Linking Childhood Maltreatment and Psychological Symptoms: The Role of Social Support,Coping Styles,and Self-Esteem in Adolescents

Abstract

Psychological symptoms are common among adolescents in China, which are associated with various negative consequences. There has been a pressing need for additional research of factors responsible for the occurrence of psychological symptoms during this developmental period, among which childhood maltreatment, personal coping style, one’s levels of social support, and self-esteem deserve our attention. The association between childhood maltreatment and psychological symptoms is evident; however, the possible mediating effect of the other three factors mentioned above remains unclear. Hence, the current study aims to investigate the possible mediating roles of social support, coping style, and self-esteem in the relationship between childhood maltreatment and the development of psychological symptoms among adolescents. An adolescent-based health survey was conducted between 2013 and 2014 in 15 schools in China. A total of 9,704 students (aged 11–19 years) were enrolled and measures on childhood maltreatment, social support, coping styles, self-esteem, and psychological symptoms were completed. It was found that childhood maltreatment was positively correlated with psychological symptoms and negative coping styles, and negatively correlated with social support, positive coping styles, and self-esteem (p < .001). Social support, coping styles, and self-esteem mediated the relationship between childhood maltreatment and psychological symptoms. The estimated effect of childhood maltreatment on the occurrence of psychological symptoms could be explained by the mediation of social support, positive coping styles, negative coping styles, and self-esteem, whose ratio of roles came to 13.8%, 7.5%, 20.9%, and 10.3%, respectively. These findings indicate a need to promote social support, self-esteem, and positive coping styles, and decrease the level of negative coping styles, to markedly reduce the impact of psychological symptoms of childhood maltreatment among adolescents.

Keywords

childhood maltreatment social support coping styles self-esteem psychological symptoms adolescents

Introduction

Psychological symptoms, including emotional symptoms (such as depression and anxiety), conduct symptoms (such as paranoid and aggressive behavior), and social adaptation symptoms (such as interpersonal difficulties and poor school adjustment), are prevalent among middle school students (Wan et al., 2015). Studies suggest that 10.2% to 21.4% of middle school students experienced psychological symptoms in China (Chen et al., 2019; Wan et al., 2015; Z. R. Zhang et al., 2018). Apart from the high prevalence, the negative consequences associated with psychological symptoms include increased nonsuicidal self-injuries, allergic diseases, substance use, and other clinically diagnosed diseases (Bierhoff et al., 2019; Gollust et al., 2008; Oh & An, 2019; Wan et al., 2015).

Childhood maltreatment in adolescence may have extensive effects on the presence of psychological symptoms (Wan et al., 2017). In a recent systematic review and meta-analysis, Hughes et al. (2017) found that adverse childhood experiences had marked correlation with mental ill health, as well as interpersonal and self-directed violence. Similarly, Badr et al. (2018) revealed that experiencing childhood physical and emotional maltreatment were independent contributors to the occurrence of depression and anxiety among both adolescents and young adults. A longitudinal study of 174 children indicated that those with higher levels of paranoid personality disorder symptoms in adolescence had higher rates of childhood maltreatment histories (Natsuaki et al., 2009). Bell and his colleagues (2018) suggest that all children with maltreatment allegations are at risk of poorer school readiness; apparently, these children may need additional support to increase their chances of successful school transitions. Taken together, these findings suggest that adolescents who report psychological symptoms may have already experienced more childhood maltreatment, but it remains unclear whether other factors may affect this relationship.

Our study applied the process-person-context-time model of ecological theory (Bronfenbrenner, 2005; Bronfenbrenner & Ceci, 1994) to examine the effect of childhood maltreatment on psychological symptoms of middle school students. Accordingly, we model the ways in which the stressful life events (such as childhood maltreatment) are associated with adolescents’ own personal capacities (such as coping styles and self-esteem) and proximal processes in the family and school domains (such as social support). Bronfenbrenner’s (2005) conceptualization of multiple personal characteristics and the significant, durative, and dynamic relations between children and their immediate environment are salient for studying the relationship between traumatic stress and mental health. Recent studies suggest that social support may be an important factor in understanding the development of psychological symptoms during adolescence. Haj-Yahia et al. reported that social support (support from friends) mediated the relationship between exposure to family violence during childhood and adolescent/current post-traumatic stress symptoms, that is, depression, sleep disturbances, dissociation, and anxiety (Haj-Yahia et al., 2019). Other studies found that social support, real or perceived, is of paramount importance in maintaining a person’s overall psychological well-being (Delli et al., 2019; Quirk et al., 2017). Together, these findings suggest a significant mediating role of social support in relationship between childhood maltreatment and psychological symptoms; however, additional studies are still in need. Another commonly studied factor in psychological symptoms is peoples’ individual coping styles, which may also play a mediating role in childhood maltreatment–psychological symptom relations. Several studies have elaborated the role of adverse childhood experiences (such as childhood abuse) in the development of a particular personality and coping style that “primed” people for later abnormal emotional and behavioral responses when confronted with reminders of their traumatic backgrounds (Power et al., 2018). Notably, childhood maltreatment experiences increase the probability of low self-esteem (Mwakanyamale et al., 2018), which may endanger individuals in a greater risk of further psychological symptoms (Freire & Ferreira, 2020; Kalemi et al., 2019). Kalemi et al. (2019) detected the association between lower self-esteem and higher levels of aggression among women. As mentioned above, the literature is consistent in identifying self-esteem as a crucial factor responsible for an increased risk of psychological symptoms, all relating to childhood maltreatment.

Based on literature review, it seems that each of the aforementioned risk factors may play an important role in understanding the etiology and risk levels of a person developing psychological symptoms in their lifetime. One shortcoming of the current literature, however, lies in the separate investigation of each factor in most studies, or in some cases, only of certain pairs of factors in relationships. Hayes and Rockwood (2017) recommend a value in testing multiple mechanisms when theory or hypothesis suggests a more complex process than that can be modeled with a single mediator. As far as we know, no study has sought to integrate all these factors into one conceptual model, followed by an empirical test in the same model. This study proposes for the first time a model on the risk of developing psychological symptoms during adolescence that integrates research findings regarding the associations between psychological symptoms and childhood maltreatment, with social support, coping styles, and self-esteem taken into account.

