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Risk, Resilience, and the Rorschach: A LongitudinalStudy of Children Who Experienced Sexual AbuseDouglas Barnett a , Hillary J. Heinze a b & Eamonn Arble aa Department of Psychology , Wayne State Universityb Department of Psychology , University of Michigan–FlintPublished online: 13 Aug 2013.

To cite this article: Douglas Barnett , Hillary J. Heinze & Eamonn Arble (2013) Risk, Resilience, and the Rorschach: ALongitudinal Study of Children Who Experienced Sexual Abuse, Journal of Personality Assessment, 95:6, 600-609, DOI:10.1080/00223891.2013.823437

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Journal of Personality Assessment, 95(6), 600–609, 2013Copyright C© Taylor & Francis Group, LLCISSN: 0022-3891 print / 1532-7752 onlineDOI: 10.1080/00223891.2013.823437

Risk, Resilience, and the Rorschach: A Longitudinal Studyof Children Who Experienced Sexual Abuse

DOUGLAS BARNETT,1 HILLARY J. HEINZE,1,2 AND EAMONN ARBLE1

1Department of Psychology, Wayne State University2Department of Psychology, University of Michigan–Flint

Experiencing sexual abuse increases the risk that children will report or otherwise demonstrate problems with emotion, behavior, and health. Thislongitudinal study of 44 children who experienced sexual abuse examined whether information processing as assessed via the Rorschach InkblotTest was associated with child-reported depression symptoms assessed via the Children’s Depression Inventory (Kovacs, 1992) concurrently and anaverage of 15 months later. Children whose Rorschach protocols were relatively free of scores suggesting intense distress, complex processing, andsexual content were more likely to experience remission of depression symptoms at follow-up. Findings provide incremental validity for certainRorschach indexes to inform prognosis regarding depression symptoms and perhaps their treatment.

In comparison to children without a history of maltreatment,children who have experienced sexual abuse have been foundto report more mental health problems, including symptoms ofdepression, anxiety, and posttraumatic stress disorder (Kendall-Tackett, Williams, & Finkelhor, 1993; Paolucci, Genuis, &Violato, 2001; Putnam, 2003). Children who have experiencedsexual abuse report a wide variety of physical and psychologicalsymptoms, and vary greatly in the severity, onset, and durationof symptoms (Irish, Kobayashi, & Delahanty, 2010; Saywitz,Mannarino, Berliner, & Cohen, 2000; Swenson & Hanson,1998). To understand this heterogeneity in outcomes, re-searchers have examined dispositional characteristics of thechild as well as the social relationships within which the childdevelops (Trickett, Kurtz, & Pizzigati, 2004; Zielinski & Brad-shaw, 2006). In our investigation, we examined whether par-ticular child personality characteristics, identified using theRorschach Inkblot Test, theoretically and statistically explainedchildren’s self-reported symptoms of depression (a) within a fewmonths after their official disclosure of sexual abuse to legal au-thorities; (b) an average of more than 1 year later, followingdisposition of their court cases; and (c) change across that timeperiod.

Increasing evidence suggests that when children experi-ence maltreatment, how they affectively and cognitively pro-cess information about their maltreatment experience is signifi-cantly associated with their current and future emotional health(Feiring, Simon, & Cleland, 2008; Feiring & Taska, 2005). Forinstance, children and adults who blamed themselves for sex-ual abuse, and who believed their suffering would not subside,were found to experience more distress and interpersonal prob-lems than those without these views (Steel, Sanna, Hammond,Whipple, & Cross, 2004; Valle & Silovsky, 2002). Longitudi-nally, children who experienced sexual abuse and had negativeabuse-specific attributions (e.g., blaming oneself) were found toreport more internalizing symptoms (e.g., depression) at abuse

Received July 30, 2011; Revised May 17, 2013.Address correspondence to Douglas Barnett, Department of Psychology,

Wayne State University, 5057 Woodward Avenue, 7th Floor, Detroit, MI 48202;Email: aa0934@wayne.edu

disclosure and at follow-up than did sexually abused childrenwho reported fewer of these beliefs (Feiring, Taska, & Chen,2002). Alternately, children who experienced sexual abuse andwho appeared to minimize, tended not to dwell on, and posi-tively reframed their maltreatment were found to report fewersymptoms in adulthood than those who did not use these strate-gies (Himelein & McElrath, 1996). Although children who ex-perienced sexual abuse had a tendency to ruminate about theirmistreatment, those who were able to attend to positive aspectsof their lives ultimately reported fewer symptoms (Conway,Mendelson, Giannopoulos, Csank, & Holm, 2004; Michael,Ehlers, Halligan, & Clark, 2005; Toth & Cicchetti, 1996).

General attribution processing—in contrast to abuse-specificprocessing—also has been related to mental health outcomes.Among children and adults who experienced child sexual abuse,those who reported a pessimistic attribution style (e.g., a gen-eral tendency to attend to negative information, to personalize it,and attribute it to internal, stable, or uncontrollable causes) werealso likely to report feelings of low self-esteem, anxiety, and de-pression (Feiring et al., 2002; Runyon & Kenny, 2002; Valle &Silovsky, 2002). Similar research has found that general attri-bution styles of self-blame might mediate the relation betweenabuse-specific attributions and youth-reported anxiety and de-pression symptoms (Daigneault, Tourigny, & Hebert, 2006).

Taken together, research on processing by those who experi-enced child sexual abuse suggests that those who report moregeneral and abuse-specific negative attributions and who re-port focusing on abuse-related thoughts, memories, or feelingstend to report significantly higher levels of internalizing symp-toms, especially of depression, anxiety, and posttraumatic stressdisorder. Alternately, those who are able to minimize negativethoughts and avoid rumination regarding sexual abuse appear tobe more resilient in regard to their mental health in the aftermathof such traumatic experiences.

The reviewed studies point to perceptual, cognitive, and emo-tional processes to explain risk and recovery from child sexualabuse. However, these investigations relied heavily (althoughnot exclusively) on self-report measures of attributions and cop-ing in an effort to theoretically and statistically explain variancein self-report measures of symptoms. These research strategies

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provide an important beginning. However, relying solely onself-report, structured response scales leaves open the possi-bility that significant findings are an artifact of measurementshortcomings such as shared method variance, response style,and item redundancy between the mediating and outcome vari-ables. For example, a mediating attribution item might read “Ibelieve others do not like me,” whereas the dependent measureof depression could include an item such as “I feel like othersdo not like me.”

Self-report measures also require the ability to accuratelyperceive and report on one’s psychological processes and states.Individual differences of the child, the trauma of the abuse, andsocialization can often combine to interfere with self-awareness,as well as the willingness and ability to report on one’s inter-nal states (Beeghly & Cicchetti, 1994; Williams, 1994). Con-sequently, when conducting assessments of survivors of childmaltreatment, it is especially important to take into consider-ation the problems with relying solely on self-report. Moregenerally, an inherent limitation of many research studies onthe aftermath of sexual abuse is that they often rely solely onsingle-informant, structured response, quantitative, self-reportmeasures for assessing all constructs (Leavitt & Labott, 1996;Podsakoff, MacKenzie, & Lee, 2003).

We sought to expand the research on child personalityand adjustment following sexual abuse by examining whethera general, performance-based, information processing mea-sure of ambiguous stimuli—in contrast to abuse-specific self-report measure of attribution style—would be significantlyassociated with current and future self-report of depressionsymptoms. Specifically, we utilized the Rorschach Inkblot Test,using Exner’s (2003) Comprehensive System for its adminis-tration, scoring, and interpretation to assess children’s process-ing of ambiguous, non-abuse-related stimuli. The Rorschachhas established reliability and validity as a visual measure ofgeneral perceptual-cognitive processing and problem solvingduring what some might see as a stressful, interpersonal inter-action (Exner, 2003; Meyer, 2004; Weiner, 2006). That is, therespondent must solve the problem of finding, evaluating, andreporting an answer to satisfy the examiner’s potentially strangerequests as to what the ambiguous inkblot “looks like” and why.How people respond to the Rorschach Inkblot Test suggests howthey might approach, think about, and react in interpersonallycomplex and perhaps stressful situations in their everyday lives.

