Stress and Psychopathology in Children and Adolescents is There Evidence of Specificity

Journal of Child Psychology and Psychiatry 44:1 (2003), pp 107–133Stress and psychopathology in children and adolescents: is there evidence of speci¢city? Susan D. McMahon,1 Kathryn E. Grant,1 Bruce E. Compas,2 Audrey E. Thurm,1 and Sydney Ey3 1 DePaul University, USA; 2University of Vermont, USA; 3Pacific University, USA Research on the relations between specific stressors and specific psychological outcomes among children and adolescents is reviewed. Specificity, the notion that particular risk factors are uniquely related to particular outcomes is discussed from a theoretical perspective, and models of specificity are described. Several domains of stressors are examined from a specificity framework (e.g., exposure to violence, abuse, and divorce/marital conflict) in relation to broad-band outcomes of internalizing and externalizing symptoms. Studies that tested for specificity conducted within the past 15 years are examined, and definitional problems are highlighted. Little evidence for specificity was found. Methodological problems in the literature and the lack of theory-driven specificity research are discussed, and directions for future research are identified. Keywords: Stress, psychopathology, specificity, child, adolescent. Understanding the role of stress in the lives of children and adolescents is of both theoretical and practical significance. At the theoretical level, most prevailing models of developmental psychopathology recognize the potential importance of psychosocial stress in the etiology and maintenance of both internalizing and externalizing disorders in youth1 (e.g., Cicchetti & Toth, 1991, 1997; Haggerty, Sherrod, Garmezy, & Rutter, 1994; Rutter, 1989). At the practical level, conditions and problems continue to worsen for children and adolescents. Levels of poverty, violence, and family adversity appear to be increasing (Children’s Defense Fund, 1999), along with rates of emotional and behavioral problems in young people (Achenbach & Howell, 1993). Despite these trends, research on psychosocial stress and its relation to maladaptive outcomes in childhood and adolescence has lagged behind similar research with adults. Reviews concerning the impact of psychosocial stress on youth published in the past 15 years present a picture of a field early in its development (Cohen & Park, 1992; Compas, 1987; Johnson, 1986; Johnson & Bradlyn, 1988). In particular, research focused on testing theoretically-driven, developmentally-based models of specific relations between particular stressors and particular psychological outcomes has been lacking. Specificity refers to the determination that a particular risk factor is uniquely related to a particular outcome (Garber & Hollon, 1991). In psychopathology research, a focus on specificity reflects an attempt to move beyond Selye’s (1956) model in which ‘general change’ is associated with ‘general distress’. Understanding specific pathways that link risk with maladjustment (e.g., death of a parent is linked to We use the term ‘youth’ throughout this review to refer to children and adolescents. 1 depressive symptoms, but not disruptive behavior) is central to the goals of developmental psychopathology (Cicchetti & Cohen, 1995). Developmental psychopathology also considers equifinality, wherein many different avenues (of stressful experiences) can lead to the same outcome, and multifinality, in which similar conditions lead to multiple outcomes (Cicchetti & Toth, 1997). It is particularly important to examine specificity in children, as it is assumed that individual pathways evolve, and the causal processes contributing to these varied trajectories are multilevel. Developmental psychopathology acknowledges that many systems affect a child’s behavior, including family variables, larger contextual variables, environmental stressors, and biological vulnerability. In this way, a model of developmental psychopathology does not presuppose evidence exists for specificity of environmental stressors and outcomes, although it does not disregard this possibility. It is only through theoretical guidance and empirical study that we may examine the strength of multifinality, equifinality and their equilibrium or middle ground, specificity. In spite of the potential importance of this avenue of research, very few investigators have intentionally tested for specificity relations between particular stressors and particular psychological outcomes. Many studies have explored the relations between particular stressors and particular outcomes, yet to date there has been no attempt to integrate these findings. The purposes of the present review are to: 1) examine research on specificity relations between particular stressors and particular psychopathological outcomes, 2) summarize and integrate empirical findings, 3) define remaining concerns, and 4) highlight important directions for the next phase of research. The integration of these findings uses a lens of broad-band patterns of outcomes Ó Association for Child Psychology and Psychiatry, 2003. Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA 108 Susan D. McMahon et al. (i.e., internalizing versus externalizing behaviors). Although the field would benefit from moving toward a more narrow focus to capture the connections between specific stressors and specific outcomes, the variability in studies, particularly in terms of measurement and definition, and the lack of studies that focus on specificity, necessitate a more global review at this point in time. Methods of specificity research The basic methodological requirement for specificity research is that the stressful experience is categorized by type of stressor, the psychological outcome is categorized by type of psychopathology, or both stressor and outcome are categorized. Although stressors can be categorized in numerous ways, categorization by type of event is the most appropriate. Categorizations based on frequency, duration, or severity of stress are less appropriate for specificity research, as specificity effects may be confounded with additive effects of stress (Rutter, 1989; Garmezy, 1987). For example, there is considerable evidence for the additive (and even multiplicative) effects of stress, such that exposure to more stressful life events or to more severe stress is predictive of more severe psychological symptoms (Rutter, 1989). However, much additional work needs to be done in conceptualizing and measuring stressors in a manner that captures the complexity of stressors in order to establish a meaningful examination of specificity in relation to psychological outcomes. Categorization by type of stressful experience can be accomplished in several ways. Specific types of major life events may be compared. For example, parental divorce may be compared to death of a parent or child abuse. Major life events may also be subcategorized based on specific characteristics. For example, child abuse may be classified as physical abuse or sexual abuse (Manly, Cicchetti, & Barrett, 1994; Wolfe, Sas, & Wekerle, 1994). Exposure to violence may be classified as experienced versus witnessed violence, and chronic versus singular. One of the major challenges with this type of approach is that major events may subsume a large number of smaller events that have different characteristics. For example, divorce and exposure to violence may involve exposure to both conflict and loss. Another approach is to group individual stressors listed on cumulative measures of stressful life events based on theoretically derived categories. For example, events may be categorized as ‘achievement events’ versus ‘affiliative events’, or ‘loss events’ versus ‘conflict events’ (Sandler, Reynolds, Kliewer, & Ramirez, 1992). This type of categorization could be further refined to include various subcategories that describe stressors that are similar in nature in order to examine specificity between stressors and outcomes. For example, in terms of loss events, death of a parent due to physical illness could be differentiated from death of a parent as a result of acts of violence. Unfortunately, there is no agreed upon taxonomy of event characteristics, and theoretical characteristics may be highly correlated with one another. In order to understand the many complexities regarding understanding the influence of stressors on psychopathology, several steps need to be taken in order to develop a taxonomy of stressors for youth of various ages and backgrounds. Grant et al. (in press) suggest several steps to developing such a system. The first step would be to conduct structured interviews that assess events/circumstances as ‘objectively threatening to the health or well-being of youth’. Then, lists of stressors can be generated and level of threat can be evaluated by external raters, taking into account the context of the stressor. Checklists can be developed for children of various ages and backgrounds, and norms can be established, using a method similar to Achenbach’s method (1991; Achenbach and Dumenci, 2001) for examining psychopathology. Psychological outcomes can be categorized by type using several different approaches. Single symptoms, clusters of symptoms (or syndromes), or disorders may be compared. For example, studies using the CBCL (Achenbach, 1991) may report results in terms of specific symptoms (e.g., endorsement of depressed mood vs. temper tantrums), narrow-band syndromes (e.g., anxious-depressed syndrome vs. aggressive syndrome), or broad-band syndromes (internalizing vs. externalizing syndromes). Categorization of psychological outcomes is complicated by the comorbidity among different outcomes. In addition, there are many methodological difficulties when stressors and psychopathology are examined together, including contamination of stress and outcomes, common method variance, and time precedence. Beyond categorization of stress and psychological outcome, specificity research does not require a specific methodology per se. However, design of a study directly affects the type and degree of specificity that may be gleaned from the results. Models of specificity Three specificity designs have been utilized in the literature and are outlined in Figure 1: Stressor specific, Outcome specific, and Stressor-Outcome specific. The Stressor specific model includes several stressors and one outcome. This design allows for the identification of specificity of stressor in relation to a particular outcome, but does not allow for determination of specificity of outcome. In this model, the effect of each stressor on the outcome should be assessed independently of other stressors. The outcome could be identified as unique or common to various stressors. For