Skip to main content Accessibility help

A longitudinal study of several potential mediators of the relationship between child maltreatment and posttraumatic stress disorder symptoms

  • Chad E. Shenk (a1), Frank W. Putnam (a2), Joseph R. Rausch (a3), James L. Peugh (a3) and Jennie G. Noll (a1)...

Child maltreatment is a reliable predictor of posttraumatic stress disorder (PTSD) symptoms. However, not all maltreated children develop PTSD symptoms, suggesting that additional mediating variables explain how certain maltreated children develop PTSD symptoms and others do not. The current study tested three potential mediators of the relationship between child maltreatment and subsequent PTSD symptoms: (a) respiratory sinus arrhythmia reactivity, (b) cortisol reactivity, and (c) experiential avoidance, or the unwillingness to experience painful private events, such as thoughts and memories. Maltreated (n = 51) and nonmaltreated groups (n = 59) completed a stressor paradigm, a measure of experiential avoidance, and a semistructured interview of PTSD symptoms. One year later, participants were readministered the PTSD symptoms interview. Results of a multiple mediator model showed the set of potential mediators mediated the relationship between child maltreatment and subsequent PTSD symptoms. However, experiential avoidance was the only significant, specific indirect effect, demonstrating that maltreated children avoiding painful private events after the abuse were more likely to develop a range of PTSD symptoms 1 year later. These results highlight the importance of experiential avoidance in the development of PTSD symptoms for maltreated children, and implications for secondary prevention and clinical intervention models are discussed.

Corresponding author
Address correspondence and reprint requests to: Chad E. Shenk, Department of Human Development and Family Studies and The Network on Child Protection and Well-Being, Pennsylvania State University, 310E Biobehavioral Health Building, University Park, PA 16802; E-mail:
Hide All
Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical Psychology Review, 30, 217237. doi:10.1016/j.cpr.2009.11.004
Barnes, J. E., Noll, J. G., Putnam, F. W., & Trickett, P. K. (2009). Sexual and physical revictimization among victims of severe childhood sexual abuse. Child Abuse & Neglect, 33, 412420. doi:10.1016/j.chiabu.2008.09.013
Beauchaine, T. P., Gatzke-Kopp, L., & Mead, H. K. (2007). Polyvagal theory and developmental psychopathology: Emotion dysregulation and conduct problems from preschool to adolescence. Biological Psychology, 74, 174184. doi:10.1016/j.biopsycho.2005.08.008
Bentley, T., & Widom, C. S. (2009). A 30-year follow-up of the effects of child abuse and neglect on obesity in adulthood. Obesity, 17, 19001905. doi:10.1038/oby.2009.160
Blechert, J., Michael, T., Grossman, P., Lajtman, M., & Wilhelm, F. H. (2007). Autonomic and respiratory characteristics of posttraumatic stress disorder and panic disorder. Psychosomatic Medicine, 69, 935943. doi:10.1097/PSY.0b013e31815a8f6b
Bremner, D., Vermetten, E., & Kelley, M. E. (2007). Cortisol, dehydroepiandrosterone, and estradiol measured over 24 hours in women with childhood sexual abuse-related posttraumatic stress disorder. Journal of Nervous and Mental Disease, 195, 919927. doi:10.1097/NMD.0b013e3181594ca0
Breslau, N., Wilcox, H. C., Storr, C. L., Lucia, V. C., & Anthony, J. C. (2004). Trauma exposure and posttraumatic stress disorder: A study of youths in urban America. Journal of Urban Health, 81, 530544. doi:10.1093/jurban/jth138
Cameron, A., Palm, K., & Follette, V. (2010). Reaction to stressful life events: What predicts symptom severity? Journal of Anxiety Disorders, 24, 645649. doi:10.1016/j.janxdis.2010.04.008
Carpenter, L. L., Carvalho, J. P., Tyrka, A. R., Wier, L. M., Mello, A. F., Mello, M. F., et al. (2007). Decreased adrenocorticotropic hormone and cortisol responses to stress in healthy adults reporting significant childhood maltreatment. Biological Psychiatry, 62, 10801087. doi:10.1016/j.biopsych.2007.05.002
Carrion, V. G., Weems, C. F., Ray, R. D., Glaser, B., Hessl, D., & Reiss, A. L. (2002). Diurnal salivary cortisol in pediatric posttraumatic stress disorder. Biological Psychiatry, 51, 575582.
