Psychology Assignment

Childhood Maltreatment and the Clinical Characteristics of Major Depressive Disorder in Adolescence and Adulthood

Morgan Vallati, Simone Cunningham, Raegan Mazurka, Jeremy G. Stewart,

Cherie Larocque, and Roumen V. Milev Queen’s University

R. Michael Bagby and Sidney H. Kennedy University of Toronto

Kate L. Harkness Queen’s University

Childhood maltreatment is widely implicated as the strongest developmental risk factor for depression onset. The current research is novel in examining the fine-grained associations of childhood emotional versus physical versus sexual maltreatment to indices of the severity, course, and presence of anxiety and trauma-related psychopathology in depression. An amalgamation across 6 previous investigations re- sulted in a sample of 575 adolescents and adults (76% female; age range 12–70, M � 27.88, SD � 13.58). All participants were in a current episode of a unipolar depressive disorder. Retrospective reports of childhood maltreatment were assessed using a rigorous contextual interview with independent, standard- ized ratings. Higher levels of emotional maltreatment and/or sexual maltreatment emerged as signifi- cantly associated with greater depression severity, number of previous episodes, and risk for posttrau- matic stress disorder (PTSD), and were significantly more strongly associated with these characteristics than was physical maltreatment. Further, emotional maltreatment perpetrated by mothers was signifi- cantly associated with depression severity and history, whereas emotional maltreatment perpetrated by fathers was significantly associated with a greater risk of PTSD. These latter results suggest that prevention and intervention efforts may need to focus on the unique roles of mothers versus fathers on the development of depressive- versus threat-related psychopathology, respectively.

General Scientific Summary This study suggests that emotional and sexual abuse are significantly associated with a higher severity and number of lifetime episodes of depression, as well as the presence of a trauma-related diagnosis. Further, they suggest that emotional abuse perpetrated by mothers is associated with higher depression severity and lifetime course, whereas emotional abuse perpetrated by fathers is associated with higher rates of trauma-related disorders co-occurring with depression.

Keywords: anxiety, childhood maltreatment, major depression, posttraumatic stress disorder

This article was published Online First April 2, 2020. X Morgan Vallati, Simone Cunningham, X Raegan Mazurka, Jeremy

G. Stewart, and Cherie Larocque, Department of Psychology, Queen’s University; Roumen V. Milev, Department of Psychiatry, Queen’s Univer- sity; R. Michael Bagby, Department of Psychology, University of Toronto; X Sidney H. Kennedy, Department of Psychiatry, University of Toronto; X Kate L. Harkness, Department of Psychology, Queen’s University.

Ethical approvals for the six investigations included in the current study were obtained from the Queen’s University Health Sciences Research Ethics Board (PSYC-056-06; PSYC-030-01; PSYC-058-06; PSYC-154- 14), the Centre for Addiction and Mental Health Research Ethics Board (103/2005), and the University of Oregon Institutional Review Board (A52-98F). Some of the data were collected as part of the Canadian Biomarker Integration Network in Depression (CAN-BIND), an Integrated Discovery Program supported by the Ontario Brain Institute. The opinions,

results, and conclusions are those of the authors and no endorsement by the Ontario Brain Institute is intended or should be inferred.

The authors gratefully acknowledge the following individuals who pro- vided assistance in the management of data and preparation of the current manuscript: Jasmine Chananna, Susan Dickens, Mateya Dimnik, Jennifer Gillies, Samantha Senyshyn, and Sally Zheng. This work was supported by the Canadian Institutes of Health Research (Kate L. Harkness, MOP- 79320) and the Ontario Mental Health Foundation (Kate L. Harkness), as well as a young investigator award from the Sick Kids Foundation (Kate L. Harkness) and a dissertation award from the Center for the Study of Women and Society (Kate L. Harkness). We also acknowledge a donation by Bombardier.

Correspondence concerning this article should be addressed to Kate L. Harkness, Department of Psychology, Queen’s University, 62 Arch Street, Kingston, ON K7L 3N6, Canada. E-mail: harkness@queensu.ca

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Journal of Abnormal Psychology © 2020 American Psychological Association 2020, Vol. 129, No. 5, 469 – 479 ISSN: 0021-843X http://dx.doi.org/10.1037/abn0000521

469

One in three children worldwide is the victim of emotional, physical, or sexual maltreatment (Moody, Cannings-John, Hood, Kemp, & Robling, 2018). Childhood maltreatment raises risk for the onset of major depressive disorder (MDD) in adolescence and adulthood two- to threefold (Liu, 2017). Further, meta-analyses and systematic reviews have revealed that among individuals who are depressed, those with a history of childhood maltreatment present with an earlier age of onset, more severe symptoms, a greater risk for recurrence, higher rates of comorbidity with other Axis I and II conditions, and more lifetime suicide attempts than those without this history (Lippard & Nemeroff, 2020; Nanni, Uher, & Danese, 2012; Teicher & Samson, 2013). Meta-analyses have also indicated that childhood maltreatment history is associ- ated with poorer response to antidepressant medication, psycho- therapy, and combination treatments (Nanni et al., 2012).

In sum, there is strong evidence that implicates childhood mal- treatment as an environmental marker of a more severe and in- tractable course in MDD. However, maltreatment is a heteroge- neous construct and it is as yet unclear whether specific types of maltreatment (e.g., emotional vs. physical vs. sexual abuse) show differential associations with the clinical features of MDD. If such fine-grained distinctions among maltreatment types are associated with clinical features in MDD that have prognostic value, this information may help in targeting prevention and intervention efforts to those who are most at risk.

There is some theoretical basis for suspecting that different types of maltreatment may be differentially associated with MDD, in general. For example, in their expanded hopelessness theory of depression, Rose and Abramson (1992) proposed that childhood emotional maltreatment should be more strongly associated with depression than physical or sexual maltreatment because parents are directly supplying the child with content to fuel a negative inferential style (e.g., “You’re worthless”). In contrast, in the context of physical or sexual maltreatment, according to Rose and Abramson, the child must make his or her own inferences, thereby allowing for the possibility for less negative attributions.

