Understanding the relationship between child maltreatment experiences and personality disorders in emerging adulthood among females who transitioned out of residential care
Masterthesis Forensic Child and Youth Care Sciences
Graduate School of Child Development and Education
University of Amsterdam
F. Scheffers 10744339
University of Amsterdam (Amsterdam, The Netherlands)
University of Sherbrooke (Montréal, Canada)
First supervisor: Dr. E.S. van Vugt
Second supervisor: Dr. N. Lanctôt
Table of contents Abstract 3 Introduction 4 Method 9 Results 13 Discussion 21 References 27 Appendix A 37
Abstract
In this study the association between child maltreatment and personality disorders has been studied in 125 females who transitioned out of residential care. The Child Trauma Questionnaire and official reports of the Child Protection services were used for the measurement of
maltreatment. Personality disorders were measured using the Personality Diagnostic
Questionnaire 4+. Hierarchical linear regressions showed that mainly self- reported types of maltreatment were associated with personality disorders. The majority and strongest
associations have been found between self- reported emotional abuse and personality disorders. Emotional abuse was significantly related to the Paranoid, Avoidant, Dependent, Passive Aggressive and Depressive personality disorders. In research and clinical practice more attention should be devoted to emotional abuse.
Understanding the relationship between child maltreatment experiences and personality disorders in emerging adulthood among females who transitioned out of residential care
Personality is defined as a psychological system consisting of various components that interact, develop over time, and influence an individual’s behavior (Mayer, 2007). Findings from twin- studies show that half of the variance in personality is attributed to genetics while the other half is explained by environmental factors, including parenting skills (Bouchard & Loehlin, 2001; Krueger, South, Johnson, & Iacono, 2008; Plomin & Caspi, 1999; Torgersen et al., 2000). Parenting practices have a great influence on the individual variation in the behavioral patterns that constitute personality (Krueger, South, Johnson, & Iacono, 2008). The development of the child can both be stimulated and harmed through the actions of the parent (Bornstein, 2011; Stormshak, Bierman, McMahon, & Lengua, 2000). Child maltreatment is an example of how parenting behavior can harm the development of the child (Belsky & Jaffee, 2006; Hankin, 2005). The definition of child maltreatment has been subjected to change over time by developments in society as well as the state of knowledge regarding the negative effects on individuals (Cichetti & Manly, 2001). Article 19 of the Convention on the Rights of the Child of the United Nations describes that all State Parties should take all appropriate legislative, administrative, social and educational measures to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse (Unicef, 1989). To date, the following forms of child maltreatment have been identified: emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect (Lobbestael, Arntz, & Bernstein, 2010).
Different methods are used to obtain information about child maltreatment. Two commonly used methods are official reports and self- reports. Official reports refer to the use of information
obtained by official institutions such as Child Protection Services; these reports can either be substantiated or unsubstantiated. Self- reports refer to the retrospective reports conducted with adolescents or adults about the occurrence of maltreatment during childhood. A discrepancy is found between the prevalence numbers on child maltreatment according to official reports and self- reports. Self- reports show a higher prevalence of maltreatment in comparison to official reports (Brown, Cohen, Johnson, & Salzinger, 1998; Gilbert, Widom, Browne, Fergusson, Webb, & Janson, 2009). In addition, the discrepancies found between official and self- reports are dependent of the specific type of maltreatment examined. For instance, the examination of acts of commissions such as physical and sexual abuse, often leaving physical marks, tend to be more equally reported in both official and self- reports than acts of omission such as neglect or emotional abuse (Hambrick, Tunno, Gabrielli, Jackson, & Belz, 2014; McGee, Wolfe, Yuen, Wilson, & Carnochan, 1995; Pinto & Maia, 2013).
The prevalence numbers on childhood maltreatment not only differ according to the use of a specific method or type of child maltreatment examined, but also differ among certain populations. In non-clinical populations self-reported child maltreatment experiences vary from 4 to 28% with the largest percentages found among females (Gilbert et al., 2009; Hussey, Chang, & Kotch, 2006; May- Chahal, & Cawson, 2005). Studies on the prevalence rates of child abuse in residential care among female adolescents appear to show higher prevalence rates compared to studies regarding non- clinical populations, ranging from 58 to 98% in residential care (Collin-Vézina, Coleman, Milne, Sell, & Daigneault, 2011). Within residential care female adolescents show significant higher prevalence rates regarding maltreatment in comparison to male adolescents. Prevalence rates vary from 60 to 80% in female adolescents in residential care according to self- reports, in comparison to approximately 40% of male adolescents in residential
care (Belknap & Holsinger, 2006; Connor, Doerfler, Toscano Jr, Volungis, & Steingard, 2004; Spertus, Yehuda, Wong, Halligan, & Seremetis, 2003). Approximately 60% of females in a clinical setting have experienced emotional abuse or neglect according to self- reports (Spertus, Yehuda, Wong, Halligan, & Seremetis, 2003). The high prevalence of maltreatment in female adolescents in residential care highlights the vulnerability of this specific group.