The research hypotheses are as follows: First, the relationships between childhood maltreatment, psychological symptoms, social support, individual coping styles, and self-esteem would be of significance. Second, social support, coping styles, and self-esteem would mediate the association between childhood maltreatment and psychological symptoms, based on the mediating model.

Method

Sample and Procedures

A total of 10,100 junior and senior middle school students (mean age = 15.60, SD = 1.80), ranging in age from 11 to 19 years old, were recruited in this study, using a health survey of adolescents in junior and senior middle schools (Grades 7–12) in two cities (Zhengzhou in Henan province and Guiyang in Guizhou province) in China. The participants were then asked to complete an anonymous questionnaire. Eight schools (four rural and four urban) were selected randomly from each city; all were either general junior or senior middle schools. As one was a combined junior and senior school, 15 schools were finally selected for inclusion within the survey. In every school, a cluster sampling method was used to extract four to six classes from each grade. The survey was conducted from November 2013 to January 2014. Due to an unwillingness to respond to the questionnaire, absence from school, high levels of missing data (a questionnaire with missing value >5% will be eliminated), or obviously fictitious responses, 396 (3.9%) participants were excluded from the study. The value of mode was employed to make up for a few missing items occasionally found. Although the missing values in the retrieved questionnaires were relatively small, some analysis was still performed on them (Widaman et al., 2013). For example, in the sixth item of the evaluation of psychological symptoms, there are 11 missing values. We analyzed the individuals with these 11 missing values separately and found that there are five boys, six girls; four only children, seven children with siblings; six urban households, and five rural households; the differences between boys–girls, only children–children with siblings, urban–rural were not statistically significant (p > .05). Thus, the data from 9,704 participants were analyzed.

The design and data collection procedures were both approved by the Ethics Committee of Anhui Medical University (2012534). Informed consent was gained from the parents or guardians of the students.

Measures

Psychological Symptoms

Psychological symptoms, experienced in the preceding 3 months, were examined by the psychological domain of the “Multidimensional Sub-health Questionnaire of Adolescents” (MSQA; Tao et al., 2009; Xing et al., 2008). The MSQA, including somatic pathological symptoms and psychological symptoms, was established for evaluation of the health status of adolescents, using the common questionnaire in China (Chen et al., 2019; Z. R. Zhang et al., 2018). The questionnaire consists of 39 questions in three dimensions as follows: emotional symptoms, conduct symptoms, and social adaptation symptoms. Emotional symptoms (including depression and anxiety symptoms, e.g., “Not enjoy anything at all,” “Blame yourself for things,” “Unable to relax when feeling tense”) were measured using the 17-item short questions for students. Conduct symptoms (including paranoid and hostile behaviors, e.g., “Feel like everyone’s against you,” “Often argue with others”) were measured using nine-item questions. Social adaptation symptoms (including bad relationships with family and friends, etc., e.g., “Feel uncomfortable in school life,” “Won’t seek for help when in trouble”) were measured using 13-item questions. The psychological domain showed good internal consistency (Cronbach’s α from .837 to .901), test–retest reliability (Cohen’s κ from 0.758 to 0.827), and split-half reliability coefficient (from r = .736 to .855). With Symptom Checklist-90 (SCL-90) as a criterion, the criterion-related validity was from 0.468 to 0.584 (Xing et al., 2008). The Cronbach’s α coefficients of the emotional, conduct, social adaptation, and psychological symptoms scale in this study were .901, .818, .856, and .920, respectively. Through this study, adolescents evaluated the severity of each criterion using a 6-point Likert-type scale, ranging from 1 to 6, where 1 = “none or lasting <1 week,” 2 = “lasting ≥1 week,” 3 = “lasting ≥2 weeks,” 4 = “lasting ≥1 month,” 5 = “lasting ≥2 months,” and 6 = “lasting ≥3 months.” Therefore, a higher score on the questionnaire indicated greater severity of the experienced psychological symptoms.

Social Support

Social support was assessed by the 17-item “Adolescent Social Support Scale” (Ye & Dai, 2008), which includes three dimensions: objective support, subjective support, and support availability. Participants reported whether an item from the scale reflected “strongly disagree,” “disagree,” “uncertainty,” “agree,” or “strongly agree.” The final scale scores were with a possible range of 17 to 85 (reflecting low to high social support levels, respectively), and Cronbach’s α coefficient was .940.

Coping Style

The Chinese Trait Coping Style Questionnaire (Jiang & Zhu, 1999) was used for assessment of positive coping (PC) and negative coping (NC) strategies of participants. The questionnaire contains two subscales: NC and PC. NC was measured using the 10-item short questions (e.g., “Be trapped in memories of events without getting rid of,” “Get angry with others and often get angry,” “Have mood swings easily caused by unpleasant things”) for students. PC was measured using 10-item questions (e.g., “Can forget the unpleasantness as soon as possible,” “Adapt quickly to difficulties and pains,” “Usually resolve embarrassing situations with humor”). Each subscale has 10 items, rated from 1 to 5, with higher scores indicating a greater intensity of the related coping style. In this study, Cronbach’s α coefficients for the PC and NC styles were .818 and .831, respectively.

Self-Esteem

Self-esteem was assessed using the Rosenberg Self-esteem Scale (Rosenberg, 1965). It consists of 10 items, each scored on a 4-point Likert-type scale, ranging from “strongly agree” to “strongly disagree.” Half of the items are positively worded and half negatively worded. The Rosenberg Self-esteem Scale is a widely used measure evaluating peoples’ self-esteem with high levels of reliability. The total scale scores have a range of 10 to 40 (reflecting low to high self-esteem, respectively). In this study, Cronbach’s α coefficient for this scale was .765.

