Elsevier

Journal of Affective Disorders

Volume 225, 1 January 2018, Pages 306-312
Journal of Affective Disorders

Research paper
Cumulative childhood trauma, emotion regulation, dissociation, and behavior problems in school-aged sexual abuse victims

https://doi.org/10.1016/j.jad.2017.08.044Get rights and content

Highlights

  • Several sexually abused children experience at least one other form of maltreatment.

  • Emotion regulation and dissociation mediate the relation between cumulative childhood trauma and outcomes.

  • Fostering emotion regulation could decrease dissociation and favor adaptation in abused children.

Abstract

Background

Child sexual abuse is associated with a plethora of devastating repercussions. A significant number of sexually abused children are likely to experience other forms of maltreatment that can seriously affect their emotion regulation abilities and impede on their development. The aim of the study was to test emotion regulation and dissociation as mediators in the association between cumulative childhood trauma and internalized and externalized behavior problems in child victims of sexual abuse.

Methods

Participants were 309 sexually abused children (203 girls and 106 boys; Mean age = 9.07) and their non-offending parent. Medical and clinical files were coded for cumulative childhood trauma. At initial evaluation (T1), parents completed measures assessing children's emotion regulation abilities and dissociation. At Time 2 (T2), parents completed a measure assessing children's behavior problems. Mediation analyses were conducted with emotion regulation and dissociation as sequential mediators using Mplus software.

Results

Findings revealed that cumulative childhood trauma affects both internalized and externalized behavior problems through three mediation paths: emotion regulation alone, dissociation alone, and through a path combining emotion regulation and dissociation.

Limitations

Both emotion regulation and dissociation were assessed at T1 and thus the temporal sequencing of mediators remains to be ascertained through a longitudinal design. All measures were completed by the parents.

Conclusions

Clinicians should routinely screen for other childhood trauma in vulnerable clienteles. In order to tackle behavior problems, clinical interventions for sexually abused youth need to address emotion regulation competencies and dissociation.

Introduction

Child sexual abuse (CSA) affects one out of five women and one out of ten men worldwide (Stoltenborgh et al., 2011). This highly prevalent social problem is associated with an array of long-term psychological, physical, and behavioral problems such as depression, suicidal ideations and attempts, substance dependence, posttraumatic stress disorder, sexual risk behaviors, and increased use of healthcare for physical health problems (Fergusson et al., 2013). While the last decades have seen major developments in research investigating long-term consequences of CSA among adults, studies of short-term correlates among children have been sparser, resulting in significant gaps in the scientific literature. Available studies indicate that sexually abused children are at higher risk of presenting a plethora of difficulties compared to non-abused children and even to children having sustained other forms of maltreatment (i.e., physical or emotional abuse, neglect), including behavior problems (Lewis et al., 2016, Maniglio, 2015), posttraumatic stress and dissociation symptoms (Hébert et al., 2016), as well as emotional dysregulation (Langevin et al., 2016, Shipman et al., 2000). Given the detrimental impacts of CSA on multiple aspects of child development, it is essential to further our understanding of the associated consequences of CSA with samples of children and explore the possible mechanisms linking CSA to negative outcomes.

Although CSA alone is sufficient to produce major dysfunctions, synergistic effects of cumulative childhood adversity – meaning that the interaction between two or more adverse experiences produces a greater combined effect than the sum of the individual effects – have been uncovered with adult samples in empirical studies (Putnam et al., 2013). Indeed, Putnam and colleagues found that the presence of four or more childhood adversities was associated with increased risk of presenting complex adult psychopathology. Furthermore, synergistic effects were found with specific combinations of trauma, several of which involved CSA (Putnam et al., 2013). Recently, a longitudinal study investigating adult functioning of survivors of childhood abuse and neglect found that exposure to a greater number of early adversities was associated with fewer years of education, higher levels of anxiety and depressive symptoms, and increased criminal arrests in adulthood (Horan and Widom, 2015). Number of trauma types also appears to be positively associated with dissociative symptoms in adults (Briere, 2006).

A study using a nationally representative sample of youth in the U.S. identified the occurrence of multiple trauma as a frequent phenomenon (Turner et al., 2015). According to this study, 21.3% of youth aged 10–17 years old have been victimized at school and at home, while 17.8% of them experienced polyvictimization (i.e., victimization occurring in multiple settings and involving multiple perpetrators). Polyvictimized children presented the worst outcomes in terms of delinquency and trauma symptom scores (Turner et al., 2015). Number of trauma types experienced was also associated with self-reported and caregiver-reported symptom complexity (i.e., clinical elevations in a variety of symptom clusters) in a clinical sample of school-aged children (Hodges et al., 2013). Finally, a study of sexually abused children found that cumulative childhood trauma was positively associated with emotional dysregulation and internalized and externalized behavior problems (Choi and Oh, 2014). Overall, studies tend to indicate that cumulative childhood trauma leads to more severe behavioral and psychological consequences than single experiences of trauma, both in adults and youth samples.

