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Language Use and PTSD Symptoms:Content Analyses of Allegations of ChildSexual AbuseSarah Miragoli PhDa, Rossella Procaccia PhDa & Paola Di Blasio PhDa

a C.R.I.d.e.e., Dipartimento di Psicologia, Università Cattolica delSacro Cuore, Milano, ItalyPublished online: 05 Nov 2014.

To cite this article: Sarah Miragoli PhD, Rossella Procaccia PhD & Paola Di Blasio PhD (2014) LanguageUse and PTSD Symptoms: Content Analyses of Allegations of Child Sexual Abuse, Journal of ForensicPsychology Practice, 14:5, 355-382, DOI: 10.1080/15228932.2014.970423

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Journal of Forensic Psychology Practice, 14:355–382, 2014Copyright © Taylor & Francis Group, LLCISSN: 1522-8932 print/1522-9092 onlineDOI: 10.1080/15228932.2014.970423

ARTICLES

Language Use and PTSD Symptoms: ContentAnalyses of Allegations of Child Sexual Abuse

SARAH MIRAGOLI, PhD, ROSSELLA PROCACCIA, PhD,and PAOLA DI BLASIO, PhD

C.R.I.d.e.e., Dipartimento di Psicologia, Università Cattolica del Sacro Cuore, Milano, Italy

The objective of this article is to understand how traumatized chil-dren report traumatic narratives. This study aims to explore themediating effects of posttraumatic stress disorder (PTSD) symptomson the relationship between child age and narrative characteris-tics in the allegations of child sexual abuse. Some characteristicsof traumatic narratives were analyzed in a group of 58 victimsof sexual abuse (M = 10; SD = 3.5 years), including 29 chil-dren (50%) with all the symptoms of PTSD. Results were consistentwith a model of PTSD symptoms as a mediator of the relation-ship between age and sensory impressions, emotional nodes, andcognitive distancing.

KEYWORDS child sexual abuse, posttraumatic stress disorder(PTSD), content analyses, allegations

INTRODUCTION

In the light of a growing number of cases of family violence, often childrenare called to give evidence in court, as victims and only eyewitnesses to acrime, and the nature of traumatic narratives is under considerable debateby scholars and practitioners.

Children are regarded as reliable witnesses by the judicial system,because of the good performances of autobiographical memory and of theability to provide accurate and consistent reports of facts that occurred (Di

Address correspondence to Sarah Miragoli, Dipartimento di Psicologia, UniversitàCattolica del Sacro Cuore, L.go Gemelli, 1, Milano 20123, Italy. E-mail: sarah.miragoli@unicatt.it

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Blasio, Miragoli, & Procaccia, 2011; Fivush, 1993; Goodman, Quas, Burley,& Shapiro, 1999). In particular, legal reliability refers to the competence torecall the autobiographical experiences in explicit and distinct memories,through a narrative description, coherently anchored to temporal and spatialdimensions and enriched with contextual details for the attribution of mean-ings (Spencer & Flin, 1990; Whitcomb, Shapiro, & Stellwagen, 1985). Thelegal reliability is assessed in relation to contents and to narrative organiza-tion, which essentially depend on the narrative expertise and the cognitivecompetences (Kleinknecht & Beike, 2004; Kulkofsky, Wang, & Ceci, 2008;O’Donohue, Benuto, & Cirlugea, 2013a; Saywitz & Snyder, 1996; Saywitz,Snyder, & Lamphear, 1996). As we know, the narrative abilities mature withage and level of development, but they can also differ on the basis of theemotional connotation of the experiences, of their traumatic seriousness, andof the presence of the traumatic consequences (for example, posttraumaticstress disorder [PTSD]; Engelberg & Christianson, 2002; Miragoli, Di Blasio,& Procaccia, 2009; O’Donohue, Benuto, Fondren, Tolle, Vijay, & Fanetti,2013b). In this paper, we analyze the literature that investigates the influ-ence of age and the presence of PTSD on the characteristics of the traumaticnarratives in order to better understand the testimony of children who arevictims of sexual abuse.

AGE AND TRAUMATIC NARRATIVE

Over the past two decades, we have learned a great deal about children’saccounts for real-world events. Children as young as 3 years of age are ableto codify, remember, and provide accurate information about their experi-ences (Pipe, Lamb, Orbach, & Esplin, 2004), about familiar and recurringevents (Ornstein, Shapiro, Clubb, Follmer, & Baker-Ward, 1997) and aboutmore distinctive events, only experienced once (Fivush & Schwarzmueller,1995; Kulkofsky et al., 2008). The literature has in fact shown that withincreasing age, significant developmental changes in narrative skills aredetected because of the emergence of language skills, socialization, and fur-ther cognitive development. Furthermore, the development of cognitive andcommunicative skills significantly affects the ability to understand thoughtsand intentions of self and others, to draw inferences, and to make hypotheseson the mental states.

However, what happens with the narratives of negative experiences,stressful or traumatic? Does age exert a similar influence? The literature hasamply demonstrated that the type of experience (neutral, positive, nega-tive, stressful, or traumatic) and age play a key role on how children telltheir own experiences (for a review see Cordon et al., 2004; Pipe et al.,2004). In particular, age predicts children’s memories of mundane expe-riences in the same way that it affects children’s verbal recall of painfuland intrusive medical procedures (e.g., Brown et al., 1999; Goodman, Quas,

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Batterman-Faunce, Riddlesberger, & Kuhn, 1994, 1997; Merritt, Ornstein, &Spicker, 1994; Salmon, Price, & Pereira, 2002), accidental injuries requir-ing treatment at an emergency facility (e.g., Peterson, 1999; Peterson &Rideout, 1998; Peterson & Whalen, 2001), and forensic accounts of suspectedmaltreatment or sexual abuse (e.g., Lamb et al., 2003; Lamb, Sternberg, &Esplin, 2000; Sternberg, Lamb, Orbach, Esplin, & Mitchell, 2001). These stud-ies have indicated the importance of age in determining the quality of thenarrative provided: for example, Peterson and colleagues (Peterson, 1999;Peterson & Bell, 1996; Peterson & Rideout, 1998) describe the changes inchildren’s accounts with respect to the increasing age of the children andindicate that older children reported significantly more information than didyounger children. Similarly, when children are interviewed within a fewweeks of having the voiding cystourethrography test, there are marked agedifferences in the amount of information and also in the accuracy of theiraccounts than the recall of routine medical examinations or other (non-traumatic) events (e.g., Brown et al., 1999; Goodman et al., 1994, 1997;Merritt et al., 1994; Salmon et al., 2002).

Age has an important influence also on children’s verbal recall oftraumatic experiences (Cordon et al., 2004): In particular, age affects the com-plexity and the content of the narratives. Regarding complexity and narrativecoherence, research appears to be rather consistent in detecting the posi-tive effect of age on the length of the reports and their internal organization.In particular, several studies on children involved in forensic investigations ofchild maltreatment or sexual abuse show that the older children produce thelonger, more coherent, and more richly detailed narratives (Chae, Goodman,Eisen, & Qin, 2011; Di Blasio et al., 2011; Eisen, Qin, Goodman, & Davis,2002; Lamb et al., 2000, 2003; Sternberg et al., 2001). In particular, in a studyof the allegations of sexual abuse, Miragoli and colleagues (2009) note thatchildren of school age (and not children of pre-school age) produce narrativeaccounts with more pertinent contents (regarding actions, interactions andmental states), which are accurate, well-ordered, contextualized (regardingthe spatial and temporal dimensions), and characterized by reflective skills.

Regarding narrative content, the results are rather more divergent.In fact, some studies show that with increasing age, children are betterable to provide narrative accounts that include more cognitive and emo-tional reactions (Peterson & Biggs, 1998). Other studies show instead thattraumatic narratives of younger children are richer in sensory and emotionaldetails (Di Blasio et al., 2011) but less accurate in terms of spatial-temporalcontextualization (Orbach & Lamb, 2007). Finally, Berliner and colleagues(2003), analyzing positive, negative, and traumatic narratives produced by30 traumatized children, found an effect of age on traumatic narratives: olderchildren tend to produce accounts with more sensory detail/coherence andmore impact/meaning.

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In conclusion, the literature confirms that under normal and stressconditions, in narratives of children, age is the best predictor of narrativeaccuracy, completeness, and the cognitive ability to attribute meaning toevents (O’Donohue et al., 2013b).

Age and PTSD

There is considerable evidence that in children/adolescents, PTSD symptomseverity varies as a function of age (Contractor et al., 2013). In discoveringcausal chain mechanisms for the development and maintenance of PTSDsymptoms, the etiological model of Foy and colleagues (Foy, 1992; Foy,Madvig, Pynoos, & Camilleri, 1996; Foy, Osato, Houskamp, & Neumann,1992) aims to identify links between exposure to traumatic events andconsequent symptoms as well as test relationships between exposure vari-ables and other environmental and individual factors (e.g., age and gender,social support, coping strategies, prior exposure to trauma). According tothis perspective, in the PTSD development the mediating variables interactwith the primary etiologic agent (traumatic event) through several possibleroutes (Cooke, 1985; Davidson & Smith, 1990; Hoffman & Bizzman, 1996).In particular, several studies of developmental and clinical psychology haveexamined the relationships between age and risk for PTSD or symptomseverity in children, but the precise nature of this functional relation remainsunclear, since findings are mixed.

Effectively, some studies suggest a significant negative effect of ageon PTSD, with younger children reporting more PTSD symptoms com-pared to older children (Anthony, Lonigan, & Hecht, 1999; Dubner & Motta,1999; Kar et al., 2007; Shannon, Lonigan, Finch, & Taylor, 1994). Loniganand colleagues (1994), investigating the effect of age on PTSD in school-age children, reveal that younger children display more PTSD symptomsafter exposure to a natural disaster (Hurricane Hugo). Similarly, Kaplowand colleagues (2005), in order to examine some factors (pretraumaticvulnerabilities, trauma characteristics, and stress reactions) as pathways toPTSD symptoms in sexually abused children, indicate that younger chil-dren are more likely to present PTSD symptoms compared to older children.Moreover, Kar and colleagues (2007), in a study exploring PTSD symptomsin pre-adolescents and adolescents after a super-cyclone in Orissa (India),show that subjects with PTSD have lower mean age than those without thediagnosis and that pre-adolescents are more vulnerable compared to adoles-cents. All these results are based on the consideration that younger childrenare at a higher risk of developing posttraumatic stress reactions due to lesseffective coping strategies and fewer mature cognitive/emotional abilitiesneeded to process the trauma (Peterson, 1989; Salmon & Bryant, 2002).