Although the Rorschach has been controversial, particularlyin regard to the assessment of individuals who have experi-enced child sexual abuse (Garb, Wood, & Nezworski, 2000;West, 1998), several studies have found significant differencesbetween children who had and had not experienced sexual abuse(e.g., Friedrich, Einbender, & McCarty, 1999; Leifer, Shapiro,Martone, & Kassem, 1991; Zimmerman & Dillard, 1994). Someconsistent findings from these studies were that children whowere sexually abused were more likely to have Rorschach in-dexes of distress (e.g., Experienced Stimulation Score—es) andSexual Content (i.e., Sx) in their protocols than children with-out a history of sexual abuse. Adolescents and adults who ex-perienced childhood sexual abuse also tended to demonstrateelevations on Rorschach variables such as Blood, Morbid, andSexual Content (Leavitt & Labott, 1996; Perfect, Tharinger,Keith, & Lyle-Lahroud, 2011). Many of these variables are partof the Trauma Content index (Armstrong & Loewenstein, 1990;Leavitt & Labott, 1996). This index is a ratio of the sum of fiveExner (2003) Rorschach variables (i.e., Blood, Anatomy, Sexual

Content, Morbid, & Aggressive Movement) to the number oftotal responses. Among adults, the Trauma Content Index wasassociated moderately to strongly with sexual abuse in child-hood (Kamphuis, Kugeares, & Finn, 2000).

Despite a variety of significant correlates with sexual abuse,the Rorschach has been criticized for demonstrating too fewconsistent, significant differences between the protocols of thosewho have and have not experienced child sexual abuse. In thisregard, Kamphuis et al. (2000) concluded, “Rorschach content ismultiply determined and there are no foolproof indicators of pastsexual abuse” (p. 223). We concur with this assertion and fur-ther contend that it is reasonable to suggest that the Rorschachprovides neither necessary nor sufficient evidence to identifythe experience of sexual abuse. This caution is particularly ger-mane given the heterogeneity of child maltreatment in regardto severity, developmental timing, and chronicity, as well as thefrequent resiliency found among those who have lived throughthe experience (Barnett, Manly, & Cicchetti, 1993; Cicchetti,2013; Himelein & McElrath, 1996). Investigations to determinewhether a child has been sexually abused are necessarily a mat-ter of legal concern, and are best assessed through standardizedforensic interviews, examination of physical evidence, witnesstestimony, and a comprehensive mental health assessment ofwhich the Rorschach can be a helpful component (Jones, Cross,Walsh, & Simone, 2005; Perfect et al., 2011). Consequently,rather than seeking further evidence that the Rorschach can dis-criminate between children who had and had not experiencedsexual abuse, we were interested in whether the Rorschach couldbe helpful in theoretically and statistically accounting for indi-vidual differences in the presence of depression symptoms inthe short and longer term following sexual abuse.

We hypothesized that the Rorschach could help clinicians elu-cidate personality processes relevant to understanding a child’sshort- and longer term depression symptoms following sex-ual abuse. We believed this latter focus was appropriate giventhe Rorschach’s foundation as a reliable and valid measureof personality characteristics relevant to perceiving, respond-ing, and coping with complexity and stress (Perry, Minassian,Cadenhead, Sprock, & Braff, 2003; Viglione, 1990; Weiner,2003). These hypotheses are consistent with the idea that theRorschach is a useful method for gathering samples of a per-son’s information processing during the interpersonally chargedcontext of a psychological evaluation.

In our review of factors associated with recovery from childsexual abuse, we were intrigued by parallels between findingsfrom the Rorschach and studies of self-reported attributions.Both suggested that overfocusing on negative aspects of theabuse were associated with reports of psychological distress.Similarly, research examining youth descriptions about theirsexual abuse found that those who were judged to be “absorbed”in regard to their abuse experience reported significantly moresymptoms of depression 6 years after disclosing the abuse thandid those judged to be avoidant or constructive in regard to theirabuse experiences (Simon, Feiring, & McElroy, 2010). Thesefindings support the idea that Rorschach indexes that reflect(a) psychological distress, (b) complex processing style, and(c) rumination and preoccupation might be more prone to in-creasing depression in the aftermath of sexual abuse. In contrast,youth who do not show evidence of distress, complex process-ing, and rumination might be those who remain psychologi-cally resilient in the aftermath of sexual abuse. To measure dis-tress and complex processing, we created two theoretically and

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empirically based Rorschach variables that were composites ofvariables that research found were associated significantly withthe experience of child sexual abuse.

According to the Comprehensive System (Exner, 2003), dis-tress (i.e., anxiety, anger, holding back anger, and depression) ismanifested by the respondents’ tendency to report higher thanaverage levels of the blackness, grayness, emptiness, shading,shaded textures, and shading indicating dimensionality whendescribing their apperception of a Rorschach inkblot (Berant,Mikulincer, Shaver, & Segal, 2005; Exner, 2003). Similarly,perceiving an image in the blots as damaged (e.g., “it looksall burnt”) has been found to be associated significantly withdepression, negative outlook, and denigrating self-view (Exner,2003).

Complex processing of the blots is evidenced by the extent towhich a respondent integrates the various areas and features ofthe blots into an animated, related whole (Exner, 2003). Highcomplexity scores suggest a tendency to think deeply and elab-orately about oneself and one’s world, as well as a tendency tobe hypervigilant and obsessive (Exner, 2003). An example ofsuch organizational activity is reflected in this sample response:“It looks like fish swimming around in a tropical scene becausethese are shaped like crabs, and these look like different coloredfish, and these green parts are like seaweed.”

To assess rumination and preoccupation with their abuse ex-periences, we examined the children’s perception and report-ing of any Sexual Content in response to the inkblots. Previ-ous research has suggested that the presence of Sexual Contenton a child’s Rorschach protocol might reflect sexual concernsand sexual trauma (Friedrich, Jaworski, Huxsahl, & Bengtson,1997). Terr (1990) described how it is not uncommon for chil-dren who are traumatized to develop vigilance for and obses-sions with literal aspects of their traumatic experiences. Conse-quently, we looked for this direct connection to manifest throughreporting Sexual Content.

For the purposes of statistically predicting children’s depres-sion scores (i.e., Time 1, Time 2, & change in depression), wegrouped the aforementioned Rorschach scores into two compos-ites, one expected to reflect emotional distress and one expectedto reflect deep, complex thinking. Our analyses also includedtwo indexes that Exner (2003) derived to identify severe clini-cal depression (i.e., the Depression Index [DEPI] & the CopingDeficit Index [CDI]). The DEPI has not fared well in several vali-dation studies (e.g., Archer & Krishnamurthy, 1997; Jorgensen,Andersen, & Dam, 2000; Viglione, 1999), particularly in re-gard to its diagnostic utility among adolescent populations. TheCoping Deficit Index represents an extension of (and in somesenses, an improvement of) the DEPI, providing evidence oftraits suggestive of depression, specifically social skills deficits(Exner, 2003). Although the Coping Deficit Index has receivedinsufficient empirical review to arrive at any firm conclusions(Meyer & Archer, 2001), some research has questioned its utilityamong children and adolescents (e.g., Stredny & Ball, 2005).Nonetheless, other research has suggested that these indexesare capable of identifying depression among sexually abusedchildren, and if nothing else, might overcome some of the diffi-culties of self-report measures of depression among adolescents(Shapiro, Leifer, Martone, & Kassem, 1990).

