Childhood Emotional Maltreatment and Post-Traumatic Stress Disorder in the Context of Centrality of the Event and Intrusive Rumination

Abstract

Psychiatric disorders, such as post-traumatic stress disorder (PTSD), are significantly more likely among those exposed to child maltreatment. Not all who are exposed to maltreatment develop PTSD; while many contributing factors are understood, more research is needed to understand why some develop this disorder. The purpose of this study was to examine relationships among an understudied form of maltreatment: childhood emotional maltreatment (CEM) and cognitive processes that may directly or indirectly explain development of PTSD among CEM survivors. A sample of college students (N = 396) completed surveys related to childhood trauma history, cognitive processing, and PTSD. Mediation analyses revealed that CEM had a significant direct effect on PTSD, and that centrality of the event and intrusive rumination significantly mediated this relationship. Recommendations are provided for identifying maladaptive cognitive processes with the aim of facilitating adaptive cognitive processing related to prior trauma exposure and current PTSD symptoms.

Keywords

trauma childhood emotional maltreatment PTSD centrality of the event intrusive rumination

Childhood maltreatment (CM) typically involves abuse (physical, sexual, or emotional) or neglect (physical or emotional) of a child or adolescent, which is often perpetrated by a parent or caregiver (Bernstein et al., 2003). Studies have consistently demonstrated the long-term developmental impact of CM (Fergusson et al., 2013; Spinazzola et al., 2014). A landmark study (N = 13,494) examining cumulative exposure to adverse childhood experiences (ACEs), including CM, revealed their relationship to chronic illness and disability (CID) in adulthood (Felitti et al., 1998). Results indicated a strong graded relationship between the number of toxic stressors encountered in childhood to CID in adulthood. Follow-up studies found increased exposure to CM is related to significant increases in mood disorders, anxiety disorders and problematic substance use (Ford et al., 2011; Turner et al., 2017), as well as increased risk for suicidal ideation and suicide attempt (Afifi et al., 2008). Extensive research has also connected CM to post-traumatic stress disorder (PTSD; Chen et al., 2010; Cloitre et al., 2012; Dorahy et al., 2015; Kilpatrick et al., 2003), a significant disability with considerable implications for those diagnosed.

PTSD

PTSD is a mental illness that can develop after a person is exposed to “an extremely threatening or horrific event or series of events” (World Health Organization [WHO], 2018). Recent updates to International Classification of Diseases, 11th Revision (ICD-11) diagnostic criteria for PTSD simplified the diagnosis (eliminating difficulties with sleep and concentration as these are more likely explained by other anxiety disorder), while adding a new category of complex post-traumatic stress disorder (CPTSD; Barbano et al., 2019; WHO, 2018). CPTSD is described similarly and includes prolonged or repetitive exposure to events such as slavery, torture, domestic violence, and child abuse. It is notable that descriptions of the preceding events necessary for the condition contain extreme forms of trauma including sexual or physical assaults, and rarely include emotional maltreatment experienced in childhood. This omission may explain why this form of maltreatment is rarely investigated in connection with PTSD. Symptoms of PTSD and CPTSD typically involve experiencing intrusive thoughts (i.e., flashbacks or distressing memories), avoidance of reminders of the particular event, having negative thoughts and feelings about self or others due to the event, difficulty regulating emotions, experiencing issues with increased arousal and reactivity (i.e., being easily startled, difficulty with emotion regulation), all of which can impede health and functioning.

It is important to mention that only a minority of those exposed to traumatic events develop PTSD (American Psychiatric Association [APA], 2013; Ehring et al., 2008; Powers et al., 2015). Consequently, understanding the pathway from traumatic exposure to PTSD is critically important for providers to target processes which likely contribute to the development, treatment, and prevention of this disorder. Pre-exposure factors that contribute to PTSD include age, number of exposures, length of time exposed, gender, lower education, lower socioeconomic status, prior traumas, and family history for psychiatric disorders, among other factors (APA, 2013; Kessler et al., 2014). Continued research to identify unique contributors to the development and prevention of PTSD following maltreatment exposure is warranted, including the nature of the traumatic event, and the emotional and cognitive processing that occurs in the context of event, as well as in the days, weeks, months, and years after exposure.

