A Step Toward a Better Understanding of the Relationship Between Victimization and Emotional Distress: Indirect Effect of Adult Attachment and Interaction With Household Dysfunction

Abstract

A history of victimization has been linked to the latter development of emotional distress. However, not all victims develop emotional distress in response to victimization, emphasizing the need to identify mediators that can guide intervention, as well as moderators to more targeted preventive actions. Within a developmental psychology framework, we aimed to test two models: (a) the role of adult attachment as a mediator in the relationship between victimization and emotional distress, and (b) the role of household dysfunctions as moderators in the relationship between victimization and emotional distress, in psychiatric patients. Participants were 120 adult psychiatric patients, between ages 20 and 79 years (M = −47.22, SD = 13.102) that responded to questions assessing household dysfunction in the family of origin, victimization, and adult attachment. Results revealed that adult attachment was a significant mediator in the association between victimization and emotional distress. Parental mental disorder and total household adversity were significant moderators for that same association. These results provide important clues for intervention. The focus on promoting secure adult relationships may contribute not only to the psychosocial adjustment of psychiatric patients but also to a healthier family functioning. Reducing the household dysfunction may provide a protective environment for the development of children, promoting a positive psychosocial adjustment, also preventing the intergenerational transmission of violence, insecure attachment, and emotional distress.

Keywords

mediator moderator interpersonal victimization psychiatric patients adult attachment household dysfunctions

Prevalence of interpersonal victimization is high in psychiatric patients; research has shown that victimization can lead to the subsequent development of emotional distress and psychiatric disorders, during adulthood (Cougle, Resnick, & Kilpatric, 2009; Goodman et al., 2001; Horwitz, Widom, McLaughlin, & White, 2001; McFarlane, Schrader, Bookless, & Browne, 2006; Mueser et al., 2004). These experiences of victimization tend to co-occur, and some categories occur in all stages of the lifecycle, with victims suffering multiple victimization and revictimization. Despite the fact that emotional distress is a likely outcome in response to a history of victimization, not all victims develop mental disorder (Jáliva & Cerezo, 2014; La Flair, Bradshaw, Mendelson, & Campbell, 2015; Sheidow, Henry, Tolan, & Strachan, 2014; Soler, Kirchner, Parentillo, & Forns, 2013), suggesting the need to further explore the association between victimization and adult emotional distress. The identification of factors that could be modified through intervention, as well as factors that would help guiding early preventive actions, will help promoting the victims’ adjustment reducing risk and increasing the effectiveness of treatments (Aspelmeier, Elliot, & Smith, 2007; Buckner, Beardslee, & Bassuck, 2004; Dimitrova et al., 2010; Hill, Kaplan, French, & Johnson, 2010; Sandberg, Suess, & Heaton, 2010; Schuck & Widom, 2001; Whiffen & MacIntosh, 2005).

The framework of Developmental Psychopathology (Cicchetti, 1984; Garmezy, Masten, & Tellegen, 1984; Sroufe & Rutter, 1984) can help us in understanding individual development and the multiple influences leading to psychopathology. The model conceives the development as occurring until adulthood, resulting from the interaction between biological, environmental, and contextual factors, with direct and indirect effects (Cicchetti & Rogosch, 2002; Masten, 2006; Pynoos, Steinberg, & Piacentini, 1999; Rutter & Sroufe, 2000). The role of the family as agent of primary socialization has been considered of great importance in understanding maladjustments (Fonagy, 2003; Garmezy et al., 1984; Masten, 2006; Rutter & Sroufe, 2000). Within this conceptual framework, two aspects are of considerable relevance for a healthy adjustment: attachment and household dysfunction. The occurrence of interpersonal victimization may compromise the subsequent emotional adjustment (Banford, Brown, Ketring, & Mansfield, 2015; Briere et al., 2012; Dimitrova et al., 2010). We will explore closely the role played by these factors in the association between interpersonal victimization and adult emotional distress.

Adult Attachment

According to the developmental psychopathology framework, attachment promotes emotional adjustment (Rutter & Sroufe, 2000). The conceptualization of adult attachment emerged from the work of Hazan and Shaver (1987). The authors conceived adult attachment in the context of a romantic relationship, in a dimensional framework that organizes individual differences ranging along three dimensions (Canavarro, Dias, & Lima, 2006; Fraley & Shaver, 2000). These dimensions reflect representations, beliefs, and internal working models of the self as worthy of love, and of others as supportive and trustworthy, influencing the way individuals perceive themselves and the world (Fraley & Shaver, 2000; Godbout, Dutton, Lussier, & Sabourin, 2009; Mickelso, Kessler, & Shaver, 1997; Mikulincer & Shaver, 2012; Roche, Runtz, & Hunter, 1999; Sandberg et al., 2010). The secure dimension of adult attachment reflects a sense of self-worth and social self-confidence. Individuals are comfortable with being close and depended on others and see their romantic partners as trustworthy, available and responsive (Brennam & Shaver, 1995; Collins & Read, 1990; Hazan & Shaver, 1987; Mickelso et al., 1997). Attachment anxiety expresses negative beliefs about the self and the others. Individuals with anxious attachment fear rejection and abandonment and lack a sense of self-worth, self-confidence, and self-control. They see others as reluctant in becoming close and intimate, leading to hypervigilant behaviors concerning signs of threat to the relationship, separations, or betrayals (Brennam & Shaver, 1995; Briere et al., 2012; Collins & Read, 1990; Godbout et al., 2009; Hazan & Shaver, 1987; Mickelso et al., 1997). The avoidant dimension describes individuals that are uncomfortable with proximity and fear intimacy. They believe that their romantic partner is unavailable, unresponsive and untrustworthy, and suppress emotional states to reduce feelings associated with vulnerability to rejection and abandonment (Brennam & Shaver, 1995; Briere et al., 2012; Godbout et al., 2009; Hazan & Shaver, 1987; Mickelso et al., 1997). As interpersonal victimization occurs within a relational context, and adult romantic relationships have been described as one of the most important in adulthood (Pielage, Luteijn, & Arrindell, 2005), its occurrence across lifetime may lead to negative representations of the self and the others, disturbing the expected social, emotional, and cognitive adjustment and creating vulnerability to emotional distress in adulthood (Liem & Boudewyn, 1999; Riggs, 2010; Tasca et al., 2013).