We also examined the Trauma Content Index, which has beenshown to be associated with a history of trauma and the use ofdissociative defenses against traumatic memories (Armstrong& Loewenstein, 1990; Kamphuis et al., 2000; Leavitt & Labott,

1996). In summary, because the literature suggested process-ing style, psychological distress, and preoccupation might beassociated with adjustment following sexual abuse, we utilizedour own and existing Rorschach indexes of these processes andexamined their relation to child report of depression symptomsconcurrently and again an average of 15 months later.

METHOD

Participants

Forty-four children and their nonoffending primary caregiverscompleted all assessments during this longitudinal study. Table 1includes descriptive characteristics of the participants, who wereall recruited from substantiated sexual abuse cases being adju-dicated in a large urban county criminal court. The childrenranged in age from 6 to 15 years at the first assessment. Theparticipating children tended to come from African American,relatively low-income, urban families. Most (n = 40) of thechildren were from single-parent homes, with 4 of the partici-pants being raised in two-parent homes. One participant was ina single father household. Three participants were living withsomeone other than their biological parent.

The families were primarily of low socioeconomic status. Theaverage school grade completed by the caregivers was 11.58(SD = 1.60). Most (n = 27, 61%) were employed. The meanHollingshead (1975) Socioeconomic Status (SES) index for thechildren was 24.32 (SD = 6.31). This index score is computedby summing ratings of caregivers’ level of education and oc-cupation. In families where multiple caregivers or parents areinvolved with the child, scores are averaged across parental fig-ures. For example, a Hollingshead SES index of 24.32 couldrepresent a family headed by a semiskilled worker who had notcompleted high school.

Sexual Abuse Characteristics

Based on information contained in the court records, ratingsof severity, frequency, and relationship to the perpetrator weremade utilizing a standardized system (Barnett et al., 1993). Data

TABLE 1.—Descriptive statistics of participant demographics and abusecharacteristics.

Categories No. (%)

Child age Time 1 M = 10.73 years (SD = 2.21)Child age Time 2 M = 11.99 years (SD = 2.35)Child sex

Girls 35 (79.5%)Boys 9 (20.5%)

EthnicityAfrican American 30 (68%)European American 14 (32%)

Number of incidents of abuse (n = 43)1 occurrence 19 (44%)2–5 occurrences 12 (28%)6–9 occurrences 4 (9%)10–24 occurrences 4 (9%)25–100 occurrences 4 (9%)

Age abuse began M = 9.18 years (SD = 2.56)Severity of abuse (1–5)a (n = 43)

3 (Genital contact) 17 (40%)4 (Penetration) 20 (47%)5 (Forced intercourse) 6 (14%)

Note. N = 44. Totals do not always add to 100% due to rounding.aHigher scores indicate greater severity.

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were missing for one child for sexual abuse severity, number ofsexual abuse incidents, and perpetrator. The children participat-ing in this study had experienced relatively severe abuse withno child scoring below a 3 on a 5-point scale (e.g., 1 = exposureto pornography to seduce child; 3 = mutual fondling; 5 = childis physically forced to have intercourse). Abuse histories werediverse, with 26 (60%) cases involving penetration (see Table 1for details). The number of sexual abuse incidents ranged from1 to 100 occurrences, with 25 of 43 children (58%) experiencingmore than one episode of abuse. The reported perpetrator wasa parent or stepparent for 19 (44%) child participants, anotherrelative for 10 (23%) children, and a nonfamily member for 14(33%) children.

Procedures

All children in the study had reports of child sexual abusethat were officially indicated after a state Child Protective Ser-vice (CPS) investigation. The children also were referred to thecourt as potential witnesses in the prosecution of the allegedperpetrator. Other inclusion criteria for the study were beingbetween the ages of 6 and 16 years, living within 15 miles ofthe university research offices, and having the parent and childable to respond to the measures in English. Given the researchteam’s limited resources, the criteria were employed (a) to max-imize the potential sample size, (b) to reduce the heterogeneityof the sample demographics, and (c) to minimize the drivingdistances for the research team. There were no additional exclu-sion criteria, and no children were ultimately excluded becauseof language barriers.

Children and their primary caregivers were recruited throughthe Child and Family Abuse Bureau of the county prosecutor’soffice in a large Midwestern American city. Child advocates atthe prosecutor’s office were trained to introduce families to thestudy. Families who expressed interest were given an initial de-scription of the study and permission was obtained for a memberof the research team to contact them to provide further informa-tion, answer questions, and obtain informed consent. Interestedfamilies were then telephoned by a member of the research teamand given a detailed description of the study. Those interestedin participating provided informed verbal consent and a homevisit was scheduled for data collection. Written informed con-sent and written child assent were obtained prior to completingthe research measures. No tangible incentives were offered forparticipation. Eighty-four percent of the families approachedagreed to be contacted by the research team. Of those eligible,73% agreed to participate. Among this 73%, 74% completed allassessments. Comparison of the current 44 participants with the151 possible children who experienced sexual abuse accordingto the prosecutor’s records of the year prior to our recruitingindicated that the sample reported here was representative ofthat entire pool of cases in regard to child age, gender, severityof abuse, and relationship to the perpetrator. In comparison tothe entire prosecutor’s sample, our subsample had a higher per-centage of African American children (68.2% vs. 51.0%), mostlikely due to the residency criteria we utilized in our sampleselection.

At the initial assessment, children were administered theRorschach Inkblot Test (Exner, 2003) and the Children’s De-pression Inventory (Kovacs, 1992). At follow-up, 3 to 33 monthslater (M = 15.10, SD = 6.85), the Children’s Depression Inven-

tory was repeated. Time of follow-up was determined by whenthe children’s court cases resolved, which resulted in a 30-monthrange in time to follow-up. The length of time to follow-up as-sessment was examined in subsequent analyses as a potentialconfounding variable.

Measures

The Children’s Depression Inventory. Children were ad-ministered the Children’s Depression Inventory (Kovacs, 1992),a 27-item instrument designed to assess cognitive, affective, andbehavioral signs of depression. The Children’s Depression In-ventory was read aloud to the participants while they followedalong and completed their own form. Kovacs (1992) reportedadequate reliability and validity of this inventory as an assess-ment of depression in children ages 6 to 17. Items are presentedin groups of three in which the child is asked to “pick out thesentences that describe you best in the past 2 weeks.” For in-stance, a sample item is I am sad once in a while = 0; I am sadmany times = 1; I am sad all the time = 2. A score of 12 onthe Children’s Depression Inventory indicates that the child’sreported symptoms are considered to be clinically significant(Kovacs, 1992). A change score in child depression was cre-ated by regressing Time 1 depression onto Time 2 depression,yielding a standardized residual that reflects change in childdepression on the Children’s Depression Inventory (i.e., higherpositive scores indicate increases in symptoms, lower negativescores indicate decreases in symptoms).

Rorschach Inkblot Test. Children were administered theRorschach Inkblot Test based on guidelines provided in theExner (2003) Comprehensive System for standardized adminis-tration and scoring. All of the study protocols were scored by aclinical psychology graduate student trained in Exner’s system.To examine reliability, 15 protocols from the sample were alsoindependently scored by a doctor-level psychologist trained inExner’s system. Intraclass correlations were calculated for eachof the Rorschach variables and ranged from .52 (DEPI) to .98(number of responses), suggesting moderate to high levels of re-liability. Protocol-level intraclass coefficients between the twoscorers are presented in Table 2. The low interrater reliabilityon Sexual Content (ICC = .65) was not due to the scorer failingto notice or recognize the Sexual Content, but rather forgettingor neglecting to indicate it on the scoring form. Although un-fortunate, the matter was quickly resolved once scorers met todiscuss disagreements and attempt to reach consensus.

Six Rorschach indexes based on Exner (2003) scoring wereselected according to their association, or their individual com-ponents’ association, with child sexual abuse or depression inprior studies. These are lettered here A through F. The first twoof these indexes were created specifically for use in this study.

