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Title: Exploring psychological abuse in childhood: I. Developing a new interview scale ,  By: Moran, Patricia M., Bifulco, Antonia, Ball, Caroline, Jacobs, Catherine, Benaim, Kate, Bulletin of the Menninger Clinic, 00259284, Summer2002, Vol. 66, Issue 3
Database: Academic Search Premier


Exploring psychological abuse in childhood: I. Developing a new interview scale



Definitions of psychological abuse

Adverse parental behavior

A sustained pattern of interaction

Child vulnerabilities

Emotional and psychological damage

A working definition of psychological abuse

Developing a new scale of psychological abuse

Childhood Experience of Care and Abuse (CECA) interview

Severity of psychological abuse

Categories of psychological abuse

Complex psychological abuse


Interrater reliability of psychological abuse scale

Prevalence of psychological abuse

Subcategories of psychological abuse

Psychological abuse and shame





Definitions of psychological abuse are reviewed and a new definition proposed, operationalized as an extension of an existing measure of childhood, the Childhood Experience of Care and Abuse (CECA). This semistructured, investigator-based interview is designed for use with adults to collect retrospective accounts of childhood adverse experience. The CECA extension identifies nine subtypes of psychological abuse, with a single global severity rating. The definition is clearly differentiated from other adverse experiences with emotionally abusive elements such as parental antipathy (hostile parenting), neglect, and role reversal. Examples are given. A community-based series of 301 women were interviewed using the extended CECA to gather a range of experiences of childhood maltreatment on which to devise the new measure. Interrater reliability was satisfactory, and several features of psychological abuse were examined, including its prevalence, frequency, and the characteristics of the abused child and perpetrator. The new scale is discussed in terms of its potential use not only by researchers but also by practitioners such as clinicians and social workers in the child protection field in order to more accurately identify and assess multiples of abuse in childhood. A companion article (Bifulco, Moran, Baines, Bunn, & Stanford, 2002) examines the relationship of psychological abuse to adult major depression. (Bulletin of the Menninger Clinic, 66[3], 213-240)

Evidence testifying to the negative effects of psychological abuse in childhood has increasingly emerged in recent years. Psychological abuse defined in terms of abuse of children's mental and emotional processes has been linked with childhood outcomes such as impaired emotional, social, and cognitive development, including helplessness and lowered self-esteem (Cerezo & Frias, 1994), aggression, emotional unresponsiveness and neuroticism (Black, Smith Slep, & Heyman, 2001), dependency, incompetence, and educational failure (see Skuse & Bentovim, 1994, for a summary). It has also been linked with psychiatric disorders in childhood such as major depression and dysthymia (Kaufman, 1991; Stone, 1993), and has been implicated in impaired physical development (Skuse, 1989). Of the few studies documenting its long-term effects, Mullen and colleagues report that childhood psychological abuse relates to low self-esteem, eating disorders, depressive illness, and suicidal behaviors in adulthood (Mullen, Martin, Anderson, Romans, & Herbison, 1996), psychological distress (Pitzner, McGarry-Long, & Drummond, 2000), and poor adult relationships (Varia & Abidin, 1999).

Yet, until most recent times, psychological abuse has rarely formed the reason for referral to child protection services, with children who are subjected to neglect, physical, or sexual abuse being far more likely to be registered (Creighton, 1992). This is partly due to the enormous pressure on child protection staff to focus on aspects of child maltreatment such as gross neglect or extreme physical abuse, which lead directly to child fatalities (Reder, Duncan, & Gray, 1993). Prevalence rates are thus likely to be underestimates, but they suggest that psychological abuse varies from 113 to 257 per 1000 children, depending on the definition applied (Fortin & Chamberland, 1995).

Another reason why psychological abuse remains a relatively neglected area of childhood experience is the problem of its definition. The term mental injury first appeared in child protection legislation in the United States as early as 1974 (Edmundson & Collier, 1993). However, the concept has remained elusive despite greater awareness of it as a form of maltreatment (Black et al., 2001). Rosenberg (1987) suggests that research in the area of psychological abuse has been hindered by a lack of consensus regarding an operational definition. Consequently, few if any satisfactory measures of psychological abuse have been developed. The current article sets out to develop an operational definition of psychological abuse and describes a new interview scale of psychological abuse for use in retrospective studies with adults. A companion article examines the long-term consequences of such abuse in terms of depressive disorder (Bifulco, Moran, Baines, Bunn, & Stanford, 2002).

Definitions of psychological abuse

Some authors prefer to distinguish psychological abuse from emotional abuse based on the type of damage the abuse is thought to inflict (e.g., O'Hagan, 1993, 1995). However, it is clear from the literature that many use the term interchangeably, with American reports typically using the former term and British reports the latter (Edmundson & Collier, 1993). In the present discussion the two labels are not distinguished, but the term psychological abuse preferred.

A survey of psychological abuse by Thompson and Kaplan (1996) identified four key features common to definitions of psychological abuse: adverse parental behavior, a sustained pattern of negative interaction, child vulnerabilities, and damage in terms of emotional and psychological functioning. These features provide a useful framework for discussion of the components required for an adequate definition of psychological abuse. Each is discussed, and the implications in terms of the development of a new measure of psychological abuse are outlined.

Adverse parental behavior

The following types of parental behavior are viewed as constituting psychological abuse: rejecting, isolating, terrorizing, ignoring, and corrupting a child or youth (Garbarino, Guttman, & Seeley, 1986). To this list Baily and Baily (1986) have added excessive threats, refusal of psychological treatment, sexual exposure and exploitation, denial of opportunities to grow socially and emotionally, singling out one child in the family to punish or criticize, and unrealistic expectations. Glaser's scheme includes persistent negative attributions or misattributions to the child, failure to recognize the child's individuality, or inconsistent developmental expectations (Glaser & Prior, 1997). Combining these and other definitions, Burnett (1993) offered the following nine parental acts as constituting types of psychological abuse: confining to a small space, public humiliation, Cinderella syndrome, severe verbal abuse, coercing into delinquency, threatening a child, refusal of psychiatric treatment, not allowing social and emotional growth, and not providing a loving home.

