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Psychological Reports: Disability & Trauma 2013, 112, 2, 340-352. © Psychological Reports 2013

Thought and Language Disorder among Sexually Abused Children in a Psychiatric Hospital1 Francine Conway

James McCarthy

Adelphi University

Queens Children’s Psychiatric Center

Priyam Talreja

Fiona Conway

Adelphi University

Rutgers University

Summary.—The empirical literature offers evidence that childhood sexual abuse is a predictor of psychopathology in adults. However, the literature examining the relations between thought disorder and psychotic symptoms in children is sparse. Children with a history of childhood sexual abuse are expected to demonstrate more disturbances in thought relative to their peers with no childhood sexual abuse. Using the Thought and Language Index, Thematic Apperception Test (TAT) narratives for four commonly used TAT cards obtained from 39 closed charts of hospitalized children were analyzed. Narratives were assessed on seven dimensions including weakening of goals, perseveration, looseness, peculiar word usage, peculiar sentence construction, non-logical reasoning, and distractibility. Good inter-rater reliability was obtained. Sexually abused children had higher aberrant scores on card number four compared to non-abused children. Sexual abuse history was a predictive factor for non-logical reasoning, with small effect size. Implications and suggestions for future research are discussed.

Childhood sexual abuse has received attention from the field of psychology beginning with Freud’s theorizing about infantile seduction (Mitchell & Black, 1995), later replaced with a theory of infantile sexuality. In 2003, the U.S. child protection agencies and legal systems estimated 1.2 children per 1,000 children have been sexually abused (United States Administration for Children & Families, 2003). Results from a meta-analysis of international studies found 25 percent of girls and eight percent of boys had been sexually abused (Finkelhor, 1994; World Health Organization, 2001; Putnam, 2003). A recent analysis of U.S. government data suggest incidences of childhood sexual abuse has declined 62 percent between 1990 and 2010—from 23 per 10,000 to 8.6 per 10,000 (Finkelhor, Jones, & Shattuck, 2010). Although the downward trend has been attributed to preventative efforts, childhood sexual abuse persists and has an adverse psychological effect that lasts into adulthood (Finkelhor, et al., 2010). Research studies have shown significant relations between schizo1 Address correspondence to Francine Conway, Adelphi University, Blodgett Hall 212 A, Garden City, NY 11530 or e-mail ([email protected]).

DOI 10.2466/16.02.PR0.112.2.340-352

ISSN 0033-2941

Childhood Sexual Abuse and Thought Disorder

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phrenia in adults and the occurrence of childhood sexual abuse. In Friedman and Harrison’s (1984) study of 20 urban schizophrenic women, 60 percent of the women were victims of childhood sexual abuse. Similarly, women presenting with psychotic symptoms also reported a history of childhood sexual abuse (Beck & Van der Kolk 1987; Greenfield, Stratowski, Tohen, Batson, & Kolbrener, 1994; Read, Agar, Argyle, & Aderhold, 2003). Associations between adult schizophrenia and childhood abuse (including sexual abuse) have been supported in the literature showing psychotic symptoms reported among those with abuse histories (see Read, Goodman, Morrison, Ross, & Aderhold, 2004) and clinical and research ratings of the symptoms (Read, et al., 2003; Janssen, Krabbendam, Bak, Hanssen, Vollebergh, de Graaf, & van Os, 2004). A meta-analysis of case controlled, prospective- and cross-sectional population-based studies indicate greater rates of psychosis among individuals with early childhood traumatic experiences with effect sizes ranging from 0.22 (95%CI = 0.10, 0.47) to 9.61 (95%CI = 4.51, 20.47) calculated using the odds ratio (including sexual abuse; Varese, Smeets, Drukker, Lieverse, Lataster, Viechtbauer, Read, van Os, & Bentall, 2012). Schizophrenia is generally not diagnosed in childhood, having a later developmental onset, thus an understanding of the precursors to schizophrenia in children may be best obtained by exploring the presence of thought disorder in children (Parnas, Schulsinger, Schulsinger, Mednick, & Teasdale, 1982; Ott, Allen, & Erlenmeyer-Kimling, 2001). Among children, one of the manifestations of thought disorders is in the child’s verbal expressions such as deviant verbalizations, semantic abnormalities, and peculiar word usage (Caplan, Guthrie, Tang, Komo, & Asarnow, 2001). Read and Argyle (1999) found evidence of thought disorders among 35% of 26 sexually abused adult patients, identifying hallucinations as a distinguishing symptom. Childhood sexual abuse was a predictor of hallucinations with a large effect size (Cohen’s d = 1.36; 90th percentile) in Read, et al. (2003). Studies on thought disorder and childhood sexual abuse have focused more on disordered thought content than disordered thought process or form. Thought Disorder in Children There has been no exploration of the relations of childhood sexual abuse and thought disorder in hospitalized children. Researchers have found an association between sexual abuse and the presence of psychiatric histories in children compared to same-age peers without such a history (Ross & Joshi, 1992; Read & Argyle, 1999). In Livingston (1987), 77% of inpatient children in a psychiatric hospital had been victims of childhood sexual abuse. Although there is some evidence that thought dis-

