Journal of Traumatic Stress, Vol. 20, No. 5, October 2007, pp.

677–687 (

C 2007)

Acute Child and Mother Psychophysiological

Responses and Subsequent PTSD Symptoms
Following a Child’s Traumatic Event
Sarah A. Ostrowski
Department of Psychology, Kent State University, Kent, OH

Norman C. Christopher
Emergency/Trauma Services, Akron Children’s Hospital, Akron, OH, and Department of
Emergency Medicine and Pediatrics, Northeastern Ohio Universities College of Medicine
(NEOUCOM), Rootstown, OH

Manfred H.M. van Dulmen

Department of Psychology, Kent State University, Kent, OH

Douglas L. Delahanty
Department of Psychology, Kent State University, Kent, OH, and Department of Psychology in
Psychiatry, Northeastern Ohio Universities College of Medicine (NEOUCOM), Rootstown, OH

This study examined the relationship between acute cortisol responses to trauma and subsequent PTSD
symptoms (PTSS) in children and their biological mothers. Urinary cortisol levels were assessed in 54
children aged 8–18 upon admission to a level-1 trauma center. Six weeks posttrauma, 15-hour urine
samples were collected from children and their mothers. Depression and PTSS were assessed at 6 weeks
(N = 44) and 7 months (N = 38) posttrauma. Higher child in-hospital cortisol significantly predicted
6-week child PTSS. This was true only for boys at 7 months. In mothers, lower 6-week cortisol levels
significantly predicted 7-month PTSS. Results extend findings of differing directions of acute hormonal
predictors of PTSS in adults versus children to a sample of genetically related individuals.

Research examining early hormonal predictors of post-
traumatic stress disorder (PTSD) has suggested that in-
dividuals who subsequently develop PTSD symptoms
(PTSS) may differ in initial biological responses to a trauma
from trauma victims who do not develop these symptoms.
However, adults and children appear to differ in the direc-
tion of the relationship between initial biological responses
(especially cortisol responses) and subsequent PTSS. As re-
viewed below, lower cortisol levels soon after a trauma have
been associated with increased risk for diagnostic levels of
PTSD and higher PTSS in adults, whereas higher urinary
cortisol levels soon after trauma have been associated with
increased risk for PTSS in child trauma victims. For the
most part, research into the biology of PTSS in adults and

Preparation of this manuscript was supported, in part, by National Institutes of Mental Health grants (R34 MH 71201 and R34 73014). Funding for this study was provided by a grant
from the Ohio Board of Regents.
Correspondence concerning this article should be addressed to: Douglas L. Delahanty, Department of Psychology, 118 Kent Hall, Kent State University, Kent, OH 44242. E-mail:
ddelahan@kent.edu.


C 2007 International Society for Traumatic Stress Studies. Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/jts.20286