Chrousos, G. P., & Gold, P. W. (1992). The concepts of stress and stress system disorders. Overview of physical and behavioral homeostasis. Journal of the American Medical Association, 267, 12441252.
Cicchetti, D., & Blender, J. A. (2004). A multiple-levels-of-analysis approach to the study of developmental processes in maltreated children. Proceedings of the National Academy of Sciences, 101, 1732517326. doi:10.1073/pnas.0408033101
Cicchetti, D., & Dawson, G. (2002). Multiple levels of analysis. Development and Psychopathology, 14, 417420. doi:10.1017.S0954579402003012
Cicchetti, D., & Rogosch, F. A. (2001). Diverse patterns of neuroendocrine activity in maltreated children. Development and Psychopathology, 13, 677693.
Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. New York: Guilford Press.
Collishaw, S., Pickles, A., Messer, J., Rutter, M., Shearer, C., & Maughan, B. (2007). Resilience to adult psychopathology following childhood maltreatment: Evidence from a community sample. Child Abuse & Neglect, 31, 211229. doi:10.1016/j.chiabu.2007.02.004
Copeland, W. E., Keeler, G., Angold, A., & Costello, E. J. (2007). Traumatic events and posttraumatic stress in childhood. Archives of General Psychiatry, 64, 577584. doi:10.1001/archpsyc.64.5.577
Cuffe, S. P., Addy, C. L., Garrison, C. Z., Waller, J. L., Jackson, K. L., McKeown, R. E., et al. (1998). Prevalence of PTSD in a community sample of older adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 37, 147154. doi:10.1097/00004583-199802000-00006
Dale, L. P., Carroll, L. E., Galen, G., Hayes, J. A., Webb, K. W., & Porges, S. W. (2009). Abuse history is related to autonomic regulation to mild exercise and psychological wellbeing. Applied Psychophysiology Biofeedback, 34, 299308. doi:10.1007/s10484-009-9111-4
De Bellis, M. D., Hooper, S. R., Woolley, D. P., & Shenk, C. E. (2010). Demographic, maltreatment, and neurobiological correlates of PTSD symptoms in children and adolescents. Journal of Pediatric Psychology, 35, 570577. doi:10.1093/jpepsy/jsp116
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319345.
El-Sheikh, M., Harger, J., & Whitson, S. M. (2001). Exposure to interparental conflict and children's adjustment and physical health: The moderating role of vagal tone. Child Development, 72, 16171636.
El-Sheikh, M., & Whitson, S. A. (2006). Longitudinal relations between marital conflict and child adjustment: Vagal regulation as a protective factor. Journal of Family Psychology, 20, 3039. doi:10.1037/0893-3200.20.1.30
Foa, E., & Rothbaum, B. (1998). Treating the trauma of rape: Cognitive-behavioral therapy for PTSD. New York: Guilford Press.
Forman, E. M., Herbert, J. D., Moitra, E., Yeomans, P. D., & Geller, P. A. (2007). A randomized controlled effectiveness trial of acceptance and commitment therapy and cognitive therapy for anxiety and depression. Behavior Modification, 31, 772799. doi:10.1177/0145445507302202
Giaconia, R. M., Reinherz, H. Z., Silverman, A. B., Pakiz, B., Frost, A. K., & Cohen, E. (1995). Traumas and posttraumatic stress disorder in a community population of older adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 34, 13691380. doi:10.1097/00004583-199510000-00023
Gordis, E. B., Feres, N., Olezeski, C. L., Rabkin, A. N., & Trickett, P. K. (2010). Skin conductance reactivity and respiratory sinus arrhythmia among maltreated and comparison youth: Relations with aggressive behavior. Journal of Pediatric Psychology, 35, 547558. doi:10.1093/jpepsy/jsp113
Gordis, E. B., Granger, D. A., Susman, E. J., & Trickett, P. K. (2006). Asymmetry between salivary cortisol and alpha-amylase reactivity to stress: Relation to aggressive behavior in adolescents. Psychoneuroendocrinology, 31, 976987. doi:10.1016/j.psyneuen.2006.05.010
Gordis, E. B., Granger, D. A., Susman, E. J., & Trickett, P. K. (2008). Salivary alpha amylase-cortisol asymmetry in maltreated youth. Hormones and Behavior, 53, 96103. doi:10.1016/j.yhbeh.2007.09.002
Gratz, K. L., Bornovalova, M. A., Delany-Brumsey, A., Nick, B., & Lejuez, C. W. (2007). A laboratory-based study of the relationship between childhood abuse and experiential avoidance among inner-city substance users: The role of emotional nonacceptance. Behavior Therapy, 38, 256268. doi:10.1016/j.beth.2006.08.006
Hart, J., Gunnar, M., & Cicchetti, D. (1995). Salivary cortisol in maltreated children: Evidence of relations between neuroendocrine activity and social competence. Development and Psychopathology, 7, 1126.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press.