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order exists among adult survivors of childhood sexual abuse, whether thought disorder exists among child victims of sexual abuse has not been explored. Studies of thought disorder with child samples are sparse (Green, Campbell, Hardesty, Grega, Padron-Gayol, Shell, & Erlenmeyer- Kimling, 1984; Arboleda & Holzman, 1985; Caplan, Guthrie, Fish, Tanguay, & David-Lando, 1989). According to the Diagnostic Statistical Manual–IV, thought disorder and Formal Thought Disorder are used interchangeably to describe disturbances in the form of thought processes that reflect illogical thinking, incoherent discourse, loosening of associations, and poverty of speech (American Psychiatric Association, 1994). These disturbances are evident in the manner in which the individual communicates their thoughts. Studies examining thought disorder in children, including Van der Gaag, Caplan, Engeland, Loman, and Buitelaar (2005), have reported thought disorder in schizophrenic children (Caplan, et al., 2001). Although thought disorder is clearly a salient feature of schizophrenia, Tompson, Asarnow, Goldstein, and Miklowitz (1990) noticed a familial pattern of deviant conversation among schizophrenic children and their parents relative to non-schizophrenic children. Thought disorder has been observed among children who are not psychotic, in children with autism, and children diagnosed with Attention Deficit Hyperactivity Disorder (Van der Gaag, et al., 2005), likely reflecting their difficulty with communication rather than the presence of psychosis. Soloman, Ozonoff, Carter, and Rochelle (2008) found illogical thinking and loose associations among children with autism spectrum disorders, attributed to language abnormalities rather than schizophrenia. Goddard and Tuber‘s (1989) study of thought-disordered children examined the quality of thought disturbances and object relations in boys meeting the DSM-IV criteria for Separation Anxiety Disorder. Boys who suffered from Separation Anxiety Disorder are likely to have thinking abnormalities, which interfere with their independent functioning. Overall, the images and ideas of these boys were found to be more unstable, boundary-compromised, fluid, idiosyncratic, tangential, and psychoticlike compared to a control group. Boys with Separation Anxiety Disorder scored high on all the categories of thought disorder on the Rorschach Thought Disorder Scale. Assessing Thought Disorder Several different methods have been employed by researchers to assess thought disorders in children. In Arboleda and Holzman’s (1985) research, the Thought Disorder Index was used to assess thought disorder in children at risk for psychosis. Goddard and Tuber (1989) utilized the


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Rorschach Thought Disorder Scale (Blatt & Rizzler, 1974) which provides an “....overall estimate of thought disorder” in order of severity (refer to Blatt & Rizzler, 1974 for examples of each of the scale points). Exner’s (1993) development of the Rorschach Perceptual-Thinking Index was considered to be a considerably more accurate measure of thought disorder (Smith, Baity, Knowles, & Hilsenroth, 2001). Tompson, et al. (1990) were the early researchers to develop the Communication Deviances Index using the Thematic Apperception Test to measure thought and communication disorders in schizophrenic children. The Thematic Apperception Test was also used by McCarthy, Lowewenthal, Herdsman, Bluestone, and Gorman (2003) to investigate the prevalence of thought disorder for inpatient children and adolescents with severe psychiatric disorders using the Bizarre-idiosyncratic Thinking Scale. Van der Gaag, et al. (2005) used the Kiddie Formal Thought Disorder Rating Scale to assess thought disorder in children. Three distinct segments of thought disorder—loose associations, illogical thinking, and poverty of content of speech, were assessed. Most of these measures require a lengthy administration and scoring time, making them less amenable for use by clinicians treating children in psychotherapy settings. For the purpose of this study, the Thematic Apperception Test in conjunction with the Thought and Language Index was used.

