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ORIGINAL ARTICLE

Emotion Regulation Mediates the Relationship between a History of Child Abuse and Current PTSD/Depression Severity in Adolescent Females

Sufna G. John1 & Josh M. Cisler2 & Benjamin A. Sigel1

Published online: 20 April 2017 # Springer Science+Business Media New York 2017

Abstract Although experiencing child abuse (i.e., physical abuse, sexual abuse, exposure to violence) is associated with a variety of mental health difficulties, simple exposure to abuse does not produce symptoms in every individual. The current study explored emotion regulation as a mediator in the relation- ship between a history of child abuse and symptoms of post- traumatic stress and depression. Adolescent females (ages 11– 17 years) were asked to retrospectively report on their exposure to child abuse, current symptoms of PTSD/depression, and emotion regulation abilities. Caregiver report of adolescent emotional difficulties was also obtained. Analyses revealed that child abuse-exposed females, when compared to females with- out a trauma history, had worse emotion regulation abilities and increased mental health difficulties. Moreover, emotion regula- tion significantly mediated the relationship between child abuse and all assessed mental health symptoms. These findings ex- tend previous work from adult samples, underscoring the im- portance of assessing emotion regulation abilities in abuse- exposed youth.

Keywords Emotion regulation . Child abuse . PTSD .

Depression . Mediation . Adolescents

Introduction

Child Abuse

Child abuse (in this study defined as physical abuse, sexual abuse, and exposure to violence) represents a widespread pub- lic health concern. In 2013, the National Child Abuse and Neglect Data System reported 122, 159 counts of physical abuse (representing 14.1% of all maltreatment reports) and 60,956 counts of sexual abuse (representing 7.0% of all mal- treatment reports) for children ages birth through 18 years. Additionally, caregiver domestic violence was reported for 27.4% of all victims of maltreatment (ages birth through 18 years), equivalent to 127,519 children nationally (U.S. Department of Health and Human Services 2015). Of note, these statistics likely underestimate the true prevalence, as these data only reflect instances of abuse that were reported to the authorities.

Child Abuse and Associated Difficulties

Experiencing child abuse is associated with an increased risk for developing mood and anxiety disorders within adulthood (Briere and Jordan 2009; Greif Green et al. 2010), as well as greater engagement in problematic behavior such as substance abuse and risky sexual behavior (Arata et al. 2005; Blumenthal et al. 2008). Adolescents who have been exposed to abuse often suffer from co-morbid conditions (i.e., depression or substance abuse), complicating the diagnostic picture, treatment considerations, and degree of functional im- pairment (Donnelly and Amaya-Jackson 2004). Given the high rate of comorbid conditions in those exposed to trauma,

* Sufna G. John [email protected]

1 Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA

2 Department of Psychiatry, University of Wisconsin, Madison, WI, USA

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it is important to examine transdiagnostic difficulties as poten- tial mediators.

Emotion Regulation

One transdiagnostic feature receiving increased attention is emotion regulation, a term which incorporates emotion under- standing, awareness, acceptance, identification, and behavioral regulation/decision-making during periods of emotional dis- tress (Gratz and Roemer 2004). Early and middle adolescence (11–14 years of age referring to early adolescence, 15–17 years of age referring to middle adolescence) represent especially important developmental periods in which to study emotion regulation, and are the focus of the present study, as they in- clude a multitude of changes in autonomy and social relation- ships that require these youth, perhaps for the first time, to develop and use emotion regulation strategies largely indepen- dent of parental guidance (American Academy of Pediatrics 2015; Larson and Richards 1991; Steinberg and Avenevoli 2000). They also represent important time periods in which to study mental health disorders, due to significant cognitive and neurodevelopmental changes (Blakemore and Choudhury 2006; Blakemore 2008), the high prevalence of mental health symptoms, and the emergence of several adult disorders within these age groups (Patton et al. 2014; Paus et al. 2008).

Poor emotion regulation skills are linked to a variety of mental health symptoms and appear to represent a strong transdiagnostic correlate of mental health symptoms in adults and adolescents (Aldao et al. 2010). Good emotion regulation skills during childhood and adolescence are linked to greater peer acceptance (Kim and Cicchetti 2010), concurrent and future social competence (Spinrad et al. 2006), and lower internalizing/ externalizing pathology (Kim and Cicchetti 2010). Conversely, poor emotion regulation is documented in individuals diagnosed with anxiety and mood disorders, eating disorders, substance abuse, and those who display ag- gression or experience peer rejection and social withdrawal (Herts et al. 2012; McLaughlin et al. 2011).

