JOINING FORCES

Joining Families

Volume 12, Issue 1 • August 2011

R E A L W O R L D R E S E A R C H F O R F A M I LY A D V O C A C Y P R O G R A M S

F E AT U R E D I N T E R V I E W

The Role of Trauma Symptoms in the Intergenerational
Transmission of Child Physical Abuse
An interview with Drs. Joel S. Milner and Cynthia J. Thomsen
Joel S. Milner, PhD

Joel S. Milner, Ph.D., is Professor Emeritusof Psychology, Distinguished Research Professor, and Director Emeritus of the Center for the
Study of Family Violence and Sexual Assault at
Northern Illinois University.
He is the author and coauthor of more than
200 scholarly publications and has received
more than 80 grants and contracts from private,
state, and federal agencies. The majority of his
research involves empirical studies in family
violence and sexual assault. His recent research
has focused on the description and assessmentof child physical and child sexual abusers, andon the testing of a social information-processing
model of child physical abuse. His current

In This Issue
This issue of Joining Forces Joining Families (JFJF) focuses on the roleof adverse childhood experiences (ACE) and trauma symptoms as they affectthe intergenerational transmission of child abuse. Our expert interview is with
Drs. Joel Milner and Cynthia Thomson whose work addresses this relationship. Another feature, Should the Army Screen Soldiers for Adverse Childhood Experiences, present arguments on why the military made the decision
not to screen entrants for ACE. In Building Bridges to Research, our regularstatistics article, we discuss the subject of mediators and moderators, variables that may be involved in studies of cause and effect, and how outcomescan be modified by such variables.
Contents
The Role of Trauma Symptoms in the Intergenerational Transmission ofChild Physical Abuse ...................................................................................1
Building Bridges to Research: Medi ators and Moderators............................3
Should the Army Screen Soldiers for Adverse Childhood Experiences?........4
Trauma Mediators of Abuse...........................................................................5
Websites of Interest.......................................................................................8

research includes a multi-year randomized clinical trial of a new, manualized intervention forpreventing child physical abuse in at-risk parents
based on his social information-processing modelof child physical abuse.

Cynthia J. Thomsen, PhD

Dr. Thomsen received her Ph.D. in Psychology from the University of Minnesota, and iscurrently a Research Psychologist at the Naval
Health Research Center in San Diego, CA. She
has authored and co-authored more than 30
scholarly publications, most of which focus on
family violence, sexual assault, substance abuse,
and psychological symptoms among members of
the US military. Her current research examines
the effects of specific military deployment experiences on risky, self-destructive, maladaptive, orviolent behavior, as well as possible mediators(e.g., psychological symptoms, resilience) andmoderators (e.g., gender, family structure) of
these effects.
Dr. McCarroll: Your work examines theintergenerational transmission of violence,
which postulates that people who are abused
as children are likely to become child abusers
as adults. How did this area of study becomeof interest?
Dr. Milner: For many years, one of mymajor programs of research has focused on the
etiology and prediction of child physical abuse(CPA). Childhood experiences are an important
contributor to the risk of an adult becoming achild abuser. So, our research has been directed
at understanding how and why childhood experiences translate into increased risk for adults toabuse their own children.
Continued on page 2

Although people who
were abused as children
are two to three times
more likely to be athigh risk of becoming
abusers, most people
who were abused do not
grow up to be abusive
toward their children.

Dr. McCarroll: It is widely accepted thatchildren who are abused are more likely toabuse their own children. Why is additional
research needed on the intergenerationaltransmission of child abuse hypothesis?
Dr. Milner: There is substantial evidence
that the childhood experience of verbal andphysical assault increases the likelihood oflater adult child abuse as well as many othernegative outcomes. However, many questions
about the nature of the association remainunanswered. For example, we know that not all
children who experience childhood abuse growup to abuse their children. Why do some victims of violence go on to perpetrate violence,
whereas others do not?
Dr. Thomsen: The relationship between
being abused as a child and being abusive as anadult is not as strong as many people think. Although our research suggests that people who
were abused are two to three times more likely
to be at high risk of becoming abusers, mostpeople who are abused are not abusive. About afourth to a third of child physical abuse victims
go on to abuse their own children (Kaufman& Zigler, 1987). Understanding these exceptions — those who go on to be abusers — isimportant.