A. The Distress Index was a composite of the Exner variables es(i.e., sum of FM, m, SumC,’ SumT, SumY, and SumV), useof White Space (i.e., S), and Morbid Content (i.e., MOR).The number of instances of white space and Morbid Contentwere converted to zscores, and es was first computed in stan-dard Exner fashion before being transformed into a z score.These z scores were then summed into a final value, whichitself was converted to a z score. The calculation of z scorespromoted equal weighting of the three Exner variables, andthe transformation of the sum value into a final z score

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TABLE 2.—Descriptive statistics of Rorschach variables and child report ofdepression symptoms and interrater reliability for Rorschach variables.

ReliabilityVariable Min Max M SD Skew ICC

Rorschach1. Number of responses 11.00 28.00 17.59 3.06 .89 .982. Zf 1.00 20.00 8.23 3.49 .98 .953. DQ+ 0.00 10.00 2.70 2.08 1.07 .754. Blends 0.00 13.00 1.73 2.32 2.92 .93

Blends SQRT transformation 0.00 3.61 .98 .88 .485. Form% 12.50 90.00 55.32 19.32 −.05 .846. Es 1.00 24.00 5.18 4.02 2.51 .92

es log transformation 0.00 1.38 .60 .32 −.267. White Space (S) 0.00 5.00 1.43 1.42 1.11 .978. Morbid (MOR) 0.00 7.00 .91 1.60 2.31 .80

Morbid SQRT transformation 0.00 2.65 .57 .77 1.089. Sexual Content 0.00 1.00 .05 .21 4.52 .65

10. Trauma Content Index 0.00 56.25 13.86 14.08 1.18 .7711. DEPI 1.00 6.00 3.43 1.15 .51 .7612. Coping Deficit Index 0.00 5.00 3.32 1.05 −.81 .5213. Distress Index −1.80 2.73 0.00 1.00 .43 .9714. Processing Index −1.48 4.07 0.00 1.00 1.63 .89

Children’s Depression Index15. Time 1 1.00 36.00 12.82 9.49 1.0216. Time 2 0.00 28.00 9.18 6.90 .7817. Change −1.47 2.60 0.00 .99 .96

Note. N = 44. Distress Index refers to an index derived specifically for this study. It isa sum of the z scores of es, White Space, and Morbid responses, with the sum value itselftransformed into a z score. Processing Index also refers to an index derived specifically forthis study. It is the z score of the sum of the z scores of Zf, DQ+, Blends, and 1-Form%.Finally, the Trauma Content Index is calculated as the ratio of all Blood, Anatomy, Sex,Morbid, and Aggressive Movement to the total number of responses. ICC = Intraclasscorrelation.

allowed for each child’s score to be more meaningful as itis expressed in standard deviation units. Each componentof the index was found to correlate significantly with theindex’s total score, suggesting that the each of the index’scomponents was contributing to the total score (of these,SumY demonstrated the lowest correlation with the overallindex: r = .33, p < .05). The Cronbach’s alpha for the Dis-tress Index was .55, with each of the components contribut-ing positively to the total, such that removing any would notimprove the overall alpha. High scores on the Distress Indexsuggest the respondent tended to dedicate significant atten-tion to acute psychological distress such as anxiety, internalstrife, anger, sadness, and depression (Exner, 2003).

B. The Processing Index was made up of the Exner variables Zf(frequency of organizational activity), DQ+ (integrative re-sponses), Blends (utilizing multiple complex determinants),and Form% (tendency to report complex apperception de-terminants), computed as “1 minus Form%” so that higherscores indicate deeper levels of processing. Form% was usedin place of Lambda, as it is both mathematically and con-ceptually similar to Lambda, but tends to be more normallydistributed (Meyer, Viglione, & Exner, 2001). As with theDistress Index, each score in the index was converted into a zscore to produce a consistent metric, and the index was com-puted by summing the z scores and converting the sum intoa final z score. Each component of the index was found tocorrelate significantly with the index’s total score, suggest-ing that the each of the index’s components was contributingto the total score (of these, Form% demonstrated the lowestcorrelation with the overall index: r = .83, p < .01). The

Cronbach’s alpha for the Processing Index was .82, witheach of the components contributing positively to the totalsuch that removing any would not improve the overall alpha.High scores on the Processing Index suggest more complexprocessing and integration of the inkblot stimuli.

C. Frequency of Sexual Content in the protocols also was exam-ined. We did not include these in our other two compositesfor two primary reasons: First, we were interested in SexualContent in its own right as it is linked directly to the chil-dren’s trauma experiences in cases of sexual abuse. Second,item analysis indicated that Sexual Content did not load withthe Distress or Processing indexes.

D and E. The Coping Deficit Index and the Depression In-dex (DEPI) were both calculated according to guidelines inExner (2003). We included these in our analyses becauseboth were composites that Exner derived specifically foridentifying individuals with severe clinical depression.

F. The Trauma Content index, a Rorschach-based score derivedby Armstrong and Loewenstein (1990), was also calculated.This score is a ratio of all Blood, Anatomy, Sex, Morbid, andAggressive Movement responses to the number of responsesin the protocol. Higher scores on this index are believed toindicate a history of trauma (e.g., sexual abuse) as well asefforts to defend against traumatic memories.

Peabody Picture Vocabulary Test. To obtain an estimateof intelligence, children were administered the Peabody Pic-ture Vocabulary Test (PPVT–III; Dunn & Dunn, 1997). ThePPVT–III is an untimed, norm-referenced, orally administeredmeasure of receptive vocabulary. The child is asked to look atfour pictures and chose the one that best represents the word spo-ken by the examiner. The PPVT–III has demonstrated strong re-liability and validity, and has been found to correlate moderatelyto highly in strength with standardized measures of intelligenceand scholastic aptitude (Dunn & Dunn, 1997).

RESULTS

Variables with skew values that exceeded 2 were subjected tostatistical transformations to allow for their inclusion in para-metric statistical analyses. Two is considered the critical cut-point where variables are considered to violate the assumptionof normal distribution held for variables analyzed using para-metric statistics (Curran, West, & Finch, 1996). Four variableswere subjected to such transformation: es, Morbid, Blends, andSexual Content. Based on the guidelines elaborated in Tabach-nick and Fidell (2007), es was subjected to a log transforma-tion, and Morbid and Blends were subjected to a square roottransformation. In each instance, the transformations resulted inskew values lower than two. Sexual Content, due to its infre-quency (i.e., two occurrences), was unable to be “normalized”via transformation, and consequently, was left as is. Descriptivedata on the study variables before and after transformation arepresented in Table 2, along with specific interrater reliabilityvalues for each variable.

Descriptive statistics for child report of depression symptomsalso are presented in Table 2. Based on clinical cutoff scoressuggested by Kovacs (1992), approximately 39% and 23% ofthe children reported depression symptoms falling within theclinical range at Time 1 and Time 2, respectively. From Time 1to Time 2, 66% of children remained in the same category (eitherdepressed or not depressed), 25% moved from the depressed

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FIGURE 1.—The 44 participants’ scores on the Children’s Depression Inventoryacross Times 1 and 2.

category to the not depressed category, and 9% moved fromthe not depressed category to the depressed category. Althoughthe correlation between Time 1 and Time 2 indicates relativestability in depression (r = .38, p < .05), a paired samplest test indicated that on average depression scores at Time 2(M = 9.18, SD = 6.90) were significantly lower than at Time1 (M = 12.82, SD = 9.49), suggesting a decrease in depressionsymptoms over time, t(43) = 2.56, p < .05 (d = .44). Changes inChild Depression Inventory self-report scores for the 44 childrenover the course of the study are depicted in Figure 1.