On the other hand, some studies report higher estimated PTSDprevalence among elementary school-age children than preschoolers

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(Meiser-Stedman, Smith, Glucksman, Yule, & Dalgleish, 2008) and that ado-lescents have higher PTSD scores than pre-adolescents (Ayer et al., 2011;Copeland, Keeler, Angold, & Costello, 2007; Garrison et al., 1995; Wolfe, Sas,& Wekerle, 1994). Green and colleagues (1991), rating the clinical reportsof 179 children (age range 2–15 years) after the Buffalo Creek dam collapsein Logan County (West Virginia), estimated that a lower incidence of PTSDwas observed among younger subjects (age range 2–7 years) as compared tothe older cohort (age range 8–15 years). Similarly, Copeland and colleagues(2007), in a longitudinal study of psychopathology, show that PTSD wasmore common in adolescence than childhood and that children displayingPTS symptoms in response to trauma exposure were more likely to be older,to have a history of exposure to trauma, to have a history of anxiety, andto come from an adverse family environment. The explanations of all thesefindings are that older youths have a greater ability than younger children toidentify and verbalize symptoms (Contractor et al., 2013; Green et al., 1991)and that adolescents develop more focal PTSD symptoms as they matureemotionally and intellectually, as opposed to the often diffuse symptoms ofdistress characterizing younger traumatized children (Briggs-Gowan, Carter,& Ford, 2012).

In order to better clarify the relationship between age and PTSD, someauthors dwell on the wide spectrum of reactions that children may have fol-lowing exposure to traumatic stressors according to age (Dyregrov & Yule,2006). In effect, younger children may display more overt aggression anddestructiveness and may also show more behavioral reenactments and repet-itive actions (play and drawing) about the traumatic event. For preschoolchildren, there is less agreement since the severity of their stress reactionsare often influenced by parental reactions to the event. The schoo- age chil-dren and adolescents show reactions more similar to those manifested byadults, since they can understand more of the situation, are able to seemore of the long-term consequences of the traumatic event, and can reflectmore on their own role in what happened. Based on these considerations, anumber of studies, as well as presenting general data on the incidence andseverity of PTSD, also analyzed the effect of age on specific posttraumaticclusters (re-experiencing, emotional numbing, hyperarousal, and avoidancesymptoms). Findings show that, compared to children, adolescents reportgreater severity in re-experiencing, numbing, and dysphoric arousal symp-toms (Ayer et al., 2011; Contractor et al., 2013; Copeland et al., 2007; Greenet al., 1991), while preschoolers and school-age children have more severeanxious symptoms, hypervigilance, and avoidance reactions (Anthony et al.,1999; Contractor et al. 2013; Kar et al., 2007).

Finally, other studies also report that age is not significantly associatedwith PTSD severity in children and adolescents (Agustini, Asniar, & Matsuo,2011; Bal & Jensen, 2007; Pynoos et al., 1993). These conflicting findings

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may be attributable to a variety of sources, including influences of moderat-ing variables (Agustini et al.; Trickey, Siddaway, Meiser-Stedman, Serpell, &Field, 2012), differences in study design and developmental differences thatexert either risk-inducing or protective effects (Salmon & Bryant, 2002).

PTSD and Traumatic Narrative

PTSD is a disorder of autobiographical memory in which the trauma memo-ries do not form a coherent narrative and are not integrated into the overalllife story of the person (e.g., Brewin, Dalgleish, & Joseph, 1996; van derKolk & Fisler, 1995). PTSD is characterized by a combination of symptomsthat influence the subjects’ mental state on the emotional and cognitive lev-els (DSM-5; APA, 2013). The tendency to re-experience the traumatic events(intrusive symptoms) cyclically invades the internal world, with strong andunexpected negative emotions that arouse a sense of severe and persistentthreat, affecting the cognitive resources and the emotional stability (Ehlers &Clark, 2000). At the same time, the opposing tendency to distancing (avoid-ance) drives the mind toward the removing of the thoughts relating to thetrauma.

The study of how the posttraumatic processes affect the narration oftraumatic events has concerned mainly adults, through extensive researcheson victims of war trauma, of physical and/or sexual assaults, and of ter-rorist attacks. In general, the adult literature shows that the way in whichtraumatized adults tell traumatic autobiographical episodes can be signifi-cantly influenced by the presence of PTSD symptoms, both in the qualitativeand quantitative aspects of the narrative (McNally, 2003). These aspectsmay relate to the structuring of the narrative account (length and inter-nal cohesion/fragmentation), the content (presence of sensory/perceptualdetails and the preponderance of negative emotions), the capacity of cogni-tive processing of the event (ability to reflect on the meaning of the traumaticevent and on their own and others’ mental states), and the contextualembedding (deficit in causal attribution and in definition of the space-timedimension).

Regarding the narrative structure, the research conducted to test theinfluence of PTSD symptoms on the length (number of words) and thecohesion of the narrative appear discordant. In fact, several studies showthat traumatized adults are predicted to tell shorter narratives about theirtraumatic event (Foa, Molnar, & Cashman, 1995; Peterson & McCabe,1983), because they are rendered speechless due to unconscious repres-sion of memories with a preponderance of the implicit memory associations(Brewin, 2001; van der Kolk & Fisler, 1995). Furthermore, the traumaticnarratives of adults with active PTSD symptoms present a lack of inter-nal coherence (Barclay, 1995), fragmentation and poor organization (Amir,Stafford, Freshman, & Foa, 1998; Foa & Riggs, 1993; Tromp, Koss, Figueredo,

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& Tharan, 1995; van der Kolk & Fisler, 1995), repetition of identical sen-tences, incomplete sentences, and interruptions (Foa et al., 1995), whichundermine the complete and coherent development of the narrative. On thecontrary, other more recent studies (Beaudreau, 2007; Gray & Lombardo,2001; Hellawell & Brewin, 2004; Rullkoetter et al., 2009) show that trau-matic narratives are characterized by a greater number of words comparedto non-traumatic recollections. However, this result can be interpreted as amarker of confusion and as a difficulty in formulating a clearly structured andrational account, in accordance with the concept of decreased coherence oftraumatic narratives (Rullkoetter et al., 2009).

Regarding narrative contents, in general, the literature on traumatizedadults is quite unified in pointing out that individuals with a PTSD profile tellmore vivid recollections of the traumatic event in terms of sensory modal-ities and of intensity of emotions (Berntsen, Willert, & Rubin, 2003; Boals& Rubin, 2011). This finding is not surprising since, as is well known, thereliving experiences or “flashbacks” of the trauma and the intense nega-tive emotions (fear, helplessness, or horror) are important features in PTSDconditions (DSM-5; APA, 2013). In fact, compared to ordinary autobiograph-ical accounts, the flashbacks are dominated by sensory details (vivid visualimages, auditory sensations, and smells, etc.; Ehlers & Clark, 2000; Hellawell& Brewin, 2004) that lead to “physically relive” the traumatic experience(Rubin, Feldman, & Beckham, 2004; van der Kolk & Fisler, 1995). Empiricalresearch and clinical observations show that in adults with PTSD symptoms,these images and sensations are typically disjointed and fragmentary and areconnected to the sense of death, of physical pain reliving, and of feelings ofthreat and helplessness (Alvarez-Conrad, Zoellner, & Foa, 2001; Beaudreau,2007; D’Andrea, Chiu, Casas, & Deldin, 2012; Hellawell & Brewin, 2004).In particular, in the expressive writing settings, the focus on death has beenidentified by Pennebaker and colleagues (1997) as an important indicator ofpsychological adjustment and of level of PTS in their narratives individualswith more severe PTSD symptoms, reported a higher number of referencesto death. Similarly, Alvarez-Conrad and colleagues (2001) connect the senseof death to the concept of mental defeat: In the traumatic narratives of femalevictims of assaults, in the pre- and posttreatment, the greater use of the deathwords is strongly related to PTSD symptoms.

Moreover, the literature shows that in the traumatic recollections, therelationship between sense of reliving and PTSD is more strengthened by theemergence of intense and negative emotionality (Ehlers, Mayou, & Bryant,1998; Talarico & Rubin, 2003). Most researchers agree that emotion is a cen-tral organizational aspect of traumatic memories and narratives (Brewin &Holmes, 2003; Stein, Trabasso, & Albro, 2001) and that the difficulties in inte-grating negative emotions are a direct consequence of PTSD (Foa & Riggs,1993; van der Kolk, 1996). Consistent with this, many studies (Beaudreau,2007; Grey & Holmes, 2008; Grey, Holmes, & Brewin, 2001; Holmes, Grey,

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& Young, 2005; Rubin, Dennis, & Beckham, 2011) show that traumatic narra-tives of traumatized adults are characterized by the predominant expressionof negative emotions—fear, disgust, anger, shame, anxiety, sadness, andpain—that were experienced at the time of the trauma itself.

Whereas in literature reliving and negative emotions appear to be directconsequences of the post-traumatic outcomes, instead other narrative dimen-sions depend on cognitive appraisal. Clinical studies, conducted beforeand after therapeutic treatment of traumatized patients who are victims ofdifferent types of trauma, have considered the changes in the cognitiveorganization of narrative as an important index of the processing of theexperience (Amir et al., 1998; Beaudreau, 2007; Foa et al., 1995; van Minnen,Wessel, Dijkstra, & Roelofs, 2002). In fact, in traumatized adults, when theactive PTSD symptoms are reabsorbed, their traumatic narratives are enrichedby references to the internal worlds (such as thoughts and cognitive evalu-ations), which are indicators of a greater reflective ability and of a moreadaptive functioning (Pennebaker et al., 1997; Pennebaker & Francis, 1996).