Childhood Emotional Maltreatment (CEM)

CEM involves parental or caretaker abuse in the form of spurning, terrorizing, isolating, exploiting/corrupting, denying emotional responsiveness, as well as educational, mental health, medical, and/or legal neglect (Brassard & Donovan, 2006; American Professional Society on the Abuse of Children, 1995). Other researchers have noted that CEM includes parents or caregivers directing insults at a child, or otherwise communicating to a child that they are unwanted or unloved (Bernstein & Fink, 1998). CEM can also include emotionally neglectful parenting, and parenting that ignores or dismisses the developmental or specific needs of the child (Wolfe & McIsaac, 2011). These behaviors may or may not be intentionally harmful, or consciously done, nor do they need to result in observable adverse outcomes (Glaser, 2002), but ultimately, they have a negative impact on an individual’s social, emotional, cognitive, and/or physical development (Hibbard et al., 2012). CEM is an understudied form of maltreatment, likely due to the difficulty assessing and substantiating cases. Many individuals exposed to this form of maltreatment are exposed to other forms that are easier to substantiate, often causing CEM to be overlooked (Hibbard et al., 2012; Trickett et al., 2009). As a result, it is frequently investigated in the context of other adversities and maltreatments, making it difficult to determine its unique impact on outcomes. CEM occurs in nearly half of substantiated claims of abuse, yet it is rarely the focus of the investigation (Chamberland et al., 2011; Trickett et al., 2009; U.S. Department of Health and Human Services, 2016).

Research has demonstrated that CEM plays a unique role in impacting clinically significant issues at the time of abuse and later in development (Evren et al., 2011; O’Dougherty-Wright et al., 2009; Weiss et al., 2013). A study by O’Dougherty-Wright et al. (2009) revealed that CEM distinctively contributed to symptoms of anxiety and depression later in development, even when controlling for gender, income, parental substance use, and other types of maltreatment. Spinazzola et al. (2014) conducted a study (N = 5,616) examining the impact of CEM on children and adolescents and found that CEM significantly contributed to multiple negative health outcomes including but not limited to anxiety, depression, suicidality, sleep disorders, attachment disorders, and problematic substance use. Out of 30 negative outcomes measured in the study, CEM significantly explained 27, to an extent equivalent to or greater than exposure to physical and/or sexual abuse. Research has also demonstrated that CEM distinctively influences the development and maintenance of PTSD symptoms later in development, even when it is considered alongside physical and sexual maltreatment (Weiss et al., 2013). The findings of this study revealed the significant and unique impact of CEM on PTSD among substance abusing participants, explained largely by emotion dysregulation (Weiss et al., 2013). Less is understood about cognitive processing in the context of CEM and PTSD.

Mechanisms Explaining PTSD

Issues related to cognitive processing and emotion dysregulation are two dominant factors explaining PTSD development. Emotion dysregulation is shown to be one of the most prevalent issues facing individuals with CM histories (Kim & Cicchetti, 2010), and appears to be a central mechanism by which these adversities influence later PTSD symptoms (Burns et al., 2010). A great deal of research has been conducted examining cortisol dysfunction and dysregulation in the stress response system (limbic and Hypothalamary Pituitary Axis [HPA]; Hunter et al., 2011). Research has demonstrated that as maltreatment history increases, problems regulating the stress response system increase, resulting in an enduring maladaptive pattern of stress management and emotion regulation (Shonkoff et al., 2012).