677
678
children has been conducted separately; and the extent to
which early psychophysiological responses to a trauma are
associated with PTSS in biologically related victims has yet
to be examined. The present study replicates and extends
prior findings by examining early hormonal predictors of
PTSS in child trauma victims and their biological mothers
following pediatric injury.
BIOLOGY OF POSTTRAUMATIC STRESS
DISORDER
Early studies of hypothalamic–pituitary–adrenal (HPA)
axis alterations in PTSD found that adults with chronic
PTSD had lower 24-hour urinary cortisol levels than sim-
ilarly traumatized individuals without PTSD and normal
controls (Mason, Giller, Kosten, Ostroff, & Podd, 1986;
Yehuda et al., 1990; Yehuda, Boisoneau, Mason, & Giller,
1993; Yehuda, Boisoneau, Lowy, & Giller, 1995). How-
ever, recently, results have been mixed, with some studies
finding higher 24-hour urinary cortisol levels in PTSD
(Lemieux & Coe, 1995; Maes et al., 1998; Pitman & Orr,
1990), and others finding no relationship between corti-
sol levels and PTSD (Baker, O’Neil, Haddon, & Long,
1999; Mason et al., 2002). A number of possible explana-
tions for these mixed findings have been posited including
failure to control for pharmacological agents, failure to
consider comorbidity, differences in samples (e.g., outpa-
tient versus inpatient), age and gender differences, and fail-
ure to account for prior trauma experiences (Rasmusson,
Vythilingam, & Morgan, 2003). Adults with a prior trauma
history have been found to have lower plasma cortisol levels
following a subsequent trauma (Resnick, Yehuda, Pittman,
& Foy, 1995; Yehuda, Resnick, Schmeidler, Yang, & Pit-
man, 1998), and cortisol levels have been found to mediate
the relationship between trauma history and PTSS (Dela-
hanty, Raimonde, Spoonster, & Cullado, 2002).
In contrast to findings in chronic PTSD patients, re-
search examining early hormonal predictors of PTSS in
adults has produced results that are more consistent. Re-
sults suggest that lower levels of cortisol within hours or
days of a traumatic event in adults are associated with
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Ostrowski et al.
greater risk for developing subsequent PTSS (Delahanty
et al., 2000; McFarlane, Atkinson, & Yehuda, 1997;
Resnick et al., 1995).
Similar to research findings in adults, studies examining
hormone levels in children with chronic PTSD have pro-
duced mixed results, with some studies finding higher levels
of cortisol in children with PTSD (DeBellis et al., 1999)
and others finding lower cortisol levels (Goenjian, Yehuda,
& Pynoos, 1996; King, Mandansky, King, Fletcher, &
Brewer, 2001). Again, a number of variables may account
for these discrepant findings including amount of time
passed since the trauma, manner in which PTSD was as-
sessed, and method of cortisol assessment (e.g., urine vs.
saliva). We have previously examined initial hormonal pre-
dictors of PTSS in child trauma victims and found results
directly opposite to our findings in adults; children subse-
quently reporting more PTSS had higher in-hospital uri-
nary cortisol levels. However, this relationship appeared to
be driven by a significant relationship in boys; in girls, cor-
tisol levels were not related to PTSS (Delahanty, Nugent,
Christopher, & Walsh, 2005). Similarly, whereas initial low
cortisol levels appear to mediate the relationship between
prior trauma history and PTSS in adults (Delahanty et al.,
2003), in children, those with a trauma history tend to look
more like our adult participants. That is, children with a
trauma history tended to report more PTSS and have lower
initial cortisol levels, whereas in children with no such his-
tory, initial cortisol levels were positively associated with
subsequent PTSS (Delahanty & Nugent, 2006).
In sum, prior research suggests that the direction of
the relationship between early urinary cortisol responses
and subsequent PTSS may differ between adult and child
trauma victims. However, relatively few studies have been
conducted in children, and research has yet to demonstrate
these contradictory findings in genetically related adults
and children. The present study examined the extent to
which the relationship between initial hormonal responses
to a trauma and subsequent PTSS differed between pedi-
atric trauma victims and their biological mothers. Specifi-