Finally, regarding to contextual embedding, in clinical observations oftraumatized adults with chronic PTSD, some authors (van der Kolk, 1996)have noted that during the initial stage of treatment, the traumatic nar-ratives are characterized by disorientation of time and space. Specifically,it is as if the traumatized subjects were stuck in the past and the trau-matic events seemed to happen in the present (Brewin & Holmes, 2003).Some authors (Holman & Silver, 1998; Pillemer, Desrochers, & Ebanks, 1998;Rullkoetter et al., 2009) link the “past orientation” with more distress and withan internal switch from a narrative-based representation to an image-basedrepresentation in memory.

As previously mentioned, compared to the literature on adults, stud-ies focused on the narratives of traumatized children (especially in casesof child abuse and maltreatment) are less numerous and with less homoge-neous results (see Dalgleish, Meiser-Stedman, & Smith, 2005). Although someauthors (for example, Drell, Siegel, & Gaensbauer, 1993; Pynoos, Steinberg,& Wraith, 1995) have suggested that children could interpret the traumaticevents and organize traumatic narratives differently from adults; howeversome studies show that, also in children, the presence of PTSD symptomssignificantly affects some specific aspects of narratives, as in traumatizedadults.

In general, compared both to children trauma-exposed without PTSDand to children who recount unpleasant comparative narratives, childrenwith PTSD symptoms produce more incomplete and disorganized traumaticnarratives (Merritt, Ornstein, & Spicker, 1994; Peterson & Biggs, 1998; Sales,Fivush, Parker, & Bahrick, 2005), often have difficulty in regulating emo-tional content (Sayfan, Mitchell, Goodman, Eisen, & Qin, 2008) and tendto distort the actual time and context of events, due to poorly developedskills of spatial-temporal memory system (Pynoos et al., 1995). In particular,

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between the most recent studies, Salmond and colleagues (2011), in a groupof traumatized children and adolescents, underline that acute posttraumaticsymptom severity is significantly predicted by the level of disorganizationin the trauma narrative and the child’s cognitive appraisals of the event.Similarly, in a study conducted with traumatized children who have experi-enced an accident requiring hospitalization, Kenardy and colleagues (2007)show that the lack of narrative cohesion is predictive of PTSD symptoms(whereas the temporal disorganization and the length of the narrative arenot connected to the post-traumatic symptomatology).

Finally, in several researches (Di Blasio et al., 2011; Di Blasio, Ionio,& Procaccia, 2004; Miragoli et al., 2009; Procaccia & Miragoli, 2011) on thetestimony of sexually abused children, the effect of presence of PTSD on theorganization and the content of traumatic narratives is confirmed. In partic-ular, compared to victims without PTSD, the victims with PTSD symptoms,in their allegations present more deficiencies in spatial contextualization, agreater use of sensorial memory, and negative emotions, directly related tothe violence (physical pain reliving and sense of death), and more inabil-ity to think, judge, and cognitively process the traumatic event (Di Blasioet al., 2011; Di Blasio & Procaccia, 2009). Furthermore, in children withactive symptoms, a greater simplicity in grammatical construction and tem-poral organization more connected to the past are pointed out (Procaccia &Miragoli, 2011), as if these children remain trapped in the temporal dimen-sion of their traumatic experience (Di Blasio, 2000). These results contrastthose of a study by O’Kearney and colleagues (2007), in which the presenceof high intrusive symptoms is connected to a paucity of sensory/perceptualdetails and a dominance of markers indicating attempts or making the eventas coherent and causally meaningful.

THE PRESENT STUDY: OBJECTIVES AND HYPOTHESIS

The literature has highlighted the importance of the age of the child in thenarrative of adverse and/or traumatic events and in the development ofPTSD symptoms and the importance of PTSD symptoms in the narrative oftraumatic events. For these reasons, the main goal of the present study wasto better understand how traumatized children report their traumatic expe-riences, exploring the possible mediational role of PTSD in the relationshipbetween age and traumatic narratives in a group of 58 children who werevictims of sexual abuse. This model assumes a three-variable system suchthat there are two causal paths (age and PTSD) feeding into the outcomevariable (narrative characteristics). To our knowledge, no study has investi-gated the possible mediational role of PTSD, but the analyses are focusedon comparisons among subjects with and without PTSD or different types ofnarratives (ordinary versus traumatic).

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According to the literature, we hypothesized that age is strongly relatedto the characteristics (organization, content, and cognitive processing) of thetraumatic narratives and that age also is an important factor in predictingsymptom severity of PTS. In particular, the presence of PTSD symptoms mayplay a mediating role in the relationship between age and features of thetraumatic accounts, changing some trajectories compared to the character-istics of typical development. The narrative characteristics evaluated in thisstudy are taken from the literature mentioned and are the length of narrative,sensory reliving, the sense of death, negative emotions, reflective ability, andcontextual embedding. In particular, we expect that the PTSD plays a medi-ating effect in all these narrative categories, mitigating the direct effect ofage. In the traumatic narratives of children we hypothesized, according tothe studies on PTSD, a positive effect of amplification on sensory reliving,the sense of death, and negative emotions and, according to the literature oneffect on age, a negative effect of reduction on length of narrative, reflectiveability, and contextual embedding.

METHODS

Participants

The study investigates characteristics of traumatic autobiographical narra-tives in a group of 58 children who were victims of sexual abuse and wereinvolved in criminal proceedings concluding in the conviction of the accusedat Criminal Court of Milan. At the time of the deposition, the mean age ofthe victims (34 female and 24 male) was 10 years (SD = 3.5 years; range,4–17 years): 13.8% of children (n = 8) were preschool aged (4–6 yearsold), 53.4% (n = 31) school-age (7–10 years old), and 32.8% (I = 19) wereadolescents (11–17 years old).

Regarding the characteristics of traumatic experiences, in 41.3% (n =24), the sexual abuse was domestic, in 39.7% (n = 23) it was outside thefamily, and in 29% (n = 11) it was both domestic and outside the family.Sexual violence in 56.9% of cases (n = 33) was committed with acts ofpenetration (genital, anal, and/or oral) and in the remaining 43.1% (n =25) with sexual assaults without penetration. The average duration of sexualabuse was 2.14 years (SD = 2.00).

A PTSD symptom profile is here defined as a specific pattern of men-tal effects from a traumatic experience, which match the formal criteria forPTSD in the DSM IV–TR (APA, 2000): 29 children (n = 50%) presented all thesymptoms required for a PTSD analysis, and 29 (n = 50%) did not presentsuch symptoms. A structured interview that assesses the PTSD symptoms’severity and frequency was used to verify participants’ diagnostic status inthe legal report phase. To meet diagnostic criteria for PTSD, an individualmust incur symptoms of re-experiencing the trauma, of avoidance/emotional

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numbing, and of increased arousal as a result of experiencing a traumaticevent. In the PTSD group, only children who had moderate-to-severe symp-toms were included, and in the no-PTSD group, only children who did notshow any symptoms of PTSD. No child had received therapeutic treatmentfor the trauma.

Procedure

Forensic interviews were conducted with the purpose of initiating a criminalinvestigation into the sexual abuse allegations and were conducted by skilledpersonnel trained in evaluating the cases of child sexual abuse. In line withthe literature (Melinder et al., 2010), each deposition was collected throughsemi-structured interviews divided into four phases (relationship building,free narrative, questioning, closure), audio-recorded, and transcribed verba-tim. Only the content, which was referring to sexual abuse, was analyzed:This could be referred by the victim spontaneously or in response to ques-tions. The interviews covered a wide range of questions concerning thecontext of the abuse (e.g., severity, duration, type of abusive action, rela-tionship to the perpetrator, and interactions with the perpetrator) as well asthe child’s thoughts and the feelings about the traumatic experience.

Linguistic analyses were conducted using Linguistic Inquiry and WordCount (LIWC; Pennebaker et al., 2007). which has computed words for sixnarrative categories, developed ad hoc (as indicated in the manual of theprogram; Pennebaker et al., 2007):

1. Length of narrative: the number of words used to describe the abuseepisodes;

2. Sensory reliving: the number of words used to consider the various senso-rial channels, (visual, auditory, olfactory, and tactile) by means of whichthe memory codifies the information on traumatic experience, and thenumber of words used to express physical pain reliving (e.g., “I felt astabbing pain”);

3. Sense of death: the number of words used to express sense of death anddying (e.g., “Thought I would die”);

4. Negative emotions: the number of words used to indicate emotions linkedto the abusive event (fear, anger, shame, guilt, sadness, betrayal, anddisgust);

5. Reflective ability: the number of words used to provide expressions ofself-awareness and of attribution of mental states (e.g., “I thought that ifI had talked to someone he would have hurt me and that he behaved inthat way to punish me” “before I was trusting, but not now,” or “at thatmoment I was thinking that . . . ”); and

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6. Contextual embedding: the number of words used to mark temporal(then, when, while, until, next, before, after, etc.), spatial, and causalrelations (because, so, in order to, therefore, consequently, etc.; e.g., “Wewere in the living room, then he arrived and took me to the bedroom forus to be alone”).

Each category was computed as a ratio with respect to total word count. Forthe creation of specific vocabulary for this study, two independent codershad analyzed and coded all the allegations. Inter-rater reliability of codingwas established by calculating the percentage of cases in which the codersagreed, also using kappa. Coders agreed in 84% of the cases with a kappaof .63. All discrepancies between the two coders were resolved throughdiscussions among the coders and a third experienced coder. Coding wascarried out by coders who were blind to the presence/absence of the PTSDsymptoms.

Strategy of Analysis

Data analyses proceeded in several steps. First, correlations were calculatedamong all variables investigated (age, presence/absence of PTSD symptoms,and narrative categories) to examine initial bivariate associations and identifypossible covariates.