example, Jarvelin, Moilanen, specific stressors linked to specific outcomes. limited to empirical studies published in scientific journals in English. it may be helpful to examine the results of available studies to take a closer look at the concept of specificity in relations between stressors and outcomes. A computer-generated search was conducted using the following keywords: stress (or events or hassles) and psychopathology (or psychological symptoms or psychological disorder) and child (or adolescent). divorce (or marital conflict). or moderated by child characteristics or environmental context (Grant et al. Theoretically. illness (or death). Thus. Brody and Forehand (1990) examined rates of internalizing and externalizing symptoms among children exposed to marital conflict and found that internalizing symptoms were associated with parental conflict while externalizing symptoms were not. it is important to acknowledge that they may influence our understanding of specific relations between stressors and outcomes.500 original empirical articles on the relation between stress and psychological symptoms during childhood or adolescence published in scientific journals between 1987 and 2001. because the last comprehensive reviews of . or community factors. Searches including these particular stressors were conducted because these stressors have not always been defined as stressors within specific studies but have received a great deal of research attention. Research from this era was selected. in the context of specific moderators) have been conducted. aggression). and Huttunen (1990) examined a number of stressful life events in relation to enuresis in children and found that divorce was the only stressful experience significantly related to enuresis. death of a parent may be linked to depressive symptoms. but this relation may be particularly strong for older (adolescent) females. (1992) utilized a StressorOutcome specific design to test the hypotheses that stressful events categorized as ‘conflict events’ would specifically predict externalizing symptoms and stressful events categorized as ‘separation events’ would specifically predict internalizing symptoms. since only one psychological outcome was examined. Optimally. depression. since only one stressful experience was examined. both the unique and common effects would be examined across different stressors. Sandler et al. mediating processes. poverty (or low income)..Specificity and stress 109 Figure 1 Models of specificity designs Vikevainen-Tervonen. however. However. in press). Stressor-Outcome specific models fully address whether a specific stressor is uniquely related to a specific outcome. However. Unlike Stressor specific and Outcome specific models. Sandler and colleagues (1992) found some evidence for their hypotheses (described further below). Using multiple categories of stressful experiences and multiple psychological outcomes. biological. or social processes. The Outcome specific model includes several outcomes but only one stressor. Method of review Literature was reviewed using both computer (PsychLit and PsychInfo) and manual methods (tracking citations). models of specificity exist within the framework of broader conceptual models that include moderators and mediators of the relation between stress and psychological symptoms as well as reciprocal and dynamic relations among these variables (see Figure 2). leaving approximately 1. the specific form of symptoms may differ as a function of individual. it is unknown whether other stressors would also predict high rates of internalizing symptoms relative to externalizing symptoms.g... For example. Specific relations between particular stressors and particular outcomes may be mediated by psychological.e. For example. Although examination of specific mediators and moderators are beyond the scope of this study. family. As a first step. Very few studies testing full specificity designs (i. The Stressor-Outcome specific model includes a heterogeneous sample of stressors and a range of psychological outcomes. Results of these additional searches were combined with the original search and duplicates removed. and the specific nature of the stressor. allowing for the identification of specificity among outcomes but not among stressors. via specific mediators. it is unknown whether divorce would also predict other outcomes in this sample (e. This search was repeated with specific additional stressors substituted for the stress term: abuse. Each of the stressors can be examined in relation to each of the outcomes. and may only exist when death of a parent is accompanied by additional household burdens. violence. 1991). and not disruptive behavior. allowing for specificity of both stressor and outcome to be determined (Garber & Hollon. 1974). examination of more specific psychological outcomes is not warranted (although many specific outcomes are reported in Table 1). psychological or physiological distress in response to external events. without intentionally setting out to do so. as these studies do not allow us to contrast psychological outcomes based on the broad categorization system of internalizing versus externalizing outcomes.. researchers included more than one stressor and more than one outcome in analyses focused on other research questions. as this definition is overly confounded with psychological symptoms. Some of the studies fit into more than one category. and findings of specificity for Stressor-Outcome studies (specificity. Johnson. and divorce/marital conflict. Figure 2 Conceptual model of the role of stress in the etiology of child/adolescent psychopathology (Grant et al. stressors were related to internalizing outcomes but other stressors within the same category were related to externalizing outcomes). and. Stressors that have been the focus of StressorOutcome specific studies include exposure to violence.. mixed specificity. Results of Stressor-Outcome and Outcome Specific studies are reviewed below. abuse. However. so these studies were not included in the review or the table. testing for specificity was not central to the research aims of most of these studies. Rather. specific relations examined were not guided by developmental psychopathology theory. examination of results of these studies is an essential first step toward evaluating the validity of specificity theory. and the variability in measurement of psychological outcomes in those studies that met inclusion criteria. We excluded studies using a pure ‘response-based’ definition of stress (i. Results of Stressor specific studies are not reviewed.e. has resulted in numerous studies with results regarding specificity effects. The major focus of this review is on the more rigorous Stressor-Outcome specific studies (summarized in Table 1) and on the broad categorization of internalizing versus externalizing outcomes. or as a transactional relationship (relationship between person and environment perceived as taxing or exceeding resources and endangering well-being. 1984). as determination of specificity of outcomes is most pertinent to the field of developmental psychopathology. 1986). Nonetheless. Approximately 15% of these studies (over 200 studies) tested for specific associations between particular stressors and particular outcomes (either cross-sectionally or longitudinally). we looked for consistent patterns of specificity. Results of Outcome specific studies are also briefly reviewed (but not presented in the table). Selye. no specificity) are presented in Table 1. in most cases. were included in this review. McMahon et al. the dearth of theory-driven studies. The relative ease with which studies may examine specificity relations. in press) this literature appeared approximately 15 years ago (Compas. Lazarus & Folkman..110 Susan D. or externalizing but not internalizing outcomes. only internalizing or externalizing outcomes were examined. so they are cross-referenced in Table 1. No evidence of specificity was reported when particular stressors were not related to either externalizing or internalizing outcomes or were related to both internalizing and externalizing outcomes.2 In each of the areas. In some cases. stressors within a particular category were related to internalizing but not externalizing outcomes. Mixed evidence for specificity was reported when there was not a consistent pattern of specificity (i.e. Given the preliminary nature of this review (it is the first to review evidence of specificity effects). 1987. Studies that defined stress as an environmental threat to the individual. 2 . That is. youth. domestic violence) (DYSSRDQ) (int & ext) Gorman-Smith & Tolan (1998) 245 youth (11–15 yrs at Time 1. 2% O) L (2 ts. 100%M. Exposure to violence was specifically related to depressive symptoms (but not general ext or int) Specificity for ext for sexual abuse: Sexual abuse was specifically related to externalizing behavior (relationship). motherreport income mother-report (CBCL) (int & ext) parent. 1 year apart) exposure to violence. 1 year apart) exposure to violence (CVS). & Koss (1995) 365 children (6–12 yrs. No Specificity for maltreatment: related to both int & ext behavior teacher report int & ext. oppositional behavior. separation anxiety. maltreatment (DSS records) Specificity and stress McCloskey. 2nd & 4th grade. exposure to domestic violence (CTS) self-report depressive sx (CDI). Pendergrast. parenting (modified PYS) witnessed battering of mother (CTS). mother to child) Author Sample Attar. 43% L) Durant. somatic & withdrawal symptoms (but not enuresis & encopresis) exposure to domestic violence (e. physical. 57% AA. 56% F. & Tolan (1994) 384 children (1st. 100% AA) C/S several types of exposure to violence (modified SECV). 50% F. obsessive-compulsive symptoms. physical fights. & Cadenhead (1994) L (2 ts. but other stressors were related to anxiety/depression. exposure to domestic violence was specifically related to domestic fighting Mixed Specificity: Exposure to violence was related to aggression & anxiety/ depression. delinquency. family relations (dev by au). child report PTSD sx (Levonn Measure). 50% F. depressive symptoms. conduct symptoms (gang fighting. partner to child.. 1 year apart) self-report cumulative stress scale (SI) teacher-report aggressive & anxious-depressed symptoms (TRF)(int & ext) Stress measure Outcome measure Findings Specificity for ext (not int): transitions & exposure to violence (but not circumscribed events) predicted aggressive symptoms cross-sectionally (not anxiousdepressed sx) & circumscribed events & exposure to violence (but not transitions) predicted aggressive symptoms over time Specificity for ext (not int): exposure to violence & victimization by violence was correlated with all types of conduct symptoms. & teacher report of anxiety/ depression & aggression (int & ext) 224 adolescents (11–19 yrs. Guerra. depression & anxiety (Checklist of Child Distress Symptoms) (int & ext) parent & self-report psychological disorders (CBCL. 2% O) in shelters or treatment C/S 111 . verbal. 