The Relationship between Emotion Regulation and Child Abuse

Poor emotion regulation also has been heavily examined as both a maladaptive outcome of child abuse and a risk factor for developing other mental health difficulties after abusive incidents (Kring and Werner 2004). Indeed, those who have experienced childhood abuse demonstrate difficulties in recog- nition, understanding, and acceptance of emotions, as well as overall difficulties with emotion regulation (Gratz et al. 2007; Pollak and Sinha 2002; Shipman et al. 2000). Moreover, sev- eral aspects of emotion regulation have been correlated with posttraumatic stress symptoms, including low emotional ac- ceptance and clarity and impulsive decision-making during

periods of distress (Ehring and Quack 2010; Lilly and Lim 2013; Tull et al. 2007; Weiss et al. 2012). Sundermann and DePrince (2015) also found that both maltreatment character- istics (e.g., types of trauma) and difficulties with emotion reg- ulation significantly predicted posttraumatic symptoms in a community sample of adolescent females with a history of maltreatment.

Despite substantive research on the relationship between child abuse and mental health symptoms, much less is known about the potential mediating role of emotion regulation in the relationship between abuse exposure and mental health symp- toms, particularly in adolescents. Results from adult samples indeed demonstrate that poor emotion regulation partially me- diates the relationship between child abuse and subsequent posttraumatic and depressive symptoms (Crow et al. 2014; Ullman et al. 2014). Research on young adults also suggests that emotion dysregulation mediates the relationship between trauma exposure and symptoms of PTSD (Goldsmith et al. 2013) and depression (Goldsmith et al. 2013; Tull et al. 2007). Examining school-aged children, Choi and Oh (2014) found that caregiver-reported emotion regulation fully medi- ated the relationship between childhood trauma, including abuse, and emotional/behavioral symptoms. Therefore, there is foundational literature to suggest that emotion regulation mediates the relationship between child abuse exposure and emotional/behavioral difficulties in several developmental pe- riods. However, the current literature does not include a con- current examination of emotion regulation and symptoms of depression and posttraumatic stress in adolescent samples with a strong history of child abuse, nor does it consistently include information from caregivers. This latter point is espe- cially crucial, as emotion regulation difficulties may bias the way that individuals report their own symptoms, underscoring the need for collateral information.

The Current Study

The current study explored emotion regulation as a mediator for the relationship between child abuse severity (i.e., physical abuse, sexual abuse, and witnessing violence) and mental health symptoms (PTSD and depression) in a sample of abuse-exposed adolescent females and a healthy comparison sample of adolescent females. This study addresses several limitations in the current literature by examining important developmental periods (early and middle adolescence), utiliz- ing a sample with a high degree of trauma exposure, and including self- and caregiver-reported measures of posttrau- matic and depressive symptoms. We hypothesized that emo- tion regulation would significantly mediate the relationship between child abuse and symptoms of PTSD and depression. We further hypothesized that this relationship would also exist for caregiver-reported mental health symptoms in their chil- dren, thus avoiding potential reporter bias.

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Method

Participants

Participants consisted of 81 early and middle adolescent girls, aged 11–16 years, who were recruited as part of two separate neuroimaging studies (Cisler et al. 2016; Lenow et al. 2014). The rationale for this age range was to focus on the important periods of early and middle adolescence while also allowing feasibility in recruitment. Participant recruitment consisted of both community-wide general advertising (e.g., newspaper ads, flyering) as well as through networking with specific trauma-focused mental health clinics and clinicians. Interested participants first underwent a phone screening to establish probable group membership (control or abuse expo- sure), which was later confirmed through the assessment mea- sures detailed below. Inclusion criteria for control girls were as follows: age between 11 and 16 years, female sex, the absence of exposure to any measured traumatic event (both abusive and non-abusive trauma – such as experiencing a natural di- saster), and current mental health disorders. Inclusion criteria for girls with a history of child abuse was as follows: age between 11 and 16 years; female sex; and a positive history of sexual abuse, physical abuse, or witnessed violence. Psychotic disorders, developmental disorders, and MRI contraindications (e.g., internal metal objects, claustrophobia) were exclusionary for all participants. Table 1 lists demographic and clinical characteristics of the sample. All procedures performed in this study were in accordance with the ethical standards of the Institutional Review Board (IRB) and with the 1964 Helsinki decla- ration and its later amendments or comparable ethical stan- dards. All participants and caregivers provided informed con- sent into the study.

