Abstract
Research on trauma- and stressor-related disorders has recently expanded to consider moral injury, or the harmful psychological impact of profound moral transgressions, betrayals, and acts of perpetration. Largely studied among military populations, this construct has rarely been empirically extended to children and adolescents despite its relevance in the early years, as well as youths’ potentially heightened susceptibility to moral injury due to ongoing moral development and limited social resources relative to adults. Application of the construct to young persons, however, requires theoretical reconceptualization from a developmental perspective. The present paper brings together theory and research on developmentally-oriented constructs involving morally injurious events, including attachment trauma, betrayal trauma, and perpetration-induced traumatic stress, and describes how they may be integrated and extended to inform a developmentally-informed model of moral injury. Features of such a model include identification of potentially morally injurious events, maladaptive developmental meaning-making processes that underlie moral injury, as well as behavioral and emotional indicators of moral injury among youth. Thus, this review summarizes the currently available developmental literatures, identifies the major implications of each to a developmentally-informed construct of moral injury, and presents a conceptual developmental model of moral injury for children and adolescents to guide future empirical research.
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References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Author.
Ames, D., Erickson, Z., Youssef, N. A., Arnold, I., Adamson, S., Sones, A. C., Yin, J., Haynes, K., Volk, F., Teng, E. J., Oliver, J. P., & Koenig, H. G. (2019). Moral injury, religiosity, and suicide risk in active duty military with PTSD symptoms. Military Medicine, 184, e271–e278. https://doi.org/10.1093/milmed/usy148
Bailey, H. N., Moran, G., & Pederson, D. R. (2007). Childhood maltreatment, complex trauma symptoms, and unresolved attachment in an at-risk sample of adolescent mothers. Attachment & Human Development, 9, 139–161. https://doi.org/10.1080/14616730701349721
Baldry, A. C., Sorrentino, A., & Farrington, D. P. (2019). Post-traumatic stress symptoms among Italian preadolescents involved in school and cyber bullying and victimization. Journal of Child and Family Studies, 28, 2358–2364. https://doi.org/10.1007/s10826-018-1122-4
Bandura, A. (2006). Toward a psychology of human agency. Perspectives on Psychological Science, 1, 164–180. https://doi.org/10.1111/j.1745-6916.2006.00011.x
Barlow, M. R., & Freyd, J. J. (2009). Adaptive dissociation: Information processing and response to betrayal. In P. F. Dell & J. A. O'Neil (Eds.), Dissociation and the dissociative disorders: DSM-V and beyond (p. 93–105). Routledge/Taylor & Francis Group.
Barnes, H. A., Hurley, R. A., & Taber, K. H. (2019). Moral injury and PTSD: Often co-occurring yet mechanistically different. The Journal of Neuropsychiatry and Clinical Neurosciences, 31, A4-103. https://doi.org/10.1176/appi.neuropsych.19020036
Begle, A. M., Hanson, R. F., Danielson, C. K., McCart, M. R., Ruggiero, K. J., Amstadter, A. B., Resnick, H. S., Saunders, B. E., & Kilpatrick, D. G. (2011). Longitudinal pathways of victimization, substance use, and delinquency. Addictive Behaviors, 36, 682–689. https://doi.org/10.1016/j.addbeh.2010.12.026
Bernstein, R. E., & Freyd, J. J. (2014). Trauma at home: How betrayal trauma and attachment theories understand the human response to abuse by an attachment figure. New Directions in Psychotherapy and Relational Psychoanalysis, 8, 18–41. https://doi.org/10.4315/0362-028X.JFP-14-376
Betancourt, T. S., Borisova, I. I., Williams, T. W., Brennan, R. T., Whitfield, T. H., de la Soudiere, M., Williamson, J., & Gilman, S. E. (2010). Sierra Leone’s former child soldiers: A follow-up study of psychosocial adjustment and community reintegration. Child Development, 81, 1077–1095. https://doi.org/10.1111/j.1467-8624.2010.01455.x
Betancourt, T. S., Borisova, I. I., Williams, T. W., Meyers-Ohki, S. E., Rubin-Smith, J. E., Annan, J., & Kohrt, B. A. (2013). Research review: Psychosocial adjustment and mental health in former child soldiers – a systematic review of the literature and recommendations for future research. Journal of Child Psychology and Psychiatry, 54, 17–36. https://doi.org/10.1111/j.1469-7610.2012.02620.x
Betancourt, T. S., & Khan, K. T. (2008). The mental health of children affected by armed conflict: Protective processes and pathways to resilience. International Review of Psychiatry, 20, 317–328. https://doi.org/10.1080/09540260802090363
Birrell, P. J., & Freyd, J. J. (2006). Betrayal trauma: Relational models of harm and healing. Journal of Trauma Practice, 5, 49–63. https://doi.org/10.1300/J189v05n01_04
Black, J. E. (2016). An introduction to the moral agency scale: Individual differences in moral agency and their relationship to related moral constructs, free will, and blame attribution. Social Psychology, 47, 295–310. https://doi.org/10.1027/1864-9335/a000284
Bossarte, R. M., Simon, T. R., & Swahn, M. H. (2008). Clustering of adolescent dating violence, peer violence, and suicidal behavior. Journal of Interpersonal Violence, 23, 815–833. https://doi.org/10.1177/0886260507313950
Bowlby, J. (1944). Forty-four juvenile thieves: Their characters and home-life (II). International Journal of Psychoanalysis, 25, 107–128.
