 (14.17) 7.08 .009* 7.12 .009* 3.03 .084
CDI Inter. 61.04 (15.56) 55.91 (13.32) 3.56 .062 4.42 .038 2.76 .100
CDI Ineffective 60.42 (12.06) 56.49 (13.67) 2.49 .118 3.44 .066 2.80 .097
CDI Anhed. 57.96 (12.23) 52.07 (10.37) 7.66 .007* 6.75 .011 3.73 .056
Downloaded by [Wayne State University] at 08:25 09 April 2015

CDI S-E 56.36 (14.96) 52.09 (12.55) 2.72 .102 3.49 .065 1.09 .299
RCMAS Total 58.00 (11.99) 52.03 (10.81) 7.28 .008* 4.47 .037 3.67 .058
RCMAS Phys. 57.41 (11.17) 51.50 (10.54) 7.61 .007* 4.28 .041 3.35 .070
RCMAS Worry 54.20 (10.44) 48.86 (11.07) 6.12 .015 4.28 .041 4.19 .043
RCMAS Social 55.73 (10.55) 51.27 (9.94) 4.86 .030 3.43 .067 2.34 .129

EF Composite = executive-functioning composite score; CF/SS = cognitive flexibility/set shifting; WM/SA = working memory/simple attention; RI/
IC = response inhibition/interference control; PS/P = problem solving/planning; Language = language composite score; Boston = Boston Naming Test
(expressive language); PPVT-III = Peabody Picture Vocabulary Test-Third Edition (receptive language); CDI Total = Childhood Depression Inventory
Total score; CDI Mood = CDI Negative Mood; CDI Inter. = CDI Interpersonal Problems; CDI Ineffective = CDI Ineffectiveness; CDI Anhed. = CDI
Anhedonia; CDI S-E = CDI Self-Esteem; RCMAS Total = Revised Children’s Manifest Anxiety Scale Total score; RCMAS Phys. = RCMAS
Physiological Anxiety; RCMAS Social = RCMAS Social Anxiety.
*p < .01. **p < .001.

DISCUSSION dysfunction in childhood maltreatment (Beers & De

This study examined the neuropsychological presentation
of adolescent inpatients with a history of childhood
maltreatment. Results from the study indicated that
compared with adolescent inpatients without maltreat-
ment history, adolescents with a history of childhood
maltreatment scored significantly lower on measures of
executive functioning, as well as significantly higher on
self-reported measures of anxiety and depression. The
majority of these findings remained significant when
controlling for the influence of intelligence (Beery VMI
served as IQ proxy). However, no significant group dif-
ferences remained after controlling for the influence of
PTSD diagnosis, suggesting that PTSD diagnosis may
be a large factor in the neuropsychological presenta-
tion of childhood maltreatment. In addition, specific
types of maltreatment were associated with unique
neuropsychological profiles.
The findings of this study identified the lower perfor-
mance on measures of executive functioning in a group of
adolescent inpatients with a history of maltreatment. The
current findings suggest that childhood maltreatment is
associated with executive dysfunction in adolescent
inpatients, consistent with previous studies on executive
Bellis, 2002; De Bellis et al., 2009; DePrince et al., 2009;
Fishbein et al., 2009; Hedges & Woon, 2011; Nolin &
Ethier, 2007; Spann et al., 2012). Additionally, specific
subdomains of executive functioning appear to be partic-
ularly implicated in childhood maltreatment, including
cognitive flexibility/set shifting, problem solving/plan-
ning, and working memory/simple attention. Alternatively,
maltreated adolescents did not differ from nonmaltreated
adolescents in the executive subdomains of response inhi-
bition/interference control and fluency. These differing
results highlight the importance of viewing “executive
functioning” as a heterogeneous domain (Baron, 2010),
with certain subdomains potentially more sensitive to the
neurobiological effects of childhood maltreatment than
other subdomains. In addition, general language perfor-
mance was not significantly lower in the maltreated
adolescents, suggesting that language may be relatively
more resilient toward childhood maltreatment. The
lack of observed language impairments in maltreated
­adolescent inpatients is in contrast with previous studies,
which have shown childhood maltreatment to be associ-
ated with language impairments (De Bellis et al., 2009).
However, these findings are consistent with the work of
Beers and De Bellis (2002), who found executive deficits,
 16    KAVANAUGH, HOLLER, & SELKE

TABLE 3
Correlations Between Psychological/Executive Measures and Type of Abuse Experienced