JOINING FORCES
Joining Families
Editor-in-Chief
James E. McCarroll, PhD
Email:
Editorial Advisor
James.McCarroll.CTR@usuhs.mil LTC Nancy D. Ruffin, LCSWFamily Advocacy Program Manager
Headquarters, Department of theJoining Forces Joining Families
Armyis a publication of the U. S.
Army Installation Management Command and theFamily Violence and Trauma
Project of the Center for the
Study of Traumatic Stress(CSTS), Bethesda, Maryland
20814-4799, tel. 301-2952470. CSTS is a part of theDept. of Psychiatry, USUHS,
and a partnering center ofthe Defense Centers of Excellence (DCoE).

2 • Joining Forces/Joining Families

Editorial Consultants
David M. Benedek, MD, COL, MC, USA
Professor and Scientist
Center for the Study of Traumatic Stress
Uniformed Services University of the
Health Sciences
dbenedek@usuhs.mil
Nancy T. Vineburgh, MA
Director, Office of Public Education
and Preparedness
Center for the Study of Traumatic Stress
Email: nvineburgh@usuhs.mil

Dr. Milner: An important related question
focuses on understanding the mechanisms
underlying the intergenerational transmissionof violence. There has been surprisingly little
research into the processes by which childhood physical abuse experiences translate into
increased adult abuse risk. In technical terms,
our approach to understanding the intergenerational transmission of child physical abuse has
focused on identifying mediators and moderators of the association between experiencing
childhood abuse and the adult risk of abusive
behavior. This approach may be one key tounderstanding these complex relationships.
[Editor’s note: See featured article, Mediators andModerators, on page 3.]
Dr. McCarroll: The distinction between
mediation and moderation is extremely
important. How would you explain this for ourreaders?
Dr. Thomsen: Both are important, but they
operate in very different ways. When you arelooking at mediators, you are trying to explain
how or why A causes B. For example, how(through what processes) does being a victim ofchild physical abuse increase the likelihood thatyou will become a perpetrator of child physical abuse when you grow up? A mediator is avariable that explains the connection between acause (or predictor) and an effect (or outcome).
A moderator is a very different animal.
When you are looking at moderators, you are
examining whether the association between
two variables, A and B, differs depending on
another variable. Moderator variables address
whether an association is stronger under someconditions or for some groups of people relative
to others. In the context of the intergenerational transmission of child abuse, a moderator variable might be something that buffers
the individual against the negative effects ofchildhood abuse — say, the individual’s levelof resilience. If resilience were a moderator, theassociation between childhood abuse and adultrisk of abuse might be weaker among people
who are high in resilience than among people
low in resilience. A moderator also could besomething that increases the likelihood that theindividual will go on to become an abuser —say, for example, the presence of other adverse
childhood events or circumstances. In short,mediation addresses why, or through what process, A causes B; whereas moderation addresses
when, or for whom, the effect of A on B is likely
to be strongest.
Continued on p. 6
August 2011

BUILDING BRIDGES TO RESEARCH: 				Mediators and Moderators
By James E. McCarroll, PhD, and David M. Benedek, MD
A mediator is afactor that lies on thepathway between an
independent variable(a predictor) and adependent variable(and an outcome).
Moderators explain
how variables affectdifferent subgroups
within a populationin which certain
relationships exist.