Bowlby, J. (1973/1998). Attachment and Loss Vol II: Separation. London, UK: Pimlico.
Branco, A. U. (2012). Values and socio-cultural practices: Pathways to moral development. In J. Valsiner (Ed.), Oxford library of psychology. The Oxford handbook of culture and psychology (p. 749–766). Oxford University Press.
Bravo, A. J., Kelley, M. L., Mason, R., Ehlke, S. J., Vinci, C., & Redman, J. C. (2020). Rumination as a mediator of the associations between moral injury and mental health problems in combat wounded veterans. Traumatology, 26, 52–60. https://doi.org/10.1037/trm0000198
Breidenstine, A. S., Bailey, L. O., Zeanah, C. H., & Larrieu, J. A. (2011). Attachment and trauma in early childhood: A review. Journal of Child and Adolescent Trauma, 4, 274–290. https://doi.org/10.1080/19361521.2011.609155
Brémault-Phillips, S., Pike, A., Scarcella, F., & Cherwick, T. (2019). Spirituality and moral injury among military personnel: A mini-review. Frontiers in Psychiatry, 10, 1–9. https://doi.org/10.3389/fpsyt.2019.00276
Bryan, C. J., Bryan, A. O., Roberge, E., Leifker, F. R., & Rozek, D. C. (2018). Moral injury, posttraumatic stress disorder, and suicidal behavior among national guard personnel. Psychological Trauma: Theory, Research, Practice, and Policy, 10, 36–45. https://doi.org/10.1037/tra0000290
Carlson, E. A., Yates, T. M., & Sroufe, L. A. (2009). Dissociation and development of the self. In P. F. Dell & J. A. O’Neil (Eds.), Dissociation and the dissociative disorders: DSM-V and beyond (pp. 39–52). Routledge.
Chaplo, S. D., Kerig, P. K., & Wainryb, C. (2019). Development and validation of the moral injury scales for youth. Journal of Traumatic Stress, 32, 448–458. https://doi.org/10.1002/jts.22408
Charuvastra, A., & Cloitre, M. (2008). Social bonds and posttraumatic stress disorder. Annual Review of Psychology, 59, 301–328. https://doi.org/10.1146/annurev.psych.58.110405.085650
Chiodo, D., Crooks, C. V., Wolfe, D. A., McIsaac, C., Hughes, R., & Jaffe, P. G. (2012). Longitudinal prediction and concurrent functioning of adolescent girls demonstrating various profiles of dating violence and victimization. Prevention Science, 13, 350–359. https://doi.org/10.1007/s11121-011-0236-3
Choi, K. R., Ford, J. D., Briggs, E. C., Munro-Kramer, M. L., Graham-Bermann, S. A., & Seng, J. S. (2019). Relationships between maltreatment, posttraumatic symptomatology, and the dissociative subtype of PTSD among adolescents. Journal of Trauma and Dissociation, 20, 212–227. https://doi.org/10.1080/15299732.2019.1572043
Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Balustein, M., Cloitre, M., DeRosa, R., Hubbard, R., Kagan, R., Liautaud, J., Mallah, K., Olafson, E., & van der Kolk, B. (2005). Complex trauma in children and adolescents. Psychiatric Annals, 35, 390–398. https://doi.org/10.3928/00485713-20050501-05
Corbin, J. N. (2008). Returning home: Resettlement of formerly abducted children in Northern Uganda. Disasters, 32, 316–333. https://doi.org/10.1111/j.0361-3666.2008.01042.x
Courtois C. A. (2008). Complex trauma, complex reactions: Assessment and treatment. Psychological Trauma: Theory, Research, Practice, and Policy, S 86–100 https://doi.org/10.1037/1942-9681.S.1.86
Crisford, H., Dare, H., & Evangeli, M. (2008). Offence-related posttraumatic stress disorder (PTSD) symptomatology and guilt in mentally disordered violent and sexual offenders. The Journal of Forensic Psychology & Psychiatry, 19, 86–107. https://doi.org/10.1080/14789940701596673
Currier, J. M., Foster, J. D., & Isaak, S. L. (2019). Moral injury and spiritual struggles in military veterans: A latent profile analysis. Journal of Traumatic Stress, 32, 393–404. https://doi.org/10.1002/jts.22378
Currier, J. M., Holland, J. M., Jones, H. W., & Sheu, S. (2014). Involvement in abusive violence among Vietnam veterans: Direct and indirect associations with substance use problems and suicidality. Psychological Trauma: Theory, Research, Practice, and Policy, 6, 73–82. https://doi.org/10.1037/a0032973
D’Andrea, W., Ford, J., Stolbach, B., Spinazzola, J., & van der Kolk, B. A. (2012). Understanding interpersonal trauma in children: Why we need a developmentally appropriate trauma diagnosis. American Journal of Orthopsychiatry, 82, 187–200. https://doi.org/10.1111/j.1939-0025.2012.01154.x187
Delker, B. C., & Freyd, J. J. (2014). From betrayal to the bottle: Investigating possible pathways from trauma to problematic substance use. Journal of Traumatic Stress, 27, 576–584. https://doi.org/10.1002/jts.21959
Delker, B. C., Smith, C. P., Rosenthal, M. N., Bernstein, R. E., & Freyd, J. J. (2018). When home is where the harm is: Family betrayal and posttraumatic outcomes in young adulthood. Journal of Aggression, Maltreatment, & Trauma, 27, 720–743. https://doi.org/10.1080/10926771.2017.1382639
Dennis, P. A., Dennis, N. M., van Voorhees, E. E., Calhoun, P. S., Dennis, M. F., & Beckham, J. C. (2017). Moral transgression during the Vietnam war: A path analysis of the psychological impact of veterans’ involvement in wartime atrocities. Anxiety, Stress, & Coping, 30, 188–201. https://doi.org/10.1080/10615806.2016.1230669
Derluyn, I., Broekaert, E., Schuyten, G., & de Temmerman, E. (2004). Posttraumatic stress in former Ugandan child soldiers. Lancet, 363, 861–863. https://doi.org/10.1016/S0140-6736(04)15734-6
Derluyn, I., Vindevogel, S., & de Haene, L. (2013). Toward the future: Implications of research and intervention with traumatized former child soldiers. Journal of Aggression, Maltreatment, & Trauma, 22, 869–886. https://doi.org/10.1080/10926771.2013.824058
Dillard, J. (2009). A slaughterhouse nightmare: Psychological harm suffered by slaughterhouse employees and the possibility of redress through legal reform. Georgetown Journal on Poverty Law & Policy, 15, 391–408.