The meta-analytic evidence to date has provided support for Rose and Abramson’s (1992) model. A meta-analysis of the asso- ciation between retrospectively recollected childhood maltreat- ment and the distinction between depressed and nondepressed groups revealed higher effect sizes for emotional abuse (odds ratio [OR] � 3.06) than neglect (OR � 2.11) or physical abuse (OR � 1.54; Norman et al., 2012). A second meta-analysis generally supported these results, finding higher effect sizes in distinguish- ing between depressed and nondepressed groups for emotional abuse (OR � 2.78) and neglect (OR � 2.75) relative to sexual abuse (OR � 2.42), physical abuse (OR � 1.98), or exposure to domestic violence (OR � 2.06; Mandelli, Petrelli, & Serretti, 2015). A third meta-analysis by Infurna et al. (2016) included only studies that assessed maltreatment using the Childhood Experience of Care and Abuse (CECA; Bifulco, Brown, & Harris, 1994) scale, a rigorous contextual interview with independent ratings that is widely regarded as the gold standard retrospective measure of maltreatment. In the CECA, scales are often dichotomized to denote the presence versus absence of severe maltreatment (see Bifulco et al., 1994). This meta-analysis confirmed that effect sizes for severe psychological abuse (d � .932), severe emotional ne- glect (d � .813), and, in this case, also severe physical abuse (d � .810) were higher than for severe sexual abuse (d � .500; Infurna

et al., 2016). However, none of these three meta-analyses above statistically compared the strength of the effects across types of maltreatment, nor did they provide evidence regarding the differ- ential association of types of maltreatment to the clinical charac- teristics within depression, such as severity or recurrence. Further, Rose and Abramson’s (1992) theory makes no predictions bearing on this latter question. Nevertheless, the weight of the evidence suggests that emotional maltreatment is the maltreatment type most strongly associated with the diagnosis of depression.

The most comprehensive recent theory regarding the differential outcomes of specific early adverse experiences is that proposed by Sheridan and McLaughlin (2014). They leverage theory and data from the preclinical and human cognitive-affective neuroscience literatures to propose that adverse experiences involving threat (i.e., physical or sexual abuse, exposure to neighborhood or do- mestic violence) have different neural and cognitive consequences than experiences involving deprivation (e.g., marked physical ne- glect, institutionalization). Of direct relevance to questions of psychopathology, Sheridan and McLaughlin (2014) propose that experiences of physical and sexual abuse should result in height- ened attentional bias, and reactivity, to threatening stimuli in the environment. Heightened threat processing is a hallmark patholog- ical feature of the fear- and trauma-related related disorders (Mogg & Bradley, 2005; Shechner & Bar-Haim, 2016), and, indeed, results from a small number of studies suggest that sexual abuse is more strongly related to these disorders than are other types of maltreatment, including neglect (Levitan, Rector, Sheldon, & Go- ering, 2003; Sullivan, Fehon, Andres-Hyman, Lipschitz, & Grilo, 2006; van Veen et al., 2013). However, although Sheridan and McLaughlin’s (2014) model provides hypothesized outcomes for extreme experiences of neglect (e.g., sensory deprivation), the model does not include a discussion of the sorts of emotional abuse experiences that have been most strongly associated with depression (e.g., marked antipathy, criticism, coldness or emo- tional disengagement). Nevertheless, their model and the empirical evidence suggest that physical and sexual maltreatment may be more strongly associated than emotional maltreatment with the presence of additional fear- and trauma-related symptoms and disorders in those with depression.

A further issue that has received almost no empirical attention is the differential impact of maltreatment perpetrated by mothers versus fathers. In the developmental literature, attachment theorists have proposed that children may form different patterns of attach- ment to mothers versus fathers based on differences in the ways in which mothers and fathers interact with their children. For exam- ple, it has been proposed that mothers may contribute to healthy emotional functioning primarily through promoting emotion reg- ulation (i.e., soothing the child when upset), whereas fathers may contribute to child development by promoting exploration and play (Bowlby, 1979; Grossmann, Grossmann, Fremmer-Bombik, Scheuerer-Englisch, & Zimmerman, 2002). Consistent with this distinction, lower levels of warmth from mothers have been found to prospectively predict future emotional maladjustment in young children more strongly than care from fathers (Han, Rudy, & Proulx, 2017). Of more direct relevance to the constructs examined in the current study, in a community sample of 1,376 women in New Zealand, retrospective reports of maltreatment (a composite of emotional, physical, or sexual abuse) perpetrated by mothers was more strongly associated with adult psychopathology, includ-

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470 VALLATI ET AL.

ing MDD, than father-perpetrated maltreatment (Mullen, Martin, Anderson, Romans, & Herbison, 1996). Results of this latter study, therefore, provide tentative preliminary evidence that maltreatment from the mother may be more strongly related to outcomes such as MDD than maltreatment from the father; however, it is unclear if this relation extends to particular types of maltreatment and/or to particular clinical characteristics of MDD.