Emotion regulation difficulties and dissociative symptoms have been documented as potential consequences associated with CSA and cumulative childhood trauma in children and adults. While the two concepts of emotion regulation and dissociation are often studied separately, there are conceptual and empirical associations between them. Some authors view dissociation as a regulatory strategy falling in the category of over-modulation or over-regulation of emotions (Bennett et al., 2015, Lanius et al., 2010), while others perceive it as the consequence of failed emotion regulation attempts (Kalill, 2013, Chaplo et al., 2015). Ford (2013) advocates for a vision of dissociation as a biologically based self-regulatory response to extreme emotions. He suggests that fostering self-regulation abilities is essential to the treatment of dissociation. Dissociation was also conceptualized as an avoidance strategy used to face emotions that overwhelm internal affect regulation capacities following a trauma (Briere et al., 2010). Therefore, while some scholars view dissociation as an emotion regulation strategy, more experts in the field tend to see it as a result of deficits in the ability to effectively self-regulate intense emotions. Thus, deficits in the area of emotion regulation are hypothesized to precede the occurrence of dissociation symptoms.

Consistent with this idea, empirical studies found that emotional dysregulation predicted dissociative symptomatology in trauma-exposed adults and sexually abused youth offenders (Briere, 2006, Chaplo et al., 2015; Powers et al., 2015). In a sample of maltreated teenagers, emotional dysregulation was found to predict dissociation symptoms over and beyond the forms of maltreatment experienced, the number of perpetrators involved, as well as the age of onset (Sundermann and DePrince, 2015). Another study with an adult sample found that affect dysregulation mediated the effect of cumulative interpersonal trauma on dysfunctional avoidance (i.e., dissociation, tension reduction behaviors, substance abuse, and suicidality) (Briere et al., 2010). In trauma-exposed youth offenders, higher levels of emotional dysregulation – including both over and under-regulation of emotional arousal – were found in individuals presenting high levels of dissociation, when compared to those presenting low levels of dissociation. In sum, coherent with theoretical models, a number of empirical reports indicate that emotional dysregulation might predict dissociation levels in traumatized adults and adolescents. However, no available study, that we are aware of, has investigated these associations in a sample of children.

To understand how variables are associated with each other, mediation and moderation analyses are indicated (Hayes, 2013). A number of past mediation and moderation studies investigated the patterns of associations among maltreatment, emotion regulation, and mental health outcomes. Eisenberg and Morris (2002) offered a conceptualization of self-regulation, including emotional self-regulation, involving three styles of control: overcontrol, undercontrol and optimal control. Overcontrolled children are thought to exert excessive control over their emotions and behaviors, and are therefore at-risk for developing internalizing problems. On the other hand, undercontrolled children tend to be less able to regulate themselves effortfully and are therefore at-risk for developing externalizing problems (Eisenberg et al., 2013). This conceptualization highlights the theoretical associations between emotion regulation and behavior problems.

Empirical findings tend to confirm this association. A study involving a sample of young adults found that emotional dysregulation mediated the association between high-betrayal trauma (i.e., abuse perpetrated by a close individual, as opposed to abuse perpetrated by a stranger or trauma that are not caused by another human being) and various mental health symptoms including anxiety, depression, intrusions, and avoidance (Goldsmith et al., 2013). Emotion regulation was also found to mediate the association between maltreatment and internalized and externalized behavior problems in school-age samples (Alink et al., 2009, Kim-Spoon et al., 2013). In one of these studies, the mediation effect was only found in insecurely attached children (Alink et al., 2009). In another study of school-age children, emotion regulation mediated the association between cumulative childhood trauma and internalized and externalized behavior problems in sexually abused children (Choi and Oh, 2014). Finally, a study indicated that, even in the preschool period, emotion regulation mediated the association between CSA and parental reports of child behavior problems (Langevin et al., 2015).

The association between dissociation and behavior problems has been less studied in maltreated children samples. However, a recent study showed that internalized behavior problems were associated with dissociation over and beyond the effects of maternal dissociation and depression/anxiety, number of traumatic events, and child gender in a sample of preschool children (Hagan et al., 2015). Kisiel and Lyons (2001) found that dissociation mediated the association between CSA and behavior problems in children aged 10–18 years old. Furthermore, dissociation was found to mediate the relationships between CSA and a number of mental health symptoms (i.e., depression, somatization, compulsive behavior, phobic symptoms, and borderline personality disorder) in a clinical sample of women (Ross-Gower et al., 1998). Berthelot et al. (2012) also found that dissociation mediated the association between CSA and internalized and externalized behavior problems in their sample of children aged 2–12 years old. They suggested that dissociation predicts the onset of behavior problems because it prevents the integration, resolution, and mentalization of the traumatic event. As a result, sexually abused children might be kept in a state of powerlessness and confusion favoring the emergence of behavioral difficulties (Berthelot et al., 2012). Overall, past studies tend to indicate that emotion regulation and dissociation symptoms explain, at least partially, the associations between traumatic events and mental health and behavioral problems in various samples of children and adults.