Childhood Maltreatment

Childhood maltreatment was evaluated using the Child Trauma Questionnaire (CTQ; Bernstein et al., 1997), a commonly used 28-item measure that assesses five different forms of childhood trauma (including physical abuse, sexual abuse, emotional abuse, physical neglect, and emotional neglect). The CTQ has been translated and validated in Chinese (Zhao et al., 2005). The participants were asked about any abusive childhood experiences that occurred before the age of 16 years. Response scores ranged from 1 = “never true,” 2 = “rarely true,” 3 = “sometimes true,” 4 = “often true,” and 5 = “very often true.” A higher score reflected more serious levels of childhood maltreatment. Cronbach’s α coefficient for this particular childhood maltreatment scale was .745. Cronbach’s α coefficients of the emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect and childhood maltreatment scale in this study were .638, .725, .792, .813, and .672, respectively.

Covariates

This study also controlled participants’ age, only-child status (whether or not the participants’ possessed any siblings), parental educational level (less than junior middle school, junior middle school, senior middle school, college, or higher), perceived economic status of the family (poor, moderate, or good), and learning burdens, all of which may affect psychological symptoms experienced (Xing et al., 2008; Zhao et al., 2005).

Analyses

All data were analyzed using SPSS (Version 23.0). First, descriptive statistics were used for the assessment of childhood maltreatment, social support, coping styles, self-esteem, and psychological symptoms. Next, Pearson correlations were conducted to test the associations among childhood maltreatment, social support, coping styles, self-esteem, and psychological symptoms, followed by a multiple mediation analysis, using the PROCESS program of mediation, moderation, and conditional analyses (Hayes, 2013; Hayes & Rockwood, 2017). To examine any explanatory mechanisms underlying the significant factors of psychological symptom and childhood maltreatment as described above, the role of social support, PC styles, NC styles, and self-esteem as mediators was tested. Multiple mediation analysis was applied in simultaneous examination of multiple variables and their indirect effects. This analysis identifies any indirect effect by controlling all other possible mediators, while reducing the alpha inflation and investigating several indirect effects simultaneously, rather than in a series of single-mediator models (Preacher & Hayes, 2008). This approach uses bootstrapping to estimate all parameters. In the mediation analyses, the bootstrap procedure, with 5,000 repetitions, was used to verify the mediating effects of the aforementioned variables, with a confidence interval (CI) of 95%. The indirect effect is considered significant when the CI did not contain 0. Finally, gender difference (boys and girls) was considered in the mediatory role of social support, coping styles, and self-esteem in exploration of the relationship between childhood maltreatment and psychological symptoms.

Results

Descriptive statistics related to childhood maltreatment, social support, coping styles, self-esteem, and psychological symptom development are presented in Table 1. Bivariate correlations between the study variables are shown in Table 2. Pearson correlation analyses revealed significant associations between childhood maltreatment and psychological symptoms (p < .001), social support (p < .001), PC styles (p < .001), NC styles (p < .001), and self-esteem (p < .001). Compared with other types of abuse and neglect, emotional abuse bore a more obvious association with psychological symptoms (r = .30, p < .001). In addition, the analyses revealed significant correlations between psychological symptoms and social support (p < .001), PC styles (p < .001), NC styles (p < .001), and self-esteem (p < .001).

Table 1.

Descriptive Statistics for Variables.

Variables	Minimum	Maximum	M	SD
Emotional abuse	5	25	7.41	3.03
Physical abuse	5	25	6.20	2.54
Sexual abuse	5	25	5.76	2.33
Emotional neglect	5	25	10.93	5.64
Physical neglect	5	25	8.42	3.25
Childhood maltreatment	25	109	38.72	11.55
Social support	17	85	67.71	14.34
PC	10	50	31.34	7.76
NC	10	50	25.84	7.76
Self-esteem	0	30	18.27	4.85
Psychological symptoms	39.00	122	69.80	36.31

Note. PC = positive coping; NC = negative coping.

Table 2.

Correlations Among Childhood Maltreatment, Social Support, Coping Style, Self-Esteem, and Psychological Symptoms in Chinese Adolescents.

Variable	1	2	3	4	5	6	7	8	9	10	11
1. Emotional abuse	1	.57**	.45**	.15**	.28**	.63**	−.26**	−.03*	.30**	−.22**	.30**
2. Physical abuse		1	.51**	.13**	.28**	.61**	−.17**	−.02	.13**	−.10**	.18**
3. Sexual abuse			1	.11**	.25**	.55**	−.10**	−.02*	.08**	−.05**	.13**
4. Emotional neglect				1	.63**	.76**	−.24**	−.27**	.01	−.22**	.09**
5. Physical neglect					1	.77**	−.25**	−.20**	.04**	−.20**	.11**
6. Childhood maltreatment						1	−.32**	−.20**	.14**	−.25**	.22**
7. Social support							1	.25**	−.25**	.34**	−.26**
8. PC								1	.15**	.35**	−.12**
9. NC									1	−.29**	.37**
10. Self-esteem										1	−.27**
11. Psychological symptoms											1

Note. PC = positive coping; NC = negative coping.

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

Figure 1 shows a multiple mediation model in which social support, PC styles, NC styles, and self-esteem mediate the relationship between childhood maltreatment and psychological symptoms during adolescence. When the direct effect of childhood maltreatment on psychological symptoms was evaluated, controlling for the mediator variables, via Path “c,” it was found to be statistically significant (p < .001). The total effect (c) of the relationship between childhood maltreatment and psychological symptom was shown to be statistically significant (p < .001).

Figure 1.

Multiple mediation analyses of direct effect of the childhood maltreatment on the psychological symptoms for the mediators (social support, positive coping style, negative coping style, and self-esteem).

Subsequently, the standardized indirect effects within the relationship between childhood maltreatment and psychological symptoms were calculated to test the possible statistical significance of these mediators, as introduced by the model. Table 3 shows that, after adjusting all covariates (including age, gender, only-child status, parents’ educational level, family economic status, and learning burdens) in Model 2, a value of 0 was not included in the CI, indicating significant indirect effects. The effects of social support, PC styles, NC styles, and self-esteem accounted for 13.8%, 7.5%, 20.9%, and 10.3% of the total effect in the sample, respectively. Similarly, in Model 3, after adjusting participants’ age, only-child status, parents’ educational level, family economic status, learning burdens, the indirect effects of these variables took up 11.6%, 10.5%, 16.6%, and 12.9%, respectively, of the total effect among boys, whereas the ratios among girls were 16.9%, 4.0%, 25.7%, and 8.3%, respectively. NC styles had a stronger mediating effect than other mediators.