62% AA. witnessed psychological abuse of mother (VAWS). 12% L.Table 1 Studies using ‘Stressor-Outcome’ designs to test for specificity between stress and symptoms (internalizing and externalizing) among children and adolescents Exposure to Violence Design C/S & L (2 ts. 47% AA) Lynch & Cicchetti (1998) 322 children (7–12 yrs): 188 maltreated. 51% F): 60 of battered women & 61 controls (53% W. stressful life events. anxiety. CAS) (int & ext) Mixed Specificity: exposure to domestic violence was associated with aggression. sexual. 35% L. 134 nonmaltreated (37% F. not aggression at Time 2 Specificity for int (not ext): exposure to battering of mother was associated with internalizing (but not externalizing) symptoms. 6% AA. Figueredo. 100% AA & L) & caregivers Levendosky & GrahamBermann (1998) C/S 121 children (7–12 yrs. partner to mother. hyperactivity. Exposure to psychological abuse of mother was associated with internalizing & externalizing symptoms No Specificity for poverty: Income was not associated with either internalizing or externalizing symptoms Mixed Specificity for exposure to violence: exposure to violence was related to ext & depressive symptoms.g. 53% W. 47% W. 90% W. 7% AS. 13% L. interparental verbal & physical abuse was associated with both depression & anxiety symptoms. & O’Leary (1987) in Abuse. 13% AA. 2% L. 21% AA. 8% O) C/S exposure to interparental violence &/or physical abuse (DFS reports) Sternberg. NFDP) Rossman. (1994) in Divorce/Marital Conflict. Marttunen et al. 44% W. Hann. 100% Chinese) See also Jouriles. 13% AA. 24% O). W) Tang (1997) 59 children (6–13 yrs): 21 in shelters. Lamb. 49% F. no specificity found for family conflict (related to both int and ext) Specificity for int (not ext): parental violence group exhibited heightened rates of parent-report internalizing symptoms (CBCL-PTSD) relative to other 2 groups & higher rates on of PTSD sx (PTSD-RI) (& dog attack group higher) than mild stress group. husband to wife verbal abuse & husband to child physical abuse were associated with depression & aggression symptoms. but father–child aggression was not related to either internalizing or externalizing No Specificity: both interparental aggression & physical abuse were related to both internalizing & externalizing behavior Specificity for int (not ext): witnessing violence & victimization were specifically related to internalizing syndrome. b). parent-report (CBCL) (int & ext) self-report of anxiety (STAI-C). modified PTSD-RI) & int & ext sx (CBCL). 27% O) & 42 mild stress controls (60% F. 31 controls (44%F. but not externalizing. mother–child aggression. Greenbaum et al. McMahon et al. 37% L. 32% AA. mother to child physical abuse was associated with aggression symptoms inter-parental verbal & physical abuse (mother report) or child abuse (verbal or physical) (modified CTS) Author Sample O’Keefe (1994a) 185 children (7–13 yrs. 59% F. (1996a. child physical abuse (modified CTS) parent-report exposure to violence (SECV).Table 1 Continued 112 Exposure to Violence Design C/S marital violence. dog attack group exhibited higher rates of child-report dissociative sx than children in the other 2 groups. See also Jouriles et al. 20 in tx. husband to child verbal abuse was associated with depression symptoms. Wewers. parent & child report mild stressors (modified LEQ) parent-report PTSD (CBCLPTSD. . Specificity for ext (not int): witnessing marital violence was associated with externalizing behaviors (no specificity for physical abuse)(parent report) (no specificity by child report) self-report depressive sx (CDI). 18 intact families (56% F. self-report PTSD sx (PTSD-RI & CDC) (int & ext) 53 children (9–12 yrs. 100% AA. father–child aggression (modified CTS) self-report inter-parental aggression. 42% W) in shelters C/S Susan D. 14 dog attack (29% F. int & ext syndromes (YSR). Barling. & Fick (1993) C/S maternal report parental violence (CTS).. 7% O) C/S Osofsky. CBCL) (int & ext) self-report (YSR) (int & ext) parent report (CBCL) (int & ext) Stress measure Outcome measure Findings Mixed Specificity: marital violence & motherchild aggression were both related to both internalizing & externalizing problems. (1993) C/S 110 children (8–12 yrs): 16 witnessed SV. 30 witnessed & abused. family conflict (CTS) parent report (SCSS. 53% L. & Emde (1997) 86 children: 30 parent violence (4–9 yrs. dog attack. 47% F. 33 physically abused.. 20% W. CDC. anxiety & aggressive symptoms. depression (DSRS) & parent-report of aggression (CBCL) (int & ext) Mixed Specificity: husband to wife physical abuse was associated with depression. Bingham. O’Keefe (1997) 935 adolescents (14–20 yrs. delinquency. non-parental family violence. & sexual acting out Stress measure Outcome measure Findings Author Sample Abuse Ackerman. sexual abuse (sexually coerced contact by adult) & boy sexual & physical abuse (based on admission) C/S sexual abuse. (1996) 105 abused children (12–18 yrs. 10% AA. NFDP C/S physical abuse (by adult family member).Table 1 Continued Design C/S physical abuse & sexual abuse. incest. nonparental family violence was specifically related to acting out at school (girls). conduct disorder. inpatient psychiatric unit self-report depressive sx (CDI). 28% AA) Bayatpour. Spirito. substance abuse & psychosis (DICA-R & clinical eval)(int & ext) No Specificity for physical or sexual abuse: for diagnoses based on type of abuse 113 . aggravated assault attempted kidnapping (dev by au) self-report symptoms of PTSD (SC-90-R. physical abuse. depression. 3% O) Caviola & Schiff (1988) 270 adolescents (13–18 yrs): 150 abused (51%F). & physical abuse & incest (treatment program & child abuse reporting records) Specificity and stress Cohen. parent & teacher report (CBCL. parental violence was associated with PTSD & acting out (but not sadness) (girls). 80%W. Sterling et al. (1992) 352 pregnant teenagers (12–19 yrs. TRF) (int & ext) Specificity for physical abuse ext (not int): physical abuse was specifically related to ODD & Conduct Disorder (DICA). DHS reports self & parent report 13 diagnoses (DICA). attempted kidnapping related to sadness in girls & acting out in boys sx of suicide. suicidal ideation & attempts (clinical interview) (int & ext) Boney-McCoy & Finkelhor (1995) 2000 children & adolescents (10–16 yrs. 48% F. behavior problems (YSR). modified by Sanders. Newston. Arata & Kilpatrick). sexual acting out (method not described)(int & ext) No Specificity for physical or sexual abuse: all abuse was related to symptoms of suicide. & acting out with teacher (dev by au)(int & ext) C/S self-report physical abuse or sexual abuse (clinical interview) self-report substance use. 69% F. violence by parents. genitalia violence was specifically related to PTSD & acting out at school (but not sadness) No Specificity for sexual assault Specificity findings by gender: simple assault relating specifically to sadness & acting out (but not PTSD)(boys). 60 controls (53%F). physical abuse was associated with more behavior problems than sexual abuse (CBCL) No Specificity for sexual abuse No Specificity for physical or sexual abuse: Both physical abuse & sexual abuse were significantly associated with suicidality & substance use in pregnant teenagers Mixed Specificity for physical abuse: aggravated assault specificity relating to PTSD & acting out at school (but not sadness). 19% W. 5% AS) C/S self-report of sexual assault. referred by hospitals & agencies. Wells et al. 72% W. attempted kidnapping was specifically related to PTSD. simple assault. (1998) 170 children (7–13 yrs): 127 sexually abused. 7% H. delinquency. personality disorder. McPherson et al. 63% L. 60 chemically dependent (39%F). sadness.. 14% AA.. 43 physically abused (49% F. NFDP). & Foa (1989) 87 children (3–13 yrs): 29 sexually abused. TRF). witnessing spouse/partner abuse (interview dev by au) Specificity for ext (not int) for physical abuse: physical abuse (& not witnessing spousal violence) was specifically associated with externalizing . 47% F.114 Table 1 Continued Design C/S physical abuse. motor excess (RBPC).. child report PTSD (DICA) (int & ext) teacher report & parent report int & ext syndromes (CBCL. 25 non-abused (100% Basque. McMahon et al. rating scales & interviews) parent & case coordinator report of sx of conduct disorder. sexually aggressive behavior (CBCL. compared to control group Specificity for sexual abuse and sexual acting out: sexual abuse (not physical abuse) found specifically related to reexperiencing symptoms of PTSD (e. 29 non-abused inpatient (47% F. Atkins. 33% L. 29 physically abused. physical neglect. 10% Haitian. motor excess. hospital medical records clinician reported sx of PTSD (re-experiencing phenomena. int & ext syndromes. 5% W. avoidance) Author Sample Susan D. psychosis. inattention. 2% O) DePaul & Arruabarrena (1995) 66 children (5–11 yrs): 17 physically abused. 38% H. or sexual acting out): sexual abuse (not physical abuse) was specifically associated with PTSD and not other outcomes No Specificity for physical abuse Feldman et al. McLeer. 1% AS) C/S physical abuse (agency report). sexually inappropriate behavior. anxietywithdrawal. (1995) 193 children (8–12 yrs): 106 physically abused. & hyperarousal). attention. NFDP) C/S parent report physical abuse and physical neglect (Child Abuse Potential Inventory (CAP)) teacher report of sx (TRF) (int & ext) Deblinger. 87 controls (29% F. teacher report (TRF). emotional abuse specifically related to socialized aggression. Claussen.. 37% AA. DICA). physical neglect specifically related to inattention. both. & Sugerman (1994) 100 maltreated children (6–17 yrs. 56% AA. 33% AA) C/S sexual abuse & physical abuse (psychiatric facilities & government agencies for abuse) Specificity for sexual abuse int (not ext. 24 physically neglected. peer report of acceptability (dev by au) (int & ext) Dykman et al.g. sexual acting out. avoidance behavior. somatic complaints (dev by au) (int only) parent report PTSD (DICA). sexual acting out. NFDP) C/S sexual abuse. physical abuse. (1997) 125 children (8–12 yrs): 109 abused in treatment & 16 controls (57% F. suicidal ideation. 18% W. psychotic symptoms. 67% W. emotional neglect specifically related to inattention symptoms No Specificity for neglect Specificity for int (not ext) for physical abuse: physical abuse was specifically related to internalizing symptoms Specificity for ext (not int) for neglect: physical neglect was specifically related to externalizing symptoms. aggression. anxiety-withdrawal. Crittenden. risk for abuse & psychological maltreatment (standardized assessments. Ralph. self-report depressive sx (CDI)(int & ext) Stress measure Outcome measure Findings Specificity for int (not ext) for physical abuse: physical abuse & depressive symptoms specifically related. anxiety withdrawal. 