Second, a set of regression analyses were conducted to examinewhether PTSD symptoms mediate the relationship between age and narrativecategories. Four regression parameters were estimated, based on proceduresrecommended by Baron and Kenny (1986): (a) the predictor (age) must besignificantly associated with the hypothesized mediator (PTSD symptoms);(b) the predictor must be significantly associated with the dependent mea-sure (narrative categories); (c) the mediator must be significantly associatedwith the dependent variable, and (d) the impact of the predictor on thedependent measure is less after controlling for the mediator. The proceduresoutlined by Baron and Kenny were deemed appropriate, as mediation analy-sis in psychological research is most often guided by their criteria. Moreover,the Sobel test (1982, 1986) was also calculated in order to determine whetherthe reduction in the effect of the predictor (age) after including the mediator(PTSD symptoms) in the model was significant.

RESULTS

Correlations, means, and standard deviations of all variables used in thepresent study are presented in Table 1. In particular, age was correlated toall narrative dimensions—positively with the length of narrative, temporal

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TAB

LE1

Des

crip

tive

Stat

istic

san

dCorr

elat

ions

for

Age

,PTSD

,an

dN

arra

tive

Cat

egories

12

34

56

78

910

11

1.A

ge—

2.PTSD

—.2

8∗—

3.Le

ngt

hofnar

rativ

e.4

1∗∗−.

07—

4.Se

nso

ryre

livin

g—

.55∗∗

.25

−.26

—5.

Phys

ical

pai

nre

livin

g—

.29∗

.37∗∗

−.03

.46∗∗

—6.

Sense

ofdea

th—

.27∗

.41∗∗

−.06

.43∗∗

.92∗∗

—7.

Neg

ativ

eem

otio

ns

—.4

3∗∗.4

1∗∗−.

17—

.57∗∗

.86∗∗

.79∗∗

—8.

Refl

ectiv

eab

ility

.31∗

—.3

1∗−.

04—

.55∗∗

—.3

6∗∗—

.34∗

—.3

5∗∗—

9.Te

mpora

lm

arke

rs.3

1∗—

.15

.26

—.4

0∗∗—

.33∗∗

—.3

0∗—

.47∗∗

.03

—10

.Sp

atia

lm

arke

rs.1

2−.

20−.

07.1

6−.

09−.

11−.

18−.

33∗

.07

—11

.Cau

salm

arke

rs−.

15.0

4.0

1−.

09.0

1.0

1.1

2.0

8.1

9−.

25—

M(S

D)

10(3

.5)

—12

44(1

20

1)

10.4

(3.7

).5

(.9

).6

(.9

)3.

2(3

.2)

3.0

(1.7

)6.

5(2

.3)

4.7

(1.9

)2.

2(.

9)

∗ p<

.05;

∗∗p

<.0

1.

367

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368 S. Miragoli et al.

markers, and reflective ability—and negatively with sensory and physicalpain reliving, negative emotions, and sense of death. This means that, withincreasing age, children provide a longer narrative report, characterized byhigher number of temporal references, more reflective capacities, fewer sen-sory details, and negative emotions. Moreover, age was correlated negativelywith PTSD symptoms: Younger children are more likely to develop PTSDsymptoms compared to older children. On the other hand, the PTSD symp-toms were correlated negatively with reflective ability and positively withthe expression of negative emotions, sense of death, and physical painreliving. This means that children with active symptoms of PTSD producenarratives less cognitively elaborate and characterized by more negative emo-tions, sense of death, and physical pain reliving than children without PTSDsymptoms.

The mediation model was tested only for the narrative variables thatwere associated with age and PTSD symptoms: negative emotions, sense ofdeath, physical pain reliving, and reflective ability. To test the effects of age(predictor) on PTSD symptoms (mediator), multiple linear regression wasperformed (Table 2; Condition 1 of the mediational model). To examinethe relative contributions of age (predictor) and PTSD symptoms (media-tor) to narrative categories (outcomes), the hierarchical multiple regressionanalyses were conducted separately for each narrative category (Table 3).Age was entered in Step 1 (Condition 2), and the presence/absence ofPTSD was added in Step 2 (Condition 3) to determine what degree PTSDsymptoms mediate the relationship between age and narrative categories(Condition 4).

Regarding the mediating role of PTSD symptoms, results revealed thatPTSD symptoms (respectively: β = .31, t = 2.64, p < .05 and β = –.24, t =–1.88, p < .05) partially mediate the relationship between age and negativeemotions and between age and reflective ability. The Sobel test (1982, 1986)further has confirmed the significance of the mediational effect of PTSDsymptoms on negative emotions (t = 2.29, p = .01) and reflective ability(t = –1.74, p = .04). This means that, in conjunction with the effect of age(which remains significant in the model), the presence of PTSD symptomshas a significant impact on the expression of negative emotions and reflective

TABLE 2 Predictor of PTSD (Condition 1 of the Mediational Model)

Predictor variable B SE B β Outcome

PTSDConstant .90 .20Age −.40 .02 −.28R2 .26F 4.57∗

∗p < .05; ∗∗p < .01.

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Language Use and PTSD in Child Sexual Abuse 369

TABLE 3 Hierarchical Regression Analysis Predicting Narratives Categories (Conditions 2 and3 of the Mediational Model)

Step 1 Step 2

B SE B β B SE B β

Outcome: Negative emotionsConstant 7.09 1.16 5.31 1.30Age −.40 .11 —.43∗∗ −.32 .11 —.34∗∗

PTSD 1.99 .75 .31∗

R2 .19 .28F 12.75∗∗ 10.53∗∗

R2 .09F 2.22∗

Outcome: Physical pain relivingConstant 1.27 .34 .77 .39Age −.07 .03 −.29∗ −.05 .03 −.20PTSD .56 .22 .32∗

R2 .08 .18F 5.13∗ 5.92∗∗

R2 .10F .79∗

Outcome: Sense of deathConstant 1.36 .37 .74 .40Age −.07 .04 −.27∗ −.05 .03 −.17PTSD .69 .23 .37∗∗

R2 .07 .20F 4.29∗ 6.74∗∗

R2 .13F 2.45∗∗

Outcome: Reflective abilityConstant 1.43 .67 2.18 .76Age .15 .06 .31∗ .12 .06 .24∗

PTSD −.83 .44 −.24∗

R2 .10 .15F 5.93∗ 4.86∗

R2 .05F 1.07∗

∗p < .05; ∗∗p < .01.

ability. In the first case, the presence of PTSD symptoms has a positive effect,increasing the number of references to negative emotions; in the secondcase, a negative effect, decreasing the number of references to reflectiveability.

Moreover, the PTSD symptoms (respectively: β = .32, t = 2.50, p <

.05 and β = .37, t = 2.93, p < .01) totally mediate the relationshipbetween age and physical pain reliving and between age and sense ofdeath. The Sobel test (1982, 1986) further has confirmed the significanceof the mediational effect of PTSD symptoms on physical pain reliving (t =2.21, p = .010) and sense of death (t = 2.50, p = .006). This means that the

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370 S. Miragoli et al.

β = –.24*

β = .32*

β = .37**

β = –.43** vs β = –.34*

β = .28* β = .31*

β = –.27* vs n.s.

β = .31* vs β = 24*

β = –.29* vs n.s.

Age

PTSD

Negative emotions

Sense of death

Physical pain reliving

Reflective ability

FIGURE 1 Posttraumatic stress as mediator of the relationship between age and narrativescategories (N = 58).

presence of PTSD symptoms has a significant impact on the expression ofphysical pain reliving and sense of death, completely obscuring the effect ofage. In both cases, the effect of the PTSD symptoms was positive: The pres-ence of PTSD increases the number of references to physical pain relivingand sense of death.

Figure 1 shows a schematic of the mediation models under investigation.

DISCUSSION

Children’s allegations typically represent the central evidence for judging theoccurrence of child sexual abuse (London, Bruck, Ceci, & Shuman, 2005)and the professionals, in doing this, must know and consider how chil-dren tell and disclose the abuse. The present study lends support to thehypothesis that, in children, the linguistic elements of trauma narratives areassociated with age and posttraumatic symptomatology. In particular, ourresults confirm that age is a key predictor for all investigated narrative skillsand plays an important role in the way children tell their traumatic experi-ences. Furthermore, age represents a significant factor for the developmentof posttraumatic symptomatology: In fact, our results show that younger chil-dren are the most vulnerable to the impact of traumatic events and that theyare more likely to develop PTSD symptoms than older children.

Regarding the specific role of PTSD symptoms, our results illustrate themediational role of PTSD symptoms in the relationship between age andsome specific features of traumatic narratives: For physical pain reliving andsense of death, this relationship is mediated totally and for negative emo-tions and reflective ability partially. According to the literature on adults(Beaudreau, 2007; Pennebaker et al., 1997), our data show that, even in chil-dren, the traumatic narratives mainly consist of sensory impressions, of which

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Language Use and PTSD in Child Sexual Abuse 371

physical pain reliving and sense of death are certainly important indexes.In fact, during the narration of sexual abuse, physical pain reliving and thecurrent sense of dying show that the memory of the violence is still aliveand real in the allegations of children with active PTSD symptoms. In ourstudy, the role of PTSD symptoms, in influencing these dramatic aspects, is sostrong as to obscure the direct effect of age. Therefore, our findings supportthe assumption that the narratives of traumatic events form vivid landmarksin autobiographical memory (Berliner et al., 2003; Berntsen et al., 2003), withmore vivid recollections and more intense re-experiencing. A further pointof reflection can arise from the fact that, as for adults (Alvarez et al., 2001;D’Andrea et al. 2012; Pennebaker et al., 1997), also for children, the languagerelated to death may be considered as a significant indicator of distress andthat, connected to fear, it may be an important risk factor for the devel-opment of more severe PTSD symptoms (e.g. Bernat, Ronfeldt, Calhoun, &Arias, 1998).