Many of these adverse behaviors overlap extensively with alternative categories of child maltreatment, and the distinction between them requires clarification. For example, ignoring a child, denial of social opportunities, or refusal of psychiatric treatment cannot readily be distinguished from neglect as defined by other taxonomies of childhood maltreatment (e.g., Childhood Experience of Care and Abuse [CECA]; Bifulco, Brown, & Harris, 1994; Bifulco & Moran, 1998). Similarly, ongoing negative interaction involving unrealistic expectations, rejecting, or singling out one child for criticism cannot readily be distinguished from parental antipathy. In the same vein, Cinderella syndrome has clear overlaps with the exploitation involved in role reversal, where this child is pressured to take on adult roles. The extent to which the distinction between psychological abuse and other forms of maltreatment is one of severity/intensity or of the specific type of parental behavior needs to be clarified. The failure to reliably distinguish specific types of abuse can lead to difficulties when attempting to establish specificity of outcome of such experiences (Crittenden, 1985). In addition, some combinations of types of abusive experiences may be more damaging than others, and estimating the precise number of multiples of abusive experience may prove critical in explaining outcome (Claussen & Crittenden, 1991; Ney, Fung, & Wickett, 1994). In addition, precision about multiplicity of abuse may prove critical in child protection settings or in legal contexts. Hence a system of measurement is needed that assesses psychological abuse together with each other form of maltreatment separately in terms of perpetrator behaviors--this while recognizing that psychological and other forms of abuse commonly co-occur in the same settings and may at times exist as features of the same actions.

This point is developed by Barnett, Manly, and Ciccetti (1991) in seeking to define psychological abuse: "an adequate operational definition cannot be developed separately from definitions of other forms of maltreatment" (p. 20). They identify six types of child maltreatment, including psychological maltreatment, and allow for acts of maltreatment to be categorized more than once rather than forcing classification into a single category. This latter point is significant given that, for example, an instance of neglect that has psychologically abusive elements might prove to be more harmful in combination than an act that is solely one of "pure" neglect or "pure" psychological abuse. The ability to capture the difference between simple and compound abuses in a measurement system is therefore important. The new interview scale to be described allows for the classification of acts of psychological abuse separately, and in addition to, a range of other forms of maltreatment. It also allows for the same abusive act at times to be cross-referenced between categories of abuse.

In addition to controversy surrounding the types of acts to be included in an operational definition of psychological abuse, there is also much debate concerning the significance of the intentions of perpetrators. Some researchers argue that motive is highly relevant to the categorization of such abuse, whereas others take the view that it may be of clinical importance, but is probably not relevant to the severity of maltreatment (e.g., Hart & Brassard, 1991). McGee and Wolfe (1991) suggest that psychologically abusive behavior should be defined irrespective of parental motive. They suggest that parental behavior be measured on a continuum ranging from mild to dangerous forms, and that parental intent will typically influence the severity along this continuum. In addition, they suggest that the child's perceptions of parental intent will influence the impact of the parental act rather than its nature, and that such perceptions should be measured separately from the parental behavior itself.

O'Hagan (1993) also recommends that psychological abuse be defined independently of the perpetrator's intentions. He suggests that failure to do so could lead to the dangerous position whereby if perpetrators deny an intention to abuse or awareness of the abuse (e.g., if drunk), their actions could be argued to be nonabusive. Yet the same argument is rarely applied to physical abuse, where the practice of harsh physical discipline is condemned whether or not the perpetrators construe it as beneficial to the child, or whether injuries inflicted on the child occur while the parent is drunk. The physical risks to the child hold equally in both scenarios, and the same could be concluded with psychological abuse. In the proposed new measure, therefore, perpetrator intention is not regarded as a necessary characteristic of psychological abuse. However, evidence of perpetrator behavioral strategies that have all the appearance of premeditation and hence intent can be used in deciding on inclusion of incidents as psychological abuse.

Many definitions of psychological abuse also limit the inclusion of abusive acts to those committed by parents. Limiting the category of those included as perpetrators omits a host of potential perpetrators, such as other caregivers, relatives, teachers, siblings, and even peers (O'Hagan, 1995; Shaver, Goodman, Rosenberg, & Orcutt, 1991; Whipple & Finton, 1995). Avoiding this definitional limitation has proved critical in the field of sexual abuse, where abuse from nonrelated adult males is common (Bifulco & Moran, 1998). Although the perpetrators most likely to be influential are primary caregivers such as parents, it is possible that significant short- and long-term damage may occur at the hands of others in the wider social network. Hence the proposed new measure of psychological abuse, while routinely assessing abuse from parents and surrogate parents, also considers abusive acts from other sources.

A sustained pattern of interaction

Another feature of the definition under debate is whether the adverse parental behavior typically involves a sustained pattern of interaction (Thompson & Kaplan, 1996). Some studies stress that repeated exposure to instances of adverse parental acts is required before an act can be defined or included as psychologically abusive (e.g., Burnett, 1993; O'Hagan, 1993, Glaser & Prior, 1997). Others allow single instances of adverse behavior to qualify as psychological abuse (e.g., Baily & Bally, 1986) and suggest that the isolated nature of these instances should be taken into account in rating its severity (McGee & Wolfe, 1991). Rather than decide on a priori grounds where the frequency threshold for inclusion lies, the new measure includes single adverse acts in addition to those of a more sustained nature. However, frequency (in addition to intensity and variety of modes of psychological abuse) is implicated in assessing severity.

Child vulnerabilities

The third element common to psychological abuse definitions involves features of the child that may make the child particularly vulnerable to damage: "low IQ, absence of nurturing adults, a child's attribution of parental misdeeds as being malevolent and a child's particular developmental level" (Thompson & Kaplan, 1996, p. 144). These are indeed factors that might render a child more vulnerable to the effects of psychologically abusive acts. However, Garbarino (1991) argues that psychological abuse, as with other abuses such as sexual abuse, should be defined independently of child characteristics. In defining sexual abuse, standards of behavior that are deemed appropriate or inappropriate are delineated by society. Thus, performing sexual acts with a minor is seen as inappropriate adult behavior, regardless of the child's characteristics. Garbarino argues that taking into account the child's vulnerabilities in a definition of abuse implies that a hardier child subjected to the same abusive act as a more vulnerable child would be considered less abused. He (1991) finds such a position untenable: "The logical (and ethically appalling) implication is that the standards for dealing with a resilient child offer less protection than the standards of care for a vulnerable child (the former can absorb more psychic assault than the latter)" (p. 47). The new measure to be described in the present report therefore makes no reference to specific child vulnerabilities and limits its definition to a description of perpetrators' acts rather than child characteristics.