Thought and Language Index In recent decades, Andreasen’s (1986) Thought, Language, and Communication (TLC) Scale of thought disorder has been most widely used, but criticized for its limited ability to detect subtle anomalies which compromises the validity of the tool (Liddle, Ngan, Caissie, Anderson, Bates, Quested, et al., 2002). In comparison, Johnston and Holzman’s (1979) Thought Disorder and Language Index were better at measuring the subtleties that the Thought, Language, and Communication Scalefailed to detect. Some disadvantages of the Thought Disorder and Language Index included the time required to administer and score the test and to obtain training (Liddle, et al., 2002). The Thought Disorder and Language Index is a standardized measure of thought disorder that provides a continuous measure of thought disorder ranging from its occurrence in healthy individuals to its prevalence in individuals with schizophrenia and psychosis. The Thought Disorder and Language Index has been tested and has proved to be reliable (Liddle, et al., 2002). Thus, using the Thought Disorder and Language Index in conjunction with the Thematic Apperception Test is theoretically sound, and provides an ideal opportunity to obtain standardized assessments of the patient while controlling the content of their verbalizations.

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f. conway, et al. Hypothesis 1. Children with a history of childhood sexual abuse will demonstrate more disturbances in thought relative to their peers with no childhood sexual abuse. Hypothesis 2. Childhood sexual abuse history will predict more variance in thought disorder than demographic variables.

Method

Participants Thirty-nine inpatient psychiatric hospitalized native English-speaking children in an urban hospital, ranging in age from 7 to 17 years, participated in this study. The participants’ mean age was 13.5 yr.; girls comprised 43.6% of the sample. Fifty-one percent (n = 20) of the children had been sexually abused. Children without a history of sexual abuse were matched as closely as possible with children who had a sexual abuse history on age, gender, and diagnosis. Children in the study were diagnosed by a licensed clinical psychologist and often had multiple disorders; thus, children may be represented in some of the diagnostic categories more than once. Diagnoses included Conduct Disorder (n = 17, 43%) including Oppositional Disorder and Conduct Disorder in general; Affective Disorder (n = 32, 82%) including Depression, Bipolar, Mood Disorders, and Schizoaffective Disorder; Attention Deficit Hyperactivity Disorder (ADHD) (n = 14, 35%); Post-Traumatic Stress Disorder (PTSD; n = 6, 15%); Gender Identity Disorder (n = 1, 0.02%); and ‘Other’ disorders (n = 6, 15%) including Learning Disorders, Pervasive Development Disorder (PDD), and Anxiety Disorders (Table 1). Analysis of variance (ANOVA) for age and chi-squared analyses for gender and diagnoses indicated that there were no statistically significant differences between the two groups on demographic variables (Table 1). Measures Demographic information.—Participants’ information on age, gender, and sexual abuse history was obtained from their charts based on licensed psychologists’ interviews with the children’s caregivers. Thematic Apperception Test (TAT).—The TAT was administered to the children at Queens Children’s Psychiatric Center by a licensed psychologist following standard procedure. A standard administration of TAT cards (TAT cards 1, 2, 3BM, and 4, 5), about which participants were asked to tell a story, was presented. After a spontaneous report of the story perceived in the cards, follow-up questions were asked: “What is happening at the moment?”, “What has led up to the events?”, “What are the characters feeling and thinking?”, and “What was the outcome of the story?” The narratives of the children’s responses on the Thematic Apperception Test were provided to the researchers for assessment using the Thought and Language Index.

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Childhood Sexual Abuse and Thought Disorder Table 1 Demographic Variables by Childhood Sexual Abuse (CSA) Group

Age, yr. Gender

Male

Female

Diagnoses

Affective disorder

Conduct disorder

ADHD

CSA (n = 20)

No-CSA (n = 19)

12

12.94

M %

80

16

50

35

30

10

Gender identity disorder

n

10

20

Other (Anxiety, Learning, PDD)

2.10

50

PTSD

SD

0

Expected count was less than 5 in two cells.