Besides the activation of sensory memory and the sense of death, ourresults also show a substantial relationship between PTSD symptoms anddysregulation of negative emotions, in which the child’s age still plays animportant predicting role. According to the literature on adults (Brewin &Holmes, 2003; Stein, Trabasso, & Albro, 2001), our data suggest that thenarratives of traumatized children are structured on the non-processing ofnegative emotions: in our study, children with PTSD symptoms reported theirtraumatic experiences with a greater amount of negative emotions, which aremanifested through a wide range of shades (such as anger, sadness, shame,guilt, and disgust; Lee, Scragg, & Turner, 2001), not only with the “standard”PTSD emotions of fear, helplessness, and horror (Grey & Holmes, 2008;Holmes et al., 2005). This result confirms previous studies on adults (Boals& Rubin, 2011; Rubin et al., 2004; Rullkoetter et al., 2009), in which thehigher use of negative emotions indicates a more immersion in the traumaticevent (Eid, Johnson, & Saus, 2005).

Similarly to negative emotions, our data show that PTSD symptomspartially mediate the relationship between age and reflective ability. In ourstudy, children with PTSD symptoms have a lower use of cognitive vocab-ulary, which can be attributed to difficulties in giving meaning. Therefore,these findings are similar to those of previous studies on adults (Alvarez-Conrad et al., 2001; Foa & Riggs, 1983), suggesting that the cognitive distanc-ing is strongly related to distress (Fivush, Edwards, & Mennuti-Washburn,2003; Tausczik & Pennebaker, 2010) and that cognitive processing, mea-sured by the use of cognitive words, is related to a better clinical outcome(Beaudreau, 2007; Pennebaker, 1993; Pennebaker et al., 1997; Pennebaker &Francis, 1996).

In general, our results illustrate that the developmental differences, inhow the children recall and report traumatic autobiographical events, are

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certainly influenced by age but also by the role that their traumatic mem-ories could play in symptom development. In our study, the significantlinks between PTSD symptoms, sensory impressions, emotional nodes, andcognitive distancing in trauma narratives can be explained by the dual rep-resentational theory of PTSD (Brewin, 2001; Brewin & Holmes, 2003; Brewinet al., 1996). This approach states that memories of a personally expe-rienced traumatic event can be of two distinct types, stored in differentrepresentational formats. One type of format (“verbally accessible mem-ory”) supports ordinary autobiographical memories that can be retrievedeither automatically or using strategic processes. The second type of format(SAM, “situationally accessible memory”) supports the specific trauma-relateddreams and “flashbacks.” SAM memories can be difficult to control becausepeople cannot always regulate their exposure to sensory impressions (sights,sounds, or smells) that act as reminders of the trauma. Moreover, the emo-tions that accompany SAM memories are restricted to ‘‘primary emotions’’that were experienced during the trauma. The characteristics of the SAMmemory seem rather consistent with the idea that the presence of PTSDsymptoms may affect some specific aspects (the content and the organiza-tion of memory materials) during the reenactment of the trauma narrative.Our data illustrate the fact that during the narration of a traumatic event inchildren with active symptoms of PTSD, it is possible to find a difficulty inthe resolution of negative beliefs connected to trauma (re-experiencing sen-sory memories and negative emotions) and in the management of flashbacksmemories. It seems that these children are not able to reduce negative emo-tions and sensory impression reliving, generated by narrative appraisal of thetrauma, through a conscious process of reaffirmation of the control and cop-ing strategies (Brewin & Holmes, 2003; Merckelbach, Muris, Horselenberg,& Rassin, 1998). In addition, through the narrative process, which anywayimplies the reorganization of the materials in the memory, it can be assumedthat some cognitive process of evaluation takes place and, next to the pri-mary emotions coded into a SAM memory (fear, helplessness, helplessness,and horror), the child experiences a range of emotions such as anger andshame, which are also recognized and included in the narrative account(Grey, Holmes, & Brewin, 2001). This may explain why, in our study, chil-dren with PTSD symptoms in their allegations produce a wide range ofnegative emotions and not just the primary and most primitive emotions.

In conclusion, this study represents one of the first to examine themediational effects of PTSD symptoms on the relationship between ageand narrative categories in traumatized children and illustrates the poten-tial for narrative reports to provide insights into the way in which childrenprocess and tell their traumatic events. The nature of traumatic narrativesmay have relevance in both clinical and legal settings. In a clinical setting,the narrative analysis can be an effective diagnostic tool for understand-ing the post-traumatic effects: In fact, O’Kearney and Perrott (2006), in a

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Language Use and PTSD in Child Sexual Abuse 373

clinical view, suggested that “the language in which people communicateabout trauma provides an important window into understanding the natureof PTSD” (p. 91) and that the narrative quality could predict the severity ofthe perceived stress. This consideration underlines the importance of target-ing such memories in the treatment of stress disorders in children (Smith,Yule, Perrin, Tranah, Dalgleish, & Clark, 2007).

On the other hand, in a legal setting, the effects of PTSD on narrativeprocesses are important to consider in the evaluation of child testimony inorder to improve how the criminal justice system deals with child sexualabuse (Di Blasio et al., 2004; Di Blasio et al., 2011; Miragoli et al., 2009).Our results could be intended for use by forensic experts who may be calledupon to evaluate the results of a forensic interview with children: The psy-chological assessment of trauma may assist the interpretation of allegationsprovided by young victims. One possible route to analyze children’s allega-tions is to reason in terms of the traumatic condition related to the abuse(O’Donohue et al., 2013a) and to assess how some apparently inconsis-tent elements may instead support the hypothesis that a traumatic event hasoccurred and that the child is still so traumatized as not to be able to providea linear and rational testimony of the facts.

LIMITATIONS OF THE STUDY AND FUTURE DIRECTIONS

The results of this study are suggestive, but a number of limitations shouldbe noted. First, the sample size was rather small and with children involvedin different types of sexual traumatic experiences, which had occurred atvarying periods in the past.

Besides the limitations related to sample size and severity of the expe-rience of sexual abuse, the current study has considered the characteristicsof the child and of traumatic event as the only factors related to qualityof narration, but children’s memory for events may also be influenced byother important factors. Narratives may be influenced by difficulties withretrieval and expression (Brewin & Holmes, 2003), a reluctance to discussthe trauma or the purpose of the narration (in this case, the testimony incourt). Moreover, in this study for the assessment of PTSD, dichotomouscategories are used rather than continuous measures, while more objectiveindices of PTSD severity would be useful. In particular, it would be importantto separate the specific posttraumatic clusters (re-experiencing, avoidanceand numbing, and increased arousal symptoms) to better understand theirconnections with the specific narrative categories.

Finally, although developmental research shows that children providemore organized reports of negative events than of neutral or emotionallypositive events (Ackil, Van Abbema, & Bauer, 2003; Fivush, Hazzard, Sales,Sarfati, & Brown, 2003), this study did not include a comparison narrative in

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order to determine the specificity of any traumatic narrative characteristics.In future studies, researchers should consider larger and more homogenoussamples, assessing clusters of PTSD symptoms, and comparing traumaticnarratives with ordinary memories.

REFERENCES

Ackil, J. K., Van Abbema, D. L., & Bauer, P. J. (2003). After the storm: Enduringdifferences in mother-child recollections of traumatic and non-traumatic events.Journal of Experimental Child Psychology, 84, 286–309. Retrieved from http://dx.doi.org/10.1016/S0022-0965(03)00027-4

Agustini, E. N., Asniar, I., & Matsuo, H. (2011). The prevalence of long-term post- traumatic stress symptoms among adolescents after the tsunamiin Aceh. Journal of Psychiatric and Mental Health Nursing, 18, 543–549.doi:10.1111/j.1365-2850.2011.01702.x

Alvarez-Conrad, J., Zoellner, L. A., & Foa, E. B. (2001). Linguistic predictors of traumapathology and physical health. Applied Cognitive Psychology, 15, 159–170.doi:10.1002/acp.839

American Psychiatric Association. (2000). Diagnostic and statistical manual ofmental disorders (4th ed., text rev.).Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and Statistical Manual ofMental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Amir, N., Stafford, J., Freshman, M. S., & Foa, E. B. (1998). Relationship betweentrauma narratives and trauma pathology. Journal of Traumatic Stress, 11,385–392. doi:10.1023/A:1024415523495

Anthony, J. L., Lonigan, C. J., & Hecht, S. A. (1999). Dimensionality of posttraumaticstress disorder symptoms in children exposed to disaster: Results from con-firmatory factor analyses. Journal of Abnormal Psychology, 108, 326–336.doi:10.1037/0021-843X.108.2.326

Ayer, L. A., Cisler, J. M., Danielson, C. K., Amstadter, A. B., Saunders, B. E., Kilpatrick,D. G. (2011). Adolescent posttraumatic stress disorder: An examination of factorstructure reliability in two national samples. Journal of Anxiety Disorders, 25,411–421. doi:10.1016/j.janxdis.2010.11.004

Bal, A., & Jensen, B. (2007). Post-traumatic stress disorder symptom clusters inTurkish child and adolescent trauma survivors. European Child and AdolescentPsychiatry, 16 , 449–457. doi:10.1007/s00787-007-0618-z

Barclay, C. R. (1995). Autobiographical remembering: Narrative constraints on objec-tified selves. In D. C. Rubin (Ed.), Remembering our past: Integration studies inautobiographical memories (pp. 94–125). New York, NY: Cambridge UniversityPress.