cally, urinary cortisol levels were assessed soon after trauma
and 6 weeks posttrauma in child trauma victims. Maternal
urinary cortisol levels were assessed 6 weeks posttrauma.
 Acute Child and Mother Psychophysiological Responses
Symptoms of posttraumatic distress were measured both
at 6 weeks and 7 months posttrauma. Based on our prior
findings, we hypothesized that elevated in-hospital urinary
cortisol levels would significantly predict child PTSS at
follow-up, particularly in boys. Conversely, lower levels of
6-week maternal cortisol were hypothesized to predict 7-
month maternal PTSS. Furthermore, given prior findings
concerning the impact of prior trauma history, we hy-
pothesized that the relationship between child in-hospital
cortisol and subsequent PTSS would be stronger in those
children without a prior trauma history.
METHOD
Participants
Of 65 families approached, 61 agreed to participate (94%
acceptance rate). Due to the impact of asthma medications
on urinary cortisol levels, children with asthma were ex-
cluded. After excluding those children with asthma (n = 7),
the total sample consisted of 54 children and their biologi-
cal mothers. Demographic data for the final sample are pre-
sented in Table 1. The children in the sample experienced
a variety of traumatic events such as vehicular accidents
(n = 30), falls (n = 11), sports related injuries (n = 10),
and burns (n = 3). Eighty-three percent (n = 45) of the
original sample was retained at the 6-week follow-up with
70% (n = 38) returning for the 7-month time point. No
differences were found in terms of demographics, PTSS,
depression, and cortisol levels at any time points between
mothers and children who did and did not complete the
follow-ups (all ps > .10).
Measures
Biological measures. Urinary free cortisol levels were as-
sessed via fluorescent polarization immunoassay (Abbott
TDx Diagnostics; Abbott Laboratories, Abbott Park, IL).
Hormonal levels were calculated as amount per 12-hour
(in-hospital) or 15-hour (6-week follow-up) sample (mi-
crogram (µg)/hour).
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
679
Posttraumatic stress disorder. Mothers were adminis-
tered the Clinician Administered PTSD Scale (CAPS;
Blake et al., 1995) to assess the presence of PTSD symp-
toms stemming from their child’s traumatic injury. The
CAPS is a structured interview that provides both a con-
tinuous and categorical measure of PTSD (Blake et al.,
1995). Diagnostic levels of PTSD were met if at least
one reexperiencing symptom (Criterion B), three avoid-
ance symptoms (Criterion C), and two arousal symptoms
(Criterion D) were present. Participants were labeled as
meeting subthreshold criteria if the participant endorsed
at least one symptom out of each symptom cluster (Stein,
Walker, Hazen, & Forde, 1997). Given the low prevalence
of diagnostic levels of PTSD in the mothers, the majority
of our analyses were performed on a continuous measure of
PTSS. The CAPS demonstrates good psychometric prop-
erties with high interrater reliability estimates of .92–.99
and good internal consistency and convergent validity esti-
mates (Weathers, Keane, & Davidson, 2001). Cronbach’s
alpha for the present study was .91.
Child PTSD was measured with the Clinician-
Administered PTSD Scale for Children and Adolescents
(CAPS-CA; Nader et al., 1996). The CAPS-CA is con-
ceptually and methodologically related to the CAPS, but
differs by its developmentally appropriate language (Nader
et al., 2002). Diagnostic and subthreshold levels of PTSD
were computed in the same manner as for the CAPS. Given
the low prevalence of PTSD in the children, the majority of
analyses were conducted on continuous measures of PTSD.
The CAPS-CA has been found to have adequate internal
consistency and concurrent validity estimates (Nader et al.,
1996). Cronbach’s alpha for the CAPS-CA was .90. Both
the CAPS and CAPS-CA were also used to assess presence
of prior trauma history in adults and children, respectively.
As part of the interview, participants were asked if they
had experienced a traumatic event in which they felt that
their life or the life of someone else was in danger and
experienced intense feelings of fear, horror, or helplessness
in addition to the index trauma.
Depression. The Children’s Depression Inventory (CDI;
Kovacs, 1992) was used to measure child depression
680 Ostrowski et al.