Assessments

Current Mental Health Diagnoses Participants whose data are analyzed in the current study were recruited as part of two separate brain imaging research studies, and as such the structured clinical interview differed between partici- pants. Participants current mental health diagnoses were assessed with either the Mini International Neuropsychiatric Interview-Kid (MINI-Kid; n = 48) or the Kiddie Schedule for Affective Disorders and Schizophrenia (K- SADS; n = 33) (Kaufman et al. 1997; Sheehan et al. 2010). Both the MINI-Kid and K-SADS are semi-structured clinical interviews that assess most mental health disorders in childhood and adolescence and have established reliabil- ity and validity (Kaufman et al. 1997; Sheehan et al. 2010), depending on the study in which they participated. Only the adolescents, and not the caregivers, completed these struc- tured interviews.

Trauma Histories Participant trauma histories were gathered with the trauma assessment sections of the National Survey of Adolescents (NSA), a structured interview used in prior epide- miological studies of child abuse and mental health functioning among adolescents (Kilpatrick et al. 2000, 2003). Both abusive and non-abusive traumas (e.g., motor vehicle accident) were assessed using this measure in order to assure that those indi- viduals in the control group had not been exposed to another type of traumatic event. Child abusive events were assessed with behaviorally-specific dichotomous questions, which in- cluded: 1) sexual abuse (i.e., anal penetration, vaginal penetra- tion, oral sex on the perpetrator, oral sex from the perpetrator, digital penetration, fondling of the adolescent, forced fondling of the perpetrator), 2) physical abuse (i.e., attacked with a weapon; attacked with a stick, club, or bottle; attacked without a weapon; threatened with a weapon; attacked with fists), 3) severe abuse from a caregiver (i.e., beaten with fists or an object to the point where bruising or bleeding occurred), 4) witnessed violence (i.e., witnessing a violent beating at home or in com- munity). Table 2 includes a list of all questions included in this study, grouped by type of trauma. Only the adolescents, and not the caregivers, completed these trauma interviews.

In line with research indicating a dose-response relation- ship between the severity of child abuse exposure and risk for subsequent mental health disorders (Cisler et al. 2011a, 2011b, 2012; Kolassa et al. 2010a, 2010b), we calculated child abuse severity as the sum of the unique categories of child abuse to which the adolescent was exposed. That is, during the NSA, participants were asked to retrospectively report on the pres- ence of 29 unique types of child abuse, and their total severity was the number of unique types of child abuse to which they answered affirmatively. This child abuse severity variable was then used in subsequent analyses testing mediation within the child abuse group.

The semi-structured clinical interviews and trauma assess- ments were conducted by a trained female clinical research coordinator with several years of experience administering these interviews who was working under the supervision of a licensed clinical psychologist.

Emotion Dysregulation Assessment Adolescents completed the Difficulties in Emotion Regulation Scale (DERS, Gratz and Roemer 2004), a 36 item self-report or care-giver report measure of six domains of emotion regulation: awareness of negative emotions, emotional clarity, strategies to regulate emotions, difficulty engaging in goal directed behavior during negative emotions, nonacceptance of negative emotions, and impulse control during negative emotions. Participants indi- cate how often the items were true for them on a five-point Likert scale (‘Almost never’ to ‘Almost always’). Subsequent psychometric analyses of the DERS suggested the removal of the awareness scale, which was only comprised of reverse coded items and correlates poorly with the remaining latent

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factors (Bardeen et al. 2012; Fairholme et al. 2013). Accordingly, we did not use the awareness scale in the present analyses. The psychometric properties of the DERS within adolescent samples has been established (Weinberg and Klonsky 2009). Chronbach’s alpha for the remaining DERS items among this sample was .95. The total DERS score was utilized as a comprehensive measure of emotion regulation, as the individual subscales within this sample were highly correlated.