38 inpatient. 100%M. violent acts) (dev by au) (int & ext) Specificity for sexual abuse int (not ext) & sexual acting out: sexual abuse was specifically related to sex items on the CBCL (parent report). 10% O): 37 sexually abused (76% F). parent–child aggression (CTS) 115 . 9% AA) (412 abused) C/S self-reported incest. 52% F) from maritally violent homes C/S parent report. anxiety-withdrawal. somatic complaints. sexual abuse was also found to be specifically related to lowered noncompliance No Specificity for physical abuse No Specificity for physical or sexual abuse: all three types of abuse were associated with eating disorders. nonincest sexual abuse. & Bengtson (1997) 350 children (7–18 yrs): 72 inpatient sexually abused (80%F). suicidal ideation (int & ext) self-report eating disorder (2 of: binge eating. & Sack (1988) 202 children (0–7 yrs. suicidal thoughts. withdrawal. attention problems. 75 control (56% F. suicidal thoughts. C-SBI) (int & ext) Stress measure Outcome measure Findings Author Sample Friedrich. & O’Leary (1987) 45 children (5–13 yrs. substance use Hernandez (1995) 6224 children (6th. Jaworski. TSC-C. aggression. 130 nonabused (42% F) C/S sexual abuse. Huxsahl. incest. 90% W. affective disorder. suicidal & delinquency sx (sexual aggressiveness. anxiety. witnessing inter-spousal aggression. Lodico. duration & nature of sexual abuse (but not physical abuse) predicted dissociation No Specificity for physical abuse Specificity for sexual abuse int (not ext) & sexual acting out: sexual abuse was specifically related to sexual behavior problems (compared to physical abuse & no abuse). sexual concerns (R. likely abused (68% F). CBCL). no specificity found for sexual concerns (no other variables predicted it). or extrafamilial sexual abuse (interview dev by au) Hernandez. anxiety sx. 9th & 12th graders. anxiety. motor excess & socialized aggression (parent report. physical abuse self-report sx of dissociation (TSC-C). & motor excess in boys. Thompson. anxiety-withdrawal. some specificity was found for dissociation symptoms. 35 physically abused (51% F). noncompliance. Moran. 165 inpatient control (42% F). inappropriate sexual behavior. CDC. parent report MMPI. inattention. but only related to anxietywithdrawal in girls Specificity and stress Jouriles. but not by child report. physical (dev by au) Specificity for sexual abuse ext (not int or sexual acting out): sexual abuse (both incest & extrafamilial) was specifically related to drinking problems (compared to physical abuse). using laxatives or vomiting). depression. & DiClemente (1993) 2983 adolescents (9th & 12th grade. Barling. substance use (dev by author)(int & ext) self-reported substance abuse.Table 1 Continued Design C/S history of sexual abuse. & withdrawal symptoms (compared to no abuse). 7% AA) C/S self-report physical abuse. 91% W. 48% F. no specificity for sexual aggression (high in both abuse groups) or for other delinquency behaviors (high in both groups except for a specific relation between sexual abuse & truancy) No Specificity for physical abuse symptoms of conduct. ‘most W’) Gale. physical abuse (referral from DSS & clinical evaluation) therapist report sx of depression. R-BPC) (int & ext) Mixed Specificity for physical abuse: parent–child aggression was related to conduct problems. 8% AI. 85% W. psychosis. 91% AA. withdrawal. # parents in home. neglect (medical records. Conners’ Teacher Rating Scale) PTSD (SKID-NP). Parental Bonding Instrument. anxiety disorders. & cigarette smoking. separation from parent. court documented) . 15 physically abused (44% F. Lawson. 100%M. dysthymia. disruptive disorders. For lifetime disorders. PTSD. anxiety. withdrawal (SASC) & aggression. but not ADHD or PTSD. McMahon et al. somatization. 72% W. anxiety. available school & medical info (int & ext) Stress measure Outcome measure Findings Mixed Specificity for physical abuse: for current diagnoses. 57% AA. 100% W) Kolko. depressive disorders.. sexual behavior. physical abuse (clinic reports of abuse) Mixed Specificity for sexual abuse: sexual abuse associated with ADHD. separation anxiety disorder. and one psychotic symptom. Kaplan et al. drug abuse or dependence. 43%W) C/S physical abuse. abuse increased the risk for being diagnosed with unipolar depressive disorders. FACES. 99 physically abused. PTSD. & 21 controls (52%F. 43% W). 9% W) C/S mother’s use of violence (CTS). 52 physically abused (27% F. 99 nonabused (50%F. & Jones (1993) 41 clinic-referred children (6–15 yrs): 26 sexually abused. sleep problems. Moser. 42% AA). head trauma depressive disorders. depression No Specificity for physical abuse Author Sample Susan D. depression (hospital chart review) (int & ext) self-report behavior disorders. family stresses (FILE) Prino & Peyrot (1994) 68 children (5–8 yrs): 21 physically abused (52% F. withdrawal. abuse increased risk of major depression. psychotic symptoms (DICA-6-R) (int & ext) parent and teacher report internalizing and externalizing syndromes (TRF. somatization symptoms. conduct disorder. physical exams & Sexual Abuse Symptom Checklist (dev au) parent report sx of sexual activity. CBCL) (int & ext) teacher reports aggressive and withdrawn behavior (PASS) (int & ext) Livingston. 48% W) C/S sexual abuse. disruptive disorders. (1997) 198 abused adolescents (12–18 yrs). only one psychotic symptom was found specifically related to sexual abuse No Specificity for physical abuse Specificity for int (not ext) for physical abuse: mother’s use of violence & family stress were associated with internalizing problems (but not externalizing) Specificity for ext (not int) for physical abuse: physical abuse was specifically related to aggressive behavior (compared to neglect or control). anxiety. 58% W. conduct problems. but not ADHD or PTSD Specificity for sexual abuse int (not ext) & sexual acting out: sexual abuse was specifically related to sexual activity.116 Table 1 Continued Design C/S physical abuse (state records). & cigarette smoking. child protective services. substance abuse (SADS for children. 26 neglected (27%F. 52% AA. & Weldy (1988) 103 inpatient children (5–14 yrs): 29 sexually abused. Specificity for int (not ext) for neglect: neglect was specifically related to withdrawn behavior (compared to abuse and control) Murata (1994) 23 children (8–12 yrs. 57% AA. 28% AA) C/S sexual abuse. depression. physical abuse (medical chart record). 23% F. 7% Aborigine. 17% F. parasomnias)(not depression) No Specificity for physical abuse Specificity for sexual abuse int (not ext) sexually (but not physically abused) participants were more likely. 99% W. attention problems. Drinkwater et al. depressive symptoms. somatic complaints. 50% F. oppositional symptoms. anxiety-depression. NFDP) from psychiatric inpatient unit Sadeh. & withdrawal. 46% F. Reinherz. Halpin. 38% AA. attention problems. children of parental substance abusers & abused were more likely to be diagnosed with schizophrenia or ODD. Levoy. & suicidal ideation.. thought problems. delinquent behavior. 93% O) C/S self-report sexual & physical abuse interview questions (dev by au) self-report substance use & suicidality sx (interview dev by au) (int & ext) Silverman. anxiety-depression. thought problems. Matzko. withdrawal. social problems. aggressive behavior (YSR) & symptoms of depression. Strom. somatic complaints. oppositional (MCDI) (int & ext) Specificity for sexual acting out: sexual abuse was specifically associated with sexual acting out (but not other symptoms) No Specificity for neglect 117 . & suicidal ideation (girls) self-reported psychological syndromes (YSR). & Seifer (1992) 109 children (4–14 yrs. physical &/or sexual abuse (intake. 6 yrs apart) & C/S physical abuse. DSM-IIIR diagnoses (interview) (int & ext) Sibthorpe. & Giaconia (1996) 375 adolescents (15 yrs at time 1 & 21 at time 2.e. 46% F. anxiety. clinical information) clinician report of DSM-IIIR diagnoses (clinical evaluation) (int & ext) Mixed Specificity for physical and sexual abuse: physical &/or sexual abuse was associated with dysphoric mood. neglect (hospital-referred) sexual acting out.Table 1 Continued Design C/S parental substance abuse. to have attempted suicide No Specificity for physical abuse Mixed Specificity for physical and sexual abuse: sexual abuse was associated with somatic complaints. 23 controls (NFDP) sexual abuse. sexual abuse (clinical interview) Threlkeld & Thyer (1992) 117 children in tx (<17 yrs. 7% O) C/S Specificity and stress C/S sexual abuse & physical abuse (record review) White. physical abuse was associated with suicidal ideation (boys). (1994) 100 inpatient children (2–13 yrs. depressive symptoms (CDI) anxiety (PHSC-S) & suicidal ideation (CDI) (int & ext) dSM diagnoses (no method identified) (int & ext) No Specificity for physical or sexual abuse Stress measure Outcome measure Findings Author Sample Rivinus. 18 neglected. & Santilli (1988) 58 children (26 yrs): 17 sexually abused. (1995) 155 Australian youth (12–17 yrs. 1% O) L (2 ts. Hayden et al. sexual abuse was specifically related to PTSD (compared to physical abuse or no abuse) & sleep problems (i. aggressive behavior. NFDP) C/S sexual abuse &/or physical abuse (from child & parent interview) self-reported depression symptoms (CDI). obsessive-compulsive symptoms & learning disabilities Specificity for sexual abuse int (not ext). 55% W. parental substance abuse was associated with enuresis. PTSD & Borderline Personality Disorder. than those not abused. anxietywithdrawal and attention problems (RBPC) (int & ext) Stress measure Outcome measure Findings Author Sample Susan D. aggression. marital dissatisfaction (DAS) parent & teacher report ext & int sx (RBPC) (int & ext) Mixed Specificity: family conflict more associated with child problems than marital satisfaction. O’Keefe (1994. McCloskey. Sternberg et al. Williamson. sexual abuse (Juvenile Court) parent report of total sx (SCL-90-R). poor marriages (57) & good marriages (62) C/S . & Howe (1991) 50 adolescents (12–17 yrs. 82% F). NFDP) Jenkins & Smith (1990) 119 British children (9–12 yrs). family conflict & witnessed marital conflict (but not marital satisfaction) predicted externalizing problems at time 1 & 2 & internalizing problems at time 1.. 