Some studies investigated the role of adult attachment, measured within a dimensional framework, in the association between victimization and adult emotional distress and mental disorders, in community samples and clinical samples as well. Roche and colleagues (1999) tested the mediating role of adult attachment in the association between childhood sexual abuse and psychological adjustment in 307 college women. The authors found that this relationship was mediated by adult attachment patterns. Another study, from Godbout, Lussier, and Sabourin (2006), tested the indirect effect of attachment in the association between victimization and psychological distress in a sample of 316 men and 316 women. Results showed that childhood sexual abuse, childhood physical abuse, childhood psychological abuse, and witnessing to physical violence between the parents were associated to psychological distress through adult attachment. In their study with women from the community, Bifulco and colleagues (2006) found that attachment mediated the relationship between childhood abuse and neglect, and symptoms of depression and anxiety in adulthood. Hankin (2005) found similar results in a study of college students. Studies carried with clinical samples revealed interesting results. Caldwell, Shaver, Li, and Minzenberg (2011), investigated the role of adult attachment in the association between childhood maltreatment and negligence and depression in adulthood. The study was conducted with 76 women recruited from risk programs from de community. Women with childhood maltreatment and negligence had high levels of anxious attachment, and more severe symptoms of depression, with anxious attachment playing a significant role in mediating this association. Another study from Tasca and colleagues (2013) investigated the role of attachment dimensions in the association between childhood victimization and eating disorders in a sample of 308 adult psychiatric patients. Results revealed that adult attachment mediated the association between childhood victimization and eating disorders. In a study conducted with 82 psychiatric patients with obsessive compulsive disorder, Carpenter and Chung (2011) found that the avoidant dimension mediated the association between childhood victimization and number of symptoms and severity of the disorder.

Additional research has focused on the role of attachment in several areas of individual functioning. Secure attachment has been associated with relationship satisfaction, well-being, a more effective coping with stress and better emotion regulation, thus reducing the likelihood of developing mental disorder (Gillath, Selcuk, & Shaver, 2008). Furthermore, studies found that attachment orientation has an important role in help-seeking behaviors in response to emotional distress and psychopathological symptoms. While individuals with attachment anxiety may accentuate their discomfort to elicit help from others, attachment avoidance may reflect in distrust over others, with rejection of help (Dozier, Lomax Tyrrell, & Lee, 2001; Vogel & Wei, 2005). The establishment of a therapeutic alliance and the attainment of positive outcomes may result hampered for the same reasons (Mikulincer, Shaver, & Berant, 2013; Sauer, Anderson, Gormley, Richmond, & Preacco, 2010; Sauer, Lopez, & Gormley, 2003; Saypol & Farber, 2010). Studies concerning symptom perception and the use of health care services found that insecure attachment have implications in the patients–provider relationship, due to the increase of perceived personal vulnerability. Patients with attachment anxiety may report more symptoms, with more extreme physiologic reactions, while patients with attachment avoidance may be suspicious of the recommendations and treatments and have low levels of compliance and adherence (Ciechanowski, Walker, Katon, & Russo, 2002; Hunter & Maunder, 2001; McWilliams & Bailey, 2010). Gormley and McNiel (2010) found that insecure attachment was associated with self-aggression behaviors in psychiatric patients. Studies have also focused on the role of attachment patterns in the caring for others’ behavior. The experience of emotional distress may compromise caring behaviors and concerns for others’ well-being. When facing others’ needs, individuals with attachment anxiety may experience increased personal distress, and individuals with attachment avoidance may experience empathy inhibition. This is important to promote and maintain the social support network, thus promoting and maintaining mental health (Mikulincer et al., 2001; Mikulincer et al., 2003). Burnette, Taylor, Worthington, and Forsyth (2007) studied the role of attachment in the forgiveness. Insecure patterns of attachment may interfere with empathy and emotional regulation, hampering forgiveness behaviors, and maintaining emotional distress.

These studies evidence the importance of studying adult attachment in the association between victimization and emotional distress. To increase the knowledge of the role played by attachment dimensions in this association, it is important to consider a wide range of victimization experiences. As victimization tend to co-occur, the focus on single categories of victimization, or a restricted set of categories, may limit the knowledge of the role played by attachment. Experiences of revictimization highlight the need to explore this role concerning lifetime victimization (Bensley, Eenwyk, & Simmons, 2003; Finkelhor, Ormrod, & Turnner, 2007; Horwitz et al., 2001; Maker, Kemmelmeir, & Peterson, 2001; Richmond, Elliott, Pierce, Aspelmeier, & Alexander, 2009; Scott, 2007, 2011; Widom, Czaja, & Dutton, 2008). The knowledge of which attachment dimensions mediate the association of victimization and adult emotional distress will help guiding interventions aimed at solving emotional issues pertaining to the victimization.