Sex Age Physical Sexual Emotional Neglect PTSD

Sex — –.018 (p = .84) –.076 (p = .40) –.177 (p = .05) –.025 (p = .79) .130 (p = .15) –.122 (p = .179)
Age –.018 (p = .84) — .116 (p = .20) .123 (p = .18) –.011 (p = .91) .032 (p = .73) .063 (p = .489)
EF –.047 (p = .61) –.148 (p = .11) –.238* (p = .009) –.284* (p = .002) –.179 (p = .049) –.146 (p = .109) –.418* (p = .000)
CF/SS –.053 (p = .56) –.157 (p = .086) –.244* (p = .007) –.250* (p = .006) –.112 (p = .22) –.146 (p = .109) –.367* (p = .000)
WM/SA –.105 (p = .25) –.049 (p = .59) –.153 (p = .094) –.172 (p = .059) –.269* (p = .003) –.021 (p = .815) –.263* (p = .004)
RI/IC –.068 (p = .476) .170 (p = .075) .118 (p = .217) .005 (p = .960) .020 (p = .834) .066 (p = .491) –.034 (p = .722)
PS/P –.023 (p = .084) –.239* (p = .010) –.253* (p = .006) –.292* (p = .001) .046 (p = .622) –.189 (p = .042) –.455* (p = .000)
Fluency .014 (p = .881) –.125 (p = .190) –.161 (p = .091) –.160 (p = .093) –.164 (p = .083) –.093 (p = .329) –.232 (p = .014)
Language .218 (p = .020) –.061 (p = .523) –.037 (p = .701) –.368* (p = .000) .035 (p = .712) –.167 (p = .076) –.298* (p = .001)
Boston .312* (p = .001) –.025 (p = .802) –.043 (p = .67) –.254 (p = .010) .012 (p = .905) –.165 (p = .099) –.329* (p = .001)
PPVT-III .059 (p = .568) –.06 (p = .564) –.07 (p = .498) –.287* (p = .005) .056 (p = .591) –.118 (p = .25) –.154 (p = .135)
CDI –.40* (p = .000) .016 (p = .86) .215 (p = .02) .119 (p = .20) .273* (p = .003) –.125 (p = .18) .215 (p = .02)
RCMAS –.285* (p = .003) .035 (p = .72) .261* (p = .006) .108 (p = .263) .180 (p = .061) –.099 (p = .308) .235 (p = .014)

EF = executive functioning; CF/SS = cognitive flexibility/set shifting; WM/SA = working memory/simple attention; RI/IC = response inhibition/
interference control; PS/P = problem solving/planning; Language = language composite score; Boston = Boston Naming Test (expressive language);
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PPVT-III = Peabody Picture Vocabulary Test-Third Edition (receptive language); CDI = Childhood Depression Inventory; RCMAS = Revised
Children’s Manifest Anxiety Scale.
*p < .01.