We examined whether child characteristics (i.e., age, gender,race, intelligence), family characteristics (i.e., socioeconomicstatus, biological parent in home), and sexual abuse character-istics (i.e., perpetrator, force through threat or use of violence,severity, number of incidents, age first abused) were correlatedsignificantly with child depression at Time 1, Time 2, and changein level of child depression symptoms. Child, family, and sexualabuse characteristics were not significantly correlated with de-pression at Time 1. However, higher intelligence estimates (r =.32, p < .05) and initial symptoms of depression (r = .38, p <.05) were associated with higher depression symptoms at Time2. Furthermore, children who lived with nonbiological parentsalso reported higher symptoms of depression at Time 2 (M =17.67, SD = 7.57) than did children living with biological par-ents (M = 8.56, SD = 6.52), t(42) = –2.32, p < .05 (d = 1.3).Greater intelligence estimates were also associated with greaterchange (i.e., increase) in depression (r = .36, p < .05), and chil-dren who lived with nonbiological parents demonstrated greaterincrease in depression (M = 1.12, SD = 1.24) than did childrenliving with biological parents (M = –.08, SD = .93), t(42) =–2.11, p < .05 (d = 1.09). Child ethnicity also was associatedwith change in depression, with African American children on

average showing a greater decrease in depression (M = .50,SD = 1.06) scores than European American children (M =–.23, SD = .88), t(42) = 2.41, p < .05 (d = .75). We also exam-ined length of time to the follow-up assessment and found thatit was not significantly related to change in depression scores.When all significant correlates of Time 2 and change in de-pression scores were included in a multiple regression, childethnicity was the only demographic variable that remained asignificant, unique predictor of depression, with African Amer-icans showing significantly greater improvement than EuropeanAmerican children. Therefore, child ethnicity was the only back-ground variable retained in regression analysis predicting Time 2depression.

Correlations among key variables of interest are presentedin Table 3. The Trauma Content Index was significantly cor-related with Time 1 depression. No other Rorschach indexeswere significantly associated with depression level at Time 1.The Rorschach Distress Index and Processing Index as well assome of their components (i.e., es, DQ+, Zf, and Blends) weresignificantly associated with Time 2 depression and increasesin depression. Sexual Content also was significantly associatedwith Time 2 depression and increases in depression, but be-cause there were only two instances of Sexual Content in thissample, its correlations should be treated with caution. Exner’sDepression Index and Coping Deficit Index were not signifi-cantly correlated with any of the child-report depression scores,although the nonsignificant finding might reflect the study’smodest sample size and moderate scorer reliability.

Sexual Content demonstrated a significant positive correla-tion with Time 2 depression, as well as increases in depressionscores. Of the two respondents who produced Sexual Content intheir protocols, each displayed a worsening of depressive symp-toms, producing residual change in depression scores of 2.6 and2.04. In contrast, the remaining 42 participants whose protocolswere absent of Sexual Content produced a mean residual de-crease in depression score of –.11 (SD = 9.65). Nonetheless,given the scarcity of Sx responses in the protocols, the stabilityof these associations is uncertain.

Hierarchical multiple regression analyses were conducted toexamine whether the Rorschach indexes accounted for uniquevariance in child depression scores at Time 2, above and beyondTime 1 depression scores and significant background charac-teristics such as child ethnicity. Because of concerns about thestability of results with Sx it was not included in the analy-ses reported in Table 4. It was determined that the RorschachProcessing Index accounted for significant unique variance inTime 2 depression, above and beyond Time 1 depression and allof the background characteristics significantly associated withdepression scores.1

1The variables of Sexual Content and the Rorschach Distress Index meritspecial comment in this regard. If Sexual Content was also allowed into theregression equation it would account for unique variance over and above allothers in predicting Time 2 depression (R2 = .54; beta = .40; with betas forT1 Coping Deficit Index, Ethnicity, and Processing Index = .31, .26, and .31,respectively). In the case of the Rorschach Distress Index, although it did notaccount for unique variance beyond that provided by the Processing Index, itproved to be a significant predictor of Time 2 depression when the ProcessingIndex was not included in the regression analyses.

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TABLE 3.—Correlations among Rorschach variables of interest and child report of depression symptoms.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Rorschach1. Number of responses 1.002. Distress Index .08 1.003. Processing Index .11 .64∗∗ 1.004. Sexual Content .17 .18 .21 1.005. Coping Deficit Index −.16 .08 −.09 .04 1.006. Depression Index .02 .40∗∗ .30 .01 .35∗ 1.007. TCI −.18 .55∗∗ .20 .14 −.01 .21 1.008. es .34∗ .70∗∗ .86∗∗ .13 −.07 .30∗ .16 1.009. White Space −.19 .56∗∗ .17 .01 .20 .38∗ .10 .23 1.00

10. Morbid .06 .62∗∗ .25 .08 .06 .30∗ .71∗∗ .20 −.00 1.0011. Form% −.09 −.53∗∗ −.83∗∗ −.03 .30∗ −.19 −.27 −.74∗∗ .05 −.24 1.0012. DQ+ .10 .55∗∗ .90∗∗ .24 −.08 .17 .17 .68∗∗ .13 .30∗ −.67∗∗ 1.0013. Zf .08 .58∗∗ .85∗∗ .33∗ .09 .31∗ .12 .66∗∗ .29 .22 −.55∗∗ .76∗∗ 1.0014. Blends .11 .53∗∗ .84∗∗ .12 −.02 .33∗ .12 .85∗∗ .22 .10 −.63∗∗ .67∗∗ .58∗∗ 1.00

Children’s Depression Inventory15. Time 1 −.07 .28 .19 .11 −.29 .08 .35∗ .08 .23 .16 −.16 .23 .14 .11 1.0016. Time 2 .01 .43∗∗ .47∗∗ .52∗∗ .03 .13 .25 .35∗ .21 .22 −.22 .53∗∗ .49∗∗ .35∗ .38∗ 1.0017. Change .04 .35∗ .43∗∗ .52∗∗ .15 .11 .13 .34∗ .13 .17 −.17 .48∗∗ .47∗∗ .34∗ .00 .93∗∗

Note. N = 44. Transformed variables were utilized for es, Morbid, and Blends. The Distress Index, an index derived for this study, is a sum of the z scores of es, White Space, andMorbid responses, transformed into a z score. The Processing Index, also derived for this study, is the z score of the sum of the z scores of Zf, DQ+, Blends, and 1-Form%. The TraumaContent Index is calculated as the ratio of all Blood, Anatomy, Sex, Morbid, and Aggressive responses to the total number of responses.

∗p < .05. ∗∗p < .01.

DISCUSSION

The maltreated children in this study demonstrated substan-tial depression symptom levels, with more than a third fallingin the “clinical range” at the initial assessment (Kovacs, 1992),and more than a fifth falling in the “clinical range” an aver-age of more than a year later. On average, depression symptomlevels were moderately stable over time. These levels of de-pression symptoms were especially high given that children inour sample were referred from a court rather than a mentalhealth clinic. Individual studies and meta-analyses have foundhigher rates of mental health problems among clinically referredsamples compared with those nonclinically referred (Hillberg,Hamilton-Giachritsis, & Dixon, 2011). On the other hand, de-spite experiencing sexual abuse, the majority of children in thesample were not in the clinical range for depression at eitherassessment, and on average, children’s reported levels of de-pression significantly decreased over time, with a quarter of thechildren demonstrating resilience or “recovery” by moving fromthe clinical to the nonclinical range. Although we did not have a

TABLE 4.—Hierarchical multiple regression model statistically predictingchange in child depression between Time 1 and Time 2.