Doyle, C., & Cicchetti, D. (2017). From the cradle to the grave: The effect of adverse caregiving environments on attachment and relationships throughout the lifespan. Clinical Psychology: Science and Practice, 24, 203–217. https://doi.org/10.1111/cpsp.12192
Drescher, K. D., & Foy, D. W. (2008). When they come home: Posttraumatic stress, moral injury, and spiritual consequences for veterans. Reflective Practice: Formation and Supervision in Ministry, 28, 85–102.
Drescher, K. D., Foy, D. W., Kelly, C., Leshner, A., Schutz, K., & Litz, B. T. (2011). An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology, 17, 8–13. https://doi.org/10.1177/1534765610395615
Elwood, L. S., Han, K. S., Olatunji, B. O., & Williams, N. L. (2009). Cognitive vulnerabilities to the development of PTSD: A review of four vulnerabilities and the proposal of an integrative vulnerability model. Clinical Psychology Review, 29, 87–100. https://doi.org/10.1016/j.cpr.2008.10.002
Espelage, D. L., Basile, K. C., & Hamburger, M. E. (2012). Bullying perpetration and subsequent sexual violence perpetration among middle school students. Journal of Adolescent Health, 50, 60–65. https://doi.org/10.1016/j.jadohealth.2011.07.015
Exner-Cortens, D., Eckenrode, J., & Rothman, E. (2013). Longitudinal associations between teen dating violence victimization and adverse health outcomes. Pediatrics, 131, 71–78. https://doi.org/10.1542/peds.2012-1029
Farnsworth, J. K., Drescher, K. D., Evans, W., & Walser, R. D. (2017). A functional approach to understanding and treating military-related moral injury. Journal of Contextual Behavioral Science, 6, 391–397. https://doi.org/10.1016/j.jcbs.2017.07.003
Farnsworth, J. K., Drescher, K. D., Nieuwsma, J. A., Walser, R. B., & Currier, J. M. (2014). The role of moral emotions in military trauma: Implications for the study and treatment of moral injury. Review of General Psychology, 18, 249–262. https://doi.org/10.1037/gpr0000018
Freyd, J. J. (1994). Betrayal trauma: Traumatic amnesia as an adaptive response to childhood abuse. Ethics & Behavior, 4, 307–329. https://doi.org/10.1207/s15327019eb0404_1
Freyd, J. J. (1996). Betrayal trauma: The logic of forgetting childhood abuse. Harvard University Press.
Freyd, J. J. (2013). Preventing betrayal. Journal of Trauma & Dissociation, 14, 495–500. https://doi.org/10.1080/15299732.2013.824945
Freyd, J. J., DePrince, A. P., & Gleaves, D. H. (2007). The state of betrayal trauma theory: Reply to McNally — conceptual issues and future directions. Memory, 15, 295–311. https://doi.org/10.1080/09658210701256514
Freyd, J. J., Klest, B., & Allard, C. B. (2005). Betrayal trauma: Relationship to physical health, psychological distress, and a written disclosure intervention. Journal of Trauma & Dissociation, 6, 83–104. https://doi.org/10.1300/J229v06n03_04
Gagnon, K. L., Lee, M. S., & DePrince, A. P. (2017). Victim-perpetrator dynamics through the lens of betrayal trauma theory. Journal of Trauma & Dissociation, 18, 373–382. https://doi.org/10.1080/15299732.2017.1295421
Garrigan, B., Adlam, A. L. R., & Langdon, P. E. (2018). Moral decision-making and moral development: Toward an integrative framework. Developmental Review, 49, 80–100. https://doi.org/10.1016/j.dr.2018.06.001
Gobin, R. L., & Freyd, J. J. (2009). Betrayal and revictimization: Preliminary findings. Psychological Trauma: Theory, Research, Practice, and Policy, 1, 242–257. https://doi.org/10.1037/a0017469
Griffin, B. J., Purcell, N., Burkman, K., Litz, B. T., Bryan, C. J., Schmitz, M., Villierme, C., Walsh, J., & Maguen, S. (2019). Moral injury: An integrative review. Journal of Traumatic Stress, 32, 350–362. https://doi.org/10.1002/jts.22362
Haight, W., Sugrue, E., Calhoun, M., & Black, J. (2016). A scoping study of moral injury: Identifying directions for social work research. Children and Youth Services Review, 70, 190–200. https://doi.org/10.1016/j.childyouth.2016.09.026
Hardy, S. A., & Carlo, G. (2011). Moral identity: What is it, how does it develop, and is it linked to moral action? Child Development Perspectives, 5, 212–218. https://doi.org/10.1111/j.1750-8606.2011.00189.x
Hecker, T., Hermenau, K., Maedl, A., Hinkel, H., Schauer, M., & Elbert, T. (2013). Does perpetrating violence damage mental health? Differences between forcibly recruited and voluntary combatants in DR Congo. Journal of Traumatic Stress, 26, 142–148. https://doi.org/10.1002/jts.21770
