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Child Maltreatment Profiles among Females with a history of residential
care placement:
A comparison in early maladaptive schemas
Master Thesis
M.Sc. Forensic Child Development Studies
Graduated School of Child Development and Education University of Amsterdam
Marieke Grimberg Student number: 12325236
Supervision and Examination Dr. E.S. van Vugt
University of Amsterdam, the Netherlands Prof. Dr. N. Lanctot
Université de Sherbrooke, Canada Prof. Dr. G.J.J.M. Stams
University of Amsterdam, the Netherlands
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Abstract
The current study examined if there were differences in Early Maladaptive Schemas (EMS) among females in residential care using different maltreatment profiles. The sample existed of 132 young adult females (Mean age = 19.41; SD = 1.48), with a history of residential placement. Child maltreatment was measured with The Childhood Trauma Questionnaire (CTQ) and early maladaptive schemas were examined using the Young Schema Questionnaire (YSQ). To identify the different child maltreatment profiles, a 3-step latent class analysis (LCA) was conducted. Three profiles were identified: the ‘severe maltreatment ’ class, ‘emotional abuse/neglect’ class and the ‘low maltreatment’ class. After comparing these different profiles in relation to the presence of early maladaptive schemas, it was found that the females in the ‘severe maltreatment’ class had more elevated schemas on all domains compared to the ‘low maltreatment’ class. Furthermore, the ‘severe maltreatment’ class had higher scores on the vulnerability to harm and abandonment schemas compared to the ‘emotional abuse/neglect’ class. Lastly, the ‘emotional abuse/neglect’ class showed higher scores on the mistrust abuse, emotional deprivation, and social isolation schemas compared to the ‘low maltreatment’ class. Therefore, this study showed that the seriousness and severity of the maltreatment experience could contribute to more elevated maladaptive schemas. Furthermore, it was shown that differences among maltreatment profiles resulted in different maladaptive schemas. This means, for clinical practice, that females with different maltreatment profiles could benefit of treatment focusing on changing their specific cognitive schemas.
Keywords: Early Maladaptive Schemas, Child Maltreatment Profiles, Females, Residential Care and Trauma
3 Child Maltreatment Profiles among Females with a history of residential care
placement:
A comparison in early maladaptive schemas Introduction
In 2008, 235.842 child-maltreatment related investigations were conducted in Canada. Over 85,000 of these investigations were substantiated. In 19,599 of these cases, the investigation resulted in an out-of-home placement of which 1432 children were placed in residential care (Public Health Agency of Canada, 2010). Children are placed in residential care because their safety and development are at risk due to either behavioral problems, mental health problems or parenting problems (Zelechoski, Sharma, Beserra, Miguel, DeMarco, & Spinazzola, 2013). These children in residential care have experienced multiple traumatic events and are more vulnerable to child maltreatment (Zelechoski, et al., 2013; Briggs et al., 2012). Between 69-90% of the children in residential care have experienced multiple types of child maltreatment such as neglect, physical, sexual and emotional abuse (Collin-Vézina, Coleman, Milne, Sell & Daigneault., 2011; Finkelhor, Ormrod, Turner, & Hamby, 2005; Lau et al., 2005; Pears, Kim, & Fisher, 2008).
Child maltreatment comes with numerous negative consequences that could be present throughout their lives. For instance, child maltreatment generally leads to more internalizing and externalizing psychopathology, more aggressive behavior problems, poorer psychological well-being, and lower self-esteem. Additionally, maltreatment leads to more motivational problems, problems at school and a higher likelihood of multiple victimizations. (Afifi & MacMillan, 2011; Maniglio, 2009; Pears et al., 2008; Pérez-González, Guilera, Pereda, & Jarne, 2017; Seto, Babchishin, Pullman, & McPhail, 2015). Among certain populations in residential care, maltreatment tends to occur more frequently. Females are known to be at higher risk for child maltreatment (Collin-Vézina et al. 2011; Connor, Doerfler, Toscano, Volugis & Steingard., 2004). These females, who experienced maltreatment, are at increased risk for
4 medical problems, sexual problems, teenage pregnancy, social isolation, and substance abuse (Afifi & MacMillan, 2011; Maniglio, 2009; Pears et al., 2008; Pérez-González, Guilera, Pereda, & Jarne, 2017; Seto, Babchishin, Pullman, & McPhail, 2015). Their problems generally continue in young adulthood where these females often have a lower income, lower social status, higher risk of hospitalization for mental health problems, increased risk for depression, and personality disorders (Norman, Byambaa, Butchart, Scott & Vos, 2012; Ireland, Smith & Thornberry, 2005; van der Molen et al., 2013).
As described above, the majority of the studies have focused on the consequences of child maltreatment based on behavioral outcomes but much less studies have examined the underlying factors that could potentially contribute to these behaviors such as cognition. Nevertheless, research illustrates that early traumatic events, such as child maltreatment, can influence an individual’s cognitions (Gould et al., 2012). For example, cognitive schemas, particularly developed early in childhood as a reality-based representation of the child’s environment to understand, respond and adapt to different circumstances (McGinn & Young, 1996). The development of cognitive schemas is a reciprocal process between the individual and its environment (Young, Klosko & Weishaar, 2003). With this in mind, children growing up in a detrimental toxic environment could develop emotions and cognitions to help them survive these toxic circumstances. According to Young, Klosko and Weishaar (2003), this will result in the development of self-defeating schemas, also known as Early Maladaptive Schemas (EMS).
Young et al. (2003) identified 16 early maladaptive schemas within five domains, appendix 1. First of all, the Rejection/Disconnection domain is referring to the expectation that relationships in any context will not provide stability. Secondly, the domain: Impaired Autonomy, describes the negative feelings about that one can function independently. The third domain, Impaired Limits, refers to the deficiency of setting boundaries, and the deficiency of
5 responsibility or setting long-term goals. The fourth domain, Other-Directness, indicates the tendency of an extreme focus on other’s needs, feelings and responses at the expense of one’s own needs. The last domain, Over Vigilance and Inhibition, refers to the suppression of spontaneity and impulses to avoid making mistakes.