Hayes, S. C., Strosahl, K., Wilson, K. G., Bissett, R. T., Pistorello, J., Toarmino, D., et al. (2004). Measuring experiential avoidance: A preliminary test of a working model. Psychological Record, 54, 553578.
Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiental avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64, 11521168.
Heim, C., Newport, D. J., Heit, S., Graham, Y. P., Wilcox, M., Bonsall, R., et al. (2000). Pituitary–adrenal and autonomic responses to stress in women after sexual and physical abuse in childhood. Journal of the American Medical Association, 284, 592597.
Hillis, S. D., Anda, R. F., Felitti, V. J., Nordenberg, D., & Marchbanks, P. A. (2000). Adverse childhood experiences and sexually transmitted diseases in men and women: A retrospective study. Pediatrics, 106, E11.
Hopper, J. W., Spinazzola, J., Simpson, W. B., & van der Kolk, B. A. (2006). Preliminary evidence of parasympathetic influence on basal heart rate in posttraumatic stress disorder. Journal of Psychosomatic Research, 60, 8390. doi:10.1016/j.jpsychores.2005.06.002
Ivanova, J. I., Birnbaum, H. G., Chen, L., Duhig, A. M., Dayoub, E. J., Kantor, E. S., et al. (2011). Cost of post-traumatic stress disorder vs major depressive disorder among patients covered by Medicaid or private insurance. American Journal of Managed Care, 17, e314323.
Juster, R. P., Bizik, G., Picard, M., Arsenault-Lapierre, G., Sindi, S., Trepanier, L., et al. (2011). A transdisciplinary perspective of chronic stress in relation to psychopathology throughout life span development. Development and Psychopathology, 23, 725776. doi:10.1017/s0954579411000289
Keary, T. A., Hughes, J. W., & Palmieri, P. A. (2009). Women with posttraumatic stress disorder have larger decreases in heart rate variability during stress tasks. International Journal of Psychophysiology, 73, 257264. doi:10.1016/j.ijpsycho.2009.04.003
Kendall-Tackett, K. A., Williams, L. M., & Finkelhor, D. (1993). Impact of sexual abuse on children: A review and synthesis of recent empirical studies. Psychological Bulletin, 113, 164180.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593602. doi:10.1001/archpsyc.62.6.593
Kiess, W., Meidert, A., Dressendorfer, R. A., Schriever, K., Kessler, U., Konig, A., et al. (1995). Salivary cortisol levels throughout childhood and adolescence: Relation with age, pubertal stage, and weight. Pediatric Research, 37, 502506.
King, J. A., Mandansky, D., King, S., Fletcher, K. E., & Brewer, J. (2001). Early sexual abuse and low cortisol. Psychiatry and Clinical Neurosciences, 55, 7174. doi:10.1046/j.1440-1819.2001.00787.x
Lansford, J. E., Dodge, K. A., Pettit, G. S., Bates, J. E., Crozier, J., & Kaplow, J. (2002). A 12-year prospective study of the long-term effects of early child physical maltreatment on psychological, behavioral, and academic problems in adolescence. Archives of Pediatrics and Adolescent Medicine, 156, 824830.
Lemieux, A. M., & Coe, C. L. (1995). Abuse-related posttraumatic stress disorder: Evidence for chronic neuroendocrine activation in women. Psychosomatic Medicine, 57, 105115.