10

7

M %

64 36 84.2

SD

3.04 n

12 7

16

Statistic F

1.59 χ2 0.02a

0.11

52.6

10

4

10.5

2

0.64

2

21.4

4

0.88

6

0

42.1 5.3

8

1

1.20

0.59

a

Thought and Language Index.—The Thought and Language Index assesses the quality of thought disorder in psychotic illness (Liddle, et al., 2002). Using speech samples from a standardized administration of the Thematic Apperception Test (Murray, 1943), specific types of aberrant thought disorder are assessed using a glossary and quantified according to standard protocol. Subscales of the Thought and Language Index assess impoverish thought and speech (weakening of goal, poverty of speech); disorganization of thought and language (looseness, peculiar sentence construction, peculiar word use, peculiar logic), and abnormal regulation of speech and thought (perseveration). Interrater reliability of Thought and Language Index items ranged from 0.60 to 0.93 (0.60 for peculiar word use, 0.82 for disorganized thought/language sub-scale, 0.88 for the impoverished thought/language subscale, 0.93 for poverty of speech). The narratives of the Thematic Apperception Tests were scored by independent raters, including the primary author, and students enrolled in a doctoral program in clinical psychology and an upper level undergraduate student. All of the raters were blind to the child’s history of sexual abuse. Precautions were taken to label the Thematic Apperception Test narratives with identification numbers and separate the narratives from other patient information. Once scoring was complete, a research assistant independent of the raters entered the data into a statistical data management program. Inter-rater reliability for raters ranged from .80 to .85 (Bartko & Carpenter, 1976; for definitions of the Thought and Language Index subscales see Liddle, et al., 2002).

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Thematic Apperception Test (TAT) narratives for the four TAT cards administered (1, 2, 3BM, and 4) were analyzed using the TLI. The various categories of the TLI were assigned weights ranging from 0.25 to 1.0, reflecting the severity of the disturbance of thinking. In general, responses to questionable deviances are weighted 0.25, while severe deviances are weighted 1.0. The categories of assessment can be further divided into two broader headings. Impoverishment of thinking includes weakening of goal and perseveration, while Disorganization of thinking includes looseness, peculiar word usage, peculiar sentence construction, non-logical reasoning, and distractibility. Weakening of goal implies a lack of relevant detail and/or excessive use of vacuous phrases that convey little information. Perseveration represents the unjustified repetition of ideas over different cards, or between different characters on the same card. Looseness measures disconnection between ideas and identifies intrusions in the train of thought. Peculiar word usage highlights the use of unusual words or words invented by the respondent; errors due to spelling are not scored. Peculiar sentence construction identifies sentences in which the meaning is obscure. Non-logical reasoning considers when conclusions are made by the respondent, based on inadequate evidence or faulty logic. Finally, distractibility measures ideas that result in the narrative due to a distraction from an external stimulus. Procedure The closed charts of discharged patients were reviewed. The charts were randomly selected. All participants’ data obtained from the closed charts were assigned an identification number and summarized on a data collection sheet. Information obtained relevant to this study included age, sex, sexual abuse history, and TAT protocols. A random sample of children’s TAT responses to cards 1, 2, 3BM, and 4 were coded. These cards were selected because they were commonly administered by all psychologists. Inter-rater reliability was obtained by using two independent raters (ICC = .85). Thereafter, each of the two raters scored independently, blind to the participants’ childhood sexual abuse status. Raters intermittently checked for consistency.

Analyses Descriptive analysis of the data was conducted to ascertain whether there were group differences among demographic variables. Chi-squared tests were performed to rule out differences between childhood sexual abuse and non-childhood sexual abuse groups for diagnosis and gender. Similarly, analysis of variance (ANOVA) was used to examine group differences in age and thought disorder (ratings on the Thought and Language Index) for groups of children with history of childhood sexual abuse (CSA

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group) and without such history (No-CSA group). Childhood sexual abuse was dummy coded and regression analyses were used to explore whether childhood sexual abuse predicted aspects of thought disorder being measured in the Thought and Language Disorder Scale while controlling demographic variables. Results

Demographic Findings No statistically significant differences were obtained in group comparisons of demographic variables (Table 1). The mean age for the CSA group was 12.0 yr. (SD = 2.1) while the mean age for the No-CSA group was 13.0 yr. (SD = 3.0). Fifty percent (n = 10) of the CSA group and 36 percent (n = 7) of the No-CSA group were girls. The CSA group did not differ significantly from the No-CSA group in terms of diagnosis.

Thought Disorder Statistically significant correlations were found between age and childhood sexual abuse among children with peculiar word usage (r = .92, p < .05, 95%CI = .12, 1.01); and between age and ADHD (r = –.34, p < .05, 95%CI = –.65, .03)—older children with a history of sexual abuse were more likely to show peculiar word usage and younger children were more likely to be diagnosed with ADHD. A statistically significant correlation between diagnosis of Conduct Disorder (dummy coded) and perseveration (r = .48, p < .01, 95%CI = .18, .76) was found for the No-CSA group. The CSA group had statistically significantly higher aberrant scores in nonlogical thinking on card #4—a card with male and female images—compared to the No-CSA group (t = –2.2, p < .05, Cohen’s d = –0.73). In addition, a statistically significant correlation was found between CSA group and non-logical reasoning (r = .33, p < .05, 95%CI = .02, .65). Table 2 Analysis of Variance for Sexual Abuse and Thought Disorder Source

Non-logical reasoning

*p < .05.