but no language deficits, in a group of maltreated
children.
The present study also found childhood maltreatment
to be associated with elevated symptoms of self-reported
anxiety and depression, notably in symptoms of negative
mood and physiological anxiety. These findings are in line
with previous research, which has identified internalizing,
externalizing, and general psychopathological symptoms
to be associated with maltreatment in adolescent inpa-
tients (Boxer & Terranova, 2008; Grilo et al., 1999; Sullivan
et al., 2006). Further, previous research has noted that the
adolescent inpatient population is a highly victimized
group, with the experience of maltreatment potentially
serving as a risk factor for psychiatric hospitalization
(Boxer & Terranova, 2008; Fehon et al., 2001; Sullivan
et al., 2006). Research has suggested that the experience of
maltreatment may limit one’s ability to develop appropri-
ate coping abilities, putting one at risk for heightened dis-
tress from posttrauma stressors (Kearney et al., 2010;
Kendall-Tackett, 2000). Therefore, these individuals may
continue to experience impairments well after the mal-
treatment has ended, and this prolonged impairment may
potentially contribute to a psychiatric hospitalization. Our
research is consistent with past research, with 40% of our
sample having experienced some form of maltreatment.
Although neuropsychological differences were noted
between the maltreatment and no-maltreatment groups,
these differences did not remain after statistically con-
trolling for PTSD. This suggests that although as a
group maltreated participants displayed a unique neu-
ropsychological presentation, the diagnosis of PTSD
appeared to be associated with significant differences in
neuropsychological functioning. This was supported in
the correlational analyses, which showed PTSD to be
negatively correlated with executive and language mea-
sures. The potential difference between maltreated ado-
lescents with PTSD and those adolescents without PTSD
is in contrast to the research of De Bellis and colleagues
(2009), who found only minimal differences (i.e., one task
of visual memory) between those neglected children with
PTSD and those neglected children without PTSD.
The neuropsychological presentation of specific
types of maltreatment was also examined. Results of
this analysis revealed notable differences in neuropsy-
chological presentation between four types of childhood
maltreatment. For example, although physical abuse
and sexual abuse were both negatively correlated with
cognitive flexibility/set shifting and problem solving/
planning, sexual abuse was additionally correlated with
language, while physical abuse was positively correlated
with self-reported anxiety symptoms. In addition, emo-
tional abuse was negatively correlated with working
memory/simple attention and positively correlated with
self-reported depressive symptoms. Alternatively, neglect
was not correlated with any neuropsychological mea-
sures. Although a clear explanation for these differences
cannot be determined, it is possible that direct threat to
bodily harm, such as in sexual and physical abuse, may
cause more dysregulated neurobiological response and
subsequently more severe neurocognitive dysregulation
and physiological arousal (i.e., anxiety symptoms). Abuse
that may threaten emotional but not bodily harm, such
as emotional abuse, may affect psychological domains
more than neurocognitive domains, resulting in more
depressive symptoms than other forms of abuse. Further,
neglect may negatively affect more global areas of devel-
opment, such as intelligence and academic skills, rather
than specific neurocognitive domains. Taken together, it
 NEUROPSYCHOLOGICAL PROFILE OF MALTREATMENT    17
appears that specific types of childhood maltreatment
may be associated with specific neurocognitive impair-
ments across domains of executive functioning, lan-
guage, and psychopathology. Future research should
continue to examine the distinct profiles of abuse types
to provide more clarity regarding these findings.
Despite these important findings, there are several limi-
tations to the current study. The primary limitation to this
study is the reliance on retrospective record review.
Researchers did not have information regarding intelli-
gence, grade level, academic skills, family information,
and other variables that may be important to consider in
childhood maltreatment. Most notably, a core intelligence
(IQ) test was predominantly not administered within the
inpatient setting during this time period. Clearly, not
having objective data on patient IQ severely limits our
findings, as we are unable to control for the influence of
IQ on other neurocognitive domains or place our findings
Downloaded by [Wayne State University] at 08:25 09 April 2015
within the context of overall intelligence. We attempted to
mitigate the limitations of not having a measure of IQ by
using the Beery VMI as an intelligence proxy. We under-
stand this limitation to our study, although we do consider
the information gathered to be an adequate neuropsycho-
logical evaluation of childhood maltreatment.
Further, information gathered on maltreatment history
was taken directly from the patient records and therefore
was dependent on the examination of maltreatment by
the assigned clinician. Future studies would benefit from
more specific information on the type and severity of mal-
treatment to more closely examine the associations
between neurocognitive and psychopathological impair-
ment and childhood maltreatment. Although impairments
were associated with maltreatment, the direction of the
association was unable to be determined and therefore
findings cannot be considered a causal direction between
maltreatment and impairments. It is possible that those
participants with a history of maltreatment possessed
neurocognitive and psychopathological impairments prior
to or independent of maltreatment. Future studies could
benefit from longitudinal methodology, allowing for exami-
nation of abilities prior to and following a high-stress
series of events such as maltreatment.
Another limitation to this study is the limited data on
PTSD. Research has begun to examine the neurocogni-
tive and psychopathological differences between those
children and adolescent victims of maltreatment who
develop PTSD and those who do not develop PTSD
(Beers & De Bellis, 2002; De Bellis et al., 2009; De Bellis,
Hooper, Woolley, & Shenk, 2010; Sullivan et al., 2006).
While identification of the neuropsychological profile of
childhood PTSD is critical, the present study examined
childhood maltreatment in a broader context than PTSD.
Further, our sample of PTSD due to maltreatment was
too small (n = 12) to conduct additional analyses on the
role of PTSD. Although we understand this limitation,
the objective of this study was to examine childhood mal-
treatment across diagnoses, not solely restricted to those
individuals with PTSD.
In conclusion, results from the current study revealed
that within an adolescent inpatient setting, childhood
maltreatment is associated with neurocognitive and psy-
chopathological impairments, specifically in executive
function and self-reported anxious and depressive
symptoms. The presence of PTSD appeared to have a
significant influence on the neuropsychological profile
of the adolescents. Various types of maltreatment were
associated with differing neuropsychological profiles.
Specifically, sexual and physical abuse were associated
with decreased executive functions, while sexual abuse
was uniquely associated with decreased language and
physical abuse was associated with increased symptoms
of anxiety. Further, emotional abuse was associated
with decreased executive function and increased symp-
toms of depression, while neglect was not associated
with any neurocognitive or psychological domains.
These findings have important implications for the
treatment of childhood maltreatment, as well as for
future research examining the underlying neuropsycho-
logical presentation of childhood maltreatment.
ACKNOWLEDGEMENTS
We would like to thank George Tremblay at Antioch
University New England for his statistical guidance and
the entire neuropsychology team at Butler Hospital.
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