Linehan, M. M. (1993). Cognitive–Behavioral treatment of borderline personality disorder. New York: Guilford Press.
MacKinnon, D. P. (2008). Introduction to statistical mediation analysis. New York: Erlbaum.
MacKinnon, D. P., Lockwood, C. M., & Williams, J. (2004). Confidence limits for the indirect effect: Distribution of the product and resampling methods. Multivariate Behavioral Research, 39, 99128. doi:10.1207/s15327906mbr3901_4
MacMillan, H. L., Georgiades, K., Duku, E. K., Shea, A., Steiner, M., Niec, A., et al. (2009). Cortisol response to stress in female youths exposed to childhood maltreatment: Results of the youth mood project. Biological Psychiatry, 66, 6268. doi:10.1016/j.biopsych.2008.12.014
Marciniak, M. D., Lage, M. J., Dunayevich, E., Russell, J. M., Bowman, L., Landbloom, R. P., et al. (2005). The cost of treating anxiety: The medical and demographic correlates that impact total medical costs. Depression & Anxiety, 21, 178184. doi:10.1002/da.20074
Marx, B. P., & Sloan, D. M. (2002). The role of emotion in the psychological functioning of adult survivors of childhood sexual abuse. Behavior Therapy, 33, 563577. doi:10.1016/s0005-7894(02)80017-x
Maxwell, S. E., & Cole, D. A. (2007). Bias in cross-sectional analyses of longitudinal mediation. Psychological Methods, 12, 2344. doi:10.1037/1082-989x.12.1.23
McEwen, B. S., & Wingfield, J. C. (2003). The concept of allostasis in biology and biomedicine. Hormones and Behavior, 43, 215. doi:S0018506X02000247
Merikangas, K. R., He, J. P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., et al. (2010). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity Survey Replication—Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 49, 980989. doi:10.1016/j.jaac.2010.05.017
Miller, G. E., Chen, E., & Zhou, E. S. (2007). If it goes up, must it come down? Chronic stress and the hypothalamic–pituitary–adrenocortical axis in humans. Psychological Bulletin, 133, 2545. doi:10.1037/0033–2909.133.1.25
Miskovic, V., Schmidt, L. A., Georgiades, K., Boyle, M., & MacMillan, H. L. (2009). Stability of resting frontal electroencephalogram (EEG) asymmetry and cardiac vagal tone in adolescent females exposed to child maltreatment. Developmental Psychobiology, 51, 474487. doi:10.1002/dev.20387
Muthén, L. K., & Muthén, B. O. (1998–2010). Mplus user's guide (6th ed.). Los Angeles: Author.
Noll, J. G., Shenk, C. E., & Putnam, K. T. (2009). Childhood sexual abuse and adolescent pregnancy: A meta-analytic update. Journal of Pediatric Psychology, 34, 366378. doi:10.1093/jpepsy/jsn098
Perez, C. M., & Widom, C. S. (1994). Childhood victimization and long-term intellectual and academic outcomes. Child Abuse & Neglect, 18, 617633.
Plumb, J. C., Orsillo, S. M., & Luterek, J. A. (2004). A preliminary test of the role of experiential avoidance in post-event functioning. Journal of Behavior Therapy and Experimental Psychiatry, 35, 245257. doi:10.1016/j.jbtep.2004.04.011
Polusny, M. A., Rosenthal, M. Z., Aban, I., & Follette, V. M. (2004). Experimental avoidance as a mediator of the effects of adolescent sexual victimization on negative adult outcomes. Violence & Victims, 19, 109120.
Porges, S. W. (2003). The polyvagal theory: Phylogenetic contributions to social behavior. Physiology & Behavior, 79, 503513.
Porges, S. W., & Byrne, E. A. (1992). Research methods for measurement of heart rate and respiration. Biological Psychology, 34, 93130.
Porges, S. W., Cohn, J. F., Bal, E., & Lamb, D. (2007). The Dynamic Affect Recognition Evaluation (DARE) software. Chicago: University of Illinois–Chicago.
Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40, 879891.
Pruessner, J. C., Kirschbaum, C., Meinlschmid, G., & Hellhammer, D. H. (2003). Two formulas for computation of the area under the curve represent measures of total hormone concentration versus time-dependent change. Psychoneuroendocrinology, 28, 916931.
