Childhood maltreatment and identity diffusion among inpatient adolescents: The role of reflective function

Journal of Adolescence 76 (2019) 65–74

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Journal of Adolescence journal homepage: www.elsevier.com/locate/adolescence

Childhood maltreatment and identity diffusion among inpatient adolescents: The role of reflective function

T

Francesca Pennera, Malgorzata Gambinb, Carla Sharpa,∗ a b

Department of Psychology, University of Houston, 3695 Cullen Blvd, Room 126, Houston, TX, 77204, USA Department of Psychology, University of Warsaw, ul. Stawki 5/7, Warsaw, 00-183, Poland

A R T IC LE I N F O

ABS TRA CT

Keywords: Adolescence Maltreatment Identity Social cognition Reflective functioning Inpatient adolescents

Introduction: Identity integration, as opposed to identity diffusion, has been associated with greater self-esteem, meaning in life, and functioning. Trauma may have negative effects on identity; however, few studies have examined trauma and identity among adolescents, particularly those with psychiatric disorders. Moreover, factors that may promote healthy identity in adolescents who have experienced trauma have not been identified. This study aimed to test associations between childhood maltreatment and identity diffusion among adolescents with psychiatric disorders, and evaluated reflective function (RF) as a mediator of these associations. Methods: 107 adolescents (Mage = 15.36, 75.7% female) who were inpatient at a psychiatric hospital in the United States completed self-report measures of childhood maltreatment (physical, sexual, and emotional abuse; physical and emotional neglect; total maltreatment), identity diffusion, and RF. Path analysis was used to test two models of the relations between childhood maltreatment, RF, and identity diffusion. Results: Total maltreatment and all forms of maltreatment except physical abuse were significantly associated with identity diffusion at the bivariate level. In path analysis (Model 1), emotional and physical neglect were directly associated with identity diffusion, and RF mediated the association between emotional abuse and identity diffusion. In Model 2, RF partially mediated the association between overall level of maltreatment and identity diffusion. Conclusions: Emotional abuse, emotional neglect, physical neglect, and total combined maltreatment exposure may be risk factors for adolescent identity diffusion. Targeting RF may help to build healthy identity among adolescents with symptoms of psychiatric disorders who have experienced maltreatment, particularly emotional abuse.

1. Introduction Adolescence is a significant period for the development of identity, during which there is a crisis between identity diffusion and identity integration (Erikson, 1950, 1968). Identity integration refers to consolidation or integration of one's previous identifications across contexts and time (Weymeis, 2016), whereas identity diffusion has been described as “a loss of capacity for self-definition and commitment to values, goals, or relationships, and a painful sense of incoherence” (Goth et al., 2012, p. 3). An integrated identity has been linked to greater self-esteem, self-efficacy, meaning in life, social relationships, and overall functioning, and to fewer internalizing and externalizing problems (Crocetti, Rubini, & Meeus, 2008; Goth et al., 2012; Schwartz et al., 2011; Weymeis, 2016),

∗

Corresponding author. E-mail address: [email protected] (C. Sharp).

https://doi.org/10.1016/j.adolescence.2019.08.002 Received 16 February 2019; Received in revised form 29 July 2019; Accepted 5 August 2019 0140-1971/ © 2019 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.