Table 1. Demographics and Descriptive Analyses of Final Sample

Total sample Boys Girls
(N = 54) (n = 30) (n = 24)
M SD M SD M SD
Children
Age 13.35 2.99 13.61 2.71 13.03 3.34
ISS score 10.08 8.39 10.32 8.15 9.78 8.86
6-week PTSS 21.40 15.43 16.58 10.35 26.17 29.11
6-week depression 8.60 6.99 9.22 8.03 7.90 5.68
7-month PTSS 12.42 11.91 9.89 8.37 15.59 14.87
7-month depression 5.73 8.36 5.57 9.12 5.94 7.53
In-hospital cortisol (µg/hr) 448.22 571.90 334.51 403.31 622.13 742.47
6-week cortisol (µg/h) 65.09 187.61 26.17 29.11 113.16 275.48
Mothers
Family income $30,000– 40,000/year
6-week PTSS 20.23 13.97
6 -week depression 14.23 10.94
7-month PTSS 15.11 15.88
7- month depression 16.53 11.44
6- week cortisol (µg/h) 129.91 290.43
Note. PTSS = Posttraumatic stress disorder symptoms.

symptoms. The CDI covers the Diagnostic and Statisti- Procedure

cal Manual of Mental Disorders, Fourth Edition (DSM-IV ;
American Psychiatric Association, 1994) criteria for major
depressive syndrome in children and provides a continuous
measure of symptom severity. Research suggests adequate
psychometric properties for the CDI with internal con-
sistency ranging from .71–.89 (Kovacs, 1992). Cronbach’s
alpha for the present study was .86.
Parental depression was measured with the Center
of Epidemiological Studies–Depression Scale (CES-D;
Radloff, 1977). The CES-D is a 20-item self-report mea-
sure of depressive symptoms. This measure has good inter-
nal consistency (r = .85–.90) and good concurrent validity
(Radloff, 1977). Cronbach’s alpha for the present study was
.93.
Injury severity. Child injury severity was assessed with
the Injury Severity Scale (ISS; Baker et al., 1974). ISS
scores were collected through trauma registry review of
patients’ charts and were computed from objective injury
data. Average ISS scores for the present study were 10.58
(SD = 8.39).
The human subjects review boards of Akron Children’s
Hospital and Kent State University approved the following
procedures. Consecutive child trauma victims aged 8–18
and their biological mothers were recruited from the emer-
gency department (ED) from May 2003 to May 2004.
All children were admitted to the hospital as trauma pa-
tients (average length of stay = 2.65 days; range = 0–19
days) and were recruited in-hospital by either the chief res-
ident or trauma nurse. Biological mother–child dyads were
recruited for a number of reasons. One was simply conve-
nience as mothers represented the parent most likely to be
with the child in the ED (>75% of the time the mother
was the sole parent present). In addition, prior research
has demonstrated that mother and child distress scores are
more highly correlated than father and child self-report
scores (Stuber, Christakis, Houskamp, & Kazak, 1996)
and that mothers typically report greater levels of distress
than fathers following a child’s trauma (Landolt, Vollrath,
Ribi, Gnehm, & Sennhauser, 2003). Additionally, biologi-
cal (as opposed to nonbiological) mothers were recruited to