Baron, R. M., & Kenny, D. A. (1986). The moderator–mediator variable distinc-tion in social psychological research: Conceptual, strategic, and statisticalconsiderations. Journal of Personality and Social Psychology, 51, 1173–1182.doi:10.1037/0022-3514.51.6.1173

Beaudreau, S. A. (2007). Are trauma narratives unique and do they predict psycho-logical adjustment? Journal of Traumatic Stress, 20, 353–357. doi:10.1002/jts

Dow

nloa

ded

by [

Uni

vers

ita C

atto

lica

del S

acro

Cuo

re]

at 0

4:00

06

Nov

embe

r 20

14

Language Use and PTSD in Child Sexual Abuse 375

Berliner, L., Hyman, I. E., Thomas, A., & Fitzgerald, M. (2003). Children’s memoryfor trauma and positive experiences. Journal of Traumatic Stress, 16 , 229–236.doi:10.1023/A:1023787805970

Bernat, J., Ronfeldt, H., Calhoun, K., & Arias, I. (1998). Prevalence of traumaticevents and peritraumatic predictors of posttraumatic stress symptoms in a non-clinical sample of college students. Journal of Traumatic Stress, 11, 645–664.doi:10.1023/A:1024485130934

Berntsen, D., Willert, M., & Rubin, D. C. (2003). Splintered memories or vivid land-marks? Qualities and organization of traumatic memories with and withoutPTSD. Applied Cognitive Psychology, 17 , 675–693. doi:10.1002/acp.894

Boals, A., & Rubin, D. C. (2011). The integration of emotions in memories: Cognitive-emotional distinctiveness and Post-traumatic Stress Disorder. Applied CognitivePsychology, 25, 811–816. doi:10.1002/acp.1752

Brewin, C. R. (2001). A cognitive neuroscience account of posttraumatic stress dis-order and its treatment. Behaviour Research and Therapy, 39, 373–393. http://dx.doi.org/10.1016/S0005-7967(00)00087-5

Brewin, C. R., Dalgleish, T., & Joseph, S. (1996). A dual representation the-ory of posttraumatic stress disorder. Psychological Review, 102, 670–686.doi:10.1037/0033-295X.103.4.670

Brewin, C. R., & Holmes, E. A. (2003). Psychological theories ofposttraumatic stress disorder. Clinical Psychology Review, 23, 339–376.doi:10.1016/S0272-7358(03)00033-3

Briggs-Gowan, M. J., Carter, A. S., & Ford, J. D. (2012). Parsing the effects violenceexposure in early childhood: Modeling developmental pathways. Journal ofPediatric Psychology, 37 , 11–22. doi:10.1093/jpepsy/jsr063

Brown, D. A., Salmon, K., Pipe, M. E., Rutter, M., Craw, S., & Taylor, B. (1999).Children’s recall of medical experiences: The impact of stress. Child Abuse &Neglect, 23, 209–216. doi:10.1016/S0145-2134(98)00127-6

Chae, Y., Goodman, G. S., Eisen, M. L., & Qin, J. (2011). Event memory and sug-gestibility in abused and neglected children: Trauma-related psychopathologyand cognitive functioning. Journal of Experimental Child Psychology, 110, 4,520–538. doi:10.1016/j.jecp.2011.05.006

Contractor, A. A., Layne, C. M., Steinberg, A. M., Ostrowski, S. A., Ford, J. D., &Elhai, J. D. (2013). Do gender and age moderate the symptom structure ofPTSD? Findings from a national clinical sample of children and adolescents.Psychiatry Research, 210, 1056–1064. doi:10.1016/j.psychres.2013.09.012

Cooke, D. J. (1985). Psychosocial vulnerability to life events during climacteric.British Journal of Psychiatry, 147 , 71–75. doi:10.1192/bjp.147.1.71

Copeland, W. E., Keeler, G., Angold, A., Costello, E. J. (2007). Traumatic events andposttraumatic stress in childhood. Archives of General Psychiatry, 64, 577–584.doi:10.1001/archpsyc.64.5.577

Cordon, I. M., Pipe, M.-E., Sayfan, L., Cord, I. M., Melinder, A., & Goodman, G. S.(2004). Memory for traumatic experiences in early childhood. DevelopmentalReview, 24, 101–132. doi:10.1016/j.dr.2003.09.003

Dalgleish, T., Meiser-Stedman, R., & Smith, P. (2005). Cognitive aspects ofposttraumatic stress reactions and their treatment in children and adolescents:

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ita C

atto

lica

del S

acro

Cuo

re]

at 0

4:00

06

Nov

embe

r 20

14

376 S. Miragoli et al.

An empirical review and some recommendations. Behavioural and CognitivePsychotherapy, 33, 459–486. http://dx.doi.org/10.1017/S1352465805002389

D’Andrea, W., Chiu, P. H., Casas, B. R., & Deldin, P. (2012). Linguistic predictors ofpost-traumatic stress disorder symptoms following 11 September 2001. AppliedCognitive Psychology, 26 , 316–323. doi:10.1002/acp.1830

Davidson, J., & Smith, R. (1990). Traumatic experiences in psychiatric outpatients.Journal of Traumatic Stress, 3, 459–475.

Di Blasio, P. (2000). Psicologia del bambino maltrattato. Bologna, Italy: il Mulino.Di Blasio, P., Ionio, C., & Procaccia, R. (2004). Traumatic narratives: Analysis of

child abuse allegations. In A.A.V.V., Forensic psychology and law (pp. 103–114).Kraków: Institute of Forensic Research Publishers.

Di Blasio, P., Miragoli, S., & Procaccia, R. (2011). Understanding children’s sexualabuse through their allegations. In V. Ardino (Ed.), Post-traumatic syndromesin children and adolescents (pp. 177–198). London, UK: Wiley Publications.

Di Blasio, P., & Procaccia, R. (2009). Narrazioni post-traumatiche nei bambini mal-trattati e abusati. In V. Ardino (Ed.), Il disturbo post-traumatico nello sviluppo(pp. 17–33). Milano, Italy: Unicopli.

Drell, M., Siegel, C., & Gaensbauer, T. (1993). Post-traumatic stress disorders. In C.Zeanah (Ed.), Handbook of infant mental health (pp. 291–304). New York, NY:Guilford Press.

Dubner, A. E., & Motta, R. W. (1999). Sexually and physically abused foster carechildren and posttraumatic stress disorder. Journal of Consulting and ClinicalPsychology, 67 , 367–373. doi:10.1037/0022-006X.67.3.367

Dyregrov, A., & Yule, W. (2006). A review of PTSD in children. Child and AdolescentMental Health, 11, 176–184. doi:10.1111/j.1475–3588.2005.00384.x

Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumaticstress disorder. Behavior Research and Therapy, 38, 319–345.doi:10.1016/S0005-7967(99)00123-0

Ehlers, A., Mayou, R. A., & Bryant, B. (1998). Psychological predictors of chronicposttraumatic stress disorder after motor vehicle accidents. Journal of AbnormalPsychology, 107 , 508–519. doi:10.1037/0021-843X.107.3.508

Eid, J., Johnson, B. H., & Saus, E. R. (2005). Trauma narratives andemotional processing. Scandinavian Journal of Psychology, 46 , 503–510.doi:10.1111/j.1467-9450.2005.00482.x

Eisen, M. L., Qin, J. J., Goodman, G. S., & Davis, S. L. (2002). Memory andsuggestibility in maltreated children: Age, stress arousal, dissociation andpsychopathology. Journal of Experimental Child Psychology, 83, 167–212.doi:10.1016/S0022-0965(02)00126-1

Engelberg, E., & Christianson, S. (2002). Stress, trauma, and memory. In M. Eisen,J. Quas, & G. S. Goodman (Eds.), Memory and suggestibility in the forensicinterview (pp. 143–163). Mahwah, NJ: Lawrence Erlbaum Associates.

Fivush, R. (1993). Developmental perspectives on autobiographical recall. In G. S.Goodman & B. L. Bottoms (Eds.), Child victims, child witnesses (pp. 1–24). NewYork, NY: Guilford.

Fivush, R., Edwards, V. J., & Mennuti-Washburn, J. (2003). Narratives of 9/11:Relations among personal involvement, narrative content and memory of the

Dow

nloa

ded

by [

Uni

vers

ita C

atto

lica

del S

acro

Cuo

re]

at 0

4:00

06

Nov

embe

r 20

14

Language Use and PTSD in Child Sexual Abuse 377

emotional impact over time. Applied Cognitive Psychology, 17 , 1099–1111.doi:10.1002/acp.988

Fivush, R., Hazzard, A., Sales, J. M., Sarfati, D., & Brown, T. (2003). Creating coher-ence out of chaos? Children’s narratives of emotionally negative and positiveevents. Applied Cognitive Psychology, 16 , 1–19. doi:10.1002/acp.854

Fivush, R., & Schwarzmueller, A. (1995). Say it once again: Effects of repeated ques-tioning on children‘s event recall. Journal of Traumatic Stress, 8(4), 555–580.doi:10.1002/jts.2490080404

Foa, E. B., Molnar, C., & Cashman, L. (1995). Change in rape narratives duringexposure to therapy for posttraumatic stress disorder. Journal of TraumaticStress, 8, 675–690. doi:10.1002/jts.2490080409

Foa, E. B., & Riggs, D. S. (1993). Posttraumatic stress disorder in rape victims. In J.Oldham, M. B. Riba, & A. Tasman (Eds.), American psychiatric press review ofpsychiatry (vol. 12, pp. 273–303). Washington, DC: American Psychiatric Press.

Foy, D. W. (1992). Treating posttraumatic stress disorder: Cognitive behavioralstrategies. New York, NY: Guilford Press.

Foy, D. W., Madvig, B. T., Pynoos, R. S., & Camilleri, A. J. (1996). Etiologic factors inthe development of posttraumatic stress disorder in children and adolescents.Journal of School Psychology, 34, 133–145.

Foy, D. W., Osato, S. S., Houskamp, B. M., & Neumann, D. A. (1992). Etiology ofposttraumatic stress disorder. In P.A. Saigh (Ed.), Posttraumatic stress disorder:A behavioral approach to assessment and treatment (pp. 28–49). Boston, MA:Allyn and Bacon.

Garrison, C. Z., Bryant, E. S., Addy, C. L., Spurrier, P. G., Freedy, J. R., & Kilpatrick, D.G. (1995). Posttraumatic stress disorder in adolescents after Hurricane Andrew.Journal of the American Academy of Child and Adolescent Psychiatry, 34,1193–1201. doi:10.1097/00004583-199509000-00017

Goodman, G. S., Quas, J. A., Batterman-Faunce, J. M., Riddlesberger, M. M., &Kuhn, J. (1994). Predictors of accurate and inaccurate memories of traumaticevents experienced in childhood. Consciousness and Cognition, 3, 269–294.doi:10.1006/ccog.1994.1016

Goodman, G. S., Quas, J. A., Batterman-Faunce, J. M., Riddlesberger, M. M., &Kuhn, J. (1997). Children’s reactions to and memory for a stressful event:Influences of age, anatomical dolls, knowledge, and parental attachment.Applied Developmental Science, 1, 54–75. doi:10.1207/s1532480xads0102_1

Goodman, G. S., Quas, J., Burley, J., & Shapiro, C. (1999). Innovations for childwitnesses: A natural survey. Psychology, Public Policy, and Law, 5, 255–281.

