A structural model of mechanisms predicting depressive symptoms in women following childhood psychological maltreatment

Child Abuse & Neglect 38 (2014) 103–113

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Child Abuse & Neglect

A structural model of mechanisms predicting depressive symptoms in women following childhood psychological maltreatment Aubrey A. Coates a,b,∗ , Terri L. Messman-Moore a a b

Miami University, USA Talbert House, Cincinnati, OH, USA

a r t i c l e

i n f o

Article history: Received 28 November 2012 Received in revised form 29 September 2013 Accepted 10 October 2013 Available online 12 November 2013

a b s t r a c t Two underlying mechanisms, emotion dysregulation and negative internalized beliefs, were examined as potential mediators of the association between childhood psychological maltreatment (PM) and depression in emerging adult women. PM was assessed as a multi-faceted construct including aspects of psychological abuse (e.g., corrupting) and psychological neglect (e.g., emotional unresponsiveness) that occurred by parents. Female undergraduates (n = 771) completed anonymous, retrospective, self-report surveys assessing childhood PM, current depressive symptoms, emotion dysregulation (lack of emotional clarity and regulation strategies), and negative internalized beliefs (mistrust, shame, and defectiveness). Psychological maltreatment was represented as four subtypes of psychological abuse or neglectful behavior: Emotional Non-Responsiveness, Spurning/Terrorizing, Corrupting, and Demanding/Rigid (i.e., controlling behavior). Both emotion dysregulation and negative internalized beliefs significantly mediated the link between childhood PM and depressive symptoms, accounting for approximately 68% of the variance in symptomatology. Findings suggest the importance of focusing intervention on development of emotion regulation capacity including emotional awareness and regulatory strategies, as well as a focus on core negative beliefs including shame, defectiveness, and mistrust of others. Implications for future research are discussed. © 2013 Published by Elsevier Ltd.

Introduction The negative effects of childhood maltreatment are widely acknowledged. Moreover, there may be pernicious underlying difficulties associated with the effects of childhood maltreatment which actually complicate therapeutic intervention. For example, women with histories of child abuse often have problems with emotion dysregulation and interpersonal relationships which impact the experience and expression of PTSD symptoms as well as impact response to treatment (Cloitre, Miranda, Stovall-McClough, & Hyemee, 2005). Research on the long-term impact of childhood maltreatment has led to several promising treatments for children and adults who experienced childhood sexual or physical abuse (for examples see Cloitre, Koenen, Cohen, & Han, 2002; Cohen, Deblinger, & Mannarino, 2005; Runyon, Deblinger, Ryan, & Thakkar-Kolar, 2004). Unfortunately, compared to sexual or physical abuse, our understanding of the long-term impact of childhood psychological maltreatment (PM) is much more limited (Wright, Crawford, & Del Castillo, 2009). It has been repeatedly demonstrated that childhood PM, alone or co-occurring with other forms of maltreatment, has severe short and long-term negative effects. In the short-term, childhood PM has been associated with childhood difficulties

∗ Corresponding author at: Talbert House, 2600 Victory Parkway, Cincinnati, OH 45206, USA. 0145-2134/$ – see front matter © 2013 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.chiabu.2013.10.005