Table 3.

Mediating Effects of Social Support, Coping Style and Self-Esteem Between Childhood Maltreatment, and Psychological Symptoms.

Mediator	Model	a	b	Direct Effect	Boot CI		Indirect Effect	Boot CI		Mediation Ratio,%
Mediator	Model	a	b	c′	LLCI	ULCI	(a*b)	LLCI	ULCI	ab/(ab + c′)
Total
Social support	1	−0.392**	−0.053**	0.070**	0.057	0.082	0.021	0.015	0.026	14.2
Social support	2	−0.369**	−0.057**	0.073**	0.060	0.085	0.021	0.016	0.026	13.8
PC	1	−0.137**	−0.089**	0.070**	0.057	0.082	0.012	0.009	0.016	8.3
PC	2	−0.123**	−0.093**	0.073**	0.060	0.085	0.011	0.009	0.015	7.5
NC	1	0.093**	0.320**	0.070**	0.057	0.082	0.030	0.025	0.035	20.3
NC	2	0.108**	0.296**	0.073**	0.060	0.085	0.032	0.027	0.037	20.9
Self-esteem	1	−0.106**	−0.134**	0.070**	0.057	0.082	0.014	0.010	0.018	9.7
Self-esteem	2	−0.100**	−0.156**	0.073**	0.060	0.085	0.016	0.012	0.020	10.3
Boys
Social support	1	−0.351**	−0.044**	0.061**	0.043	0.079	0.016	0.009	0.022	11.8
Social support	3	−0.333**	−0.047**	0.065**	0.047	0.083	0.016	0.009	0.022	11.6
PC	1	−0.147**	−0.104**	0.061**	0.043	0.079	0.015	0.011	0.021	11.6
PC	3	−0.133**	−0.106**	0.065**	0.047	0.083	0.014	0.010	0.019	10.5
NC	1	0.090**	0.257**	0.061**	0.043	0.079	0.023	0.017	0.030	17.5
NC	3	0.096**	0.234**	0.065**	0.047	0.083	0.022	0.016	0.029	16.6
Self-esteem	1	−0.113**	−0.147**	0.061**	0.043	0.079	0.017	0.011	0.023	12.7
Self-esteem	3	−0.104**	−0.167**	0.065**	0.047	0.083	0.017	0.012	0.024	12.9
Girls
Social support	1	−0.428**	−0.063**	0.074**	0.055	0.093	0.027	0.018	0.036	15.9
Social support	3	−0.409**	−0.071**	0.077**	0.059	0.096	0.029	0.021	0.038	16.9
PC	1	−0.124**	−0.058**	0.074**	0.055	0.093	0.007	0.003	0.012	4.3
PC	3	−0.112**	−0.062**	0.077**	0.059	0.096	0.007	0.003	0.011	4.0
NC	1	0.118**	0.397**	0.074**	0.055	0.093	0.047	0.038	0.056	27.8
NC	3	0.121**	0.364**	0.077**	0.059	0.096	0.044	0.036	0.053	25.7
Self-esteem	1	−0.106**	−0.128**	0.074**	0.055	0.093	0.014	0.008	0.020	8.1
Self-esteem	3	−0.096**	−0.148**	0.077**	0.059	0.096	0.014	0.009	0.020	8.3

Note. CI = confidence interval; LLCI = lower level confidence interval; ULCI = upper level confidence interval; PC = positive coping; NC = negative coping.

a: Effect of CM on mediators.

b: Effect of mediators on psychological symptoms.

Model 1: Single factor analysis.

Model 2: Adjusted for age, gender, only-child status, parents’ education level, economic status of family, learning burden.

Model 3: Adjusted for age, only-child status, parents’ education level, economic status of family, learning burden.

p < .001.

Within the relationship between different types of childhood maltreatment and psychological symptom, the mediating effects of social support, PC styles, NC styles, and self-esteem are shown in Appendices 1 to 5. Social support, PC styles, NC styles, and self-esteem mediated the relationship between emotional abuse and psychological symptoms development, as well as the link between physical neglect and psychological symptoms. Social support, NC styles, and self-esteem mediated the relationship between physical and sexual abuse and psychological symptoms. No significant mediating factor was detected in the relationship between emotional neglect and psychological symptoms.

Discussion

The first objective of this study was to identify the relationships among psychological symptoms, childhood maltreatment, social support, coping styles, and self-esteem. The significant association values found between the different variables were, generally, in the expected directions. Childhood maltreatment bore a positive correlation with the development of psychological symptoms during adolescence, that is, the more childhood maltreatment, the more psychological symptoms. The results coincide with those of previous findings (Badr et al., 2018; Bell et al., 2018; Hailes et al., 2019; Natsuaki et al., 2009). Likewise, the positive relationship between childhood maltreatment and NC styles was confirmed, as consistently reported in the reviewed literature (Tao et al., 2006). Compared with other types of abuse and neglect, emotional abuse was more markedly associated with psychological symptoms. This finding is consistent with the research purporting that those experienced emotional abuse were at greater risk of developing mental disorders than those with other types of abuse or neglect (Norman et al., 2012). Childhood maltreatment, as expected, was significantly and negatively associated with social support, PC styles, and self-esteem. This result suggests that adolescents with childhood maltreatment tend to experience reduced PC styles, increased negative ones, decreased self-esteem levels, and are generally less confident in receiving social support.

The studied psychological symptoms in uncovered correlations basically support the hypotheses about the expected relationships. In addition to the link with childhood maltreatment, psychological symptoms were negatively associated with social support, PC styles, and self-esteem, corroborating the conclusions of the conducted systematic reviews and meta-analyses, which support the significant link between psychological symptoms, social support, PC styles, and self-esteem (Bohet et al., 2019; de Boer et al., 2017; Linden et al., 2020; Rückholdt et al., 2019). Moreover, psychological symptoms demonstrated a significant positive relationship with NC styles. H. Zhang et al. (2017) revealed that PC styles weaken the effect of negative life events on depressive symptoms in healthy older adults, which was contrary to the effect of negative ones.