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whereas identity diffusion is associated with poor psychological functioning (Berman, Weems, & Petkus, 2009), and is particularly associated with personality pathology (Kernberg, 1985; Marcia, 2006). Given the importance of identity for future outcomes and its significance during adolescence, there is a growing focus on the public health impact of promoting healthy identity (i.e., identity integration; Schwartz & Petrova, 2018). Childhood trauma is thought to adversely influence identity development (Berman, 2016; Lawson & Quinn, 2013). Following a traumatic event, adolescents may experience negative expectations regarding the self or the future, self-blame, feelings of detachment, diminished interest in previously enjoyed activities, or major disruptions in the social context, all of which may negatively impact identity (American Psychiatric Association (APA), 2013; Scott et al., 2014). Empirical research has begun to confirm theoretical links between trauma and identity, demonstrating significant associations between adolescent identity problems (i.e., identity diffusion) and traumatic events including witnessing domestic violence (Idemudia & Makhubela, 2011), sexual abuse (Bailey, Moran, & Pederson, 2007), hurricane exposure (Scott et al., 2014), and war exposure (Guler, 2014). One study also found that youth who had experienced physical neglect had significantly higher scores on the identity problems subscale of the Borderline Personality Features Scale for Children (BPFS–C; Crick, Murray–Close, & Woods, 2005) relative to non-maltreated children (Hecht, Cicchetti, Rogosch, & Crick, 2014). In summary, despite theoretical links between childhood trauma and identity during adolescence, empirical evaluation of these links is in its nascent stages (Berman, 2016). Moreover, aside from Hecht and colleagues’ (2014) study, which measured identity problems only in the context of borderline pathology, no study has yet concurrently tested relationships between different types of childhood maltreatment experiences and identity in adolescents. Doing so would help to elucidate whether there are certain types of childhood maltreatment that are more strongly associated with adolescent identity problems (i.e., identity diffusion). A further gap is that there is a lack of studies examining links between trauma and identity among adolescents with psychiatric disorders. Adolescents with psychiatric disorders typically have higher levels of trauma (Bernstein, Ahluvalia, Pogge, & Handelsman, 1997) and more difficulties with identity (Berman et al., 2009) relative to community youth. Therefore, studying trauma and identity in clinical populations may help to improve conceptualization and treatment for adolescent psychopathology. The first aim of this study was therefore to test links between childhood maltreatment experiences (including five separate forms of maltreatment and a total combined index of maltreatment) and identity among adolescents with psychiatric disorders.

1.1. The role of reflective function in the relationship between maltreatment and identity Recent research has called for an increasing policy and public health focus on interventions to foster healthy identity (i.e., identity integration) among youth (Schwartz & Petrova, 2018). Interventions to promote healthy identity among youth who have experienced maltreatment may be particularly beneficial, as up to 27% of youth ages 18 and younger experience one type of abuse or neglect (CDC, 2016), and therefore may be at heightened risk for identity diffusion. We propose that one candidate treatment target to help promote healthy identity among adolescents is reflective function (RF; Fonagy, Gergely, Jurist, & Target, 2002). RF refers to the social-cognitive ability to imagine and recognize mental states (i.e. thoughts, feelings, desires, intentions) in the self and others. RF involves taking a reflective stance, being curious about the content of one's own and others' minds, and interpreting behavior in terms of underlying mental states (Fonagy et al., 2002). RF is the focus of mental health interventions such as Mentalization-Based Treatment (Bateman & Fonagy, 1999) and has been shown to be modifiable via intervention (see Malda-Castillo, Browne, & PerezAlgorta, 2018; Toth, Rogosch, & Cicchetti, 2008). In addition, RF has been associated with greater identity integration in adults (Fonagy et al., 2016). RF is therefore a useful potential intervention factor to consider for promoting identity integration in adolescents. Notably, RF is also thought to be detrimentally impacted by early maltreatment (Fonagy & Luyten, 2016). It is therefore possible that RF mediates the link between childhood maltreatment and identity diffusion. For example, if maltreatment is perpetrated by a parent, this experience is likely to affect the healthy development of RF because the child does not feel a sense of safety or security to be curious about others' minds (Fonagy & Luyten, 2016). Additionally, an abusive or neglectful parent is less likely to be psychologically minded toward his or her child, adversely affecting the child's own development of social-cognitive abilities, including RF (Allen, Fonagy, & Bateman, 2008; Fonagy & Luyten, 2016). Finally, for children who have experienced maltreatment, the desire to understand other people's minds may be defensively blocked, as others may have mal-intent (Allen, 2013; Fonagy et al., 2002). Thus not only can maltreatment impair children's RF, but the experience of maltreatment could go on to negatively influence identity via the child's impaired RF, that is, the impaired ability to imagine mental states, even in one's self, and to link behavior to underlying mental states. Building on these theoretical associations between maltreatment and impaired RF, two studies have demonstrated that children who were maltreated had impaired theory of mind (a construct closely related to RF) compared to non-maltreated children (Cicchetti, Rogosch, Maughan, Toth, & Bruce, 2003; Pears & Fisher, 2005). Related, there were lower levels of RF observed among children who had experienced sexual abuse compared to children who had not (Ensink et al., 2015). In addition, RF partially mediated the association between childhood sexual abuse and children's internalizing and externalizing symptoms (Ensink, Begin, Normandin, & Fonagy, 2016), and RF partially mediated the relationship between early maltreatment and potential for violence in adolescents (Taubner, Zimmermann, Ramberg, Schroder, 2016). Finally, in two studies, impaired RF mediated the relation between childhood emotional abuse and adolescent personality pathology (Duval, Ensink, Normandin, & Fonagy, 2018; Quek et al., 2017). No study has yet tested RF as a mediator of the link between childhood maltreatment and identity in adolescence.