Household Dysfunctions

Victimization experiences tend to occur within a context of household dysfunction, whether the perpetrators are familiars or unknown. Household dysfunctions are known to be related with emotional distress (Dong et al., 2004; English, Marshall, & Stewart, 2003; Herrenkohl, Sousa, Tajima, Herrenkohl, & Moylan, 2008; Hooven, Nurius, Logan-Greene, & Thompson, 2012; Houg et al., 2012; Markson, Lamb, & Lösel, 2015): Growing up in a dysfunctional household may expose the individual to a set of nonvictimizing adversities that might worsen the consequences of victimization. In addition, studies suggest that the negative impact of household dysfunctions is cumulative, with a dose-response effect (Chartirer, Walker, & Naimark, 2010; Sachs-Ericsson, Rusting, Stanley, & Sheffler, 2015). Some household dysfunctions that have been positively associated with later emotional distress include alcohol and drug consumption, parental mental disorder and parental suicide, parental divorce/separation, living with stepparents, and parental incarceration. Having parents with alcohol and/or drug addictions increases the risk of later psychological maladjustment (Bradley, 2001; Dunn et al., 2002; Herrenkohl et al., 2008; Jaffe, 2005; Markson et al., 2015). Families where one or both parents have addictions tend to be more negligent, with low supervision and low support and criminal activities. This can affect the adjustment of the offspring through self-esteem, negative affect and difficulties in the social interaction (Barnow, Schuckit, Lucht, John, & Freyberger, 2002; Kirisci, Dunn, Mezzich, & Tarter, 2001; White, Johnson, & Buyske, 2000). Hooven and colleagues (2012) followed 125 adolescents into adulthood and found that parental alcohol and substance abuse predicted emotional distress. Parental mental disorder also places the child at risk of victimization (Johnson & Easterling, 2012; Riggs et al., 2007). Parents may have reduced parenting capabilities, leaving the children exposed to criticism, harsh punishment behaviors, inconsistent discipline, low supervision, domestic violence, lack of warmth and support, and reduced number of interactions. Feelings of shame, stigma, self-blame, and isolation may compromise psychosocial adjustment (Hinshaw, 2005; Maybery & Reupert, 2009; Mowbray, Bybee, Oyserman, MacFarlane, & Bowersox, 2006; Pilowsky, Wickramaratne, Nomura, & Weissman, 2006; Walsh, MacMillan, & Jamieson, 2003; Whiffen & MacIntosh, 2005). In addition, having a parent with mental disorder can lead to parental suicide, leading to feelings stigma, rage, shame, and mourning (Abela, Skitch, Anerbach, & Adams, 2005; Bradley, 2001; Brent, Melhem, Donohoe, & Walker, 2009; Cerel & Roberts, 2005; Herrenkohl et al., 2008; Markson et al., 2015). Parental divorce, and the possibility of subsequent remarriage or living with stepparents, can compromise the psychosocial adjustment of the offspring, leading to later emotional distress. The experience of divorce, and the frequent parental conflict experienced, may affect the child’s self-esteem and self-efficacy, reducing the social support and coping resources (D’Onofrio et al., 2007; Størksena, Røysamba, Moumc, & Tambsa, 2005). Parenting styles may be harsh, punitive, and low on warmth, with less emotional availability (Riggio, 2004). Children may experience feelings of shame, self-blame, fear, anger, rejection, with difficulties in affect regulation, impulsivity, and social interaction (Kelly, 2000). Furthermore, stepparents may create stress in their stepchildren, affecting routines and family dynamics (Coleman, Ganong, & Fine, 2000). Stepparents invest in an intimate partner relationship, and may not attach closely to the child, as they may be competing for attention, love, time, and affection of the biological parent (Alexandre, Nadonovsky, Moraes, & Reichenheim, 2010; Coleman et al., 2000). On the other hand, the remaining biological parent may be less available and less supportive due to the investment in the new relationship, leading to less warmth, supervision, and positive interactions (Coleman et al., 2000; Hetherington, 2003). Jablouska and Lindberg (2007) investigated symptoms of emotional distress in a sample of 12,582 adolescents living in different family structures: 68.5% lived with both parents, 23.2% lived with a single mother, 4.8% lived with a single father, and 3.5% had shared custody. Results showed that adolescents living with single parents were at higher risk of anxiety and depression; the risk was even higher for adolescents living with single fathers. Bjarnason and colleagues (2012) examined differences in life satisfaction in 184,496 adolescents between ages 11 and 15 from 36 countries, living in different family structures. The results evidenced that life satisfaction was higher in intact families, followed by single mother families, mother with stepfather families, single father families, and finally, father with stepmother families. Parental criminal behaviors are frequently related to parental substance use (Kirisci et al., 2001) and may lead to incarceration, creating additional distress in the remaining family. The responsibility of taking care of children and providing for the household lies on the remaining parent, when there is one, that may not be able to adequately supervise the children (Johnson & Easterling, 2012; Turner, Finkelhor, & Ormrod, 2007). The children may experience stigma, mourning, and loss of contact with the incarcerated parent (Dallaire & Wilson, 2010; Murray, Farrington, Sekol, & Olsen, 2009; Murray & Farrington, 2008). The co-occurrence of household dysfunctions may have more detrimental consequences for the mental health of the adult, with changes in the cerebral functioning, resulting in neural dysregulation (Afifi, Boman, Fleisher, & Sareen, 2009; Kelly, 2000; Lee, Fang, & Luo, 2013).

The reviewed studies illustrate the association between household dysfunctions and emotional distress. It is possible that these dysfunctions may interact with victimization in creating vulnerability to emotional distress. The knowledge of the moderating factors of this association might allow intervening to minimize the negative impact of victimization and to promote a positive adjustment. As most of the studies were conducted with participants from the community, it is important to explore the moderation hypothesis in psychiatric samples, considering the high levels of victimization in this population. In addition, studies exploring the role of contextual moderators in the association between victimization and emotional distress tend to focus on parental support in response to victimization, especially childhood sexual abuse (Folger & O’Dougherty, 2013; Nurius, Logan-Greener, & Green, 2012; Sperry & Widom, 2013), with less research with specific dysfunctions.

Childhood and Adolescent Victimization

In her review on childhood sexual abuse, Arata (2002) found that one limitation in this field of investigation was related with inconsistencies in the distinction between childhood, adolescent and adult sexual abuse. While some studies separated the three stages, others integrated adolescent sexual abuse either in the category of childhood sexual abuse, either of adult sexual abuse, thus hampering the comparison across studies. Arata highlights the need to clearly differentiate experiences of childhood sexual abuse from adolescent sexual abuse. Sabri, Hong, Campbell, and Cho (2013) undertook a systematic review that aimed at identifying definitions and categories of victimization experiences across studies. The researchers found several inconsistencies pertaining to the definition of adolescent victimization, with variations in its limits; in addition, several studies failed to distinguish between childhood and adolescent victimization, and adolescent and adult victimization. This lack of distinction interferes with the understanding of the dynamics involved in the outcomes of victimization experiences. In our study, we chose to explore childhood, adolescent, and adult experiences of interpersonal victimization separately.

The Current Study

Stemming from the finding that not all victims of interpersonal victimization develop emotional distress later in life, and considering the importance of identifying factors that could help with early preventive actions, we define our goals for this study within a developmental psychopathology framework. To deepen the knowledge of factors accounting for the association between childhood, adolescent, and adult victimization and emotional distress, and in an attempt to overcome some of the limitations mentioned earlier, namely, the fact that studies of mediation focus on specific categories of victimization, and studies of moderation explore the role of parental support in response to victimization in community samples, we aimed to test two different models in a sample of adult psychiatric patients, a population with a path of maladaptive development: (a) the potential mediating role of adult attachment, considering the effect of secure, anxious and avoidant dimensions; and (b) the potential moderating role of individual household dysfunctions (parental consumption behaviors, parental divorce/separation, living with stepparents, parental mental disorder, parental suicide, and parental incarceration), as well as the role of the cumulative effect of these household dysfunctions. Our work expands the existing literature by focusing on several categories of victimization across all the stages of the lifecycle, considering the occurrence of adolescent victimization, and exploring the role of a diversity of household dysfunction, tested individually and cumulatively, in a sample of adult psychiatric patients. We expect that our results will help to identify who is at risk of developing emotional distress in response to victimization, and to increase the effectiveness of interventions and preventive programs.