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such as depression, learning difficulties, delinquency, emotion dysregulation, and interpersonal problems (Binggeli, Hart, & Brassard, 2001; Claussen & Crittenden, 1991; Vissing, Straus, Gelles, & Harrop, 1991). In the long-term, childhood PM has been associated with adult psychological difficulties including depression, anxiety, PTSD symptoms, low self-esteem, emotional inhibition, emotional avoidance, interpersonal conflict, and a higher risk for psychopathology in general (Briere & Runtz, 1990; Krause, Mendelson, & Lynch, 2003; Messman-Moore & Coates, 2007; Reddy, Pickett, & Orcutt, 2006). Further, PM effects may even be long-lasting than other forms of child maltreatment (Teicher, Samson, Polcari, & McGreenery, 2006). Of all of the long-term psychological difficulties, PM has been most consistently linked with depression (Gibb, Chelminiski, & Zimmerman, 2007; Wright et al., 2009). In a review of the literature, Alloy, Abramson, Smith, Gibb, and Neeren (2006) concluded that depression was more consistently linked with PM than with childhood physical or sexual abuse. Importantly, PM was consistently found to precede and predict depression. While other long-term psychological difficulties, such as anxiety, PTSD symptoms, and stress have also been associated with PM, such problems have not been linked with PM as consistently as has depression (Alloy et al., 2006; Taussig & Culhane, 2010). Of different types of child maltreatment, physical abuse has been the least strongly associated with depressive symptoms (Liu, Jager-Hyman, Wagner, Alloy, & Gibb, 2012), and childhood sexual abuse may actually be a risk factor for psychopathology in general, rather than depression in particular (Kender et al., 2000). Although childhood psychological maltreatment is significantly associated with long-term negative experiences, particularly depression, there is yet no consensus regarding the mechanisms responsible for this association. Thus continued research identifying mechanisms underlying the link between PM and depression is critical to development of effective, empirically based interventions which aim to reduce levels of depression. Factors such as self-referent emotional and cognitive appraisals linked to PM may be relevant to the expression of long-term adult outcomes including depression. The experience of shame following PM may be particularly relevant to the development of depression especially for women. Among individuals reporting a history of childhood PM, women report higher levels of distress and depression compared to men. Furthermore, shame interacts with prior childhood PM to increase risk for depression among women, but not among men (Harper & Arias, 2004). Other studies suggest investigation of two mechanisms, focusing on cognitive schemas or beliefs and emotion dysregulation, may prove to be promising avenues for research (Gibb, Alloy, Abramson, & Marx, 2003; Reddy et al., 2006). Cognitive mechanisms: PM, beliefs, and depression One proposed explanation for the link between childhood PM and depression in adulthood is that PM may lead children to internalize negative messages about themselves and events in their lives. It has been suggested that children who experience maltreatment may over time internalize the abuser’s messages and come to believe that the maltreatment is deserved (Briere, 1992). When maltreatment is chronic, children may come to the conclusion that their experience is unavoidable or due to something negative within them. Over time these negative inferences regarding maltreatment generalize to other negative events, which may cause maltreated children to believe that all negative events are unavoidable, far-reaching, and due to negative characteristics within themselves. These general negative inferential styles contribute to a greater vulnerability to depression (Abramson, Metalsky, & Alloy, 1989; Rose & Abramson, 1992). The internalization of negative messages and the development of negative inferences are particularly salient for children who are psychologically maltreated because they often explicitly hear their caregivers tell them that they are unworthy and unlovable, or they are overtly ridiculed and demeaned. Research indicates childhood PM, but not childhood physical abuse or childhood sexual abuse, is specifically related to the development of negative inferential styles and an increased vulnerability to depression in young adults (Gibb et al., 2003). Further, in prospective studies PM precedes and is particularly related to negative changes in inferential styles and depressive symptoms over time in children (Gibb & Abela, 2008; Gibb & Alloy, 2006). Research has established the link between PM and the development of negative inferential styles, but there may be a general cognitive vulnerability for depression affected by PM such as dysfunctional beliefs about the self and others. Automatic depressive self-associations, such as beliefs that one is unlovable and hopeless (Gibb, Abramson, & Alloy, 2004), and self-critical beliefs such as dwelling on one’s mistakes (Sachs-Ericsson, Verona, Joiner, & Preacher, 2006), have been associated with PM. Furthermore, young adults with histories of PM not only endorse negative beliefs about themselves, but also negative beliefs about others (i.e., others will not provide adequate support, may abandon or abuse me) (MessmanMoore & Coates, 2007). Additionally, adults with histories of PM endorsed negative beliefs related to mistrusting others and sacrificing one’s own needs for others (Crawford & Wright, 2007). Moreover, negative beliefs significantly mediate the relationship between PM and difficulties in adult interpersonal relationships (Crawford & Wright, 2007; Messman-Moore & Coates, 2007). Negative beliefs may generalize to many areas of PM survivors’ lives, impacting perceptions and expectations of themselves and others which may contribute to an increased risk for depression (Rose & Abramson, 1992). Emotion mechanisms: PM, emotion dysregulation, and depression An alternate way in which childhood PM may lead to long-term psychological difficulties is through interference with the development of adequate emotion regulation. The development of a child’s ability to understand and manage his or her emotions relies heavily on caregiver support and responsiveness to the child’s emotions (Saarni, 1999). Children learn through their caregiver’s acknowledging, labeling, and mirroring of emotions, and also learn strategies for accepting their