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Fig. 1. The proposed Model 1 in the current study. Note. “+” - positive relation, “-” - negative relation; “Various forms of childhood maltreatment” refers to separate subscales of the CTQ.

2. Study aims and proposed theoretical model Against this background, the current study aimed to extend research on trauma and identity among adolescents by 1) testing cross-sectional associations between different types of retrospective childhood maltreatment experiences, as well as total combined level of maltreatment, and identity diffusion among a sample of adolescents with psychiatric disorders, and 2) testing RF as mediator of the association between maltreatment and identity diffusion. As such, we aimed to evaluate whether RF may be an important factor to promote in the context of interventions for building healthy identity in adolescence following childhood abuse and/or neglect. Based on theoretical and empirical links between trauma, RF, and identity that have so far been demonstrated, we hypothesized two models (Figs. 1 and 2) in which 1) forms of childhood maltreatment (emotional abuse, sexual abuse, physical abuse, emotional neglect, physical neglect; total combined index of maltreatment) would be directly associated with identity diffusion. Due to skewness and kurtosis and low levels of sexual abuse and physical abuse reported in our sample, we included in Model 1 only three separate forms of maltreatment: emotional abuse, emotional neglect, and physical neglect. Model 2 utilizes a combined index (CTQ total score), which sums scores from all five maltreatment categories. We also hypothesized 2) that RF would have a direct relationship to identity diffusion, and that, 3) the three forms of childhood maltreatment (Model 1) and the total level of maltreatment (Model 2) would be significantly associated with impaired RF. Finally, we hypothesized that 4) there would be indirect associations from the three forms of childhood maltreatment (Model 1) and the total level of maltreatment (Model 2) to identity diffusion through the relation of maltreatment to RF. Importantly, gender differences have been shown in reports of childhood maltreatment; for example, females report more childhood sexual abuse than males (Tolin & Foa, 2006). Therefore, we considered gender as a covariate. Figs. 1 and 2 show the theoretical models, which outline the expected direct and indirect relations between childhood maltreatment, RF, and identity diffusion. 3. Methods 3.1. Participants The current sample included 107 adolescents ages 12–17 (Mage (SD) = 15.36 (1.33), 75.7% female) recruited from the adolescent inpatient unit of a private psychiatric hospital in a large city in the southwestern United States. All consecutive admissions were approached for participation in the study. Parents were approached for consent, and if granted, adolescents approached for assent. Inclusion criteria were admission to the adolescent unit and English fluency to be able to complete study assessments. Exclusion criteria were IQ below 70 or diagnoses of a psychotic disorder or autism spectrum disorder. Of 197 adolescents who were approached about this study's measures, 166 met inclusion/exclusion criteria and consented to participate in the study. Of 166 teens who participated, 59 were missing one of the three main study measures. Therefore, the current study included a final sample of N = 107 adolescents. The 59 adolescents who were missing one of the three study measures did not differ from the 106 included adolescents in age, race, ethnicity, or diagnoses (ps > .22); however, there was a significantly higher proportion of females among the 107 included adolescents, χ2(1) = 6.91, p = .009. The racial and ethnic characteristics of the current sample were as follows: 70.1% White/

Fig. 2. The proposed Model 2 in the current study. Note. “+” - positive relation, “-” - negative relation; “Childhood maltreatment” refers to CTQ total score, which is a sum of scores from emotional abuse, physical abuse, sexual abuse, physical neglect, and emotional neglect subscales. 67