Several studies have found a link between child maltreatment and mental health problems during adolescence and adulthood (Briere & Elliott, 2003; Higgins & McCabe, 2001; Lansford, Dodge, Pettit, Bates, Crozier & Kaplow, 2002; Van Vugt, Lanctôt, Paquette, Collin- Vézina, & Lemieux, 2014). Considering the high prevalence of maltreatment of female adolescents in residential care, this subgroup is assumed to be especially at risk of developing mental health problems. The development of a personality disorder is a possible mental health problem following childhood adversity (Johnson, Smailes, Cohen, Brown, & Bernstein, 2000; Lobbestael, Arntz, & Bernstein, 2010; Tyrka, Wyche, Kelly, Price, & Carpenter, 2009; Waxman, Fenton, Skodol, Grant, & Hasin, 2014). A broad range of personality disorders has been identified, and based on their similarities have been fitted in three different clusters (American Psychiatric Association, 2013). Cluster A consists of the Paranoid, Schizoid and Schizotypal disorders. Individuals with a cluster A personality disorder are referred to as odd or eccentric. Cluster B includes the Antisocial, Borderline, Histrionic and Narcissistic borderline personality disorders. Characteristics of individuals with cluster B personality disorders are overemotionality and theatricality. Finally, cluster C consists of the avoidant, dependent and obsessive- compulsive personality disorders. Individuals with a personality disorder within cluster C generally appear to be frightful and anxious. In the appendix of the DSM-IV-TR the Passive Aggressive and Depressive personality disorders have been added (American Pyschiatric Association, 2000). The definition of a Passive
Aggressive personality disorder is a behavioral pattern of negative attitudes and passive resistance to requirements for adequate performance. The Depressive personality disorder is described as a pattern of depressive cognitions and behaviors (American Psychiatric Association, 2000).
The prevalence of personality disorders varies from 9 to 14% in community samples (Lenzenweger, 2008; Samuels et al., 2002; Torgersen, Kringlen, & Cramer, 2001), and up to 60% in clinical samples (Lobbestael, Arntz, & Bernstein, 2010). Females are prone to develop different personality disorders in comparison to males. For instance, males are more likely to develop Antisocial, Narcissistic, Schizotypal, Passive Aggressive or Obsessive- Compulsive personality disorders than females (Cale & Lilienfeld, 2002; Torgersen, Kringlen, & Cramer, 2001; Waxman, Fenton, Skodol, Grant, & Hasin, 2014). Complications experienced as a result of these disorders are delusions as well as problems with the conformity to social norms and values. The Avoidant, Borderline, Dependent, Paranoid and Depressive personality disorders, on the other hand, are more prevalent in females than in males (Grant, Hasin, Stinson, Dawson, Chou, Ruan, & Pickering, 2004; Torgersen, Kringlen & Cramer, 2001; Waxman, Fenton, Skodol, Grant, & Hasin, 2014). Difficulties experienced by individuals with an Avoidant, Borderline, Dependent, Paranoid or Depressive personality disorders tend to center around relationships, and are more common in women.
Women show a focus on relationships in different skills throughout the entire life- course (Alimo-Metcalfe, 2010; Rose & Rudolph, 2006). The study of Wilson, Pritchard, and Revalee (2005) has shown that females use a wide range of coping strategies. However a relational orientation style is found to be more characteristic for females than males (Rose & Asher, 2004; Strough & Berg, 2000). When given a task young females use strategies that involve the social network, such as seeking for support (Rose & Asher, 2004). When discussing a conflict females
use more communicative tools that are characterized by collaboration and mutual participation. Since females appear to be more focused on relationships with others, females are expected to be more vulnerable to the effects of maltreatment. More precisely, it is expected that females are specifically affected by emotional abuse since this type of maltreatment impacts the manner in which the child constitutes relationships with others (Dance, Rushton, & Quinton, 2002). The child develops a poor self- image through emotional abuse and immature defense mechanisms which cause the child to start a pattern of destructive and instable relationships (Finzi- Dottan, & Karu, 2006). The experience of emotional abuse is expected to make females more vulnerable to the development of a personality disorders characterized by emotional problems with others such as the avoidant, borderline, dependent, paranoid or depressive personality disorder.