Hickman, L. J., Jaycox, L. H., & Aronoff, J. (2004). Dating violence among adolescents: Prevalence, gender distribution, and prevention program effectiveness. Trauma, Violence, & Abuse, 5, 123–142. https://doi.org/10.1177/1524838003262332
Hodgson, T. J., & Carey, L. B. (2017). Moral injury and definitional clarity: Betrayal, spirituality, and the role of chaplains. Journal of Religion and Health, 56, 1212–1228. https://doi.org/10.1007/s10943-017-0407-z
Holt, M. K., & Espelage, D. L. (2007). Perceived social support among bullies, victims, and bully-victims. Journal of Youth and Adolescence, 36, 984–994. https://doi.org/10.1007/s10964-006-9153-3
Idsoe, T., Dyregrov, A., & Idsoe, E. C. (2012). Bullying and PTSD symptoms. Journal of Abnormal Clinical Psychology, 40, 901–911. https://doi.org/10.1007/s10802-012-9620-0
Jinkerson, J. D. (2016). Assessing moral injury: A syndrome perspective. Traumatology, 22, 122–130. https://doi.org/10.1037/trm0000069
Jordan, A. H., Eisen, E., Bolton, E., Nash, W. P., & Litz, B. T. (2017). Distinguishing war-related PTSD resulting from perpetration- and betrayal-based morally injurious events. Psychological Trauma: Theory, Research, Practice, and Policy, 9, 627–634. https://doi.org/10.1037/tra0000249
Kelley, L. P., Weathers, F. W., Mason, E. A., & Pruneau, G. M. (2012). Association of life threat and betrayal with posttraumatic stress disorder symptom severity. Journal of Traumatic Stress, 25, 408–415. https://doi.org/10.1002/jts.21727
Kerig, P. K. (2017). Posttraumatic stress disorder in childhood and adolescence: A developmental psychopathology perspective. Momentum Press.
Kerig, P. K., & Becker, S. P. (2010). From internalizing to externalizing: Theoretical models of the processes linking PTSD to juvenile delinquency. In S. J. Egan (Ed.), Post-traumatic stress disorder (PTSD): Causes, symptoms and treatment (pp. 33–78). Hauppauge, NY: Nova Science.
Kerig, P. K., & Bennett, D. C. (2013). Beyond fear, helplessness, and horror: Peritraumatic reactions associated with posttraumatic stress symptoms among traumatized delinquent youth. Psychological Trauma, 5, 431–438. https://doi.org/10.1037/a0029609
Kerig, P. K., Bennett, D. C., Thompson, M., & Becker, S. P. (2012). “Nothing really matters:” Emotional numbing as a link between trauma exposure and callousness in delinquent youth. Journal of Traumatic Stress, 25, 272–279. https://doi.org/10.1002/jts.21700
Kerig, P. K., Chaplo, S. D., Bennett, D. C., & Modrowski, C. A. (2016). “Harm as harm:” Gang membership, perpetration trauma, and posttraumatic stress symptoms among youth in the juvenile justice system. Criminal Justice and Behavior, 43, 635–652. https://doi.org/10.1177/0093854815607307
Kerig, P. K., Ludlow, A., & Wenar, C. (2012). Developmental psychopathology: From infancy through adolescence. McGraw-Hill Education.
Kerig, P. K., Wainryb, C., Twali, M. S., & Chaplo, S. D. (2013). America’s child soldiers: Toward a research agenda for studying gang-involved youth in the United States. Journal of Aggression, Maltreatment, & Trauma, 22, 773–795. https://doi.org/10.1080/10926771.2013.813883
Kim, S., & Kochanska, G. (2019). Evidence for childhood origins of conscientiousness: Testing a developmental path from toddler age to adolescence. Developmental Psychology, 55, 196–206. https://doi.org/10.1037/dev0000608
Klasen, F., Oettingen, G., Daniels, J., Post, M., Hoyer, C., & Adam, H. (2010). Posttraumatic resilience in former Ugandan child soldiers. Child Development, 81, 1096–1113. https://doi.org/10.1111/j.1467-8624.2010.01456.x
Klasen, F., Reissmann, S., Voss, C., & Okello, J. (2015). The guiltless guilty: Trauma-related guilt in former Ugandan child soldiers. Child Psychiatry & Human Development, 46, 180–193. https://doi.org/10.1007/s10578-014-0470-6
Klomek, A. B., Kleinman, M., Altschuler, E., Marrocco, F., Amakawa, L., & Gould, M. S. (2013). Suicidal adolescents’ experiences with bullying perpetration and victimization during high school as risk factors for later depression and suicidality. Journal of Adolescent Health, 53, S37–S42. https://doi.org/10.1016/j.jadohealth.2012.12.008
Kobak, R., Cassidy, J., & Zir, Y. (2004). Attachment-related trauma and posttraumatic stress disorder. In W. S. Rholes & J. A. Simpson (Eds.), Adult attachment: Theory, research, and clinical implications (pp. 388–407). Guilford.