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Caucasian, 6.5% Multiracial or other, 5.6% Hispanic/Latinx, 3.7% Asian, 2.8% Black or African American, and 16.8% did not report. Diagnostically, 63.6% youth met DSM-IV criteria for a mood disorder, 61.7% for an anxiety related disorder (11.2% Post-Traumatic Stress Disorder), 32.7% for an externalizing disorder, and 10.3% for an eating disorder. 3.2. Measures 3.2.1. Identity diffusion The Assessment of Identity Diffusion in Adolescents (AIDA; Goth et al., 2012) is a 59-item self-report measure that assesses identity in youth on a dimension from identity diffusion to identity integration. The measure includes items such as “I am often confused about what kind of person I really am” and “I often feel lost, as if I had no clear inner self.” Items are rated on a scale from 0 (no) to 4 (yes) and are summed for a total score, with higher scores indicating greater levels of identity diffusion. The total score was used in the present study. Good internal consistency reliability has been reported for the AIDA in a sample of clinical and community adolescents, as well as evidence for the measure's construct validity (Goth et al., 2012). Cronbach's alpha for the AIDA in this sample was α = .95. 3.2.2. Reflective function The Reflective Function Questionnaire – Youth (RFQY; Ha, Sharp, Ensink, Fonagy, & Cirino, 2013) is a self-report measure that was adapted from the adult version of the RFQ (Fonagy et al., 2016) by modifying question wording so that it is developmentally appropriate for youth. Responses are rated on a 6-point Likert-type scale, ranging from 1 (Strongly Disagree) to 6 (Strongly Agree). Fonagy and colleagues' (2016) validation of the RFQ in adults identified two subscales of 6 items each, RFQ-Uncertainty (RFQ-U) and RFQ-Certainty (RFQ-C). For detailed RFQ scoring information, see Fonagy et al. (2016). The construct validity and two-factor structure of the RFQ has been validated among French adolescents (Badoud et al., 2015). In addition to the two scales, a difference/ total RFQ score can be calculated (Badoud et al., 2018) from the difference between the RFQ-C and RFQ-U scales, which puts the two subscales into one dimension, with higher difference scores indicative of better RF abilities. The difference/total score was used in the current study in order to have only one score to represent both scales, and to reduce potential redundancy. Cronbach's alpha for the RFQ-U was .70 and for the RFQ-C was .68. 3.2.3. Childhood maltreatment The short form of the Childhood Trauma Questionnaire (CTQ-SF; Bernstein et al., 2003) is a 28-item self-report measure that screens for history of childhood abuse and neglect. CTQ items ask about experiences during childhood and adolescence, which are rated on a scale from 1 (never true) to 5 (very often true). The measure yields five scales: physical abuse (e.g. “I was punished with a belt, a board, a cord, or some other hard object”), sexual abuse (e.g. “someone molested me”), emotional abuse (e.g. “people in my family said hurtful or insulting things to me”), physical neglect (e.g., “I didn't have enough to eat”), and emotional neglect (e.g. “I felt loved,” reverse coded). Each scale includes five items and three additional items make up a Minimization/Denial validity scale. Items were coded such that higher scores were indicative of greater levels of maltreatment, with each scale score ranging from 5 to 25. The scores can then be classified for severity, from “None to minimal,” “Slight to moderate,” “Moderate to severe,” and “Severe to extreme.” A combined index of maltreatment can also be calculated by summing the five scales for a CTQ total score. Evidence for the CTQ-SF's construct validity has been demonstrated among adolescents with psychiatric disorders (Bernstein et al., 2003). The CTQ subscale scores have also demonstrated good test–retest and internal consistency reliability in initial validation studies (Bernstein et al., 2003). In the current sample, Cronbach's alphas for the scales were: α = .56 (Physical Neglect), .61 (Physical Abuse), .86 (Emotional Abuse), .90 (Emotional Neglect), and .95 (Sexual Abuse). 3.3. Data analytic strategy All analyses were conducted in SPSS (version 24) and AMOS (version 24). Prior to data analysis, the data were evaluated for normality. Because sexual abuse and physical abuse had skewed distributions caused by low levels of these forms of abuse reported in our sample, Spearman's Rank correlations were used to calculate correlations among the key study variables, as well as between age of participants and all the study variables. Independent samples t-tests were run to test differences between girls and boys across key study variables. Next, path analysis, a form of structural equation modeling that uses observed variables, with exogenous variables was used to test our hypothesized models (Figs. 1–2). In Model 1, we did not include sexual abuse and physical abuse, because only a very small number of participants in our sample reported these forms of maltreatment and in effect the distributions of these variables were highly skewed. Model 2 included an overall combined maltreatment score rather than testing different forms of abuse separately. In evaluating initial models, saturated model significance and effect sizes of each of the path coefficients were examined. In evaluating modified models, the maximum likelihood chi-square statistic (χ 2) was examined, with a non-significant result indicating that there is no significant discrepancy between the model and the data. Additional fit indices were also examined, including the Tucker–Lewis Index (TLI), Bentler Comparative Fit Index (CFI), and Root-Mean-Square Error of Approximation (RMSEA). The suggested cut-off criteria for good fit are as follows: TLI ≥0.90, CFI > 0.95 (Hu & Bentler, 1999) and RMSEA ≤0.05 (Browne & Cudeck, 1993; MacCallum, Browne, & Sugawara, 1996). To assess mediation, the present study employed a bootstrapping approach (n = 5000 bootstrap samples; Preacher and Hayes, 2008). This approach produces estimates of the standard errors of parameter estimates and a bias-corrected confidence interval of the mediation effects. All confidence intervals reported below refer to 95% biascorrected confidence intervals. 68