Maladaptive cognitive processing is another likely mechanism explaining the development of PTSD. The cognitive vulnerabilities explanation of PTSD includes negative attribution style, rumination tendencies, anxiety sensitivities, and the ability to make predictions about current and future threats (Elwood et al., 2009). The traumatic memory argument asserts that traumatic experiences are processed and remembered differently than other life events (Porter & Birt, 2001). Pillemer (2001) suggested that such traumatic events are more likely to function as turning points in an individual’s life, and the most traumatic and highly stressful memories are commonly well remembered when compared with other autobiographical events (Berntsen & Rubin, 2006; Porter & Birt, 2001). Evidence suggests that maltreatment exposure alters one’s capacity for attention, as well as interpretation of “threats” (Fani et al., 2012; Pollak et al., 2005; Shackman et al., 2007). Some have suggested that PTSD symptoms result when trauma survivors repeatedly respond to environmental stimuli in this way so that over time, cognitive processing becomes maladaptive, resulting in symptoms of PTSD. Maladaptive beliefs (or schemas) that individuals develop as a result of traumatic experiences early in development have been shown to increase the likelihood of negative psychological symptoms and distress (Boyda et al., 2018; O’Dougherty-Wright et al., 2009). Therefore, two cognitive processes that have received growing attention in the literature, and are believed to relate to PTSD, were investigated in this study.

Centrality of the event is operationalized as the degree of importance an individual attributes to a traumatic or stressful event and the relative impact of the event in shaping thoughts and behaviors (Berntsen & Rubin, 2006). In short, negative memories related to trauma “form reference points for the organization of less salient experiences in individuals lives” which in turn is likely to have a negative impact on an individual’s mental health, and ultimately serves as a significant aspect of one’s personal identity (Berntsen et al., 2003, p. 686). O’Dougherty-Wright et al. (2009) emphasized that how individuals appraise and internalize experiences may be more significant than the events themselves in influencing the long-term negative impact. When considering CEM during critical developmental periods, children are likely to develop certain beliefs as a result of chronically emotionally abusive situations such as the following: “I am worthless,” “Others are abusive,” or “The world is threatening and dangerous.” These beliefs affect mental health even into early adulthood (O’Dougherty-Wright et al., 2009). The style of cognitive processing that an individual engages in the aftermath of a traumatic experience has important implications for the psychological impact (Cann et al., 2011). Centrality of the event has been positively associated with PTSD among female survivors of childhood sexual abuse, among combat veterans and among college undergraduate students (Barton et al., 2013; Groleau et al., 2013; Robinaugh & McNally, 2011).

Rumination is operationalized as being either “intrusive,” which involves repetitive thoughts that occur involuntarily, or can be “deliberate,” which involves intentional thinking or processing about an event, often in an attempt to make sense of it (Cann et al., 2011). Intrusive rumination about a negative event is regarded as being harmful in the form of worry and therefore more likely to contribute to distress or worsening of health and functioning. Deliberate rumination is usually regarded as “positive” and likely to lead to growth due to focus on the “lessons learned” from an event, or strategies to prevent a future occurrence (Cann et al., 2011). Rumination was found to relate significantly to the presence and maintenance of PTSD symptoms among traffic accident survivors (Ehring et al., 2008), and significantly explains PTSD presence and maintenance among survivors of sexual and physical assaults (Michael et al., 2007). Both the amount and type of rumination is central when considering cognitive processing involved in the development of PTSD.

Purpose of the Study

Much is understood about the emotional and cognitive factors involved in PTSD development among trauma survivors, with a substantial emphasis on sexual and physical assaults, and survivors of traffic accidents and natural disasters. The limited research on CEM and PTSD explains the relationship via emotional dysregulation (Weiss et al., 2013). Continued research on the cognitive processes involved in PTSD development is important, as is continued research on the broader health impact of CEM. Using prior research on CM and PTSD, as well as research on cognitive processing as our guide, we aim to understand the direct and indirect relationships among CEM, intrusive rumination, centrality of the event, and PTSD symptoms using path analyses.