Emotional and psychological damage

Definitions that incorporate outcome factors such as emotional or psychological damage to the child are problematic and potentially tautological (McGee & Wolfe, 1991). An operational definition useful in empirical research should distinguish the predictor (i.e. parental behavior) from the criterion (i.e., psychological harm). Therefore there is a need to develop an operational definition independent of outcome so that the effects of the abuse can be established empirically. A useful distinction used in deriving definitions of childhood maltreatment that avoids such circularity is the "consequences" model versus the "standard of care" model (Garbarino, 1991). Definitions of abuse that incorporate outcomes for the child are examples of consequences models, as in the case of definitions of physical abuse that depend on evidence of physical injury. These are perhaps more relevant to child protection practice than research criteria. For example, in the UK, mandated intervention requires evidence of "significant harm," which includes both parental action and observable harm to the child (Glaser & Prior, 1997). In contrast, a standard of care model defines abuse in terms of what society deems to be unacceptable treatment of a child, whether evidence of damage to the child is present or not: "The definition, while informed by theory and research, must be formulated according to societal standards of appropriate parental behavior" (Barnett et al., 1991, p. 24). In this vein, McGee and Wolfe (1991) argue for a probabilistic model of psychological abuse, based on the potential for harm to a child rather than the observable harm. In the new measure of psychological abuse outlined in this report, actual or observable harm is irrelevant to the judgment of whether an act is one of abuse or not: it is the likelihood of damage that is assessed.

A working definition of psychological abuse

The first aim of this article is to develop an operational definition of psychological abuse. Given some of the difficulties just described, this might be considered "working" rather than "definitive" with results contributing to a later "firming up" of the definition and replications in new series. In sympathy with Haugaard's position (1991), we agree that it may be worth delaying the formulation of a final definition of psychological abuse until results from empirical studies are sufficient to clarify which parent-child interactions result in psychological harm. The definition we offered here is derived in part from existing literature on the topic, but also from scrutiny of psychological abuse examples gleaned inductively from hundreds of retrospective accounts of childhood gathered in the course of a program of research stretching back over many years (Bifulco & Moran, 1998). The proposed working definition is as follows:

Psychological abuse is concerned with cruelty demonstrated by verbal and nonverbal acts, repeated or singular, intended or not, from a close other in a position of power or responsibility over the child. These have potential for damaging the social, cognitive, emotional, or physical development of the child and are demonstrated by behaviors which are humiliating/degrading, terrorizing, extremely rejecting, depriving of basic needs or valued objects, inflicting marked distress/discomfort, corrupting/exploiting, cognitively disorientating, or emotionally blackmailing. The perpetrator behaviors involved in psychological abuse exclude physical or sexual attack, although psychological abuse may accompany these. They also exclude those forms of maltreatment identified as neglect, antipathy, role reversal, high discipline, or lax supervision, as these fall into alternative categories.

In terms of differentiation from existing abuse categories, the most controversial may be that of antipathy--a negative ongoing relationship with the parent where the latter is critical, cold, hostile, or rejecting on a day-to-day basis. Although antipathy is identified as emotional abuse in other categorizations, it is contrasted by its established definition within the lack of care domain (Andrews & Brown 1988; Bifulco & Moran, 1998; Parker, Tupling, & Brown, 1979), its overlap with more normalized family behavior, and its rare inclusion as behavior relevant for mandated intervention and child protection, which typically does not reach the identifiable abusive peaks and categories of psychological abuse outlined in the literature and in the present report. Therefore verbally aggressive parental behavior and other negative interaction with parents is differentiated from psychological abuse in this report.

Developing a new scale of psychological abuse

The second aim of this article is to introduce a new scale designed to study psychological abuse in conjunction with other forms of neglect, abuse, and poor parenting. There are relatively few published measures of psychological abuse, and nearly all are self-report questionnaires. An exception is the Psychological Maltreatment Rating Scale (PMRS; Brassard, Hart, & Hardy, 1993), which is designed for rating mother-child interaction during a 15-minute videotaped teaching task. Other alternatives to self-report include scrutiny of case files (McGee & Wolfe, 1991) and the multiclassification of Barnett and colleagues (1991). A self-report measure that soleley assesses psychological abuse is the Psychological Maltreatment Scales (PMS; Briere & Runtz, 1988; Varia & Abidin, 1999). This measures uses a Likert scale to endorse seven statements of parental behavior toward a child under age 16 for an average year in childhood, including "yelled at you," "criticized you," "made you feel guilty," and "ridiculed or humiliated you." Most other measures are extensions to existing childhood measures such as the Child Abuse and Trauma Scale (CATS; Sanders & Becker-Lausen, 1995). This is a 38-item questionnaire for use with adults that assesses various aspects of adversity in childhood. Seven items have been incorporated, aimed at tapping psychological abuse in childhood (Kent & Waller, 1998). Another measure modified to incorporate childhood psychological abuse is the Child Abuse Questionnaire (CAQ) as used by Gross and Keller (1992) to examine psychological abuse in relation to depression, self-esteem, and attribution styles. An Australian measure, the Comprehensive Child Maltreatment Scales (CCMS; Higgins & McCabe, 2001), is a self-report scale that covers five types of childhood maltreatment, including psychological abuse. However, in addition to these extensions of self-report measures adding specific items to reflect psychological abuse, other investigators have used existing measures of neglect or physical abuse to answer questions about psychological abuse. Thus a widely used measure of care and control in childhood (Parental Bonding Instrument) has been relabeled in terms of emotional abuse for some analyses with no increase of items (Mullen et al., 1996). Similarly, the Conflict Tactics Scale (CTS; Straus, 1979) has been used in terms of subscales relating to parent-to-child verbal aggression in relation to psychosocial problems in the children, but again without broader psychologically abusive categories (Vissing, Straus, Gelles, & Harrop, 1991).

Examination of the items that have been added to existing measures of childhood experience suggests that they may often be assessing other related but previously categorized forms of maltreatment, such as parental neglect or antipathy, which may lead to an overinclusiveness in prevalence figures and to unreliable assessments of the relationship of psychological abuse to other forms of abuse and neglect. It may also confound results concerning the differential effects of psychological and other abuse in relation to outcomes such as depression in adulthood or suicidal behavior, as discussed in a companion article (Bifulco et al., 2002).

The proposed new measure differs from existing measures of psychological abuse in its administration. It is a semistructured interview designed for use with adults, and involves investigator-based judgements of childhood history gathered retrospectively. Narrative, chronological accounts of childhood experience are collected on the basis of extensive probing questioning, and the classification and severity assessment are determined by trained researchers according to predetermined criteria. This has many similarities to a diagnostic clinical interview. The new assessment is an extension of an existing measure of childhood, the CECA (Bifulco, Brown, & Harris, 1994), a semistructured interviewing instrument originally developed in the 1980s to assess experiences such as physical and sexual abuse, neglect, antipathy, role reversal, supervision, and discipline. As an addition to an existing measure, the psychological abuse component has the benefit of being assessed in relation to, and distinct from, other forms of abuse using the same scaling procedures. As with the other forms of maltreatment that the CECA covers, the new measure treats psychological abuse as a continuous variable, as recommended by authors such as McGee and Wolfe (1991). However, it also identifies categories of perpetrator behavior to aid in identification of relevant items.