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Table 1 Descriptive statistics for main study variables. Minimum

Maximum

Mean

SD

Skewness

Kurtosis

Classificationa

Age in years AIDA Identity Diffusion RFQ – Total CTQ Emotional Abuse

12 12 −2.00 5

17 188 1.50 25

15.36 111.65 −0.26 10.15

1.34 40.70 0.69 5.14

-.46 -.29 -.04 .98

-.54 -.62 .14 .16

CTQ CTQ CTQ CTQ CTQ

5 5 5 5 25

17 25 24 17 91

6.46 6.81 10.85 7.36 41.62

2.53 4.88 5.00 2.75 15.36

2.35 2.96 .71 1.35 1.37

5.77 7.76 -.24 1.42 1.71

– – – None-minimal: 15.9% None-minimal: None-minimal: None-minimal: None-minimal: –

Physical Abuse Sexual Abuse Emotional Neglect Physical Neglect Total

45.8%; Low: 28.0%; Moderate: 10.3%; Severe: 79.4%; Low: 9.3%; Moderate: 6.5%; Severe: 4.7% 80.4%; Low: 3.7%; Moderate: 6.5%; Severe: 9.3% 49.5%; Low, 25.2%; Moderate 15.0%; Severe 10.3% 63.6%; Low: 16.8%; Moderate: 11.2%; Severe: 8.4%

Note. AIDA = Assessment of Identity Development in Adolescence; RFQ = Reflective Function Questionnaire; CTQ = Childhood Trauma Questionnaire. a Severity classification on the CTQ. Shows percentage of sample whose scores fell within each severity category: none to minimal, low (or slight) to moderate, moderate to severe, and severe to extreme.

4. Results 4.1. Descriptive statistics Descriptive statistics are shown in Table 1. The sample's mean scores on each of the five CTQ subscales were similar to global estimates on these scales, and the sample's mean total CTQ score was lower than North American estimates, according to a recent meta-regression analysis (Viola et al., 2016). The sample's mean identity diffusion score (M = 111.65, SD = 40.70) was higher than the mean AIDA score reported for community samples of youth (M = 65.87, SD = 26.26) and lower than the mean AIDA score reported for a clinical sample of youth with personality disorders (M = 129.75, SD = 32.57) (Goth et al., 2012). There were no gender differences for either outcome variable (AIDA, t(105) = .61, p = .54; RFQ, t(105) = −1.26, p = .21), or for physical abuse (t (105) = -.45, p = .65), physical neglect, (t(105) = .59, p = .56), emotional neglect (t(105) = .95, p = .34), or CTQ total scores (t (72.93) = 1.83, p = .07). However, female participants reported significantly higher levels of emotional abuse (M = 10.63) than male participants (M = 8.65, t(64.80) = 2.12, p = .04), and also reported higher levels of sexual abuse (M = 7.23) than male participants (M = 5.50, t(102.68) = 2.40, p = .02). Thus, we included gender as a covariate in Model 1. 4.2. Bivariate associations between childhood maltreatment and identity diffusion Due to high levels of skewness and kurtosis in CTQ physical abuse and sexual abuse subscales because of the low levels reported in this sample, bivariate associations were tested using Spearman's rank correlations (Table 2). All forms of maltreatment were significantly and positively correlated with each other and with the CTQ total score. Identity diffusion was significantly associated with emotional abuse, sexual abuse, physical neglect, emotional neglect, and overall combined maltreatment such that higher reports of maltreatment were related to greater levels of identity diffusion. These correlations were small to large: emotional abuse, emotional neglect, physical neglect, and CTQ total scores showed large associations with identity diffusion, and sexual abuse demonstrated a small association with identity diffusion. Physical abuse was not significantly associated with identity diffusion. Physical abuse, emotional neglect, and CTQ total scores had small but significant correlations to RF, and emotional abuse had a medium, significant correlation to RF, such that higher levels of each of these forms of maltreatment was associated with lower levels of RF. RF had a medium and significant relation to identity diffusion, such that greater levels of RF were associated with lower identity diffusion. Table 2 Spearman's rank correlations between main study variables.