http://www.CSTSonline.org

As described in this issue, Milner et al.
(2010) tested the hypothesis that trauma symptoms mediate the relationship between earlychildhood physical abuse (CPA) and the lateroccurrence of the abuse of children by parents
who were abused as children, the intergenerational transmission of CPA. In behavioral science research, one often reads that an outcome
is mediated or moderated by a third variable.
These important terms, sometimes misused orused interchangeably, represent very dif­ferent
concepts. Each has a different meaning whenused to describe research procedures and results. This article explains the differences.
A mediator is a factor that explains how or
why the relationship exists (Baron & Kenny,1986). In order for a factor to be a mediator,
it must lie on the pathway between the independent variable (the factor you are interested
in studying for its effect on the outcome) andthe dependent variable (the outcome). In otherwords, a mediating variable must demonstrate
a significant degree of relationship be­tween
the independent and the dependent variable.
In order for trauma symptoms to mediate therelationship between childhood physical abuse
and later adult risk of perpetrating physicalabuse, the trauma symptoms must be associated with both childhood abuse and the later riskof adult physical abuse (Milner, et al., 2010).
To illustrate, we use a simple example from
Buckner, Bassuk, & Beardslee (2004) who
examined the association between exposure toviolence and mental health in poor children.
They found that children exposed to violence(the independent variable) experienced moremental health symptoms (the outcome) thanthose who had not been exposed (the direct
relationship). To help explain this relationship,
they investigated four factors as possible mediators of violence and men­tal health symptoms:
1) perceptions of environmental danger, 2)
locus of control, 3) self-esteem, and 4) emotional regulation. They found that exposure toviolence led to lower self-esteem and a higher
perception of danger, both of which, in turn,led to internalizing symptoms and poor mental
health. Therefore, self-esteem and perceptionsof danger were found to be mediators in therelationship between exposure to violence andmental health because they were related to boththe independent variable and the outcome.
These mediators help explain why exposure toviolence is related to poor mental health.
Moderators, as distinguished from mediators, explain how variables affect different
subgroups within a population in which certain
relationships exist. A moderator may affect thedirection or the strength of the relationship ofinterest. A moderating variable, unlike a mediating variable, should have little or no statistical
relationship to either the independent or the
dependent variable.
Gender is often a moderator. In the Buckner et al. (2004) study, there was a relationship between exposure to violence and mental
health symptoms (internalizing symptoms suchas anxiety, depression, and somatic complaints)
and it was stronger for girls than for boys.
Thus, gender was a moderating variable in therelationship between exposure to violence andmental health symptoms. It affected one group(girls), but not the other (boys).
The above examples provide a brief introduction to the concepts of mediators and moderators. We have only highlighted the differences. In addition, terms other than mediatorsand moderators are found in scientific literature, which also affect the design and outcomeof research. Some of these are risk, risk factors,
correlates and confounders.

References
Baron R & Kenny D. (1986.) The moderator-mediator variable distinction in social psychological research: conceptual, strategic, andstatistical considerations. Journal of Personality
and Social Psychology, 51:1173–1182.
Buckner JC, Bassuk EL, & Beardslee WR. (2004.)
Exposure to violence and low-income children’s mental health: direct, moderated, andmediated relations. American Journal of Orthopsychiatry, 74:413–423.
Milner JS, Thomsen CJ, Crouch JL, Rabenhorst
MM, Martens Patricia M, Dyslin CW, Guimond JM, Stander VA, & Merrill LL. (2010).
Do trauma symptoms mediate the relationship between childhood physical abuse andadult child abuse risk? Child Abuse & Neglect;
34:332-344.
Joining Forces/Joining Families • 3

Should the Army Screen Soldiers for Adverse
Childhood Experiences? Pros and ConsBy James E. McCarroll, PhD, and David M. Benedek, MD
While there appears
to be evidence of astrong relationshipbetween ACE andadult outcomes, someauthors have urged
caution about theseresults.