12 neglected. covert tension. conduct. child reports indicated that all types of conflict were related to externalizing problems. discrepancy in reading (MMRS interview) David. witnessed marital conflict predicted internalizing problems at time 1 (teacher report) 31 int & ext behavioral sx. all 3 types of abuse (compared to control) were associated with attention problems Mixed Specificity for sexual abuse: sexual abuse was associated with conduct problems and anxietywithdrawal (compared to control) Specificity for ext (not int) for neglect: Neglect was associated with conduct problems (compare to control) and socialized aggression (compared to sexual abuse and control) See also Lynch & Cicchetti (1998). McMahon et al. marital satisfaction predicted externalizing problems at time 2. (FES).118 Table 1 Continued Design C/S neglect. 11 control (75–92% W. Figueredo. 8–25% AA) Specificity for ext (not int) for physical abuse: physical abuse was specifically associated with conduct problems and socialized aggression (compared to control). & Armistead (1996) 146 adolescents (11–15 yrs. 1997). 52% F. 1 year apart) family conflict. physical abuse. (1993) & Tang (1997) in Exposure to Violence Divorce/Marital Conflict L (2 ts. witnessed marital conflict only predicted internalizing at time 2 (mother report). & Koss (1995). Borduin. witness of marital conflict (OPS). Forehand. 15 sexually abused. 12 physically abused. but not internalizing problems (no differences for parent reports) overt parental conflict. parent report & child report (interview dev by Graham & Rutter plus ICD9 criteria)(int & ext) Specificity for ext (not int): there were more correlations between overt parental conflict & child behavior problems than for covert tension or discrepancy in child rearing practices. int sx (SCL-90 depression & hostility subscales). parental divorce. McDonald. & Vincent (1996b) C/S parental violence. & behavioral) (CTS) parent-report externalizing and internalizing behavior (conduct & personality subscales of the BPC) (int & ext) Specificity for ext (not int): physical marital aggression and other forms of marital aggression both related to externalizing (but not to internalizing problems)..Table 1 Continued Design C/S marital aggression (physical. Henriksson. 100% Finnish) who committed suicide See also Conger et al. conflicts. 17% F. interpersonal separations were more common among alcohol abusing victims than depressive victims. 66% F. 1994) in Poverty Poverty C/S parent-report economic hardship scale. observer-report marital conflict measure (dev by au) self-report hostility symptoms (modified BDHS). 100% W) Specificity and stress Mixed Specificity for poverty: economic hardship indicator ‘debts to assets ratio’ was associated with sibling-report hostility symptoms. 39% W. & Vincent (1996a) 55 children (5–12 yrs. Lorenz. & Whitbeck (1992) 205 adolescents (7th grade) (100% M. verbal. Norwood. ‘material needs’ & ‘economic adjustments’ were associated with self-report internalizing symptoms & economic pressure indicator ‘material needs’ was associated with sibling-report hostility symptoms Specificity for ext (not int) for marital conflict: marital conflict was associated with self-report (but not sibling-report) hostile symptoms (but not self-report internalizing symptoms) 119 . separations. substance abuse & other disorders (int & ext) 199 children (5–12 yrs. stressor specific: other forms of aggression were more specifically related to externalizing problems than physical aggression Mixed Specificity: physical aggression was specifically related to externalizing & other forms of marital aggression were specifically related to internalizing Specificity for ext (not int): parental violence was more common among alcohol abusing victims than among depressive victims. Aro. economic pressure indicators ‘make ends meet’. Conger. 95% W. economic pressure. 5% O) from families seeking marital therapy Jouriles. Jr. (1992. & Lonnqvist (1994) 53 adolescents (13–19 yrs. 37% L) in battered women’s shelters C/S marital aggression. Simons. (archival records. clinician & parent-report depressive disorder. 24% AA. Norwood. 1993. divided into physical violence & other forms of aggression (CTS) parent report (CBCL) (int & ext) Marttunen. Elder. siblingreport hostility sx (dev by au) (int & ext) Conger. clinicianreport stress interviews) (dev by au) composite of archival. 47% F. McDonald. Specificity by gender: interpersonal conflicts were more common among alcohol-abusing male (but not female) victims than depressive victims Stress measure Outcome measure Findings Author Sample Jouriles. parent-report stress interviews. Conger. Simons et al. & Gore (1993) 918 adolescents (9th–11th grade. graduation status (dev by au) self-report depressive sx (CES-D). delinquency (modified BDS) (int & ext) Specificity: family & friend stress predicted depressive symptoms (but not alcohol abuse symptoms). friend relationship stress scale. Banis.. 100% W) See also Levendosky & Graham-Bermann (1998) in Exposure to Violence Illness C/S established illness (patients recruited based on physician diagnosis) parent-report int & ext sx (CBCL) (int & ext) Specificity: no differences between groups on internalizing. 7th grade. Jr. Lorenz. 52% F. observer-report marital conflict was associated with 3 of the 4 externalizing measures (all but self-report aggressive behavior) Stress measure Outcome measure Findings Author Sample Susan D.. 59% F. Lorenz. 30 chronic obesity. Conger.. Elder. Jr. 1 year apart) self-report family relationship stress scale. economic pressure. Varni. Babani. observer-report marital conflict (dev by au) self-report hostility sx (modified BDHS). 100% W) . 100% W) Conger. 1 year apart parent-report economic hardship scale. & trait anxiety (int). & Simons (1994) L (3 ts. sibling-report hostility sx (dev by au) (int & ext) Specificity for ext (not int) for poverty: economic hardship indicator ‘debts to assets ratio’ was associated with selfreport hostility symptoms. 77 spina bifida. marital conflict.120 Table 1 Continued Design C/S parent-report economic hardship scale. cerebral palsy group lower on social competence Wallander. but decreases in depressive symptoms Aseltine. & aggression (ABS-dev by au) (int & ext) 378 adolescents (7th grade. graduation from high school predicted increases in alcohol abuse symptoms. economic pressure. friend (but not family) stress predicted increases in delinquent symptoms. Mixed Specificity for marital conflict: father-report marital conflict was associated with trait hostility (ext). int sx (SCL-90 depression. Ge. alcohol use (dev by au). SCL-90 & NEO-personality hostility subscales). juvenile rheumatoid arthritis lower on externalizing than other groups. hostility. McMahon et al. No Specificity for marital conflict: marital conflict was associated with all three symptom measures No Specificity for poverty: no poverty indicators were associated with symptoms. Jr. Elder. economic hardship indicator ‘income loss’ was associated with sibling-report hostility symptoms. 24 juvenile rheumatoid arthritis. & 19 with cerebral palsy Cumulative Stress L (2 ts. & Wilcox (1988) 270 children: 80 diabetes. anxiety. 40 hemophilia. ext sx (modified BDHS. somatization subscales). observer-report marital conflict (dev by au) self-report depression & anxiety sx (SCL-90 & NEO-personality anxiety & depression subscales). (1993) 220 adolescents (12–14 yrs. 100% F. Gotlib. C-SBI ¼ Child Sexual Behavior Inventory. HURTE ¼ Hurricane-Related Traumatic Experiences. 74 controls See also Attar. SI ¼ Stress Index. 9% O) Sandler. PHSC-S ¼ Piers-Harris Self Concept Scale. L ¼ Longitudinal. DSRS ¼ Depression Self-Rating Scale. CBCL-PTSD ¼ Child Behavior Checklist Post-traumatic Stress Disorder. & Seeley (1995) 1507 adolescents (14–18 yrs at Time 1. Kliewer. M ¼ male. LER ¼ Life Events Record. GLESC ¼ General Life Events Schedule for Children. R ¼ Rorschach. & Tolan (1994) in Exposure to Violence General Abbreviations Key F ¼ female. SCL ¼ Symptom Checklist. SECV ¼ Survey of Exposure to Community Violence. Reynolds. O ¼ Other. SASC ¼ Sexual Abuse Symptom Checklist. STAIC-TF ¼ State Trait Anxiety Inventory for Children-Trait Form. PTSD-SS ¼ PTSD Symptom Scale. 94 whose parents had divorced. BPI ¼ Behavior Problems Index. RBPC ¼ Revised Behavior Problem Checklist. DYSSRDQ ¼ Denver Youth Study Self Reported Delinquency Questionnaire. CAS ¼ Child Assessment Schedule. PBQ ¼ Preschool Behavior Questionnaire. 92 who had lost a parent. FES ¼ Family Environment Scale. NFDP). SCSS ¼ Survey of Children’s Stress Symptoms. C/S ¼ Cross-sectional. L ¼ Latino. events categorized as ‘conflict events’ & ‘loss events’ self-report depression (CDI) & conduct disorder sx (YHS) (int & ext) self-report conflict with parents & parental death (psychosocial interview dev by au) self-report major depressive disorder & substance abuse disorder (K-SADS) (int & ext) Stress measure Outcome measure Findings Mixed Specificity: those with higher rates of conflict with parents (but not parental death) were more likely to be depressed & use substances Specificity: conflict (but not loss) events were associated with conduct (but not depression) sx. PTSD-RI ¼ PTSD Reaction Index. & Ramirez (1992) 359 youth (8–16 yrs. 1 year apart) C/S & L self-report cumulative stress scale (GLESC) & interview (dev by au). OPS ¼ O’Leary Porter Scale. NFDP ¼ no further demographic information provided. CDI ¼ Child Depression Inventory. GI ¼ Grief Index. PYS ¼ Pittsburgh Youth Study. RCMAS ¼ Revised Children’s Manifest Anxiety Scale. DICA ¼ Diagnostic Interview for Children & Adolescents. MMRS ¼ Maudsley Marital Rating Scale. KSADS ¼ Schedule for Affective Disorders and Schizophrenia. ts ¼ Data Collection Time Points. Specificity and stress 121 . BDHS ¼ Buss & Durkee Hostility Scale. AI ¼ American Indian. CVS ¼ Community Violence Survey. JMAS ¼ Jesness Manifest Aggression Scale. loss (but not conflict) events were associated with depression (but not conduct) sx. MMRS ¼ Maudsley Marital Rating Scale. 91% W. HCSI ¼ Hispanic Children’s Stress Inventory. TRF ¼ Teacher Report Form. AS ¼ Asian-American. CDC ¼ Child Dissociative Checklist. TSC-C ¼ Trauma Symptom Checklist-Children. YSR ¼ Youth Self Report.Table 1 Continued Design L (2 ts. DICA-R ¼ Diagnostic Interview for Children & Adolescents Revised. CCDS ¼ Checklist of Child Distress. FILE ¼ Family Inventory of Life Events. int ¼ internalizing. 54% F. 43% F. Guerra. YHS ¼ Youth Hostility Scale. LEQ ¼ Life Events Questionnaire. Stress Measures Key CTS ¼ Conflict Tactics Scale. P-PTSD-S ¼ Purdue PTSD Scale. CBCL ¼ Child Behavior Checklist. opposite pattern in sample of youth whose parents had recently divorced Author Sample Lewinsohn. ext ¼ externalizing. DAS ¼ Dyadic Adjustment Scale. DIS ¼ Diagnostic Interview Schedule. Outcome Measures Key ABS ¼ Aggressive Behavior Scale. MCDI ¼ Minnesota Child Development Inventory. BDS ¼ Bachman Delinquency Scale. W ¼ White/European American. WWPS Werry Weiss Peters Scale. VAWS ¼ Violence Against Women Scale. AA ¼ African American. BORRTI ¼ Bell Object Relations & Reality Testing Inventory. dev by au ¼ developed by authors. PASS ¼ Pittsburgh Adjustment Survey. 