Against this backdrop, this study aims to further our understanding of CSA associated consequences in childhood by testing two mediation models investigating the relationships among cumulative childhood trauma, emotion regulation, dissociation, and internalized and externalized behavior problems in a sample of sexually abused school-aged children. Fig. 1 illustrates the hypothesized mediation model. Even though the two mediators were measured concurrently, we suggest a sequence where emotion regulation deficits precede dissociation symptoms based on previous theoretical and empirical works described earlier.

Section snippets

Participants

The sample consisted of 309 sexually abused children (203 girls, 106 boys) aged 6–12 years old (M = 9.07, SD = 2.17) and their non-offending parent (85.8% maternal figure, 9.6% father figure, 4.6% other known adult). Exclusion criteria were to not speak French or English and/or the presence of a developmental delay preventing from understanding the questionnaires. Children were recruited in five intervention centers offering services to abused children and their parents in the province of

Data analysis

In order to determine how cumulative childhood trauma affects internalized and externalized behavior problems, mediation analyses were conducted with emotion regulation and dissociation as sequential mediators using Mplus software, v.7.31. A multiple mediator model based on the product of coefficients approach was selected as an appropriate method to test the hypotheses (Preacher and Hayes, 2008). Bootstrapping method (Shrout and Bolger, 2002) was used for testing the significance of the total

Discussion

The aim of this study was to examine the possible mediation effect of emotion regulation and dissociation in the relationships between cumulative childhood trauma and internalized and externalized behavior problems in a sample of school-aged CSA victims. In line with our hypotheses and with results of past studies, cumulative childhood trauma was associated with higher levels of emotional dysregulation, dissociation, and behavior problems (Briere, 2006, Choi and Oh, 2014; Hodges et al., 2015;

Implications and contributions

While our findings still need replication, especially with non-concurrent measures of emotion regulation and dissociation, important clinical implications can be derived. Cumulative childhood trauma, emotion regulation, dissociation, and behavior problems should be routinely assessed when sexually abused children consult for treatment. Parent-report validated questionnaires, like those used in this study, are easily available and could provide useful information. Psychiatrists and mental health

Limitations

Research implications can also be derived from this study and are directly related with its limitations. The two mediators of interest (emotion regulation and dissociation) were both assessed at T1. While previous findings and theoretical models advocate for a direction of the effect where emotion regulation deficits precede dissociation symptoms, the cross-sectional nature of the relation between these two variables in the present study does not allow to draw such a conclusion. Therefore, it

Role of funding source

This research was supported by a grant from the Canadian Institutes of Health Research (CIHR # 235509) awarded to Martine Hébert.

Acknowledgements

The authors wish to thank the children and the parents who participated in the study and members of the different intervention centers involved namely the Child Protection Clinic of Sainte-Justine Hospital, the Centre d’expertise Marie-Vincent, the Centre d’intervention en abus sexuels pour la famille (CIASF), the Centre jeunesse de la Mauricie et du Centre-du-Québec, and Parents-Unis. The authors also wish to thank Manon Robichaud for data management.

Martine Hébert (Ph.D. in psychology) is the Tier I Canada Research Chair in Interpersonal Traumas and Resilience and co-holder of the Marie-Vincent Interuniversity Chair in Child Sexual Abuse. She is also director of the Sexual Violence and Health Research Team, and full professor at the Department of sexology, Université du Québec à Montréal (UQAM), Canada. Her research projects focus on the diversity of profiles in survivors of interpersonal traumas and the evaluation of intervention and

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  • Cited by (0)

    Martine Hébert (Ph.D. in psychology) is the Tier I Canada Research Chair in Interpersonal Traumas and Resilience and co-holder of the Marie-Vincent Interuniversity Chair in Child Sexual Abuse. She is also director of the Sexual Violence and Health Research Team, and full professor at the Department of sexology, Université du Québec à Montréal (UQAM), Canada. Her research projects focus on the diversity of profiles in survivors of interpersonal traumas and the evaluation of intervention and prevention programs.

    Rachel Langevin (Ph.D. in psychology) completed her doctoral dissertation exploring emotion regulation in sexually abused children. She is currently completing a postdoctoral scholarship at the Department of Psychology of Concordia University and is involved in research projects examining factors related to the inter-generational transmission of violence in at-risk families.

    Essaïd Oussaïd, (M.Sc. in Mathematics) is statistical consultant for the Research Chair in Interpersonal Traumas and Resilience.

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