Relationships among Child Maltreatment, Picture Completion Test, and Posttraumatic Symptoms: Two Examinations Using WISC-III for Japanese Children

doi:10.4236/psych.2012.38090

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Psychology

2012. Vol.3, No.8, 601-605

Published Online August 2012 in SciRes (http://www.SciRP.org/journal/psych) http://dx.doi.org/10.4236/psych.2012.38090

Relationships among Child Maltreatment, Picture Completion

Test, and Posttraumatic Symptoms: Two Examinations Using

WISC-III for Japanese Children

Kohske Ogata1,2

1Graduate School for Creative Cities, Osaka City University, Osaka, Japan

2Osaka Prefectural Government Higashiosaka Child-Family Center, Osaka, Japan

Email: [email protected]

Received May 18th, 2012; revised June 20th, 2012; accepted July 13th, 2012

The aim of the present studies was to confirm a relationship among child maltreatment, Picture Comple-

tion (PC) test, and posttraumatic symptoms in Japanese maltreated children. In some previous researches,

it was found that maltreated children scored higher on the PC test within the Wechsler series subtests. It is

hypothesized that the relative higher score of maltreated children may be an indicator of hyperarousal

symptoms in posttraumatic stress disorder (PTSD). In prior studies, there were some weaknesses on

methodology. They had problems with a small sample size and indirect methods to test the hypothesis. In

study I, the prior finding was replicated through the same indirect methodology as previous studies, using

a larger sample size. The participants were 490 Japanese children (170 maltreated and 320 controls) sam-

pled from the records of Child Guidance Centers in Japan. Results showed that a significant difference

was found only for the PC score in all the subtests in the Wechsler Intelligence Scale for Children third

edition (F[1, 487] = 12.6, p < .001), replicating the previous finding using a larger sample. In study II, the

hypothesis was verified directly using another sample set (40 maltreated). Only the correlation coefficient

was significant between the deviated score on the PC test and the subscale of PTSD in Alternate version

of the Trauma Symptom Checklist for Children (r = .33 for all subtests, p < .05; r = .38 for performance

subtests, p < .05). It may be a robust finding that the relative higher performance on PC in maltreated

children relates to hyperarousal symptoms in PTSD. The author concludes that the hypothesis in the prior

researches was demonstrated through the present two studies.

Keywords: WISC-III; Child Maltreatment; Intelligence; Traumatic Stress

Introduction

Child abuse and neglect are enormous traumatic events for

children and have various traumatic impacts on their develop-

ment. There have been abundant researches, particularly exam-

ining their intellectual development. It is well known that the

psychometric intelligence, defined as intelligence measured

using an intelligence test, of maltreated children is lower than

that of non-maltreated children (Ex. Buckle, Lancaster, Powell,

& Higgins, 2005; Delaney-Black, Covington, Ondersma, Nord-

strom-Klee, Templin, Ager, Janisse, & Sokol, 2002; Prasad,

Kramer, & Ewing-Cobbs, 2005). Findings that show a lower

intelligence level have been established, whereas there is little

information on subtest scatter and/or the intellectual profile of

maltreated children.