Large samples are required to address the relations of specific types of maltreatment to particular clinical characteristics in MDD because of the low base rates of particular forms of maltreatment (e.g., sexual abuse) and the high degree of co-occurrence among the maltreatment types (see Sheridan & McLaughlin, 2014). At the same time, when examining characteristics of depression, such as severity, it is important to assess maltreatment in a way that minimizes the effect of depression in biasing recollections (Hark- ness & Monroe, 2016). Self-report checklist measures of emo- tional maltreatment, in particular, contain items that more closely reflect subjective perceptions of parenting rather than the actual maltreatment exposure (e.g., “I thought that my parents wished I had never been born” from the Childhood Trauma Questionnaire; Bernstein et al., 1994; italics added). As such, use of such mea- sures to address the current research question may result in spu- riously inflated associations between MDD severity and emotional maltreatment relative to physical or sexual maltreatment. As noted above, the gold standard methods for retrospectively assessing maltreatment exposure are contextual interviews, such as the CECA, which query in detail about the contextual and behavioral features of the maltreatment and use independent judges and a manual of standardized exemplars to anchor ratings of maltreat- ment presence and severity (Bifulco et al., 1994). A recent review determined that maltreatment retrospectively assessed using con- textual interview measures is more strongly associated with reports of maltreatment taken at the time of the abuse (either officially documented reports or self-report) than is maltreatment retrospec- tively assessed by self-report checklist (Baldwin, Reuben, New- bury, & Danese, 2019). However, the contextual method is time- and labor-intensive, thereby working at cross-purposes with the

goal of collecting large samples. For the current study, we com- bined data across six smaller previous investigations that utilized the CECA interview to derive a sample of 575 individuals in a current episode of MDD. To our knowledge, this represents the largest sample to date of individuals in a current major depressive episode who have been rigorously characterized in terms of both the clinical features of the illness and contextual histories of specific forms of childhood maltreatment.

The current study addresses the novel question of whether emotional, physical, and sexual maltreatment are differentially associated with the severity and course of depression, as well as with the presence of a fear-related anxiety disorder or a trauma- related disorder (i.e., PTSD). Taken together, the above theory and preliminary evidence to date suggest that when including other forms of maltreatment in our models, (a) emotional maltreatment will have independent associations with a greater severity and greater number of episodes of MDD, (b) physical and sexual maltreatment will have independent associations with higher rates of anxiety disorders and PTSD, and (c) maltreatment perpetrated by mothers will be more strongly associated with all clinical characteristics of MDD than maltreatment perpetrated by fathers.

Method

Participants

The current report included 575 participants (76% female; age range 12–70, M � 27.88, SD � 13.58), drawn from one of six investigations conducted previously across three sites investigating the relation of stress in individuals with depression compared with individuals with no psychiatric history (see Harkness & Luther, 2001; Harkness, Bruce, & Lumley, 2006; Harkness et al., 2015; Harkness, Bagby, & Kennedy, 2012; Mazurka, Wynne-Edwards, & Harkness, 2018; see Table 1). Only participants in the depressed group of the previous investigations were relevant to the current research question and, thus, only these participants were included in the current report. All participants were recruited through com-

Table 1 Demographic and Clinical Characteristics by Study

Characteristic Study 1 (n � 79)

Study 2 (n � 77)

Study 3 (n � 134)

Study 4 (n � 95)

Study 5 (n � 76)

Study 6 (n � 114) �2 or F

Age, M (SD) 15.78 (1.55)a 16.51 (1.90)a 21.19 (3.45)b 31.44 (14.23)c 37.30 (11.12)d 42.57 (11.66)e 149.48 ���

Sex Female, n (%) 56 (70.9)a 59 (76.6)a 102 (76.1)a 68 (71.6)a 76 (100)b 74 (64.9)a 33.48

���

Ethnicity White, n (%) 76 (96.2)a 63 (81.8)bde 98 (73.7)bc 71 (77.2)cd 69 (90.8)ae not assessed 34.52

���

Asian, n (%) 0 (0) 2 (2.6) 16 (12.0) 13 (14.1) 1 (1.3) Other, n (%) 3 (3.8) 12 (15.6) 19 (14.3) 8 (8.7) 6 (7.9)

Years of education, M (SD) 10.47 (1.59)a 11.21 (1.90)a 14.51 (2.35)b 16.53 (2.55)c 16.74 (2.37)c 16.18 (2.31)c 128.50 ���

Age of first onset, M (SD) 12.68 (3.19)a 14.14 (2.60)a 18.00 (4.49)b 19.57 (11.58)b not assessed 30.14 (12.24)c 65.80 ���

Lifetime episodes, M (SD) 1.72 (1.48)ab 1.44 (0.80)b 1.69 (1.69)b 2.96 (2.67)a 7.62 (6.50)c 2.82 (2.82)a 46.06 ���

Anxiety: Yes, n (%) 22 (28.0)ab 18 (23.4)a 46 (34.3)ab 47 (49.5)b 22 (28.9)ab 12 (10.5)c 41.28 ���

PTSD: Yes, n (%) 8 (10.1)ab 3 (3.9)a 5 (3.7)a 16 (16.8)bc 17 (22.4)c 0 44.07 ���

BDI-II, M (SD) 23.57 (11.79)a 29.20 (10.40)b 31.33 (8.93)b not assessed 28.61 (8.51)b 30.45 (7.89)b 9.31 ���

HRSD-17, M (SD) not assessed not assessed 15.15 (6.28)a 18.11 (5.39)b 16.93 (4.94)ab 17.94 (3.59)b 8.28 ���

Note. Anxiety disorders included panic disorder, social phobia, specific phobia, and separation anxiety. PTSD � posttraumatic stress disorder; BDI-II � Beck Depression Inventory II; HRSD-17 � Hamilton Rating Scale for Depression. Subscripts indicate study differences. ��� p � .001.

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471CHILDHOOD MALTREATMENT AND DEPRESSION

munity advertisements (n � 499) or clinician referrals (n � 76). Each of these previous investigations received ethical approval from the sponsoring institution. Written informed consent was provided by all participants, and by parents/guardians for partici- pants under age 18 years.

All participants in the depressed group of each of the six larger investigations had to meet Diagnostic and Statistical Manual of Mental Disorders (DSM–IV–TR; American Psychiatric Associa- tion, 2000) criteria for a current episode of a nonbipolar, nonpsy- chotic depressive disorder. Further, for inclusion in the current report participants must have completed the CECA (Bifulco et al., 1994) interview and have ratings for a mother and father caregiver. Exclusion criteria across all six prior investigations were the presence of a lifetime psychotic disorder, bipolar disorder, sub- stance dependence, developmental disability, a medical condition that better accounted for depression, or acute suicidality necessi- tating inpatient treatment. In addition, Study 6 excluded individ- uals meeting criteria for any comorbid disorder other than an anxiety disorder or PTSD.