Considering the high prevalence rates of child maltreatment among female adolescents in residential care, it is important to gain more insight in the association between child maltreatment and personality disorders in females. More information about the specific association between maltreatment and personality disorders is needed so clinicians will be better equipped to respond to the specific needs of female adolescents in residential care. Significantly more attention is devoted to sexual and physical abuse in clinical practice (Gilbert, Widom, Browne, Fergusson, Webb, & Janson, 2009; Rees, 2010; Trickett, Mennen, Kim, & Sang, 2009). In addition research has mainly focused on physical and sexual abuse while the effects of these forms of abuse were expected to be more detrimental than emotional abuse (Glaser, 2002; Kaplan, Pelcovitz, & Labruna, 1999). There is a need for more research regarding the specific types of maltreatment to show which specific form of maltreatment has the greatest impact on personality disorders. Current study
The present study seeks to understand the differential relationships between specific types of maltreatment and personality disorders in young adult females who have transitioned out of residential care. Apart from the association between maltreatment and personality disorders, the use of different methods for measuring maltreatment are compared including official and self- reports on child maltreatment. The objectives of the current study are (1) to establish an overview of the different forms of childhood maltreatment in young adult females in residential care; (2) to establish an overview of the different personality disorders in young adult females in residential care; (3) to assess the strength of the differential relations between childhood maltreatment and personality disorders.
Method Participants
In 2007- 2008 a longitudinal study was carried out among 182 female adolescents placed in residential care in Montreal, the longitudinal study concerned an impact study regarding treatment in residential care. The present study is part of this large longitudinal study. The adolescent females who were admitted to the youth center were placed for a minimum of three months and for an average period of six months. The majority of the adolescent females were placed in residential care because of severe behavioral problems compromising their security and development. The total data collection consisted out of six data collection waves, covering the period from mid- adolescence to emerging adulthood. The present study was based on data from the sixth data wave only and derived from 125 young adult females. The participants from wave six were all out of care at the time of the study. The average age of the young female adults was M = 19.41 (SD = .13), and varied from 15.5 to 22.08.
The data collection procedure was approved by the institutional review board of the University of Sherbrooke (Canada). The participants consented to participate at each wave of the data collection. After obtaining the consent, an interviewer administered the questionnaire individually. The interviewer was available to assist the young female adults in completing the questionnaire. The interviewers consisted of university students who were trained in research ethics and techniques. Filling out the questionnaires took approximately 90 minutes.
Instruments
Official reports. A history of child maltreatment was based on the substantiated reports by the Child Protection Services, Quebec, Canada. The reports cover the period up to the
admission to residential care and were collected retrospectively. Four different categories of maltreatment are included: emotional, physical and sexual abuse and neglect.
Childhood maltreatment. Childhood maltreatment was measured using the Childhood Trauma Questionnaire (CTQ). The CTQ is a retrospective self- report instrument containing 28 items (Bernstein & Fink, 1998). The CTQ measures the severity of five types of maltreatment respectively emotional, physical and sexual abuse and emotional and physical neglect. The items of each scale were summed so that higher scores represented higher levels of childhood
maltreatment- related symptoms. An example of emotional abuse is: “People in my family said hurtful or insulting things to me”. The scale physical abuse consists of items such as: “I was punished with a belt, a board, a cord or some other hard object”. An example of sexual abuse is: “Someone tried to make me do sexual things or watch sexual things”. Examples for emotional and physical neglect are “I felt loved” and “I did not have enough to eat”. Each scale consists of five items and was rated on a 5- point Likert scale ranging from “never true” to “very often true”. The reliability and validity of the CTQ has been proven in different studies, with both clinical
and community samples (Bernstein, Ahluvalia, Pogge, & Handelsman, 1997; Paivio & Cramer, 2004). The Cronbach’s alphas of the various child maltreatment scales for this sample ranged from .764 to .946.
Personality Disorder. Personality Disorders were assessed using the Personality Diagnostic Questionnaire 4+ (PDQ4+). A description of the different personality disorders can be found in Table 1. The PDQ4+ is a questionnaire containing 99 questions. For the analyses a sum of the scores was computed, a higher score on this scale implies a higher severity of symptoms of a specific personality disorder. An example of a question is: `I know that people will take advantage of me or cheat me if I let them`. For the current study an extra response option was added to the continuous scale to increase variance, respectively the participant could choose from the following options `often true`, `sometimes true` or `false`. The Cronbach’s alphas of the various personality disorder scales for this sample ranged from .538 to .795 The Schizotypal and Obsessive Compulsive scales were not included in this study because of the low Cronbach’s alphas, when these scales were excluded the Cronbach’s alphas ranged from .641 to .795. The psychometric properties of the PDQ4+ are sufficient for both continuous and dichotomous response formats (Davison, Leese, & Taylor, 2001; Fonseca-Pedrero, Paino, Lemos- Giráldez, & Muñiz, 2013; Huang, Ling, Yang, & Dou, 2007).