Between-groups Within-groups Total

SS

df

8.38

37

1.05 9.44

1

38

MS

1.05 0.22

F

4.65*

The ANOVA showed higher occurrences of non-logical reasoning in the CSA group (F1,37 = 4.65, p < .05, η2 = .11; Table 2). Regression analyses showed childhood sexual abuse status predicted non-logical reasoning, accounting for 13 percent of the variance (R2 = .13, df = 1, 35,p < .05) (Table 3).

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Table 3 Childhood Sexual Abuse as a Predictor of Thought Disorder/Non-logical Reasoning β B SE T R2 Change

Step 1

Age

Gender

Step 2

Age

Gender

Childhood sexual abuse

*p < .05.

–.01

.03

–.07

–0.39

–.03

.03

–.14

–0.83

.36

.16

.37

.01

–.04

.17

.16

.01

–.04

0.03

–0.23

2.26*

.004

.13*

Discussion In sum, the study’s findings show that peculiar word usage persists among older children who have been sexually abused. In terms of diagnostic categories, greater perseveration was found among non-childhood sexual abuse participants who were diagnosed with Conduct Disorder. As hypothesized, a significant relationship was found between history of childhood sexual abuse and non-logical reasoning with sexual abuse history as a significant predictive factor of this form of thought disorder. For the relationship between age and No-CSA among peculiar word usage, this study supports commonly held clinical knowledge that age is negatively correlated with peculiar word usage. It is common for younger children to create their own personal jargon, a practice which subsides with age (Shulman & Capone, 2010). However, as children age, peculiar word usage generally decreases. Findings show that children who experienced sexual trauma depart from this developmental expectation and peculiar word usage persists. Findings also showed a statistically significant association between Conduct Disorder and perseveration among the No-CSA group; specifically, the children who suffered from either Oppositional Defiant Disorder or General Conduct Disorder were more likely to repeat themes or ideas on a specific card. This could be an expression of their opposition to completing the task. Childhood Sexual Abuse and Thought Disorder Among participants, childhood sexual abuse status was a predictor of non-logical Reasoning. When exposed to stimuli hinting at male-female interactions, children who were survivors of childhood sexual abuse were more likely to demonstrate peculiar logic or faulty logic. Childhood sexual abuse survivors may have difficulty in making sense of male-female interactions (Read, Agar, Argyle, Barker-Collo, Davies, & Moskowitz, 2001).


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For adults, however, these potentially confusing experiences can be mitigated by choices, including avoiding personal interactions with potential triggers. Children have limited opportunities to avoid triggers due to their dependence on adults for care and supervision. This may explain why children resort to non-logical thinking as an avoidance strategy. Limitations Given the small size of the sample from one psychiatric hospital in an urban area, the generalizability of the findings is limited. This was the first time the TLI was used with children, so findings should be interpreted with caution.

Implications This study is important because for the first time the Thought and Language Index has been used to analyze Thematic Apperception Test narratives among children. Earlier studies using the Thematic Apperception Test cards applied the Bizarre-idiosyncratic Thinking Scale to analyze the narratives (McCarthy, et al., 2003), but its findings were limited to schizophrenia and sexual abuse. The findings of this study, when taken together with McCarthy, et al. (2003), suggest thought disorder should be assessed in children who are sexual abuse survivors. Although thought disorder symptoms may not be observed among adult survivors, its occurrence among children may detract from the child’s learning ability and interpersonal relations. Trauma caused by childhood sexual abuse may affect children’s learning capacity. Children with a history of abuse may resort to nonlogical reasoning due to conflict experiences, so their ability to comprehend information and stories with any relational or sexual content may be affected. In Western society, where learning in childhood is often conducted via stories, this is an important fact to keep in mind. This provides an avenue of future research on therapy to help childhood sexual abuse survivors integrate male - female interactions in stories in a “normal” manner. Findings expand theoretical knowledge about the effects of childhood sexual abuse and may inform interventions for treatment of children who survive childhood sexual abuse. References American Psychiatric Association. (1994) Diagnostic and Statistical Manual of Mental Disorders. (4th ed.) Washington, DC: Author. Andreasen, N. C. (1986) Scale for the Assessment of Thought, Language and Communication (TLC). Schizophrenia Bulletin, 12(3), 473-483. Arboleda, C., & Holzman, P. S. (1985) Thought disorder in children at risk for psychosis. Archives of General Psychiatry, 42(10), 1004-1013.

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