Measures

Diagnosis. Participants under the age of 18 years were admin- istered all sections of the child and adolescent version of the Schedule for Affective Disorders and Schizophrenia (K-SADS; Kaufman, Birmaher, Brent, Rao, & Ryan, 1996). Participants age 18 years and older were administered all sections of the Structured Clinical Interview for DSM–IV Axis I Disorders (SCID-I/P; First, Spitzer, Gibbon, & Williams, 2002). All interviews were con- ducted by senior graduate students in clinical psychology who were trained to gold standard reliability status (see Grove, Andrea- sen, McDonald-Scott, Keller, & Shapiro, 1981) by Kate L. Hark- ness.

At least one additional disorder was reported by 275 participants (47.8%). We created two dependent variables for analysis: (a) presence versus absence of a fear-related anxiety disorder (n � 164, 28.5%; Kotov et al., 2017). Specific anxiety disorders in- cluded panic disorder (n � 58), social phobia (n � 89), specific phobia (n � 24), and separation anxiety disorder (n � 1)1; (b) presence versus absence of trauma-related psychopathology, namely a diagnosis of PTSD (n � 49, 8.5%).

Eighty-four (14.6%) participants met criteria for a diagnosis other than an anxiety disorder or PTSD. However, owing to differences in exclusion criteria, these disorders were not evenly distributed across the original investigations, and no one class of disorders was frequent enough to permit analysis. Therefore, they are listed here solely for descriptive purposes: obsessive– compulsive disorder (n � 24), alcohol use disorder (n � 16), substance use disorder (n � 23), bulimia nervosa (n � 9), anorexia nervosa (n � 4), attention-deficit/hyperactivity disor- der (n � 6), oppositional-defiant disorder (n � 6), and conduct disorder (n � 8).2

Depression severity. Depression severity was assessed with the 21-item Beck Depression Inventory (BDI-II; Beck, Steer, & Brown, 1996; Studies 1– 4 and 6) and/or the 17-item Hamilton Rating Scale for Depression (HRSD-17; Hamilton, 1960; Studies 3– 6). Both measures have good to excellent internal consistency (Bagby, Ryder, Schuller, & Marshall, 2004; Dozois, Dobson, & Ahnberg, 1998). To include the full sample in analyses examining

depression severity, we z standardized the BDI-II and HRSD scores and calculated their average for those who received both. The resulting standardized score was used in analyses (skew � 0.018). However, the scores on the original instruments are pre- sented in Tables 1 and 3 for descriptive purposes.

Childhood maltreatment. The CECA (Bifulco et al., 1994) is a semistructured contextual interview that assesses the quality of parental care and experiences of maltreatment up to age 18. All interviews were conducted by senior graduate students who were trained by Kate L. Harkness in the Bedford College contextual method of life stress assessment (Bifulco et al., 1994). An impor- tant concern with the retrospective approach to the assessment of maltreatment, particularly in cross-sectional designs, is that sub- jective perceptions of childhood may bias reports of maltreatment, thereby potentially leading to spuriously inflated relations between maltreatment and outcomes such as depression. The CECA ad- dresses the issue of bias at all stages of the procedure. First, in the interview, respondents are encouraged to tell the story of their childhood experiences. Both positive and negative experiences are queried, and respondents are asked to provide specific behavioral and contextual details and examples (e.g., verbatim statements) to support their reports. Respondents are never queried about their subjective feelings or attributions regarding their experiences. Sec- ond, the material from the interview is rated by independent raters who are unaware of participants’ psychiatric status or subjective responses to the exposures. Ratings are based on the behavioral and contextual details and are anchored to a large manual of over 500 standardized exemplars that cover each scale and rating scale point. The manual also includes extensive descriptions and rating rules for each scale (see Bifulco et al., 1994). All maltreatment exposures reported in the current sample had their onset prior to the onset of the index episode of MDD, even among the adoles- cents.

The following scales were included in the current analyses: (a) emotional maltreatment (rated separately for mother and father)— hostility, criticism, and/or coldness or emotional distance3; (b) physical maltreatment (rated separately for mother and father)— violence directed toward the child; and (c) sexual maltreatment— coercive and/or age-inappropriate sexual contact by any perpetra- tor. As expected in an unselected community sample, most of the incidences of sexual maltreatment reported by the current partic- ipants had not been perpetrated by parents, and thus, it was not feasible to stratify the sexual maltreatment variable by mother versus father. Instead, to capture the diversity of experience, we

1 In the DSM–IV obsessive– compulsive disorder was defined as an Anxiety Disorder. However, to more clearly support implications to current nosological systems, we classified it for analyses in the other disorder category.

2 The individual diagnoses do not add up to the total because some participants had more than one additional diagnosis. In addition, there was overlap among the groups (e.g., some participants had both an anxiety disorder and PTSD.).

3 The CECA also queries for neglect. However, because our participants were all relatively high-functioning volunteers from the community who were recruited based on their depression status (not their maltreatment history), a very small number of participants had exposure to material neglect (i.e., deprivation of food, clothing, shelter, or sensory input) and none had been institutionalized as children. Therefore, we did not include neglect in the current analyses.

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472 VALLATI ET AL.

examined two sexual maltreatment variables that were distin- guished by the degree of relationship to the perpetrator (see Cun- ningham et al., 2019): relative-perpetrated (parent, sibling, grand- parent, or aunt/uncle/cousin) and nonrelative-perpetrated (stranger, same-age peer, adult family friend, or other adult [e.g., teacher, nanny, etc.]).