Table 1
Description of the different personality disorders. Personality disorder Description
Paranoid A pattern of distrust and suspiciousness such that others’ motives are interpreted as malevolent.
Schizoid A pattern of detachment from social relationships and a restricted range of emotional expression.
Schizotypal* A pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities in behavior.
Antisocial A pattern of disregard for and violation of the rights of others. Borderline A pattern of instability in interpersonal relationships, self-
image, and affects, and marked impulsivity
Histrionic A pattern of excessive emotionality and attention seeking. Narcissistic A pattern of grandiosity, need for admiration, and a lack of
empathy.
Avoidant A pattern of social inhibition, feelings of inadequacy, and a hypersensitivity to negative evaluation.
Dependent A pattern of submissive and clinging behavior related to an excessive need to be taken care of.
OCD* A pattern of preoccupation with orderliness, and control. Passive Aggressive A pattern of passive resistance for adequate social and
occupational achievements.
Depressive A pattern of negativistic and pessimistic beliefs about oneself and others.
* The cronbach alpha’s of these scales were too small and therefore excluded from the study. (American Psychiatric Association, 2013)
Analyses
The data contained missing values, because of these missing values 9 cases were excluded from the sample. Different statistical analyses were conducted using SPSS statistics version 20. Descriptive analyses were conducted for the personality disorders, and self- and official reports of child maltreatment. For the descriptive analysis of the personality disorders a categorical scale was used. A categorical scale of the PDQ4+ was constructed for the descriptive analysis, consisting of
three categories. The category ‘None’ meant the participant had a score of 0 on this scale. The category ‘Minimal to Moderate’ referred to a score from 0 to 1, finally the category ‘Moderate to Severe’ referred to a score from 1 to 2. Regarding the descriptive analyses of child maltreatment categorical scales for the self- reports and dichotomous scales for the official reports were used. The correlational analyses were executed using the continuous scale of personality disorders, the continuous scale of self- reported child maltreatment and a dichotomous scale for the official reports. For the hierarchical regression analyses, the dichotomous scales were used for the self- reports and official reports of child maltreatment. The following variables were controlled for: age and group evaluation. The variable group evaluation regards a difference in conditions. The data from the longitudinal study concerned the effect of a specific treatment; in different conditions a group evaluation was used. In the current study the group evaluation was not used, therefore in this study the variable group evaluation was controlled for.
Prevalence of the different types of maltreatment according to official and self- reports.
Table 2 presents the results on maltreatment according to the results of the official reports. Emotional abuse was the least prevalent, in 11.2% of the participants emotional abuse was present according to official reports. Physical abuse was prevalent in 24.8% of the participants in this sample. Sexual abuse has occurred in 16% of the participants according to official reports. Neglect was the most prevalent type of maltreatment, in 52% of the participants neglect was present according to the official reports.
In Table 3 the prevalence of maltreatment according to the retrospective self- reports is described, five categories were used. The categories vary according to the severity of the symptoms, starting from the least severe symptoms to the most extreme symptoms. The category ‘none to minimal’, indicates that about 60% of females reported little or no symptoms of sexual
and physical abuse. Within the category ‘low to moderate’ emotional neglect was the most prevalent. Thirty-four point four percent of the young female adults reported low to moderate symptoms of emotional neglect. Physical neglect was the most prevalent within the category ‘moderate to severe’, with 16.8% of the participants experiencing moderate to severe symptoms of physical neglect. Emotional abuse was the most prevalent in the category ‘severe to extreme’, 31.2 % of the participants experienced severe to extreme symptoms of emotional abuse.
Table 2
Prevalence of maltreatment measured using official reports expressed in percentages (N= 125)
No Yes Emotional Abuse 88.8 11.2 Physical Abuse 75.2 24.8 Sexual Abuse 84.0 16.0 Neglect 48.0 52.0 Table 3
Prevalence of maltreatment measured using self- reports expressed in percentages (N= 125)
None to Minimal Low to Moderate Moderate to Severe Severe to Extreme
Emotional Abuse 45.6 17.6 5.6 31.2
Physical Abuse 64.8 8.8 4.0 22.4
Sexual Abuse 64.0 7.2 7.2 21.6
Emotional Neglect 29.6 34.4 9.6 26.4
Physical Neglect 46.4 11.2 16.8 25.6
Prevalence of the different personality disorders in terms of severity.