The association between an adult’s historyof childhood physical abuse and the abuseof children by that same adult is one typeof intergenerational transmission of abuse.
Milner et al. (2010) reviewed the evidence forsuch transmission of abuse and concluded
that while findings are mixed, most studies
have found an association. People who experience violence are likely to develop symptoms
based on that trauma and these symptoms canincrease the likelihood that the individuals will
later display violent behavior toward their own
children.
Intergenerational transmission of abusecan be one effect of adverse childhood experiences (ACE) on adult health (Felitti. Anda,
Nordenberg, et al, 1998). Prior to this study,
the relationship between health risk behaviors
and disease in adulthood had not been investigated. The authors mailed a questionnaire
to over 13,000 adults in a health maintenanceorganization asking about their exposure toa variety of childhood experiences and thencompared the respondents’ responses to findings from their medical histories and healthrisk behaviors. Categories of adverse experiences included were: psychological, physical,
or sexual abuse, witnessing domestic violence,living with household members who were
substance abusers, mentally ill or suicidal, or
imprisoned. More than half of respondents
reported at least one, and one-fourth reported
more than two categories of childhood exposures. There was a graded relationship between
the number of categories of these childhood
experiences and each of the adult health risks
they exhibited. Those participants who had
experienced four or more categories comparedto those who had experienced none, had 4-to
12-fold increased risks for alcoholism, drug
abuse, depression, and suicide attempts. These
results have suggested the potential value ofscreening for ACE in adult populations.
The relationships between ACE on adultbehaviors and health are complex and do
not suggest a uniform effect, but support the
exploration of such experiences, particularly
childhood physical, sexual, and emotional
abuse and neglect (Rodgers, Lang, Laffaye, etal., 2004). The relationship between ACE and4 • Joining Forces/Joining Families

later health and behavior seems to strongly
suggest the need for interventions to preventor alleviate the effects of ACE. Why not screen
recruits and perhaps other active duty military
personnel for ACE? Given the risks to adult
health and negative behaviors found in the ACE
literature, one might suppose that there could
be special educational and treatment programsfor those who screened positive to help them
reduce negative adult health outcomes.
While there appears to be evidence of astrong relationship between ACE and adult outcomes, some authors have urged caution about
these results. Some studies have cast doubt on
the validity of adult retrospective reports of
their own ACE in childhood (Hardt & Rutter,2004). Measurement errors are possible including the likelihood of a substantial number offalse negative reports. Retrospective reports
are often underestimates of abuse, neglect andother types of experiences. About one third ofadults do not report ACE in adulthood evenwhen asked directly about them. On the other
hand, false positive reports are probably rare.
Another problem noted is that contemporary
reports often involve a different person (usually
the parent) than the person presented at follow
up (usually the subjects of the research). The
authors urged caution, but not blanket discarding of accounts of ACE.
The question of whether to implement new
screening, services, education, and intervention to portions of the active duty population
was considered by the Armed Forces Epidemiologic Board in 2005 (www.health.mil/dhb/
afeb/meeting/2005/june/Day1-Ruscio_ACE_
June2005_AFEB.ppt). While no formal report
was produced, participants recommended that
it was premature to implement a DoD-wide
ACE surveillance plan. This caution was due togaps in predicative validity between ACEs andadult outcomes, overly ambiguous goals of sucha program, the lack of an evidence base for specific interventions for ACE, and the significant
potential for misuse of ACE surveillance data.
In clinical settings, ACE can be considered.
While the negative experiences cannot be
undone, the outcomes such as family maltreatment, substance abuse, and negative lifestyleContinued on p. 8
August 2011

Trauma Mediators of Abuse — How Does 		Childhood Trauma Become Adult Distress?
By James E. McCarroll, PhD, and David M. Benedek, MD
The relationshipbetween child physicalabuse and adult
physical abuse risk
remained significant
even after controllingfor demographic
variables and otherforms of childhood
abuse such as
witnessing violence
between adults andchild sexual abuse.