Frankel, Boetsch, and Harmon (2000) studied the elevated

Picture Completion (PC) score of 14 maltreated children. The

researchers demonstrated that maltreated preschoolers scored

significantly higher on the PC subtest of Wechsler Preschool

and Primary Scale of Intelligence Revised (WPPSI-R) than the

children’s mean score of performance subtests and of all sub-

tests. Frankel et al. suggested from their results that a higher

score on the PC related to a hyper-vigilance symptom of post-

traumatic stress disorder (PTSD) in maltreated children; how-

ever, their study had defects in the research design regarding

both the small sample size and no comparison group. Ogata

(2011) replicated the finding using a Japanese sample. In the

study, a comparison group (n = 12) was set and differences in

the types of child maltreatment were analyzed; however, this

investigation also had the weakness of a small sample size (12

sexually abused, 12 physically abused, 12 neglected, and 12

comparison). Nolin and Ethier (2007) investigated neglected

and/or physically abused children using neuropsychological

assessments. The unexpected results surprised the researchers

by showing that neglected children (n = 28) scored significantly

higher on problem-solving ability and abstract reasoning than

non-maltreated (n = 53) and neglected with physical abuse (n =

56) groups. These findings suggest that maltreated children

may have a specific intellectual profile, probably influenced by

their abuse and/or neglect experiences. Thus, to clarify the in-

tellectual profile in maltreated children is considered to par-

tially contribute to understanding their traumatic status. How-

ever, some pioneering researches have the problem on method-

ology.

The following two studies addressed the problems on meth-

odology in the prior researches. In particularly, the hypothesis

that the PC score may relate to the hyperarousal symptom in

PTSD was examined.

Study I

The primary weakness in the prior researches involves the

K. OGATA

small sample size. A larger sample size is indispensable for

generalization of the previous findings. The purpose of study I

was to confirm the robustness of the findings relating to the

intellectual profile of maltreated children. In study I, the prior

finding that the PC scores of the maltreated children were

higher than those of non-maltreated children was replicated

using a larger sample size.

Method

The participants included 490 Japanese children (207 girls

and 283 boys). The samples were retrospectively selected from

the records of child guidance centers (CGC) in Osaka prefec-

ture, in a region where the child maltreatment were reported

most frequently, in Japan. The CGC, like Child Protective Ser-

vices, are required to investigate child maltreatment reports, to

protect children (under 18 years old) from further maltreatment,

and to provide rehabilitative services to children, parents, and

other family members involved. The children that participated

were classified into two groups (170 maltreated and 320 com-

parisons) according to the CGC records, in which maltreatment

was determined through review of the records. Mean age (in

months) at maltreatment was 135.5 (SD = 32.0) and that of

comparisons was 146.9 (SD = 30.5). The maltreated group con-

sisted of 76 physically abused, 15 sexually abused, 26 psycho-

logically abused, and 53 neglected children. The comparison

group had been neither abused nor neglected according to the

CGC records. Physical abuse consisted of bruises, burns, cuts,

scratches, or bone fractures. Sexual abuse was defined in this

study as attempted or actual sexual contact or interaction of any

form between the participant and a caregiver or other responsi-

ble adult for purposes of the adult’s sexual gratification. Sexual

contact experiences ranged from fondling, genital touching, and

masturbation of or by another person to attempted or completed

vaginal intercourse. In this study, all psychologically abused

children were eyewitnesses to domestic violence. Following

Kotch, Lewis, Hussey, English, Thompson, Litrownik et al.

(2008), neglect was composed of two subtypes: the first sub-

type, failure to provide, involves the failure of the caregiver or

responsible adult to meet the minimum physical needs of the

child; the second subtype, lack of supervision, occurs when the

caregiver or responsible adult does not take sufficient, devel-

opmentally appropriate action to ensure the child’s safety inside

and outside the home setting. The comparison group consisted

of children needing foster care, who needed to be admitted to

child welfare institutions, with school maladaptation, and with

personality problems alleged by their parents; however, they

had not experienced any child maltreatment according to the

information on the records obtained from their parents and

themselves. All the CGC reports, whether substantiated or not,

were considered reliable indicators of maltreatment in Japan.

The intellectual functioning of children was assessed by 10

core subtests of the Wechsler Intelligence Scale for Children

third edition (WISC-III). A child’s cognitive development was

measured by the WISC-III Japanese version; the author con-

firmed from the case files that a trained child psychologist had

administered the WISC-III to the child in a CGC. The intelli-

gence test was administered after informed consent by their

parents or caregivers, and/or themselves. The scale has been

standardized on a national sample of 1125 children ranging in

age from 5 through 16 years and 11 months. Psychometric traits

of the WISC-III Japanese version were adequate on reliability

and validity (Wechsler, 1991/1998). Reliability coefficients,

based on split-half correlations, range from .64 to .85 for the 10

core subtests, and .95 for the full-scale intelligence quotient

(FIQ); reliability coefficients, based on test-retest correlations,

range from .54 to .89 for the 10 core subtests, and .93 for the

FIQ. Construct validity was also confirmed using factor analy-

sis; the four factor model was adopted, which is the same as the

original Wechsler model.