These early maladaptive schemas are all-dimensional, meaning they have different levels of severity and persistency. The more severe and persistent a schema, the more frequently the schema will be activated in a number of different circumstances, consequently resulting in more inadequate behavior (Young, Klosko, & Weishaar, 2003). In addition, the more persistent the maladaptive schema, the more difficult to change it into new adaptive behavior and the longer the negative results will remain (Schmidt, Joiner, Young, & Telch, 1995). Considering the fact that traumatic events and negative circumstances in the environment could trigger the development of these maladaptive schemas, children experiencing child maltreatment could therefore develop higher rates of early maladaptive schemas. This is concerning given that those wrong cognitive pathways, such as maladaptive schemas, can lead to more severe forms of psychopathology (Cukor & McGinn, 2008). Furthermore, cognitive models suggest that an individual’s ability to process trauma will effectively be impaired because of their pre-existing rigid schemas (Brewin & Holmes, 2003). A considerable amount of literature has been published on early maladaptive schemas and child maltreatment, explaining how the schemas differ among the several types of maltreatment (Gibb, 2002; Cukor & McGinn, 2008; Calvette, 2014;Rezaei & Ghazanfari, 2016; Atmaca & Gencoz, 2016; Estevez, Ozerinjauregi, Herrero-Fernandez & Jauregi, 2019; Harding, Burns & Jackson, 2012; Pritt, 2018; Wenninger & Ehlers, 1998; Gold, 1986). The review of Gibb (2002) indicated a relation between all types of child maltreatment and the development of negative cognitive schemas.
Moreover, specifically focused on females, Cukor and McGinn (2008) illustrated that females with a history of child maltreatment demonstrated more maladaptive schemas
6 compared to females without a history of child maltreatment. The schemas defectiveness and shame, emotional deprivation, mistrust and abuse, abandonment, social introversion, isolation and entitlement were all significantly higher in the child maltreatment group compared to the non-child maltreatment group. Their study, therefore, implies that women with a history of abuse learn to believe that they are defective, experience shame about themselves, have difficulties to trust others, and feel emotionally deprived, abandoned and isolated. Furthermore, Karatzias, Jowett, Begley, and Deas (2016) also indicated that females with a history of interpersonal trauma displayed elevated levels of maladaptive schemas with regard to disconnection and impaired autonomy. This suggests that these females have little faith in any relationship and feel incompetent to function independently. Estevez, Jauregui, Ozerinjauregi, and Herroro-Fernandez (2017) findings indicate that emotional neglect and sexual abuse were more strongly related to early maladaptive schemas than other types of maltreatment. Additionally, other studies proposed that females with a history of sexual abuse had a higher score on early maladaptive schemas in comparison to females without this history (Estevez et al., 2019; Harding, Burns & Jackson, 2012). Overall, all research points out that a history of child maltreatment is related to elevated maladaptive schemas in females in young adulthood.
Along these lines, the effects of single type maltreatment on early maladaptive schemas are well-known. However, the above-mentioned studies did not take into account the co-occurrence or severity of the maltreatment experience. This is remarkable because research demonstrated that co-occurrence of at least two maltreatment types (e.g. sexual abuse, physical abuse, emotional abuse, neglect) also referred to multi-type maltreatment (MTM), is extremely common (Higgins, 2004; Witt et al., 2016; Cortes, Canton-Cortes & Canton, 2011). Moreover, different studies demonstrated that children who were victims of multi-type maltreatment, show more negative effects in the future than children who have suffered of only one single specific
7 type of maltreatment (Ackard, Neumark-Sztainer, Hannan, French & Story, 2001; Hazen, Connelly, Roesch, Hough & Landsverk 2009; Evans, Li, & Whipple, 2013; Finkelhor et al., 2007). Besides research which takes into account the multi-type maltreatment, demonstrated that especially the severity of the maltreatment may impact problems later in life resulting in poorer mental health and a negative effect on social functioning (Edwards, Holden, Felitti & Anda, 2003; Pears et al., 2008). Therefore, it is preferred that researchers study the full exposure to child maltreatment i.e. child maltreatment profile, including the severity and do not only take into account the type of abuse.
Another reason to study child maltreatment profiles is that clinical settings are progressively aiming for services to be client-centered (Mansell & Beadle-Brown, 2004). Yet, most of the research is using a variable-centered approach, instead of a person-centered approach. Therefore, using profiles in research is more valuable for the present clinical setting (Harding et al., 2012). Nonetheless, just a handful of studies are published using maltreatment profiles. This is remarkable because all these studies reported that children with a history of severe child maltreatment profiles, also experience worse outcomes in different areas of life (Pears et al., 2007; Higgins, 2010; Lau et al., 2002; Hazen et al., 2009; Witt et al., 2016). Therefore, the present study tries to examine the presence of early maladaptive schemas among different maltreatment profiles in females with a history of residential care placement.
Method Participants
The present study is part of a larger longitudinal study among 182 adolescent females who were placed in a residential care setting in Montreal between 2007 and 2008 (Lanctot & Lemieux, 2012). Placement in residential centers is considered a last resort, reserved for young people with serious adjustment problems compromising their security and development. In this
8 study, the main reason for placement was the severe behavior problems of the females (45.5%). Other motives for placement, measured by official reports through child protection services, were abandonment (3.0%), neglect (21.2%), psychological abuse (4.5%), physical abuse (5.3%), sexual abuse (8.3%), voluntary placement (8.3%) and delinquencies (0.8%). All females stayed in the residential care setting for at least three months. Six assessments were performed (T1-T6), covering the period from mid-adolescence to emerging adulthood. For the present study, only the data of the sixth wave (T6) was used, comprising 132 young adult females (Mean age = 19.41; SD = 1.48). All females were out of care at the time of the present study.
Procedure
Prior to commencing the study, the data collection was authorized by the ethical commission of the University of Sherbrooke, Canada. The data was collected over six waves (T1-T6), and at each wave, a new consent was obtained. When the participants were under 14 years of age, parental consent was also obtained. The females participated on a voluntary base. All respondents answered the questionnaires individually. Completion of the questionnaires took approximately 90 minutes. At the end of the interviews, the participants were asked to provide their contact information to be invited for follow up assessment.
Measures
For the purpose of this study, child maltreatment profiles were established based on the Childhood Trauma Questionnaire (CTQ), which assesses both the type and severity of the maltreatment experience. The CTQ is a retrospective self-report questionnaire existing of 28 items divided over five subscales representing one of the five different types of maltreatment 1) physical abuse, 2) sexual abuse, 3) emotional abuse, 4) emotional neglect and, 5) physical neglect (Bernstein & Fink, 1997). Each subscale consists of five items that had to be answered on a 5-point Likert scale ranging from ‘never true’ to ‘very often true’. A higher score on a
9 scale indicated higher levels of child maltreatment related symptoms. The physical abuse scale was measured with items such as “I was beaten with a belt, a stick or a rope (or any other hard object)”. An example of the sexual abuse item was “Someone touched me sexually”. Emotional abuse was measured by items such as “My parents tell me hurtful and/or insulting things”. Emotional neglect was measured using, for example, the reversed item “I feel that my family believes in me” and physical neglect for example “My parents got drunk and/or took drugs too much to take care of me”. The reliability and validity of the CTQ have been established in different studies, within both clinical (Pavio & Cramer, 2004) and community samples (Bernstein, Ahluvalia, Pogge, & Handelsman, 1997). The Cronbach’s alpha of the child maltreatment scales for this sample ranged from .76 to .95 (N=132).