At the rating stage, independent raters assigned a numerical ranking for each scale above. The scale points were 4 � marked; 3 � moderate; 2 � some; 1 � little/none for emotional maltreat- ment, and 5 � marked; 4 � moderate; 3 � some; 2 � little; 1 � no maltreatment for physical and sexual maltreatment.4 Each scale point has anchored exemplars in the CECA manual. The distribu- tion of scores, and means and standard deviations, for each of the six maltreatment variables included in the current analyses is provided in Table 2.

Procedure

Full details regarding the procedures of each investigation from which participants were drawn are outlined in previous reports. Studies 1 through 5 included two 2-hr assessments conducted one week apart. During the first session, participants were adminis- tered the K-SADS or SCID-I/P and the BDI-II and/or HRSD-17; the CECA was administered during the second session. Study 6 was a 16-week treatment trial. Participants were administered the SCID-I/P, BDI-II, and HRSD-17 at the baseline session, and the CECA at the end of the 16-week treatment period. At the termi- nation of each protocol, all participants currently in treatment were referred back to their provider and participants not in treatment received a referral for services. All participants also received nominal financial compensation for their time.

Data Analysis

Preliminary univariate analyses were conducted to examine the relations of the demographic characteristics of the sample to the childhood maltreatment variables. The primary study hypotheses were assessed through a series of four regression models. The dependent variables included the standardized composite severity score (multiple linear regression), number of previous episodes (Poisson regression), the presence versus absence of an anxiety disorder (i.e., panic disorder, social phobia, specific phobia, sep- aration anxiety; logistic regression), and the presence versus ab- sence of PTSD (logistic regression). The independent variables included the six maltreatment variables entered together as a block: mother emotional maltreatment, father emotional maltreat- ment, mother physical maltreatment, father physical maltreatment, relative-perpetrated sexual maltreatment, and nonrelative perpe- trated sexual maltreatment. The resulting parameters thus provide an estimate of the statistical relation of the specific maltreatment type in question, over and above the variance accounted for by the other maltreatment types. The bias-corrected confidence intervals on the parameter coefficients were provided based on 1,000 boot- strapped samples, and we tested the statistical difference between hypothesis-relevant coefficients using the overlap in the confi- dence intervals method (Cumming, 2009).

We corrected for multiple tests using the False Discovery Rate (FDR; Benjamini & Hochberg, 1995) q statistic. This statistic represents the minimum false discovery rate at which a test is

considered significant, and is equal to a Bayesian-derived quantity measuring the probability that a significant test is a true null hypothesis. We calculated the FDR q-statistic in the current study across all 24 observed p values in our primary regression models reported below (four dependent variables � six independent vari- ables). This yielded a q statistic of .01. This is interpreted to mean that only 1% of all significant effects in this sample are true null hypotheses (i.e., false positives). Therefore, observed p values less than or equal to this value are considered significant (see Storey, 2002).

Results

Preliminary Relations of Maltreatment Types to Demographic Characteristics

Women reported significantly greater severity than men of mother emotional maltreatment (Ms � 1.89, 1.43; SDs � 0.99, 0.69; t[338.00] � 6.12, p � .001), relative-perpetrated sexual maltreatment (Ms � 0.42, 0.09; SDs � 1.15, 0.51; t[517.56] � 4.66, p � .001), and nonrelative-perpetrated sexual maltreatment (Ms � 0.82, 0.23; SDs � 1.42, 0.80; t[425.03] � 6.17, p � .001). Older age was significantly associated with greater severity of mother emotional maltreatment, r � .12, p � .005 and father physical maltreatment, r � .11, p � .01. Further, higher years of education was significantly associated with greater severity of nonrelative-perpetrated sexual maltreatment, r � 0.11, p � .006. Ethnicity was not significantly related to any of the maltreatment variables (all ps � 0.01). In preliminary model-building we deter- mined that the results of all the primary models below were robust when accounting for sex, age, years of education, and ethnicity, both separately and together (for sex and age). Therefore, the models without covariates are presented below for ease of inter- pretability.

Relations of Childhood Maltreatment Types to Depression Characteristics

Table 3 presents the bivariate, zero-order correlations of each maltreatment type with each of the clinical characteristics. The parameters for each regression model are provided in Tables 4, 5, and 6. As noted above, significant differences between parameter estimates were determined using the 0 (p � .01) overlap in the bootstrapped confidence interval rule (Cumming, 2009).

Depression severity. The linear regression model for the stan- dardized composite depression severity score was significant, F(6, 568) � 6.02, p � .001 (see Table 4). Higher severity of nonrelative-perpetrated sexual maltreatment was significantly as- sociated with higher depression severity, and greater severity of

4 In the CECA, the rating of 1 � none is distinguished from 2 � little for physical and sexual maltreatment because it is possible (and, indeed, most common) for children to have never been touched in a violent or sexual manner by any perpetrator at any point in childhood; that is, maltreatment is legitimately absent in these cases. However, for the con- struct of emotional maltreatment it is not as straightforward to distinguish little from none. Arguments, and even some minor criticism and coldness, are likely to occur at some point across the 18 years of childhood even in the most loving parent– child relationships.

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mother emotional maltreatment was associated with higher depres- sion severity as a trend. Both were associated with small-medium effect sizes (ds � .20). The bias-corrected parameter estimate for nonrelative-perpetrated sexual maltreatment was significantly higher than that for father physical maltreatment and higher at a trend than that for mother physical maltreatment. No other differ- ences between parameter estimates emerged as significant at the stringent 0.01 level.

Number of depressive episodes. Because number of previous episodes is a count variable, and was positively skewed (skew � 3.375), this model was run as a Poisson regression. The overall model was significant (see Table 5).5 Greater severity of mother emotional maltreatment and nonrelative-perpetrated sexual mal- treatment were significantly associated with a greater number of previous episodes. The incidence risk ratios (IRRs) indicated that those with marked ratings of mother emotional maltreatment or nonrelative perpetrated sexual maltreatment had a 60% to 70% greater number of previous episodes than those with ratings of little and/or none. The parameter estimate for mother emotional maltreatment was higher at a trend (p � .05) than the estimates for father emotional maltreatment, and father and mother physical maltreatment. Further, the parameter estimate for nonrelative- perpetrated sexual maltreatment was significantly higher (p � .01) than the estimate for father physical maltreatment, and higher as a trend than the estimate for father emotional maltreatment and mother physical maltreatment.