Köber, C., Schmiedek, F., & Habermas, T. (2015). Characterizing lifespan development of three aspects of coherence in life narratives: A cohort-sequential study. Developmental Psychology, 51, 260–275.
Kochanska, G., & Aksan, N. (2006). Children’s conscience and self-regulation. Journal of Personality, 74, 1587–1617. https://doi.org/10.1111/j.1467-6494.2006.00421.x
Kochanska, G., Forman, D. R., Aksan, N., & Dunbar, S. B. (2005). Pathways to conscience: Early mother-child mutually responsive orientation and children’s moral emotion, conduct, and cognition. Journal of Child Psychology and Psychiatry, 46, 19–34. https://doi.org/10.1111/j.1469-7610.2004.00348.x
Kochanska, G., Koenig, J. L., Barry, R. A., Kim, S., & Yoon, J. E. (2010). Children’s conscience during toddler and preschool years, moral self, and a competent, adaptive developmental trajectory. Developmental Psychology, 46, 1320–1332. https://doi.org/10.1037/a0020381
Koenig, A. L., Cicchetti, D., & Rogosch, F. A. (2004). Moral development: The association between maltreatment and young children’s prosocial behaviors and moral transgressions. Social Development, 13, 97–106. https://doi.org/10.1111/j.1467-9507.2004.00258.x
Kohlberg, L. (1969). Stage and sequence: The cognitive developmental approach to socialization. In D. A. Goslin (Ed.), Handbook of socialization theory and research. Chicago: McNally.
Kohlberg, L. (2008). The development of children’s orientations toward a moral order: 1. Sequence in the development of human thought. Human Development, 51, 8–20. https://doi.org/10.1159/000112530
Komarovskaya, I., Maguen, S., McCaslin, S. E., Metzler, T. J., Madan, A., Brown, A. D., Galatzer-Levy, I. R., Henn-Haase, C., & Marmar, C. R. (2011). The impact of killing and injuring others on mental health symptoms among police officers. Journal of Psychiatric Research, 45, 1332–1336. https://doi.org/10.1016/j.jpsychires.2011.05.004
Layne, C. M., Kaplow, J. B., Oosterhoff, B., Hill, R. M., & Pynoos, R. S. (2017). The interplay between posttraumatic stress and grief reactions in traumatically bereaved adolescents: When trauma, bereavement, and adolescence converge. Adolescent Psychiatry, 7, 220–239. https://doi.org/10.2174/2210676608666180306162544
Lentz, L. M., Smith-MacDonald, L., Malloy, D., Carleton, R. N., & Brémault-Phillips, S. (2021). Compromised conscience: A scoping review of moral injury among firefighters, paramedics, and police officers. Frontiers in Psychology, 12, 639781. https://doi.org/10.3389/fpsyg.2021.639781
Lind, M. N., Adams-Clark, A. A., & Freyd, J. J. (2020). Isn’t high school bad enough already? Rates of gender harassment and institutional betrayal in high school and their association with trauma-related symptoms. PLoS One, 15, e0237713. https://doi.org/10.1371/journal.pone.0237713
Litwiller, B. J., & Brausch, A. M. (2013). Cyber bullying and physical bullying in adolescent suicide: The role of violent behavior and substance use. Journal of Youth and Adolescence, 42, 675–684. https://doi.org/10.1007/s10964-013-9925-5
Litz, B. T., & Kerig, P. K. (2019). Introduction to the special issue on moral injury: Conceptual challenges, methodological issues, and clinical applications. Journal of Traumatic Stress, 32, 341–349. https://doi.org/10.1002/jts.22405
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695–706. https://doi.org/10.1016/j.cpr.2009.07.003
Maas, C., Herrenkohl, T. I., & Sousa, C. (2008). Review of research on child maltreatment and violence in youth. Trauma, Violence, & Abuse, 9, 56–67. https://doi.org/10.1177/1524838007311105
Macfie, J., Cicchetti, D., & Toth, S. L. (2001). Dissociation in maltreated versus nonmaltreated preschool-aged children. Child Abuse & Neglect, 25, 1253–1267. https://doi.org/10.1016/S0145-2134(01)00266-6
MacNair, R. (2002). Perpetration-induced traumatic stress. Praeger.
MacNair, R. (2015). Causing trauma as a form of trauma. Peace and Conflict, 21, 313–321. https://doi.org/10.1037/pac0000116
Maguen, S., Lucenko, B. A., Reger, M. A., Gahm, G. A., Litz, B. T., Seal, K. H., Knight, S. J., & Marmar, C. R. (2010). The impact of reported direct and indirect killing on mental health symptoms in Iraq war veterans. Journal of Traumatic Stress, 23, 86–90. https://doi.org/10.1002/jts.20434
Maguen, S., Metzler, T. J., Litz, B. T., Seal, K. H., Knight, S. J., & Marmar, C. R. (2009). The impact of killing in war on mental health symptoms and related functioning. Journal of Traumatic Stress, 22, 435–443. https://doi.org/10.1002/jts.20451
Maguen, S., Vogt, D. S., King, L. A., King, D. W., Litz, B. T., Knight, S. J., & Marmar, C. R. (2011). The impact of killing on mental health symptoms in gulf war veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 3, 21–26. https://doi.org/10.1037/a0019897
Maltby, L. E., & Hall, T. D. (2012). Trauma, attachment, and spirituality: A case study. Journal of Psychology & Theology, 40, 302–312. https://doi.org/10.1177/009164711204000405
Malti, T., & Ongley, S. F. (2014). The development of moral emotions and moral reasoning. In M. Killen & J. G. Smetana (Eds.), Handbook of moral development (2nd ed., pp. 163–183). Taylor and Francis.