Adolescent Clinical Symptom Assessment Adolescents also completed the UCLA PTSD Reaction Index – Adolescent version (Steinberg et al. 2004; 2013) and the adolescent ver- sion of the Short Mood and Feelings Questionnaire (SMFQ). The UCLA PTSD Index consists of 22 items assessing DSM- IVre-experiencing, avoidance, and hyperarousal symptoms of PTSD using a five-point Likert Scale (BNever^ to BAlmost every day^). Cronbach’s alpha for the UCLA PTSD Index among this sample was .96. For the present analyses, we used

a summed PTSD symptom severity score from all DSM-IV symptom items. The SMFQ consists of 13 items assessing depression symptoms using a three-point Likert Scale. A total depression symptom severity score was created by summing all the items. Cronbach’s alpha for the SMFQ among this sample was .94.

Caregiver Clinical Symptom Assessment Caregivers addi- tionally completed the Child Behavior Checklist (Achenbach 1991), a broad measure of childhood mental health difficulties across several domains. For the purpose of the present analy- ses, we focused on total internalizing symptoms, consisting of the sum of the anxious/depressed, withdrawn/depressed, and somatic complaints subscales. Cronbach’s alpha for the CBCL Internalizing items among this sample was .93.

Additional Assessments Adolescent’s verbal IQ was mea- sured using the Receptive One Word Picture Vocabulary Test administered by a female research coordinator. This measure

Table 1 Demographic and clinical characteristics of the sample

Abuse-exposed (n = 61) Controls (n = 20)

Variable Mean (frequency) SD Mean (frequency) SD P value of group difference*

Age 14.44 1.51 13.7 1.6 .06

Verbal IQ 96.05 14.81 105.7 16.4 .02

Ethnicity 46% Caucasian 80% Caucasian .053 20% African

41% African American American

10% Biracial

3% Hispanic

Current PTSD 62% 0 <.001

Total number of abusive events 5.3 4.4 0 NA

Direct physical abuse 43% 0

Physical abuse from caregiver 44% 0

Sexual abuse 67% 0

Witnessed violence 88% 0

DERS nonacceptance 8.1 6.9 3.3 3.8 .006

DERS goals 11.1 5.2 6.2 5.4 <.001

DERS impulse 8.1 6.1 2.1 3.3 <.001

DERS strategies 11.0 8.3 3.0 3.1 <.001

DERS clarity 7.4 5.0 4.6 4.1 .03

DERS total 45.8 26.2 19.1 15.2 <.001

UCLA PTSD Index 26.98 19.9 .25 1.1 <.001

SMFQ 10.0 7.9 2.7 3.0 <.001

CBCL – anxious 7.4 5.9 2.1 2.4 <.001

CBCL – depressed 5.1 3.5 1.1 1.8 <.001

CBCL – somatic complaints 5.0 4.9 1.3 1.8 .002

SMFQ Short Mood and Feelings Questionnaire, CBCL Child Behavior Checklist

*Given evidence of group differences in age, verbal IQ, and ethnicity, the remainder of group comparisons includes these variables as covariates

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was included to characterize any group differences in general cognitive function.

Statistical Analyses

Preliminary analyses assessed general linear model (GLM) statistical assumptions and potential confounding factors that differ between groups to be used as covariates in primary analyses. Missing data was addressed directly during data col- lection by having the research coordinator review all question- naires and if an item was missing, the participant was notified and asked to complete the item.

To test hypotheses that difficulties with emotion regulation mediate the relationship between child abuse exposure and PTSD, depression, and caregiver-reported internalizing symp- tom severity, we conducted two sets of analyses to verify three predictions of a mediation pathway (Baron and Kenny 1986; MacKinnon et al. 2007; Preacher and Hayes 2008): 1) path a, such that there is a significant relation between the indepen- dent variable and the hypothesized mediator; 2) path b, such that there is a significant relation between the proposed medi- ator the dependent measure, controlling for the independent variable; and 3) that the total effect, path c (direct relation between the independent variable and the outcome measure), weakens in the presence of the indirect effect (i.e., total effect c

equals the direct effect c’ minus the indirect effect ab). Figure 1 illustrates the generic mediation framework and the hypothesized mediation pathway in the current study.

