Child multi-type maltreatment and associated depression and PTSD symptoms: The role of social support and stress

Abstract

Objective

This retrospective, cross-sectional study explored the hypothesis that multiple forms of child abuse and neglect (child multi-type maltreatment; CMM) would be associated with women's lower social support and higher stress in adulthood, and that this, in turn, would amplify their vulnerability to symptoms of depression and posttraumatic stress disorder (PTSD).

Method

Participants were 100 women recruited from an inner-city gynecological treatment center for low-income women. Data were analyzed via structural equation modeling (SEM) with Lisrel 8.0.

Results

CMM was directly predictive of decreased social support and increased stress in adulthood. CMM was also directly predictive of PTSD symptoms, but not depression symptoms in adulthood. Social support partially mediated the relationship between CMM and adult PTSD symptoms, and stress fully mediated the relationship between CMM and adult symptoms of depression.

Conclusions

Findings support both direct and mediational effects of social resources on adult depression and PTSD symptoms in women with histories of CMM, suggesting that resources are key factors in psychological adjustment of CMM victims.

Résumé/Resumen

French- and Spanish-language abstracts not available at time of publication.

Introduction

Child maltreatment's negative impact often persists into adulthood. Two potentially negative outcomes of child maltreatment are post-traumatic stress disorder (PTSD) and depression (e.g., Browne & Finkelhore, 1986; Schaaf & McCanne, 1998; Shalev et al., 1998). A connection between child maltreatment and adult depression and PTSD has already been established (e.g., Briere & Runtz, 1988). Recently there has been a proliferation of theoretical and empirical work suggesting that social support and stress are key intervening factors in the manner in which maltreatment survivors function psychologically in adulthood. However, few attempts have been made to test the role of social support and stress simultaneously with victims of child maltreatment. Hence, the purpose of this study is to integrate stress and social support into one model, in an attempt to understand the etiological processes in the mental health of child maltreatment survivors.

Previous research has mainly focused on the effects of single types of maltreatment, typically sexual abuse (e.g., Briere & Runtz, 1993; Paolucci & Violato, 2001), and to a lesser extent physical abuse and neglect (e.g., Malinosky-Rummell & Hansen, 1993), emotional abuse (e.g., Briere & Runtz, 1988; O’Hagan, 1995), and witnessing family violence (e.g., Parkinson & Humphrey, 1998). However, most maltreated children experience more than one form of abuse and neglect (Kinard, 1994). This co-existence of multiple types of maltreatment (e.g., sexual abuse, physical, emotional, neglect and witnessing family violence) is termed in the maltreatment literature as child multi-type maltreatment (CMM; Higgins & McCabe, 2001b).

Prior investigations identified a general, rather than a unique effect of a particular type of maltreatment on adult psychological functioning (Varia, Abidin, & Dass, 1996; Widom & Ames, 1994). In explaining this general effect, Emery (1989) argued that aversive arousal is common across all types of maltreatment, leading to employment of similar maladaptive coping mechanisms, and indirectly to similar negative psychological outcomes. Higgins and McCabe, 1994, Higgins and McCabe, 2000 and Zlotnick et al. (1996) argued that studies that found a unique, rather than a general effect of abuse did not assess other forms of abuse and neglect.

Accordingly, results of such studies may, in fact, reflect the cumulative effect of multiple types of maltreatment that went unassesed. This thesis is consistent with previous research done by Felitti and co-workers (e.g., Chapman et al., 2004; Edwards, Holden, Felitti, & Anda, 2003; Felitti et al., 1998), that found a graded relationship between the number of adverse childhood experiences and adult physical and psychological distress.

Individuals who were maltreatmented as children have smaller supportive networks, are less satisfied with their supportive networks (Gibson & Harthorne, 1996; Harmer, Sanderson, & Mertin, 1999) and perceive their relationships as less supportive (Stroud, 1999). One potential explanation for these effects is that the maltreatment causes distortions in children's cognitions regarding themselves and others. These distortions become internalized, leading to unhealthy adult relationships (Briere, Berliner, Bulkley, Jenny, & Reid, 1996). It is also likely that maltreated children have less actual support in adulthood because their potential family support is limited as their parents and siblings may have been perpetrators, or may have suffered maltreatment experiences (Browne & Finkelhore, 1986), and thus may be ineffectual as supporter providers (Elliot & Carnes, 2001). In addition, often children who were maltreated grew up in dysfunctional family environments, and may have poor scripts for healthy adult relationships (Browne & Finkelhor, 1996). This social support linkage is important because low social support is consistently related to depression (Brown & Harris, 1987; Cutrona & Troutman, 1986; Dohrenwend, 2000).

Recent research supports the connection between social support and PTSD in adulthood. Studies in veteran samples and victims of natural disasters indicate that low levels of social support after the traumatic event are related to PTSD symptoms (Gold et al., 2000). Further, recent research asserts that individuals newly diagnosed with PTSD endorse lower levels of social support when compared to controls (Kotler, Iancu, Efroni, & Amir, 2001; Widows, Jacobsen, & Fields, 2000). Brewin, Andrews, and Valantines (2000) confirmed these assertions in a recent meta-analysis of studies assessing populations exposed to trauma in adulthood, where he found that lack of social support was a major risk factor in the development of PTSD.

In addition to having impaired social support, women with a history of child maltreatment are more susceptible to the effects of daily stressors (Thakkar & McCanne, 2000) and report more stress compared to their non-maltreated counterparts (Harmer et al., 1999). Moreover, survivors of maltreatment may perceive life events as more stressful because of their predisposition to a pervasive sense of helplessness (Seligman, 1975) and decreased coping resources (Cole & Putnam, 1992; Davis, Petric-Jackson, & Ting, 2001).

The role of stress in the development of depression has been extensively studied. The majority of studies support the critical role of stress in provoking episodes of depression, including clinical depression among vulnerable individuals (Brown & Harris, 1987; Dohrenwend, 2000, Hammen, 1999). Some individuals may develop only depression following a traumatic stress, whereas others develop PTSD or depression and PTSD.

Although extensive research shows that traumatic stressors lead to the development of PTSD, less research has been conducted on the role of stress in the development of PTSD in victims of child maltreatment. Theories of the effect of traumatic events posit that either the whole event or aspects of the events are carved onto the memory of individuals (Horowitz, Wilner, & Alvarez, 1979). These stimuli that are associated with the event are theorized to become cues that evoke both the visualization and the negative emotions that were originally associated with the occurrences when the new stressors occur. In this vein, Brewin, Andrews, and Valantines (2000) provided evidence that post trauma life stressors place individuals traumatized in adulthood at risk of PTSD. However, former victims’ adult sensitivity to new stressors has not been appropriately tested in victims of child maltreatment, and to our knowledge, has never been assessed in women with histories of CMM.

This review leads to an overarching model that specifies how social support and stress can act and be depicted as potential mediators between CMM and depression or PTSD symptoms (see Fig. 1).

The purpose of the current study was to provide a better understanding of the mechanism through which CMM may negatively impact women's lives, by examining the role of social support and stress in the development of depression and PTSD. The present study was built on limitations of previous research by including social support and stress within a comprehensive model and by assessing multiple forms of child maltreatment experienced by women during childhood.

We hypothesized that CMM would be related to women having lower levels of social support and greater exposure to stress during adulthood. We further predicted that this lower social support and greater stress exposure would be related to greater vulnerability to depression and posttraumatic stress disorder (PTSD) symptoms in adulthood.