Method

Participants

Participants were 120 adult psychiatric patients between ages 20 and 79 years (M = 47.22, SD = 13.102), from four Portuguese psychiatric hospitals; 80 were inpatients (67.5%) and 40 were outpatients (32.5%). Sixty-eight were female (56.7%), and 52 were male (43.3%). Participants were receiving mental health care in a public psychiatric hospital, as either an inpatient or an outpatient with a mental disorder diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994). Participants were included regardless of the diagnosis they presented. The exclusion criteria were not understanding Portuguese, mental retardation, and active psychotic symptoms. Participants too disturbed to participate were identified by the health care professionals and were not included in the study. Participants’ sociodemographic and clinical information is described in Table 1.

Table 1.

Participants Socio-Demographic and Clinical Information.

	N = 120	%
Marital status
Married	74	61.7
Single	26	21.7
Divorced	17	14.1
Widower	3	2.5
Employment status
Employed	63	52.5
Retired	32	26.6
Unemployed	17	14.2
Student	4	3.3
Never worked	4	3.3
Education level
Elementary school or less	89	74.2
High school or less	21	17.5
College	10	8.3
Psychiatric diagnosis
Mood disorders	53	44.2
Substance-related disorders	21	17.5
Schizophrenia and other psychotic disorders	19	15.8
Anxiety disorders	19	15.8
Personality disorders	7	5.8
Eating disorders	1	0.8

Procedures

We obtained approval for inpatients and outpatients from the National Commission of Data Protection, and from the Ethics Committees of each Psychiatric Hospital. After approval, patients were approached. For inpatients, the chief nurse made the first contact with patients who met the inclusion criteria and introduced the researchers. Outpatients were approached on scheduled appointment days; their psychiatrist presented the researchers, who proceeded to present the study. After this presentation, patients who agreed to participate signed an informed consent. Participation was voluntary. Two experienced researchers, with training in assessing psychiatric patients, approached 131 participants. Of the 131 patients, 11 were not included. Six participants refused to participate, one tried to participate but felt too disturbed to proceed, and four had no identifiable psychopathology. Assessments lasted between 60 and 180 min and were conducted in a quiet room in psychiatric hospitals, where patients could feel comfortable and at ease. Confidentiality was ensured for all participants enrolled. Data were collected on specific days, determined by hospitals teams.

Measures

Sociodemographic information

A sociodemographic questionnaire was created to collect information about sex, age, marital status, employment status, and education level. Ten additional items were included, concerning household dysfunction within the family of origin. These 10 items were obtained from the Adverse Childhood Experiences (ACE) Study Questionnaire (Felitti et al., 1998; Portuguese version from Silva & Maia, 2008). The categories of household dysfunction assessed parental divorce/separation (three items), parental consumption behaviors (four items), mental illness (two items), and criminal behavior (one item), during the first 18 years of the participant. Items are dichotomous; a positive response to any item was considered as indicative of the presence of that household dysfunction. The sum of all items resulted in an index of total household adversity.

Diagnosis of mental disorder

Structured Interview for DSM-IV Axis I Disorder (SCID-I; First, Spitzer, Gibbon, & Williams, 1997; Portuguese version from Maia, 2005) is a semistructured interview that enables to do the main diagnosis of Axis I, according to DSM-IV. Structured Interview for DSM-IV Axis II Disorders (SCID-II; First, Spitzer, Gibbon, & Williams, 1997; Portuguese version from Gouveia, Matos, Rijo, Castilho, & Salvador, 2011) is a semistructured interview that enables to evaluate the presence/absence of the diagnostic criteria of the personality disorders from Axis II of DSM-IV. The instruments allow a quantitative measurement of the mental health; items are dichotomous, with a score of 1 indicating the presence of a mental disorder.

Psychological distress

Brief Symptom Inventory (BSI; Derogatis, 1982; Portuguese version from Canavarro, 1999a) is an instrument with 53 items that evaluates the presence of psychological distress within the previous 7 days in a 5-point scale. It evaluates nine symptom dimensions, allowing to calculate three indexes that constitute brief evaluations of emotional distress: the Global Severity Index (GSI), the Positive Symptoms Total (PST), and the Positive Symptom Distress Index (PSDI). For the purpose of this study, GSI was used to represent emotional distress. This index reflects a combined score that weighs the intensity of the distress experienced and the number of symptoms checked, and it was obtained summing the score of all items, and dividing the result by the total number of answers. In our study, alpha of Cronbach varied between .62 (paranoid ideation) and .88 (depression).

Interpersonal victimization

Lifetime Trauma and Victimization History (LTVH; Widom, Dutton, Czaja, & DuMont, 2005; Portuguese version from Matos, Dias, & Costa, 2012) is a checklist of victimization experiences, with 15 items distributed for seven categories of victimization: psychological victimization (two items, describing experiences of verbal abuse and threats), physical victimization (three items), sexual victimization (one item, describing any type of forced/coerced sexual contact), neglect (one item, describing any type of negligent behavior from caretakers), witnessing to victimization (two items, describing any type of violent behavior witnessed), discrimination (one item, describing any type of discriminating behavior experienced), and institutional victimization (two items, describing experiences of inadequate/unfair treatment in different institutions). For each experience, participants are asked about the occurrence of victimization during childhood (0-11 years), adolescence (12-17 years), or adulthood (18 and older). Items are dichotomous; a positive response to any item was considered as indicative of the presence of a given victimization experience. All categories were assessed in regard to any possible perpetrator (family members, peers, unknown perpetrators). Three victimization indexes were created, representing the sum of the victimization categories experienced in each stage of the lifecycle: Childhood Victimization Index, Adolescent Victimization Index, and Adult Victimization Index, varying from 0 to 7. Items were re-coded for each stage of the lifecycle, and we obtained a dichotomous value of each of the seven categories. Victimization indexes for each lifecycle stage were calculated summing the seven victimization categories.

Attachment

Adult Attachment Scale (AAS; Collins & Read, 1990; Portuguese version from Canavarro, 1995, 1999b) is an instrument used to measure adult attachment. Answers are given in a 5-point scale. With 18 items, it has three dimensions, representing attachment styles: (a) Anxious dimension refers to the anxiety the individual feels about interpersonal issues of abandonment or not being loved (α = .81), (b) secure dimension refers to the degree in which the individual feels comfortable with proximity and intimacy (α = .66), and (c) avoidant dimension refers to the confidence the individual has in others, as well as their availability when needed (α = .69). Internal consistency scores for the Portuguese version of the AAS are as follows: anxious = −.84, secure = −.67, and avoidant = −.54.