Method

Participants (N = 396) comprised a convenience sample of college students at two universities in the southern region of the United States. Inclusion criteria for this study emphasized that participants must be 18 years or older and provide voluntary consent to participate in the study. Participants’ were on average 23.63 (SD = 6.91) years of age. A majority (79.8%) of participants were female, 19.4% were male, 0.3% were transgender, and 0.5% were ambonec or non-binary. Most (42.7%) of the sample was White/Caucasian, 21.2% were Hispanic/Latino(a), 23.0% were African American/Black, 9.6% were Asian American/Pacific Islander, and 3.5% were “other.” Over half (66.2%) of participants were employed. The majority (74.2%) of participants were single/never married, whereas 11.9% were married, in a domestic partnership or civil union, 11.1% reported living with a partner, 2.0% were divorced, and 0.8% were separated. Most (80.1%) of participants were strait/heterosexual, whereas 12.9% were bisexual, 4.5% were lesbian or gay, and 2.5% reported “other,” later clarifying that they were asexual or pansexual. Finally, the majority (42.7%) of the sample were college seniors, 31.3% were juniors, 11.9% were sophomores, 4.5% were freshman, and 9.6% were graduate students.

In an effort to capture participants who accurately recalled their childhood experiences, we used the Minimization/Denial subscale of the Childhood Trauma Questionnaire (CTQ) as a validation screening tool in our sample to detect participants who were likely underreporting CM. This scale screens participants who are likely providing an unrealistic account of their past interactions with family. According to the CTQ manual (Bernstein & Fink, 1998), participants who report scores between 1 and 3 on this validation scale are indicating a tendency to minimize or deny the presence of CM. As such, we removed (N = 140) participants who indicated minimization or denial tendencies in regard to their CM exposure. The remaining participants (N = 396) were likely not altering their memories of childhood events, and as such, we are more confident in their recall about sensitive events. A chi-square analysis revealed nonsignificant differences among the full sample (536) and the screened sample (396) on all demographic characteristics. The screened sample (N = 396) was used to investigate our hypotheses.

Procedures

Procedures for this study were approved by the primary investigator’s Institutional Review Board. The primary investigator sent emails to faculty members outlining details related to the study and a request to participate providing course credit as an incentive. Instructors in agreement were provided with a prompt outlining details of the study, which included a link to an online Qualtrics survey. Participants were informed of the voluntary nature of the study and that no identifying information would be collected. Prior to engaging in the survey, participants were notified of the sensitive nature of the survey content. As some of the questions involved reporting different types of traumatic experiences, participants were notified that they were free to discontinue taking the survey at any time. Participants were also provided with a 24-hr suicide hotline, in addition to contact information for free counseling and testing services for each campus. After each section of the survey that involved traumatic material, we provided a short debriefing statement outlining these services should a participant choose to discontinue the survey at that point. At the end of the survey, participants were also provided with a web-link to track results of the research study should they desire to do so.

Instruments and variables

CEM was measured using the emotional abuse subscale of the CTQ (Bernstein & Fink, 1998). The CTQ is a 28-item self-report measure that is used to screen for abuse (physical, emotional, and sexual) and neglect (physical and emotional) that occurred before the age of 18. Three items on the assessment constitute a validity scale to assess for minimization and denial of maltreatment. Participants respond on a 5-point Likert-type scale (1 = never true to 5 = very often true) to the degree in which they experienced specific instances of emotional abuse or neglect before the age of 18. The CTQ is one of the most commonly used assessments for both clinical evaluation and research, and has demonstrated strong psychometric properties (Bernstein & Fink, 1998). Overall scale has exhibited strong convergent validity as it correlates significantly to clinician ratings of CM (r = .48–.75; Bernstein et al., 2003). The emotional abuse subscale demonstrated a very strong degree of internal reliability for this sample (α = .87). The three-item minimization/denial subscale demonstrated strong internal reliability (α = .80).