Early maladaptive schemas were measured by the French short version of the Young Schema Questionnaire- Short (YSQ-S3; Young, Pascal, & Cousineau, 2005). The short version is the most commonly used in clinical research consisting of 75 items measuring the 15 schemas divided over the 5 domains. For each schema, the questionnaire consists of 5 items on a six-point Likert scale ranging from 1 (completely untrue for me) to 6 (describes me perfectly). A higher score indicated higher levels of the early maladaptive schemas. The study of Bach, Simonsen, Christoffersen, and Kriston (2015) showed that the psychometric qualities are good in community samples as well as clinical samples. Table 1 includes an explanation of the different domains and schemas with the belonging items and their reliabilities.
Data analysis
At the start of the analysis, one participant was excluded because of missing data on the schema questionnaire. To identify the different child maltreatment profiles, a 3-step latent class analysis (LCA) was conducted. This analysis identifies subgroups of females with similar maltreatment patterns and compares these afterwards with the different early maladaptive schemas. M-plus was used to conduct the LCA analysis as the data was non-binomially
10 distributed.
The first step of the LCA was to identify the different classes by combining individuals based on similar patterns and experiences of child maltreatment. In this LCA the possibility of a 5-class solution was examined to discover the best fit for the profiles based on the CTQ data. The analysis started with the model fit for one class, afterward, classes were added up to a five-class solution. To establish the optimal number of five-classes, the Bayesian information criteria (BIC), Akaike information criteria (AIC), entropy and Lo-Mendell-Rubin likelihood ratio test (LMR/LRT) were used. Where a smaller BIC and AIC demonstrate a better fit of the model and a larger entropy is an indicator of the percentage of participants correctly assigned to the right class (Entropy>.800). The LMR/LRT offers a p-value in terms of a model comparison between the classes. If the p-value is less than .05, it indicates that the n-class model is better than the (n-1) class model (Choi, Weston, & Temple, 2017). Thus, the LMR/LRT determines whether a model with an extra class is preferred over the model with one fewer class. To determine the best model fit for the data, all these statistical as well as the interpretive considerations were taken into account.
The second step, after the identification of the best model, was to determine the probability of each participant belonging to each class. Higher probabilities indicate a better classification of the specific group the participant was assigned to. In the third step, a post hoc (Tukey) Analysis of Variance (ANOVA) was conducted to discover the differences between ‘the child maltreatment profiles’ formed by the LCA with regard to ‘the early maladaptive schemas’. The advantage of conducting a 3-step LCA over a 1-step LCA approach is that it takes into account the probabilities of the chances of being in one or another group.
11 Results
Identification of the classes
Table 2 illustrates the fit index of the five model solutions, to discover the best fit for the profile analysis. In this study, the best model fit solution consisted of three classes. Even though the AIC and BIC were not at their lowest, considering the sample size, the three-class model was superior to the other classes.
Table 2
Fit index of the five model solutions.
Fit Index
1-class 2-classes 3-classes 4-classes 5-classes
AIC 3966 3725 3671 3641 3619
BIC 3995 3771 3734 3721 3717
N 132 79;53 37;29;66 20;37;10;65 32;10;62;19;8
Entropy 0.89 0.91 0.92 0.92
LMRT 0.00 0.00 0.0272 0.0197
The 3-class solution has the best fit considering a lower AIC, lower BIC, significant entropy and relatively highest N in each class
Profiles of Child Maltreatment
The descriptives of each class are illustrated in Table 3. The first class consisted of n = 37 (28%) females who reported a combination of emotional abuse, physical neglect, and emotional neglect. Therefore, this class is referred to as the ‘emotional abuse/neglect’ class. The second and smallest class of n = 29 (22%) existed of females experiencing more severe levels of child maltreatment and were classified as the ‘severe maltreatment’ class. More specifically, they reported a three times higher score on sexual abuse and one and a half times higher scores on physical abuse, reflecting the seriousness of their abuse experiences. The third and largest class N=66 (50%), was represented by females reporting relatively lower levels of child maltreatment and were therefore labeled as the ‘low maltreatment’ class. These females experienced significantly lower levels of emotional and physical abuse as well as emotional and physical
12 neglect compared to the other classes. Nevertheless, similar levels of sexual abuse were reported within the ‘low maltreatment’ and ‘emotional/neglect’ class.
Table 3
Descriptives of the 3-class solution
3-class Solution CTQ Subscale Class 1 N=37 Class 2 N=29 Class 3 N=66
Mean S.E. Mean S.E. Mean S.E.
Emotional abuse 16.11 0.81 17.28 1.08 6.56 0.22 Physical abuse 9.84 0.81 13.83 1.36 5.68 0.18
Sexual abuse 5.59 0.22 18.38 0.85 5.56 0.18
Emotional neglect 17.59 0.66 15.97 0.98 9.67 0.49 Physical neglect 12.73 0.84 12.10 0.60 6.24 0.24
Descriptive analysis in m-plus giving the number of participants in each class and their mean.
Comparison of cognitive schemas and domains
With a post-hoc ANOVA test, the differences between the three classes and the early maladaptive schemas were examined. First of all, the two schemas, enmeshment undeveloped self and entitlement grandiosity had non-significant overall results and therefore will not be discussed below. From this point forward, multiple significant results were found among females with different maltreatment profiles. Table 4 gives an overview of all results.
The first domain disconnection/ rejection showed multiple significant results between the different maltreatment classes. First of all, the ‘severe maltreatment’ class significantly differed from the ‘low maltreatment’ class. Females who experienced severe forms of maltreatment reported higher levels of all maladaptive schemas within this domain. This suggests that females who experienced higher rates of physical and sexual abuse have the expectation that one’s needs for security, safety, stability, nurturance, and empathy will not be met in a predictable manner. Additionally, they think they will not be accepted and respected by others. Furthermore, the comparison between the ‘severe maltreatment’ and the ‘emotional abuse/neglect’ class only showed one significant result on the schema abandonment. This
13 indicates that females who suffered more severe maltreatment, more frequently believed that they would be abandoned by others and would not receive any support. The last result found in this domain was between the ‘low maltreatment’ and ‘emotional abuse/neglect’ class on the schemas mistrust abuse, emotional deprivation, and social isolation. Females who experienced higher rates of emotional abuse and neglect had stronger believe that their relationships would not provide any stability. They also reported feelings of isolation, that others would take advantage of them, and that their desire for social support could not be realized by others. In the second domain impaired autonomy, multiple significant results were found between the different classes. First of all, there were significant differences between the ‘severe maltreatment’ class and the ‘low maltreatment’ class. Females who experienced more severe maltreatment had significantly higher scores on the schemas, dependence, vulnerability to harm and failure compared to the females who experienced milder forms of maltreatment. Females in the ‘severe maltreatment’ class had stronger believe that they could not function independently. More specifically, they had stronger believe that they needed help in every situation, could not overcome forthcoming tragic events and that they could not succeed. Secondly, comparing the females from the ‘severe maltreatment’ class with the ‘emotional abuse/neglect’ class the same difference was found for the vulnerability to harm schema. Females who experienced more severe maltreatment reported higher scores on the vulnerability to harm and had stronger feelings that they could not overcome forthcoming tragic events. Last, it was found that females from the ‘emotional abuse/neglect’ class reported stronger feelings of failing in every situation compared to the females from the ‘low maltreatment’ class. In the third domain impaired limits, only one significant result was found between the ‘severe maltreatment’ and the ‘low maltreatment’ class on the schema insufficient self-control. The females who experienced higher rates of physical and sexual abuse in the severe class had a higher score on the schema insufficient self-control, meaning they had more difficulties with
14 controlling their emotions and impulses.
In the fourth domain other directedness, significant results were also found between the ‘severe maltreatment’ and the ‘low maltreatment’ class on both schemas; subjugation and self-sacrifice. Females who experienced more severe forms of maltreatment had the tendency to extremely focus on other’s needs and had the tendency to meet the needs of others at the expense of their own needs.
In the last domain over-vigilance and inhibition, only significant differences were found between the ‘severe maltreatment’ and ‘low maltreatment’ class on both schemas; emotional inhibition and unrelenting standards. Females who suffered of more severe maltreatment, demonstrate more suppressed spontaneity and impulsivity in order to avoid making mistakes.
15 Table 4
Comparison of the different profiles and schemas
A Comparison Moyenne 3-step analysis in M-plus with * p significant with α ≤ 0.05 or ** p significant with α ≤ 0.01
Domain Schema 1 Emotional
abuse/neglect N37 2 Severe maltreatment N29 3 Low maltreatment N66 Comparison
Mean S.E. Mean S.E. Mean S.E. Overall test 1 VS 2 1 VS 3 2 VS 3
Disconnection Abandonment 16.75 1.315 19.45 1.31 13.95 0.90 12.39 0.00** 1.99 0.00** 2.95 0.09 11.90 0.00** Mistrust abuse 14.39 1.19 15.45 1.23 9.84 0.78 18.98 0.00** 0.35 0.56 9.45 0.00** 14.53 0.00** Emotional deprivation 15.80 1.40 18.72 1.59 8.50 0.72 47.12 0.00** 1.68 0.19 20.42 0.00** 32.51 0.00** Defectiveness shame 8.35 1.53 11.93 1.97 6.34 0.39 16.50 0.00** 1.32 0.25 1.69 0.19 7.49 0.01** Social isolation 12.39 1.21 14.28 1.28 8.88 0.62 18.86 0.00** 1.03 0.31 6.41 0.01** 14.45 0.00** Impaired autonomy Dependence / incompetence 9.27 0.95 10.32 0.94 7.40 0.37 12.76 0.00** 0.49 0.49 3.33 0.07 8.31 0.00** Vulnerability to Harm 10.16 0.97 13.75 1.256 8.65 0.62 13.43 0.00** 4.36 0.04* 1.73 0.19 12.68 0.00** Enmeshment Undeveloped self 9.47 1.15 9.88 1.28 8.44 0.52 1.66 0.44 0.05 0.82 0.66 0.42 1.09 0.297 failure 8.50 1.12 10.50 1.43 6.23 0.37 15.38 0.00** 0.91 0.34 3.76 0.05* 8.28 0.00** Impaired limits Entitlement grandiosity 12.39 0.99 13.01 1.28 10.98 0.58 3.13 0.21 0.13 0.72 1.47 0.23 2.08 0.15 Insufficient self-control 11.48 0.87 12.91 1.06 9.76 0.62 7.39 0.03* 1.00 0.32 2.48 0.12 6.49 0.01** Other-directedness Subjugation 8.69 0.97 10.17 1.37 6.97 0.30 9.80 0.01** 0.63 0.43 2.88 0.09 5.25 0.02* self-sacrifice 20.65 1.33 23.56 1.22 18.05 0.67 16.30 0.00** 2.43 0.12 2.87 0.09 15.41 0.00** Overvigilance/Inhibiton Emotional inhibition 10.52 1.10 13.41 1.37 9.53 0.63 6.74 0.03* 2.39 0.12 0.61 0.44 6.51 0.01** Unrelenting standards 14.84 1.04 17.12 0.91 14.36 0.64 6.12 0.05* 2.52 0.11 0.15 0.70 6.04 0.01**
16 Discussion
The aim of this study was to discover if there were differences in early maladaptive schemas among females with a history of residential placement and different maltreatment profiles. To date, research has mainly focused on the effect of single type maltreatment on early maladaptive schemas. However, co-occurrence and severity of the experience are important parameters to take into account when assessing the effects of child maltreatment. In this study, three profiles were identified among females; the ‘severe maltreatment’ class, ‘emotional abuse/neglect’ class and the ‘low maltreatment’ class. The results of this study indicate that seriousness of, and differences between, child maltreatment profiles could contribute to different elevated maladaptive schemas. Multiple interesting findings were found.
The first finding was that females who experienced severe forms of maltreatment, had more elevated schemas on every domain compared to the females who experienced milder forms child maltreatment. The females in the severe class reported a three times higher score on sexual abuse and two times higher score on the other forms of maltreatment, reflecting the seriousness of their abuse experiences. This result is supporting Young’s assumption that children, growing up in a more adverse environment, develop more elevated maladaptive schemas, to be able to cope with the toxic situation (Young et al., 2003).
Secondly, there were only two differences found between the ‘severe maltreatment’ class and ‘emotional abuse/neglect’ class. One explanation could be found in the maltreatment profiles of the females. Their profiles were nearly the same, except for the rate of physical and sexual abuse. The ‘severe maltreatment’ class reported a three times higher score on sexual abuse and one and a half times higher scores on physical abuse, compared to the ‘emotional abuse/neglect’ class. Edwards et al., (2003); Cukor & McGinn., (2003); Estevez et al., (2019) and Harding, Burns & Jackson (2012) where stating, that the combination of sexual and physical abuse results is more elevated schemas. Consequently, one would expect that the
17 severe class should have worsened schemas over all domains, because of the high rates of physical and sexual abuse. Nonetheless, the females in the ‘severe maltreatment class in this study, did not differ that on every domain from the females in the ‘emotional abuse/neglect’ class. One reason for this could be that the study of Edwards et al., (2003) focusses on a mixed sample of females and males in a high school setting, where current study only focused on females in a clinical residential setting.
Still, in this study, two differences were found between these two classes. It was found that females who had suffered from severe maltreatment reported greater fears of getting hurt and had higher believes they could not prevent getting hurt, vulnerability to harm. One explanation for this could be found in the different types and severity of maltreatment the females were exposed to. The females in the ‘emotional abuse/neglect’ class, were mainly exposed to emotional abuse or neglect. Where neglect is characterized by the absence of support and lack of affection and emotional abuse by the verbal aggression and the disparaging behavior of the parents towards the child. These types of maltreatment therefore does not involve direct physical violence, does not leave physical injuries and is more characterized by the psychological violence. On the other hand the females in the ‘severe maltreatment’ class have suffered of more physical and sexual abuse. These types of maltreatment are including more direct physical pain. Literature states that physical and sexual abuse makes the victims feel powerlessness, it is overcoming them, and they do not have any influence on the negative event. They could develop a form of learned helplessness (Nuvvula, 2016). Seligman (1972) described learned helplessness as failing to escape shock induced by uncontrollable aversive events. For some children, the only way to survive, is to repress their experiences. They learn to distrust their thoughts, instincts, and emotions. Furthermore, repeatingviolence sends a clear message to the child that it is a normal and unavoidable happening (Miller, 2006). These differences in types of violence namely; the physical or mental pain, could be the reason that females in the
18 ‘severe maltreatment’ class, who have experienced higher levels physical pain, have developed the schema vulnerability to harm and fear for external catastrophes such as victimization and that they cannot prevent such negative events.
The last finding worth to mention is that females who have experienced high rates of emotional abuse and neglect compared to the females who have experienced lower forms of maltreatment, had more elevated schemas of mistrust abuse, emotional deprivation and, social isolation. Noteworthy is that all these schemas are a part of the rejection/disconnection domain, referring to the expectation that relationships in any context would not provide any stability. This is in line with Karatzias et al., (2016) and Calvette (2014) who indicated that females with a history of interpersonal trauma displayed elevated levels of maladaptive schemas with regard to disconnection. One explanation for this could be found in the type of maltreatment, the females suffered from high rate emotional neglect and abuse. Emotional neglect expresses itself in a lack of verbal affection, encouragement, intellectual stimulation, and the absence of support as parents are not physically home or do not take care of the physical needs of their children (Ney, Fung & Wickett, 1994). Where emotional abuse is represented by acts of verbal abuse, spurning, or terrorizing the child (Wright, Crawford & Castillo, 2008). Furthermore, Young (1994) characterizes families where this problem occurs as, ‘detached, cold, rejecting, withholding, lonely, explosive, unpredictable, or abusive.’. Therefore, it is not surprising that females growing up in this kind of environment are developing more elevated schemas on the disconnection/rejection domain because they perceive that no one would fulfill their needs.
To date, little attention has been given towards child maltreatment profiles and cognitions. However, the findings above suggest that different maltreatment profiles and severity of maltreatment could lead to different levels and types of early maladaptive schemas. Young (1994) states that when an individual has more elevated levels of early maladaptive
19 schemas, these inadequate schemas tend be activated in a higher number of different situations, resulting in misinterpretations of other’s behaviors (Young, 1994; Chapter 1). This is interesting for clinical practice because following the Risk Needs Responsivity (RNR) principles of effective treatment, treatment should be aligned with the individual’s risks and needs to lower the risk factors for victimization (Andrews & Bonta, 2006). This indicates that an individual with more elevated schemas should have a more intensive treatment. Another reason why treatment should be aligned with the clients need, is that research showed that the drop-out rates for girls in residential care are relatively high (Sunseri, 2003). This is alarming because youths who drop out of care show more negative outcomes than youths who do not drop out (Robbins, Turner, Alexander, & Perez, 2003). Andrews and Bonta (2007) showed that treatment embracing the RNR principles could help with lower dropout rates (Andrews & Bonta, 2007).
Accordingly, this indicates that the different classes could benefit of different treatment. First of all, the severe maltreatment class should have more intensive treatment, because they have more elevated schemas in every domain. Their schemas are more persistent which means that it is harder to change them because of the chronicity. Secondly, the treatment of the emotional abuse/neglect group should have a higher focus on the disconnection/rejection domain. This group has higher feelings of getting abandonment, and rejected by others and have difficulties with trusting others. Hence, emotional abuse is characterized by insecure attachment and it is reasonable these females will have more doubt about seeking safety and emotional regulation in treatment (Hart et al., 1997; Cloire et al., 2008). This means, considering their more elevated schema in the disconnection domain and the type of maltreatment they suffered of, that these females could have more difficulties with trusting the therapist, which in the end could influence the therapeutic relationship. However, research showed that a therapeutic relationship with the client is the basis for good treatment (Sainsbury, Krishnan & Evans, 2004).
20 Therefore, the treatment for females who have experienced high rates of emotional abuse and neglect should first focus on this therapeutic relationship.
One treatment developed to change one’s maladaptive schemas is; schema therapy. Schema therapy is an integration of different therapies and theories such as: cognitive behavior therapy, interpersonal psychotherapy and the attachment theory, focusing on the client’s early maladaptive schema’s. Schema therapy is used to perceive, recognize and change old maladaptive me behavior into new adaptive behavior (Young, 1994). Moreover, within schema therapy the therapist tries to influence the perception and meaning attached to trauma experiences (Boterhoven, Haan, Hayes, Fassbinder, Lee, 2019). The effectiveness of schema therapy is well proved on personality disorders, substance abuse, anorexia and psychotic disorders (Young, Bernstein, 2003, Masley et al., 2018). In 2003, Young added modes, to his model for understanding the more complex schema representations. Modes are referring to the moment to moment emotional and behavioral state of a person at a given time. This addition is particularly beneficial for complex schema presentations, such as individuals who often present a number of active schemas simultaneously (Young et al., 2003). The girls in the ‘severe maltreatment’ class could therefore provide from schema therapy since they have different schemas and multiple complex traumas.
Furthermore the females in the emotional abuse/neglect class could also benefit from schema therapy because schema therapy emphasis on building a therapeutic relationship. In all treatments, the therapeutic relationship is seen as the foundation for change to occur (Hurley, Lambert, Ryzin, Sullivan & Stevens, 2013). Schema therapy is focusing on the early maladaptive schemas arising when core needs are not met, schema therapists aim to identify and meet these previously unmet needs by using a variety of conversations techniques supporting the therapeutic relationship (Masley, Gillanders, Simpson, & Taylor 2012). Because
21 of this focus on the unmet needs of a client, schema therapy is a good option for the females in the ‘emotional abuse/neglect’ class.
Limitations
A strength of this study is that it is one of the first studies which is taking into account child maltreatment profiles in females with a residential care history and early maladaptive schemas. Another strength of the study is the person-centered focus of this research, taking into account both the severity and types of child maltreatment. This gives the current study a higher generalizability and makes it more relevant for the use in clinical practice where one should focus on the personal needs of a client (Warmingham et al., 2019). Nevertheless, this study also comes with a number of limitations.