http://www.CSTSonline.org

The association between the history ofchildhood physical abuse in an adult and theabuse of children by that same adult is known
as the intergenerational transmission of abuse.
The evidence for this type of abuse is mixed,
but most studies have found the association
between childhood abuse and later risk ofphysical abuse to one’s own children to be present (Milner et al., 2010). Since it is also truethat such intergenerational transmission of
abuse does not always occur, it is important tounderstand the mechanisms by which it occurs
or does not occur.
Several theories have been proposed asmeans of attempting to understand the intergenerational transmission of abuse. Two of
the most prominent have been social learningtheory (Bandura, 1973) and attachment theory(Bowlby, 1973). Both focus on the effects ofearly experience on later behavior. According
to social learning theory, abusive behaviors arelearned through observing and imitating adults
such as parents. We identify with our parents’behavior. Attachment theory is more abstract
as it focuses on cognitive models of relationships. For example, this theory proposedthat children who have been abused develop
negative models of themselves that increases
the likelihood that they will abuse others. An
alternative to these two theories is a trauma-focused model (Milner et al., 2010). This model
suggests that people who experience violence
are likely to develop symptoms based on thattrauma and that these symptoms can increase
the likelihood that the individual will later
display violent behavior. Symptoms of anxiety
or externalization, for example, might increase
violence.
This research was conducted in two
samples of young adults: US Navy recruits
and college students. Participants completed
self-reports of their own childhood history ofabuse, particularly severe physical abuse, current trauma symptoms, and their risk of adult
physical abuse risk. The risk of adult physicalabuse was based on responses to the Child
Abuse Potential Inventory (CAPI) (Milner,
1994). The CAPI was chosen as the measureof adult physical abuse risk due to its strong

psychometric properties of reliability andvalidity and because obtaining data on actual
adult physical abuse is subject to many limitations such as underreporting. Trauma symptoms were measured via the Trauma Symptom
Inventory (Briere, 1995).
Milner et al. (2010) found that trauma
symptoms did mediate the relationships
between childhood and adult physical abuse.
The relationship between child physical abuse
and adult physical abuse risk remained significant even after controlling for demographic
variables and other forms of childhood abusesuch as witnessing violence between adults andchild sexual abuse. Also important, they foundthat the effects of the three types of child abuse(physical abuse, sexual abuse, and exposure toadult violence) were additive. Each type of childabuse was an independent predictor of adult
physical abuse risk regardless of whether theother types of abuse had occurred.
Among the possible clinical implicationof these results is to provide interventions to
reduce trauma symptoms in abuse survivors
as a means of reducing the intergenerationaltransmission of child maltreatment.   

References
Bandura A. (1973). Aggression: A social learning
analysis. Englewood Cliffs, NJ: Prentice-Hall.
Bowlby J. (1973). Attachment and loss: Vol. 2.
Separation. New York: Basic Books.
Briere, J. (1995). Trauma Symptom Inventory
Professional Manual. Odessa, FL: Psychological
Assessment Resources.
Milner, J. S. (1994). Assessing physical child abuserisk: The Child Abuse Potential Inventory.
Clinical Psychology Review; 14:547–583.
Milner JS, Thomsen CJ, Crouch JL, Rabenhorst
MM, Martens PM, Dyslin CW, Guimond JM,
Stander VA, & Merrill LL. (2010). Do trauma
symptoms mediate the relationship between
childhood physical abuse and adult childabuse risk? Child Abuse & Neglect; 34:332–344.