Statistical Analyses

Data were analyzed using descriptive statistics and frequencies for sociodemographic and clinical data and victimization experiences. Mediation and moderation analyses were made following recommendations of Field (2013), using the PROCESS macros for Statistical Package for Social Science (SPSS), developed by Hayes (2012). We tested the indirect effect according to Lambert’s mediation model, using boostrapping to generate confidence intervals (CI) for this indirect effect (Field, 2013). We used 1,000 boostrap samples, with bias corrected. Mediation hypothesis was tested looking for a significant indirect effect from the predictor (victimization) in the outcome variable (emotional distress), in the presence of the mediator (attachment) and attending to the effect size given by kappa-square (κ²; Preacher & Kelley, 2011). To test for the moderation hypothesis, Aiken and West (1991) propose to make simple slope analyses, which present the scores for the predictor and the outcome variable in the presence of different levels of the moderator. Scores are presented and grouped according to low, mean, and high levels of the moderators. The PROCESS dialog box uses one standard deviation above and below the mean to create the groups. For dichotomous variables, the scores presented relate to the values the moderator assumes. The use of PROCESS for moderation analyzes allows for the predictors to be centered, creates the interaction term, and produces CIs. Data analyzes were made with the support of the software IBM SPSS, version 22 for Windows.

Results

Descriptive Data

Table 2 displays information concerning the prevalence of victimization experiences for each stage of the lifecycle. Childhood victimization varied from 0 to 6 (M = 1.31, SD = 1.41); adolescent victimization also varied from 0 to 6 (M = 1.25, SD = 1.55), and adult victimization varied from 0 to 6 victimization experiences (M = 2.04, SD = 1.69). Data concerning mean scores for the attachment dimensions and the prevalence of each household dysfunction are illustrated in Table 3. Correlations and associations among study variables are presented in Table 4.

Table 2.

Victimization Indexes: Total Number of Victimization Categories in Childhood, Adolescence, and Adulthood.

Number of Victimization Experiences	Childhood N, n%		Adolescence N, n%		Adulthood N, n%
0	44	36.7	54	45.0	29	24.2
1	33	27.5	27	22.5	22	18.3
2	19	15.8	14	11.7	24	20.0
3	12	10.0	9	7.5	14	11.7
4	7	5.8	10	8.3	17	14.2
5	3	2.5	3	2.5	11	9.2
6	1	0.8	2	1.7	1	0.8

Table 3.

Household Dysfunction and Attachment Information of the Participants (N = 120).

	n	%
Parental alcohol problems	45	37.5
Parental drug problems	11	9.2
Parents separated/divorced	11	9.2
Lived with a stepfather	6	5
Lived with a stepmother	3	2.5
Parental mental disorder	33	27.5
Parental suicide	14	11.7
Parental incarceration	6	5
	M	SD
Anxious attachment	2.59	0.889
Secure attachment	3.26	0.598
Avoidant attachment	3.00	0.643

Table 4.

Correlations and Associations Between the Variables.

	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15
1. Emotional distress
2. Anxious attachment	.351**
3. Secure attachment	ns	ns
4. Avoidant attachment	−.318**	−.382**	ns
5. Parental alcohol consumption	.191*	ns	ns	−.191*
6. Parental drug consumption	ns	ns	ns	ns	ns
7. Parental mental disorder	.268**	ns	ns	ns	7.83**	ns
8. Parental suicide	ns	ns	ns	ns	ns	ns	4.02*^a
9. Parental divorce	ns	ns	ns	ns	ns	ns	ns	ns
10. Living with stepmother	ns	ns	ns	ns	ns	ns	ns	ns	ns
11. Living with stepfather	ns	ns	ns	ns	ns	ns	ns	ns	4.43*^a	ns
12. Parental incarceration	ns	ns	ns	ns	5,66*	42.69***	ns	ns	4.43*^a	ns	ns
13. Total household dysfunction	.197*	ns	ns	−.247**	6.94**	0.292**	ns	.468**	ns	ns	.246**	.514**
14. Childhood victimization	.261**	.254**	ns	−.198*	0.338*	ns	0.317**	.197*	ns	ns	ns	ns	.379**
15. Adolescent victimization	.252**	ns	ns	−.278**	0.224*	ns	0.421**	.194*	0.211*	ns	ns	ns	.374**	.714**
16. Adult victimization	.256**	ns	.188*	−.186*	0.232*	ns	0.186*	ns	ns	ns	ns	ns	.256**	.378**	.423**

Chi-square associations.

p < .05. **p < .01. ***p < .001.

Regression Model

Based on the results of correlation analyses, we tested three multiple hierarchical regression models to predict emotional distress based on attachment, parental mental disorder, and total household dysfunction, controlling for victimization. Results are presented in Table 5.

Table 5.

Results From the Multiple Linear Regression Models Predicting Emotional Distress.

	B	SE	β
Model 1
Step 1
Childhood victimization	.133**	.046	.261
Step 2
Childhood victimization	.083, ns	.044	.163
Anxious attachment	.175*	.075	.216
Secure attachment	−.142, ns	.102	−.117
Avoidant attachment	−.221*	.102	−.198
Step 3
Childhood victimization	.06, ns	.047	.114
Anxious attachment	.162*	.075	.200
Secure attachment	−.138, ns	.102	−.114
Avoidant attachment	−.218*	.104	−.195
Parental mental disorder	.314, ns	.174	.196
Total household dysfunction	−.016, ns	.081	−.022
Model 2
Step 1
Adolescent victimization	.117**	.042	.252
Step 2
Adolescent victimization	.074, ns	.041	.159
Anxious attachment	.191*	.074	.236
Secure attachment	−.147, ns	.103	−.121
Avoidant attachment	−.199*	.104	−.178
Step 3
Adolescent victimization	.039, ns	.044	.085
Anxious attachment	.177*	.074	.219
Secure attachment	−.143, ns	.108	−.118
Avoidant attachment	−.204*	.107	−.183
Parental mental disorder	.288, ns	.180	.180
Total household dysfunction
Model 3
Step 1
Adult victimization	.109*	.038	.256
Step 2
Adult victimization	.100**	.037	.234
Anxious attachment	.193**	.073	.238
Secure attachment	−.205*	.104	−.169
Avoidant attachment	−.192, ns	.102	−.172
Step 3
Adult victimization	.088*	.037	.205
Anxious attachment	.173*	.073	.213
Secure attachment	−.192, ns	.103	−.159
Avoidant attachment	−.189, ns	.104	−.169
Parental mental disorder	.310, ns	.172	.193
Total household dysfunction	−.016, ns	.079	.022

p < .05. **p < .01. ***p < .001.