The data were analyzed as follows. First, t-tests were used

repeatedly to confirm that there were no differences between

the maltreated and comparison groups on the 10 subtests. Next,

multivariate analysis of covariance (MANCOVA) was used to

examine the difference between the maltreated and comparison

groups as controlled for the FIQ. Overall significance on

MANCOVA was followed by Bonferroni-corrected ANCOVA.

Statistical significance was set at p < .05, except for Bon-

ferroni-corrected ANCOVA (p < .005). Statistical analyses

were performed using IBM SPSS 20 Japanese version.

Results and Discussion

All results of subtest profiles are summarized in Table 1.

There was no difference in the FIQ between the groups (Mal-

treated M = 82.3, SD = 14.3; Comparison M = 83.5, SD = 13.8;

t [488] = .94, p = .35). To examine subtest scatters, it was nec-

essary to compare the subtest profiles to control for the overall

level of the FIQ. Thus, the FIQ was used as a covariate.

MANCOVA revealed a significant difference in the WISC-III

subtest results between the two groups (Wilks λ = .92, F [10,

478] = 3.91, p < .001). The obtained results demonstrated that

the intraindividual variability in the subtest profile of the mal-

treated children differed from that of the comparison group;

therefore, further examinations are needed to identify the origin

of the significant difference (Table 2).

A significant difference by Bonferroni-corrected ANCOVA

(p < .005) was found only for the PC subtest score (F [1, 487] =

12.6, p < .001). The adjusted score, controlled for the FIQ, of

the maltreated (M = 7.9) was significantly higher than that of

the comparison (M = 7.4) children. Differences in the other

subtests failed to reach statistical significance.

The results were consistent with the findings of both Frankel

et al. (2000) and Ogata (2011), showing a robustness of the

Table 1.

Subtest profiles and differences between maltreated and comparison

children in study I.

Maltreated

(n = 170)

Comparison

(n = 320)

Difference

between groups

Subtests M SD M SD t p

Picture completion 7.8 2.4 7.4 2.4 1.91.057

Information 7.0 2.8 7.5 2.8 1.77.077

Coding 7.9 2.9 8.2 2.8 .89 .374

Similarities 7.2 3.0 7.6 2.9 1.42.155

Picture arrangement7.1 3.1 7.6 2.7 1.85a.066

Arithmetic 7.2 2.8 7.7 2.7 1.87.062

Block design 8.0 3.0 8.3 3.4 1.23.218

Vocabulary 7.4 2.6 7.4 2.9 .09 .924

Object assembly 7.4 3.2 7.9 2.7 1.82a.070

Comprehension 8.0 2.7 8.0 2.9 .11 .916

Note: Student’s t-test, df = 488, aWelch’s t-test.

602

K. OGATA

Table 2.

ANCOVAs controlled for the FIQ as a covariate in study I.

Equivalent slope across the groups Regression significance Levene test ANCOVA

Subtests F p F p F p F p

Picture Completion 1.30 .255 455.44 .000* 1.34 .248 12.63 .000*

Information .58 .446 448.56 .000* .40 .525 2.39 .123

Coding .00 .977 204.37 .000* .01 .911 .20 .654

Similarity 2.07 .151 467.16 .000* 2.24 .135 1.15 .285

Picture Arrangement 6.32 .012 344.36 .000* .55 .458 2.92 .088

Arithmetic 4.34 .038 528.49 .000* 13.15 .000* 2.96 .086

Block Design 3.24 .073 401.39 .000* 2.27 .132 .66 .419

Vocabulary 6.84 .009 466.25 .000* 1.01 .316 .62 .432

Object Assembly 3.45 .064 315.01 .000* 2.02 .156 2.90 .089

Comprehension 1.46 .228 277.18 .000* .41 .522 .33 .564

Note: Statistical significance level set at .005 (.05/10), representing with the symbol*.

finding that the PC test score of maltreated may be higher than

that of comparison children. An adequate sample size (n = 490)

may strongly support the evidence. The larger sample size in

the present study, approximately tenfold that in previous studies,

would add robustness to the previous finding. In addition to the

adequate sample size, using a comparison group could enhance

the validity of the findings.