Gray, M. J., & Lombardo, T. W. (2001). Complexity of trauma narratives as an index offragmented memory in PTSD: A critical analysis. Applied Cognitive Psychology,15, 171–186. doi:10.1002/acp.840

Green, B. L., Korol, M., Grace, M. C., Vary, M. G., Leonard, A. C., Gleser, G. C.,& Smitson-Cohen, S. (1991). Children and disaster: Age, gender, and parentaleffects on PTSD symptoms. Journal of the American Academy of Child andAdolescent Psychiatry, 30, 945–951. doi:10.1097/00004583-199111000-00012

Grey, N., & Holmes, E. A. (2008). “Hotspots” in trauma memories in the treat-ment of post-traumatic stress disorder: A replication. Memory, 16 , 7, 788–796.doi:10.1080/09658210802266446

Dow

nloa

ded

by [

Uni

vers

ita C

atto

lica

del S

acro

Cuo

re]

at 0

4:00

06

Nov

embe

r 20

14

378 S. Miragoli et al.

Grey, N., Holmes, E. A., & Brewin, C. R. (2001). Peritraumatic emotional ‘hot spots’in memory. Behavioral and Cognitive Psychotherapy, 29, 357–362. http://dx.doi.org/10.1017/S1352465801003095

Hellawell, S. J., & Brewin, C. R. (2004). A comparison of flashbacks and ordinaryautobiographical memories of trauma: Content and language. Behavior Researchand Therapy, 42, 1–12. doi:10.1016/S0005-7967(03)00088-3

Hoffman, M. A., & Bizzman, A. (1996). Attributions and responses to the ArabIsraeli conflict: A developmental analysis. Child Development, 67 , 117–128.doi:10.1111/j.1467-8624.1996.tb01723.x

Holman, E. A., & Silver, R. C. (1998). Getting “stuck” in the past: Temporal orienta-tion and coping with trauma. Journal of Personality and Social Psychology, 74,1146–1163. doi:10.1037/0022-3514.74.5.1146

Holmes, E. A., Grey, N., & Young, K. A. (2005). Intrusive images and “‘hotspots’”of trauma memories in posttraumatic stress disorder: An exploratory investi-gation of emotions and cognitive themes. Journal of Behavior Therapy andExperimental Psychiatry, 36 , 3–17. doi:10.1016/j.jbtep.2004.11.002

Kaplow, J. B., Dodge, K. A., Amaya-Jackson, L., & Saxe, G. N. (2005). Pathways toPTSD, Part II: Sexually abused children. American Journal of Psychiatry, 162,1305–1310. doi:10.1176/appi.ajp.162.7.1305

Kar, N., Mohapatra, P. K., Nayak, K.C., Pattanaik, P., Swain, S. P., &.Kar, H. C. (2007).Post- traumatic stress disorder in children and adolescents one year after asuper-cyclone in Orissa, India: Exploring cross-cultural validity and vulnerabilityfactors. BMC Psychiatry, 7 , 8. Retrieved from http://www.biomedcentral.com/1471-244X/7/8

Kenardy, J., Smith, A., Spence, S. H., Lilley, P., Newcombe, P., Dob, R.,& Robinson, S. (2007). Dissociation in children’ s trauma narratives:An exploratory investigation. Journal of Anxiety Disorders, 21, 456–466.doi:10.1016/j.janxdis.2006.05.007

Kleinknecht, E., & Beike, D. R. (2004). How knowing and doing inform an auto-biography: Relations among preschoolers’ theory of mind, narrative, and eventmemory skills. Applied Cognitive Psychology, 18, 745–764. doi:10.1002/acp.1030

Kulkofsky, S., Wang, Q., & Ceci, S. J. (2008). Do better stories make better memories?Narrative quality and memory accuracy in preschool children. Applied CognitivePsychology, 22, 21–38. doi:10.1002/acp.1326

Lamb, M. E., Sternberg, K. J., & Esplin, P. W. (2000). Effects of age and delay on theamount of information provided by alleged sex abuse victims in investigativeinterviews. Child Development, 71, 1586–1596. doi:10.1111/1467-8624.00250

Lamb, M. E., Sternberg, K. J., Orbach, Y., Esplin, P. W., Stewart, H., & Mitchell, S.(2003). Age differences in young children’s responses to open-ended invita-tions in the course of forensic interviews. Journal of Consulting and ClinicalPsychology, 71, 926–934. doi:10.1037/0022-006X.71.5.926

Lee, D. A., Scragg, P., & Turner, S. (2001). The role of shame and guilt in traumaticevents: A clinical model of shame-based and guilt-based PTSD. British Journalof Medical Psychology, 74, 451–466. doi:10.1348/000711201161109

London, K., Bruck, M., Ceci, S. J., & Shuman, D. W. (2005). Disclosureof child sexual abuse. What does the research tell us about the ways

Dow

nloa

ded

by [

Uni

vers

ita C

atto

lica

del S

acro

Cuo

re]

at 0

4:00

06

Nov

embe

r 20

14

Language Use and PTSD in Child Sexual Abuse 379

that children tell? Psychology, Public Policy, and Law, 11, 1, 194–226.doi:10.1037/1076-8971.11.1.194

Lonigan, C. J., Shannon, M. P., Taylor, C. M., Finch, A. J., & Sallee, F. R. (1994).Children exposed to disaster: Risk factors for the development of posttraumaticsymptomatology. Journal of the American Academy of Child and AdolescentPsychiatry, 33, 94–105. doi:10.1097/00004583-199401000-00013

McNally, R. J. (2003). Progress and controversy in the study ofposttraumatic stress disorder. Annual Review of Psychology, 54, 229–252.doi:10.1146/annurev.psych.54.101601.145112

Meiser-Stedman, R., Smith, P., Glucksman, E., Yule, W., & Dalgleish, T. (2008). Theposttraumatic stress disorder diagnosis in preschool- and elementary school-agechildren exposed to motor vehicle accidents. American Journal of Psychiatry,165, 1326–1337. doi:10.1176/appi.ajp.2008.07081282

Melinder, A., Alexander, K., Cho, Y., Goodman, G. S., Thoresen, C., Lonnum,K., & Magnussen, S. (2010). Children’s eyewitness memory: A comparison oftwo interviewing strategies as realized by forensic professionals. Journal ofExperimental Psychology, 105, 157–177. http://dx.doi.org/10.1016/j.jecp.2009.04.004

Merckelbach, H., Muris, P., Horselenberg, R., & Rassin, E. (1998). Traumaticintrusions as ‘worse case scenarios’. Behaviour Research and Therapy, 36 ,1075–1079. doi:10.1016/S0005-7967(98)00101-6

Merritt, K. A., Ornstein, P. A., & Spicker, B. (1994). Children’s memory for a salientmedical procedure: Implications for testimony. Pediatrics, 94, 17–23.

Miragoli, S., Di Blasio, P., & Procaccia, R. (2009). Un’analisi del contenuto dellatestimonianza infantile. Maltrattamento e abuso all’infanzia, 11(3), 83–97.doi:10.3280/MAL2009-003008

O’Donohue, W., Benuto, L. T., & Cirlugea, O. (2013a). Analyzing child sex-ual abuse allegations. Journal of Forensic Psychology Practice, 13, 296–314.doi:10.1080/15228932.2013.822245

O’Donohue, W., Benuto, L. T., Fondren, R. N., Tolle, L., Vijay, A., & Fanetti,M. (2013b). Dimensions of child sexual abuse allegations: What is unusualand what is not? Journal of Forensic Psychology Practice, 13, 456–475.doi:10.1080/15228932.2013.838103

O’Kearney, R. O., & Perrott, K. (2006). Trauma narratives in posttraumatic stressdisorder: A review. Journal of Traumatic Stress, 19, 81–93. doi:10.1002/jts.20099

O’Kearney, R. O., Speyer, J., & Kenardy, J. (2007). Children’s narrative memory foraccidents and their post-traumatic distress. Applied Cognitive Psychology, 838,821–838. doi:10.1002/acp

Orbach, Y., & Lamb, M. E. (2007). Young children’s references to temporal attributesof allegedly experienced events in the course of forensic interviews. ChildDevelopment, 78, 1100–1120. doi:10.1111/j.1467-8624.2007.01055.x

Ornstein, P. A., Shapiro, L. R., Clubb, P. A., Follmer, A., & Baker-Ward, L. (1997).The influence of prior knowledge on children‘s memory for salient medicalexperiences. In N. Stein, P. A. Ornstein, B. Tversky, & C. J. Brainerd (Eds.),Memory for everyday and emotional events (pp. 83–112). Hillsdale, NJ: Erlbaum

Dow

nloa

ded

by [

Uni

vers

ita C

atto

lica

del S

acro

Cuo

re]

at 0

4:00

06

Nov

embe

r 20

14

380 S. Miragoli et al.

Pennebaker, J. W. (1993). Putting stress into words: Health, linguistic, andtherapeutic implications. Behaviour Research and Therapy, 31, 539–548.doi:10.1016/0005-7967(93)90105-4

Pennebaker, J. W., Booth, R. E., & Francis, M. E. (2007). Linguistic Inquiry and wordcount: LIWC2007–Operator’s manual. Austin, TX: LIWC.net.