In Model 1, Step 1, childhood victimization predicted emotional distress, F(1, 117) = 8.53, p = .01, explaining 6.8% of the variance. After entering attachment in the regression, childhood victimization was no longer a significant predictor of emotional distress. The model was significant, F(4, 114) = 7.28, p = .001, and the explained variance increased to 20.4%. In Step 3, the general model remained significant, F(6, 112) = 5.69, p = .001, with an increase in the variance explained (R² = .234), but individual predictors were not significant.

In Model 2, adolescent victimization was a significant predictor of emotional distress in Step 1, F(1, 117) = 7.952, p = .01, explaining 6.4% of the variance. In Step 2, we enter attachment in the model, and adolescent victimization ceased to be a significant predictor. The model was significant, F(4, 114) = 7.23, p = .001, explaining 20.2% of the variance. When we entered parental mental disorder and total household dysfunction in Step 3, the general model remained significant, F(6, 112) = 5.54, p = .001, and the variance explained increased (R² = .229), but as for Model 1, individual predictors were not significant.

Adult victimization predicted emotional distress in Model 3, F(1, 116) = 8.116, p = .01, explaining 6.5% of the variance. After entering attachment in the regression, the variance increased to 22.9%, F(4, 113) = 8.41, p = .001. Adult victimization remained a significant predictor. In Step 3, parental mental disorder and total household dysfunction were not significant predictors. The variance explained increased to 26%, F(6, 111) = 6.49, p = .001.

The results concerning attachment suggest that the role of victimization on emotional distress may be mediated by attachment. Concerning parental mental disorder and total household dysfunction, their introduction in the model increased the variance explained, despite the fact that they did not reached significance as individual predictors, suggesting a moderation effect.

Mediation Model

Table 6 presents the significant results from the mediation model. Results are described presenting the significance of the general model, the indirect effect with bootstrap CIs, and the effect size of the CI with the kappa-square scores. Attachment anxiety mediated the association between childhood victimization and emotional distress, explaining 15.4% of the variance in the outcome, F(2, 116) = 10.56, p < .001, B = .038, 95% BCa CI = [.007, .087]. The indirect effect of childhood victimization on emotional distress, after anxious attachment was entered into the model, revealed a small effect size, κ² = .075, BCa CI = [.014, .168]. Attachment avoidance was also a significant mediator, F(2, 116) = 10.01, p < .001, B = .029, 95% BCa CI = [.007, .0693], explaining 14.7% of the variance of emotional distress, with a small effect size, κ² = .058, BCa CI = [.014, .139]. For adolescent victimization, attachment avoidance explained 13.5% of the variance, F(2, 116) = 9.09, p < .01, B = .037, 95% BCa CI = [.009, .075]. The indirect effect was close to a medium effect size, κ² = .08, BCa CI = [.021, .168]. Secure dimension had a negative indirect effect on the association of adult victimization and emotional distress, F(2, 115) = 7.70, p < .001, B = −.019, 95% BCa CI = [−.052, −.003], explaining 11.8% of the variance of emotional distress, with a small effect size, κ² = .049, BCa CI = [.009, .139]. Attachment avoidance also had an indirect effect in the association of adult victimization and emotional distress, F(2, 116) = 9.88, p < .001, B = .023, 95% BCa CI = [.002, .063], explaining 14.7% of the variance, with a small effect size, κ² = .055, BCa CI = [.006, .145].

Table 6.

Results of the Test for Mediation Using Process.

	Path Coefficients			t	Kappa-Square
	B	SE B	95% CI	t	κ²	SE	95% CI
Model 1—Emotional distress
Childhood victimization	.133	.045	[0.043, 0.223]	2.92**
Anxious attachment	.24	.071	[0.104, 0.386]	3.44**
Direct effect	.095	.045	[0.006, 0.184]	2.12*
Indirect effect	.038	.021	[0.007, 0.087]		.075	.041	[0.014, 0.168]
Model 2—Emotional distress
Childhood victimization	.133	.045	[0.043, 0.223]	2.92**
Avoidant attachment	−.32	.098	[−0.514, −0.127]	−3.28**
Direct effect	.104	.45	[0.016, 0.192]	2.33*
Indirect effect	.03	.015	[0.007, 0.693]		.058	.031	[0.014, 0.139]
Model 3—Emotional distress
Adolescent victimization	.117	.042	[0.035, 0.199]	2.82**
Avoidant attachment	−.312	.10	[−0.511, −0.113]	−3.11**
Direct effect	.081	.042	[−0.002, 0.1638]	1.95, ns
Indirect effect	.037	.017	[0.01, 0.075]		.08	.037	[0.021, 0.168]
Model 4—Emotional distress
Adult victimization	.109	.038	[0.333, 0.186]	2.85**
Secure attachment	−.283	.108	[−0.498, −0.069]	−2.62**
Direct effect	.128	.038	[0.053, 0.204]	3.36**
Indirect effect	−.02	.01	[−0.05, −0.003]		.049	.03	[0.009, 0.139]
Model 5—Emotional distress
Adult victimization	.109	.038	[0.333, 0.186]	2.85**
Avoidant attachment	−.324	.098	[−0.518, −0.13]	−3.31**
Direct effect	.086	.038	[0.012, 0.161]	2.32*
Indirect effect	.023	.015	[0.002, 0.063]		.055	.035	[0.012, 0.161]

p < .05. **p < .01. ***p < .001.