Table 4 shows the results on the prevalence of personality disorders, categorized in the clusters A, B, C and Other. Three categories were used to describe the severity of the symptoms of the personality disorders: ‘none’, ‘minimal to moderate’ and ‘moderate to severe’. The Avoidant, Dependent and Passive Aggressive personality disorder were the least prevalent within
this sample. In all of the clusters the majority of the participants reported symptoms within the minimal to moderate category, ranging from 66.4 to 97.6%. In the category `moderate to severe` the Paranoid, Borderline, and Depressive personality disorders were the most prevalent. Remarkably, all of the personality disorders were prevalent within young female adults in residential care.
The high prevalence of the personality disorders was further explored by a correlation analysis, which can be found in Appendix A. The majority of the personality disorders were significantly interrelated with correlations ranging from r = 0.202 to r = 0.707. Exceptions were found for the associations between the Narcissistic, Avoidant, and Depressive disorder and the Antisocial personality disorder, these associations were not significantly correlated. The Antisocial personality disorder had the least strong correlations with the other personality disorders.
Table 4
Prevalence of personality disorders in terms of severity expressed in percentages (N= 125)
Cluster Type None Minimal to Moderate Moderate to Severe
A Paranoid 3.2 66.4 30.4 Schizotypal 9.6 84.8 5.6 B Histrionic 6.4 86.4 7.2 Narcissistic 4.8 90.4 4.8 Borderline 1.6 87.2 11.2 Antisocial 0.8 97.6 1.6 C Avoidant 12.8 76.0 11.2 Dependent 25.6 68.0 6.4
Other Passive Agressive 16.8 76.0 7.2
Depressive 8.8 68.8 22.4
The strength of the differential relations between maltreatment and personality disorders. In Table 5 the Pearson r correlations are presented between the different forms of maltreatment, and the official reports and self- reports successively. No significant relations were found between officially reported child maltreatment and personality disorders. The majority of the personality disorders were significantly correlated to self-reported emotional abuse. The strongest associations between maltreatment and personality disorders have been found within emotional abuse and emotional neglect. For self- reported emotional abuse the strongest associations were found with the Avoidant r= .368, Dependent r =.351 and Depressive r = .425 personality disorders. Within emotional neglect the strongest associations were found in the Borderline r= 0.352 and Depressive r = .313 personality disorders.
Table 5
Correlations between personality disorders and maltreatment, official reports versus self- reports (N= 125)
* p < .05, **p < .01, ***p < .001 (two- tailed)
Official Report (dichotomous scale) Self- Report (continuous scale) Emotional Abuse Physical Abuse Sexual Abuse Neglect Emotional Abuse Physical Abuse Sexual Abuse Emotional Neglect Physical Neglect Paranoid 0.048 0.058 0.030 -0.049 0.303** 0.199* 0.220* 0.098 0.200* Schizotypal -0.060 0.098 0.084 -0.067 0.222* 0.124 0.195* 0.117 0.218* Histrionic 0.029 0.024 0.054 -0.108 0.226* 0.074 0.201* 0.155 0.100 Narcissistic -0.040 0.054 -0.009 -0.022 0.127 0.091 0.075 0.051 0.049 Borderline 0.055 -0.053 -0.165 -0.087 0.243** 0.084 0.131 0.352*** 0.195* Antisocial -0.045 -0.059 -0.068 0.010 0.085 -0.005 0.170 0.134 0.080 Avoidant 0.008 0.012 0.040 0.093 0.368*** 0.214* 0.197* 0.218* 0.250** Dependent -0.059 -0.051 -0.011 -0.090 0.351*** 0.109 0.254** 0.296** 0.242** Passive Aggressive Depressive -0.019 0.036 0.003 0.015 -0.053 0.055 -0.002 -0.048 0.269** 0.425*** 0.071 0.199* 0.067 0.255** 0.210* 0.313*** 0.160 0.257**
Table 6 shows the results on the hierarchical regression analysis. A test for multicollinearity showed that the level of multicollinearity was not problematic, a problematic level of multicollinearity is shown through VIF values higher than 4 and a tolerance under 0.25 (O’Brien, 2007). In this study the highest VIF value is found for self- reported emotional abuse, a VIF of 3.068 and a tolerance of 0.326.
For the first step two control variables were entered: age and treatment group. This model was not statistically significant for any of the personality disorders.