The use of an interview rather than a questionnaire for the assessment of psychological abuse has the advantage of flexibility in identifying psychologically abusive behaviors which are notorious not only for being varied but also at times idiosyncratic. The format of a semistructured interview with open questions thus allows for exploration of both typical and atypical parental behaviors, which may not lend themselves easily to itemization on a questionnaire. The use of investigator or "expert" judgment rather than respondent judgment in assessing inclusion and severity of psychological abuse has advantages of avoiding underassessment due to respondent unawareness of its definition or normalization of "odd" parental behavior. Investigator-based measurement allows the investigator to decide on the inclusion of an item as psychological abuse, using anchoring examples as a guide. Thus the same thresholds for inclusion and severity of examples can then be applied consistently across samples.

Childhood Experience of Care and Abuse (CECA) interview

The CECA interview involves detailed questioning regarding relationship with, and behavior of, biological parents and surrogate parents who have responsibility for the participant before age 17, for any period lasting 12 months or more. To facilitate recall, experiences are asked about in chronological order. Most of the relevant experiences are rated on a 4-point scale of severity ranging from "1-marked" for the most severe to "4-little/none" for the least negative experience. Ratings rely on "objective" details of behavior impinging on the child based on collecting details of specific incidents, their frequency, age at which they occurred, who was involved, and so on, regardless of the individual's responses to those experiences or current feelings about them. A manual containing hundreds of benchmark examples is available to interviewers to assist rating and regular researcher trainings held by the UK research team (Bifulco, Brown, Neubauer, Moran, & Harris, 1994). Reliability of the instrument is high, with interrater agreement reaching above 0.78 (Kw, weighted Kappa; Cohen 1968) on all scales (Bifulco, Brown, & Harris, 1994). Validity in terms of interrespondent agreement (e.g., sisters reporting on each others' childhood experience) is also good, reaching an average of 0.60 Kw across numerous scales (Bifulco, Brown, Lillie, & Jarvis, 1997). The following types of childhood experience are included in the CECA and are here differentiated from psychological abuse.

Parental neglect. Neglect reflects parental lack of interest in the child's material care, health, friendships, schoolwork, or career plans, or being emotionally unavailable when the child is distressed. Severity of neglect is determined on the range of such indicators being present and rated on a 4-point scale from "marked" through "little/none." Each parent is rated independently and an overall assessment is made.

Parental antipathy. The amount of dislike, rejection, irritation, and coldness shown by parents and surrogate parents is rated as antipathy. Information regarding critical and rejecting comments and verbal aggression directed at the subject is taken into account, as are behavioral instances of rejection or "scapegoating" the child. Severity is again reflected on a 4-point scale.

Role reversal. The extent to which parents require the child to takeover a parental or adult role is identified as role reversal. This includes taking on responsibility in the household for running the home (washing, cooking, ironing) and for looking after younger siblings. It also includes the parent using the child as confidant or support figure, bearer of family secrets, and source of comfort for the parent when distressed. Severity is determined by the number of areas in which such role reversal occurs and its frequency. It is rated on a 4-point scale.

Parental discipline. Discipline imposed by parents or surrogate parents is rated using information regarding the presence and enforcement of rules about manners and behavior, socializing, clothing, smoking, and drinking. The scaling differs from those just described, in that moderate is regarded as the most acceptable form of discipline and is distinguished from high, low, or variable levels. Thus the scale points used are "1-marked," "2-moderate," "3-1ax," "4-variable."

Parental supervision. The extent to which parents monitor the child's behavior and maintain safety is defined as supervision. This includes the child being left home alone, being allowed out unsupervised or late at night, or in dangerous surroundings. The scaling is the same as for the discipline scale.

Physical abuse. Physical abuse from any household member, including mothers, fathers, surrogate parents, older siblings, or other adults living in the home, is assessed. Each instance of abuse by a different perpetrator is rated independently. A number of features of assaults are asked about, including frequency of attacks, use of implements or weapons, number of hits, age at time of attack, and injuries sustained. This information was used to derive a rating of severity of physical abuse on a 4-point scale.

Sexual abuse. Unlike other forms of maltreatment, incidents of sexual abuse are included regardless of whether the perpetrator was a household member or not. Each abuse by a different perpetrator is rated separately. As with physical abuse, a rating of severity on a 4-point scale is derived based on a number of features of the assault, such as frequency and duration, age of victim at time of abuse, relationship to perpetrator, and intrusiveness of the sexual contact.

Felt shame. In addition to objective characteristics of maltreatment, a rating of subjective feeling of shame in childhood was included. This involves feelings of shame, embarrassment, or stigma for any aspect of childhood, including appearance (e.g., shabbiness, unfashionable clothes, uncleanness), family characteristics (e.g., parents drinking, fighting, causing scenes at school), and social deprivation (e.g., poverty, deprived home conditions). This is rated on a 4-point scale of severity.

The origins of the CECA interview lie in a protocol first designed in UK in the early 1980s when the effects of early maternal loss and lack of care on adult depression were investigated (Harris, Brown, & Bifulco, 1986). The basic measure at that stage included care and control scales such as neglect, role reversal, supervision, and discipline from birth or surrogate parents. The measure was subsequently used on a large representative series of inner-London mothers where scales for abuse (physical and sexual) and antipathy (hostile parenting) were added. The interviews involved collecting extensive narratives about individual's childhood experiences before age 17. The biographical information was transcribed and then ratings were made of the level of severity of each different childhood experience. During the course of using the measure over 10 years on subsequent series of women, it became apparent that some experiences of abuse were not sufficiently covered in the existing scales, particularly psychological abusive experience involving coercive control and sadistic behavior. For example, while it was common to hear about parents who were critical, disrespectful, scapegoating, cold, or rejecting, the CECA investigators also learned about a child who had confessed to a fear of the dark being locked in a room with no light bulb, about another whose pet was destroyed in front of her for some minor misdemeanor, and about a child whose sole photograph of her dead mother was torn to shreds by a cold and controlling stepmother. Such incidents seemed to raise the level of cruelty and control to a new level.