Moderation Model

Table 7 shows the significant results from moderation analyzes. Parental mental disorder and total household adversity were significant moderators in the association between childhood and adolescent victimization and emotional distress. In all analysis, the moderator played an enhancing effect. No moderators reached significance for adulthood victimization. Results are described with reference to the significance of the general model and of the interaction term, and the interpretation of the moderation effect of simple slope analyzes. Figure 1 displays the graphic results of the simple slopes for the significant models. We use the results from the Johnson–Neyman method to describe the level at which the association between victimization and emotional distress become significant, for continuum variables. Parental mental disorder moderated the association between childhood victimization and emotional distress, explaining 18.8% of the variance, F(3, 115) = 9.54, p < .001, B = .301, 95% CI = [.127, .474], t = 3.44, p < .01. Figure 2 (Model 1) shows that childhood victimization is positively associated with emotional distress in the presence of parental mental disorder, B = .258, 95% CI = [.117, .399], t = 3.62, p < .001. Total household adversity explained 14% of the variance of emotional distress, F(3, 115) = 5.16, p < .01, B = .125, 95% CI = [.036, 214], t = 2.78, p < .01. We can observe in Figure 2 (Model 2) that childhood victimization is positively associated with emotional distress at high levels of total household adversity, B = .174, 95% CI = [.049, .299], t = 2.77, p < .01. From a b = .465, increases in total household adversity increases the significance of the relationship between childhood victimization and emotional distress. Parental mental disorder also moderated the association between adolescent victimization and emotional distress. The interaction term explained 14.3% of the variance of emotional distress, F(3, 115) = 6.58, p < .001, B = .214, 95% CI = [.03, .397], t = 2.31, p < .05. Figure 2 (Model 3) shows the same pattern observed for childhood, as adolescent victimization is positively associated with emotional distress in the presence of parental mental disorder, B = .180, 95% CI = [.039, .32], t = 2.54, p < .05. Total household adversity was a significant moderator in the relation between adolescent victimization and emotional distress, explaining 14% of the variance of emotional distress, F(3, 115) = 5.16, p < .01, B = .093, 95% CI = [.016, .171], t = 2.38, p < .05. The graphic representation of the simple slope (Figure 2, Model 4) replicated the findings observed for childhood: Adolescent victimization is positively associated with emotional distress at high levels of total household adversity, B = .140, 95% CI = [.037, .243], t = 2.69, p < .01. From a b = .509, increases in total household adversity increases the significance of the relationship between adolescent victimization and emotional distress.

Table 7.

Results of the Test for Moderation Using Process.

	Coefficients
	B	95% CI	SE B	t
Constant	1.14	[1.01, 1.27]	.065	17.58***
Childhood victimization	0.273	[−0.062, 0.675]	.17	1.61, ns
Parental mental disorder	0.041	[−0.041, 0.123]	.042	0.981, ns
Childhood victimization × Parental mental disorder	0.301	[0.127, 0.474]	.087	3.44**
Constant	1.13	[0.994, 1.27]	.07	16.27***
Childhood victimization	0.067	[−0.078, 0.212]	.073	0.915, ns
Total household adversity	0.048	[−0.58, 0.155]	.054	0.895, ns
Childhood victimization × Total household adversity	0.125	[0.036, 0.214]	.045	2.78**
Constant	1.14	[0.995, 1.278]	.071	15.93***
Adolescent victimization	0.272	[−0.113, 0.656]	.194	1.4, ns
Parental mental disorder	0.025	[−0.069, 0.119]	.048	0.525, ns
Adolescent victimization × Parental mental disorder	0.214	[0.03, 0.397]	.093	2.31*
Constant	1.145	[0.101, 1.28]	.071	16.21***
Adolescent victimization	0.046	[−0.054, 0.146]	.05	0.916, ns
Total household adversity	0.074	[−0.073, 0.220]	.074	0.996, ns
Adolescent victimization × Total household adversity	0.093	[0.016, 0.171]	.039	2.38*

p < .05. **p < .01. ***p < .001.

Figure 1.

Simple slope equations of moderation models tested.

Figure 2.

Mediation model for victimization and emotional distress.

Discussion

Following a developmental psychology conceptual framework, we aimed to test two models in the association between interpersonal victimization and adult emotional distress. This framework conceives the development as occurring until adulthood; adult attachment and the family functioning are considered especially important in the emergence of maladjustment.

Attachment as Mediator

We tested the role of adult attachment as mediator in the association between interpersonal victimization and emotional distress. Anxious and avoidant dimensions of attachment mediated the association between childhood victimization and emotional distress. The indirect effect of the anxious dimension was stronger, suggesting that the impact of childhood victimization is mediated by internal working models based on beliefs of rejection and abandonment. Negative representations of the self may interfere with the capability to regulate emotional states and cope with painful emotions. The belief of being helpless and vulnerable may precipitate memories of childhood victimization, leading to hypervigilance in adult relationships (Brennam & Shaver, 1995; Collins & Read, 1990; Godbout et al., 2009; Hazan & Shaver, 1987; Mickelso et al., 1997; Sandberg et al., 2010). Briere and colleagues (2012) suggest that the experience of childhood victimization may lead to attachment anxiety concerning the motives of attachment figures, eliciting fear of victimization in future relationships. The association between adolescent victimization and emotional distress was mediated by the avoidant dimension of adult attachment. Interpersonal victimization tends to occur through all stages of the lifecycle, with experiences of revictimization and multiple victimization (Dong et al., 2004; Finkelhor et al., 2007). The indirect effect of attachment avoidance may represent suspicion of the motives of attachment figures, and the expectation that they are untrustworthy and unavailable when needed. As a consequence, there may be a strategic deactivation of the attachment system throughout the development, to reduce painful emotional states in response to victimization (Briere et al., 2012; Dimitrova et al., 2010; Fraley & Shaver, 2000; Godbout et al., 2009; Mickelso et al., 1997). Secure and avoidant dimensions mediated the association between adult victimization and emotional distress. Attachment avoidance had a stronger indirect effect, pointing to some continuity with adolescent internal working models. The negative indirect effect of secure attachment suggests that during adulthood, the establishment of secure romantic relationships may exert a protective effect against emotional distress, promoting a healthy adult adjustment in response to interpersonal victimization (Dinero, Conger, Shaver, Widaman, & Larsen-Rif, 2011; Fraley & Shaver, 2000; Godbout et al., 2009; Mikulincer & Shaver, 2012).