First of all, the specific target group of this study affects the generalizability. The sample only exists of young adult females with a history of residential placement. Nevertheless, it is known that this group of females shares a numerous similarities with other clinical groups such as gender, problems in their home situation, behavior problems and mental health problems (Hussey & Guo, 2002; Baker & Purcell, 2005). From that perspective, this sample is a good representation of the females within out of home care.
Another limitation found in the sample is that the sample exists of females who were for different reasons in residential care. The demographics show that the main reason these females are in residential care is their behavior problems, and not child maltreatment. This is interesting because this study is focusing on the child maltreatment profiles of these females. However, as stated before, placement in residential centers is considered a last resort, reserved for young people with serious adjustment problems compromising their security and development. These problems are most often starting at home, were most children in residential care have experienced child maltreatment (Collin-Vézina et al. 2011; Connor, Doerfler,
22 Toscano, Volugis & Steingard., 2004).). So even though the demographics of this study show that maltreatment is not the main reason, one could imagine that the experiencing of child maltreatment could be an underlying factor of the female’s behavior problems.
The third and fourth limitations could be found in the measurements. First of all, the CTQ is a retrospective self-report. Retrospective measures of child maltreatment is not completely accurate, because it relies on the recall of events. Furthermore, self-report is based on own experiences. This together may lead to bias because of factors such as social desirability or limitations in recall (Walker, Bernstein & Keegar, 2007). However, the CTQ has been shown in previous research to provide reliable and valid data on adolescents’ maltreatment histories (Bernstein et al., 1997).
Another limitation in the measurements is that the Young Schema Questionnaire was only measured at time six when the females were already out of care. Hence, it could be that the treatment the females received already has affected their maladaptive schemas. Therefore, no causal relations nor conclusions could be drawn.
The last limitation is that no conclusions could be drawn about the relationship between early maladaptive schemas and child maltreatment. Next to child maltreatment, there could have been other factors that have influenced the early maladaptive schemas. The demographics for example, show that these females have multiple forms of behavioral problems. Therefore, it could be that other underlying factors have influenced the presence of early maladaptive schemas. For example, the transition into adulthood itself could already come with multiple behavior changes, mental health issues and stresses (MacLeod & Brownlie, 2014). This indicates that no conclusion could been drawn if the schemas are coming from the maltreatment profile or that other factors could have influenced the differences in schemas. However, this study is still a good start for further research. Future studies could elaborate on this study with taking into account extra parameters.
23 Conclusion
Altogether, clinical practice has shifted lately to a more client-centered approach, meaning that treatment is more and more personalized to the client’s needs and that the client is more leading during the treatment process. Research has shown that this approach contribute to better relationships with the clinician, treatment outcomes and prolonged results (Rogers, 1946). The person-orientated approach of the current study is supporting this client-centered approach, that the seriousness of the child maltreatment could contribute to different maladaptive schemas and that individuals therefore need a more intensive treatment based on their personal experience with maltreatment. Therefore, it is recommended that the clinical practice should have a more holistic approach taking into account both the severity and (different) type(s) of child maltreatment experiences during the treatment.
Acknowledgment
I would like to thank Dr. E.S. van Vugt for all her support, feedback, advice and most of all her time during the last year. Her positivity has supported me through the whole process. Further, I want to thank Prof. Dr. N. Lanctot for her input and specific feedback for improvements. I also want to thank both of them for their openness and social support during my stay in Canada. I learned a lot and had an amazing time in Montreal.
24 Literature
Ackard, D. M., Neumark-Sztainer, D., Hannan, P. J., French, S., & Story, M. (2001). Binge and purge behavior among adolescents: Associations with sexual and physical abuse in a nationally representative sample: the Commonwealth Fund survey. Child abuse &
neglect, 25(6), 771-785.
Afifi, T. O., & MacMillan, H. L. (2011). Resilience following child maltreatment: A review of protective factors. The Canadian Journal of Psychiatry, 56(5), 266-272
Atmaca, S., & Gençöz, T. (2016). Exploring revictimization process among Turkish women: The role of early maladaptive schemas on the link between child abuse and partner violence. Child abuse & neglect, 52, 85-93.
Bach, B., Simonsen, E., Christoffersen, P., & Kriston, L. (2015). The Young Schema Questionnaire 3 Short Form (YSQ-S3). European Journal of Psychological Assessment. Baker, A. J., & Purcell, J. F. (2005). New York state residential treatment center admissions: Differences in histories of maltreatment, behavioral problems, and mental health problems. Residential Treatment for Children & Youth, 22(3), 39-53.
Bernstein, D. P., Fink, L., Handelsman, L., Foote, J., Lovejoy, M., Wenzel, K., et al. (1994). Initial reliability and validity of a new retrospective measure of child abuse and negect. American Journal or Psychiatry, 151, 1132-1136
Bernstein, D. P., Ahluvalia, T., Pogge, D., Handelsman, L. (1997). Validity of the Childhood Trauma Questionnaire in an adolescent psychiatric population. Journal of the American Academy of Child & Adolescent Psychiatry, 36 (3), 340-348.
Bernstein, D. P., Stein, J. A., Newcomb, M. D., Walker, E., Pogge, D., Ahluvalia, T., & Zule, W. (2003). Development and validation of a brief screening version of the Childhood Trauma Questionnaire. Child abuse & neglect, 27(2), 169-190.
25
Boterhoven de Haan, K. L., Fassbinder, E., Hayes, C., & Lee, C. W. (2019). A schema therapy
approach to the treatment of posttraumatic stress disorder. Journal of Psychotherapy
Integration, 29(1), 54.
Bonta, J., & Andrews, D. A. (2007). Risk-need-responsivity model for offender assessment and rehabilitation. Rehabilitation, 6(1), 1-22.
Brewin, C. R., & Holmes, E. A. (2003). Psychological theories of posttraumatic stress disorder. Clinical psychology review, 23(3), 339-376.
Briggs, E. C., Greeson, J. K. P., Layne, C. M., Fairbank, J. A., Knoverek, A. M., & Pynoos, R. S. (2012). Trauma exposure, psychosocial functioning, and treatment needs of youth in residential care: preliminary findings from the NCTSN Core Data Set. Journal of Child and Adolescent Trauma, 5, 1–15.
Calvete, E. (2014). Emotional abuse as a predictor of early maladaptive schemas in adolescents: Contributions to the development of depressive and social anxiety symptoms. Child abuse & neglect, 38(4), 735-746.
Cantón-Cortés, D., Cantón, J., Justicia, F., & Cortés, M. R. (2011). A model of the effects of child sexual abuse on post-traumatic stress: The mediating role of attributions of blame and avoidance coping. Psicothema, 23(1), 66-73.
Choi, H. J., Weston, R., & Temple, J. R. (2017). A three-step latent class analysis to identify how different patterns of teen dating violence and psychosocial factors influence mental health. Journal of youth adolescence 46(4), 854-866.