1 2 3 4 5 6 7 8 9

Age in years at admission AIDA Identity Diffusion RFQ – Total CTQ Emotional Abuse CTQ Physical Abuse CTQ Sexual Abuse CTQ Emotional Neglect CTQ Physical Neglect CTQ Total

1

2

3

4

5

6

7

8

0.03 0.12 0.07 0.12 −0.03 0 0.02 .03

−0.42∗∗ 0.56∗∗ 0.13 0.29∗∗ 0.57∗∗ 0.50∗∗ .61∗∗

−0.31∗∗ −0.20∗ −0.14 −0.25∗∗ −0.04 -.27∗∗

.46∗∗ .40∗∗ .74∗∗ .46∗∗ .88∗∗

.31∗∗ .29∗∗ .20* .52∗∗

.31∗∗ .32∗∗ .55∗∗

.59∗∗ .87∗∗

.67∗∗

Note. *Correlation is significant at the 0.05 level (2-tailed). ** Correlation is significant at the 0.01 level (2-tailed). 69

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Fig. 3. Final path model for Model 1, controlling for gender. Mediation model testing the effect of different forms of childhood maltreatment on identity diffusion through RF. Note.+p < .10, *p < .05, **p < .01, ***p < .001. Values are standardized path coefficients. Direct and total effect of the independent variable on the dependent variable are reported inside and outside of parentheses, respectively. R2 is presented at the upper right side of the predicted variables.

4.3. Testing RF as a mediator of the associations between childhood maltreatment and identity diffusion Path analysis was used to test the relationships among study variables proposed in our hypothesized models (Figs. 1 and 2). In Model 1, gender was controlled for by adding paths between gender and all the variables in the model. In Model 1, since our initial model was saturated (i.e., it had zero degrees of freedom), tests of model fit could not be calculated. Unexpectedly, investigation of the significance and effect sizes of each of the path coefficients revealed that both emotional and physical neglect were not significantly related to RF and their effect sizes were close to zero. The small coefficient between emotional neglect and RF likely occurred because emotional neglect and emotional abuse were highly correlated, and emotional abuse appeared to have the stronger relationship to RF. The lack of significant path between physical neglect and RF made sense given the low bivariate correlation between these two constructs. Based on these statistical considerations, we deleted these two paths from Model 1. Investigation of model fit indicated that our modified model fit the data better than the initial, saturated model and is characterized by excellent model fit (χ2 (2) = 1.96, p = .38, RMSEA = .000, CFI = 1.000, TLI = 1.002). The final model for Model 1 is presented in Fig. 3. To explore mediation for Model 1, the indirect effect was tested using bootstrapping. RF completely mediated the relationship between emotional abuse and identity diffusion (ab = .747, 95% CI [.258, 1.476], p < 0.01). The direct effect between emotional abuse and identity diffusion became nonsignificant (β = .20, p = .09) upon the inclusion of RF as a mediator. Next, we tested if RF mediated the relation between the total combined index of maltreatment experiences and identity diffusion (Model 2, Fig. 2). RF partly mediated the relationship between total combined index scores and identity diffusion (ab = .222, 95% CI [.057, .411]). The direct effect between total combined childhood maltreatment and identity diffusion (β = .56, p < .001) was reduced (β = .48, p = .001) upon the inclusion of RF as a mediator. Together, these two predictors accounted for 38% of the variance in the identity diffusion (adjusted R2 = .39, R2 = .38). The final model for Model 2 is presented in Fig. 4. 5. Discussion The current study aimed to extend previous research on the connections between traumatic experiences and identity diffusion in adolescence by 1) testing associations between specific types of childhood maltreatment experiences, as well as total combined maltreatment, and identity diffusion among adolescents with a broad range of psychiatric disorders, and by 2) testing whether childhood maltreatment is associated with identity diffusion via impaired reflective functioning (RF). In bivariate results, emotional abuse, emotional neglect, physical neglect, and total combined maltreatment had strongest associations to identity diffusion in this sample of adolescents with psychiatric disorders. In path analysis Model 1, which tested 70