Household Dysfunctions as Moderators

Our second model aimed to test the individual role of a set of household dysfunctions, as well as their cumulative effect. From the household dysfunctions tested, only parental mental disorder reach significance as individual moderator. The cumulative effect of the household dysfunctions was also a significant moderator. Both factors moderated the association between childhood and adolescent victimization and emotional distress, through an enhancing effect: The presence of parental mental disorder, as well as higher levels of total household adversity, increased the association between victimization and emotional distress. The developmental psychopathology framework helps us understand the normal development for each stage of the lifecycle, considering the developmental tasks that are required for each stage (Cicchetti & Rogosch, 2002; Masten, 2006). Childhood is a critical developmental stage where children need protection against their physical and psychological vulnerabilities (Gladstone, Boydell, & McKeever, 2006; Johnson & Easterling, 2012; Riggs et al., 2007). Mentally ill parents may have reduced capability to exert their parental responsibilities, either by increasing punishment behaviors or by not exerting proper supervision, which in turn raises the risk of victimization by perpetrators outside the household (Maybery & Reupert, 2009; Walsh et al., 2003; Whiffen & MacIntosh, 2005). Furthermore, children whose parents have mental disorders are themselves at increased risk of developing mental disorders during adulthood (Gladstone et al., 2006; Maybery & Reupert, 2006; Reupert & Maybery, 2007). In the presence of co-occurring household dysfunction, children are particularly vulnerable to victimization from caretakers as well as from nonfamilial perpetrators, and to the later development of emotional distress and mental disorders (Afifi et al., 2009; Dong et al., 2004; Dube et al., 2001). Adolescence, in turn, is a stage where the individual faces new challenges in autonomy and independence. To fulfill these developmental tasks, the family must be a source of support, providing a functional household (Sprinthall & Collins, 1994). Families where one or both parents have mental disorders frequently have domestic violence, practice harsh punishment, are low on support and supervision, and offspring are often victims of physical abuse (Ritter, Stewart, Bernet, Coe, & Brown, 2002), increasing, therefore, the chances of victimization inside and outside the family (Maybery & Reupert, 2009; Walsh et al., 2003). No moderator reached significance for adult victimization. Other factors may play a role in moderating this association; factors such as current social support, coping mechanisms, and self-esteem require further investigation to explore these hypotheses. In addition, it is possible that potential moderators of the association between adult victimization and emotional distress are more related to the quality of current family functioning, and less related with the functioning of the family of origin (Dinero et al., 2011). Most household dysfunctions did not reach significance as moderators, despite their important contribution found in other studies. It is possible that their low prevalence in our sample might explain the lack of significance. Parental divorce (9.2%), living with a stepfather (5%) and/or a stepmother (2.5%), parental suicide (11.7%), and parental incarceration (5%) were fairly reported in this study. Parental alcohol consumption was the most prevalent dysfunction (37.5%); the lack of significance may indicate that its negative effect is not sufficient to change the relation between victimization and emotional distress. Moreover, it is possible that alcohol problems play a role explaining the moderator effect of other household dysfunctions, suggesting the need of exploring more complex interaction models.

Limitations

This study has some limitations. The cross-sectional nature of the design does not allow us to assess causation, thus limiting the generalization of our findings. In addition, our sample is a convenience one; participation was voluntary, introducing some response bias to our findings. Our study is also retrospective, using self-report measures to gather data. The use of such methodology raises concerns about the reliability of the information given. Furthermore, participants are psychiatric patients; psychiatric symptoms may interfere with the accuracy of the memories, leading to more inconsistencies (Kramers, van Gizen, van der Dos, & van Dyck, Spinhoven, 2007). The sensitive nature of the information required and aspects related to disclosure may have also played a role in the assessment: Participants may have felt ashamed, guilty, or afraid about what had happened to them, feared rejection, stigma and not receiving support, or were in denial (Goodman-Brown, Edelstein, Goodman, Jones, & Gordon, 2003; O’Leary, Cooley, & Easton, 2010). In cases where the perpetrator was a family member or someone close, participants may have chosen to preserve the image of their family and their idealized self-identity (Somer & Szwarcberg, 2001; Ullman, 2002), reflecting the need to appear to be well. Our data were not normally distributed, raising concerns with the reliability and validity of our results. Additional studies are required, with larger samples, to confirm our results. The size of our sample also prevented us from testing more integrative statistical models.

Practical Implications

The family environment is the context where the first interpersonal experiences take place, and where internal working models are shaped. Considering the importance of this context and the results obtained in our study, interventions aimed to promote the psychological adjustment of psychiatric patients should operate at two levels: the promotion of secure adult attachment relationships, and the promotion of a healthy household functioning. Attachment provides a framework that allows understanding and guiding processes of change in the context of clinical therapy (Barber et al., 2006; Ewing, Levy, & Boamah-Wiafe, 2014). During individual sessions, the therapist can play the role of the attachment figure, creating a secure base that allows for a decrease in emotional distress (Levy, Johnson, Clouthier, Sclala, & Temes, 2015; Unger & De Luca, 2014). In addition, the inclusion of the romantic partner in the therapy could help focusing on the promotion of a secure bound between the couple (Sandberg et al., 2010). Furthermore, the promotion of secure attachment patterns has implications in help-seeking behaviors (Ciechanowski et al., 2002; Dozier et al., 2001; Hunter & Maunder, 2001; McWilliams & Bailey, 2010; Vogel & Wei, 2005), management of self-aggressive behaviors (Gormley & McNiel, 2010), caring behaviors (Mikulincer et al., 2001; Mikulincer et al., 2003), and forgiveness (Burnette et al., 2007).

The presence of parental mental disorder and insecure attachment patterns may co-occur with additional household dysfunctions. Preventive measures that carefully assess the presence of additional household dysfunctions within families of psychiatric patients might be successful in reducing the risk of victimization, insecure attachment, and emotional distress for other family members, especially children (Neger & Prinz, 2015; Riggs, 2010; Waldmand-Levi, Finzi-Dottan, & Waintraub, 2015).

Conclusion

The study of mechanisms that may mediate/moderate the association between victimization and emotional distress increases the knowledge of factors that can be targeted for modification through intervention, reducing the risk and promoting the psychological adjustment (Barchia & Bussey, 2010; Karaszia, Berlin, Armstrong, Janick, & Darling, 2014; Whiffen & MacIntosh, 2005; Wright, 2007), within a developmental psychopathology framework (Cicchetti & Rogosch, 2002; Masten, 2006; Pynoos et al., 1999; Rutter & Sroufe, 2000). The screening for at-risk families, namely, families where there is violence, mental disorder, parental consumption behaviors, crime and incarceration, unemployment, and poverty (Arata, 2002; Ellonen & Salmi, 2011; Finkelhor et al., 2007; Gladstone et al., 2006; Hooven et al., 2012; Lauritsen & Carbone-Lopez, 2011; Maker et al., 2001; Maybery & Reupert, 2009; Romano, Bell, & Bilette, 2011; Reupert & Maybery, 2007; Turner et al., 2007), would allow to intervene to interrupt the intergenerational transmission of insecure attachment patterns and violence, promoting the healthy adjustment of all family members.

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

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Cristina dos Santos Mesquita is a PhD researcher at University of Minho, in the Applied Unity of Forensic Psychology. Her major focuses of investigation are interpersonal victimization experiences, psychiatric patients, health risk behaviors, and trauma exposure.

Ângela da Costa Maia is a professor at Minho University, with her research interests concerning victimization experiences, trauma and posttraumatic stress disorder (PTSD), and methodological considerations concerning the use of self-report measures.

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