Study II

Study I replicated the previous researches. The relative

higher PC score in maltreated children was obtained using a

larger sample size; however, the methodology may have an-

other problem for examining the hypothesis suggested in the

discussion of Frankel et al. (2000). The hypothesis involved the

relationship between a deviated PC score, from the mean score

of all/performance subtests, and hyperarousal symptoms of

PTSD in maltreated children. To elucidate the hypothesis,

bivariate correlation needs to be confirmed between the PC

score and the measure on the PTSD. Therefore, study II did not

examine indirect evidence that maltreated children scored

higher on the PC subtest than the average subtest score, but

direct evidence of the correlation coefficient between the two

variables.

Method

Participants included 40 maltreated children aged (in months)

73 - 197 (M = 143, SD = 30), 26 boys and 14 girls who had

experienced physical abuse (n = 16), sexual abuse (n = 2), psy-

chological abuse (n =6), or neglect (n = 16). Data were elicited

from the same CGC as in study I. They were assessed to evalu-

ate cognitive functioning using the WISC-III and to measure

posttraumatic symptoms using an Alternate version of the

Trauma Symptom Checklist for Children (TSCC-A). Following

or preceding the WISC-III, the TSCC-A was administered after

informed consent by their parents or caregivers, and/or them-

selves.

The Japanese version of TSCC-A was standardized for 1698

children. Psychometric traits were as follows. On internal con-

sistency, Cronbach’s alpha was .81 for anxiety, .78 for depres-

sion, .86 for anger, .84 for PTSD, and .78 for dissociation. The

validity was examined using 787 children in child welfare in-

stitutions. Correlations between 33 items on the trauma-related

child behavior checklist and TSCC-A were as follows:.14 for

anxiety, .20 for depression, .25 for anger, .15 for PTSD, and .15

for dissociation (Briere, 1996/2009).

Data were analyzed as follows. After deviation score of PC

was calculated, correlation coefficients between deviated PC

score and TSCC-A were computed. Statistical analyses were

performed using IBM SPSS 20 Japanese version.

Results and Discussion

Results of the two assessments of the participants are shown

in Table 3. Their FIQ was 89.5 (SD = 12.5) and performance

IQ was 90.4 (SD = 12.6). Following Frankel et al. (2000), the

deviation of PC scores from all or performance subtests were

calculated. Correlation coefficients between the deviated PC

score and the subscales of TSCC-A were shown in Figure 1.

Of five subscales, only the PTSD measure was correlated with

PC scores deviating from the average of both all and perform-

ance subtests.

Table 3.

Descriptive statistics on the WISC-III and TSCC-A in study II.

M SD

WISC-III

Picture Completion 8.3 2.2

Information 7.9 2.3

Coding 9.1 3.2

Similarities 8.4 2.8

Picture Arrangement 8.6 3.3

Arithmetic 8.5 2.9

Block Design 8.7 3.2

Vocabulary 8.7 2.3

Object Assembly 8.4 2.7

Comprehension 9.0 2.7

TSCC-A

Anxiety 57.1 9.0

Depression 54.9 10.7

Anger 52.4 9.2

PTSD 57.2 8.7

Dissociation 54.4 9.9

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00.1 0.2 0.3 0.4

All subtests

Performance

subtests

Dissociation

PTSD

Ang e r

Depression

Anx i ety

Figure 1.

Correlation coefficients between deviated PC score from all/performance subtests and sub-

scales of TSCC-A. Dotted line represents statistical significance at p < .05.