To assess incidents as psychologically abusive, the trained CECA raters considered for inclusion any communications to the child that were cruel, overcontrolling, or manipulative, including both verbal and nonverbal behavior from the perpetrator. It was decided to set a high threshold for inclusion of abusive behaviors, relevant to long-term effects and to psychopathological outcomes, and to differentiate them from those already covered in related scales. Evidence of the perpetrator's apparent premeditated strategy in "designing" a punishment or means of control specifically tailored to the child's fears and vulnerabilities would make inclusion as psychological abuse easier to determine. One woman we interviewed claimed that her stepfather would spend the day thinking of new ways to torment her in the evenings when he returned home, as evidenced by the many new varieties of abuse he would impose. Malevolent intent often appeared evident in the detailed descriptions of childhood experiences, as, for example, in the case of a father who told his young daughter that he would derive great pleasure from withholding her life-saving medication and watching her die slowly. However, perpetrator strategy was at times unclear, even though the nature of the abusive behavior toward the child in terms of categories identified qualified: Explicit malevolent perpetrator strategy was regarded as a sufficient but not a necessary feature for defining such abuse.

Based on the examples to emerge from the participants' accounts of childhood recounted in the course of the CECA interview, an overall assessment of severity was determined and a taxonomy of nine psychologically abusive behaviors was generated.

Severity of psychological abuse

Instances of psychological abuse were rated in terms of overall severity using the same 4-point scale used for the majority of the CECA scales (i.e., 1, marked; 2, moderate; 3, some/mild, or 4, little/none). The overall severity was influenced by the number of subcategories of psychological abuse rated but equally by the intensity and frequency of single forms of such abuse. Judgments were made by considering a number of features of the abuse in the child's particular context, consistent with predefined rating criteria. As with other CECA scales, severity ratings reflected the potential for long-term psychological and emotional damage rather than actual damage to the subject, and raters were always blind to the psychiatric outcome of the subject or his or her reported reactions to the abuse.

The following are examples of overall severity of psychological abuse determined from the cases examined and typical of those used as rating benchmarks.

Marked psychological abuse. "I went through a phase of having a bag by my bed at night because quite often Dad would come home late at night and order us all out of the house. My mother had to take us children out, whatever the time or weather, to go and stay with friends. There was no warning, you never knew when it would happen" (subcategory of "deprivation of basic needs"). "Also, I had asthma as a child and I used to keep my tablets and my inhaler and a few personal bits and pieces with me just in case I needed them at night. One night when Dad came in drunk, he came into my room and woke me up and threatened to take my medication away. He said that nothing would give him more pleasure than to take my tablets away and watch me die slowly" (subcategory of "extreme rejection").

Moderate psychological abuse. The girl was brought up by her aunt after being separated from her parents at age 5. Her aunt was cold and critical throughout the relationship. When the girl went on a school trip lasting a few days, her aunt offered to look after her pet dog, to feed and walk the dog, usually the girl's responsibility. The girl describes her return from the trip: "I went on a school trip, I was about 9. My aunt picked me up from the school at the end of the trip. She handed me the dog's collar and lead and said, "You won't be needing these any more. The dog's dead. I had it put down." "It was the first thing she said as I got off the school bus." No explanation was given of this action. The dog had been perfectly healthy, and there were no practical reasons for disposing of it. There was no prior discussion of the aunt's decision (subcategory of "deprivation of valued object").

Mild psychological abuse. The woman reported that as a child she had a kidney complaint, which was never diagnosed or treated, and as a result had poor bladder control. She used to wet the bed at night and wet her knickers regularly by day. "I was still wetting at the age of 7 or 8, and at primary school. At home we didn't have a washing machine. Washing was a problem--there were no radiators or drying facilities. I can remember mother saying to me once: "If you wet your knickers again, I'm going to rub them in your face," and I came home from school with wet knickers and so she did" (subcategory of "humiliation").

Categories of psychological abuse

On the basis of examples such as those just given, careful scrutiny of 300 cases of childhood experience, and following the definitions in the psychological abuse literature, the following subcategories of psychological abuse were derived to help in the identification and scoring of the severity of the experience.

Humiliation/degradation. The key feature of this category is those actions or comments that degrade and humiliate the child and have the potential for invoking shame. The rating is based on the likelihood of shame being induced in most children subjected to such treatment rather than the actual degree of shame reported. Public viewing of such humiliation would add to the severity. (See the example of bedwetting under mild abuse.)

Terrorizing. This involves attempts to invoke extreme fear or dread in the child in a calculated way, excluding physical attacks. This includes, for example, deliberately playing on a fear that the child is known to have, such as forcing the child to sweep insects out of the basement when the child is known to be terrified of insects. As with the humiliation category, the rating is based on the likely response by the child in such a situation, rather than the actual response invoked.

Cognitive disorientation. This type of abuse includes a number of techniques aimed at confusing and disorienting the child in terms of (1) his or her belief in the evidence of his or her senses (e.g., repeatedly telling the child she had misunderstood a command, which had in fact been correctly followed), (2) memory (e.g., enforcing a belief that the could not recall valued experiences in the past) or (3) sense of identity (e.g., convincing the child that a biological parent was not the child's parent or that a separated parent was dead). In extreme instances, strategies akin to brain washing are utilized. One woman described her stepfather's behavior: "I was on house duty, where everything had to be scrubbed and then when you'd finished, you had to start it all again. And it was like mental torture ... 'Hang the washing out,' and you'd put it out and then he'd say, 'No, I didn't want it out, I wanted it in,' and you'd go and bring it all back in and he'd put it on the table and say, 'I thought I'd told you to hang that washing out.' ... He was making you feel as though you'd misunderstood the first command or you'd done the opposite to what he'd asked. Until you wondered if you were going mad."

Deprivation of basic needs. This involves depriving the child of basic needs such as light, sleep, food, or the company of others. This type of abuse is closely related to neglect, but it may be distinguished from the latter by the way in which the resource is controlled and rationed by the parent/perpetrator. This is not typically present in neglect, where depriving a child is often a by-product of mismanagement and poor coping. In the following example, the child was deprived of social contact with her siblings. The woman talks about when her father remarried when she was 6: "I wasn't allowed to speak to my half-siblings. It was sort of like "us" (me and my sister) and "them" (my stepmother's children). My stepmother always favored her own children. She wouldn't feed me like her own children. It was different when my father was at home. Then I was allowed to sit and eat at the table with the others. When he wasn't there, I used to have to stand in the corner when they ate."