In step 2 the official reports of child maltreatment were included. One significant association was found, a negative association between sexual abuse and the Borderline personality disorder (β = -.235, p < .05). When Child Protection services reported higher levels of sexual abuse in young female adolescents, these women also reported lower levels of Borderline personality disorder traits upon exiting residential care.
In the final step the self- reported child maltreatment was added to the model. Emotional abuse was significantly associated to the Paranoid, Avoidant, Dependent, Passive Aggressive and the Depressive personality disorder. Participants who reported more serious levels of emotional abuse also successively reported more severe traits of the Paranoid personality disorder (β = .368, p < .05), the Dependent personality disorder (β = .315, p < .05) the Passive Aggressive personality disorder (β = .351, p < .05), and the Depressive personality disorder (β = .471, p < .01). Physical abuse was significantly associated to the Dependent personality disorder (β = -.258, p < .05), indicating that higher levels of physical abuse were associated with higher scores on the Dependent personality disorder. Sexual abuse was significantly associated with the Antisocial personality disorder (β = .272, p < .05). Young female adults who reported high scores on sexual abuse also reported high scores on the Antisocial personality disorder. According to the self- reports
emotional neglect was significantly related to Borderline (β = .436, p < .001). Physical neglect was not significantly associated to any of the personality disorders.
The R change in Table 6 expresses the percentage of explained variance of a specific model. In the models with the results on the official reports none of the R changes were significant, this means that in none of the personality disorders the use of any official reports adds any significant proportion of explained variance. For the self- reports significant associations were found for the following personality disorders: Paranoid, Borderline, Avoidant, Dependent, Passive Aggressive and Depressive. Especially the results regarding emotional abuse seem to contribute to the high percentages of the explained variances of self- reported maltreatment.
Table 6
Hierarchical Lineair Regression (N= 125)
* p < .05, **p < .01, ***p < .001 step 1 contains the control variables
step 2 contains the forms of maltreatment measured using the official reports
step 3 contains the forms of maltreatment measured using the retrospective self- reports Paranoid Schizotypal Histrionic Narcissistic Borderline Anti
Social
Avoidant Dependent Passive Aggressive Depressive Step 1 Age 0.043 -0.003 -0.075 -0.012 -0.084 0.024 0.027 -0.148 -0.088 0.070 Group -0.034 0.006 -0.166 -0.168 -0.031 0.057 0.002 -0.070 0.077 0.088 Step 2 Emotional abuse 0.014 -0.075 0.033 -0.058 -0.029 -0.091 -0.094 -0.131 -0.105 -0.048 Physical abuse 0.014 0.108 0.023 0.003 -0.028 -0.054 -0.043 -0.030 0.042 0.005 Sexual abuse 0.008 0.040 0.020 -0.030 -0.235* -0.145 0.008 -0.095 -0.066 0.016 Neglect -0.083 -0.103 -0.104 0.016 -0.085 -0.003 0.088 -0.079 -0.016 -0.097 R change(step1-2) 01.10 02.50 01.20 00.20 03.80 01.10 01.00 00.80 00.50 01.20 Step 3 Emotional abuse 0.368* 0.200 0.273 0.187 0.038 -0.049 0.411** 0.315* 0.351* 0.471** Physical abuse -0.051 -0.136 -0.235 -0.011 -0.118 -0.134 0.005 -0.258* -0.135 -0.133 Sexual abuse 0.078 0.108 0.192 0.023 0.144 0.272* -0.015 0.211 -0.067 0.065 Emotional neglect -0.250 -0.138 0.055 -0.047 0.436** 0.186 -0.061 0.178 0.129 0.089 Physical neglect 0.148 0.228 -0.066 -0.016 -0.098 -0.025 0.041 -0.010 -0.063 -0.059 R change(step 2-3) 11.60* 08.10 08.70 02.30 16.10** 06.90 14.00** 19.20*** 09.70* 19.40***
Discussion
The aim of the present study was to explore the association between child maltreatment and personality disorders in young adult females who transitioned out of residential care. To gain insight in the association between childhood maltreatment and personality disorders, four objectives were studied. The first objective was to establish an overview of the different forms of childhood maltreatment in young adult females in residential care. All forms of maltreatment were prevalent according to the official and self- reports, the prevalence numbers of the specific types of maltreatment varied depending on the method used. The second objective of this study was to establish an overview of the different personality disorders in young female adults in residential care. All personality disorders were highly prevalent in adolescent females in residential care. Finally, the strength of the differential relations between childhood maltreatment and personality disorders were assessed. In the majority of young female adults in residential care associations were found between self- reported measures of maltreatment and personality disorders. Of the different types of maltreatment measured by self- reports, self- reported emotional abuse seemed to add the highest contribution to the explained variance by self- reported maltreatment.