First, we compared the child abuse exposed and control participants on each subscale of the DERS, adjusting for co- variates as needed, within a GLM framework using iteratively reweighted least squares estimation (‘robustfit’ in Matlab using a bisquare weighting function). These analyses effectively test path a, such that there is a relation be- tween child abuse severity and the hypothesized mediator, emotion regulation. Given that, by DSM definition, our healthy and non-trauma-exposed control group cannot have any PTSD symptoms, analyses testing paths b and the indirect effect ab were conducted solely within the child abuse group (n = 61), which required re-establishing path a within this restricted sample as well.

As recommended (Baron and Kenny 1986; MacKinnon et al. 2007; Preacher and Hayes 2008), these analyses entailed four separate multiple regression GLM analyses using itera- tively reweighted least squares estimation: 1) path a, such that child abuse severity is associated with emotion regulation, 2) path b, such that emotion regulation is associated with clinical symptom severity when controlling for child abuse severity, 3) path c, such that child abuse severity is associated with clinical symptom severity, and 4) that the indirect pathway, a x b,

Table 2 Trauma questions from the national survey of adolescents, organized by abuse type

Physical abuse Physical abuse Witness violence Witness violence Sexual abuse

Attacked you with a gun, knife, or other weapon, regardless of when it happened or whether you told the police or other authorities?

Has a caregiver ever beat you up, hit you with a fist, or kicked you hard?

Heard or seen your caregivers throw objects at each other, without hitting the other person?

Seen someone actually shoot someone else with a gun?

Has a man or boy ever put a sexual part of his body inside your private sexual parts, inside your rear end, or inside your mouth when you didn’t want him to?

Physically attacked you without a weapon, and you thought they were trying to kill or seriously injure you?

Has a caregiver ever grabbed you around the neck or choked you?

Heard or seen them (caregivers) throw ob- jects that hit one an- other?

Seen someone actually cut or stab someone else with a knife or other sharp weapon?

Has anyone, male or female, ever put fingers or objects inside your private sexual parts or inside your rear end when you didn’t want them to?

Threatened you with a gun or knife, but didn’t actually shoot or cut you?

Has a caregiver ever burned or scalded you on purpose?

Heard or seen them (caregivers) pushing or shoving each other?

Seen someone being molested, sexually assaulted or raped?

Has anyone, male or female, ever put their mouth on your private sexual parts when you didn’t want them to?

Beat you up, attacked you, or hit you with something like a stick, club, or bottle so hard that you were hurt pretty badly?

Has a caregiver ever locked you in a closet, tied you up, or tied you to something?

Heard or seen them (caregivers) hitting each other or beating each other up with their hands or fists?

Seen someone being mugged or robbed?

Has anyone, male or female, ever touched any of your private sexual parts when you didn’t want them to?

Beat you up with their fists so hard that you were hurt pretty badly?

Has a caregiver ever threatened you with a gun, knife, or other weapon?

Heard or seen them (caregivers) hitting or beating each other with objects, like stick, belt?

Seen someone threaten someone else with a knife, a gun, or some other weapon?

Has anyone, male or female, ever made you touch their private parts when you didn’t want to?

Has a caregiver ever spanked or hit you so hard it caused bad marks, bruises, cuts, or welts?

Has a caregiver ever used a knife or fired a gun at you on purpose?

Heard or seen them (caregivers) using a weapon, like a gun or knife on each other?

Seen someone beaten up, hit, punched, or kicked such that they were hurt pretty badly?

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significantly differs from 0 (i.e., that the difference between path c and c’ is significant). We tested the indirect ab pathway using the percentile bootstrapping method (Preacher and Hayes 2008), implemented in Matlab with 10,000 iterations and resampling with replacement. These analyses were con- ducted separately for each of the three outcome measures (PTSD symptom severity, depression symptom severity, and CBCL internalizing symptoms).

Results

Participant Characteristics and Preliminary Analyses

Preliminary analyses indicated non-normal distributions for internalizing symptoms, child abuse severity, PTSD symptom severity, depression severity, and DERS total and subscale scores, which were corrected through square root transforma- tions in all cases except child abuse severity, which was corrected through log transformation. Participant characteris- tics are provided in Table 1. As can be seen, the child abuse and control groups differed either significantly or marginally significantly in terms of age, IQ, and ethnicity; thus, these variables were include as covariates in all subsequent analy- ses. Adolescent girls who had experienced child abuse dem- onstrated self-reported PTSD and depression symptoms and greater caregiver-rated internalizing symptoms compared to the control adolescent girls.