Deprivation of valued objects. This form of abuse involves depriving the child of a specific object that the he or she values or treasures. This may be an inanimate object, such as a toy or precious memento, or it may be animate, as with a pet, but it may also occasionally extend to significant others to whom the child is forbidden to talk (such as separated parents or relatives). It may also be more abstract in terms of a valued aim or achievement (e.g., taking up educational or sports opportunities). Frequently the object is the only source of comfort available to the child, for example, a toy or a special present, and it is typically removed or destroyed in a deliberate, calculating fashion to maximize distress and disappointment. (See the example of the pet being destroyed under moderate abuse).

Extreme rejection. This involves peaks of rejection that indicate abandonment or wishing the child was dead. Examples include locking the child out of the house when he or she is distressed or hurt for a long period of time, or abandoning a young child in an unfamiliar place, then returning some time later without explanation. The example of the wish for the child's death when undergoing an asthma attack described earlier would also fit this criterion.

Inflicting marked distress or discomfort. Although distress and discomfort are features accompanying most types of abuse, notably physical and sexual abuse, particular elements distinct from these are required for psychological abuse. One is force feeding, not only at mealtime but also with noxious substances such as shoe polish or feces. Vomiting often ensues, and physical pain, discomfort, or revulsion are involved. One woman related: "If I didn't want to eat what she'd cooked, I'd have my nose held to force me to eat. If she didn't manage to get it all into me, it would be presented cold at a later meal, then again at another. Eventually the food made me vomit."

Emotional blackmail. The key feature of this category of abuse is the use of serious threats to close others to ensure control and compliance. Emotional blackmail may also include threats to reveal stigmatizing information about the child or family, which will have negative consequences for the child. This form of psychological abuse often accompanies sexual abuse in order to induce compliance by threats to harm others (e.g., siblings) or to tell others of the child's "guilt." (See the example of telling others the child was a liar to prepare for possible disclosure of sexual abuse.)

Corruption/exploitation. This type of abuse involves forcing the child to take part in (usually) illicit activities such as stealing or drug taking. For example, one 10-year-old child was repeatedly given amphetamine by her mother and told it was sherbet. Incidents of exploitative sexual activity are also included in this category, for example, taking pornographic photographs of the child for distribution, or involvement in pedophile groups. The latter would rate on both sexual and psychological abuse. Thus child prostitution and ritualized sexual abuse would also be rated as both sexual and psychological abuse.

Complex psychological abuse

The last two categories indicate how psychological abuse can integrally co-occur with other abuse such as sexual abuse. An abuse "complex" was rated only when psychological abuse formed an integral part of the same incident with either physical or sexual abuse. For example, a 14-year-old girl was punished by her father for a minor infraction by pulling down her underwear and belting her on her bare bottom in front of her family and relatives. Here the psychological abuse subcategory of humiliation was rated in addition to physical abuse. Abuse complexes were distinguished from pure forms of psychological abuse, where sexual or physical abuse did not form part of the same incident as the psychological abuse example. However, it was also possible for the perpetrator of pure psychological abuse to be engaging in other forms of abuse or neglect on separate occasions with the same victim. For example, if the 14-year-old girl was hit by her father on other occasions with no publicly humiliating element, then she would rate as having recurrent physical abuse in addition to the specific psychological/physical abuse complex just described.

Similarly, psychological abuse could be a complex with sexual abuse. One woman described sexual abuse from her father: "It was full intercourse. And if I refused, I would get a hiding [beating] from him. If, for instance, if I bunked off [skipped] school and he found out, he would threaten to tell my mother--and I was more frightened of my mother funny enough--but if I let him screw me, he wouldn't say nothing about the school thing. He always said that if I got pregnant, I must say that it was my boyfriend who did it. He also made me out to be a liar ....It was like preparing in case I ever did say anything [about the abuse]."

Psychological abuse accompanying sexual abuse usually related to compliance or secrecy, such as campaigns of terrorizing the child or threatening the safety of close others to increase compliance and prevent the child from disclosing. Elements intrinsic to the sexual abuse, such as the betrayal of trust by a perpetrator who is a close other and the inappropriateness of the sexual behavior, were reflected purely in the severity rating of the sexual abuse. Helplessness on the part of one parent in relation to any abuse from the other parent (e.g., "bystander apathy") did not in itself qualify as psychological abuse. Greater collusion or participation in tormenting the child was required in order to rate psychological abuse; only the figure active in the abuse rated as the perpetrator. For example, a mother who did nothing to stop sexual abuse of her child by the father was not rated as perpetrating psychological abuse, although her behavior was considered an indicator of neglect.


The CECA, together with the psychological abuse scales, was tested on a community-based series of women interviewed between 1990 and 1994. The participants were selected from responses to screening questionnaires sent to women in the 18 to 50 age group who were registered with general practitioner physicians in Islington, North London, UK. The sample is discussed at length in the companion article (Bifulco et al., 2002). The series consisted of 105 women selected by screening questionnaire for adult depressive vulnerability such as poor support and low self-esteem and 59 selected by screening questionnaire for adverse childhood, particularly maternal neglect and antipathy. Forty consecutive questionnaire responders formed a comparison group. The latter two groups were also used for a validation of childhood experience and for each a sister within 5 years of age was interviewed (N = 99). In the process of developing a reliable scale of psychological abuse, it was decided to include all 304 women in the series, including sisters, in order to maximize the number of examples obtained. (In the companion article, the sisters were excluded because of possible familial confounds in the association with adult disorder.)

Overall, 45% responded to the initial screening questionnaire, 64% of suitable women agreed to complete the full interview, 23% refused, and 16% proved unobtainable. In terms of demographics, the average age of the women was 35 (range 19-53), more than (60%) were middle class, 67% were working full or part time, 61% were married or cohabiting, and 77% had children.

All the women were questioned about using the full CECA. The psychological abuse categories were determined on the basis of reading the transcribed childhood material, blind to depressive outcome. This was conducted by a team of six researchers trained and experienced in the CECA but who were not responsible for the original interviews and who were blind to psychiatric outcome. The scale was devised on the basis of full discussion on positive examples for half the series and then reliability was undertaken on cases from the second half of the series.

Interrater reliability of psychological abuse scale

The new scale was devised on the basis of examples in half the series, where rules for inclusion and severity were determined, and then examples from the second half were used to determine interrater reliability. Twenty examples of psychological abuse were rated independently for severity by two trained raters, and a correlation of.68 (Kw; Cohen, 1968) was initially achieved. When the severity scale was dichotomized about its midpoint (marked/moderate vs. mild/little-none) as used in the quantitative analysis, inter-rater reliability rose to.80 (Kw). This latter figure is comparable with figures for interrater reliability of other CECA scales (see Bifulco, Brown, & Harris, 1994).