Joining Forces/Joining Families • 5

Featured Interview, from page 2

Dr. McCarroll: What theoretical perspectives have guided
your study of the intergenerational transmission of violence?
Dr. Milner: Two of the oldest models focus on early learning experiences: one involving the application of social learning theory and the other implicating developmental processes.
Models based on social learning theory suggest that children
who experience childhood abuse learn parenting behavior byobserving and imitating the behavior of their parents. According to this perspective, children who experience verbal
and physical assault learn violent behaviors that they later use
when parenting their own children. In turn, their children
learn violent behaviors and employ these behaviors when they
become parents. Thus the cycle of violence continues generation after generation.
Models based on developmental theories typically focus
more on the impact of the child abuse on children’s thoughtprocesses or cognitive structures. For example, attachment
theory suggests that children construct cognitive models of
relationships based on their experiences with caregivers during the first few years of life. Specifically, attachment models
suggest that children develop positive (secure) or negative(insecure) internal working models of the self and others. Inturn, these internal models guide later interpersonal behaviors, influencing the way in which the individual responds andreacts to others, including their own children. This could thenlead their own children to develop insecure attachments andso on.
Dr. Thomsen: More recently, trauma-based models of
the intergenerational transmission of violence have been
proposed. These models are quite different from the social
learning and attachment models. Violent victimization is traumatic. Children who experience violence are likely to develop
trauma symptoms such as depression, anxiety, dissociation, or
emotional dysregulation. If these symptoms persist, they may
increase the likelihood of later aggressive and violent behavior.
From this perspective, it’s not social modeling nor internalized
models of relationships that are responsible for the intergenerational transmission of violence, it’s trauma symptoms.
Dr. McCarroll: Why did you decide to test the trauma model
rather than one of the other two?
Dr. Thomsen: We actually tested the attachment model
first. We expected that adult attachment might prove to bea powerful factor in accounting for the association between
childhood abuse and adult abuse risk.
Dr. Milner: We were drawn to test attachment as a mediator, in part, because the theory had been well-elaborated,
and there was a commonly held belief that attachment was amediator of the intergenerational transmission of child abuse.
In contrast, the idea of a trauma-based mediation study was
not as well grounded in theory and previous research as was
the adult attachment study.
Dr. Thomsen: Also, we were not as excited about testingsocial learning theory because that theory has been the subject
6 • Joining Forces/Joining Familiesof substantial research over the past few decades. Although
there is empirical support for the theory, in that disciplinary
styles tend to be repeated within families across generations,the evidence is less conclusive when it comes to the intergenerational transmission of child physical abuse.
Dr. McCarroll: What did your attachment study show?
Dr. Milner: Much to our surprise, using a large Navy
sample we found that there was no evidence that adult attachment styles mediated the association between being physicallyabused during childhood and adult child physical abuse risk
(Merrill et al, 2005).
Dr. McCarroll: Adult attachment was not related to adult riskfor physical child abuse?
Dr. Thomsen: Actually, it was related. As we expected,
people with insecure adult attachment were at elevated risk
for adult child abuse. Also, as expected, people who had been
physically abused during childhood generally had more insecure adult attachments than those who had not been abused.
Both of these findings are consistent with the possibility that
attachment mediates the intergenerational transmission ofchild abuse. However, direct tests of the mediational model
showed that adult attachment did not explain the association
between the experience of childhood physical abuse and adultchild physical abuse risk. Although both the childhood experience of physical abuse and adult attachment style were associated with increased adult child abuse risk, they were largely
separate and unique (independent) predictors. Thus, in thisstudy, attachment style was not a mediator between childhood
physical abuse and the risk of adult CPA.
Dr. Milner: We also tested a moderation hypothesis, which
was the idea that the impact of childhood abuse experienceson adult child abuse risk might be weaker among those withsecure attachment styles relative to those with insecure attachment styles. However, our results did not support this hypothesis; the relationship between childhood abuse and adult
physical abuse risk was equally strong for people who had
secure attachment styles and those who had insecure attachment styles. So having secure adult attachment did not reducethe intergenerational transmission of child abuse, and likewise,
having insecure adult attachment did not exacerbate the intergeneration transmission of abuse.
Dr. McCarroll: But when you tested the trauma model, you
did find evidence of mediation.
Dr. Milner: Yes, strong evidence of mediation. But, let me
explain this result in the following way. First, note that ourstudy found that only about 10% of adult child abuse risk is
explained by the childhood experience of abuse. We wanted
to know how much of this 10% is explained by mediators. We
found that trauma symptoms explained between 79% (in ourcollege student sample) and 90% (in our Navy recruit sample)of the association between childhood history of physical abuse
and adult child physical abuse risk, which is substantial (Milner et al., 2010). In other words, trauma symptoms accounted
August 2011for 79–90% of the 10% connection between the childhood
experience of physical abuse and adult child abuse risk. So,
there is more work to be done to figure out the other important variables involved in the intergenerational transmissionof child physical abuse. Many factors go into predicting who
will be at risk of abusive behavior. A history of violence exposure is just one of them; however, it is the factor that we were
trying to explain in testing the trauma-based model.
Dr. Thomsen: Also, because our study was the first study
to test for a role of trauma symptoms in mediating the intergenerational transmission of child physical abuse risk, it isimportant to replicate the findings in order to establish thatthey are robust.
Dr. McCarroll: How specific is the intergenerationaltransmission of violence? Does it have to be the same typeof victimization and perpetration? How do other types ofchildhood maltreatment and other types of trauma moregenerally fit into this model?
Dr. Milner: In our studies, we have controlled for otherforms of childhood violence such as child sexual abuse andobserved domestic violence because we know that different types of adverse childhood experiences are related. Our
results consistently show that all types of childhood violence
we examined, whether experienced or observed, are predictiveof increases in the risk of adult child physical abuse, increases
in attachment problems, and in psychological symptoms.
Generally, we have found that their effects are additive. Thatis, each additional form of violence that children experience
increases their risk of becoming abusers. Based on research todate, there does not appear to be a great deal of specificity; instead, all types of violence toward the child appear to increase
the likelihood of future violence as an adult.
Dr. McCarroll: Can you generalize the trauma mediation
model to predict other types of violence besides childphysical abuse? How similar would a model be if we were
trying to predict a different type of violence?
Dr. Thomsen: Although empirical tests of this are few, we
suspect that there are some common predictors of violence,
regardless of type. Trauma symptoms, violent victimization,and insecure attachment are examples of factors that arelikely to increase the risk of all, or most, types of violence. But
there also may be some unique predictors of specific types ofviolence. For example, in their model of adult sexual assault,
Malamuth and colleagues (1995) implicated two key factors,
that of hostile masculinity and impersonal sexual behavior, aspredictors of sexual assault perpetration. There is not a strong
logical or theoretical basis for assuming that these factors
would predict other types of violence, such as child physical abuse. So there may be specific risk factors for particular
types of violence, as well as general risk factors for all types ofviolence.