Comparison of DERS Scores between Child Abuse and Control Groups

Between-group comparisons, adjusting for age, verbal IQ, and ethnicity, demonstrated significantly higher scores among the child abuse group for the DERS total score (t(76) = 4.5, p < .001) as well as all subscale scores: nonacceptance (t = 3.6(76), p < .001), goal-directed behavior (t = 3.8(76), p < .001), impulse control (t = 5.1(76), p < .001), strategies (t = 4.0(76), p < .001), and clarity (t = 2.2(76), p = .03). Table 1 lists means and SD of the total score and subscale scores for each group.

Mediation Analyses among the Child Abuse Group

A summary of mediation analyses across the dependent mea- sures is provided in Table 3. All analyses reported below con- trolled for age, verbal IQ, and ethnicity. Regarding path a (which is identical across the dependent measures), there was a significant positive relation between child abuse sever- ity and PTSD symptom severity (t(56) = 3.08, p < .003). Regarding path b across the dependent measures, there were significant relations between DERS total score and PTSD symptom severity (t = 3.94(55), p < .001), depression severity

(t = 7.8(55), p < .001), and caregiver-rated internalizing symp- toms (t = 2.14(55), p = .04) upon controlling for child abuse severity. Regarding path c across the dependent measures, there were significant positive relations between child abuse severity and PTSD symptom severity (t = 6.3(56), p < .001), depression severity (t = 3.5(56), p < .001), and caregiver-rated internalizing symptoms (t = 4.3(56), p < .001). The indirect pathways ab (product of path a and b) were significantly greater than zero across the dependent measures (see Table 3), demonstrating that the indirect pathway from child abuse severity to the dependent measure through DERS total score significantly mediates the direct relation between child abuse severity and each dependent measure. However, path c’ remained significant for each dependent measures, indicating the robustness of the direct relationship between child abuse exposure and clinical symptom severity.

Discussion

Overall Study

The goals of this study were to examine emotion regulation as a possible mediator for the relationship between child abuse severity and PTSD/depression severity in a sample of adoles- cent females. This study aimed to address several important limitations in the current literature by examining adolescents with a high degree of abuse exposure, including a comparison group of adolescents without trauma exposure, and utilizing both self- and caregiver-report measures. Adolescents ex- posed to child abuse demonstrated greater difficulties in all aspects of emotion regulation relative to control females, as has been previously demonstrated in adult and adolescent samples. As hypothesized, emotion regulation significantly mediated the relationship between child abuse severity and symptoms of posttraumatic stress and depression. Moreover, these results do not appear to be related to reporter bias, as self-reported emotion regulation also mediated the relation- ship between child abuse severity and caregiver-reported in- ternalizing symptoms. These results strengthen previous find- ings from other populations, emphasizing the mediating role of emotion regulation in the occurrence of pathological symp- toms in adolescents who are exposed to trauma. The current results further supports prior data suggesting that emotion reg- ulation potentially operates as a transdiagnostic risk factor for mental health difficulties (McLaughlin et al. 2011) by exam- ining a heavily-traumatized population and including post- traumatic symptoms and caregiver-reported measures.

Research Implications

Although exposure to traumatic events is necessary in the de- velopment of PTSD and an established risk factor in the

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development of depression, many individuals who experience child abuse do not go on to develop these symptoms. Though the rate of PTSD varies by type of trauma experienced, a meta- analysis conducted by Alisic et al. (2014) found that children and adolescents who appear most at risk are females who ex- perience interpersonal trauma, such as the abusive events in- cluded in the current study (Alisic et al. 2014). Specifically, they found that 32.9% of females who had been exposed to interpersonal trauma met criteria for PTSD. Given the variety of outcomes in presentation that can occur in individuals who

have experienced abuse, continued work examining mediators remains an important goal for risk-factor research. Specifically, future work should examine how established mediators (e.g., emotion regulation, abuse characteristics) work in concert to confer risk for impairing maladaptive symptoms associated with experiencing abuse. For example, emotion regulation should be tested as a mediator for other types of traumatic events, such as natural disasters or motor vehicle accidents. Moreover, established mediators should be confirmed through longitudinal design, in order to establish the timing in which the

Table 3 Results of mediation regression analyses across the three dependent measures