PTSD symptomology was measured using the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT; Connor & Davidson, 2001). The SPRINT is a self-report instrument that is intended to measure core symptoms of PTSD. Participants are asked to respond to eight items on a 5-point Likert-type scale (0 = not at all, 5 = very much) to explain the degree to which they agree with each item. Higher scores indicate higher levels of PTSD symptomology. Example items include “In the past week, how much have you been bothered by unwanted memories, nightmares, or reminders of the event?”; “How much have you been bothered by poor sleep, poor concentration, jumpiness, irritability or feeling watchful around you?” Connor and Davidson (2001) found that the SPRINT had strong interrater reliability with three different clinicians (intraclass correlation coefficient [ICC] of .998 Rater 1 vs. 2, .995 Rater 1 vs. 3, .996 Rater 2 vs. 3). The SPRINT also significantly correlates with the Davidson Trauma Scale (DTS), Overall Scale (r = .66, p < .0001) and all subscales of the DTS: Intrusion (r = .54, p < .0001); Avoidance (r = .59, p < .0001); Numbing (r = .50, p < .0001); Hyperarousal (r = .40, p < .0001); Stress Vulnerability (r = .41, p < .0001); and Disability (r = .56, p < .0001). The SPRINT demonstrated an excellent degree of internal consistency reliability for this sample (α = .92).

Centrality of the event was measured using the Centrality of Event Scale (CES; Berntsen & Rubin, 2006). Centrality of the event is a construct designed to determine how central an event is to a person’s identify and life story. The CES specifically measures the degree to which memories for a stressful event “shape a reference point for personal identity and for the attribution of meaning to other experiences in a person’s life.” For this study, the short (seven-item) version of the scale was used. Participants were asked to think back to the most stressful or traumatic event in their lives and respond on 5-point Likert-type scale ranging from (“totally disagree” to “totally agree”). Higher scores represent higher levels of centrality of the event. Sample items include “I feel that this event has become part of my identity,” “This event was a turning point in my life.” Iterated principle factor analysis indicated a good model fit for a single factor solution (Berntsen & Rubin, 2006). Predictive validity was assessed by examining the relationship between the CES and the Beck Depression Inventory (r = .37, p < .001) and the PTSD Checklist (r = .24, p < .001). Internal consistency reliability for this sample was very high (α = .90).

Intrusive rumination was measured using a subscale of the Event Related Rumination Inventory [ERRI] Intrusive subscale (Cann et al., 2011). Intrusive rumination involves having thoughts about a stressful or traumatic experience even though individuals aim to avoid it. For this study, the (10-item) negative rumination subscale was used. Participants were asked to consider a stressful or traumatic event in their lives and respond on 4-point Likert-type scale ranging from “not at all” to “often” to rate the degree to which they agree with scale items. Higher scores represent higher levels of intrusive rumination. Sample items include “I thought about the event when I did not want to” and “Thoughts about the event caused me to relive my experience.” Confirmatory factor analysis indicated a good model fit for a two-factor solution for intrusive and deliberative rumination (Cann et al., 2011). Convergent validity was assessed by examining the relationship between the ERRI-Intrusive subscale and the Rumination Scale (r = .38, p < .01). Discriminant validity was established by examining the relationship between the ERRI-Intrusive subscale and several subscales from the Coping Orientation to Problems Experienced (COPE) scale. Internal consistency reliability for the subscale in this sample was excellent (α = .97).

Preliminary Analysis

Prior to conducting analysis, data were reviewed to ensure statistical assumptions were met for correlational and mediation analysis (Kline, 2016). In particular, normal probability plots and skewness and kurtosis indexes were viewed to ensure data were normally distributed and there were no extreme outliers. Tests of univariate skewness and kurtosis revealed that the distributions for all continuous variables were well within the parameters for univariate normality (Chou & Bentler, 1995). Correlational analysis also revealed that variables were correlated, but evidenced no serial correlation.

Consistent with recommendations by Frazier et al. (2004), a priori power calculations were conducted in G*Power (version 3.1.9.2; Faul el al, 2007) to determine appropriate sample size. To achieve power of 0.80 needed to detect an effect, given an alpha level of .05, a minimum total sample size of 89 was deemed sufficient to distinguish hypothesized main and interaction effects (Cohen, 1988). For the mediation analyses, Monte Carlo simulations were run using Schoemann et al. (2017) web-based power analysis tool. Power was calculated using correlations and standard deviations which were calculated from previous research studies (Brooks et al., 2017; Cann et al., 2011; Connor & Davidson, 2001). To achieve 0.80 power to detect an indirect effect of childhood trauma on post-traumatic stress symptoms through parallel mediators (centrality of event and intrusive rumination), a minimum total sample size of 241 would be required detect an indirect effect at α = .05 level. Our sample of N = 396 was deemed sufficient to proceed with analysis.