http://www.CSTSonline.org

Dr. McCarroll: Do your findings have implications forinterventions that might reduce the intergenerationaltransmission of child physical abuse risk?
Dr. Milner: One advantage of studying mediators of theintergenerational transmission of child physical abuse risk isthat it has the potential for providing insights into possible
treatment and intervention approaches. We cannot undo thefact that a person was abused as a child, but if we know howthat experience translates into adult child abuse risk, we may
be able to intervene through the mediator. Given the results ofour study, treating children or young adults with a childhood
history of abuse to reduce their trauma symptoms may not
only improve their psychological adjustment, but also reduce
their risk of abusive behavior.
Dr. Thomsen: It is important to keep in mind, though,that our study just raises this as a possibility. Also, although
trauma symptoms explained most of the association between
childhood victimization and adult risk of abuse in our study,
trauma symptoms did not explain as much of the variance inchild abuse risk overall. There are doubtless many other factors that are important in explaining abuse risk, and some ofthose may also be good candidates for intervention.
Dr. Milner: Still, because trauma symptoms do appear to
explain much of the link between childhood abuse and adultrisk of abusing, the possibility that intervening to reduce
trauma symptoms might short-circuit the intergenerationaltransmission of violence is very exciting.
Dr. McCarroll: Thank you both for helping us to understandthese complex issues.
Dr. Milner and Dr. Thomsen: You are welcome.