Variable R2 R2� F� B SE B β

Step 1 .14 .14 6.91∗T1 child depression symptoms .27 .10 .38∗

Step 2 .25 .11 5.77∗T1 child depression symptoms .30 .10 .42∗∗Child ethnicitya 4.81 2.00 .33∗

Step 3 .39 .14 9.10∗∗T1 child depression symptoms .25 .09 .34∗Child ethnicitya 4.27 1.84 .29∗Rorschach Processing Index 2.66 .87 .38∗∗

Note. N = 44.a0 = Black, 1 = White.∗p < .05. ∗∗p < .01.

comparison sample in this study, our findings are consistent withother longitudinal studies of depression and child sexual abuse,which have found elevated rates of depression symptoms com-pared to nonmaltreated children and decreases in symptoms withtime (Feiring, Coates, & Taska, 2001; Kendall-Tackett et al.,1993; Toth & Cicchetti, 1996).

The African American children in our study demonstratedgreater improvement on depression symptoms than did theWhite children, a robust finding that was over and above otherdemographic characteristics or Rorschach variables. Workingwith a sample of children demographically similar to our sam-ple, Feiring et al. (2001) did not find significant ethnic differ-ences between African American and White children in regardto symptoms of depression, although their means were in direc-tions that mirrored our findings. Like others, we hope furtherempirical attention is devoted to understanding the complexinteractions among culture, ethnicity, and child maltreatment(Elliott & Urquiza, 2006; Feiring et al., 2001). We also em-phasize that research from around the world suggests that nocultural or ethnic groups are free of the considerable problem ofchild sexual abuse and its sequelae (Li et al., 2009; Stoltenborgh,van IJzendoorn, Euser, & Bakermans-Kranenburg, 2011).

The finding that Rorschach indexes of distress and depres-sion were not significantly associated with initial levels of de-pression was unexpected, especially given that they were bothadministered around the same time. One possible explanationfor the absence of these findings is that most of the childrenexperienced an increase in “normal” distress immediately fol-lowing the abuse and its disclosure, thereby masking or sup-pressing part of the association between depression symptomsand the Rorschach indexes. Conversely, the Trauma ContentIndex was found to correlate significantly with Time 1 depres-sion, consistent with the immediate traumatic impact of theseexperiences.

Because children for this study were recruited when theywere initially referred for court proceedings, all of them had

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recently disclosed sexual abuse to the authorities. An initial in-crease in self-reported depression symptoms may be expectedand understandable, especially given the recent disruption andconfusion children are likely going through in the immediate af-termath of abuse (e.g., change in family relationships, police andcourt involvement). Around the time of abuse discovery, familymembers, investigators, attorneys, and clinicians might increasechildren’s distress by encouraging them to talk about their mem-ories, thoughts, and feelings about the abuse. With time, and asthe pressures collateral to sexual abuse diminish, children havebeen found to experience some emotional recovery (Quas et al.,2005). Moreover, although only the Trauma Content Index wassignificantly correlated with depression symptoms at Time 1,a few additional variables had correlations in the expected di-rection that were approaching significance. For instance, thecorrelations for the Rorschach Distress Index and the Cop-ing Deficit Index with Time 1 depression were .28 and –.29,respectively. With the power of a larger sample, correlations ofthis magnitude would be statistically significant.

Regardless of children’s general tendency to improve, theRorschach demonstrated incremental validity as it was associ-ated with depression symptoms at Time 2 over and above initialdepression levels. Specifically, children who at Time 1 gaveRorschach protocols with an absence of Sexual Content andlower scores on indexes of psychological distress, complex pro-cessing, and integration of stimuli were significantly more likelyto report fewer depression symptoms at Time 2 than at Time 1compared with children whose Rorschach protocols had moreof these indexes. We believe the results of this study provideevidence of not only an important relation between Rorschachvariables and levels of depression among sexually abused chil-dren across time, but also perhaps information regarding theprocess of recovery from sexual abuse.

Our Rorschach data suggest that children in distress, whoprocess information complexly or who might be preoccupiedwith the abuse, are at risk to sustain their depression level orincrease it over time. Conversely, children without those ten-dencies appeared to have fewer depression symptoms over time.These findings based on the Rorschach, along with those fromself-report attribution measures, suggest that interventions thatencourage children to focus on their sexual abuse and processit at a deep emotional and cognitive level might have the coun-terproductive effect of increasing a child’s distress in the shortand long term. Perhaps this is why interventions that not onlyhelp children cope with sad thoughts, memories, and feelings,but also teach them to reduce the emergence of such rumina-tions, have been shown to be effective in reducing symptomsfollowing child sexual abuse (Cohen, Mannarino, & Deblinger,2006).

According to Exner (2003), children scoring high on process-ing variables are more likely to have an active, vigilant approachto integrating and incorporating internal (e.g., emotions andthoughts) and external (e.g., others’ actions) information. Un-der conditions of threat or negative experience, we hypothesizethat this tendency to overincorporate information might con-tribute to rumination and preoccupation with negative thoughtsand experiences, contributing to maintaining or worsening ofdepression symptoms with time.

Reporting Sexual Content in response to the Rorschach alsowas a unique indicator of poor prognosis in regard to depressionsymptoms. We believe it could be a further sign that a child

is ruminating or preoccupied with the sexual abuse experienceand might represent a symptom of posttraumatic stress disorder.Reporting Sexual Content on the Rorschach is relatively rareamong children and adults. Even in this sample, only 2 childrenreported Sexual Content, although this was a unique markeras both of these children had depression scores that greatlyincreased across the study. One was a 12-year-old girl who re-ported that Card II looked like the “vaginal area,” going on tosay about her response, “I know I’m sick minded.” Later shereported that Card VIII looked like “the guy who tried to molestme, a big ole fat slob.” The other was a 15-year-old girl whoreported that Card III looked like “two males . . . each has a badconscience because the devil is red. Here are their penises.” Suchresponses might indicate a preoccupation and vigilance that hasdeveloped to protect oneself from further abuse, but might con-tribute to an increase in depressive symptoms if it is maintainedchronically. However, it must be remembered that because onlytwo protocols contained Sexual Content responses, our abil-ity to provide theoretical extrapolations based on the meaningof Sexual Content within the Rorschach is limited. AlthoughSexual Content was indeed a significant predictor of Time 2depression, this result is more suggestive than conclusive. Fur-ther research is required to understand this finding more fullyand whether Sexual Content on the Rorschach would be morecommon among child victims of sexual abuse who are clinicallyreferred with significant mental health concerns (Hillberg et al.,2011; West, 1998).

Neither Exner’s Depression Index nor his Coping Deficit In-dex was significantly associated with any of the child-reporteddepression scores. This could be because of the reduced powerto detect significant findings with our small sample size. It isnoteworthy that these indexes had associations in the expecteddirection with Time 2 depression and change in depression, al-though these effects were small in magnitude. However, otherstudies also have failed to find statistically significant relationsbetween the Depression Index and Coping Deficit Index anddepression (Hartman, Wang, Berg, & Saether, 2003; Stredny &Ball, 2005).

Although we believe these findings offer important guid-ance for further research into the psychological processes ofresiliency following sexual abuse, our results are tentative andshould be interpreted with caution pending further replication.This is especially true given the small and relatively homoge-nous sample. We also believe that there are multiple pathwaysto resilient outcomes (Cicchetti, 2013), and indeed, researchhas identified factors ranging from interpersonal relatedness(Viglione & Kates, 1997) to a “trauma-based, adaptive regres-sion” (Viglione, 1990) as possibly indicative of resilience usingthe Rorschach. Moreover, the findings reported here do not pro-vide information on whether Rorschach scores reflect process-ing differences that predate or are a result of the children’s ex-periences of maltreatment (a particularly relevant concern givenour lack of a comparison group without an abuse history). Wedeveloped indexes by combining theoretically related variablesthat prior studies have found to be associated with both sexualabuse and depression. Future studies might wish to examinewhether these processes identified by the Rorschach assessmentmediate the relation between trauma and mental health outcome.