Data Analyses

Analyses were conducted with IBM SPSS Version 24 (2016) and Mplus Version 8.2 (Muthén & Muthén, 2012), using the robust maximum likelihood (MLR) estimator to impute missing data; it is important to note that a majority of the data (94.25%) were present before imputing values. Adequacy of the measures was evaluated using confirmatory factor analyses (CFAs). Acceptable model fit would be supported with the comparative fit index (CFI) in the 0.90 to 0.95 range and root mean square error of approximation (RMSEA) near or less than 0.06 (Hu & Bentler, 1999). We used the product of path coefficients approach for examination of direct and indirect effects (MacKinnon et al., 2007; MacKinnon et al., 2002). Bootstrapping method was utilized to estimate standard errors and 95% bias-corrected confidence intervals of the indirect effect (Bollen & Stine, 1990). Partial mediation was maintained if the mediator associated with both the predictor and the outcome after controlling for covariates, and the confidence interval of the indirect effect must not include zero. An alpha level of .05 (two-tailed) was used to determine significance in all analyses. We first examined Pearson correlations among variables. We then examined the direct effects of (a) CEM to PTSD, (b) CEM on centrality of the event, (c) CEM on intrusive rumination, (d) centrality of the event on PTSD, and (e) intrusive rumination on PTSD. We examined the indirect effects of CEM on PTSD through centrality of the event and intrusive rumination.

Results

To examine the relationships among the variables, Pearson correlations were calculated. Results indicated a moderate and significant relationship among CEM, PTSD symptoms, centrality of the event, and intrusive rumination. Table 1 provides a depiction of correlations among all variables along with significance levels. Standardized path coefficients and error estimates for centrality of the event, intrusive rumination, and PTSD accounted for in the model are included in Figure 1.

Table 1.

Pearson Correlations Among Study Variables.

Variable	1	2	3	4
1. CEM	1.00
2. PTSD	0.46*	1.00
3. Intrusive rumination	0.35*	0.54*	1.00
4. Centrality of the event	0.32*	0.46*	0.47*	1.00

Note. CEM = childhood emotional maltreatment; PTSD = post-traumatic stress disorder.

Correlation is significant at the p = .01 level (two-tailed).

Figure 1.

Indirect effect of child emotional abuse on PTSD, mediated by centrality of the event and intrusive rumination.

The hypothesized path model had good fit indices χ² = 882.5 (N = 396, p = .00; CFI = 0.94, RMSEA = 0.055, confidence interval [CI] = [0.050, 0.006]). We examined the indirect effects of CEM on PTSD via centrality of the event and intrusive rumination, using Mplus path analysis. Our analysis revealed that CEM had a significant effect on centrality of the event (b = 0.297, p < .001) and intrusive rumination (b = 0.308, p < .001). CEM had a significant direct effect on PTSD (b = 0.280, p < .001). Centrality of the event had a significant effect on PTSD (b = 0.228, p < .001), indicating an indirect effect of CEM on PTSD via centrality of the event (b = 0.068, p = .001). In addition, intrusive rumination had a significant effect on PTSD (b = 0.352, p < .001), also revealing a significant indirect effect of CEM on PTSD via intrusive rumination (b = 0.108, p < .001). The model revealed a significant total indirect effect, b = 0.176, p < .001. Table 2 provides a full description of parameter estimates from the mediation model.

Table 2.

Parameter Estimates From the Mediation Model of Childhood Emotional Abuse on PTSD via Centrality of Events and Intrusive Rumination.

Parameter	PTSD model
Parameter	B	SE	β	ρ
IV → DV	0.280	0.051	5.524	0.000
IV → M₁	0.297	0.051	5.889	0.000
IV → M₂	0.308	0.049	6.308	0.000
M₁→ DV	0.228	0.056	4.039	0.000
M₂→ DV	0.352	0.062	5.678	0.000
IV → M₁ → DV	0.068	0.020	3.464	0.001
IV → M₂ → DV	0.108	0.026	4.170	0.000

Note. PTSD = post-traumatic stress disorder; Β = unstandardized coefficient; β = standardized coefficient; IV = childhood emotional abuse; M₁ = Centrality of Events, M₂ = intrusive rumination; DV = dependant variable.