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
 Acute Child and Mother Psychophysiological Responses
increase the genetic similarity of the sample. Seven mothers
were direct victims of the child’s trauma (e.g., in the car
during the motor vehicle accident); however, these moth-
ers did not require medical attention for injuries sustained
during the trauma. There were no differences in terms of
demographics, PTSS, depression, or cortisol levels between
women who were direct victims of the trauma and those
who were not (all ps > .10). Children with Glasgow Coma
Scale (GCS) scores ≤13 were excluded.
According to hospital protocol, patients are catheter-
ized immediately following their admission to allow for
the collection of urine for various medical assessments.
All urine collected during the first 12 hours after admis-
sion was aliquoted and frozen until cortisol assays were
conducted. Although 24-hour samples would allow exam-
ination of hormone levels across the diurnal rhythm (Baum
& Grunberg, 1995), catheters are typically removed after
12 hours to decrease discomfort for the child. Urine of
patients who declined to participate was discarded upon
refusal; urine of individuals who consented was assayed
for levels of free cortisol. Time of urine collection initia-
tion was not significantly related to cortisol levels (r = .20,
p = .24). Furthermore, medications, foods, and drinks that
the child ingested the day of the trauma were not signifi-
cantly related to cortisol levels (all ps > .31). There were
no systematic differences in cortisol levels associated with
type of trauma or injuries. Given maternal acute distress
and preoccupation with the child’s welfare, we did not col-
lect maternal urine at the time of the child’s admission to
the hospital.
Six weeks and 7 months following the child’s trauma,
mother and child PTSS and depression were assessed.
At each time point, a master’s-level clinical psychology
student administered the Clinician-Administered PTSD
Scale for Children and Adolescents to the child and
the Clinician-Administered PTSD Scale to the mother
with the child’s trauma as the targeted index event.
Mothers and children were separated for the inter-
views. Children (Child Depression Inventory; CDI) and
mothers (Center for Epidemiological Studies–Depression;
CES-D) also completed a self-report measure of
depression.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
681
At the 6-week follow-up, both mothers and children
were instructed to collect all urine voided from 6 p.m. until
9 a.m. the following morning in a polypropylene container
provided by the interviewer. Again, although 24-hour urine
collections would allow for the assessment of urinary hor-
mone levels across the circadian rhythm, collection from
the children was problematic during school days, and to
minimize confusion, mothers and children were instructed
to collect urine over the same time frame. The influence of
circadian forces was minimized by standardizing the timing
of the urine sampling (Baum & Grunberg, 1995). Medica-
tions, substance (alcohol) use, foods and drinks, maternal
menstrual cycle phase, and behaviors that may influence
cortisol were not significantly related to mother or child
cortisol levels (all ps >.26). All urine collections were stored
in participants’ freezers and aliquots were frozen at −80◦ C
until cortisol assays were conducted.
Data Analysis
Pearson product-moment correlations were conducted to
determine potential covariates and initial associations be-
tween cortisol, PTSS, and depressive symptoms. Subse-
quent hierarchical linear regressions examined whether ini-
tial child cortisol levels predicted 6-week and 7-month
PTSS, and tested the main and interaction effects of child
gender. Additional hierarchical linear regressions were con-
ducted to test whether 6-week maternal and/or child uri-
nary cortisol levels predicted 7-month PTSS in the mother
and/or child. Few children reported a history of prior trau-
matic events (n = 7), so rather than include prior trauma
history in the model, analyses were run both with and
without these children. Twenty-four mothers reported a
trauma history; therefore, prior trauma was included in
the maternal model. Further, because PTSD and depres-
sion are highly comorbid, and concurrent assessments of
PTSD and depression are highly correlated, we conducted
all analyses with and without controlling for concurrent
depression. Small discrepancies in samples sizes and de-
grees of freedom for the analyses reflect infrequent missing
data.
682
RESULTS
Demographics
Child age, race, parental education, and ISS were not re-
lated to child PTSS at either follow-up (all ps > .21). Girls
reported significantly higher levels of PTSS than boys at
6 weeks (M = 26.9, SD = 18.5 vs. M = 15.6, SD = 10.4,
respectively), F (1,44) = 5.53, p < .05, but did not signif-
icantly differ from boys at 7 months, F (1, 37) = 2.25,
ns. Family income was negatively correlated with 7-month