Pennebaker, J. W., & Francis, M. (1996). Cognitive, emotional, and lan-guage processes in disclosure. Cognition and Emotion, 10, 601–626.doi:10.1080/026999396380079

Pennebaker, J. W., Mayne, T., & Francis, M. E. (1997). Linguistic predictors of adap-tive bereavement. Journal of Personality and Social Psychology, 72, 863–871.doi:10.1037/0022-3514.72.4.863

Peterson, C. (1999). Children’s memory for medical emergencies: 2 years later.Developmental Psychology, 35, 1493–1506. doi:10.1037/0012-1649.35.6.1493

Peterson, C., & Bell, M. (1996). Children’s memory for traumatic injury. ChildDevelopment, 67 , 3045–3070. doi:10.1111/j.1467-8624.1996.tb01902.x

Peterson, C., & Biggs, M. (1998). Stitches and casts: Emotionality and narrativecoherence. Narrative Inquiry, 8, 51–76. doi:10.1075/ni.8.1.04pet

Peterson, C., & McCabe, A. (1983). Developmental psycholinguistics: Three ways oflooking at a narrative. New York, NY: Plenum.

Peterson, C., & Rideout, R. (1998). Memory for medical emergencies experi-enced by one and two year olds. Developmental Psychology, 34, 1059–1072.doi:10.1037/0012-1649.34.5.1059

Peterson, C., & Whalen, N. (2001). Five years later: Children’s memory for medicalemergencies. Applied Cognitive Psychology, 15, 7–24. doi:10.1002/acp.832.

Peterson, L. (1989). Coping by children undergoing stressful medical procedures:Some conceptual, methodological, and therapeutic issues. Journal of Consultingand Clinical Psychology, 57 , 380–387. doi:10.1037/0022-006X.57.3.380

Pillemer, D. B., Desrochers, A. B., & Ebanks, C. M. (1998). Remembering the pastin the present: Verbe tense shifts in autobiographical memory narratives. In C.P. Thompson & D. J. Hermman, (Eds.), Autobiographical memory: Theoreticaland applied perspectives (pp. 145–162). Mahwah, NJ: Erlbaum.

Pipe, M. E., Lamb, M. E., Orbach, Y., & Esplin, P. W. (2004). Recent research onchildren’s testimony about experienced and witnessed events. DevelopmentalReview, 24, 440–468. doi:10.1016/j.dr.2004.08.006

Procaccia, R., & Miragoli, S. (2011). La narrazione traumatica infantile nei casi diabuso sessuale: Influenza di età e disturbo post-traumatico da stress. Posterpresented at the XXIV National Congress of Development and EducationPsychology, Genova, September 19–21 2011.

Pynoos, R. S., Goenjian, A., Tashjian, M., Karakashian, M., Manjikian, R., Manoukian,G.. Fairbanks, L. A. (1993). Post-traumatic stress reactions in children afterthe 1988 Armenian earthquake. British Journal of Psychiatry, 163, 239–247.doi:10.1192/bjp.163.2.239

Pynoos, R. S., Steinberg, A. M., & Wraith, R. (1995). A developmental model ofchildhood traumatic stress. In D. Cicchetti & D.J. Cohen (Eds.), Developmentalpsychopathology: vol. 2. Risk, disorder, and adaptation (pp. 72–95). New York,NY: Wiley.

Dow

nloa

ded

by [

Uni

vers

ita C

atto

lica

del S

acro

Cuo

re]

at 0

4:00

06

Nov

embe

r 20

14

Language Use and PTSD in Child Sexual Abuse 381

Rubin, D. C., Dennis, M. F., & Beckham, J. C. (2011). Autobiographicalmemory for stressful events: The role of autobiographical memory inpost-traumatic stress disorder. Consciousness and Cognition, 20, 840–856.doi:10.1016/j.concog.2011.03.015

Rubin, D. C., Feldman, M. E., & Beckham, J. C. (2004). Reliving, emotions andfragmentation in the autobiographical memories of veterans diagnosed withPTSD. Applied Cognitive Psychology, 18, 17–35. doi:10.1002/acp.950

Rullkoetter, N., Bullig, R., Driessen, M., Beblo, T., Mensebach, C., & Wingenfeld,K. (2009). Autobiographical memory and language use: Linguistic analysesof critical life event narratives in a non-clinical population. Applied CognitivePsychology, 23, 278–287. doi:10.1002/acp

Sales, J., Fivush, R., Parker, J., & Bahrick, L. (2005). Stressing memory: Long-termrelations among children’s stress, recall and psychological outcome follow-ing hurricane Andrew. Journal of Cognition and Development, 6 , 529–545.doi:10.1207/s15327647jcd0604_5

Salmon, K., & Bryant, R. A. (2002). Posttraumatic stress disorder in children: Theinfluence of developmental factors. Clinical Psychology Review, 22, 163–188.doi:10.1016/S0272-7358(01)00086-1

Salmon, K., Price, M., & Pereira, J. K. (2002). Factors associated with young children‘slong-term recall of an invasive medical procedure: A preliminary investigation.Journal of Developmental and Behavioral Pediatrics, 23, 347–352.

Salmond, C. H., Glucksman, E., Thompson, P., Dalgleish, T., & Smith, P.(2011). The nature of trauma memories in acute stress disorder in chil-dren and adolescents. Journal of Child Psychology & Psychiatry, 52, 560–570.doi:10.1111/j.1469-7610.2010.02340.x

Sayfan, L., Mitchell, E. B., Goodman, G. S., Eisen, M. L., & Qin, J. (2008). Children’sexpressed emotions when disclosing maltreatment. Child Abuse & Neglect, 32,1026–1036. doi:10.1016/j.chiabu.2008.03.004

Saywitz, K. J., & Snyder, L. (1996). Narrative elaboration: Test of a new procedurefor interviewing children. Journal of Consulting and Clinical Psychology, 64,1347–1357. doi:10.1037/0022-006X.64.6.1347

Saywitz, K. J., Snyder, L., & Lamphear, V. (1996). Helping children tell whathappened: A follow-up study of the narrative elaboration procedure. ChildMaltreatment, 1, 200–212. doi:10.1177/1077559596001003003

Shannon, M. P., Lonigan, C. J., Finch, A. J., & Taylor, C. M. (1994). Children exposedto disaster. I: Epidemiology of post-traumatic symptoms and symptom pro-files. Journal of the American Academy of Child and Adolescent Psychiatry, 33,80–93. doi:10.1097/00004583-199401000-00012

Smith, P., Yule, W., Perrin, S., Tranah, T., Dalgleish, T., & Clark, D. (2007). Cognitivebehavior therapy for PTSD in children and adolescents: A preliminary random-ized controlled trial. Journal of the American Academy of Child and AdolescentPsychiatry, 46 , 1051–1061. doi:10.1097/CHI.0b013e318067e288

Sobel, M. E. (1982). Asymptotic intervals for indirect effects in structural equa-tions models. In S. Leinhart (Ed.), Sociological methodology (pp. 290–312). SanFrancisco, CA: Jossey-Bass.

Sobel, M. E. (1986). Some new results on indirect effects and their standard errors incovariance structure models. Sociological Methodology, 16 , 159–186.

Dow

nloa

ded

by [

Uni

vers

ita C

atto

lica

del S

acro

Cuo

re]

at 0

4:00

06

Nov

embe

r 20

14

382 S. Miragoli et al.

Spencer, J., & Flin, R. (1990). The evidence of children: The law and psychology.London, UK: Black-Stone.

Stein, N. L., Trabasso, T., & Albro, E. R. (2001). Understanding and organizing emo-tional experience: Autobiographical accounts of traumatic events. EmpiricalStudies of the Arts, 19, 111–130. doi:10.2190/KHDG-165T-2TEN-YC8A

Sternberg, K. J., Lamb, M. E., Orbach, Y., Esplin, P. W., & Mitchell, S. (2001b).Use of a structured investigative protocol enhances young children‘s responsesto free recall prompts in the course of forensic interviews. Journal of AppliedPsychology, 86 , 997–1005. doi:10.1037/0021-9010.86.5.997

Talarico, J. M., & Rubin, D. C. (2003). Confidence, not consistency,characterizes flashbulb memories. Psychological Science, 14, 455–461.doi:10.1111/1467-9280.02453

Tausczik, Y. R., & Pennebaker, J. W. (2010). The psychological meaning of words:LIWC and computerized text analysis methods. Journal of Language and SocialPsychology, 29, 24–54. doi:10.1177/0261927X09351676

Trickey, D., Siddaway, A. P., Meiser-Stedman, R., Serpell, L., & Field, A.P. (2012). A meta-analysis of risk factors for post-traumatic stress disor-der in children and adolescents. Clinical Psychology Review, 32, 122–138.doi:10.1016/j.cpr.2011.12.001

Tromp, S., Koss, M. P., Figueredo, A. J., & Tharan, M. (1995). Are rape memo-ries different? A comparison of rape, other unpleasant, and pleasant mem-ories among employed women. Journal of Traumatic Stress, 8, 607–627.doi:10.1002/jts.2490080406

van der Kolk, B. A. (1996). The body keeps the score: Approaches to the psychobi-ology of posttraumatic stress disorder. In B. A. van der Kolk, A. C. McFarlane,& L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experienceon mind, body, and society (pp. 303–327). New York, NY: Guilford Press.

van der Kolk, B. A., & Fisler, R. (1995). Dissociation and fragmentary nature oftraumatic memories: Overview and exploratory study. Journal of TraumaticStress, 8, 505–525. doi:10.1002/jts.2490080402

van Minnen, A., Wessel, I., Dijkstra, T., & Roelofs, K. (2002). Changes in PTSDpatients’ narratives during prolonged exposure therapy: A replication and exten-sion. Journal of Traumatic Stress, 15, 255–258. doi:10.1023/A:1015263513654

Whitcomb, D., Shapiro, E., & Stellwager, L. (1985). When the victim is a child: Issuesfor judges and prosecutors. Washington, DC: National Institute of Justice.

Wolfe, D. A., Sas, L., & Wekerle, C. (1994). Factors associated with the developmentof posttraumatic stress disorder among child victims of sexual abuse. ChildAbuse & Neglect, 18, 37–50. doi:10.1016/0145-2134(94)90094-9

Dow

nloa

ded

by [

Uni

vers

ita C

atto

lica

del S

acro

Cuo

re]

at 0

4:00

06

Nov

embe

r 20

14