Discussion

The purpose of this study was to investigate the relationship between CEM and PTSD symptoms via two cognitive processes believed to explain PTSD development among trauma survivors, but had not been studied in the context of CEM. Researchers have emphasized the importance of examining specific types of CM and their distinct contributions to mental health outcomes (Shapero et al. 2014; Tonmyr et al., 2011). Results of this study indicate a significant and moderate relationship between CEM and PTSD symptoms (r = .46; p < .01), suggesting that as severity of CEM increases, symptoms of PTSD also increase. These results confirm prior research results suggesting CEM’s impact on post-traumatic stress-related symptoms and PTSD severity (Weiss et al., 2013). The Weiss et al (2013) study explained the relationship via emotional dysregulation. Our results suggest cognitive vulnerabilities are also contributing to PTSD symptoms in the wake of CEM.

Results of the correlational analysis demonstrated a significant and moderate relationship between CEM and centrality of the event and CEM and intrusive rumination, indicating that as CEM increased for this sample, so did negative rumination and the degree of importance attributed to these events in shaping their life story and personal identity. Moreover, all these factors significantly correlated with PTSD. We further examined the indirect effects of CEM on PTSD via centrality of the event and intrusive rumination. Results revealed that CEM had a significant effect on both centrality of the event and intrusive rumination, both of which increased the likelihood of PTSD.

Previous research reported that rumination was found to mediate the relationship between CEM and anxiety and depressive symptoms (Kim et al., 2017), but the findings of this study are the first to our knowledge to indicate that intrusive rumination mediates the relationship between CEM and PTSD. As previously mentioned, how individuals appraise and internalize experiences of abuse may be more significant than the events themselves in influencing the long-term negative impact (O’Dougherty-Wright et al., 2009). This study found that severity of CEM also shaped the degree of importance given to these events and increased the impact these events had in shaping thoughts and behaviors. This relationship suggests that CEM serves as a reference point for organizing day-to-day experiences for participants. Although we cannot know participants’ precise thoughts or beliefs resulting from CEM, it is reasonable to assume that these schemas are negative based on the results of previous research and likely are tied to low self-worth, perceiving the world as a threatening place, and that others are abusive (O’Dougherty-Wright et al., 2009). These negative beliefs have the capacity to hinder optimal growth and development, and restrict engagement in productive behaviors that could facilitate post-traumatic growth.

Our results indicate that CEM is an important form of maltreatment to consider in the development (and maintenance) of PTSD. As much of the research focused on PTSD emphasizes physical or sexual assaults, or acute traumas including traffic accidents, natural disasters, or combat experience, our findings are important. Survivors of CEM, and the providers who work with them, may be conditioned to assess for a range of mental health conditions such as depression and anxiety, but not PTSD. Even though CEM does not fit the typical way of operationalizing “immediate threat of harm,” a factor necessary for PTSD, we believe the chronic nature of CEM can and does result in PTSD for some survivors. The results of our mediation analysis may help explain this relationship. The intrusive rumination and degree of importance that our participants placed on their past experiences likely contributed to the development of PTSD symptoms.

Implications for Practice

The results of this study are relevant to rehabilitation counselors and other counseling providers who work with people living with PTSD, and CEM survivors. General trauma-informed approaches are recommended when working with CEM survivors. Trauma-informed approaches include assessment for trauma types; conceptualizing maltreatment, including CEM, as an important contextual factor relevant to health and functioning; knowing when to report suspected child maltreatment; knowing when to include trauma specialists on the rehabilitation team; and knowing how to implement trauma informed communication strategies, such as validations (Linehan, 1997). The importance of validating the impact of CEM on life outcomes is particularly important as this form of maltreatment continues to be underreported and overshadowed by other forms of maltreatment (Hibbard et al., 2012). In many instances, the behaviors used by perpetrators of CEM contribute to self-doubt, including doubts that maltreatment occurred. For instance, if a parent humiliates a child, the child responds by crying, later the parent tells the child “stop crying” or “you are being a baby.” This child might develop negative beliefs about themselves due to the humiliation, and they also might develop beliefs about themselves for being affected by the emotional abuse in general based on the parent’s comments (i.e., I am weak, I should not have been affected). A trauma-informed rehabilitation provider who validates this experience as being a form of maltreatment that has lasting effects is a potentially positive and potent intervention.