child and mother PTSS (child: r = −.48, p < .01; mother:
r = −.43, p < .01). Within-gender analyses also revealed
that, in boys, age was significantly correlated with 7-
month PTSS (r = −.47, p < .05; in girls, r = .08, ns).
As such, age and income were used as covariates in relevant
analyses.
Posttraumatic Stress Symptoms in Mother and Child
Six weeks following the child’s admission, one child and
one mother (not related to each other) met full criteria for
acute PTSD. Thirty-one percent (n = 14) of the children
and 18% (n = 8) of the mothers met subthreshold criteria
for PTSD. At the 7-month follow-up, one child met full
PTSD criteria (not the child who met criteria at the 6-week
assessment), whereas no mothers met full PTSD criteria.
Thirteen percent of the children (n = 5) and 16% (n = 6)
Table 2. Correlations Between Urinary Free Cortisol Response and Posttraumatic Stress Disorder
Symptoms (PTSS)
6-week PTSS
total sample
Cortisol levels N = 45
Child
In-hospital total sample .29
In-hospital boys .23
In-hospital girls .26
Mother
6-week total sample .02
* p < .05.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Ostrowski et al.
of the parents continued to meet subthreshold criteria for
PTSD 7 months posttrauma.
In prior analyses on the present sample (Ostrowski,
Christopher, & Delahanty, 2007), we examined the rela-
tionship between mother and child posttraumatic distress.
Results revealed that 6-week maternal PTSS was related to
6-week child PTSS in boys, but not for girls. However, at 7
months posttrauma, mother and child overall PTSS were
significantly correlated for both boys and girls. Further-
more, we found that child and maternal 6-week avoidance
interacted such that persistent PTSS was associated with
high child avoidance symptoms, but low maternal avoid-
ance at 6 weeks. However, this was significant only in girls.
Child Cortisol Response and Child PTSD Symptoms
Pearson product moment correlations between the vari-
ables of interest are presented in Table 2. Hierarchical linear
regression analyses were conducted to examine the extent
to which in-hospital cortisol levels predicted 6-week child
PTSS. Gender was entered on the first step, in-hospital
cortisol levels were entered on the second step, and the
interaction of gender and cortisol was entered on the third
step. Results revealed no significant main effects or inter-
actions. However, upon excluding children with a prior
trauma history (n = 7), identical analyses produced signif-
icant main effects for both gender and cortisol (
R 2 = .12,
p < .05,
R 2 = .12, p < .05, respectively, see Table 3).
Being female and having higher cortisol levels were
6-week PTSS 7-month PTSS 7-month PTSS
excluding prior trauma total sample excluding prior trauma
N = 38 N = 38 N = 33
.41* .06 .16
.50* .04 .36
.31 .12 .04
−.29 −.20 −.27
 Acute Child and Mother Psychophysiological Responses
Table 3. Summary of Hierarchical Regression Analy-
sis for Variables Predicting 6-Week Child Posttraumatic
Stress Disorder Symptoms (PTSS)
Step Variables B SE B β
R 2
1 Gender 7.91 3.89 .35 .12*
2 In-hospital cortisol levels 0.01 0.00 .36 .12*
3 Gender × cortisol −0.01 0.01 −.21 .01
Note. Significance of regression model, F (3,31) = 3.16, p < .05.
* p < .05.
associated with greater PTSS. Similar analyses controlling
for concurrent (6-week) depression produced a significant
main effect of gender (
R 2 = .12, p < .05), but the pre-
viously significant cortisol main effect was decreased to
marginal (
R 2 = .09, p = .07).
Although a nonsignificant interaction was found be-
tween child gender and in-hospital cortisol, to parallel our
prior findings (Delahanty et al., 2005), we conducted addi-
tional analyses in boys and girls separately. Whether or not
depression was included in the model, within-gender anal-
yses revealed nonsignificant findings for both boys and girls
separately (all ps > .20). However, after excluding children
with prior trauma histories, cortisol significantly predicted
6-week PTSS in boys (
R 2 = .25, p < .05). Once again,
upon controlling for concurrent depression, this finding
was reduced to the level of a trend (
R 2 = .23, p ≤ .06).
Additional hierarchical linear regression analyses were
conducted to examine the extent to which child in-hospital
urinary cortisol levels predicted 7-month child PTSS. Fam-
ily income and age were entered into the first step followed
by child gender in the second step, in-hospital cortisol lev-
els in the third step, and the interaction of gender and in-
hospital urinary cortisol in the final step. Results revealed
no significant main effects or interaction, and within gen-
der analyses revealed nonsignificant findings in boys and
girls (all ps >.15). Results remained nonsignificant after
controlling for concurrent depression (all ps >.44). After
excluding those children who reported a prior trauma his-
tory (n = 5), identical regressions revealed that in-hospital
cortisol responses did not significantly predict 7-month