McEwen, C., Alisic, E., & Jobson, L. (2020). Moral injury and mental health: A systematic review and meta-analysis. Traumatology. Advance online publication. https://doi.org/10.1037/trm0000287
McNeely, C., & Blanchard, J. (2009). The teen years explained: A guide to healthy adolescent development. Center for Adolescent Health at Johns Hopkins Bloomberg School of Public Health.
McVie, S. (2014). The impact of bullying perpetration and victimization on later violence and psychological distress: A study of resilience among a Scottish youth cohort. Journal of School Violence, 13, 39–58. https://doi.org/10.1080/15388220.2013.841586
Menesini, E., Modena, M., & Tani, F. (2009). Bullying and victimization and adolescence: Concurrent and stable roles and psychological health symptoms. The Journal of Genetic Psychology, 170, 115–133. https://doi.org/10.3200/GNTP.170.2.115-134
Midgette, A. (2018). Children’s strategies for self-correcting their social and moral transgressions and perceived personal shortcomings: Implications for moral agency. Journal of Moral Education, 47, 231–247. https://doi.org/10.1080/03057240.2017.1396965
Modecki, K. L., Minchin, J., Harbaugh, A. G., Guerra, N. G., & Runions, K. C. (2014). Bullying prevalence across contexts: A meta-analysis measuring cyber and traditional bullying. Journal of Adolescent Health, 55, 602–611. https://doi.org/10.1016/j.jadohealth.2014.06.007
Monteith, L. L., Bahraini, N. H., Matarazzo, B. B., Soberay, K. A., & Smith, C. P. (2016). Perceptions of institutional betrayal predict suicidal self-directed violence among veterans exposed to military sexual trauma. Journal of Clinical Psychology, 72, 743–755. https://doi.org/10.1002/jclp.22292
Mozley, M. M., Lin, B., & Kerig, P. K. (2018). Posttraumatic overmodulation, callous-unemotional traits, and offending among justice-involved youth. Journal of Aggression, Maltreatment & Trauma, 27, 744–758. https://doi.org/10.1080/10926771.2017.1420724
Mynard, H., Joseph, S., & Alexander, J. (2000). Peer-victimization and posttraumatic stress in adolescents. Personality and Individual Differences, 29, 815–821. https://doi.org/10.1016/S0191-8869(99)00234-2
Nash, W. P., & Litz, B. T. (2013). Moral injury: A mechanism for war-related psychological trauma in military family members. Clinical Child and Family Psychology Review, 16, 365–375. https://doi.org/10.1007/s10567-013-0146-y
National Child Traumatic Stress Network. (2018, May 25). Complex Trauma, National Child Traumatic Stress Network. https://www.nctsn.org/what-is-child-trauma/trauma-types/complex-trauma
Nichter, B., Norman, S. B., Maguen, S., & Pietrzak, R. H. (2021). Moral injury and suicidal behavior among US combat veterans: Results from the 2019–2020 National Health and Resilience in Veterans Study. Depression & Anxiety, 38, 606–614. https://doi.org/10.1002/da.23145
Nucci, L. (2014). The personal and the moral. In M. Killen and J. G. Smetana (Eds.), Handbook of moral development (2nd ed., pp. 538–558). New York, NY: Taylor and Francis. https://doi.org/10.4324/9780203581957.ch25
Oosterhoff, B., Kaplow, J. B., Layne, C. M., & Pynoos, R. S. (2018). Civilization and its discontented: Links between youth victimization, beliefs about government, and political participation across seven American presidencies. American Psychologist, 73, 230–242. https://doi.org/10.1037/amp0000189
Papanastassiou, M., Waldron, G., Boyle, J., & Chesterman, L. P. (2004). Post-traumatic stress disorder in mentally ill perpetrators of homicide. The Journal of Forensic Psychiatry & Psychology, 15, 66–75. https://doi.org/10.1080/14789940310001630419
Pasupathi, M., & Wainryb, C. (2010). Developing moral agency through narrative. Human Development, 53, 55–80. https://doi.org/10.1159/000288208
Piaget, J. (1965). The moral development of a child. Free Press.
Platt, M., Barton, J., & Freyd, J. J. (2009). A betrayal trauma perspective on domestic violence. In E. Stark & E. Buzawa (Eds.), Violence against women in families and relationships making and breaking connections (Vol. 1, pp. 185–207). Greenwood Publishing.