A further limitation is that the study does not provide in-formation about outcomes other than self-reported depressionsymptoms. Sexual abuse is associated with a variety of outcomes

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including sexual behavior problems, conduct problems, anxiety,and posttraumatic stress disorder (Kendall-Tackett et al., 1993).Furthermore, we only had a single measure of depression; and aclinical elevation on the Child Depression Inventory is not syn-onymous with the Diagnostic and Statistical Manual of MentalDisorders (4th ed., text revision; American Psychiatric Associ-ation, 2000) diagnostic criteria for depression. Hopefully, futureinvestigations will report other outcomes and informants suchas parents and teachers.

Research suggests that the Rorschach should not be used asa test of whether a child has been sexually abused (West, 1998),and as articulated previously, no single measure can make sucha claim. We endorse this conclusion, and at the same time, webelieve the data presented herein support the premise that theRorschach sheds light on processes deserving clinical attentionwhen providing mental health services to children who experi-enced sexual abuse. For instance, the Rorschach might revealtendencies to focus on negatives, process things deeply, and bepreoccupied with or ruminate on the abuse. Knowledge of thesedifferences might be useful in both personality assessments andthe development of therapeutic interventions. Moreover, pro-viding interactive feedback to children about their Rorschachprotocol might be one way to help them better understand theirprocessing styles such as a tendency to focus on negatives, rumi-nate and be preoccupied with the maltreatment they experienced(Finn, 2007).

ACKNOWLEDGMENTS

This study was funded by a grant from the Richard J. Bar-ber Fund for Interdisciplinary Legal Research. The authors alsowish to thank Nancy Diehl and the staff of the Wayne CountyChild & Family Abuse Bureau. We thank Michael Behen, MaryHeaton, Lilly Jacobson, Kristin Kaylor Richardson, and Eliza-beth Robbins for assistance with data collection, as well as MaryHeaton for assistance with Rorschach scoring. We are especiallygrateful to the children and their parents who gave their timeand effort so generously. Portions of this paper were presentedat a meeting of the Society for Research in Child Development,Tampa, Florida, April 2003.

REFERENCES

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

Archer, R. P., & Krishnamurthy, R. (1997). MMPI–A and Rorschach indicesrelated to depression and conduct disorder: An evaluation of the incrementalhypothesis. Journal of Personality Assessment, 69, 517–533.

Armstrong, J. G., & Loewenstein, R. J. (1990). Characteristics of patients withmultiple personality and dissociative disorders on psychological testing. Jour-nal of Nervous and Mental Disorders, 178, 448–454.

Barnett, D., Manley, J. T., & Cicchetti, D. (1993). Defining child maltreatment:The interface between policy and research. In D. Cicchetti & S. Toth (Eds.),Child abuse, child development, and social policy (pp. 7–73). Norwood, NJ:Ablex.

Beeghly, M., & Cicchetti, D. (1994). Child maltreatment, attachment, and theself system: Emergence of an internal state lexicon in toddlers at high socialrisk. Development and Psychopathology, 6, 5–30.

Berant, E., Mikulincer, M., Shaver, P. R., & Segal, Y. (2005). Rorschach cor-relates of self-reported attachment dimension: Dynamic manifestations ofhyperactivating and deactivating strategies. Journal of Personality Assess-ment, 84, 70–81.

Cicchetti, D. (2013). Annual research review: Resilient functioning in maltreatedchildren—Past, present, and future perspectives. Journal of Child Psychologyand Psychiatry, 54, 402–422.

Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma andtraumatic grief in children and adolescents. New York, NY: Guilford.

Conway, M., Mendelson, M., Giannopoulos, C., Csank, P. A. R., & Holm,S. L. (2004). Childhood and adult sexual abuse, rumination on sadness, anddysphoria. Child Abuse & Neglect, 28, 393–410.

Curran, P. J., West, S. G., & Finch, J. F. (1996). The robustness of test statis-tics to nonnormality and specification error in confirmatory factor analysis.Psychological Methods, 1, 16–29.

Daigneault, I., Tourigny, M., & Hebert, M., (2006). Self-attributions of blamein sexually abused adolescents: A mediational model. Journal of TraumaticStress, 19, 153–157.

Dunn, L. M., & Dunn, L. M. (1997). Peabody Picture Vocabulary Test–Thirdedition (PPVT–III). Los Angeles, CA: Western Psychological Services.

Elliott, K., & Urquiza, A. (2006). Ethnicity, culture, & child maltreatment.Journal of Social Issues, 62, 787–809.

Exner, J. E. (2003). The Rorschach: A comprehensive system. Vol. 1 (4th ed.).New York, NY: Wiley.

Feiring, C., Coates, D. L., & Taska, L. S. (2001). Ethnic status, stigmatiza-tion, support, and symptoms development following sexual abuse. Journal ofInterpersonal Violence, 16, 1307–1329.

Feiring, C., Simon, V. A., & Cleland, C. M. (2008). Childhood sexual abuse,stigmatization, internalizing symptoms, and the development of sexual diffi-culties and dating aggression. Journal of Consulting and Clinical Psychology,77, 337–349.

Feiring, C., & Taska, L. (2005). The persistence of shame following childhoodsexual abuse: A longitudinal look at risk and recovery. Child Maltreatment,10, 26–41.

Feiring, C., Taska, L., & Chen, K. (2002). Trying to understand why horriblethings happen: Attribution, shame, and symptoms development followingsexual abuse. Child Maltreatment, 7, 26–41.

Finn, S. E. (2007). In our clients’ shoes: Theory and techniques of therapeuticassessment. Mahwah, NJ: Erlbaum.

Friedrich, W. N., Einbender, A. J., & McCarty, P. (1999). Sexually abusedgirls and their Rorschach responses. Psychological Reports, 85, 355–362.

Friedrich, W. N., Jaworski, T. M., Huxsahl, J. E., & Bengtson, B. S. (1997). Dis-sociative and sexual behaviors in children and adolescents with sexual abuseand psychiatric histories. Journal of Interpersonal Violence, 12, 155–171.

Garb, H. N., Wood, J. M., & Nezworski, M. T. (2000). Projective tech-niques and the detection of child sexual abuse. Child Maltreatment, 5, 161–168.

Hartman, E., Wang, C. E., Berg, M., & Saether, L. (2003). Depression andvulnerability as assessed by the Rorschach method. Journal of PersonalityAssessment, 81, 242–255.

Hillberg, T., Hamilton-Giachritsis, C., & Dixon, L. (2011). Review of meta-analyses on the association between child sexual abuse and adult mentalhealth difficulties: A systematic approach. Trauma, Violence, & Abuse, 12,38–49.

Himelein, M., & McElrath, J. A.V. (1996). Resilient child abuse survivors:Cognitive coping and illusion. Child Abuse & Neglect, 20, 747–758.

Hollingshead, A. B. (1975). Four factor index of social standing. New Haven,CT: Yale University, Department of Sociology.

Irish, L., Kobayashi, I., & Delahanty, D. L. (2010). Long-term physical healthconsequences of childhood sexual abuse: A meta-analytic review. Journal ofPediatric Psychology, 35, 450–461.

Jones, L. M., Cross, T. P., Walsh, W. A., & Simone, M. (2005). Criminalinvestigations of child abuse: The research behind “best practices.” TraumaViolence Abuse, 6, 254–268.

Jorgensen, K., Andersen, T. J., & Dam, H. (2000). The diagnostic efficiencyof the Rorschach Depression Index and the Schizophrenia Index: A review.Assessment, 7, 259–280.

Kamphuis, J. H., Kugeares, S. L., & Finn, S. E. (2000). Rorschach correlates ofsexual abuse: Trauma content and aggression. Journal of Personality Assess-ment, 75, 212–224.