Cloitre, M., Stovall‐McClough, C., Zorbas, P., & Charuvastra, A. (2008). Attachment organization, emotion regulation, and expectations of support in a clinical sample of women with childhood abuse histories. Journal of Traumatic Stress: Official Publication of The International Society for Traumatic Stress Studies, 21(3), 282-289.
26
Collin-Vézina, D., Coleman, K., Milne, L., Sell, J., & Daigneault, I. (2011). Trauma experiences, maltreatment-related impairments, and resilience among child welfare youth in residential care. International Journal of Mental Health and Addiction, 9(5), 577-589.
Connor, D. F., Doerfler, L. A., Toscano, P. F., Volungis, A. M., & Steingard, R. J. (2004). Characteristics of children and adolescents admitted to a residential treatment center. Journal of Child and Family Studies, 13(4), 497-510.
Cortés, M. A., Cantón, J. D., & Canton-Cortes, D. (2011). Characteristics of sexual abuse of minors and its consequences on victims' mental health. Gaceta sanitaria, 25(2), 157-165.
Cukor, D., & McGinn, L. K. (2006). History of child abuse and severity of adult depression: The mediating role of cognitive schema. Journal of Child Sexual Abuse: Research, Treatment, and Program Innovations f
Edwards, V. J., Holden, G. W., Felitti, V. J., & Anda, R. F. (2003). Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: results from the adverse childhood experiences study. American Journal
of Psychiatry, 160(8), 1453-1460.
Estévez, A., Jauregui, P., Ozerinjauregi, N., & Herrero-Fernández, D. (2017). The role of early maladaptive schemas in the appearance of psychological symptomatology in adult women victims of child abuse. Journal of child sexual abuse 26(8), 889-909.
Estévez, A., Ozerinjauregi, N., Herrero-Fernández, D., & Jauregui, P. (2019). The mediator role
of early maladaptive schemas between childhood sexual abuse and impulsive symptoms
in female survivors of CSA. Journal of interpersonal violence, 34(4), 763-784.
Evans, G. W., Li, D., & Whipple, S. S. (2013). Cumulative risk and child
27
Finkelhor, D., Ormrod, R., Turner, H., & Hamby, S. L. (2005). The victimization of children and youth: A comprehensive, national survey. Child maltreatment, 10(1), 5-25.
Gibb, B. E. (2002). Childhood maltreatment and negative cognitive styles: A quantitative and
qualitative review. Clinical psychology review, 22(2), 223-246.
Gould, F., Clarke, J., Heim, C., Harvey, P. D., Majer, M., & Nemeroff, C. B. (2012). The effects of child abuse and neglect on cognitive functioning in adulthood. Journal of psychiatric
research, 46(4), 500-506.
Harding, H. G., Burns, E. E., & Jackson, J. L. (2012). Identification of child sexual abuse survivor subgroups based on early maladaptive schemas: Implications for understanding differences in posttraumatic stress disorder symptom severity. Cognitive Therapy Research 36(5), 560-575.
Hart, S. N., Binggeli, N. J., & Brassard, M. R. (1997). Evidence for the effects of psychological maltreatment. Journal of Emotional Abuse, 1(1), 27-58.
Hazen, A. L., Connelly, C. D., Roesch, S. C., Hough, R. L., & Landsverk, J. A. (2009). Child maltreatment profiles and adjustment problems in high-risk adolescents. Journal of
interpersonal violence, 24(2), 361-378.
Higgins, D. J. (2004). The importance of degree versus type of maltreatment: A cluster analysis of child abuse types. The Journal of Psychology, 138(4), 303-324.
Hussey, D. L., & Guo, S. (2002). Profile characteristics and behavioral change trajectories of young residential children. Journal of Child and Family Studies, 11(4), 401-410. Ireland, T. O., Smith, C. A., & Thornberry, T. P. (2002). Developmental issues in the impact of
28 Karatzias, T., Jowett, S., Begley, A., & Deas, S. (2016). Early maladaptive schemas in adult survivors of interpersonal trauma: foundations for a cognitive theory of psychopathology. European journal of psychotraumatology, 7(1), 30713.
Lanctôt, N., & Lemieux, A. (2012). Expression et régulation de la colère: Les effets d’un programme cognitif-comportemental appliqué à des adolescentes hébergées en centre de réadaptation. Revue de psychoéducation, 41(2), 209-229.
Lau, A. S., Leeb, R. T., English, D., Graham, J. C., Briggs, E. C., Brody, K. E., & Marshall, J. M. (2005). What's in a name? A comparison of methods for classifying predominant type of maltreatment. Child abuse & neglect, 29(5), 533-551.
Leenarts, L. E., Hoeve, M., Van de Ven, P. M., Lodewijks, H. P., & Doreleijers, T. A. (2013). Childhood maltreatment and motivation for treatment in girls in compulsory residential care. Children and Youth Services Review, 35(7), 1041-1047.
Masley, S. A., Gillanders, D. T., Simpson, S. G., & Taylor, M. A. (2012). A systematic review of the evidence base for schema therapy. Cognitive Behaviour Therapy, 41(3), 185-202. MacLeod, K. B., & Brownlie, E. B. (2014). Mental health and transitions from adolescence to emerging adulthood: developmental and diversity considerations. Canadian Journal of
Community Mental Health, 33(1), 77-86.
McGinn, L. K., & Young, J. E. (1996). Schema-focused therapy.
van der Molen, E. V. R. R. J. M., Vermeiren, R. R. J. M., Krabbendam, A. A., Beekman, A. T. F., Doreleijers, T. A. H., & Jansen, L. M. C. (2013). Detained adolescent females’ multiple mental health and adjustment problem outcomes in young adulthood. Journal
of child psychology and psychiatry, 54(9), 950-957.
Maniglio, R. (2009). The impact of child sexual abuse on health: A systematic review of reviews. Clinical psychology review, 29(7), 647-657.
29
Mansell, J., & Beadle‐Brown, J. (2004). Person‐centred planning or person‐centred action? Policy and practice in intellectual disability services. Journal of Applied Research in
Intellectual Disabilities, 17(1), 1-9.
Merkel-Holguin, L., Fluke, J. D., & Krugman, R. D. National Systems of Child Protection.
Miller, D. K. (2006). The effects of childhood physical abuse or childhood sexual abuse in battered women's coping mechanisms: Obsessive-compulsive tendencies and severe depression. Journal of Family Violence, 21(3), 185-195.
Norman, R. E., Byambaa, M., De, R., Butchart, A., Scott, J., & Vos, T. (2012). The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS medicine, 9(11), e1001349.
Nuvvula, S. (2016). Learned helplessness. Contemporary clinical dentistry, 7(4), 426.