Anxiety disorder. The logistic regression model for the pres- ence versus absence of an anxiety disorder failed to reach statis- tical significance (see top panel of Table 6), and, contrary to hypotheses, none of the maltreatment variables emerged as signif- icant in this model. However, the parameter estimate for father emotional maltreatment approached significance. The odds ratios indicated that those with marked ratings of father emotional mal- treatment were twice as likely to have an anxiety disorder diag- nosis than those with little/none ratings. None of the parameter estimates differed significantly.

Posttraumatic stress disorder. The logistic regression model for the presence versus absence of PTSD was significant (see bottom panel of Table 6). Consistent with hypotheses, greater severity of relative-perpetrated and nonrelative-perpetrated sexual maltreatment were significantly associated with greater risk of a PTSD diagnosis. And, contrary to expectations, greater severity of father emotional maltreatment was also significantly associated with greater PTSD risk in this model. The odds ratios indicated that those with marked ratings of father emotional maltreatment and relative- and nonrelative-perpetrated sexual maltreatment had a 3– 4 times greater risk of a PTSD diagnosis than those with little

or no maltreatment. The parameter estimate for nonrelative- perpetrated sexual maltreatment was significantly higher than the estimates for physical maltreatment and higher as a trend than the estimate for mother emotional maltreatment. No other differences between parameter estimates emerged as significant at the strin- gent 0.01 level.

Discussion

Childhood maltreatment is strongly associated with the onset of MDD, as well as with greater severity, recurrence, and the pres- ence of additional diagnoses among those who are depressed (Nanni et al., 2012). In the current sample of adolescents and adults, we found evidence for specific patterns of association between types of maltreatment and characteristics of the MDD syndrome. Specifically, emotional maltreatment and/or nonrelative perpetrated sexual maltreatment were the only maltreatment types to emerge as significantly associated with a greater severity and lifetime history of depression, and higher odds of PTSD. In con- trast, a history of physical maltreatment was not significantly related to any of the clinical characteristics of MDD. Further, emotional maltreatment and/or nonrelative perpetrated sexual mal- treatment emerged as significantly more strongly associated with depression severity, lifetime episodes of depression, and the pres- ence of PTSD than physical maltreatment. This pattern of findings is consistent with the meta-analysis by Mandelli et al. (2015), which reported the smallest effect size for the relation of physical maltreatment to depression, in general, in comparison with emo- tional and sexual maltreatment (see also Keyes et al., 2012). The current results provide a novel extension of these previous findings to the specific patterns of association with the clinical character- istics of MDD.

The relations of emotional maltreatment and nonrelative perpe- trated sexual maltreatment to depression outcomes, although both significant, did not differ significantly from each other. This result appears to run contrary to the meta-analytic evidence showing stronger associations of emotional maltreatment to depression than both sexual and physical maltreatment (Infurna et al., 2016; Man- delli et al., 2015; Norman et al., 2012). However, it is important to note that none of these meta-analyses statistically compared the strength of the effects across the maltreatment types.

The lack of a significant difference in the effect sizes for emotional and sexual maltreatment also appears to run contrary to Rose and Abramson’s (1992) expanded hopelessness theory of

5 Results of the model were robust when examining women only and including age as a covariate.

Table 2 Descriptive Statistics of Clinical Characteristics by Maltreatment Types (n � 575)

Maltreatment type Marked Moderate Some Little/none Absent M SD

Mother emotional 42 (7.3) 83 (14.4) 155 (27) 295 (51.3) — 1.78 0.95 Father emotional 39 (6.8) 98 (17) 170 (29.6) 268 (46.6) — 1.84 0.94 Mother physical 21 (3.7) 56 (9.7) 38 (6.6) 25 (4.3) 435 (75.7) 0.61 1.18 Father physical 25 (4.3) 58 (10.1) 39 (6.8) 20 (3.5) 433 (75.3) 0.65 1.22 Relative sexual 30 (5.2) 15 (2.6) 14 (2.4) 1 (0.2) 515 (89.6) 0.34 1.03 Nonrelative sexual 49 (8.5) 36 (6.3) 36 (6.3) 13 (2.3) 441 (76.7) 0.68 1.32

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depression, which posited that emotional maltreatment should show specific and preferential association with depression over other forms of maltreatment (again, including both physical and sexual maltreatment) because it provides the child with explicit content for the development of a negative self-schema. However, Rose and Abramson’s theory was specific to the development of hopelessness depression, a subtype characterized by apathy, low energy, psychomotor retardation, and interpersonal dependency (Abramson, Metalsky, & Alloy, 1989; Joiner et al., 2001). It is possible that emotional and sexual maltreatment, although both associated with higher overall severity, are each associated with specific symptoms or clusters of symptoms within the heteroge- neous depression syndrome. Therefore, although beyond the scope of the current investigation, future research investigating this level of specificity is warranted.

A particularly novel dissociation in the current study was that emotional maltreatment perpetrated by the mother was signifi- cantly associated with higher depression severity and a greater number of previous depressive episodes, whereas emotional mal- treatment perpetrated by the father was not. In direct contrast, emotional maltreatment perpetrated by the father was significantly associated with a PTSD diagnosis (and associated with an anxiety disorder diagnosis at a trend level), whereas mother-perpetrated emotional maltreatment was not. This latter finding is consistent with a large study of 945 schoolchildren in China, which also found larger associations across all anxiety disorders for father- versus mother-perpetrated emotional maltreatment (Wang, Wang, & Liu, 2016). However, Wang et al. (2016) did not statistically compare the strength of the effects for father versus mother mal- treatment.