child PTSS in boys or girls (all ps >.20). However, after
controlling for concurrent depression, in-hospital corti-
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
683
sol levels significantly predicted 7-month PTSS in boys
(
R 2 = .23, p < .05), but not in girls (
R 2 = .01, ns).
To determine the specificity of the relationship between
cortisol levels and PTSD, additional analyses were con-
ducted examining the extent to which in-hospital corti-
sol levels predicted subsequent depressive symptoms. Re-
sults indicated nonsignificant interactions and main effects
in predicting 6-week and 7-month depression. Further,
within gender analyses revealed that after accounting for
income, child age, and concurrent PTSS, child in-hospital
cortisol levels did not significantly predict 6-week or 7-
month depression in boys or girls separately (all ps >.30).
Similarly, subsequent analyses examining the relation-
ship between 6-week child urinary cortisol levels and 7-
month child PTSS revealed only nonsignificant interac-
tions and main effects and within gender analyses revealed
nonsignificant relationships for boys and girls separately
with and without controlling for depression (all ps > .10).
Maternal 6-Week Urinary Cortisol Levels and Maternal
PTSD Symptoms
Hierarchical linear regression analyses were conducted to
examine the extent to which maternal 6-week cortisol lev-
els significantly predicted 7-month maternal PTSS. Family
income was entered into the first step followed by prior
trauma on the second step, 6-week maternal urinary cor-
tisol levels on the third step, and the interaction of prior
trauma and cortisol levels in the final step. Results revealed
no significant main effects or interactions (all ps >.10).
However, after controlling for concurrent depression, re-
sults revealed a significant main effect of 6-week cortisol
(
R 2 = .09, p < .05). Lower 6-week urinary cortisol levels
were associated with higher PTSS at 7 months.
Paralleling the child analyses, additional hierarchical
linear regression analyses were conducted examining the
extent to which 6-week maternal cortisol predicted 7-
month maternal depression symptoms. Results revealed
that higher levels of maternal 6-week cortisol levels sig-
nificantly predicted greater levels of 7-month maternal
684
depression above and beyond income and concurrent PTSS
(
R 2 = .18, p < .01).
DISCUSSION
The present study examined the relationship between
urinary-free cortisol levels and subsequent PTSS in child
trauma victims and their biological mothers following pe-
diatric injury. Results of the present study replicate and ex-
tend prior findings of differential hormonal alterations in
adults versus children following a traumatic event. Specif-
ically, after excluding children with a trauma history, el-
evated in-hospital cortisol levels in the child were signif-
icantly related to subsequent 6-week PTSS. At 7 months
posttrauma, this relationship remained significant only in
boys. This finding is consistent with our prior work (Dela-
hanty et al., 2005). Conversely, lower maternal 6-week cor-
tisol levels significantly predicted 7-month maternal PTSS.
These findings are similar to those reported in a study of
mothers of child cancer survivors (Glover & Poland, 2002).
Furthermore, child in-hospital cortisol levels significantly
predicted 6-week PTSS, but not depression symptoms; in
mothers, cortisol levels were found to predict both PTSS
and depression symptoms. These findings suggest that risk
afforded by heightened cortisol is relatively specific to PTSS
in children, but that cortisol alterations may reflect a non-
specific predictor of psychopathology in adults.
The results of the current study are particularly notewor-
thy given the genetic similarity between biological mothers
and their offspring. By demonstrating opposite directions
of the relationship between cortisol levels and subsequent
PTSS in mothers and children, the present results question
the extent to which alterations in HPA axis functioning
alone serve a causal role in the development of PTSD.
Rather, these results underscore the importance of examin-
ing the biology of PTSD from a developmental perspective.
According to DeBellis’ (2001) developmental trauma-
tology model of PTSD, a subset of child trauma victims
may initially respond to a traumatic event with abnormally
elevated levels of cortisol that, over time, may alter normal
HPA axis functioning. This disruption may result in en-
hanced negative feedback inhibition of the HPA axis. Over
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Ostrowski et al.
time (probably years), enhanced negative feedback could
result in lower levels of basal cortisol, possibly explaining
some of the findings of lowered cortisol in adults with
PTSD. In this case, low cortisol levels in adults may sim-
ply serve as a marker of risk afforded by prior traumatic
experiences, rather than a causal role in the development
of PTSD.
Research in child trauma victims has supported