Platt, M. G., & Freyd, J. J. (2015). Betray my trust, shame on me: Shame, dissociation, fear, and betrayal trauma. Trauma: Theory, Research, Practice, and Policy, 7, 398–404. https://doi.org/10.1037/tra0000022
Plattner, B., Silvermann, M. A., Redlich, A. D., Carrion, V. G., Feucht, M., Friedrich, M. H., & Steiner, H. (2003). Pathways to dissociation: Intrafamilial versus extrafamilial trauma in juvenile delinquents. The Journal of Nervous and Mental Disease, 191, 781–788. https://doi.org/10.1097/01.nmd.0000105372.88982.54
Pressley, J., & Spinazzola, J. (2015). Beyond survival: Application of a complex trauma treatment model in the Christian context. Journal of Psychology & Theology, 43, 8–22. https://doi.org/10.1177/009164711504300102
Putnam, F. W. (1997). Dissociation in children and adolescents: A developmental perspective. The Guilford Press.
Ramage, A. E., Litz, B. T., Resick, P. A., Woolsey, M. D., Dondanville, K. A., Young-McCaughan, S., Borah, A. M., Borah, E. V., Peterson, A. L., & Fox, P. T. (2016). Regional cerebral glucose metabolism differentiates danger- and non-danger-based traumas in posttraumatic stress disorder. Social Cognitive and Affective Neuroscience, 11, 234–242. https://doi.org/10.1093/scan/nsv102
Rawls, J. (1971). A theory of justice. Cambridge, MA: Harvard University Press.
Recchia, H. E., Wainryb, C., Bourne, S., & Pasupathi, M. (2015). Children’s and adolescents’ accounts of helping and hurting others: Lessons about the development of moral agency. Child Development, 86, 864–876. https://doi.org/10.1111/cdev.12349
Rohlf, V., & Bennett, P. (2005). Perpetration-induced traumatic stress in persons who euthanize nonhuman animals in surgeries, animal shelters, and laboratories. Society & Animals, 13, 201–220. https://doi.org/10.1163/1568530054927753
Ross, J., Armour, C., Kerig, P. K., Kidwell, M. C., & Kilshaw, R. E. (2020). A network analysis of posttraumatic stress disorder and dissociation in trauma-exposed adolescents. Journal of Anxiety Disorders, 72, 1–9. https://doi.org/10.1016/j.janxdis.2020.102222
Saltzman, W. R., Layne, C. M., Pynoos, R. S., Olafson, E., Kaplow, J. B., & Boat, B. (2018). Trauma and grief component therapy for adolescents: A modular approach to treating traumatized and bereaved youth. Cambridge University Press.
Shay, J. (1991). Learning about combat stress from Homer’s Iliad. Journal of Traumatic Stress, 4, 561–579. https://doi.org/10.1007/BF00974590
Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31, 182–191. https://doi.org/10.1037/a0036090
Sherman, L. J., Rice, K., & Cassidy, J. (2015). Infant capacities related to building internal working models of attachment figures: A theoretical and empirical review. Developmental Review, 37, 109–141. https://doi.org/10.1016/j.dr.2015.06.001
Smith, C. P., & Freyd, J. J. (2013). Dangerous safe havens: Institutional betrayal exacerbates sexual trauma. Journal of Traumatic Stress, 26, 119–124. https://doi.org/10.1002/jts.21778
Smith, C. P., & Freyd, J. J. (2014). Institutional betrayal. American Psychologist, 69, 575–584. https://doi.org/10.1037/a0037564
Smith, C. P., & Freyd, J. J. (2017). Insult, then injury: Interpersonal and institutional betrayal linked to health and dissociation. Journal of Aggression, Maltreatment, & Trauma, 26, 1117–1131. https://doi.org/10.1080/10926771.2017.1322654
Spinazzola, J., Ford, J. D., Zucker, M., van der Kolk, B. A., Silva, S., Smith, S. F., & Blaustein, M. (2005). Survey evaluates complex trauma exposure, outcome, and intervention among children and adolescents. Psychiatric Annals, 35, 433–439.
Spinazzola, J., van der Kolk, B., & Ford, J. D. (2018). When nowhere is safe: Interpersonal trauma and attachment adversity as antecedents of posttraumatic stress disorder and developmental trauma disorder. Journal of Traumatic Stress, 31, 631–642. https://doi.org/10.1002/jts.22320
Spinazzola, J., van der Kolk, B., & Ford, J. D. (2021). Developmental trauma disorder: A legacy of attachment trauma in victimized children. Journal of Traumatic Stress, Advance online publication. 0.1002/jts.22697
Steinmetz, S. E., Gray, M. J., & Clapp, J. D. (2019). Development and evaluation of the perpetration-induced distress scale for measuring shame and guilt in civilian populations. Journal of Traumatic Stress, 32, 437–447. https://doi.org/10.1002/jts.22377
Sterzing, P. R., Auslander, W. F., Ratliff, G. A., Gerke, D. R., Edmond, T., & Jonson-Reid, M. (2020). Exploring bullying perpetration and victimization among adolescent girls in the chid welfare system: Bully-only, victim-only, bully-victim, and noninvolved roles. Journal of Interpersonal Violence, 35, 1311–1333. https://doi.org/10.1177/0886260517696864
Steuwe, C., Lanius, R. A., & Frewen, P. A. (2012). Evidence for a dissociative subtype of PTSD by latent profile and confirmatory factor analyses in a civilian sample. Depression and Anxiety, 29, 689–700. https://doi.org/10.1002/da.21944
Sun, D., Phillips, R. D., Mulready, H. L., Zablonski, S. T., Turner, J. A., Turner, M. D., & Morey, R. A. (2019). Resting-state brain fluctuation and functional connectivity dissociate moral injury from posttraumatic stress disorder. Depression and Anxiety, 36, 442–452. https://doi.org/10.1002/da.22883
Thompson, R. A. (2012). Wither the preconventional child? Toward a life-span moral development theory. Child Development Perspectives, 6, 423–429. https://doi.org/10.1111/j.1750-8606.2012.00245.x
Tracy, J. L., Robins, R. W., & Tangney, J. P. (Eds.). (2007). The self-conscious emotions: Theory and research. Guilford Press.