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emotional experience through the caregiver’s validation and responsiveness (Thompson, Flood, & Lundquist, 1995). A responsive caregiver helps the child learn to tolerate frustration, as well as develop appropriate strategies to modulate distress (Keiley, 2002). Thus, the development of basic emotional understanding and emotion regulation strategies are significant achievements in childhood that may be undermined by psychological maltreatment. Emotion regulation includes both cognitive and behavioral elements. While originally thought of as primarily involving the suppression of emotion, it is now understood that the ability to regulate one’s emotions reflects cognitive capacities such as recognizing, experiencing, and having a clear understanding of one’s emotions (Denham, 1998), as well as behavioral capacities such as developing and using emotion regulation strategies appropriately and flexibly (Gratz & Roemer, 2004). When deficits exist in either of these areas of emotion regulation, then emotional and behavioral difficulties may develop. Alexithymia, a disorder defined by deficits in the ability to identify and describe emotions, is one component of emotion dysregulation that has been associated with a history of PM (Hund & Espelage, 2006). Individuals who do not possess clarity about their emotional experiences may find it particularly difficult to identify, develop, and utilize adaptive emotion regulation strategies. When adaptive emotion regulation strategies are lacking, maladaptive strategies such as various forms of behavioral and emotional avoidance emerge (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). Emotional inhibition, one maladaptive strategy, mediated the relationship between PM and adult psychological distress in general (Krause et al., 2003), and emotionally avoidant coping styles are a key mechanism in the relationship between PM and the experience of depression, anxiety, and stress in college students (Reddy et al., 2006). It may be that the experience of PM in childhood has a significant effect on emotion regulation development which may in turn increase one’s vulnerability to depression, perhaps due to unregulated negative emotions such as sadness and hopelessness, or perhaps due to the negative impact of using maladaptive emotion regulation strategies, such as emotional avoidance. Aims of the current study Previous studies of the long-term impact of childhood PM have failed to examine both cognitive and emotion-related mechanisms in the same model, instead arguing that each factor (either cognitive or emotional) was the single most important mechanism leading to negative outcomes following PM (e.g., Gibb & Alloy, 2006; Reddy et al., 2006). In reality, both cognitive and emotional mechanisms may likely predict depressive symptoms following PM (Joormann, 2009; Joormann & D’Avanzato, 2010). The current study aims to contribute to the extant literature by empirically examining mechanisms underlying the relationship between childhood PM and depressive symptoms in emerging adult women. It is important to examine childhood PM and depressive symptoms in women given that they are twice as likely as men to suffer from Major Depressive Disorder (Kessler et al., 2003). Thus, identifying explanatory mechanisms that link PM and depression are important. Previous studies involving PM mechanisms typically include only a single mediating variable (e.g., Krause et al., 2003; Sachs-Ericsson et al., 2006). Based upon earlier studies, it seems possible that both emotion dysregulation and negative beliefs may mediate the development of depressive symptoms in emerging adult women following childhood PM (Gibb & Alloy, 2006; Reddy et al., 2006). Several hypotheses will be tested: (a) It is hypothesized that childhood PM will be significantly associated with depression. (b) It is hypothesized that childhood PM will be significantly associated with heightened levels of emotion dysregulation and negative internalized beliefs. (c) It is hypothesized that negative internalized beliefs and emotion dysregulation will predict depression and mediate the link between PM and depression (rendering the direct path non-significant). Method Participants Participants included 771 female undergraduate students between the ages of 18 and 25 recruited from a midsized public university in the Midwest. Participants received introductory psychology course credit for their participation. These 771 participants were randomly divided in order to conduct exploratory and confirmatory analyses on two independent subsamples. Initial hypothesis testing and exploratory analyses were conducted on Sample 1 (n = 388) and these results were confirmed on Sample 2 (n = 383). The sample was comprised mostly of Caucasian students (92%) in their first (66%) or second years (25.6%). The average age of participants was 18.78 (SD = 1.02) and the majority of participants (92.3%) had never been married. The average family income reported by participants was between $50–75,000. There were no significant differences between the two subsamples on any demographic characteristics. Sample descriptive statistics of study variables are presented in Table 1. Measures Psychological maltreatment. Psychological maltreatment (PM) was assessed using the Computer Assisted Maltreatment Inventory (CAMI; DiLillo, DeGue, Kras, Di Loreto-Colgan, & Nash, 2006; Nash, DiLillo, Messman-Moore, & Rinkol, 2002). The CAMI is a retrospective self-report measure of childhood stressors PM. The CAMI PM scale originally included 57 behaviorally specific questions. These 57 items were then reduced to 24 items which had the strongest factor

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Table 1 Demographic characteristics and difference tests in Sample 1 and Sample 2. Characteristic

Age

Ethnicity Caucasian Asian African American Hispanic/Latina Biracial Marital status Not Married Current year in school Freshman Sophomore Junior Senior Family income $20–29 K $30–39 K $40–49 K $50–74 K $75–99 K $100–149 K $150–199 K Above $200 K

Subsample 1 (n = 388)

Subsample 2 (n = 383)

Total sample (n = 771)