Rosenthal, M. Z., Cheavens, J. S., Lynch, T. R., & Follette, V. (2006). Thought suppression mediates the relationship between negative mood and PTSD in sexually assaulted women. Journal of Traumatic Stress, 19, 741745. doi:10.1002/jts.20162
Sack, M., Hopper, J. W., & Lamprecht, F. (2004). Low respiratory sinus arrhythmia and prolonged psychophysiological arousal in posttraumatic stress disorder: Heart rate dynamics and individual differences in arousal regulation. Biological Psychiatry, 55, 284290.
Sahar, T., Shalev, A. Y., & Porges, S. W. (2001). Vagal modulation of responses to mental challenge in posttraumatic stress disorder. Biological Psychiatry, 49, 637643.
Santa Ana, E. J., Saladin, M. E., Back, S. E., Waldrop, A. E., Spratt, E. G., McRae, A. L., et al. (2006). PTSD and the HPA axis: Differences in response to the cold pressor task among individuals with child vs. adult trauma. Psychoneuroendocrinology, 31, 501509. doi:10.1016/j.psyneuen.2005.11.009
Scheeringa, M. S., Zeanah, C. H., Myers, L., & Putnam, F. (2004). Heart period and variability findings in preschool children with posttraumatic stress symptoms. Biological Psychiatry, 55, 685691.
Scott, K. M., Smith, D. R., & Ellis, P. M. (2010). Prospectively ascertained child maltreatment and its association with DSM-IV mental disorders in young adults. Archives of General Psychiatry, 67, 712719. doi:10.1001/archgenpsychiatry.2010.71
Sedlak, A. J., Mettenburg, J., Basena, M., Petta, I., McPherson, K., & Greene, A. (2010). National Incidence Study of Child Abuse and Neglect (NIS–4), 20042009. Washington, DC: US Department of Health & Human Services, Administration for Children & Families, Office of Planning, Research & Evaluation.
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. Unpublished manuscript.
Shea, A., Walsh, C., Macmillan, H., & Steiner, M. (2005). Child maltreatment and HPA axis dysregulation: Relationship to major depressive disorder and post traumatic stress disorder in females. Psychoneuroendocrinology, 30, 162178. doi:10.1016/j.psyneuen.2004.07.001
Shenk, C. E., Putnam, F. W., & Noll, J. G. (2012). Experiential avoidance and the relationship between child maltreatment and PTSD symptoms: Preliminary evidence. Child Abuse & Neglect, 36, 118126. doi:10.1016/j.chiabu.2011.09.012
Stroud, L. R., Foster, E., Papandonatos, G. D., Handwerger, K., Granger, D. A., Kivlighan, K. T., et al. (2009). Stress response and the adolescent transition: Performance versus peer rejection stressors. Development and Psychopathology, 21, 4768. doi:10.1017/s0954579409000042
Sullivan, T. P., Meese, K. J., Swan, S. C., Mazure, C. M., & Snow, D. L. (2005). Precursors and correlates of women's violence: Child abuse traumatization, victimization of women, avoidance coping, and psychological symptoms. Psychology of Women Quarterly, 29, 290301. doi:10.1111/j.1471–6402.2005.00223.x
Tolin, D. F., & Foa, E. B. (2006). Sex differences in trauma and posttraumatic stress disorder: A quantitative review of 25 years of research. Psychological Bulletin, 132, 959992. doi:10.1037/0033-2909.132.6.959
Trickett, P. K., Noll, J. G., Susman, E. J., Shenk, C. E., & Putnam, F. W. (2010). Attenuation of cortisol across development for victims of sexual abuse. Development and Psychopathology, 22, 165175. doi:10.1017/s0954579409990332
US Department of Health and Human Services. (2010). Child maltreatment, 2009. Retrieved from
Widom, C. S. (1999). Posttraumatic stress disorder in abused and neglected children grown up. American Journal of Psychiatry, 156, 12231229.
Yehuda, R. (2001). Biology of posttraumatic stress disorder. Journal of Clinical Psychiatry, 62(Suppl. 17), 4146.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Development and Psychopathology
  • ISSN: 0954-5794
  • EISSN: 1469-2198
  • URL: /core/journals/development-and-psychopathology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed