Young females aging out of care: Examining the mediating role of social support in the association between child maltreatment and trauma related symptoms.
Masterthesis Forensic Child and Youth Care Sciences Graduate School of Child Development and Education University of Amsterdam M.P.M. Tolsma 11120711 University of Amsterdam (Amsterdam, The Netherlands) University of Sherbrooke (Montréal, Canada) First supervisor: Dr. E.S. van Vugt Second supervisor: Dr. N. Lanctôt Amsterdam, July 2016
Table of contents Abstract 3 Introduction 4 Method 8 Results 12 Discussion 19 References 24
Abstract
Aim: In this study the mediating effect of social support in the relation between child maltreatment and trauma related symptoms was examined in 132 young adult females who transitioned out of residential care.
Method: Child abuse and neglect was assessed with the Child Trauma Questionnaire and trauma related symptoms were assessed with the Trauma Symptom Inventory 2. Social support was examined using the Multidimensional Scale of Perceived Social Support. Results: No mediation effect of social support was found in the relation between child maltreatment and trauma related symptoms. However, indirect effects were found for social support in the relation between emotional neglect and, respectively, self-disturbance,
depression, insecure attachment and sexual disturbance.
Conclusion: Possibly, social support could decrease the level of trauma related symptoms for female adolescents with an history of emotional neglect. Treatment should be focused on social support, especially because of the relation orientation style of females. Further research must explore what aspects may possibly show a mediating effect between the other forms of child maltreatment and trauma related symptoms.
Introduction
Child maltreatment is a serious public health problem (Min, Minnes, Kim, & Singer, 2012). Recent international studies reveal that many children have been subjected to one or more forms of child maltreatment, among which emotional, physical and sexual abuse and emotional and physical neglect (World Health Organization, 2014). Determining the prevalence rates of child maltreatment is not easy and can differ depending on, for instance, the methods used to obtain this information or the population in which it was examined. For instance, researchers generally use either official reports from Child Protect Services (CPS) or child self-reports to establish the prevalence of child maltreatment (Hambrick, Tunno, Gabrielli, Jackson, & Belz, 2014). However, large differences in prevalence rates of child maltreatment have been found between official reported and self-reported data, with much lower percentages found among official data. One of the reasons for this is that official reports tend to only include substantiated forms of maltreatment, and therefore the often more visible forms such as physical and sexual abuse (Pinto & Maia, 2013). Additionally, the prevalence of child maltreatment also strongly differs between populations. More precisely, in residential care the prevalence rates of child abuse vary between 38% and 98% (Collin-Vézina, Coleman, Milne, Sell, & Daigneault, 2011), while the prevalence among non-clinical populations is much lower, between 4% and 16% (Gilbert et al., 2008).
Different forms of child maltreatment often co-occur (Glaser, 2005). This phenomenon, experiencing more than one form of child maltreatment, is also known as multitype maltreatment (Higgins & McCabe, 2000). In the study of Collin-Vézina et al. (2011), more than half of the sample reported four or five different forms of abuse and neglect. However, to the author’s best knowledge, very few studies can be found in which various forms of maltreatment have been assessed simultaneously. Most of the child maltreatment literature is dominated by research on sexual abuse (Stoltenborgh,
Bakermans-Kranenburg, Alink, & Van IJzendoorn, 2015) and physical abuse, and only more recently, on emotional abuse or witnessing of domestic violence (Edwards, Holden, Felitti, & Anda, 2003). The more passive forms of child maltreatment, such as emotional and physical neglect, have been studied less.
Child maltreatment has long been recognized as a traumatic event causing short- and long-term distress, with a substantial variability in the degree of the psychological difficulties reported by child maltreatment victims (Evans, Steel, & DiLillo, 2013). The effects may impact multiple aspects of the individuals’ development (physical, cognitive, psychological and behavioural) and can manifest in childhood, adolescence and/or adulthood (Merrick & Latzman, 2014). This symptom complexity includes posttraumatic stress symptoms and symptoms in affective and interpersonal self-regulatory capacities (Cloitre et al., 2009). One of the most prevalent linkages between child maltreatment and long-term mental health sequelae is the link between child maltreatment and adult trauma symptomatology (Evans, 2010). Trauma symptomatology includes the effects of child maltreatment and refers to clusters of symptoms, found in some traumatized children (Brière, 1996).
Adolescents in residential care are assumed to be especially at risk to develop trauma symptomatology for two reasons. The first reason is the high prevalence of child maltreatment among this youth. Second, recent research has found that mental disorders and physical health problems are substantially more common in adolescents in residential care (Fazel, Doll, & Lângström, 2008; Nelson et al., 2014). Besides, female youth in residential care seem to be more troubled than male youth (Handwerk et al., 2006). This accumulation of problems increases the likelihood of negative outcomes in the transition towards adulthood (Trout et al., 2009). As reported by Connor, Doerfler, Toscano, Volungis and Steingard (2004), who studied the characteristics of 397 children and adolescents admitted to a residential care center, female adolescents showed higher levels of physical and sexual abuse than male
adolescents in residential care. Besides, female adolescents exhibited consistently higher levels of psychopathology.
Much is known about both the prevalence and the consequences of the various types of child maltreatment and about the relationship between these two aspects. Fewer studies have focused on the specific aspects that may possibly mediate this relationship. It is important to gain a better understanding of factors which possibly promote or hamper the consequences of child maltreatment to establish prevention and intervention targets. It appears that, in general, social support has a positive influence on the ability to cope with trauma (Haden, Scarpa, Jones, & Ollendick, 2006). The interest in the role of social support has been increasing since the mid-1970’s (Cohen & Wills, 1985) and, although there is a lot of literature about social support, there are difficulties to define social support, because of its multidimensional character. In general, researchers define positive social support as the cognitive and emotional assistance provided by an individual to someone coping with a problem (Evans, 2010).
Perceived support, support behaviour and support resources are the three categories of social support which are often assessed (Chalise, 2010). Perceived support refers to one’s subjective assessment of the availability and adequacy of support, whereas support behaviour describes the actual emotional and/or instrumental assistance received. Support resources constitute the social support networks (Chalise, 2010), for example family, friends, co-workers and romantic partners and spouses (Thoits, 1986; Procidano & Heller, 1983 in Evans, 2010). In particular, perceived social support has been identified as a mediator for psychological distress (Cohen & Wills, 1985).
For adolescents in residential care, the social network constitutes mostly of people belonging to the institution. The quality of the relationship with the significant figures within the institution, but also of the relationship with significant figures outside the institution,
seems to play an important role in the protection and development of the well-being of these adolescents (Mota & Matos, 2015). However, these youths generally lose the support of the child welfare system in emerging adulthood when transitioning out of care (Gretchen, Cusick, & Courtney, 2007). On top of that, there are numerous significant life transitions during emerging adulthood for which transitional distress seems to be a catalyst (Lane & Fink, 2015). These transitions can be seen in terms of self-regulation, establishment of identity, and development of personal meaning (Shulman, Feldman, Blatt, Cohen, & Mahler, 2005). A number of studies identified social support as an important protective factor in the development towards emerging adulthood (Polach, 2004; La Greca & Harrison, 2010).
Some researches demonstrated that social support acts as a buffer between stressful life and physical symptoms in a direct way (Chu, Saucier, & Hafner, 2010). Positive effects of social support on the development of depression and anxiety were found for children with a history of physical abuse (Ezzell, Swenson, & Brondino, 2000). Another study showed that social support had a mediating effect in the relationship between child sexual and physical abuse and psychological stress and self-esteem later in life (Runtz & Schallow, 1997). In their meta-analysis, Brewin, Andrews and Valentine (2000) have shown that a lack of social support was the strongest predictor for posttraumatic stress disorder (PTSD) severity (explaining 40% of the variance). Evans (2010) found the same results among 193 couples recruited from a publicly available marriage license database: negative social support received from a spouse was associated with increased trauma symptomatology or general psychological distress.
In sum, child maltreatment is a common problem that is associated with a variety of negative short- and long-term consequences. These consequences include trauma related symptoms in emerging adulthood (Evans, Steel, & DiLillo, 2013; Merrick & Latzman, 2014). Considering the high prevalence rates of child maltreatment among female adolescents in
residential care, it is important to gain more knowledge about the association between child maltreatment and trauma related symptoms in females. Further, there is evidence that social support has a buffering role in the negative consequences of child maltreatment. However, this effect may vary depending on the type, severity and complexity of the maltreatment experience (Salazar, Keller, & Courtney, 2011). To meet the specific needs of females in residential care, it is important to gain knowledge about the role of social support in the associations between different types of child maltreatment and trauma related symptoms.
Current study
The major goal of this study was to examine the mediating effect of social support in the association between child maltreatment and trauma related symptoms in young adult females who have transitioned out of residential care. The objectives of the current study are 1) to examine the associations between the study variables, respectively child maltreatment, social support and trauma related symptoms, and 2) to examine if the relation between the different forms of child maltreatment and trauma related symptoms is mediated by social support.
Method
Participants
The present study is part of a larger longitudinal study, carried out in 2007-2008, among 182 female adolescents placed in residential care in Montréal, Canada. The average duration of the placement in the youth center of the participating young women was six months, with a minimum duration of three months. Serious behaviour problems were the main reason for placement. The total data collection consisted of six waves (T1-T6), covering the period from mid-adolescence to the emerging adulthood. For the present study, only data from the sixth wave was used. The dataset was checked for misfits and outliers. Two of the 134 young adult females participating in the sixth wave, did not complete the measurement for social support. For this reason, the total number of participating young adult females in this
study was 132 (Mean age = 19.41; SD = 1.48). All females were out of care at the time of the present study.
Procedure
The data collection procedures were approved by the institutional review board of the University of Sherbrooke, Canada. All female adolescents consented to participate at each wave of the data collection and parental consent was acquired for female adolescents under the age of 14. The interviews were conducted by a team of interviewers, composed of university students with training in interviewing techniques and research ethics. The assessment took about 90 minutes to complete. The participants were asked to supply contact details for follow-up assessments at the end of the interviews.
Instruments
Independent variable
Child maltreatment. Child maltreatment was measured retrospectively during the sixth wave,
using the Childhood Trauma Questionnaire (CTQ). This questionnaire measures the severity of five types of child maltreatment: emotional, physical and sexual abuse and emotional and physical neglect. The CTQ is a self-report measure, which comprises 28 items to assess maltreatment experiences in childhood and adolescence (Bernstein & Fink, 1998). An example of an item of the emotional abuse scale is: “People in my family said hurtful or insulting things to me”. “I was punished with a belt, a board, a cord or some other hard object” and “Someone tried to make me do sexual things or watch sexual things” are examples of successively the physical and sexual abuse scale. Examples of items of the emotional and physical neglect scale are: “I felt loved” and “I did not have enough to eat”. All items were rated on a 5-Point-Likert scale, ranging from 1 (Never true) to 5 (Very often true). It takes about 10 to 15 minutes to complete the CTQ). The scores were summed and higher
scores indicated more severe forms of child maltreatment. The Cronbach’s alphas of the various child maltreatment scales for this sample ranged from .764 to .946.
Potentially mediating variable
Social support. Social support was measured using the Multidimensional Scale of Perceived
Social Support (MSPSS). This 12-item questionnaire measures perceived adequacy of social support from three sources: family, friends and significant others (Zimet, Dahlem, Zimet, & Farley, 1988). An example of an item of the family subscale is: “My family really tries to help me.”. Examples of, respectively, the friends’ subscale and the significant others subscale are: “I can count on my friends when things go wrong” and “I have a special person who is a real source of comfort to me”. A Four-Point-Likert scale was used, ranging from 1 (Strongly disagree) to 4 (Strongly agree). Higher scores indicated higher levels of social support. For the purpose of the current study, a total scale was formed, including all three subscales. The Cronbach’s alpha of the total scale of the MSPSS was 0.966.
Dependent variable
Trauma related symptoms. Trauma related symptoms were evaluated in emerging adulthood,
at the sixth wave, using the Trauma Symptom Inventory 2 (TSI-2). The TSI-2 is a 100-item self-report measure developed to assess posttraumatic stress and other psychological symptoms of traumatic events (Brière, 1995). Four broad symptom scales and their respective indicators were assessed: disturbance (depression, insecure attachment, impaired self-reference), posttraumatic stress (anxious arousal, intrusive experiences, defensive avoidance, dissociation), externalization (anger, sexual disturbance, suicidality, tension reduction behaviour), and somatization (somatic preoccupations). A Three-Point-Likert scale was used, anchored from 0 (It has never happened) to 3 (It has happened frequently) to indicate the frequency of symptoms within the past six months. Higher scores indicated more trauma
related symptoms. The Cronbach’s alpha’s of the four summary factors and their indicators ranged from .84 to .97.
Analytic strategy
The first aim of this study was to examine the associations between the study variables, respectively child maltreatment, social support and trauma related symptoms. Therefore, Pearson correlation analyses were performed using SPSS version 21. To interpret the strength of the correlations, Cohen’s (1988) criteria were used, with r = 0.10-0.29 considered as small, r = 0.30-0.49 considered as moderate and r ≥ 0.5 considered as strong.
The second aim was to examine the mediating effect of social support in the relation between child maltreatment and trauma related symptoms. Mediation analysis were conducted via a structural equation modelling framework, using Mplus 7.2. Fifteen single mediation models were performed. In each model we included the five forms of child maltreatment simultaneously as independent variables (emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect), one of the trauma related symptoms as the dependent variable (self-disturbance, depression, insecure attachment, impaired self-reference, posttraumatic stress, anxious arousal, intrusive experiences, defensive avoidance, dissociation, externalization, anger, sexual disturbance, suicidality, tension reduction behaviour or somatization) and social support as a mediator. All models were controlled for age.
In the mediation analysis (Figure 1), the direct link between child maltreatment and trauma related symptoms was indicated by the c-link. The link from child maltreatment to social support was indicated by the a-link and the link from social support to trauma related symptoms by the b-link. Last, the association between child maltreatment and trauma related symptoms while taking into account the a- and b-link, was indicated as the c’-link (Hayes, 2009).
Figure 1: A single mediation model per trauma related symptom. The c’-link is not
indicated in this figure.
A full mediation is established when the c-link is significant, but the c’-link is not significant anymore. A partial mediation is found when both the c-link and the c’-link are significant. An indirect effect is established when the c-link is not significant, while the c’-link is (Hayes, 2009).
A bootstrapping procedure was used to test for mediation and indirect effect models, with 500 bootstrapped samples being taken. Model fit was determined using the following indices: The Chi-Square p-value, Confirmatory Fit Index (CFI), and Root Mean Square Error of Approximation (RMSEA). According to Hu and Bentler (1999) the p-value of the Chi-square test of model fit had to be non-significant (p >.05) to indicate a good fit. For the RMSEA, values between .06 and .08 indicated an acceptable fit, and values less than .06 indicated a good fit. The CFI values of .90 or greater indicated an acceptable fit and .95 or higher indicated a good model fit.
Results
Pearson’s correlation analyses were performed to examine the relationship between the different forms of child maltreatment, social support, trauma related symptoms and age. Table 1 presents the means, standard deviations, and the correlation coefficients.
All the different forms of child maltreatment were positively related to each other, which implies that the different forms of maltreatment co-occur. The largest association was found between physical neglect and emotional neglect (r = .68, p = .000). In addition, also the four broad trauma symptom domains and their related symptoms were moderately to strongly associated, with the largest relation found between the self-disturbance and the posttraumatic stress domain (r = .86, p = .000).
All the different forms of child maltreatment were moderately related to the different trauma related symptoms. More specifically, it was found that more severe levels of child maltreatment were related to more trauma symptoms. The moderate associations were found for emotional abuse and trauma related symptoms in each domain. More precisely, the associations between respectively emotional abuse and anxious arousal (r = .54, p = .000) and defensive avoidance (r =.55, p =.000) were found as the strongest.
Descriptive statistics and associations between the study variables (n = 132).
Note. 1 = emotional abuse; 2 = physical abuse; 3 = sexual abuse; 4 = emotional neglect; 5 = physical neglect.
***p < 0.001. **p < 0.01. * p < 0.05. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 M SD 1. Age 1 19,41 11,48 2. Emotional abuse -0.12** 1 11,59 16,42 3. Physical abuse -0.07** -0.61*** 1 18,63 15,47 4. Sexual abuse -0.09** -0.48*** -0.49*** 1 18,39 15,86 5. Emotional neglect -0.06** -0.62*** -0.34*** -0.28*** 1 13,27 15,62 6. Physical neglect -0.03** -0.62*** -0.38*** -0.28*** -0.68*** 1 19,35 14,60 7. Social support -0.01** -0.26*** -0.18*** -0.07*** -0.44*** -0.32*** 1 13,39 10.62 8. Self-disturbance -0.17** -0.54*** -0.37*** -0.35*** -0.32*** -0.29*** -0.30*** 1 27,35 19,45 9. Depression -0.12** -0.52*** -0.39*** -0.32*** -0.29*** -0.30*** -0.26*** 0.91*** 1 11,53 17,78 10. Insecure attachment -0.14** -0.53*** -0.34*** -0.32*** -0.30*** -0.27*** -0.36*** 0.93*** 0.77*** 1 18,33 17,14 11. Impaired Self-reference -0.23** -0.43*** -0.29*** -0.31*** -0.27*** -0.23*** -0.20*** 0.89*** 0.70*** 0.78*** 1 17,49 16,37 12. Posttraumatic stress -0.19** -0.57*** -0.43*** -0.45*** -0.30*** -0.35*** -0.22*** 0.86*** 0.82*** 0.82*** 0.71*** 1 40,50 27,09 13. Anxious arousal -0.15** -0.54*** -0.36*** -0.37*** -0.28*** -0.32*** -0.21*** 0.86*** 0.85*** 0.81*** 0.68*** 0.91*** 1 10,76 16,78 14. Intrusive Experiences -0.24** -0.53*** -0.40*** -0.41*** -0.29*** -0.35*** -0.22*** 0.78*** 0.76*** 0.75*** 0.62*** 0.95*** 0.81*** 1 10,64 18,18 15. Defensive Avoidance -0.15** -0.55*** -0.46*** -0.45*** -0.25*** -0.29*** -0.17*** 0.76*** 0.75*** 0.73*** 0.59*** 0.93*** 0.80*** 0.86*** 1 13,40 19,40 16. Dissociation -0.15** -0.37*** -0.30*** -0.34*** -0.27*** -0.32*** -0.18*** 0.70*** 0.58*** 0.66*** 0.70*** 0.79*** 0.67*** 0.69*** 0.59*** 1 15,70 15,60 17. Externalization -0.22** -0.45*** -0.32*** -0.34*** -0.35*** -0.32*** -0.28*** 0.85*** 0.80*** 0.79*** 0.75*** 0.79*** 0.76*** 0.75*** 0.67*** 0.66*** 1 18,87 15,39 18. Anger -0.15** -0.35*** -0.24*** -0.28*** -0.29*** -0.20*** -0.18*** 0.74*** 0.74*** 0.66*** 0.63*** 0.73*** 0.74*** 0.69*** 0.65*** 0.53*** 0.82*** 1 10,64 16,84 19. Sexual Disturbance -0.23** -0.43*** -0.22*** -0.30*** -0.31*** -0.37*** -0.34*** 0.66*** 0.54*** 0.66*** 0.61*** 0.63*** 0.61*** 0.61*** 0.52*** 0.55*** 0.81*** 0.52*** 1 14,84 16,08 20. Suicidality -0.15** -0.33*** -0.31*** -0.24*** -0.24*** -0.23*** -0.17*** 0.65*** 0.63*** 0.57*** 0.56*** 0.53*** 0.46*** 0.51*** 0.45*** 0.52*** 0.78*** 0.43*** 0.46*** 1 13,40 16,19 21. Tension Reduction Behaviour -0.20** -0.38*** -0.23*** -0.28*** -0.29*** -0.29*** -0.17*** 0.81*** 0.75*** 0.73*** 0.75*** 0.78*** 0.73*** 0.75*** 0.67*** 0.70*** 0.89*** 0.72*** 0.69*** 0.74*** 1 15,93 15,99 22. Somatization -0.12** -0.44*** -0.31*** -0.20*** -0.27*** 0.31*** -0.18* 0.64*** 0.61*** 0.59*** 0.55*** 0.65*** 0.67*** 0.58*** 0.52*** 0.59*** 0.55*** 0.53*** 0.47*** 0.31*** 0.49*** 1 17,92 16,15
negatively related to social support, which implies that severe child abuse and neglect was associated with lower levels of social support. In addition, the trauma related symptoms were (small to moderate) negatively related to social support, which indicates that lower levels of social support were related to more trauma symptoms. Defensive avoidance, referring to the suppressing or avoidance of thoughts or memories associated to the child maltreatment, was not significantly related to social support.
Direct effect models
Table 2 presents an overview of the direct links between the different forms of child maltreatment and the trauma related symptoms. For the self-disturbance domain, which represents the inability to form a stable model of the self or a stable identity, a unique association was found with emotional abuse (b = 1.47, p = .000), when taking into account the other forms of abuse and neglect. Depression (b = 0.550, p = .000) and insecure attachment (b = 0.59, p = .000) had the largest contribution to this domain. A smaller contribution was found for a general lack of self-knowledge and confusion over one’s own thoughts and beliefs (impaired self-reference, b = 0.33, p = .007).
In the posttraumatic stress domain, uniquely direct associations were found with emotional abuse (b = 1.78, p = .000), taking into account the other forms of abuse and neglect. Precisely, females with an history of emotional abuse reported symptoms of anxiety (anxious arousal, b = 0.54, p = .000), intrusive sensory memories of a previous traumatic event through nightmares and flashbacks (intrusive experiences, b = 0.48, p = .002) and suppressing or avoiding thoughts or memories associated to the abuse (defensive avoidance, b = 0.66, p =.000). Also a uniquely direct association with sexual abuse (b = 0.92, p = .020) was found in the posttraumatic stress domain, taking account the other forms of child maltreatment. The association between posttraumatic stress and sexual abuse also mainly translated through
symptoms of intrusive experience (b = 0.26, p = .035) and defensive avoidance (b = 0.32, p = .010).
Within the externalization domain, representing a pattern of problematic, self-destructive and aggressive behaviours as a response to underlying emotions, a direct effect was found between emotional neglect and anger (b = 0.28, p = .035), taking into account the other forms of child maltreatment. This implies that more severe emotional neglect resulted in higher levels of angry cognitions, moods and behaviours. Greater pain symptoms and general discomfort were only uniquely associated with emotional abuse (somatization, b = 0.35, p = .012), while taking into account the other forms of child maltreatment.
Tabel 2
Direct effect models.
Independent variables c1 c2 c3 c4 c5 Self-disturbance 1.47*** -0.16 -0.35* -0.10* -0.29 Depression 0.55*** -0.12 -0.09* -0.02* -0.05 Insecure attachment 0.59*** -0.03 -0.11* -0.02* -0.13 Impaired self-reference 0.33*** -0.01 -0.15* -0.10* -0.11 Posttraumatic stress 1.78*** -0.31 -0.92* -0.31* -0.29 Anxious arousal 0.54*** -0.03 -0.16* -0.09* -0.02 Intrusive experience 0.48*** -0.09 -0.26* -0.07* -0.13 Defensive avoidance 0.66*** -0.20 -0.32* -0.19* -0.03 Dissociation 0.10*** -0.05 -0.18* -0.04* -0.17 Externalization 0.59*** -0.07 -0.35* -0.43* -0.02 Anger 0.21*** -0.01 -0.13* -0.28* -0.21 Sexual disturbance 0.27*** -0.11 -0.15* -0.04* -0.22 Suicidality 0.12*** -0.19 -0.07* -0.11* -0.01 Tension reduction behaviour 0.21*** -0.02 -0.15* -0.10* -0.08 Somatization 0.35*** -0.08 -0.05* -0.021* -0.10
Note. 1 = emotional abuse; 2 = physical abuse; 3 = sexual abuse; 4 = emotional neglect; 5 =
physical neglect.
Mediation analysis
No mediation was found. However, there was a link between emotional neglect and social support (b = -0.05, p = .000) that resulted in four indirect effect models (Table 3). All models had a good model fit.
Indirect effects were found for social support in the relation between emotional neglect and, respectively, self-disturbance (b = 0.31, p = .018), depression (b = 0.10, p = .041), insecure attachment (b = 0.15, p = .017) and sexual disturbance (b = 0.11, p = .037). This implies that more severe emotional neglect significantly was associated with lower levels of social support and that lower levels of social support were related to higher levels of self-disturbance symptoms, mainly translating through higher levels of depression and insecure attachment, and sexual disturbance symptoms.
The direct effects were largely maintained when including social support in the full model. Nevertheless, the direct c-link between emotional neglect and anger disappeared when including social support. Further, a significant c’-link between emotional abuse and sexual disturbance appeared (b = 0.28, p = .032) in the full model. This might possibly be explained by the indirect effect that was found between emotional neglect and sexual disturbance and the high association between emotional abuse and emotional neglect (r = 0.62, p =.000).
Potential mediating social support in the association between child maltreatment and trauma related symptoms (n = 132).
Note. 1 = emotional abuse; 2 = physical abuse; 3 = sexual abuse; 4 = emotional neglect; 5 = physical neglect.
***p < 0.001. **p < 0.01. * p < 0.05
a-link b-link C’-link ab-link
a1 a2 a3 a4 a5 B c`1 c`2 c`3 c`4 c`5 ab1 ab.2 ab3 ab4 ab5
Self-disturbance 0.00 -0.01 0.01 -0.05*** -0.01 -6.64*** 1.50*** -0.07 -0.39** -0.19 -0.37 -0.02 0.06 -0.06 0.31* 0.05 Depression 0.00 -0.01 0.01 -0.05*** -0.01 -2.16*** 0.56*** -0.10 -0.11** -0.12 -0.07 -0.01 0.02 -0.02 0.1-* 0.02 Insecure attachment 0.00 -0.01 0.01 -0.05*** -0.01 -3.30*** 0.60*** -0.03 -0.12** -0.12 -0.18 -0.01 0.03 -0.03 0.15* 0.03 Impaired Self-Reference 0.00 -0.01 0.01 -0.05*** -0.01 -1.18*** 0.34*** -0.01 -0.15** -0.05 -0.13 -0.00 0.01 -0.01 0.05* 0.01 Posttraumatic Stress 0.00 -0.01 0.01 -0.05*** -0.01 -4.89*** 1.80*** -0.29 -0.98** -0.56 -0.28 -0.02 0.05 -0.05 0.23* 0.04 Anxious arousal 0.00 -0.01 0.01 -0.05*** -0.01 -1.36*** 0.54*** -0.03 -0.18** -0.16 -0.02 -0.01 0.01 -0.01 0.06* 0.01 Intrusive Experience 0.00 -0.01 0.01 -0.05*** -0.01 -1.56*** 0.49*** -0.07 -0.27** -0.14 -0.11 -0.01 0.02 -0.01 0.07* 0.01 Defensive Avoidance 0.00 -0.01 0.01 -0.05*** -0.01 -1.25*** 0.67*** -0.19 -0.34** -0.25 -0.03 -0.01 0.01 -0.01 0.06* 0.01 Dissociation 0.00 -0.01 0.01 -0.05*** -0.01 -0.73*** 0.10*** -0.05 -2.00** -0.01 -0.18 -0.00 0.01 -0.01 0.03* 0.01 Externalization 0.00 -0.01 0.01 -0.05*** -0.01 -4.00*** 0.61*** -0.05 -0.41** -0.22 -0.01 -0.02 0.04 -0.04 0.18* 0.03 Anger 0.00 -0.01 0.01 -0.05*** -0.01 -0.77*** 0.21*** -0.02 -0.17** -0.22 -0.18 -0.00 0.01 -0.01 0.04* 0.01 Sexual Disturbance 0.00 -0.01 0.01 -0.05*** -0.01 -2.48*** 0.28*** -0.14 -0.17** -0.08 -2.00 -0.01 0.02 -0.02 0.11* 0.02 Suicidality 0.00 -0.01 0.01 -0.05*** -0.01 -0.75*** 0.12*** -0.17 -0.07** -0.08 -0.01 -0.00 0.01 -0.01 0.03* 0.01 Tension Reduction Behavior 0.00 -0.01 0.01 -0.05*** -0.01 -0.58*** 0.22*** -0.04 -0.14** -0.08 -0.06 -0.00 0.01 -0.01 0.03* 0.00 Somatization 0.00 -0.01 0.01 -0.05*** -0.01 -0.68*** 0.36*** -0.09 -0.04** -0.06 -0.11 -0.00 0.01 -0.01 0.03* 0.01
association between child maltreatment and trauma symptoms in emerging adulthood, among a group of females who transitioned out of residential care. All different forms of child maltreatment and all trauma related symptoms were positively related. Direct effects were found between different forms of child maltreatment and different trauma related symptoms. The majority of the associations were found for emotional abuse and sexual abuse, while one relation was found for emotional neglect. No mediation was found, but indirect effects were found for social support in the relation between emotional neglect and, respectively, self-disturbance, depression, insecure attachment and sexual disturbance.
The finding that all forms of child maltreatment were positively related concurs with findings of previous research (Bifulco et al, 2002; Edwards, Holden, Felitti, & Anda, 2003; Ney, Fung, & Wickett, 1994; McGee, Wolfe, Yuen, Wilson, & Carnochan, 1995). Since we knew from previous research that the different forms of child maltreatment often co-occur, we were interested in examining the unique contribution of each form of child maltreatment in relation to trauma related symptoms. For that reason, all forms of child maltreatment were included simultaneously in every single model.
Survivors of child maltreatment frequently report that they are likely to experience several episodes of traumatic exposure and rarely experience only one traumatic event (Kessler, 2000). Exposure to multiple traumas has been proposed to result in complex symptom presentation (Kessler, 2000). Especially childhood cumulative trauma seems to be associated to a complex symptom set and influences the presence of these symptoms in adulthood significantly (Cloitre et al., 2009). Complex trauma exposure results in interpersonal relatedness and in a loss of core capacities for self-regulation (Cook et al., 2005). Van der Kolk, Roth, Pelcovitz, Sunday and Spinazzola (2005) have found that victims of long standing interpersonal trauma had a high incidence of problems with regulation of
affect and impulses, memory and attention, self-perception, interpersonal relations, somatization, and systems of meaning. The current study shows several direct associations between child maltreatment and trauma related symptoms in emerging adulthood.
Direct effects were found for emotional abuse, sexual abuse and emotional neglect. When exploring these associations, it shows that, while controlling for the other forms of child maltreatment, the majority of associations have been found between emotional abuse and trauma related symptoms. Emotional abuse was significantly associated to a number of posttraumatic and self-disturbance symptoms. It has been argued that emotional abuse is the ‘core’ issue in childhood trauma: it seems to be inherent in all forms of child maltreatment (Hart & Brassard, 1987). Emotional abuse affects the way we feel, how we deal with our feelings, how we understand them and how we relate with others. These things are important in coping with the challenges of daily life and in interactions with other people (O’Hagan, 1995). Thus, emotional abuse interferes with a child’s developmental trajectory (Hibbard, Barlow, & MacMillan, 2012). As a result of the abuse, a child develops a pattern of dysfunctional relationships and this pattern of dysfunctional relationships leads to inappropriate socio-emotional skills, low self-esteem and immature defense mechanisms (Riggs, 2010; Scheffers, Van Vugt, & Lanctôt, 2015). Since females appear to be more focused on relationships with others than boys, this makes them more vulnerable for the effects of emotional abuse and it is expected that they will develop a poor self-image (Dance, Rushton, & Quinton, 2002).