Dependent measure Mediation path B t (Confidence interval) p

PTSD

a .55 3.08 .003

b 1.1 3.94 <.001

c 2.57 6.3 <.001

c’ 1.82 4.77 <.001

a x b indirect path .61 95% CI = .16–1.11 <.05

Depression

a .55 3.08 .003

b 1.2 7.8 <.001

c 1.05 3.5 <.001

c’ .41 2.02 .048

a x b indirect path .65 95% CI = .22–1.14 <.05

Internalizing symptoms*

a .55 3.08 .003

b .52 2.14 .04

c 1.38 4.3 <.001

c’ 1.08 3.2 .002

a x b indirect path .29 95% CI = .01–.65 <.05

Age, verbal IQ, and ethnicity were included as covariates in all analyses. These analyses were conducted among abuse-exposed adolescents only (n = 61)

*Symptoms are caregiver-reported

Child Abuse Severity

Fig. 1 Illustration of the generic mediation framework and the hypothesized mediation pathway in the current study

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development of mental health symptoms, mediators (e.g., emo- tion regulation abilities), and abusive incidents occur.

Clinical Implications

Early and middle adolescence represent time periods of devel- opment in emotion regulation capacities as well as mental health disorders, and thus, are sensitive times in which inter- ventions may produce long-lasting change. Given the potential problematic trajectory of individuals who have been exposed to child abuse, intervention to alter this course is crucial. There is a current call in the literature to examine mediators for treat- ment responsiveness in high-risk populations. Particularly with PTSD, research on adult individuals with severe symptoms (mirroring our population in a different developmental period) demonstrates that roughly 40% - 50% of individuals with chronic PTSD symptoms fail to meet criteria for functional improvement or symptom discontinuation after receiving a course of treatment (Foa et al. 2002). Given that emotion reg- ulation difficulties may mediate symptom presentation, per- haps they also may mediate treatment responsiveness. Addressing emotion dysregulation could be an important pre- ventative area, as it associated with a variety of mental health disorders. Moreover, given the high comorbidity rate between PTSD and other mental health conditions, traumatized youth could represent an ideal sample to target for such interventions.

However, there is disagreement in the field as to whether the current evidence-based interventions for adolescent trau- ma (e.g., Trauma-Focused Cognitive Behavioral Therapy, TF- CBT) adequately build emotion regulation or whether a phase-based approach including treatments specifically targeting poor emotion regulation should be used. Indeed, studies with adult PTSD patients have found greater improve- ment in PTSD symptoms by adding a component specifically addressing emotion regulation to the typical course of trauma treatment (Bryant et al. 2013; Cloitre et al. 2010). For cases of complex trauma, the creators of TF-CBT have suggested ex- tending the emotion regulation/stabilization phase of treat- ment, acknowledging the deficits in these skills for highly traumatized youth (Cohen et al. 2012). However, limited re- search has been done on the traditional and extended treatment models of TF-CBT related to efficacy in building emotion regulation. This is an important empirical question that should be examined in future work.

Indeed, emotion regulation could be an important area to target within family work for a variety of reasons. First, genetic studies on emotion regulation (specifically alexithymia) sug- gest that between 30% and 40% of the variability within this trait can be accounted for by genetic influences (Jørgensen et al. 2007; Picardi et al. 2011), suggesting that parents/caregivers of these children may also struggle with regulating emotions. Second, developmental theorists posit that emotion regulation during infancy and childhood is largely influenced by parental

behaviors (see Shipman et al. 2007 for a review), suggesting a model in which parenting behaviors confer risk for poor emo- tion regulation, subsequently conferring risk for developing emotional or behavioral symptoms. Taken together, these findings suggest that targeting emotion regulation and its’ impact on parenting may help caregivers to support adolescent gains within treatment and improve the caregiver-child relation- ship. Although our study was not able to explicitly test the development of emotion regulation skills or symptoms over time, as it was cross-sectional in nature, it underscores the im- portant role these skills have in impacting the association be- tween prior adverse life events and current pathological symp- tom presentations. Future research should examine whether parent/caregiver emotion regulation mediates the relationship between childhood abuse and child maladaptive symptoms and whether these symptoms improve during evidence-based youth trauma treatment. Fortunately, most evidence-based trauma treatments for youth (e.g. Trauma-Focused Cognitive Behavioral Therapy, Child Parent Psychotherapy) explicitly in- volve considerable parent/caregiver work and thus already pro- vide the framework to target parent/caregiver emotion regula- tion, if needed.