DeBellis’ (2001) model, suggesting that initially and within
2 years posttrauma, PTSS are associated with higher levels
of cortisol (DeBellis et al., 1999). However, studies exam-
ining child trauma victims after a longer duration of time
since the trauma (e.g., 5 years) have found lower levels of
cortisol to be associated with PTSS (Goenjian et al., 1996).
The results of the present study support this developmental
model, as higher cortisol levels were associated with higher
PTSS in children who did not have a trauma history. When
children with a trauma history were included in the anal-
yses, the relationship between cortisol and PTSS became
nonsignificant. In adults, lower cortisol levels were associ-
ated with increased PTSS. The present study underscores
the importance of examining the role of prior trauma in
biological studies of PTSD.
Consistent with our prior research demonstrating child
gender differences regarding the strength of the relation-
ship between cortisol and subsequent PTSS (Delahanty
et al., 2005), the present study found that the relationship
between child in-hospital urinary cortisol levels and 6-week
child PTSS was driven primarily by boys. Furthermore,
in-hospital cortisol levels significantly predicted 7-month
PTSS only in boys. Differences in hormonal or cognitive
factors due to age or pubertal status might account for the
lack of findings between urinary cortisol and subsequent
PTSS in girls. However, caution should be used when inter-
preting these findings as there were no main or interaction
effects involving gender in the relationship between cor-
tisol levels and PTSS. Future research in larger samples
should further examine the developmental trajectory of
psychophysiological responses following a traumatic event
with a specific focus on potential gender differences and
the impact of pubertal status on initial hormonal response
and PTSD in girls versus boys.
 Acute Child and Mother Psychophysiological Responses
The current study was limited by a relatively small sam-
ple size of moderately injured trauma victims. Therefore,
the present results may not generalize to more symptomatic
trauma victims. Further, due to the high levels of acute dis-
tress in mothers, the present study did not assess in-hospital
maternal urinary hormone levels. Therefore, the extent to
which initial cortisol levels are associated with PTSS in
mothers of child trauma victims is unknown. Additionally,
the 12-hour and 15-hour urine collections did not allow
for the assessment of cortisol levels across a 24-hour time
frame. Consequently, the timing of urine collection does
not encompass the typical drop in cortisol levels observed
during the day hours and does not allow for the examina-
tion of normal or flattened gradients.
Additionally, we recruited only biological mothers and
did not collect data from fathers. Future studies should fur-
ther examine the relationship between adult and child psy-
chophysiological responses by recruiting both mothers and
fathers. Although our prior research in adults found that
men and women did not differ in the extent to which low
cortisol predicted PTSS (Delahanty, Raimonde, & Spoon-
ster, 2000), including both mothers and fathers would
allow testing of whether low cortisol levels continue to pre-
dict subsequent PTSS in a mixed gender sample. Similarly,
it is possible that the differing direction of findings may be
due to the differences in the traumatic experience between
children and adults. That is, all children were direct trauma
victims; the majority of mothers were secondary victims.
In our prior research, low cortisol levels predicted PTSS
in adult direct motor vehicle accident victims (Delahanty
et al., 2000), but differing aspects of the trauma may ac-
count for some of the differences observed between chil-
dren and adults.
Despite these limitations, the results of the present study
demonstrate differing directions of the relationship be-
tween early cortisol levels and subsequent PTSS in chil-
dren and their mothers. These results may further theory
of biological risk and development of PTSD, and replica-
tion and clarification of the findings may aid in the early
identification and targeting of trauma victims at greatest
risk of developing PTSD. Further information regarding
acute psychophysiological responses following a traumatic
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
685
event may lead to the development of acute pharmaco-
logical interventions that may buffer or prevent the devel-
opment of PTSS. However, the present findings are sug-
gestive that secondary pharmacological interventions may
differ for children and adults. Further, the present results
caution against the administration of hydrocortisone as
a secondary intervention in children, despite initial pro-
tective effects demonstrated in adults (Schelling, Kilger,
Roozendaal, de Quervain, Briegal, Dagge et al., 2004).
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