Prevalence of psychological abuse

Sixteen per cent (49/301) of women in the total series experienced marked to mild levels of psychological abuse from at least one perpetrator. This is similar, but lower than, the levels of neglect (27%), sexual abuse (24%), role reversal (24%), and antipathy from father (19%) in this particular highly selected series. However, it is substantially lower than physical abuse (40%) and antipathy from mother (51%), the latter being one of the sample selection criteria. Given the high threshold for inclusion of psychological abuse, its relatively low apparent prevalence might be expected in community-based series. It was extremely rare in the comparison series, where only 4% (3/80) were found.

In total, there were 56 instances of psychological abuse when those from mother, father, and others were included. In terms of the frequency with which abuse occurred, 66% (37) of these cases involved repeated psychological abuse, occurring at least weekly in most instances. The remaining 34% (19) were isolated instances. The age at which the psychological abuse began was evenly distributed across three age ranges: beginning at age 5 or below, 38% (20); between age 6 and 10, 25% (13); and between age 11 and 17, 36% (19). There was no distinct pattern regarding the severity of abuse in relation to the age at which it began, with similar proportions of mild (55%), moderate (75%) and marked (64%) abuse examples beginning before age 11 (p = ns). Most perpetrators (90%, 52) were parents or surrogate parents. The few nonparental perpetrators involved teachers, other relatives, boyfriends and strangers. Perpetrators were as likely to be female as male: 50% (29) of of the instances of psychological abuse were committed by women compared with 45% (26) by men, and the remaining 5% (3) were committed by men and women jointly. Although the proportions of male and female perpetrators were similar, cases rated "marked" in severity were twice as likely to be committed by men: 67% (10/15) compared with 33% (5/15) by women. However when male and female perpetrator cases were compared, there was no significant difference in the proportion rated mild, moderate, or marked.

Subcategories of psychological abuse

Most cases of childhood psychological abuse (76%, 44) were rated on only one of the nine subcategories. A further 17% (10) rated on two subcategories, 5% (3) rated on three subcategories, and the remaining 2% (1) rated on a total of five subcategories. In terms of frequency, humiliation was the subcategory most often rated, featuring in 38% of the cases, followed by deprivation of valued object (24%), deprivation of basic needs (16%) and extreme rejection (16%). Inflicting distress/discomfort occurred in 14% of cases. Less common categories were emotional blackmail (9%), terrorizing (7%), and cognitive disorientation (7%) corruption was the least-rated category, featuring in only 5% of cases. The subcategory of emotional blackmail occurred only as a feature of abuse complexes, in particular in relation to sexual abuse.

The number of subcategories rated was related to the overall severity of the abuse, producing a correlation of .48 (Pearson's r, p < .001). To elaborate this relationship further, a score was derived based on the individual severity ratings for the subcategories of psychological abuse and summed for each case of abuse. This score was correlated with the overall rating for severity of abuse and was found to be highly related, producing a correlation of .69 (Pearson's r, p < .001).

Psychological abuse and shame

Psychological abuse was examined in relation to reports of the subjective state of shame. This was assessed for the 198 women in the child risk and comparison series, with 43% rated as having marked or moderate levels of shame in childhood. For those with any level of psychological abuse rating 72% (21/29) reported high levels (marked or moderate) of shame in childhood compared with 39% (65/168) of those without any psychological abuse (p < 0.001).


Given the lack of consensus regarding the definition of childhood psychological abuse, it is not surprising that relatively little empirical research has specifically addressed this topic. The current article has presented a working definition based on a standard of care rather than a consequences model (Garbarino, 1991). This avoids the tautology so often featured in definitions of this form of abuse, namely, that psychological abuse is that which causes psychological damage. The definition presented here specified nine ways in which psychological abuse can be demonstrated and derived a scheme for rating overall severity in the childhood histories of just over 300 community-based women. Such examples were specifically distinguished from related experiences of parental neglect, antipathy, role reversal, discipline, and supervision and rules for co-occurrence with physical and sexual abuse were determined. The prevalence of psychological abuse in this series was lower than for related experiences such as neglect, antipathy, or physical abuse. It also proved rare in the unselected comparison series. Although parents were by far the most frequent perpetrators in this series (consistent with the family-based focus of the measure) examples of psychological abuse were identified from other relatives and teachers. There was no specific patterning of severity of psychological abuse in relation to age of child or gender of perpetrator. The objective assessment of psychologically abusive experience was highly related to feelings of shame in childhood.

Limitations of this study should be noted:

  1. The analysis of psychological abuse was essentially exploratory, with the scale designed after the narrative data were collected. It may therefore be an underestimate of actual experience of psychological abuse. This needs to be reexamined using specific probing questions now constructed.
  2. The sample on which the new scale was tested was highly selected, so the prevalence of this psychological abuse assessment in the representative community is unknown. In a similar vein, the sample was only of women. Thus the scale needs to be assessed on a mixed-gender series.
  3. The retrospective nature of the measurement may have involved underreporting of psychologically abusive experience.
  4. Consistent with the literature, categories of psychological abuse identified were varied and the numbers in subcategories were small in this series. It is possible that on larger numbers, it would be possible to group the psychological abuse subcategories further to extend the taxonomy in terms of the components of negative care versus high control.
  5. Although most abuse was by parents, a small proportion was by other adults (such as teachers) with responsibility for the child. This indicates the importance of considering the wider social context when assessing childhood abuse. In future investigations, greater exploration of such abuse in school, leisure, and peer settings needs to be undertaken.

There are, however, advantages to using a retrospective, semistructured, investigator-based interview. The retrospective approach to measurement allows for the exploration of outcomes that may be associated with abuse in the long term as well as the short term. Such an approach is advocated by other researchers (e.g., Burnett, 1993), and there is now good evidence to suggest that retrospective accounts are reliable when the material is carefully collected (Bifulco et al., 1997; Brewin, Andrews, & Gotlib, 1993). Also, the use of a semistructured approach in preference to a structured questionnaire or interview allows for the possibility of eliciting new categories of psychological abuse, thus extending and clarifying the list of abusive perpetrator behaviors used in the definition. Hence the definition of psychological abuse may continue to evolve as a result of this method of data collection. The list of categories of psychological abuse presented here is not exhaustive, but is a summary of the types of abusive behavior to emerge inductively from accounts of childhood supplied by a community-based sample. Childhood histories obtained from other cohorts such as clinical populations might involve more complex or perverse forms of psychological abuse, thus requiring extension of the categorization.