However, the analysis of psychological symptoms should be considered from a more complex perspective than simple bivariate relationships. These relationships may be affected by a third variable, such as some mediators (Baron & Kenny, 1986), which can provide detailed information on how or why two variables are related at all. In fact, another objective of this study was to investigate the possible mediating roles of social support, coping styles, and self-esteem in the link between childhood maltreatment and psychological symptom development among adolescents. Due to the possible involvement of various mediators in the relationship between childhood maltreatment and psychological symptoms, it is more accurate and resourceful to include all of them in the same model to simultaneously investigate their various indirect effects, rather than using a series of single-mediator models (Preacher & Hayes, 2008). Huang et al. (2019) have confirmed higher risks of psychoses among individuals who have experienced childhood trauma, negative life events, and a lack of social support when compared with a healthy control group. A study on middle school students in Haikou City, China, indicated a negative correlation between the symptoms of adolescent depression and PC styles and a positive correlation with negative ones (Wang et al., 2018). A cross-sectional study showed the link between more childhood maltreatment and higher levels of psychopathology and lower levels of overall well-being under the regulation of self-esteem (Greger et al., 2017). Freire et al. proved that self-esteem can be a positive tool for adolescents to better manage, regulate, or minimize their psychological distress and to create higher levels of subjective happiness as a source of more positive mental health (Freire & Ferreira, 2020). Our findings substantiated the fitness of the ecological theory model (Bronfenbrenner, 2005; Bronfenbrenner & Ceci, 1994), by confirming that childhood maltreatment posed a risk of psychological symptoms among adolescents via its negative impact on their own characteristics (coping styles and self-esteem) and peer or parent relationships (social support). The results derived from multiple mediation model of the present study showed an apparent mediating role of social support, coping styles, and self-esteem in the relationship between childhood maltreatment and psychological symptom among adolescents. Evidently, childhood maltreatment leads to the development of a particular personality and coping style (Power et al., 2018), which could possibly include experiencing lower levels of social support, NC styles, and lower levels of self-esteem. All of this then primes individuals for later emotional and behavioral response problems, such as the aforementioned psychological symptoms. Another noteworthy point in the present study was the gender difference not observed in the mediating effects of social support, coping styles, and self-esteem in the relationship between childhood maltreatment and psychological symptoms.

NC styles were also found to exert a larger mediating effect than other mediation variables did for both boys and girls. Childhood maltreatment appears to have an indirect relationship with psychological symptoms that is more likely to be expressed via NC styles. However, in light of our findings and the extensive literatures of coping as well, it is of necessity to consider that individuals who experienced childhood maltreatment would use more NC strategies, leading to an elevated risk for mental health (Sheffler et al., 2019). These findings are consistent with research indicating that the negative effect of avoidant coping is especially well-documented in anxiety research, which demonstrates that avoidant and emotion-focused coping are closely related to anxiety disorders (Mennin et al., 2009; Panayiotou et al., 2017).

Childhood maltreatment may influence an individual’s view of themselves and their surrounding environments (Su et al., 2019); however, as social support, coping styles, and self-esteem are prone to constant changing, their perspectives could be modulated in a positive way, given the right tools. Thus, developing PC styles, enhancing an individual’s sense of social support and their self-esteem, especially for changing NC styles among the high-risk adolescent population, would prevent the occurrence of more psychological symptoms resulted from exposure to childhood maltreatment. This population is an important target for intervention, in addition to trauma therapy, when appropriate. Moreover, carried out among a large sample of Chinese adolescent students, the preliminary exploration in the study of the factors affecting the association between childhood maltreatment and psychological symptoms would hopefully provide a reference for future cohort studies.

The main contribution of this study, beyond the intrinsic importance of studying childhood maltreatment in relation to psychological symptoms in adolescents, lies in its revelation of the roles of social support, coping styles, and self-esteem in the relationship between these two factors. Besides, the large sample coverage of both urban and rural areas in China indicates better representativeness of the study. However, several limitations should also be noted when interpreting these results. First, the cross-sectional design of this study may induce vagueness in the temporal ordering of the variables. Children with lower social support, self-esteems, and NC styles were more likely to report psychological symptoms, with the associated depression negatively biasing their recall of childhood maltreatment. Second, the background of participants in this study were traditional school environments; as such, the findings did not represent adolescents absent from school, a point worth noticing, as childhood maltreatment, low self-esteem, low social support, NC styles, and psychological symptoms are more prevalent in individuals with lower educational achievements and socioeconomic statuses. Thus, the effects discovered by the current study may be underestimated. Third, with all participants from two cities in mainland China, the extent to which one can generalize these findings to adolescents in other countries or cultures needs further elaboration. Finally, the fact that psychological symptoms were investigated using a screening question instead of a specific psychometric instrument should be considered.

Conclusion

The mediating role of social support, coping styles, and self-esteem were all observed in the relationship between childhood maltreatment and psychological symptoms. Hopefully, these findings may have implications for the ways in which childhood maltreatment, coping styles, and self-esteem are incorporated into prevention and intervention programs of psychological symptoms in adolescents.

Footnotes

Appendix

Appendix E.

Mediating Effects of Social Support, Coping Style, and Self-Esteem Between Physical Neglect and Psychological Symptoms.