References
Kaufman J & Zigler E. (1987). The intergenerational transmission of child abuse. In D. Cicchettti & E. Zigler (Eds.), Childmaltreatment: Theory and research on the causes and consequences of child abuse and neglect (pp. 129–150). Cambridge,
UK: Cambridge University Press.
Malamuth N Linz D, Heavy C, Barnes G. & Acker M. (1995).
Using the confluence model of sexual aggression to predict
men’s conflict with women: A ten year follow-up study. Journal of Personality and Social Psychology; 69: 353–369
Merrill LL, Thomsen C, Crouch JL, May P, Gold SR, & Milner
JS. (2005). Predicting adult risk for child physical abuse fromchildhood exposure to violence: Can interpersonal schemata
explain the association? Journal of Social and Clinical Psychology; 24: 981–1002.
Milner JS, Thomsen CJ, Crouch JL, Rabenhorst MM, Martins PM, Dyslin CM, Guimond JM, Stander VA, & Merrill
LL. (2010). Do trauma symptoms mediate the association
between childhood physical abuse and adult child abuse risk?
Child Abuse & Neglect; 24: 332–344.

Joining Forces/Joining Families • 7

Websites of Interest■■ http://acestudy.org/ The Adverse Childhood Experiences(ACE) study is an ongoing collaboration between the Centers for Disease Control (CDC) and Kaiser Permanente. This
website presents the basic concept of the ACE study and thequestions used.
■■ http://www.cdc.gov/Features/dsACEs/ The CDC publishedsome basic results of a 2009 study of ACE that were incorporated into a module of the Behavioral Risk Factor Surveillance System (BRFSS) described below. The analysis presented the differences in ACE by gender, race/ethnicity, and total
ACE scores. It was concluded that ACE are common acrossboth genders and race/ethnic groups. The website next listed
provides more complete results of this study.
■■ http://www.cdc.gov/mmwr/pdf/wk/mm5949.pdf The December 17, 2010 edition of the CDC Morbidity and Mortality
Weekly Report (MMWR) presents detailed results of the 2009
study of ACE. The MMWR is the primary vehicle of the CDC
for scientific publication of timely, reliable, authoritative, accurate, objective,
and useful public health information
and recommendations. The ACE study
revealed that 41% of the population
reported no ACE. The highest prevalence reported, 21.1%, was for substanceabuse. Other results were given by race/
ethnicity, age, education, and gender.
■■ http://www.cdc.gov/brfss/about.
htm The CDC Behavioral Risk Factor Surveillance System(BRFSS) is a state-based system of health surveys that collect information on health risk behaviors, preventive healthpractices, and health care access primarily related to chronic
disease and injury. Data are collected monthly in all 50 states,
the District of Columbia, Puerto Rico, the U.S. Virgin Islands,
and Guam. More than 350,000 adults are interviewed eachyear making the BRFSS the largest telephone health survey inthe world. This website provides a wealth of information including the questionnaires used for measuring health-related
behaviors.

Should the Army Screen, from p. 4
behaviors such as smoking and other risky behav­iors may beamenable to modification.

References
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Kose MP, & Marks JS. (1998). Relationship of childhood abuse and household dysfunction to many of the leading
causes of death in adults: The adverse childhood experiences
study. American Journal of Epidemiology; 14:245–258.
8 • Joining Forces/Joining Families

Hardt & Rutter, (2004). Validity of adult retrospective reports
of adverse childhood experiences: review of the evidence.
Journal of Child Psychology and Psychiatry; 45:260–273.  
Rodgers CS, Lang AJ, Laffaye C, Satz LE, Dresselhaus TR,& Stein MB. (2004). The impact of individual forms ofchildhood maltreatment on health behavior. Child Abuse &Neglect; 28:575–586.

August 2011