Another advantage of the current measurement system is that it offers the ability to grade examples of abuse in terms of severity. It may therefore be possible to specify a level of abuse requiring intervention by child protection agencies, a point raised by Edmundson and Collier (1993) in a discussion of the role of educationalists in the identification and prevention of abuse. In the present study, it was both the number and the severity of abuse strategies used by the perpetrator that related to the overall severity level of the abuse, although lack of complete correspondence still required interviewer judgment to weigh the degree of cruelty involved, the potential for short- and long-term damage to the child, and the extent to which the abuse was tailored to the child's characteristics in assessing an overall rating. Indeed, Garbarino (1991) states that it is not practical to specify in concrete detail what constitutes psychological maltreatment in the way that might be possible for physical or sexual abuse. The present study also indicates the importance of considering single attacks in addition to repeated examples of psychological abuse, because as many as one third of examples rated marked in severity involved such single attacks. In addition, such single attacks might well have formed part of a more sustained pattern of abuse that the subjects were unable to report or recall, and thus might constitute the tip of the iceberg in relation to ongoing interaction.

The likely impact and meaning of psychological abuse needs to be explored in future studies to develop theoretical understanding. For example, to search for specific effects, the short-term response to psychological abuse needs to be contrasted with responses to other forms of maltreatment. The presence of psychological abuse in this series was highly related to feelings of shame in childhood. This might be expected because subcategories of psychological abuse such as humiliation can be seen as forms of shame induction. For example, denying a child access to basic facilities for washing can potentially be shaming to the point where the child is reluctant to socialize with peers, and experiences great isolation (Bifulco & Moran, 1998). Similarly, aberrant parental behaviors would be expected to make the child feel stigmatized and embarrassed about allowing friends to observe the child's family life. Shame about appearance has been shown to act as a mediator between other types of abuse and depression using the CECA approach (Andrews,1995). It has also been suggested that the shame induced by humiliation is closely associated with subordination and defeat (Gilbert, 1989). Indeed, in the most extreme cases seen in the present series, the perpetrator strategy appeared to be directed toward subjugation of the victim. The coercive control that formed the central feature of some of the most severe examples of psychological abuse has much in common with the process of domination seen in other contexts, such as women in situations of domestic violence, and even that of political hostages (Herman, 1994). Goddard and Stanley (1994) suggest that an understanding of child abuse can be increased if the abusive parent and the abused child are viewed as captor and hostage. The perpetrator at times has the power to distort the child's cognitions and emotions over substantial periods of childhood. This not only has obvious implications for self-esteem and helplessness, which are known to be associated with adult disorders such as depression, but it also has a high potential for more enduring personality damage, with implications for personality disorder outcomes.

In some instances, psychological abuse may arise as a function of overzealous parenting. An example is the case of a father who, on discovering that his 10-year-old daughter had been smoking, made her smoke 40 cigarettes in succession to induce vomiting in order to try to extinguish her desire for cigarettes. Similar examples of mothers force-feeding their children were set in a context of trying to "train" them to eat a full meal at each sitting. This is consistent with reported findings of a series of borderline personality disorder patients who had psychologically dominant and abusive parents who had grandiose ideas of their own competence as parents. The abuse was demonstrated in tactics of control rather than in long-term designs of deliberate harm (Park, Imboden, Park, Hulse & Unger, 1992).

Psychological abuse, often not directly observable in its effects, is in danger of being overlooked in favor of more physically tangible forms of abuse such as physical or sexual abuse: "With society more likely to denounce blatant forms of abuse (Ney, 1987) psychological abuse may pass less conspicuously" (Fortin & Chamberland, 1995, p. 281). In the United Kingdom, statutory guidelines for registering a child as "at risk" specify that if other abuse is present, then psychological abuse should not be listed as the reason for registering. Thus the true rate of psychological abuse among children on risk registers is still largely unknown. These guidelines also imply that psychological abuse is subsidiary, posing less danger to the well-being of the child than other forms of neglect or abuse. However, the damage inflicted as a result of psychological abuse may prove to be just as far-reaching and may have its own specific damaging effects. Thompson and Kaplan (1996) suggest that it has implications for development of insecure attachment, delay or damage to psychological development, and failure of physical growth. Outcomes involving adult depression and suicide attempts are explored in the companion article (Bifulco et al., 2002) and highlight the importance of acting to reduce the prevalence of psychological abuse.

We hope that the present discussion has advanced knowledge of psychological abuse not only by offering an operational definition, but also by providing a system by which it can be measured. The definition and measurement of psychological abuse are still evolving and are open to adjustment as new examples come to light. In the meantime, the current approach to definition and measurement may advance theory and research into this neglected area of childhood and will, we hope, ultimately contribute to the development of child protection policy. Arriving at a consensus regarding the definition of psychological abuse is of paramount importance. Not only does a definition aid future research into the prevalence and damaging effects of such ill-treatment, but it is also of use to child welfare agencies and judicial services aimed at child protection, where there is a pressing need for such a definition (Edmundson & Collier, 1993). However, what constitutes "actionable psychological abuse" (Garbarino, 1978, 1987) in legal and child protection terms may differ from the definition required for research purposes (Glaser & Prior, 1997). The definition presented here may offer a starting point for definitions required for use in other contexts, such as courts of law and social service child protection departments.

This study was funded by the Medical Research Council (program grant G702833; principal investigator, Professor George W. Brown). Additional funding was provided by the John T. and Catherine D. MacArthur Development and Psychopathology Network, which enabled the development of the measure and a training package. We would like to thank Ann Brackenridge, Julie Jarvis, Amanda Lillie, Amy Neubauer, Hedy Wax, and Caroline Campbell for the data collection and Laurence Letchford for computer analysis. Finally, we would like to express our gratitude to the general practitioners who allowed us access to their patients, and to the women themselves who participated in the study.


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By Patricia M. Moran, PhD; Antonia Bifulco, PhD; Caroline Ball, BSc; Catherine Jacobs, BSc and Kate Benaim, BA

The authors are with the Lifespan Research Group, Department of Health and Social Care, University of London, United Kingdom. Correspondence may be sent to Dr. Moran at the Lifespan Research Group, Department of Health and Social Care, Royal Holloway, University of London, 11 Bedford Square, London WC1, United Kingdom; e-mail: (Copyright 2002 The Menninger Foundation)



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Source: Bulletin of the Menninger Clinic, Summer2002, Vol. 66 Issue 3, p213, 28p
Item: 8506751



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