The results may directly support the hypothesis suggested in

Frankel et al. (2000) that only the PTSD scale correlated with

the deviated PC score. The present findings could be evidence

directly examining the relationship between the PC subtest and

posttraumatic symptoms. In addition, results showing that the

other subscales did not correlate with the deviated PC score

suggest a discriminative validity for the higher PC score being

an indicator of the hyperarousal symptom.

However, study II may also have a limitation. Significant

correlation coefficients were found, but the PTSD subscale of

TSCC-A involved all aspects of posttraumatic symptoms: in-

trusion, avoidance, and hyperarousal. Thus, it is possible that

this finding suggests a relation among the other PTSD symp-

toms. Future research needs to measure the PTSD symptoms

separately and to confirm that the higher PC score relates to the

hyperarousal symptom rather than other symptoms.

Total Discussion

The present studies provide and add to evidence for the find-

ing that maltreated children scored higher on the PC subtest

because of a relationship between the PC score and the hy-

perarousal symptom. The hypothesis suggested in Frankel et al.

(2000) was verified through the two studies. In study I, a larger

sample size was used to confirm the robustness of the prior

finding and, in study II, correlations were examined directly to

verify the relationship between the deviated PC score and the

measure of PTSD. The author concludes that the present report

contributes to the body of literature on child abuse and neglect,

particularly to understanding the diverse impact of child mal-

treatment on child development.

However, there are some differences from the prior findings.

Ogata (2011) reported different effects of the types of mal-

treatment on the intellectual profile. Only sexually abused chil-

dren scored higher on the PC test in the research. The design of

Ogata’s study adopted matching methodology. Group differ-

ences were readily detected in the matching design because

their correlation coefficients were considered; however, the

sample size of a matched design is likely to be small. The total

participants in Ogata’s study was 48, whereas study I in the

current report included 490 participants; therefore, this study

did not focus on the type of maltreatment but paid attention to

the overall robustness of the finding.

These findings might demonstrate the adverse and deleteri-

ous circumstance where maltreated children live. Because daily

atmosphere in their family should influence on their emotional

status strongly, they may suffer from hypervigilance and/or

hyperarousal symptom.

There are some clinical implications. Firstly, in these analy-

ses, controlling the FIQ was important because raw subtest

scores between groups were not significantly different (Table

1). The results indicated that the intellectual characteristics of

maltreated children were represented not as a raw score but as

an adjusted score in the PC subtest, controlled for the overall

level of the FIQ. Therefore, it may be useful in clinical settings

to calculate the ratio (subtest score/FIQ), and it was recom-

mended to evaluate intraindividual differences to assess chil-

dren who have experienced maltreatment. Secondly, it was

recommended to include the PC subtest in the test battery to

assess cognitive functioning. The WISC-IV excludes the PC

subtest from 10 core subtests in the current revision. As a sup-

plemental subtest, the PC score is unnecessary to compute the

FIQ; however, the author recommends the PC subtest for as-

sessing maltreated children on the basis of the current findings.

The PC test might be able to screen their hyperarousal symp-

toms in PTSD. A maltreated child who scores relative higher on

the PC should be referred to a child psychiatrist for detailed

diagnosis of PTSD. Whether or not maltreated children have

symptoms related to the PTSD, their psychological treatment

may vary according to their mental status. The author provides

some recommendations from the view of the clinical setting.

Finally, the findings are discussed from cultural standpoints.

The current investigations were conducted in Japan. Almost all

previous researches were Western findings. Thus, the present

findings replicating Western studies should be compared with

other non-Western reports. For example, in the Turkish litera-

ture, Bulut and colleagues studied PTSD in children who have

experienced natural disasters (Bulut, 2004, 2006, 2010; Bulut,

Bulut, & Tayli, 2005). Bulut (2010) reported from longitudinal

investigations that overall PTSD rates in children gradually

decreased. The research revealed gender differences that were

detected in intrusion and avoidance symptoms. It is difficult to

directly compare these findings with the current research be-

cause of the difference in the participants in each study.

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