The overview of the different forms of childhood maltreatment showed a discrepancy when comparing the results of official versus self- reports. Official reports showed lower percentages in comparison to self- reports regarding emotional, physical and sexual abuse. According to the official reports approximately the half of the participants had experienced maltreatment. While the self- reports showed that up to three- quarters of all participants experienced maltreatment. This is in accordance with previous research showing that self- reported measurements of maltreatment show higher prevalence numbers in contrast to official reports (Brown, Cohen, Johnson, & Salzinger, 1998; Gilbert, Widom, Browne, Fergusson, Webb, & Janson, 2009). A difference
between official and self- reports of emotional abuse was expected while emotional abuse does not show clear physical marks and is less visible (McGee, Wolfe, Yuen, Wilson, & Carnochan, 1995; Pinto & Maia, 2013). In addition, emotional abuse is viewed as less harmful in society which can explain why practitioners are less focused on emotional abuse in comparison to physical and sexual abuse (Hamarman, Pope, & Czaja, 2002). The current study shows that not only emotional abuse is underreported in official reports but also physical and sexual abuse and neglect. A possible explanation for this discrepancy comes from the perspective of the construction of the official reports. The official reports were based on substantiated reports from Child Protection Services which means that these reports were based on sufficient evidence to provide a case in court. With regard to efficiency there is a tendency to choose one type of maltreatment to build a case which leads to the underestimation of the various types of childhood maltreatment (Finkelhor, Omrod, & Turner, 2007).
All personality disorders are highly prevalent in young adult females with residential care experiences. With regard to the highly severe symptoms of personality disorders the Avoidant, Borderline, Paranoid and Depressive personality disorders were most prevalent in young female adults in residential care and occurred in up to three out of ten participants. This is in accordance with the literature, young female adolescents in residential care are more prone to develop personality disorders characterized by relational aspects (Grant, Hasin, Stinson, Dawson, Chou, Ruan, & Pickering, 2004; Torgersen, Kringlen & Cramer, 2001; Waxman, Fenton, Skodol, Grant & Hasin, 2014).
When exploring the association between childhood maltreatment and personality disorders it shows that the majority of associations have been found between self- reported emotional abuse and personality disorders, over and above official reports of child maltreatment. Emotional abuse
was significantly associated with higher levels of the Paranoid, Avoidant, Dependent, Passive Aggressive and the Depressive personality disorder. Emotional abuse teaches the child that other individuals are not to be trusted, affecting the child’s mental representations of the world. As a result the child develops a pattern of dysfunctional relationships (Riggs, 2010). Through this pattern of dysfunctional relationships the child or adolescent develops inappropriate socio- emotional skills, low self- esteem and immature defense mechanisms (Dimaggio, Nicolò, Popolo, Semerari, & Carcione, 2006; Muralidharan, Sheets, Madsen, Craighead, & Craighead, 2011; Finzi-Dottan, R., & Karu, 2006). The current study shows that emotional abuse leads to the development of a disruptive behavioral pattern regarding the way in which a person constitutes relationships, either unhealthy in the sense of extreme dependency or paranoia towards others and complete isolation from social activities.
Physical abuse measured by self- reports was negatively related to the Dependent personality disorder. Possibly, physically abused children may withdraw from the social context while the child is not able to trust the surrounding environment. Children who are physically abused cope with the abuse by minimalizing their contact with the social environment and thus become more independent and less likely to for instance develop a Dependent personality disorder (Elliott, Cunningham, Linder, Colangelo, & Gross, 2005). Sexual abuse measured by self- reports was positively associated to the Antisocial personality disorder. Through sexual abuse the mental representation of the adolescent gets altered in a way that the adolescent learns to normalize the violation of the rights of others which could create a cycle of violence (Christopher, Lutz- Zois, & Reinhardt, 2007; Noll, 2005). The child will not learn to respect the rights of other persons and becomes vulnerable to the development of the Antisocial personality disorder (Bierer et al., 2003). Different studies have found a reversed link between antisocial behaviour and sexual abuse,
childhood antisocial behavior is associated to early sexual activity and risky sexual behavior (Ramrakha, Bell, Paul, Dickson, Moffitt, & Caspi, 2007; Schofield, Bierman, Heinrichs, & Nix, 2008). Early sexual activity and risky sexual behavior increase the risk of sexual abuse (Vezina, & Hebert, 2007). The direction of the link between sexual abuse and antisocial behavior is unclear at this moment.