99 w/ asthma. Outcomes examined include PTSD.e. Lynch & Cicchetti. Borduin. 1991). somatization. O’Keefe. Aro.. Of these studies. 1995. Bayatpour. McMahon et al. Flisher. general anxiety. 1993. 1996. Osofsky.. Reinhertz.. & Giaconia. and three reporting specificity for internalizing outcomes (Crittenden.. Bingham. Silverman. Norwood. Brent. DePaul & Arruabarrena. Among those reporting specificity. 1994a.. In most cases.. and broad-band internalizing and externalizing syndromes. & O’Leary. & Greenwald. & Tolan. 1991). Results of Outcome specific studies reveal a similar pattern of findings.. 1996) while one found specificity for externalizing outcomes (Cooley-Quille. Of the sixteen StressorOutcome specific studies examining both internalizing and externalizing outcomes. For example. 1993. & Roosa. Pelcovitz et al. sexual abuse. 1996. thus limiting conclusions that may be drawn. & Canobbio. Moritz. 1993. Prino & Peyrot. Jouriles. 1996. Jouriles et al.e. Feldman et al.. and suicide of a peer. 1988. general anxiety. withdrawal. and aggression symptoms. Schwab-Stone et al. Four of these studies. 1995.. White. Turner. Rossman. Abuse Thirty-three Stressor-Outcome specific studies tested for specific relations between child abuse and particular internalizing and externalizing psychological outcomes (see Table 1). & Beidel. Williamson. PTSD) and externalizing (i. six reported specificity for internalizing outcomes (Dykman et al. Halpin. failed to find evidence of specificity (Glod & Teicher. and neglect. and war violence. Newton. Claussen. & Sugerman. The two studies that found evidence of specificity reported evidence of specificity for externalizing outcomes (Hennessy. Perper. we grouped outcomes into internalizing (i. attention problems. which examined both internalizing and externalizing outcomes. 1993. 1988. Moritz. depression. two outcome-specific studies reporting specificity effects found specificity for internalizing (Brent. Hann. Rivinus. Downey & Bergman. sexual acting out. . Pendergrast. & Holford. Livingston. delinquency. & Emde. Allman et al. substance abuse) categories. 1997).. & Santilli. 1995). Spaccarelli. 1996. substance abuse. 1996. Levoy. Threlkeld & Thyer. Henriksson. & Lonnqvist. Sternberg et al. aggression. Guerra. Nineteen Stressor-Outcome specific studies examined both internalizing and externalizing outcomes in relation to sexual abuse. Durant. & Cummings. Williamson et al. Specific types of abuse examined include physical abuse. A theory-based explanation for these discrepant findings is suggested by the fact that both of the studies reporting specificity for internalizing symptoms focused on experiences that may also be conceptualized as loss events (i. O’Keefe. & Mahoney. Vincent. 1994. Perper. few of these studies used the same measures of stressors and outcomes. Friend et al. & Seifer. 1995. attention problems. withdrawal. as a whole. & Cadenhead. McCloskey. & Koss. & Jones. Unfortunately. Pfeffer et al. Wells. Jouriles. 1994. Moritz.. thus limiting conclusions that may be drawn. 1989). Exposure to the following specific types of violence has been examined: domestic violence. Figueredo. 1996. one-half of the studies reported evidence of mixed specificity or no specificity for particular outcomes (Gorman-Smith & Tolan. 1992. 1993). with four reporting specificity for externalizing outcomes (Ackerman. Shaffer & Smith.. Murata. eating disorders. Freeman et al. seven studies demonstrated evidence for specificity. aggression. few of these studies used the same measures of stressors and outcomes. 1998. Caviola & Schiff. & Fick. & Howe. Perper. Trickett. As with exposure to violence studies. 1993. which suggests a pattern inconsistent with the one found in Stressor-Outcome specific studies. oppositionality. Friend et al. depression symptoms. 1994. To examine general patterns across this disparate body of studies. 1994. Cohen et al. Twelve of these failed to find evidence of specificity (Ackerman et al. McDonald. 1995). Marttunen. 1998. 1994). 1995. 1997. Walker. Hernandez. study 1. 1994. 1987. Tang. Wewers. and broad-band internalizing and externalizing syndromes. Rabideau. BoneyMcCoy & Finkelhor.122 Susan D. Jones. 1993). PTSD. Bridge. 1994. these particular types of abuse were compared with one another in relation to several specific outcomes. 1998. Of the 33 Stressor-Outcome specific studies focusing on abuse. murder of a sibling. 1992. Exposure to violence Sixteen Stressor-Outcome specific studies tested for specific relations between exposure to violence and particular internalizing and externalizing psychological outcomes (see Table 1). study 2. Freeman. However. Abuse. McPherson.. 1998. Sandler. Specific outcomes examined include suicidality. Moritz. Perper. 31 studies examined internalizing and externalizing outcomes related to physical abuse. Lawson. 1997. 1994. the four studies using the most similar methodology (all four used a version of the Conflict Tactic Scale and CBCL and examined a sample of predominantly preadolescent children) reported inconsistent results. Barling. 1996. was rarely examined in relation to other categories of stress. delinquency. depression. 1998. 1994b.e. Five of the eight reporting specificity reported a specific relation between exposure to violence and externalizing outcome (Attar. anxiety. somatization.. Strom. 1997). 1995. & Dykman. community violence. and three reported a specific relation between exposure to violence and internalizing outcome (Levendosky & Graham-Bermann. Matzko. Cicchetti. 1994). Brent... Kramer. Hoven. 1992. 1997. Most Outcome specific studies of exposure to violence failed to find evidence of specificity (Brent. Methodological explanations for discrepancies across studies are not readily apparent.. 1995). 1989. & Orvaschel. temper conclusions that may be drawn. Hibbard & Hartman. & Wallen. Hayden. 1996.. 1992.. 1995). 1989. 1995. Smith & Howard.... Chandy et al. Higgins & McCabe. & Bengston. 1989.. Dykman et al. McLeer. Livingston et al. & Harrington. All eight of the Stressor-Outcome studies (100%) found specificity in the relation between sexual abuse and PTSD (Deblinger. 1997. 1994). 1989. Friedrich et al. 1997. 1996. Inderbitzen-Pisaruk et al. Einbender & Friedrich. 1996. Lodico. Jaworski. Mian. White et al. & Langabeer.. & Gaines. Koopman. & Woods. Hussey. In addition. A small handful of Stressor-Outcome specific studies examined both internalizing and externalizing outcomes in relation to neglect. 1997). Kuhn.. youth failed to control for differences in gender representation across the two samples). Sadeh et al. Watts & Ellis. Weinberg. 1988.. Gentile. Six (75%) found evidence of specificity (Deblinger et al. Adams... O’Toole. two reported specificity for externalizing outcomes (DePaul & Arruabarrena. we examined studies testing for specificity between sexual abuse and this particular psychological outcome. Rivinus et al.. McClellan. 1988. & Chavez. 1992. & Resnick. Lynch. Sachs. Kinscherff. Most of these studies failed to take gender into account in their examination of specificity effects (i. & Bammer. 1996). Blum. and one (which included only males) reported specificity for externalizing outcomes (Hernandez. Kumar. 1996. Gale et al. Two failed to find evidence of specificity (Crittenden et al. and three failed to find evidence of specificity for sexual abuse and sexual acting out (Berliner & Conte. Dykman et al. 1992. & Fenton. 1995. 1987. Goldston. Mian et al. 1996. Gould. Rotheram-Borus et al. As this outcome has varied from conceptualization as an internalizing outcome (symptom of PTSD. Thirty of 35 studies that examined both internalizing and externalizing outcomes failed to find evidence of specificity (Black. 1994). Hazzard. 1992) while one study did not find a specific relation between sexual abuse and PTSD (Berliner & Conte. Divorce/Marital conflict Eight Stressor-Outcome specific studies tested for specific relations between divorce (or marital . Lawry. & Webb. Inderbitzen-Pisaruk. 1992. 1995. Mannarino. Bergandi. Due to the significant attention paid to the relation between sexual abuse and PTSD. Kolko et al. 1997. Friedrich et al. 1995. we chose to examine it separately from these broad-band classification systems. 1997. McLeer et al. 1988. Thus. The majority of studies conducted in this area suggest there is a specific relation between sexual abuse and PTSD. Brand. of the three Outcome specific studies that examined the relation between sexual abuse and PTSD. Stern et al. 1997. & Hoier. 1991. Alpert. Timmons-Mitchell. Several sexual abuse studies also tested the hypothesis that sexual abuse is specifically associated with ‘sexual acting out’. Meyer-Bahlburg. Mahler. Turnquist. Oates. Deblinger et al. studies reporting heightened rates of internalizing symptoms among sexually abused. Atkins. 1995. Callaghan. Holtz.. & Titus... & Storck. Moser. Kolko. 1996. Cosentino et al.. 1988. 1988). Young. 1993). Sonne. & Wolfe. Mannarino & Cohen. Unfortunately. 1988. and one reported specificity for internalizing outcomes (Prino & Peyrot. Markward. McCurry. 1988) and two did not (Dykman et al. 1997.. McLeer. Thompson. & Knutson. McCann. 1992. 1989. 1994. Wells. 1996. 1994. & Deblinger. 1998. 1988. Twelve of these (80%) found a specific relation between sexual abuse and sexual acting out behaviors (Cohen & Mannarino.. 1989) to conceptualization as an externalizing outcome (an aggressive act.. Oates. & Semple.. methodological concerns related to gender-specific effects. 1998. Haviland... 1994). Sibthorpe. 1992) over externalizing outcomes (Hussey & Singer. Wolfe. Friedrich. 1998. Mannarino & Cohen.e. & Kassem. & LeBaron. The few which reported specificity effects split slightly in favor of internalizing (Johnson & Kenkel. Results of Outcome specific studies of sexual abuse provide little evidence of specificity. Eight Stressor-Outcome specific studies tested for specificity for sexual acting out. 1994. 1996. The two Outcome specific studies to examine both internalizing and externalizing outcomes failed to find evidence of specificity (Famularo. Ghaziuddin. relative to physically abused. Hernandez et al. Huxsahl. & Cooney. Garnefski & Arends.. 1992. Henry. Mannarino. Smith & Howard. Einbender & Friedrich. Deblinger.Specificity and stress 123 1997. Shawchuck. Henry. highlighted above. Marone. 1993). 1995). 1992. Ralph. Although these studies suggest a pattern of increased risk for internalizing outcomes. 1995. McLeer. 1994.. 1994. Cohen & Mannarino. & McDowell. 1994. Gardner. 1988. Hibbard & Hartman. Fifteen Outcome specific studies tested for specificity for sexual acting out. & DiClemente. Sadeh. Shapiro. Williamson et al. 1995. 1997). Voris. Dubowitz. Drinkwater. McGuire. Celano. 1996. 