Van Damme, E. (2017). Mareros and pandilleros in Honduras: The reintegration of youth gang members. In Viano, E. (Ed.), Cybercrime, organized crime, and societal responses. London, UK: Springer International Publishing.
van der Kolk, B., Ford, J. D., & Spinazzola, J. (2019). Comorbidity of developmental trauma disorder (DTD) and post-traumatic stress disorder: Findings from the DTD field trial. European Journal of Psychotraumatology, 10, 1562841.
van der Kolk, B. A. (2005). Developmental trauma disorder: Toward a rationale diagnosis for children with complex trauma histories. Psychiatric Annals, 35, 401–408. https://doi.org/10.4324/9781315678610-42
Vindevogel, S., Coppens, K., Derluyn, I., de Schryver, M., Loots, G., & Broekaert, E. (2011). Forced conscription of children during armed conflict: Experiences of former child soldiers in northern Uganda. Child Abuse & Neglect, 35, 551–562. https://doi.org/10.1016/j.chiabu.2011.03.011
Waelde, L. C., Silvern, L., & Fairbank, J. A. (2005). A taxometric investigation of dissociation in vietnam veterans. Journal of Traumatic Stress, 18, 359–369. https://doi.org/10.1002/jts.20034
Wainryb, C. (2011). ‘And so they ordered me to kill a person’: Conceptualizing the impacts of child soldiering on the development of moral agency. Human Development, 54, 273–300. https://doi.org/10.1159/000331482
Wainryb, C. (2006). Moral development in culture: Diversity, tolerance, and justice. In M. Killen & J. Smetana (Eds.), Handbook of moral development (2nd ed., pp. 211–240). Taylor and Francis.
Wainryb, C., Brehl, B., & Matwin, S. (2005). Being hurt and hurting others: Children’s narrative accounts and moral judgments of their own interpersonal conflicts. Monographs of the Society for Research in Child Development, 70 (Serial No. 281).
Wainryb, C., & Pasupathi, M. (2010). Political violence and disruptions in the development of moral agency. Child Development Perspectives, 4, 48–54. https://doi.org/10.1111/j.1750-8606.2009.00117.x
Wainryb, C., & Pasupathi, M. (2015). Saints, and the rest of us: Broadening the perspective on moral identity development. Human Development, 58, 154–163. https://doi.org/10.1159/000437174
Weierstall, R., Schalinski, I., Crombach, A., Hecker, T., & Elbert, T. (2012). When combat prevents PTSD symptoms—results from a survey with former child soldiers in Northern Uganda. BMC Psychiatry, 12, 1–8. https://doi.org/10.1186/1471-244X-12-41
Weinfield, N. S., Sroufe, L. A., Egeland, B., & Carlson, E. (2008). The nature of individual differences in infant-caregiver attachment. In J. Cassidy & R. P. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (2nd ed.). New York, NY: Guilford.
Whiting, T. L., & Marion, C. R. (2011). Perpetration-induced traumatic stress – a risk for veterinarians involved in the destruction of healthy animals. The Canadian Veterinary Journal, 52, 794–796.
Williamson, V., Stevelink, S. A. M., & Greenberg, N. (2018). Occupational moral injury and mental health: Systematic review and meta-analysis. The British Journal of Psychiatry, 212, 339–346. https://doi.org/10.1192/bjp.2018.55
Wilson, H. W., Samuelson, S. L., Staudenmeyer, A. H., & Widom, C. S. (2015). Trajectories of psychopathology and risky behaviors associated with childhood abuse and neglect in low-income urban African American girls. Child Abuse & Neglect, 45, 108–121. https://doi.org/10.1016/j.chiabu.2015.02.009
Wisco, B. E., Marx, B. P., May, C. L., Martini, B., Krystal, J. H., Southwick, S. M., & Pietrzak, R. H. (2017). Moral injury in U.S. combat veterans: Results from the national health and resilience in veterans study. Depression and Anxiety, 34, 340–347. https://doi.org/10.1002/da.22614
Wolf, E. J., Lunney, C. A., Miller, M. W., Resick, P. A., Friedman, M. J., & Schnurr, P. P. (2012a). The dissociative subtype of PTSD: A replication and extension. Depression and Anxiety, 29, 679–688. https://doi.org/10.1002/da.21946
Wolf, E. J., Miller, M. W., Reardon, A. F., Ryabchenko, K. A., Castillo, D., & Freund, R. (2012b). A latent class analysis of dissociation and PTSD: Evidence for a dissociative subtype. Archives of General Psychiatry, 69, 698–705.
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Kidwell, M.C., Kerig, P.K. To Trust is to Survive: Toward a Developmental Model of Moral Injury. Journ Child Adol Trauma 16, 459–475 (2023). https://doi.org/10.1007/s40653-021-00399-1
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DOI: https://doi.org/10.1007/s40653-021-00399-1