M

SD

M

SD

M

SD

18.77

.91

18.80

1.11

18.78

1.02

t

p

.46

.64

%

%

%

2

p

92.4 .5 1.8 1.8 1.3

90.5 2.3 2.8 1.5 1.3

92.0 1.4 2.3 1.7 1.3

7.40

.49

91.4

93.3

92.3

4.12

.39

66.8 25.3 5.0 2.9

65.2 25.8 5.2 3.9

66.0 25.6 5.1 3.4

.67

.88

1.9 2.1 1.6 8.2 13.0 19.0 11.0 19.0

1.3 1.8 1.8 13.7 9.8 18.5 6.6 22.2

1.6 2.0 1.7 11.0 11.4 18.8 8.9 20.6

.60

.15

loadings for each PM subtype scales (DiLillo, personal communication, July 2009). In the current study, four subscales were examined (Nash, 2005): Spurning/Terrorizing (i.e., “My parents threatened to hurt me.”), Emotional Nonresponsiveness (i.e., “My parents paid attention to me.” reverse scored), Corrupting (i.e., “My parents didn’t care if I did something wrong.”), and Demanding/Rigid (i.e., “My parents were very controlling.”). These four subscales were combined to form a latent PM construct. Participants responded using a 5-point scale ranging from 1 = Strongly Disagree to 5 = Strongly Agree. Internal consistency alphas for the PM scales have ranged from .90 to .96 in college and community samples. In the current sample, the internal consistency alphas were .91 for the Emotional Nonresponsiveness scale, .80 for the Spurning/Terrorizing scale, .58 for the Corrupting scale, and .70 for the Demanding/Rigid scale (Table 2). Negative internalized beliefs. Negative internalized beliefs were assessed using the Young Schema Questionnaire – Short Form (YSQ-S; Young & Brown, 2003). The YSQ-S is a 75-item self-report questionnaire; however, in this dataset 9 of the 15 early Table 2 Means, standard deviations, and corresponding subtypes of the psychological maltreatment items of the Computer Assisted Maltreatment Inventory. Item

Scale

Current study, M (SD)

Nash (2005), M (SD)

My parents showed a lot of interest in me (R) My parents liked spending time with me (R) I felt loved by my parents (R) My parents acknowledged my achievements (R) My parents paid attention to me (R) My parents often asked me about my day (R) My parents threatened to hit or physically hurt me My parents cursed or swore at me My parents made me cry for no good reason My parents embarrassed me in front of my friends My parents got angry and destroyed my things My parents put me in frightening situations I saw my parents do illegal things My parents encouraged me to do illegal things I used illegal drugs with my parents My parents didn’t care when I did things that were wrong Being second best was not good enough Only A’s were good enough My parents were very controlling My parents used me to meet their emotional needs

EN EN EN EN EN EN ST ST ST ST ST ST CO CO CO CO DR DR DR DR

1.47 (.74) 1.49 (.79) 1.32 (.68) 1.51 (.80) 1.55 (.78) 1.51 (.83) 1.52 (1.02) 1.94 (1.24) 1.63 (1.05) 1.70 (1.00) 1.35 (.78) 1.41 (.84) 1.16 (.61) 1.10 (.40) 1.06 (.34) 1.34 (.68) 2.07 (1.25) 2.60 (1.31) 2.03 (1.18) 1.61 (.90)

1.50 (80) 1.63 (.81) 1.36 (.70) 1.47 (.76) 1.59 (.78) 1.56 (.80) 1.89 (1.23) 1.99 (1.23) 1.58 (.94) 1.61 (.94) 1.45 (.89) 1.63 (.99) 1.21 (.72) 1.18 (.55) 1.11 (.50) 1.33 (.64) 2.23 (1.26) 2.66 (1.29) 2.31 (1.25) 1.89 (1.03)

EN, Emotional Nonresponsiveness; ST, Spurning/Terrorizing; CO, Corrupting; DR, Demanding/Rigid.