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Fig. 4. Final path model for Model 2. Mediation model testing the effect of total combined maltreatment (CTQ total score) on identity diffusion through RF. Note. **p < .01, ***p < .001. Values are standardized path coefficients. Direct and total effects of the independent variable on the dependent variable are reported inside and outside of parentheses, respectively.

different forms of maltreatment as separate independent variables, emotional and physical neglect retained direct associations to identity diffusion, and emotional abuse had a total effect on identity diffusion via RF. These findings may be understood in the context of Maslow's hierarchy of needs (Maslow, 1943). According to Maslow's theory, when an individual's basic needs for warmth, food and physical safety are not met (as in children and adolescents who experience physical neglect) and basic needs for love and belonging, as well as self-esteem building, are not satisfied (as in children who experience emotional maltreatment), the individual cannot strive toward personal growth and self-actualization, and may therefore experience difficulties building an integrated identity. Overall, these results suggest that emotional maltreatment and physical neglect during childhood may be important to consider as potential risk factors for problems in identity development. Importantly, in path analysis Model 2, higher levels of total combined maltreatment (across all five maltreatment categories including sexual and physical abuse) were also directly associated with greater levels of identity diffusion, taking into account the influence of RF. These results highlight that overall level of maltreatment experience, regardless of the particular type of maltreatment, may also be a risk factor for problems in identity development. In path analysis Model 1, impaired RF fully mediated the association between emotional abuse and identity diffusion, and in path analysis Model 2, impaired RF partially mediated the association between total combined maltreatment and identity diffusion. The CTQ emotional abuse scale asks about emotional abuse at home, by parents. Parents who emotionally abuse their children are unlikely to adequately recognize, understand, and reflect their child's affective signals and mental states, which is likely to impair the healthy development of RF in children (Fonagy & Luyten, 2016). Similar impairments in RF development may occur for children who experience multiple types of maltreatment by their caregivers. Overall level of maltreatment may also detrimentally impact RF by leading to post-traumatic stress responses such as re-experiencing, difficulty concentrating, or increased hypervigilance and reactivity (American Psychiatric Association, 2013), all of which could get in the way of the mental effort and reflectiveness needed to use RF. Impairments in RF in turn could hinder the child's capacity to recognize his or her own mental states, recognize boundaries between his or her own mind and others, and to perceive and understand the self and others in terms of mental states (Fonagy & Target, 1997; Meins, Fernyhough, Russel, & Clark-Carter, 1998; Sharp & Fonagy, 2008), which may lead to difficulties in developing an integrated identity that is distinct from others. In bivariate results, though sexual abuse had a relation to identity diffusion, it was not related to RF, which differs from previous studies (Ensink et al., 2015). This result may have been due to the nature of the sexual abuse experienced in our sample. While abuse by an attachment figure is likely to disrupt development of RF (Fonagy & Luyten, 2016), when abuse occurs outside the family it may have less of an impact on the adaptive development of RF. It is possible that fewer youth in our sample experienced sexual abuse perpetrated by an attachment figure compared to perpetration by other adults or peers, and therefore did not experience impaired RF as a result. This finding may also have been due to the low levels of sexual abuse reported in our sample. Low levels of physical abuse were also reported in this sample relative to the other forms of maltreatment, which may be due to the demographics of our sample, which was majority middle class youth. The current study has implications for intervention. RF had a large, negative association with identity diffusion at the bivariate level, and a medium association with identity diffusion in path analysis results, when the influence of emotional abuse, emotional neglect, and physical abuse was accounted for (Model 1) and when the influence of total combined maltreatment was accounted for (Model 2). Additionally, RF fully mediated the association between emotional abuse and identity diffusion and partially mediated the association between total combined maltreatment and identity diffusion. These findings point to RF as a potential intervention factor to promote healthy identity among youth with psychiatric disorders who have experienced maltreatment, particularly emotional abuse. Given the cross-sectional nature of this study and the use of only self-report measures, the following implications for intervention are highly tentative, but may provide insights for future research. RF could be targeted in identity interventions with adolescents in several ways. For example, the primary focus of Mentalization Based Treatments (MBT; Bateman & Fonagy, 1999) is improving mentalization or RF abilities. MBT approaches have now been used with a number of adolescent populations (see Malda-Castillo et al., 2018, for a review), and a recent study of MBT for adolescents (MBT-A; Rossouw & Fonagy, 2012) found that identity integration improved over the course of treatment (Laurenssen et al., 2014). Of note, MBT-A can be implemented with a parallel MBT-Parents group to help increase parents' RF abilities (Bo et al., 2016; Sharp & Rossouw, 2019). Even in the absence of caregiver change, though, it is possible that youth with abusive parents may still see improvements in RF from MBT. For example, MBT therapists may help to model and teach an adolescent RF when he or she has not had a parent who did so. MBT may also help the teen identify his or her own mental states, understand that they are distinct from 71