Public Health Agency of Canada, (2010). Canadian Incidence Study of Reported Child Abuse
and Neglect – 2008: Major Findings. Retrieved from:
https://cwrp.ca/sites/default/files/publications/en/CIS-2008-rprt-eng.pdf.
Paivio, S. C., & Cramer, K. M. (2004). Factor structure and reliability of the Childhood Trauma Questionnaire in a Canadian undergraduate student sample. Child abuse & neglect, 28(8), 889-904.
Pears, K. C., Kim, H. K., & Fisher, P. A. (2008). Psychosocial and cognitive functioning of children with specific profiles of maltreatment. Child abuse & neglect, 32(10), 958-971. Pérez-González, A., Guilera, G., Pereda, N., & Jarne, A. (2017). Protective factors promoting
resilience in the relation between child sexual victimization and internalizing and externalizing symptoms. Child abuse & neglect, 72, 393-403.
Rezaei, M., & Ghazanfari, F. (2016). The role of childhood trauma, early maladaptive schemas, emotional schemas and experimental avoidance on depression: A structural equation modeling. Psychiatry research, 246, 407-414.
30 Rogers, C. R. (1946). Significant aspects of client-centered therapy. American
Psychologist, 1(10), 415-422.
Robbins, M. S., Turner, C. W., Alexander, J. F., & Perez, G. A. (2003). Alliance and dropout in family therapy for adolescents with behavior problems: individual and systemic effects. Journal of Family Psychology, 17(4), 534.
Sainsbury, L., Krishnan, G., & Evans, C. (2004). Motivating factors for male forensic patients with personality disorder. Criminal Behaviour and Mental Health, 14(1), 29-38. Schmidt, N. B., Joiner, T. E., Young, J. E., Telch, M. J., & research. (1995). The schema
questionnaire: Investigation of psychometric properties and the hierarchical structure of a measure of maladaptive schemas. Journal of Cognitive therapy, 19(3), 295-321. Seligman, M. E. (1972). Learned helplessness. Annual review of medicine, 23(1), 407-412.
Seto, M. C., Babchishin, K. M., Pullman, L. E., & McPhail, I. V. (2015). The puzzle of intrafamilial child sexual abuse: A meta-analysis comparing intrafamilial and extrafamilial offenders with child victims. Clinical psychology review, 39, 42-57. Simone, L., Wettstein, A., Senn, O., Rosemann, T., & Hasler, S. (2016). Types of abuse and
risk factors associated with elder abuse. Swiss medical weekly, 146(0304).
Sunseri, P. A. (2003). Predicting treatment termination due to running away among adolescents in residential care. Residential Treatment for Children & Youth, 21(2), 43-60.
Tanaka, M., Wekerle, C., Schmuck, M. L., Paglia-Boak, A., & MAP Research Team. (2011). The linkages among childhood maltreatment, adolescent mental health, and self-compassion in child welfare adolescents. Child Abuse & Neglect, 35(10), 887-898. Ney, P. G., Fung, T., & Wickett, A. R. (1994). The worst combinations of child abuse and
neglect. Child abuse & neglect, 18(9), 705-714.
31
Van Wijk-Herbrink, M. F., Broers, N. J., Roelofs, J., & Bernstein, D. P. (2017). Schema therapy in adolescents with disruptive behavior disorders. International Journal of Forensic
Mental Health, 16(3), 261-279.
Wenninger, K., & Ehlers, A. (1998). Dysfunctional cognitions and adult psychological functioning in child sexual abuse survivors. Journal of Traumatic Stress: Official
Publication of The International Society for Traumatic Stress Studies, 11(2), 281-300.
Witt, A., Münzer, A., Ganser, H. G., Fegert, J. M., Goldbeck, L., & Plener, P. L. (2016). Experience by children and adolescents of more than one type of maltreatment: association of different classes of maltreatment profiles with clinical outcome variables. Child Abuse & Neglect, 57, 1-11.
Wright, M. O. D., Crawford, E., & Del Castillo, D. (2009). Childhood emotional maltreatment and later psychological distress among college students: The mediating role of maladaptive schemas. Child abuse & neglect, 33(1), 59-68.
Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner's guide. Guilford Press.
Young, J. E., & Brown, G. (1994). Young schema questionnaire. Cognitive therapy for personality disorders: A schema-focused approach, 63-76.
Zelechoski, A. D., Sharma, R., Beserra, K., Miguel, J. L., DeMarco, M., & Spinazzola, J.
(2013). Traumatized youth in residential treatment settings: Prevalence, clinical
presentation, treatment, and policy implications. Journal of Family Violence, 28(7),
32 Appendix I
Table 1
Description of the domains, the EMS scales and belonging items with their alpha
Domains EMS scale Description Item α (n=132)
Disconnection/Rejection Abandonment The belief that others will abandon them or won’t be available for emotional support
I cling to people I am close to because I am afraid to lose them.
0.87
Mistrust/Abuse The belief that others will take advantages of them for own selfish ends
I have the impression that others will take advantage of me
0.89 Emotional Deprivation The belief that the desire for emotional
support will not be adequately realized by others
I rarely need a strong person to give me good advice or to guide me when I did not know what to do.
0.94
Defectiveness/Shame The belief that one is defective, bad, unwanted and inferior of another.
I do not deserve other’s people love, attention and respect.
0.91 Social Isolation/Alienation The belief that one is isolated, different
and does not belong somewhere
I do not fit in 0.85
Impaired Autonomy Dependence/Incompetence The belief that one is unable to handle everyday responsibilities without help from others
I think of myself as a dependent person, when it comes to everyday functioning.
0.75
Vulnerability to Harm or Illness
The belief that they are unable to overcome forthcoming tragic events that are coming to them
I feel that a disaster (natural, criminal, financial, or medical) could strike at any moment
0.78
Enmeshment/Undeveloped Self
The belief that one cannot meet an individual identity because of over involve to significant others
My parents and I tend to be over involved in each other’s problems
0.78
Failure to achieve The belief that one constantly fails I'm not as talented as most people are at their school/work
33 Impaired Limits Entitlement/Grandiosity The belief that one is superior to others
and has special privileges
I feel that I should not have to follow the normal rules and conventions that other people do
0.73 Insufficient
Self-Control/Self-Discipline
The belief that one cannot regulate expression of emotions and impulses
I have trouble finishing daily chores or boring tasks.
0.75 Other-Directedness Subjugation The belief that one needs to be in control
of everything and others
I have always let others make choices for me, so I really don't know what I want for myself
0.78 Self-Sacrifice The tendency to meet the needs of others
at the expense of their own needs
I am a good person because I think more about others than myself.
0.85 Overvigilance and
Inhibition
Emotional Inhibition The excessive inhibition of spontaneous action, feeling or communication
I control myself so much that people think I am unemotional
0.84 Unrelenting Standards/
Hyper criticalness
The belief that one must strive to meet the very high internalized standards of behavior and performance