The Borderline personality disorder was the only personality disorder which was associated to an officially reported type of maltreatment namely officially reported sexual abuse. Borderline was also associated to self- reported emotional neglect. More specifically, a negative association was found for the Borderline personality disorder associated with officially reported sexual abuse. It is possible that an official institution labels behavior as sexual abuse while the female adolescent does not perceive this as sexual abuse. For instance when the girl is 15 years old the law views the girl as developmentally unprepared but perhaps the girl feels confident enough to engage in sexual activities. A positive association was found between emotional neglect and the Borderline personality disorder. Emotional neglect means that the child experiences that his feelings and developmental needs were not met nor recognized. Emotionally neglected children often have a disorganized attachment style which is characterized by the lack of an organized strategy for making contact and dealing with separations (Rees, 2008; Tyler, Allison, & Winsler, 2006). This attachment style could result in the development of maladaptive coping strategies in relationships, resulting these children to develop a Borderline personality disorder (Barone, 2003).
Several limitations should be mentioned for the current study. To date, no perfect method for measuring child maltreatment is available. Official reports generally underestimate the prevalence numbers of maltreatment, especially regarding emotional abuse (Brown, Cohen, Johnson, & Salzinger, 1998; Pinto & Maia, 2013). Self- reports may be prone to denial,
minimization, amnesia and feelings of shame and guilt; these factors could lead to an underestimation of maltreatment (Swahn et al., 2006). Different studies have found that the influence of negative factors on the recollection of childhood abuse are less detrimental then expected, victims of abuse and traumatic childhood experiences are well able to recall these events since the memory retains emotional events in more detail (Alexander et al., 2005; Cordón, Pipe, Sayfan, Melinder, & Goodman, 2004). The recollection of childhood maltreatment is dependent on different factors and should be interpreted carefully. The officially reported maltreatment was measured up to admission, while the self- reported maltreatment was measured after the adolescents transitioned out of care. It is possible that in the period between adolescence and emerging adulthood maltreatment has occurred which the self- reports could measure but were not included in the official reports. With regard to maltreatment in different studies it has been found that different types of maltreatment co- occurred, the official reports only reported one of the types of maltreatment and did not measure the co- occurrence of several types of maltreatment which can cause the low prevalence in official reports. The measurement of personality disorders also relied on self- reports. While all of the measurements were executed on the same point in time this study cannot claim anything about the causality between maltreatment and personality disorders. Finally the external validity of the present study is limited while the results are only applicable to young female adults in residential care in Quebec (Canada).
Following the results in this study recommendations are made about the utility of these results in clinical practice. Professionals and society have given little attention to the influence of emotional abuse. Emotional abuse, in this study, has the most detrimental effect in comparison to physical and sexual abuse and emotional and physical neglect. In clinical practice professionals tend to focus on physical and sexual abuse, while they should also be aware of the effects of
emotional abuse (English, Thompson, White, & Wilson, 2015). Upon entering residential care a full assessment regarding childhood maltreatment using standardized questionnaires should be administered. Future research should study the social skills and other constructs that mediate the process between emotional abuse and the development of a personality disorder. Knowledge and insight into the specific constructs that lead to the development of a personality disorder will help with the design of interventions and give professionals guidelines. Finally these recommendations should be implemented with caution; while emotional abuse has a great influence one should not underestimate the influence of the other types of maltreatment. Previous research has shown that the different types of maltreatment often co- occur (Arata, Langhinrichsen- Rohling, Bowers, & O'Farrill- Swails, 2005; Edwards, Holden, Felitti, & Anda, 2003). Future research should also focus on the interactions between different types of maltreatment and which consequences specific combinations can have.
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Appendix A Appendix A: Correlational Matrix of Personality Disorders
Paranoid Schizotypal Histrionic Narcissistic Borderline Antisocial Avoidant Dependent Passive Depressive Paranoid - Schizotypal 0.640*** - Histrionic 0.454*** 0.480*** - Narcissistic 0.514*** 0.506*** 0.592*** - Borderline 0.463*** 0.476*** 0.588*** 0.393*** - Antisocial 0.243** 0.242** 0.258** 0.148 0.412*** - Avoidant 0.419*** 0.528*** 0.419*** 0.354*** 0.436*** -0.026 - Dependent 0.329*** 0.377*** 0.508*** 0.332*** 0.560*** 0.202* 0.593*** - Passive 0.511*** 0.555*** 0.608*** 0.459*** 0.644*** 0.254** 0.506*** 0.565*** - Depressive 0.525*** 0.565*** 0.574*** 0.391*** 0.626*** 0.172 0.707*** 0.597*** 0.633*** -