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maladaptive schemas thought most relevant to child abuse were assessed with five items each for a total of 45 items. The current study focused on two early maladaptive schemas chosen to examine negative internalized beliefs related to PM: mistrust/abuse and defectiveness/shame. The Mistrust/Abuse subscale consists of 5 items which measure negative beliefs about others and includes items such as “I feel that people will take advantage of me.” The Defectiveness/Shame subscale consists of five items which measure negative beliefs about the self and includes items such as “I feel that I am not lovable.” Responses are measured on a 6-point scale indicating how accurately the statement describes the respondent ranging from 1 = Completely untrue of me to 6 = Describes me perfectly. In the current study, the alpha was .91 for the Mistrust/Abuse subscale and .93 for the Defectiveness/Shame subscale, similar to reported alphas for the two subscales of the YSQ-75 (.91 for both subscales; Welburn, Coristine, Dagg, Pontefract, & Jordan, 2002). Emotion dysregulation. Emotional dysregulation was assessed using the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004). The DERS is a 36-item self-report measure developed to assess six domains (subscales) of clinically relevant difficulties in emotion regulation. Participants are asked to indicate how often the statements apply to themselves using a 5-point scale ranging from 1 = almost never to 5 = almost always. Responses are summed so that higher scores indicate greater emotion dysregulation. In the current study, the cognitive and behavioral aspects of emotion dysregulation were measured as a latent factor comprised of two subscales: (lack of) Emotional Clarity (i.e., “I have no idea how I’m feeling.”) and (lack of) Access to Strategies (i.e., “When I’m upset, it takes me a long time to feel better.”). In the current study, the Clarity subscale had an alpha of .85 and the Strategies subscale had an alpha of .90, similar to alphas reported in the development sample (Clarity .84, Strategies .88; Gratz & Roemer, 2004). Depressive symptoms. Depressive symptoms were assessed using the Trauma Symptom Inventory (TSI; Briere, 1995). The TSI consists of 100 items on a 4-point scale assessing how often the participant experienced psychological symptoms related to traumatic events over the past six months. The scale ranges from 0 = never to 3 = often. The questionnaire includes ten clinical scales that measure trauma-related symptoms; however, for the current study only the Depression scale, which has 10 items, was used. Items correspond to both depressed mood (i.e., “feeling depressed”) and cognitions (i.e., “feeling hopeless”). The TSI has demonstrated adequate reliability and validity with a mean internal consistency alpha of .84 for college populations. The internal consistency alpha in the current study was .91. Procedure All procedures were approved by the Internal Review Board for Human Subjects in Research. Participants were recruited from the Introduction to Psychology subject pool with an online system. After being informed of the purpose of the study and their rights as research participants, individuals were assured that all information was anonymous, and that they could discontinue at any time without penalty. Participants then completed the packet of questionnaires (stamped with an identification code), returned them to the experimenter in a closed envelope, were debriefed, and given contact information for the investigators. Statistical analysis Prior to testing the structural models, descriptive statistics and bivariate correlations of all study variables were computed. All study variables were significantly correlated at the bivariate level and were therefore included in the analyses of the structural models. Next, measurement models of the three latent structures – psychological maltreatment, negative internalized beliefs, and emotion dysregulation – were conducted. Finally, structural equation modeling was used to test the hypotheses. One-half of the entire dataset was randomly selected and used for the initial analyses (Sample 1, n = 388) and the other half of the dataset (Sample 2, n = 383) was used to replicate the results of these analyses. Results Descriptive analyses Bivariate correlations indicated that all variables were significantly correlated (Table 3). As hypothesized, correlations indicated that PM was associated with increased levels of emotion dysregulation, increased negative beliefs, and increased levels of depressive symptoms. Further, as levels of emotion dysregulation and negative internalized beliefs increased, levels of depression also increased. Measurement models All SEM analyses were conducted using Mplus 4.21 software (Muthen & Muthen, 2004). For SEM analyses, the goodnessof-fit was assessed using maximum likelihood estimation (MLE). The MLE Chi-square test assessed the overall fit of the hypothesized model with the actual data, but is influenced by sample size and can lead to incorrectly rejecting the null hypothesis in large samples (Raykov & Marcoulides, 2000). Therefore, additional fit indices, such as the CFI, TLI, and RMSEA,

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Table 3 Bivariate correlations, means, and standard deviations among study variables.

1. Psychological Maltreatment Total 2. Emotional Nonresponsiveness 3. Spurning/Terrorizing 4. Corrupting 5. Demanding/Rigid 6. Strategies 7. Clarity 8. Negative Beliefs: Others 9. Negative Beliefs: Self 10. Depression M SD * **

1

2

3

4

5

– .84** .88** .44** .75** .33** .26** .45** .44** .37**

– .63** .28** .47** .26** .24** .34** .37** .29**

– .34** .53** .32** .22** .42** .38** .37**

– .14** .19** .09* .17** .21** .17**

– .21** .21** .35** .33** .25**

8.85 3.82

9.52 4.26

4.66 1.43

8.29 3.36

31.32 10.13

6

– .56** .43** .48** .69** 16.12 6.36

7

– .38** .41** .53** 11.01 3.63

8

– .56** .48** 11.25 5.67

9

10

– .55**

–

7.67 4.49

6.55 5.24

p < .05. p < .01.