Dow

nloa

ded

by [

UQ

Lib

rary

] at

20:

14 1

2 N

ovem

ber

2014

RISK, RESILIENCE, AND THE RORSCHACH 609

Kendall-Tackett, K. A., Williams, L. M., & Finkelhor, D. (1993). Impact ofsexual abuse on children: A review and synthesis of recent empirical studies.Psychological Bulletin, 113, 164–180.

Kovacs, M. (1992). Children’s depression inventory. Toronto, ON, Canada:Multi-Health Systems.

Leavitt, F., & Labott, S. M. (1996). Authenticity of recovered sexual abusememories: A Rorschach study. Journal of Traumatic Stress, 9, 483–496.

Leifer, M., Shapiro, J. P., Martone, M. W., & Kassem, L. (1991). Rorschachassessments of psychological functioning in sexually abused girls. Journal ofPersonality Assessment, 56, 14–28.

Li, X., Barnett, D., Fang, X., Lin, X., Zhao, G., Zhao, J., . . . Stanton, B. (2009).Lifetime incidences of traumatic events and mental health among childrenaffected by HIV/AIDS in rural China. Journal of Clinical Child & AdolescentPsychology, 38, 731–744.

Meyer, G. J. (2004). The reliability and validity of the Rorschach and ThematicApperception Test (TAT) compared to other psychological and medical pro-cedures: An analysis of systematically gathered evidence. In M. Hersen, M.Hilsenroth, & D. Segal (Eds.), Comprehensive handbook of psychologicalassessment: Vol. 2. Personality assessment (pp. 315–342). Hoboken, NJ: Wi-ley.

Meyer, G. J., & Archer, R. P. (2001). The hard science of Rorschach research:What do we know and where do we go? Psychological Assessment, 13,486–502.

Meyer, G. J., Viglione, D. J., & Exner J. E. (2001). Superiority of form% overLambda for research on the Rorschach Comprehensive System. Journal ofPersonality Assessment, 76, 68–75.

Michael, T., Ehlers, A., Halligan, S. L., & Clark, D. M. (2005). Unwanted mem-ories of assault: What intrusion characteristics are associated with PTSD?Behavior Research and Therapy, 43, 613–628.

Paolucci, O., Genuis, E., & Violato, M. L. (2001). A meta-analysis of thepublished research on the effects of child sexual abuse. Journal of Psychology,135, 17–36.

Perfect, M. M., Tharinger, D. J., Keith, T. Z., & Lyle-Lahroud, T. (2011).Relations between Minnesota Multiphasic Personality Inventory–A Scalesand Rorschach variables with the scope and severity of maltreatment amongadolescents. Journal of Personality Assessment, 93, 582–591.

Perry, W., Minassian, A., Cadenhead, K., Sprock, J., & Braff, D. (2003). Theuse of the Ego Impairment Index across the schizophrenia spectrum. Journalof Personality Assessment, 80, 50–57.

Podsakoff, P. M., MacKenzie, S. B., & Lee, J. (2003). Common method biasesin behavioral research: A critical review of the literature and recommendedremedies. Journal of Applied Psychology, 88, 879–903.

Putnam, F. W. (2003). Ten-year research update review: Child sexual abuse.Journal of American Academy of Child and Adolescent Psychiatry, 42,269–278.

Quas, J. A., Goodman, G. S., Ghetti, S., Alexander, K. W., Edelstein, R., Redlich,A. D., . . . Haugaard, J. J. (2005). Childhood sexual assault victims: Long-term outcomes after testifying in criminal court. Monographs of the Societyfor Research in Child Development, 70, 1–139.

Runyon, M. K., & Kenny, M. C. (2002). Relationship of attributional style,depression, and posttrauma distress among children who suffered physical orsexual abuse. Child Maltreatment, 7, 254–264.

Saywitz, K. J., Mannarino, A. P., Berliner, L., & Cohen, J. A. (2000). Treatmentfor sexually abused children and adolescents. American Psychologist, 55,1040–1049.

Shapiro, J. P., Leifer, M., Martone, M. W., & Kassem, L. (1990). Multimethodassessment of depression in sexually abused girls. Journal of PersonalityAssessment, 55, 234–248.

Simon, V. A., Feiring, C., & McElroy, S. K. (2010). Making meaning oftraumatic events: Youth’s strategies for processing childhood sexual abuseare associated with psychosocial adjustment. Child Maltreatment, 15, 229–241.

Steel, J., Sanna, L., Hammond, B., Whipple, J., & Cross, H. (2004). Psycho-logical sequelae of childhood sexual abuse: Abuse-related characteristics,coping strategies and attributional style. Child Abuse & Neglect, 28, 785–801.

Stoltenborgh, M., van IJzendoorn, M. H., Euser, E. M., & Bakermans-Kranenburg, M. J. (2011). A global perspective on child sexual abuse:Meta-analysis of prevalence around the world. Child Maltreatment, 16, 79–102.

Stredny, R. V., & Ball, J. D. (2005). The utility of the Rorschach coping deficitindex as a measure of depression and social skills deficits in children andadolescents. Assessment, 12, 295–302.

Swenson, C. C., & Hanson, R. F. (1998). Sexual abuse of children: Assessment,research, and treatment. In J. R. Lutzker (Ed.), Handbook of child abuseresearch and treatment (pp. 475–499). New York, NY: Plenum.

Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate statistics (5th ed.).Boston, MA: Pearson Education.

Terr, L. (1990). Too scared to cry: Psychic trauma in childhood. New York, NY:Basic Books.

Toth, S. L., & Cicchetti, D. (1996). Patterns of relatedness, depressive symp-tomatology, and perceived competence in maltreated children. Journal ofConsulting and Clinical Psychology, 64, 32–41.

Trickett, P. K., Kurtz, D. A., & Pizzigati, K. (2004). Resilient outcomes inabused and neglected children: Bases for strengths-based intervention andprevention policies. In K. I. Maton, C. J. Schellenbach, B. J. Leadbeater, &A. L. Solarz (Eds.), Investing in children, youth, families, and communities:Strengths-based research and policy (pp. 73–95). Washington, DC: AmericanPsychological Association.

Valle, L. A., & Silovsky, J. F. (2002). Attributions and adjustment followingchild sexual and physical abuse. Child Maltreatment, 7, 9–24.

Viglione, D. J. (1990). Severe disturbance or trauma induced adaptive reac-tion: A Rorschach child case study. Journal of Personality Assessment, 55,280–295.

Viglione, D. (1999). A review of recent research addressing the utility of theRorschach. Psychological Assessment, 11, 251–265.

Viglione, D. J., & Kates, J. (1997). A Rorschach child single subject studyin divorce: A question of psychological resiliency. In J. R. Meloy, M. W.Acklin, C. B. Gacono, J. F. Murray, & C. A. Peterson (Eds.), ContemporaryRorschach interpretation (pp. 365–388). Hillsdale, NJ: Erlbaum.

Weiner, I. B. (2003). Principles of Rorschach interpretation (2nd ed.). NewYork, NY: Routledge.

Weiner, I. (2006). The Rorschach inkblot method. In R. Archer (Ed.), Forensicuses of clinical assessment instruments (pp. 181–207). Mahwah, NJ: Erlbaum.

West, M. M. (1998). Meta-analysis of studies assessing the efficacy of projectivetechniques in discriminating child sexual abuse. Child Abuse & Neglect, 22,1151–1166.

Williams, L. M. (1994). Recall of childhood trauma: A prospective study ofwomen’s memories of child sexual abuse. Journal of Consulting & ClinicalPsychology, 62, 1167–1176.

Zielinski, D., & Bradshaw, K. (2006). Ecological influences of the sequelaeof child maltreatment: A review of the literature. Child Maltreatment, 11,49–62.

Zimmerman, D. P., & Dillard, J. (1994). The Rorschach assessment of sexu-ally abused children in residential treatment: A research note. ResidentialTreatment for Children & Youth, 12, 59–72.

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