Because of the often severe, periodical, and early onset nature of the traumatic events individuals with a history of sexual abuse have experienced, their neural capacities for managing-regulating stress arousal levels may have been compromised in a serious way (Frewen & Lanuis, 2006). Emotion-regulation difficulties are part of the complex consequences of early-onset chronic interpersonal trauma, more than following late-onset or
single-event traumas (Ehring & Quack, 2010). Badour and Feldner (2013) have shown that emotion-regulation difficulties independently predict posttraumatic stress symptoms. The current study shows direct associations between sexual abuse and respectively defensive avoidance and intrusive experience. Intrusive sensory memories of the previous traumatic event through nightmares and flashbacks, and unwillingness to re-experience negative thoughts and feelings and high efforts to escape from them (Ehring & Quack, 2010) are two hallmark symptoms of posttraumatic stress (Badour & Feldner, 2013).
Indirect effects were found for emotional neglect. Emotional neglect is defined as “refusals or delays in psychological care; inadequate attentions to a child’s need for affection, emotional support, attention or competence; exposing the child to extreme domestic violence; and permitting a child’s maladaptive behaviors” (De Bellis, 2005, p.151). Because of this lack of parental care, emotionally neglected children might feel isolated, what is also shown in the study of Hildyard and Wolfe (2002). In their review, connecting each developmental period to major developmental processes in children subjected to emotional neglect, they found that emotional neglected children are more isolated in social interactions and more avoidant in their interactions than abused or non-maltreated children. The current study shows indirect effects for social support in the relation between emotional neglect and, respectively, self-disturbance, depression, insecure attachment and sexual disturbance. Self-disturbance and depression can be seen in terms of isolation. For instance, young females who are emotionally neglected might feel depressed and insulate themselves from the world. In a study of Bernet and Stein (1999) almost 85% of the 47 adults with DSM-IV major depression in adulthood had an history of childhood emotional neglect. Insecure attachment and sexual disturbance can be seen in terms of problematic social interactions. Neglected children might have difficulties developing emotional intimacy (Perry, 2013).
Our study adds to the current state of knowledge by demonstrating that among a sample of out-of-care females, social support has an indirect effect on the association between emotional neglect and self-disturbance, depression, insecure attachment and sexual disturbance, respectively. This implies that emotional neglect leads to less social support and less social support leads to more trauma symptoms. Establishing social support in treatment could possibly lead to a decline in trauma related symptoms. As mentioned before, females appear to be more focused on relationships with others than males. Especially because females in residential care will lose social support again when they transition out of this setting, it is important to focus on their relation orientation style in intervention programs. Emotional neglect means that the child does not get any attention and that it is isolated. This study implies that social support may buffer the level of trauma related symptoms in girls with experiences with emotional neglect. This effect was not found for the other forms of child maltreatment. Further research must explore what aspects may possibly show this mediating effect between child maltreatment and trauma symptoms.
Exposure to multiple forms of child maltreatment has been proposed to result in a complex of trauma symptoms, particularly when the maltreatment took place in childhood. Problems with regulation of affect and impulses, memory and attention, self-perception, interpersonal relations, somatization, and systems of meaning are mentioned as common symptoms as a result of interpersonal trauma (Van der Kolk et al., 2005). Because of this severity of trauma symptoms, traumatized youth need a flexible approach in intervention. The Attachment, Self-Regulation, and Competency model has been developed as an intervention framework to address to the array of developmental vulnerabilities experienced by this youth (Kinniburgh, Blaustein, Spinazzola, & Van der Kolk, 2005). Treatment is focusing on four areas: caregiver attachment, child’s self-regulation, child’s competency and trauma experience integration. The framework emphasizes the developmental significance of
relationship skills regarding others, the self and the wider context (Lawson & Quinn, 2013). Relationship skills could play an important role in the mobilization of a support network. For example, female adolescents with greater relationship skills are likely to be more able to communicate the need for help (Cohen, Clark, & Sherrod, 1986).
Several limitations of this study should be mentioned. First, measures of child maltreatment experiences were assessed retrospectively by means of self-report, which can lead to recall biases. Recalling traumatic events is dependent on different factors and should be interpreted carefully. Especially traumatic events that occurred in childhood may be difficult to recall (Hardt & Rutter, 2004). However, traumatic events may be better remembered than non-traumatic experiences. Traumatic and stressful events tend to be long lived in children’s minds (Cordon, Pipe, Sayfan, Melinder, & Goodman, 2004). Another limitation of this study is that it only focused on social support as a possible mediator. Further research should identify other possible mediators. Finally, in this study, the three different sources of social support (friends, family and significant others) were assessed simultaneously. However, different sources of support may have different effects on psychological distress (Boudreault-Bouchard, et al., 2013). For example, adolescents may feel more at ease to confide in their friends than to their parents, which may relate to the fact that adolescents become increasingly autonomous from their parents (Dion et al., 2016). Further research should take a closer look at the mediating role of each source of social support individually.
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