Study Strengths

The greatest strength of this study is our unique sample, as we examined adolescent females with a high degree of child abuse severity. Prior to this study, emotion regulation as a mediating factor in the relationship between child abuse and PTSD/depressive symptoms had not been established in highly-impaired adolescent samples, which are more repre- sentative of those that present to treatment. Prevalence rates reported by a variety of mental health clinics within the National Traumatic Stress Network suggest an average of 3– 4 trauma types experienced by children ages 1.5 to 18 years (Greeson et al. 2014). By comparison, adolescent girls in the current sample were exposed to 5.3 child abusive traumas on average; therefore, our sample is high-risk and largely repre- sentative of highly-impaired individuals who present for treat- ment. Moreover, this sample was diverse in nature, allowing for generalization of these findings to a broader patient popu- lation. We also controlled for several confounding variables, including verbal IQ, age, and ethnicity, and can therefore be more confident of the relationship between these variables. Finally, utilizing caregiver- and self-report measures of mental health symptoms helps to avoid reporter bias, as one could easily argue that individuals with poor emotion regulation may be biased in their self-report of emotional symptoms.

Study Limitations

Study strengths should be considered along with limitations. Due to the cross-sectional nature of the study, true mediation

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was not able to be measured. This would require a longitudi- nal study that could fully establish the timing of abuse events and symptom development. Despite this limitation, the results are similar to previous findings on adult and undergraduate samples without the cost and time of conducting a longitudi- nal study with a difficult population to track and measure. Examining highly-impaired individuals often leads to a small- er sample size, as is this case with our study. However, statis- tical measures were taken to correct for the smaller sample, including bootstrapping techniques and iterative least squares regression to minimize the impact of outliers. Moreover, al- though the sample was small, recruitment took place within the community in addition to trauma-specific clinics and the participants were ethnically-diverse and largely representative of the geographical location of the current study. Our study also included several covariates (e.g., age, verbal IQ, ethnici- ty), but did not include other variables that may impact this relationship (such as income level, household composition) that would be important to include in future studies. Therefore, these results should be replicated in a larger sam- ple, in order to ensure the generalizability of our findings. Moreover, our study focused on early and middle adolescence as important developmental periods for both emotion regula- tion abilities and mental health disorders. It would be impor- tant to assess whether these findings would remain true for other periods of adolescence. Also, this study made use of subjective measures of all variables, which are inherently sus- ceptible to individual bias. Future work should examine this relationship using objective measures of emotion regulation. Similarly, no caregiver-report measure of emotion regulation was obtained, which could have offered a more comprehen- sive examination of these deficits. It is also important to note that our measure of child abuse severity was defined as the number of categories of child abuse to which the child was exposed, as opposed to the total number of times that the child has been abused independent of the number of categories. Our methodology also focused on the number of categories so that the child would only have to provide ‘yes/no’ responses to whether a given category occurred, towards the goal of in- creasing reliability, given that these were retrospective reports of child abuse exposure. Assessing categories of trauma, as opposed to number of traumatic episodes experienced is also consistent with prior research (Kolassa et al. 2010a, b). However, it is certainly possible that a child who was only exposed to one category of child abuse could be exposed multiple times to that category (e.g., several episodes of witnessing domestic violence within this category). As such, future research is needed that spans a range of methodology for measuring trauma exposure to establish the robustness of the current findings. Finally, our choice to frame abuse expo- sure questions in a Byes/no^ format without asking partici- pants to elaborate further also prevented the inclusion of sev- eral other factors that would be important to examine in future

studies, including age of exposure, relationship to perpetrator, or perception of betrayal associated with the abuse.

Experiences of child abuse put youth at great risk for a multitude of mental and physical health concerns. Work that examines mediators in symptom presentations for highly- traumatized populations can directly inform care for those who arguably need it most. Our findings underscore the im- portance of examining individual traits, such as emotion reg- ulation, as potential mediators for the relationship between a history of child abuse exposure and current symptoms of post- traumatic stress and depression. These results also support emotion regulation skills training as an important point of intervention for youth with extensive child abuse exposure.

Acknowledgements This research was supported in part by grants MH097784 and DA036360 from the National Institutes of Health.

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