It is possible that emotional abuse from the father may be perceived by the child as more hostile and threatening than that perpetrated by the mother. Indeed, in studies of emotion perception generally, male faces are more likely to be misperceived as angry than female faces (Neel, Becker, Neuberg, & Kenrick, 2012), and recognition memory is better for angry male faces than for angry female faces (Tay & Yang, 2017). In the current qualitative CECA interview transcripts, participants reported that fathers were more often hostile and threatening in their tone, and participants were more likely to used words such as angry and mean, and to report being frightened, when describing emotional maltreatment perpe- trated by fathers relative to mothers. As such, although speculative, it is possible that emotional maltreatment from the father may be more likely than from the mother to result in the sorts of neuro- cognitive processes that are associated with the development of posttraumatic and fear symptoms, such as attentional bias to threat (Okon-Singer, 2018; see Sheridan & McLaughlin, 2014). In con- trast, it is possible that mother emotional maltreatment may be more likely to disrupt mechanisms that have been associated with the onset and chronicity of depression symptoms, such as the development of internal working models of security and attach- ment, and the development of core beliefs related to self-worth (Gibb, Alloy, Abramson, & Marx, 2003; Lumley & Harkness, 2007; Riggs & Kaminski, 2010). It is important to note that the parameter estimates for mother versus father emotional maltreat- ment did not differ significantly at the stringent p � .01 level across any of the depression characteristics, although in the case of number of previous episodes and PTSD they approached signifi- cance. Therefore, more targeted research with samples of individ- uals recruited on the basis of their maltreatment histories is re-

Table 3 Bivariate Correlations of Maltreatment Types and Clinical Characteristics

Maltreatment type BDI-II

(n � 493) HRSD-17 (n � 432)

Number of episodes (n � 575)

Anxiety disorder (n � 575)

PTSD (n � 575)

Mother emotional maltreatment 0.19��� 0.09 0.24��� 0.04 0.17���

Father emotional maltreatment 0.09 0.11� 0.09� 0.13�� 0.21���

Mother physical maltreatment 0.07 0.06 0.13�� 0.002 0.14��

Father physical maltreatment 0.01 0.05 0.03 0.08 0.11�

Relative sexual maltreatment 0.09 0.13�� 0.12�� 0.05 0.23���

Nonrelative sexual maltreatment 0.15�� 0.18��� 0.23��� 0.07 0.25���

Note. BDI-II � Beck Depression Inventory II; HRSD-17 � Hamilton Rating Scale for Depression 17; PTSD � posttraumatic stress disorder. � p � .05. �� p � .005. ��� p � .001.

Table 4 Parameter Estimates for Linear Regression Model for Depression Severity

Variable R2 B t d

Bootstrapped

p Bias-corrected CI95(B)

DV: Depression severity 0.06��

Mother emotional maltreatment 0.10 2.06 0.21 0.02 [0.01, 0.19] Father emotional maltreatment 0.06 1.26 0.12 0.20 [�0.03, 0.15] Mother physical maltreatment 0.005 0.12 0.01 0.90 [�0.07, 0.07] Father physical maltreatment �0.13 �0.35 0.03 0.71 [�0.08, 0.06] Relative sexual maltreatment 0.06 1.53 0.13 0.08 [�0.007, 0.13] Nonrelative sexual maltreatment 0.11 3.64 0.31 0.001 [0.05, 0.17]

Note. DV � dependent variable; CI95(B) � 95% confidence interval of B. �� p � .001.

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quired to confirm the preliminary differential associations reported here.

In terms of sexual maltreatment, our results are consistent with those of prior studies showing associations with particularly severe and chronic manifestations of depression (Harkness & Monroe, 2002; Holshausen, Bowie, & Harkness, 2016; Sitko, Bentall, Shev- lin, O’Sullivan, & Sellwood, 2014) and comorbid trauma-related symptoms (e.g., Mueller-Pfeiffer et al., 2013). In particular, in the current sample, sexual maltreatment perpetrated by a nonrelative showed the strongest effect size in relation to PTSD; those with marked levels of nonrelative perpetrated sexual maltreatment were four times more likely to have a diagnosis of PTSD than those with no history of sexual maltreatment. PTSD is the most common psychiatric disorder associated with sexual violence exposure (life- time prevalence 26.6% to 45.2%; Walsh et al., 2012) and, thus, the current results are not surprising. Close to half of these exposures in the current sample involved rape by a stranger, acquaintance, or partner. The particularly violent and uncontrollable nature of sex- ual assault from a nonrelated perpetrator, along with feelings of shame, guilt, and betrayal that prevent disclosure and seeking of support following such victimization, are mechanisms that have been proposed to mediate its strong relation to PTSD (Walsh,

Galea, & Koenen, 2012). Future research is now needed to deter- mine whether such mechanisms account for the differential rela- tion of sexual maltreatment to PTSD in depression over other forms of adverse childhood experiences.

Although nonrelative-perpetrated sexual maltreatment consis- tently evidenced a stronger effect size in all models compared with relative-perpetrated sexual maltreatment, the parameter estimates did not differ significantly in any model. In previous studies, including the National Comorbidity Study, chronic childhood sex- ual abuse and victimization by a known perpetrator was associated with significant odds of psychiatric outcomes than isolated inci- dents or victimization by an unknown perpetrator; although in these specific analyses the investigators did not statistically com- pare the strength of the effects (Molnar, Buka, & Kessler, 2001). In the current sample, most of the perpetrators, even in the nonrelative-perpetrated group, were known to the participant (e.g., family friend, boyfriend, classmate; only 19 incidences involved strangers). Within the known perpetrator group, incestuous sexual abuse has been associated with significantly worse mental health outcomes than nonincestuous abuse (Edwards, Freyd, Dube, Anda, & Felitti, 2012). However, only 22 of the relative-perpetrated incidences in the current sample involved relatives in the home,