Our results suggest that intrusive rumination about past events and the stories people tell about the events they survived are critically important for understanding development of PTSD symptoms. Rehabilitation counselors are trained to implement a range of cognitive-based strategies as one way to help individuals experiencing PTSD symptoms. Rehabilitation providers can help individuals identify the source of the intrusive rumination, as well as appreciate how this sort of thinking affects health and functioning. Rehabilitation providers can identify these tendencies and target them in favor of more adaptive cognitive processing. For instance, the use of deliberative rumination to reduce the intrusive rumination is recommended, as deliberative rumination has been connected to post-traumatic growth (Cann et al., 2011; Watkins, 2008). Use of Narrative Therapy (Brown & Augusta-Scott, 2006) techniques to facilitate “re-writing” of their life story so as to decentralize past traumatic events in identify construction may be also be an effective approach.

Other approaches to consider include use of Acceptance and Commitment Therapy (ACT; Hayes, 2004), an outgrowth of Relational Frame Theory, and posits that the paradox of trying to control automatically generated distressing thoughts may be too much work and ultimately unrealistic. Rather than try to control intrusive thoughts, rehabilitation providers can teach strategies such as acceptance, defusing, and mindfulness (Fletcher & Hayes, 2005). The goal of ACT is to practice flexibility, which allows negative thoughts to come and go, but with less intensity. These strategies may be effective when targeting intrusive rumination. Use of the above-mentioned strategies may be helpful when used in conjunction with other established interventions targeting PTSD symptoms.

Limitations and Future Research

Results from this study should be interpreted in the context of its limitations. A convenience sample was utilized, and the cross-sectional research design prevents any causal inferences that could be drawn from the data, or that findings can be generalized to the population as a whole. Participants also voluntarily selected to participate in the study, which could potentially bias results. Provider validation of PTSD symptoms would likely enhance results; our participants self-reported PTSD symptoms. Results on the CEM subscale on the CTQ were also retrospective in nature, and no other mechanisms or data sources were utilized to validate self-reported responses; however, our screening procedure that eliminated participants who indicated minimizing and denial tendencies strengthens our confidence that our sample accurately reflected childhood experiences.

Multiple researchers emphasized the importance of clearly defining the construct of CEM to fully understand its prevalence and impact on health, functioning, and a range of life outcomes. Researchers also emphasize the importance of separating types of abuse experienced in childhood to fully understand the unique impact each type of abuse has on negative outcomes in adulthood. Currently, there is limited knowledge regarding effective treatment options for individuals with PTSD and a history of CEM. Future research to confirm if similar relationships and pathways among the variables in our study are detected in non-college student samples is recommended. We strongly encourage investigations of targeted interventions for rumination and centrality of the event for reductions in PTSD symptoms to determine if prevention and worsening of symptoms is possible using trauma-informed cognitive approaches. Our study used a brief instrument to identify PTSD symptoms that are reflective of a mix of PTSD symptoms from Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) and International Classification of Diseases, 10th Revision (ICD-10), as well as symptoms reflective of the new category of CPTSD in the ICD-11.Future research to determine if CEM is more likely related to PTSD or CPTSD is needed to help with accurate diagnosis.

Conclusion

This study found a significant and moderate relationship between CEM and PTSD symptoms, which was mediated by centrality of the event and intrusive rumination. A range of trauma-informed strategies targeting cognitive processes was provided as relevant to rehabilitation providers in their clinical work with people living with PTSD who survived CEM. Suggestions for future research were also included.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

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