were examined when assessing model fit (Browne & Cudeck, 1993). The CFI and TLI are both alternative fit indices which contrast the fit of the hypothesized model to the fit of the null model. Both indices range from 0 to 1.0 with values of .9 and greater indicating acceptable fit and values of .95 and greater indicating well-fitting models (Bentler, 1990). However, the TLI decreases with the addition of parameters and is therefore always more conservative than the CFI. The RMSEA is constrained by zero with values less than .05 indicating well-fitting models and values greater than .10 indicating poor fitting models (Browne & Cudeck, 1993). The RMSEA considers the hypothesized model’s complexity and is less sample size dependent than other fit indices such as the Chi-square test (Browne & Cudeck, 1993). The R2 statistic was also consulted in order to determine the proportion of variance in depressive symptoms accounted for by the model parameters. The current study uses a latent PM construct identified during a previous factor analysis of the PM scale of the CAMI which found four identifiable factors of PM (Nash, 2005): Emotional Nonresponsiveness, Spurning/Terrorizing, Corrupting, and Rigid/Demanding. A confirmatory factor analysis (CFA) model tested this four-factor structure in the current sample. The entire sample (n = 815) was used to conduct the CFA analyses. CFA results indicated that the four factor structure was an adequate fit to the current data, 2 (166, n = 815) = 692.36, p < .001, CFI = .919, TLI = .907, RMSEA = .062. Each factor loading was significant at the p < .001 level and in the hypothesized direction. The factor loadings for each PM subtype in the current sample were: Emotional Nonresponsiveness = .95, Spurning/Terrorizing = .78, Corrupting = .44, and Demanding/Rigid = .77. The factor loadings for three of the four PM subtypes were greater than .7 which suggests that they are measuring a latent structure and may be retained given the theoretically driven nature of the structural models (Garson, 2009). Although the factor loading for the corrupting subtype was below .7, model modification indices did not suggest that omitting any of the items on the corrupting scale (including omitting the scale itself) would significantly improve the fit of the data to the model. Further, all other fit statistics indicated an adequate fit of the four-factor structure to the current data. Thus, in order to maintain consistency with the previous factor analysis (Nash, 2005), and based upon the current CFA and SEM fit statistics, the four-factor latent PM construct was retained for the mediation models. Next, the latent construct of negative internalized beliefs was measured by two subscales of the YSQ which assess early maladaptive schemas believed to develop following negative and hostile communications directed at the child (Young & Brown, 2003). Exploratory analyses revealed adequate factor loadings for negative beliefs regarding the self ( = .88) and negative beliefs regarding others ( = .64). The latent construct of emotion dysregulation was measured by two subscales of the DERS (Gratz & Roemer, 2004): clarity and strategies. These subscales represent two aspects of emotion dysregulation: a general lack of understanding of emotions (i.e., clarity) and an inadequate repertoire of emotion regulation strategies (i.e., strategies), as well as encompass both cognitive and behavioral aspects of emotion regulation. Exploratory analyses revealed adequate factor loadings for emotional clarity ( = .91) and strategies ( = .62) suggesting a latent structure. Because the factor loading of strategies is approaching .7, it is likely the two variables comprise a latent structure and thus may be used in theoretically driven structural models (Garson, 2009). Structural equation models Negative internalized beliefs and emotion dysregulation were proposed mediators of the link between childhood PM and depressive symptoms in adulthood which have been frequently associated in extant literature (for a review see Alloy et al., 2006). In order to examine these mediators, it was first necessary to confirm the relationship between PM and depressive symptoms. The four-factor construct was comprised of the four PM subtypes – Emotional Nonresponsiveness, Spurning/Terrorizing, Corrupting, and Demanding/Rigid – predicting depressive symptoms. Results showed all path coefficients to be in the hypothesized direction. This model’s fit statistics indicated that it was a good fit for the data, 2 (5, n = 388) = 6.62, p = .251, CFI = .996, TLI = .992, RMSEA = .029, R2 = .14 indicating that the four-factor latent PM structure did predict

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Fig. 1. Psychological maltreatment directly predicting depressive symptoms. ***p < .001.

depression (Fig. 1). Because the exploratory model indicated well-fitting representations of the data, no modifications were made prior to the confirmatory analyses. Confirmatory results also indicated a well-fitting model, 2 (5, n = 383) = 13.99, p = .016, CFI = .982, TLI = .962, RMSEA = .069, R2 = .19. The next model examined the hypothesis that emotion dysregulation and negative internalized beliefs would mediate this relationship between PM and depressive symptoms. This exploratory model’s fit statistics, 2 (23, n = 388) = 49.78, p = .001, CFI = .977, TLI = .963, RMSEA = .057, R2 = .68 suggested a good fit between the model and the data (Fig. 2). PM no longer directly predicted depressive symptoms in this model, indicating emotion dysregulation and negative internalized beliefs were mediators of this relationship. All other paths were significant and in the hypothesized directions. Of note, the R2 increased from .14 to .68 when the two mediators were added. Again, the exploratory model indicated well-fitting representations of the data; therefore no modifications were made prior to the confirmatory analyses. This model’s fit statistics also were good, 2 (23, n = 383) = 50.76, p < .001, CFI = .979, TLI = .968, RMSEA = .056, R2 = .70. However, the confirmatory model did not show a significant path coefficient between negative internalized beliefs and depressive symptoms. The direct path from PM to depression was not significant when the mediators were included. All other path coefficients were significant and in the hypothesized directions. Discussion In the current study childhood psychological maltreatment (PM) predicted depressive symptoms, consistent with previous studies (Allen, 2008; Krause et al., 2003; Reddy et al., 2006). Such findings add to a growing literature documenting the severity and deleterious impact of childhood PM. However, the primary purpose of the current study was to contribute to the current empirical literature on mechanisms underlying the negative effects of childhood PM. Utilizing structural equation models to examine two potential underlying mechanisms, there was consistently strong evidence that emotion dysregulation mediates the relationship between childhood PM and depressive symptoms in emerging adulthood for women, whereas the evidence that internalized beliefs mediate the impact of PM on depression was less consistent. In the exploratory