Mediator	Model	a	b	Direct Effect	Boot CI		Indirect Effect	Boot CI		Mediation Ratio,%
Mediator	Model	a	b	c′	LLCI	ULCI	(a*b)	LLCI	ULCI	ab/(ab + c′)
Total
Social support	1	−1.114**	−0.063**	0.076**	0.031	0.121	0.070	0.054	0.086	25.8
Social support	2	−1.022**	−0.066**	0.085**	0.040	0.130	0.068	0.052	0.083	23.3
PC	1	−0.487**	−0.097**	0.076**	0.031	0.121	0.047	0.036	0.060	17.5
PC	2	−0.439**	−0.100**	0.085**	0.040	0.130	0.044	0.034	0.055	15.2
NC	1	0.104**	0.327**	0.076**	0.031	0.121	0.034	0.017	0.052	12.6
NC	2	0.154**	0.305**	0.085**	0.040	0.130	0.047	0.031	0.064	16.2
Self-esteem	1	−0.292**	−0.148**	0.076**	0.031	0.121	0.043	0.032	0.055	16.1
Self-esteem	2	−0.270**	−0.171**	0.085**	0.040	0.130	0.046	0.035	0.058	15.9
Boys
Social support	1	−0.990**	−0.051**	0.066*	0.002	0.130	0.051	0.032	0.072	19.2
Social support	3	−0.919**	−0.054**	0.076*	0.012	0.140	0.050	0.032	0.070	18.5
PC	1	−0.547**	−0.112**	0.066*	0.002	0.130	0.061	0.044	0.082	23.3
PC	3	−0.501**	−0.114**	0.076*	0.012	0.140	0.057	0.041	0.077	21.3
NC	1	0.120**	0.264**	0.066*	0.002	0.130	0.032	0.012	0.053	12.0
NC	3	0.131**	0.242**	0.076*	0.012	0.140	0.032	0.013	0.051	11.8
Self-esteem	1	−0.328**	−0.164**	0.066*	0.002	0.130	0.054	0.037	0.074	20.4
Self-esteem	3	−0.293**	−0.184**	0.076*	0.012	0.140	0.054	0.038	0.073	20.0
Girls
Social support	1	−1.204**	−0.074**	0.070*	0.007	0.133	0.089	0.065	0.117	30.3
Social support	3	−1.128**	−0.082**	0.088*	0.026	0.151	0.093	0.069	0.119	29.7
PC	1	−0.418**	−0.064**	0.070*	0.007	0.133	0.027	0.013	0.042	9.1
PC	3	−0.375**	−0.068**	0.088*	0.026	0.151	0.026	0.013	0.039	8.2
NC	1	0.170**	0.406**	0.070*	0.007	0.133	0.069	0.040	0.099	23.3
NC	3	0.178**	0.374**	0.088*	0.026	0.151	0.066	0.039	0.094	21.3
Self-esteem	1	−0.286**	−0.141**	0.070*	0.007	0.133	0.040	0.026	0.058	13.6
Self-esteem	3	−0.245**	−0.161**	0.088*	0.026	0.151	0.039	0.026	0.055	12.6

Note. CI = confidence interval; LLCI = lower level confidence interval; ULCI = upper level confidence interval; PC = positive coping; NC = negative coping.

a: Effect of physical neglect on mediators.

b: Effect of mediators on psychological symptoms.

Model 1: Single factor analysis.

Model 2: Adjusted for age, gender, only-child status, parents’ education level, economic status of family, learning burden.

Model 3: Adjusted for age, only-child status, parents’ education level, economic status of family, learning burden.

p < .05; **p < .001.

Acknowledgments

We would like to acknowledge all school action teams, the staff and students from the participating schools, and our co-operators, including Guiyang and Zhengzhou School Children Health Clinic, for assistance in data collection.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for the project was provided by National Natural Science Foundation of China (81773453 and 81202223) and Natural Science Foundation of Anhui province (1708085QH223). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

ORCID iD

Yuhui Wan

Author Biographies

Shanshan Wang is studying for a master’s degree. Her research focuses on psychological behavior problems among adolescents. She is interested in exploring the adverse effects of childhood maltreatment on health and the prevention and control measures for childhood maltreatment, attempting to discover possible mechanisms.

Huiqiong Xu is studying for a master’s degree. Her research focuses on mental health of adolescents. She is interested in exploring the adverse effects of childhood maltreatment on mental health and improving the mental health of adolescents from the perspective of society and family.

Shichen Zhang, PhD, is an associate professor in the School of Public Health of Anhui Medical University. His research focuses on adolescent health literacy. She is interested in exploring factors that affect adolescent health literacy and a range of health problems associated with lower health literacy.

Rong Yang is studying for a master’s degree. Her research focuses on nonsuicidal self-injury of adolescents. She is interested in exploring the risk factors and protective factors of nonsuicidal self-injury behavior among adolescents,

Danlin Li is studying for a master’s degree. Her research focuses on development of adolescent health literacy questionnaire. She is interested in exploring the risk factors affecting adolescents’ health literacy and trying to develop a questionnaire that can better evaluate health literacy.

Ying Sun, PhD, is a professor in the School of Public Health of Anhui Medical University. His research focuses on physiological and psychological development during adolescence. She is interested in exploring physiological mechanisms in advance of puberty and possible causes of adolescent psychological and physiological developmental abnormalities.

Yuhui Wan, PhD, is an associate professor in the School of Public Health of Anhui Medical University. His research focuses on adverse childhood experiences among adolescents and its role on health problems and risky behaviors. He is interested in exploring the mediated variables and biological mechanisms between adverse childhood experiences and risky behaviors.

Fangbiao Tao, PhD, is a professor in the School of Public Health of Anhui Medical University. His research focuses on child and adolescent health. He is interested in exploring factors such as society, families, schools, and communities that affect children’s health, and exploring ways to improve children’s health in an all-round way.

References

Badr

H. E.

Naser

Al-Zaabi

Al-Saeedi

Al-Munefi

Al-Houli

Al-Rashidi

(2018). Childhood maltreatment: A predictor of mental health problems among adolescents and young adults. Child Abuse & Neglect, 80, 161–171. https://doi.org/10.1016/j.chiabu.2018.03.011

Baron

R. M.

Kenny

D. A.

(1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51(6), 1173–1182.