1997). Young et al. Wells et al. Although the findings are quite consistent. Steer. & Sack. Leifer. Douglas. 1997. & Dahl. 1996. White et al. Chandy. Rotheram-Borus. the association between sexual abuse and internalizing outcomes may simply reflect this wellestablished relation. & Foa. Cosentino. Olson. 1994. Marton. & Weldy. Luster & Small. Of those reporting specificity effects. & Naylor. Adams. 1988. Arrelano.. Stern.. two found evidence of specificity (McClellan et al. 1991). Martin. the vast majority of studies reviewed above were not designed to maximally examine specificity hypotheses. Gale. 1989. Tong. King. 1995. Glod & Teicher. 1993. 1996. 1996). 1993. Moran. 1992. girls are at substantially higher risk both for sexual abuse and for internalizing symptoms (Berliner & Elliott. Strom.. & Civita. 1997. 1995. 1993. & Singer.. failed to find evidence of specificity (Durkin. 1990. for co-occurring internalizing symptoms (O’Koon. Reynolds. those reporting specific associations were split. slightly. ‘pull for’ internalizing outcomes (Sandler et al. 1991. Baca. 1993) found evidence of specificity for externalizing outcomes. Specific outcomes examined include depression. ClarkLempers. La Greca. Outcome specific studies on divorce/marital conflict provide an interesting contradiction. antisocial. & Borquez. child-report measures of witnessing conflict. Foster.e. 1992. and observer-report ratings of marital interactions. 1999). Amayaj-Jackson. Levendosky et al. Mandel. & Postlethwaite. Sheppard. and one (Conger et al. As with the exposure to violence and child abuse studies. in favor of internalizing (Brody & Forehand. the series of Conger studies. 1998. somatization. 1991. examination of the studies reporting specificity for internalizing outcomes provides evidence of an interesting pattern. Jenkins & Smith. Only one Stressor-Outcome illness study has been conducted (see Table 1). & Stein. Although these findings appear contradictory. 1988) over externalizing outcomes (Gould. Johnston. Jameson. Rodgers.. One-half (four of eight) of the divorce/marital conflict studies reported evidence of specificity for externalizing outcomes (Conger et al. 1994. Although the Conger studies do not define themselves as specificity studies. may be associated. Forehand. 1993.. 1998). which examined both internalizing and externalizing outcomes. There were no Stressor-Outcome specific disaster (i. Davidson. Konig. Shaw et al. Brody. & Krier. conflict) and particular internalizing and externalizing psychological outcomes (see Table 1). 1989. Graham-Bermann. 1991). & Monroe. Engstrom. 1993. Felner et al.. Stressors from various categories Remaining Stressor-Outcome specific studies are spread thinly across several categories (poverty. and most Outcome specific disaster studies. & Fauber. Those reporting evidence of specific effects were evenly split between specificity for internalizing (Garralda. Most Outcome specific poverty studies also failed to find specific effects (Bolger. thus.. & Campbell. Najarian. 1993. Conger. reported specificity for internalizing outcomes (Breton. Smith. 1992). in the context of recent divorce. 1994. As with most of the specificity studies reviewed. & Wasserstein. using similar methodologies in differing samples (Conger et al. Pillow.. All found evidence of specificity between marital conflict and internalizing symptoms within samples of youth who had recently experienced their parents’ divorce. 1993. 1994. Most of these studies have focused on marital conflict. thus limiting conclusions that may be drawn. Laor et al. & Neemann. Sandler.. Marttunen et al. Masten.. This pattern is consistent with theory-based work by Sandler and colleagues (reviewed below). Thompson. & Morris. Four Stressor-Outcome specific studies have included poverty as a stressor. Forehand. 1994 ). McLoyd. 1988.. Those that reported specificity findings found evidence of specificity for internalizing outcomes (Brody & Flor. 1993). Miliotis. Conger et al. natural or human-made disaster) studies.. & Ardelt. 1993). Jr. 1990. Gonzalez. Fisher. relative to male counterparts. but not in their all-female sample (Conger et al. Siegel et al. 1997. None of the Stressor-Outcome specific cumulative stress studies examined similar categories of stress . Zaman. & Simons.. 1997. 1998.. 1992) and in their mixed sample (52% female. aggression. 1998). Ramirez. Neighbors. Silverman. Mikail & Von Baeyer. hostility. Shaffer. Forehand. examining both internalizing and externalizing outcomes (see Table 1). variability in methodology hampers comparisons across studies for the purpose of understanding discrepancies in outcomes. 1995. Horwood. Kolko & Kazdin.. which examined internalizing and externalizing outcomes. which suggests that marital conflict. and broad-band internalizing and externalizing syndromes. substance abuse. Elder. Wilfley. 1992.. provides an exception to this pattern. in meaning. 1996). & Najarian. Valla. 1988. 1991. This pattern fits with recent findings that girls exhibiting heightened rates of externalizing symptoms are particularly at risk.124 Susan D. Felner. & Alpert-Gillis. illness. the incremental. 1988) and externalizing outcomes (Smith et al. 1997. Howard. 1994. and most Outcome specific studies in this area.. Terry. March.. 1995. per se. & Costanzo. & Kupersmidt. 1996. Conger and colleagues found evidence of specificity between observer-report marital conflict and externalizing outcomes in their all-male sample (Conger et al. Although most (six) of those examining both internalizing and externalizing outcomes failed to find specificity effects (Fergusson. 1998) failed to find evidence of specificity. Specific measures of marital conflict have included parent-report measures of inter-parental conflict. 1993. few of these studies used the same measures of stressors and outcomes. Pedro-Carroll. Cowen. & Fauber. 1994). Long. 1992. anxiety. Long.. Jouriles et al. Reese & Roosa. programmatic nature of their research provides an excellent example of the type of research needed in this area. Jayaratne. & Lambert. & Garfinkel. Ceballo. & Lynskey.. 1990. 1995). Pelcovitz.. 1992). Slater. 1989). 1992. DuBois. rather than divorce. Among these studies. McMahon et al. Khan. 1996. and hyperactivity symptoms. failed to find evidence of specificity (Burke et al. 1994). 1994. Meares. Patterson. Goenjian. Mezzich et al. cumulative stress). Kashani.. West. Hoyt. Lempers... 1987. All three of those which did find evidence of specificity. & Wierson. McCombs. 1992. However. Reinherz et al. with separation and loss events and. three (Conger et al. & Gersten. Second. Forehand et al. Summary and integration of findings Results of studies testing the hypothesis that particular stressors are specifically related to internalizing or externalizing outcomes provide little support for this hypothesis.. Related to Sandler and colleagues’ study (1992) is an Outcome specific study. 1988). there are significant rates of co-occurrence and comorbidity of psychopathology among youth (Compas & Hammen. the outcomes of PTSD and sexual acting out are the two areas in this review that are more specific in nature. family relationships/ responses and community contexts). a group who had experienced their parents’ divorce. Boergers. Across the various stressors examined (exposure to violence. and separation events were associated with internalizing symptoms.. Shirk. 1985. offender–victim relationships. in two of their samples (parental death and control samples). symptoms. Conflict events were associated with externalizing symptoms. poverty. The pattern of findings demonstrating a specific relation between sexual abuse and internalizing outcomes should be interpreted with caution. These findings may reflect that researchers examining sexual abuse are interested in these particular theoretically based outcomes (PTSD and sexual acting out). Sexual abuse was associated specifically with internalizing outcomes. symptoms in a sample of 8th grade youth and that interpersonal schema would moderate the relation between interpersonal stress and depression. 1994) argue that sexual abuse is linked with both internalizing and externalizing outcomes. and a control group of children who had not experienced any of these stressors) to examine the interaction of specificity findings with varying environmental contexts. conflict events were associated with internalizing and separation events were associated with externalizing symptoms. There are several limitations represented in the current state of the field that may have influenced our ability to detect patterns of specificity between particular stressors and broad-band outcomes. cognitions.g.. building upon these theoretical frameworks. Interestingly. These hypotheses were tested in four samples of children (a group of children who had experienced the death of a parent. as the differing contexts of the various samples in this study moderated the specific relations between particular stressors and particular outcomes. divorce/marital conflict. and Van Horn (1998) hypothesized that interpersonal stress would predict depression. In particular. Nonetheless. Spaccarelli. and (2) stressful events involving conflict will be specifically associated with externalizing symptoms. in two of their samples (parental death and asthma samples). 1988. and interpersonal schema moderated the relation between interpersonal stress and depression (but not hostility) symptoms. In general. and with sexual acting out across several studies. 1994). Sandler and colleagues (1992) reported partial support for their hypotheses. Sandler and colleagues (1992) propose that the differences in specificity findings across different samples may reflect differences in meaning applied to the stressful events for different groups of children. the results of this review are more consistent with tenets of equifinality and multifinality in the relation between stress and psychological problems in children and adolescents than they are of specificity. but not externalizing symptoms. there were enough comparable studies examining these specific relationships to reveal patterns of specificity. illness. there are difficulties associated with the lack of a well-established .. Future research. given the fact that this association may reflect heightened risk for both sexual abuse and internalizing outcomes among girls. 