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Fig. 2. Exploratory model examining psychological maltreatment, emotion dysregulation, negative internalized beliefs and depressive symptoms. **p < .01, ***p < .001. Note: the confirmatory model did not reveal a significant path from negative internalized beliefs to depressive symptoms; all other paths were consistent with the exploratory model.

sample, both negative internalized beliefs and emotion dysregulation mediated the relationship between PM and depressive symptoms. However, in the confirmatory sample negative internalized beliefs no longer predicted depressive symptoms. Thus, this study provides some tentative, preliminary evidence this factor also impacts depression, although more research is needed to substantiate this claim. The current study is an important addition to the extant literature given these two mechanisms previously have been linked separately to PM and depression, but have not yet been studied in relation to one another (Gibb & Abela, 2008; Gibb et al., 2004; Krause et al., 2003; Reddy et al., 2006). The exploratory model, as well as previous research, suggests that negative internalized beliefs are relevant in the formation of depressive symptoms after PM. However, it appears that emotion dysregulation is the stronger of the two mediators when the two factors compete in the same model. Nevertheless, the distinction between cognitive and emotional processes in the development of psychological difficulties is not necessarily clear cut, as some models suggest an important role of cognitive processes underlying the regulation of emotion and mood (Joormann, 2009). It is feasible that negative internalized beliefs increase vulnerability to the development of emotion dysregulation, which is the most significant proximal predictor of depressive symptoms. A PM survivor’s negative self-beliefs may extend to perceptions regarding control and interfere with one’s expectation to manage negative emotion, which can lead to a general lack of self-esteem and poor self-efficacy. Expectations that one cannot manage emotionally challenging events then subsequently impede the use of effective emotion regulation strategies. Additional studies that examine the relationship between negative internalized beliefs and emotion dysregulation are needed to disentangle their mutual influence and impact on depression. Emotion dysregulation In the current study, emotion dysregulation was predicted by childhood PM and was also a significant mediator of the relationship between PM and later depressive symptoms. These findings are similar to patterns observed in previous studies in which emotion dysregulation was a significant mediator of the association between PM and later psychological difficulties (Krause et al., 2003; Reddy et al., 2006). The current study adds to the emotion dysregulation literature by assessing both cognitive (i.e., difficulties with emotional identification and understanding) and behavioral (i.e., difficulties utilizing emotion regulation strategies) aspects of emotion regulation. Results indicate that emotion regulation strategies are not the