Bell

M. F.

Bayliss

D. M.

Glauert

Ohan

J. L.

(2018). School readiness of maltreated children: Associations of timing, type, and chronicity of maltreatment. Child Abuse & Neglect, 76, 426–439. https://doi.org/10.1016/j.chiabu.2017.12.001

Bernstein

D. P.

Ahluvalia

Pogge

Handelsman

(1997). Validity of the Childhood Trauma Questionnaire in an adolescent psychiatric population. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 340–348. https://doi.org/10.1097/00004583-199703000-00012

Bierhoff

Haardorfer

Windle

Berg

C. J.

(2019). Psychological risk factors for alcohol, cannabis, and various tobacco use among young adults: A longitudinal analysis. Substance Use & Misuse, 54(8), 1365–1375. https://doi.org/10.1080/10826084.2019.1581220

Bohet

Besson

Jardri

Manouvrier

Catteau-Jonard

Cartigny

Aubry

Leroy

Frochisse

Medjkane

(2019). Mental health status of individuals with sexual development disorders: A review. Journal of Pediatric Urology, 15, 356–366. https://doi.org/10.1016/j.jpurol.2019.04.010

Bronfenbrenner

(2005). Ecological systems theory (1992). In Bronfenbrenner

(Ed.), Making human beings human: Bioecological perspectives on human development (pp. 106–173). SAGE.

Bronfenbrenner

Ceci

S. J.

(1994). Nature-nurture reconceptualized in developmental perspective: A bioecological model. Psychological Review, 101(4), 568–586.

Chen

D. Y.

Zhou

Huang

Y. Y.

Wang

X. H.

(2019). Psychological sub-health status and its relationship with suicidal behaviors among middle school students in Shenzhen. Chinese Journal of School Health, 40(3), 381–383. https://doi.org/10.16835/j.cnki.1000-9817.2019.03.018

10.

de Boer

S. F.

Buwalda

Koolhaas

J. M

. (2017). Untangling the neurobiology of coping styles in rodents: Towards neural mechanisms underlying individual differences in disease susceptibility. Neuroscience & Biobehavioral Reviews, 74(Pt. B), 401–422. https://doi.org/10.1016/j.neubiorev.2016.07.008

11.

Delli

Z. G.

Sangiovanni

Brioni

Ratti

M. M.

Sciarrone

A. M.

Spotti

Manunta

Sarno

(2019). Psychological assessment of a sample of women with ADPKD: Quality of life, body image, anxiety and depression. Giornale Italiano di Nefrologia, 36(2), 2019-vol2.

12.

Freire

Ferreira

(2020). Do I need to be positive to be happy? Considering the role of self-esteem, life satisfaction, and psychological distress in Portuguese adolescents’ subjective happiness. Psychological Reports, 123(4), 1064–1082. https://doi.org/10.1177/0033294119846064

13.

Gollust

S. E.

Eisenberg

Golberstein

(2008). Prevalence and correlates of self-injury among university students. Journal of American College Health, 56(5), 491–498. https://doi.org/10.3200/JACH.56.5.491-498

14.

Greger

H. K.

Myhre

A. K.

Klockner

C. A.

Jozefiak

(2017). Childhood maltreatment, psychopathology and well-being: The mediator role of global self-esteem, attachment difficulties and substance use. Child Abuse & Neglect, 70, 122–133. https://doi.org/10.1016/j.chiabu.2017.06.012

15.

Hailes

H. P.

Danese

Fazel

(2019). Long-term outcomes of childhood sexual abuse: An umbrella review. Lancet Psychiatry, 6(10), 830–839. https://doi.org/10.1016/S2215-0366(19)30286-X

16.

Haj-Yahia

M. M.

Sokar

Hassan-Abbas

Malka

(2019). The relationship between exposure to family violence in childhood and post-traumatic stress symptoms in young adulthood: The mediating role of social support. Child Abuse & Neglect, 92, 126–138. https://doi.org/10.1016/j.chiabu.2019.03.023

17.

Hayes

A. F.

(2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. The Guilford Press.

18.

Hayes

A. F.

Rockwood

N. J.

(2017). Regression-based statistical mediation and moderation analysis in clinical research: Observations, recommendations, and implementation. Behaviour Research and Therapy, 98, 39–57. https://doi.org/10.1016/j.brat.2016.11.001

19.

Huang

Z. H.

Hou

C. L.

Huang

Y. H.

X. Y.

Wang

Q. W.

Chen

Wang

Z. L.

Wang

S. B.

Jia

F. J.

(2019). Individuals at high risk for psychosis experience more childhood trauma, life events and social support deficit in comparison to healthy controls. Psychiatry Research, 273, 296–302. https://doi.org/10.1016/j.psychres.2019.01.060

20.

Hughes

Bellis

M. A.

Hardcastle

K. A.

Sethi

Butchart

Mikton

Jones

Dunne

M. P.

(2017). The effect of multiple adverse childhood experiences on health: A systematic review and meta-analysis. Lancet Public Health, 2(8), e356–e366. https://doi.org/10.1016/S2468-2667(17)30118-4

21.

Jiang

Q. J.

Zhu

Y. H.

(1999). Further explorations for a coping style questionnaire. Chinese Journal of Behavioral Medical Science, 8, 167–169.

22.

Kalemi

Michopoulos

Efstathiou

Tzeferakos

Gkioka

Gournellis

Douzenis

(2019). Self-esteem and aggression in women: Differences between female prisoners and women without criminal records. Women & Health, 59, 1199–1211. https://doi.org/10.1080/03630242.2019.1593284

23.

Linden

M. A.

O’Rourke

Lohan

(2020). Traumatic brain injury and social competence among young male offenders. Disability and Rehabilitation, 42(17), 2422–2429. https://doi.org/10.1080/09638288.2019.1629699

24.

Mennin

D. S.

McLaughlin

K. A.

Flanagan

T. J.

(2009). Emotion regulation deficits in generalized anxiety disorder, social anxiety disorder, and their co-occurrence. Journal of Anxiety Disorders, 23(7), 866–871. https://doi.org/10.1016/j.janxdis.2009.04.006

25.

Mwakanyamale

A. A.

Wande

D. P.

Yizhen

(2018). Multi-type child maltreatment: Prevalence and its relationship with self-esteem among secondary school students in Tanzania. BMC Psychology, 6(1), Article 35.