1988. (1992) tested two theory-based specificity hypotheses: (1) stressful events involving separation from important family members will be specifically associated with internalizing symptoms. one Stressor-Outcome specific cumulative stress study merits discussion. and because of this interest. and that these relations are moderated by particular environmental contexts (e. which represents the sole study to include specificity of moderator in their theory-based specificity design. abuse. First. is needed to determine the ways in which gender (and other moderators) interact with sexual abuse in relation to particular mediating processes and specific psychological outcomes. and these are the outcomes in which there was evidence of specificity.. Dominant theoretical models of sexual abuse (Finkelhor & Brown. Long et al. These findings illustrate the importance of integrating specificity and moderator designs. findings directly contradictory to the authors’ hypotheses were found among the group of children who experienced divorce. but not hostility. PTSD. and cumulative stress). reported in the divorce/marital conflict section. the most consistent evidence for specificity was found in relation to sexual abuse. In this group. but not hostility. that marital conflict was associated with internalizing symptoms among youth recently exposed to their parents’ divorce (Forehand et al. This hypothesis is consistent with the findings. children of divorced parents may respond differently from other children to conflict and separation events because of the interrelatedness of these two experiences within the context of divorce. Interpersonal stress was specifically predictive of depressive symptoms. coping). but not internalizing symptoms. precluding comparisons across studies. through varying mediating processes (e. Sandler et al. Eason. However. The authors report support for both their hypotheses. a group of children with chronic asthma. emotions.Specificity and stress 125 (see Table 1).g. as it provides a prototype of theory-based specificity research. physical abuse. the approach utilized is likely to influence the findings reported. It should also be noted that given the variability in methodology. which lead to aggression symptoms. the relational approach is generally more stringent than the comparison approach. different theoretical frameworks and methodological characteristics of studies may pull for particular specificity results. links between parent reports of abuse and child externalizing symptoms may be stronger due to mono-informant or mono-method bias or the difficulty of assessing internalizing symptoms in a psychometrically sound manner. In addition. Although there is considerable heterogeneity within these approaches. A developmental approach. which. Methodological issues Specificity research has been fraught with variability in specific constructs examined. theoretically driven hypotheses regarding relationships between stressors and outcomes. separations. . and StressorOutcome Specific). by definition.g. For example. and multifinality may improve our understanding of the pathways between stress and psychopathology.. Most of the research conducted in the stress and coping literature is cross-sectional in nature. Thus. necessitates examining specific stressors in relation to specific outcomes. exposure to conflict among adolescent boys leads to external. we determined that a qualitative approach to the review would be the most appropriate. which test specific etiological models of developmental psychopathology.126 Susan D. which. Further. which takes into account changes across time and developmental trends. only in the presence of particular moderating and mediating processes. a meta-analytic approach to reviewing the literature is recommended. Further discussion of the theoretical model presented (see Figure 2) may help to illustrate and highlight the type of work that is necessary in order to better understand the complex relations between stress and psychological outcomes. Directions for future research There is a need to develop and test specific models that examine the complex relations between stress and psychopathology. Thus. in turn. taxonomy of stressors. it is unclear the extent to which relations between stressors and outcomes change across time. disasters). and samples studied. whereas other studies utilized a ‘relational approach’ in which associations between particular stressors and particular outcomes were examined in a single sample of youth. measures. It is noteworthy that no single study has yet tested full specificity models (including examination of specific mediating and moderating pathways) of the role of stress in the etiology of a particular psychological outcome (see Figure 2).g. Thus. Categorizing stressors based on type may include a variety of stressors that were different in nature. stable cognitive appraisals. stressors. which include both ‘conflict’ (e. For instance. It may also be helpful to consider differences in sampling strategies (i. In light of the large number of studies meeting minimal methodological requirements for specificity research.e. it is striking how few studies tested theory-based models of specificity. there are several methodological issues that should be considered within the context of this review. For an example. clinical samples versus population-based samples) in examining specificity. Outcome Specific. For example. More studies like these. measures used. This model may be tested with various simple and complex. global. For example. outcomes. some studies utilized a ‘comparison approach’ in which rates of psychological problems were compared across groups exposed to differing stressors. and samples. seriously limiting conclusions which may be drawn about specificity itself and conclusions about why discrepancies in findings exist. Thus. Further. it is possible that greater specificity may exist between particular stressors and particular outcomes in community-based samples than clinic samples. For example. are needed. The work of Sandler and colleagues (1992) and Shirk and colleagues (1998) represent important exceptions. the way children express their distress in response to stressors changes over the course of development. however. divorce/marital conflict) and ‘loss’-based stressors (e. analytical and statistical procedures utilized were found to be quite disparate across studies. to understanding specificity. so age may be one potential explanation for the mixed findings on specificity. equifinality.. exposure to violence. lead to further conflict-based stressors. particular stressors may be linked with particular outcomes. In addition to these limitations. Such research is necessary to develop an empirically supported model of the role of stress in the etiology of developmental psychopathology. For example. specific methods for examining specificity have varied.. as the field of developmental psychopathology progresses. Related to methodological variability is the dearth of theory-driven specificity research. poverty is associated with a range of additional specific stressful experiences. A third explanation is that specificity findings are moderated by specific childbased characteristics and environment-based contexts. although variability in measurement and definition led us to focus on internalizing versus externalizing outcomes. McMahon et al. it is possible that this more global review led to more difficulty in detecting evidence of specificity. Beyond the level of design (Stressor Specific. deaths. comorbidity of mood and conduct disorders in children and adolescents has been found to be higher in clinic samples than community populations. Tel: 773-325-2039.. In sum. test the hypothesis that male gender strengthens the association between exposure to violence and aggressive behavior through increases in distraction and avoidant coping). 1145–1154. 6) use a relational approach.. or 3) examine specificity (example 1). USA. methodological discrepancies and the lack of theory-driven research have limited the degree to which the specificity hypothesis has been tested. a violent attack at school) and additional specific psychological symptoms might be tested. N. loss.. and the influence of a particular moderator on both a particular stressor and a particular mediator (e. Such research provides an ideal method for examining the individual patterns of adaptive and maladaptive outcomes across development (Cicchetti & Rogosch..M. Friedrich.e. L.. C. 22. Achenbach. multifinality. DePaul University. J. poverty.. In order to begin to establish more comparability between studies and to conduct a clear test of specificity. Achenbach. Journal of Consulting and Clinical Psychology. Advances in empirically based assessment: Revised cross-informant syndromes and new DSM-oriented scales for the CBCL. T.. physical. R. J. in the examination of specificity.M. (2001).B. L. (1992). & Holford. S. (1996). test the hypothesis that male gender strengthens the association between exposure to violence and aggressive behavior).g. 69. R.T. hostility from classmates at school) that. in turn. Email: smcmahon@ depaul. (1994). M. provide evidence that integrates these theories (i. 4) identify both unique and common effects of various stressors in relation to various outcomes.T. 32. and in the meantime. Berliner. etiological models of developmental psychopathology.. Jones. through discovery that specific relations between particular stressors and particular outcomes occur only in the context of specific moderators and/or specific mediating processes). examining the relations between stressors and outcomes within a particular population.). 271–278. such as child characteristics and environmental context.. and several outcomes – i.. Chicago. aggressive behavior) lead to the development of a moderating context (e. 391–400. 5) include moderators. 2219 N. McMahon. reciprocal and dynamic relations among a particular moderator and a particular stressor. Bayatpour.edu References Achenbach. Sadowksi.. Correspondence to Susan D. B..g.M. aggressive behavior. 1.. Journal of Child and Adolescent Psychopharmacology. Newton. The APSAC handbook on . Jenny. 7) use multiple methods of assessment to reduce reporter bias and generate more confidence in the findings..g. examination of full specificity models (using maximally effective methodology) is needed to fully test hypotheses related to equifinality. 699–702. Berliner. Attar. 3. & Dykman. J. a potential moderator (example 2). test the hypothesis that there is an association between exposure to violence and aggressive behavior by using the ‘relational’ approach of examining several stressors – i. and specificity in the relation between stress and psychological symptoms in children and adolescents. Prevalence of post traumatic stress disorder and other psychiatric diagnoses in three groups of abused children (sexual. In J. T. and Fisher (2001). For example. the hypothesis that psychological problems (e.G. Are American children’s problems getting worse? Journal of the American Academy of Child and Adolescent Psychiatry. P. P. S. and TRF: Comment on Lengua. & Gore. D.A.g. Kenmore. 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