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only important factor in explaining the link between PM and depressive symptoms; having a clear understanding of one’s emotions is important as well (Denham, 1998; Frewen, Evans, Maraj, Dozois, & Partridge, 2008; Hayes et al., 1996). However, earlier studies typically only examined behavioral coping strategies, and failed to assess other aspects of emotion regulation such as being able to identify and make sense out of one’s emotions. In particular, Reddy et al. (2006) examined experiential avoidance, which is a maladaptive strategy for coping with internal experiences. Krause et al. (2003) assessed emotional inhibition, which could be subsumed under experiential avoidance, and is also a strategy for coping with unwanted emotional experiences. Current theory of emotion dysregulation no longer revolves only around coping with negative emotions, but also focuses on clearly understanding and experiencing one’s emotions as well (Gratz & Roemer, 2004; Hayes et al., 1996; Krause et al., 2003; Saarni, 1999). Results suggest that PM affects both of these aspects of emotion dysregulation, which then increase risk for depressive symptoms. Negative internalized beliefs The current findings are consistent with previous studies which found significant associations between PM and negative beliefs regarding the self (Gibb & Alloy, 2006; Gibb et al., 2003; Sachs-Ericsson et al., 2006) and negative beliefs regarding others (Crawford & Wright, 2007; Messman-Moore & Coates, 2007). PM may be associated with negative internal beliefs primarily due to the critical and demeaning messages explicitly and implicitly communicated to maltreated children. These negative messages are believed to be internalized by the child and to negatively impact thoughts about the self (Gibb & Alloy, 2006; Gibb et al., 2003). Maltreated children often generalize negative beliefs regarding their maltreatment to a general negative attributional style, which has been shown to contribute to a vulnerability to developing depressive symptoms (Abramson et al., 1989; Rose & Abramson, 1992). The caregiver’s critical and demeaning behavior also has been suggested to negatively affect the child’s beliefs about others and affect their ability to form stable relationships (Messman-Moore & Coates, 2007; Sachs-Ericsson et al., 2006). The current study supports assumptions that these critical messages negatively affect the child’s internal belief system. Results demonstrated that emotionally nonresponsive parenting, corruptive parenting, spurning and fear-based parenting, and overly demanding parenting increased levels of depression, negative internalized beliefs, and emotion dysregulation in college women. However, bivariate correlations suggest a slightly stronger link between the PM composite score and negative internal beliefs (about self and others) compared to lack of emotional strategies, or lack of emotional clarity. It may be that adult children of emotionally nonresponsive parents who interpret their caregivers’ uninterested, inappropriate, and overly demanding behavior as due to negative traits within themselves (e.g., that one is not worthy of love or attention) not only generalize expectations regarding their caregivers’ negative behavior to others, but also fail to develop effective emotion regulation capacities. Furthermore, as has been previously discussed, these general negative beliefs increase the risk for experiencing later depressive symptoms (Abramson et al., 1989; Rose & Abramson, 1992). Strengths and limitations Findings provide empirical support for a behaviorally specific and comprehensive definition of childhood psychological maltreatment (PM) that is comprised of four factors, contributing additional support for the theory of PM as a complex and multi-faceted construct. The current study also advances PM research by examining mechanisms that may explain the association between PM and depression. These mechanisms were examined rigorously, using SEM with both exploratory and confirmatory samples to test both the proposed relationships between constructs and the structural makeup of the constructs. SEM assesses relationships among all variables simultaneously and takes into account measurement error which produces a more stringent assessment of the models being assessed than do typical regression analyses (Bollen & Long, 1993). Previous studies that examined PM and depression focused on single predictors and single mechanisms, yet the current results suggest that the relationship between PM and depression is multi-determined and involves both emotional and cognitive factors. However, despite these strengths, there are important drawbacks to note. The current study’s use of an entirely female, convenience sample may have impacted findings. Some previous studies found gender differences in the effects of PM (Harper & Arias, 2004; Taussig & Culhane, 2010), although others have not (Crawford & Wright, 2007). However, this study provides important information for those individuals who are at greatest risk – women – who are twice as likely as men to suffer from depression (Kessler et al., 2003). The exclusive focus on undergraduate women limits generalization of findings, thus future studies should examine similar models among men as well as more diverse samples in terms of education, age, race, ethnicity, and socioeconomic status. Given that sample demographics may impact the factor structure of the CAMI’s psychological abuse subscales, additional studies are warranted. In the current study, the corrupting subscale showed low internal reliability and had a low factor loading on the PM construct. However, the levels of corrupting PM reported in the current sample were similar to a CAMI development study (Nash, 2005). Thus, it is important to continue examining different aspects of the construct of PM, particularly utilizing conservative statistical methods such as structural models, to determine the stability of the construct and its expression in different samples. Related, although the cognitive and behavioral mediators studied here have important theoretical merit, future studies should seek to determine the level of overlap among depression symptoms, levels of negative beliefs, and facets of emotion dysregulation. While the constructs under examination were not one and the same (only 24–52% of the variance in depression was accounted for by negative internalized beliefs and emotion dysregulation respectively), cognitions and emotion regulation skills are key facets of the

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experience of depression, and deserve continued research. Moreover, of great importance given the nature of the research question is that a cross-sectional retrospective design does not allow for causal or temporal predictions. Future studies with longitudinal designs are needed to confirm current findings regarding the predictive ability of PM, negative internalized beliefs, and emotion dysregulation. Clinical implications The finding that both negative internal beliefs and emotion dysregulation may impact depressive symptoms is consistent with therapeutic models which approach clinical intervention for chronic PTSD through dual avenues: addressing deficits in emotion regulation through skill building and addressing the deeper internalized beliefs (Cloitre et al., 2002). This finding suggests that interventions such as cognitive-behavioral therapies which include emotion regulation skill building components may be particularly useful to increase one’s ability to manage emotions following PM (Cloitre et al., 2005; Linehan, Cochran, & Kehrer, 2001). Findings also suggest that some individuals seeking treatment after childhood PM may need to focus on deeper, core intra- and interpersonal schemas to reduce the severity of and minimize relapse of depressive symptoms (Young, Klosko, & Weishaar, 2003). The current findings tentatively suggest that in order to exact significant and long-standing improvement in depression, intervention may need to focus on underlying belief patterns as well as emotion regulation. Consistent with this, researchers have found that women who had difficulty describing their emotions also believed that expressing their emotions would lead to negative consequences (Lawson, Emanuelli, Sines, & Waller, 2008). Such core beliefs may undermine therapeutic intervention. Taken together, the current study and early research point to the importance of not only focusing on decreasing symptomatology, but also the importance of improving emotion regulation and addressing core beliefs which influence expectations and perceptions of emotions for long-term recovery. Conclusion The current study extends our knowledge of the structure of the PM construct, the potential long-term effects of PM, and two potential underlying mechanisms that may be relevant to the development of depressive symptoms following PM. The examination of both emotional and cognitive mechanisms allowed us to better understand two of many reasons that PM can be so detrimental to those who experience it. This emerging knowledge may contribute to the development of interventions to help ameliorate the negative consequences associated with this pervasive type of child maltreatment. 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