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others, and connect that a parent's behavior is driven by his or her internal states and is not caused by the teen him/herself. MBT is meant to be a therapeutic “stance” rather than a strictly manualized treatment (Bateman & Fonagy, 2012). Due to this flexibility, it may be possible to incorporate RF-promoting strategies from MBT into existing interventions for building healthy identity during adolescence, such as the Miami Youth Development Project (Kurtines et al., 2008) and the Changing Lives Program (Eichas, Kurtines, Rinaldi, & Farr, 2018), among others (see Ferrer-Wreder, Montgomery, Lorente, & Habibi, 2014). Further, given similarities between RF and social-cognitive constructs such as metacognition and theory of mind, promoting these abilities in the context of existing identity interventions may also be beneficial. Researchers who study identity in the context of positive youth development highlight the promise of interventions that promote healthy identity through group participation (Curran & Wexler, 2017), mentorship (Meschke, Peter, & Bartholomae, 2012), or within educational settings (Schwartz & Petrova, 2018). Recent research has tested the idea of creating “mentalizing communities” in school settings by training teachers in mentalizing strategies in order to improve mentalizing (RF) among youth (Bak, 2012; Fonagy et al., 2009; Twemlow, Fonagy, & Sacco, 2005a, b; Valle et al., 2016). These principles could be applied to other group or mentorship settings (e.g., positive youth development programs, camps, mentorship programs, sports teams) in order to promote healthy identity. This study's findings should be considered alongside its limitations. First, due to sample size, analysis may have been underpowered to detect certain effects in the hypothesized Model 1. Future research should test this mediation with larger samples, and in both psychiatric and healthy samples of youth. A second limitation relates to the nature of our sample, which was largely Caucasian, middle class, and female. These factors may have affected the degree and types of maltreatment reported and limited results related to sexual abuse and physical abuse in particular. Due to the low reports of these forms of abuse and skewness of these scales, we did not include sexual and physical abuse in the mediation model, which is a further limitation. In addition, the nature of our sample may limit the generalizability of findings to youth of more diverse ethnic/racial backgrounds. In the future, research should include more ethnoracially and socioculturally diverse samples of youth and should also consider whether these results hold cross-culturally, in other countries than the United States. Third, all measures used in this study were self-report, meaning that significant associations may have been due in part to shared method variance. Finally, this study was cross-sectional, which limits any conclusions about causality between trauma, RF, and identity. Future research should examine these questions using multi-method design and longitudinal or experimental designs. Future research may also benefit from considering the role of parent-child attachment or parenting styles in associations between child maltreatment, RF, and identity in adolescence. Despite these limitations, our study extends extant research on trauma and identity among adolescents in important ways. Findings highlight emotional maltreatment, physical neglect, and combined maltreatment as risk factors for identity problems among adolescents with psychiatric disorders, and demonstrate that emotional abuse and overall level of combined maltreatment may be associated with identity diffusion through impairments in adolescents’ RF. Findings suggest RF as a potential intervention factor that can be incorporated into existing identity interventions, school- and community-level youth programming, or addressed in the course of mental health treatments in order to foster healthy identity among youth with psychiatric disorders. Acknowledgements We thank the adolescents and parents for their participation in this study and the Menninger ATP research team for their work with data collection and coding. This study was funded by The Robert and Janice McNair Foundation, grant awarded to Dr. Carla Sharp, no grant number. References Allen, J. G. (2013). 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