26.

Natsuaki

M. N.

Cicchetti

Rogosch

F. A.

(2009). Examining the developmental history of child maltreatment, peer relations, and externalizing problems among adolescents with symptoms of paranoid personality disorder. Development and Psychopathology, 21(4), 1181–1193. https://doi.org/10.1017/S0954579409990101

27.

Norman

R. E.

De Byambaa

M. R.

Butchart

Scott

Vos

(2012). The long-term health consequences of child physical abuse, emotional abuse, and neglect: A systematic review and meta-analysis. PLOS Medicine, 9(11), Article e1001349. https://doi.org/10.1371/journal.pmed.1001349

28.

(2019). Depressive symptoms, emotional aggression, school adjustment, and mobile phone dependency among adolescents with allergic diseases in south Korea. Journal of Pediatric Nursing, 47, e24–e29. https://doi.org/10.1016/j.pedn.2019.04.010

29.

Panayiotou

Karekla

Leonidou

(2017). Coping through avoidance may explain gender disparities in anxiety. Journal of Contextual Behavioral Science, 6(2), 215–220. https://doi.org/10.1016/j.jcbs.2017.04.005

30.

Power

Hannigan

Coen

Bruce

Gibb

McCarthy

Robinson

Lawlor

B. A.

(2018). Prosopagnosia as a type of conversion disorder. Case Reports in Psychiatry, 2018, Article 5972954. https://doi.org/10.1155/2018/5972954

31.

Preacher

K. J.

Hayes

A. F.

(2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40(3), 879–891.

32.

Quirk

Crank

Harrop

Hock

Copeland

(2017). Understanding the experience of initiating community-based physical activity and social support by people with serious mental illness: A systematic review using a meta-ethnographic approach. Systematic Reviews, 6(1), Article 214. https://doi.org/10.1186/s13643-017-0596-2

33.

Rosenberg

(1965). Rosenberg self-esteem scale (RSE). Acceptance and commitment therapy. Measures Package, 61, Article 52.

34.

Rückholdt

Tofler

G. H.

Randall

Buckley

(2019). Coping by family members of critically ill hospitalised patients: An integrative review. International Journal of Nursing Studies, 97, 40–54. https://doi.org/10.1016/j.ijnurstu.2019.04.016

35.

Sheffler

J. L.

Piazza

J. R.

Quinn

J. M.

Sachs-Ericsson

N. J.

Stanley

I. H.

(2019). Adverse childhood experiences and coping strategies: Identifying pathways to resiliency in adulthood. Anxiety, Stress & Coping, 32(5), 594–609. https://doi.org/10.1080/10615806.2019.1638699

36.

D’Arcy

Yuan

Meng

(2019). How does childhood maltreatment influence ensuing cognitive functioning among people with the exposure of childhood maltreatment? A systematic review of prospective cohort studies. Journal of Affective Disorders, 252, 278–293. https://doi.org/10.1016/j.jad.2019.04.026

37.

Tao

F. B.

Huang

Kim

Sun

Zhang

C. Y.

Zhou

Y. S.

P. Y.

Zhu

(2006). Correlation between psychopathological symptoms, coping style in adolescent and childhood repeated physical, emotional maltreatment. Zhonghua er ke za zhi, 44(9), 688–693.

38.

Tao

F. B.

Xing

Yuan

C. J.

(2009). Development of national norm for Multidimensional Sub-health Questionnaire of Adolescents (MSQA). Chinese Journal of School Health, 30(4), 292–295.

39.

Wan

Y. H.

S. S.

S. J.

Zhang

S. C.

Hao

J. H.

Tao

F. B.

(2017). Study of association between adverse experiences in childhood, social support, and physical and psychological sub-health status among middle school students in 3 cities in China. Chinese Journal of Preventive Medicine, 51(9), 786–791. https://doi.org/10.3760/cma.j.issn.0253-9624.2017.09.003

40.

Wan

Y. H.

S. J.

Chen

C. L.

Tao

F. B.

(2015). Longitudinal effects of psychological symptoms on non-suicidal self-injury: A difference between adolescents and young adults in China. Social Psychiatry and Psychiatric Epidemiology, 50(2), 237–247. https://doi.org/10.1007/s00127-014-0917-x

41.

Wang

Yang

Zhu

(2018). Correlation between life events, coping styles and depression of adolescents in Haikou City in 2015. Wei Sheng Yan Jiu = Journal of Hygiene Research, 47(6), 942–946.

42.

Widaman

K. F.

Grimm

K. J.

Early

D. R.

Robins

R. W.

Conger

R. D.

(2013). Investigating factorial invariance of latent variables across populations when manifest variables are missing completely. Structural Equation Modeling, 20(3), 384–408. https://doi.org/10.1080/10705511.2013.797819

43.

Xing

Tao

F. B.

Yuan

C. J.

Wan

Y. H.

X. U.

C. L.

Hao

J. H.

Yao

R. Y.

(2008). Evaluation of reliability and validity of the multidimensional sub-health questionnaire of adolescents. Chinese Journal of Public Health, 24(9), 1031–1033.

44.

Dai

(2008). Development of social support scale for university students. Chinese Journal of Clinical Psychology, 16, 456–458.

45.

Zhang

Gao

Kong

Wang

Mei

(2017). A comparative study of negative life events and depressive symptoms among healthy older adults and older adults with chronic disease. International Journal of Social Psychiatry, 63(8), 699–707. https://doi.org/10.1177/002076401773654

46.

Zhang

Z. R.

Liang

J. Z.

Zhang

J. X.

(2018). State of psychological sub-health and influencing factors of middle school students in three regions of China. Chinese Journal of School Health, 39(7), 1030–1032. https://doi.org/1016835/j.cnki.1000-9817.2018

47.

Zhao

X. F.

Zhang

Y. L.

L. F.

Zhou

Y. F.

H. Z.

Yang

S. C.

(2005). Reliability and validity of the Chinese version of Childhood Trauma Questionnaire. Chinese Journal of Clinical Rehabilitation, 9, 105–107.