Table 5 Parameter Estimates of Poisson Regression Model for Number of Depressive Episodes

Variable �2 B Wald IRR

Bootstrapped

p Bias-corrected CI95(B)

DV: Number of episodes 214.15��

Mother emotional maltreatment 0.20 44.50 1.22 0.001 0.08, 0.30 Father emotional maltreatment 0.02 0.79 1.03 0.75 �0.13, 0.17 Mother physical maltreatment 0.02 1.00 1.02 0.63 �0.07, 0.12 Father physical maltreatment �0.03 1.87 0.97 0.54 �0.13, 0.07 Relative sexual maltreatment 0.05 6.00 1.05 0.26 �0.05, 0.15 Nonrelative sexual maltreatment 0.14 73.65 1.15 0.001 0.06, 0.21

Note. DV � dependent variable; IRR � incidence risk ratio; CI95(B) � 95% confidence interval of B. �� p � .001.

Table 6 Parameter Estimates of Logistic Regression Models for Anxiety Disorder and PTSD

Variable �2 B OR

Bootstrapped

p Bias-corrected CI95(B)

DV: Anxiety disorder 11.63†

Mother emotional maltreatment 0.04 1.04 0.75 �0.21, 0.29 Father emotional maltreatment 0.22 1.25 0.03 �0.007, 0.46 Mother physical maltreatment �0.09 0.92 0.40 �0.30, 0.11 Father physical maltreatment 0.07 1.07 0.42 �0.11, 0.25 Relative sexual maltreatment 0.04 1.04 0.65 �0.17, 0.24 Nonrelative sexual maltreatment 0.08 1.09 0.29 �0.07, 0.46

DV: PTSD 58.69��

Mother emotional maltreatment 0.07 1.07 0.76 �0.33, 0.44 Father emotional maltreatment 0.48 1.62 0.01 0.05, 0.93 Mother physical maltreatment 0.17 1.18 0.19 �0.08, 0.40 Father physical maltreatment 0.003 1.00 0.98 �0.31, 0.28 Relative sexual maltreatment 0.36 1.43 0.004 0.04, 0.67 Nonrelative sexual maltreatment 0.43 1.53 0.001 0.20, 0.68

Note. DV � dependent variable; PTSD � posttraumatic stress disorder; OR � odds ratio; CI95(B) � 95% confidence interval of B. † p � .07. �� p � .001.

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and only 15 involved a parent. Therefore, although the current results confirm the strong and general association of sexual mal- treatment with a more severe and recurrent depression, and with higher rates of trauma-related psychopathology, future studies that include larger numbers of individuals with perpetrators at the extremes (i.e., incestuous and stranger-perpetrated) may be re- quired to uncover significant differential patterns of association.

The findings of the current study should be interpreted in light of the following limitations. First, the design was cross-sectional and, thus, relied on reports of maltreatment taken when partici- pants were in their index episode of depression. This raises the possibility that individuals with more severe manifestations of MDD may have been more likely to recall their childhoods as abusive regardless of their actual level of exposure. To address the important concern of depressive bias, we used a rigorous contex- tual interview with standardized ratings of maltreatment. The CECA, in particular, addresses concerns of reporting bias by focusing the interview on behavioral and contextual details of childhood experience and employing independent raters who an- chor their ratings to a large manual of standardized exemplars and rating rules. No retrospective measure of childhood maltreatment can provide a purely objective assessment, and, indeed, reliance solely on objective reports (e.g., court documents) would not be appropriate in the current design as epidemiological studies sug- gest that close to two thirds of maltreatment cases go unreported, resulting in a large number of false negatives (London, Bruck, Ceci, & Shuman, 2005). The contextual interview approach to retrospective assessment has recently been shown to be more strongly related to reports of maltreatment taken at the time of the abuse (either officially documented reports or self-report) than the self-report checklist approach to retrospective assessment (Bald- win et al., 2019), and the CECA, in particular, is considered the gold standard in this area of maltreatment assessment. Neverthe- less, prospective longitudinal studies are needed to definitively rule out recall bias as an alternative explanation for the current findings.

Second, all participants were volunteers from the community based on their depression status. Our results, therefore, may not be generalizable to epidemiological or patient samples of individuals with MDD or to the population of individuals with a maltreatment history. In particular, use of this sample precluded the investiga- tion of very severe forms of material and sensory deprivation/ neglect, such as institutionalization, that have been associated by Sheridan and McLaughlin (2014) with unique neurobiological and pathological outcomes. Relatedly, an important area for future research is to examine more complex models of the interactions among forms of maltreatment. Although such moderation effects were beyond the scope of the current investigation, they are warranted in future research given that forms of maltreatment are not independent and, thus, may very well exert joint influence on the characteristics of MDD.

Finally, the effect sizes for all significant parameters were in the small to medium range. This suggests that other, more proximal variables likely drive the relations of maltreatment types to spe- cific clinical outcomes. Therefore, a crucial next step for future research is to examine mediators and moderators of the relation between specific types of childhood maltreatment and the clinical features of depression at multiple levels of analysis—neurobiolog- ical, psychological, and sociocultural.

The current results are novel in showing that emotional and nonrelative-perpetrated sexual maltreatment are significantly more strongly associated with a greater lifetime history of depression than physical maltreatment. Further, they provide preliminary ev- idence that hostility, criticism, and rejection from the mother relative to the father may represent specific risk for depression versus trauma-related outcomes, respectively. A history of child- hood maltreatment is widely regarded as one of the strongest risk factors for MDD. Therefore, the development of targeted programs aimed at preventing and intervening in MDD for those at greatest risk has the potential to lower rates, and reducing the suffering, associated with this devastating disorder.

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Received July 3, 2019 Revision received February 20, 2020

Accepted February 26, 2020 �

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479CHILDHOOD MALTREATMENT AND DEPRESSION