Abstract
Childhood maltreatment (CM) has long been recognized as a risk factor for good intimate relationships. Research on the effects of CM on relationship functioning has focused on sexual abuse in girls. However, CM also includes emotional and physical abuse and neglect and is also common in boys. Moreover, prior research has mostly focused on individuals in isolation, ignoring that marriage is a system in which two partners mutually influence each other. Questions also remain about mediating and protective factors for healthy relationships in the context of CM. This article reviews the literature on the link between different forms of CM and one’s own and one’s partner relationship quality. It reviews 43 empirical studies that assessed associations between CM in any form and relationship quality. Also, mediating and protective factors and major methodological topics are examined. The review indicated that CM (neglect, sexual, emotional, or physical abuse) is associated with lower relationship quality in men and women. Psychological distress, cognitive and behavioral problems, insecure attachment, and self-dysregulation were identified as mediating factors. Protective processes involve good coping strategies, emotion regulation, parental support, and early secure attachment, but not partner characteristics. The results regarding gender are inconclusive. It is crucial to broaden the research on the dyadic effects of CM of various forms on relationship quality and study mediating and protective factors. More studies on neglect and diverse populations are needed, as well as prospective studies. This will enable the development of prevention programs for couples with a partner exposed to CM.
Childhood maltreatment (CM) is a global public health concern. A recent meta-analysis documented a high prevalence of CM in nonclinical populations worldwide (23% physical abuse, 13% sexual abuse, 36% emotional abuse, 16% physical neglect, and 18% emotional neglect; Stoltenborgh et al., 2015). Considerable research points to the adverse effect of CM on adult relationship quality (RQ; for a review, see Nielsen et al., 2018). CM survivors are six times more likely than non-CM to experience marital difficulties (McCarthy & Taylor, 1999) including intimate partner violence (IPV; for a review, see Li et al., 2019), restricted intimacy, more conflicts (Fleming et al., 1999; Kim et al., 2009), lower levels of marital satisfaction (Liang et al., 2006), and a greater likelihood of divorce (Colman & Widom, 2004).
Marital discord predicts poor mental (Choi & Marks, 2008) and physical health (Robles et al., 2014), parenting dysfunction, and child maladjustment (Conger et al., 1992). It is, therefore, crucial to identify mediating and protective factors involved in the link between CM and RQ. This knowledge can advance the development of prevention programs targeting RQ in adults exposed to CM. Also, although heavy attention has been paid to the effects of child sexual abuse (CSA) on RQ in women, similar effects have been detected in other forms of CM and also in men (Davis et al., 2001; DiLillo et al., 2009). Moreover, theory and research mostly focused on the effects of CM on one’s marital functioning, while overlooking that marriage is a system within which mutual processes affect the two dyad members (Kelley & Thibaut, 1978). This literature review has two main aims: first, to identify the effects of different types of CM on one’s own and one’s partner’s RQ in men and women and, second, to identify mediating and protective factors involved in these effects. The review will also evaluate several key methodological issues.
Definitions
CM refers to sexual, physical, and emotional abuse (CSA, CPA, and CEA, respectively) and physical and emotional neglect (CPN and CEN, respectively) occurring under the age of 18 in a relationship of responsibility, trust, or power resulting in actual or potential harm to the child’s health, survival, development, or dignity (World Health Organization, 2016). Specifically, CM includes (a) CPA, the intentional use of physical force that can result in physical injury; (b) CSA, referring to pressuring or forcing a child to engage in sexual acts (e.g., fondling, penetration); (c) CEA, referring to behaviors that harm a child’s self-worth or emotional well-being (e.g., name-calling, shaming, rejection); and (d) neglect, referring to a failure to provide a child’s basic physical and emotional needs (e.g., housing, food; Centers for Disease Control and Prevention, 2020).
RQ is conceptualized in various ways, some of which consider RQ as the way romantic partners globally evaluate their relationship in terms of satisfaction or happiness. A more dominant approach, the marital adjustment school, defines RQ as the characteristics of a couple’s relationship including communication (i.e., the expressed behaviors when a couple is interacting, such as care, warmth, disagreements, control; Kelly et al., 2003) and intimacy (i.e., the emotional closeness a person feels toward his partner; Glenn, 1990; Miller & Lefcourt, 1982). The current study adopts a broad definition of RQ comprising the two approaches.
Mediating factors refer to elements that underlie the effects of CM on RQ, in that they are outcomes of CM that predict low RQ. Protective factors are the elements that buffer against or moderate the effects of CM on RQ or qualities that are more frequent among those who experienced CM but exhibit healthy intimate relationships (Gutman et al., 2002).
A Theoretical Model: The Couple Adaptation to Traumatic Stress (CATS)
CM is recognized as a complex trauma, which refers to chronic and prolonged stressors including physical or psychological threats, mostly occurring in a child’s caregiving system (Courtois & Ford, 2012; van der Kolk et al., 2005). Therefore, this review employs the CATS model (Goff & Smith, 2005) as a theoretical framework. The CATS is a trauma-informed model that combines a systemic approach, family stress models, and attachment theory to elucidate dyadic processes of mediating and protective factors for poor RQ in couples exposed to CM. Specifically, the long-term complications of CM include emotional (e.g., depression or anxiety, anger), behavioral (e.g., risky behaviors, substance abuse), cognitive (e.g., dissociation, biased perceptions of the self and others), and biological symptoms. Trauma-related distress, in turn, can be transmitted to the spouse. This process is circular, such that the trauma-related distress of each partner can intensify the other’s symptoms, with each partner’s symptoms disrupting RQ in terms of happiness or satisfaction, intimacy, and communication. The CATS model outlines several mediating mechanisms for disrupted RQ when a partner is exposed to trauma including (a) elevated physiological arousal associated with trauma-related distress that triggers negative communication, avoidance of intimacy, or IPV; (b) living with a distressed partner that can intensify distress in the other partner; (c) post-traumatic symptoms of CM survivors that obstruct their capacity to respond to their partner’s attachment needs and develop a secure attachment bond; and (d) identification with the trauma victim that intensifies distress in the identifying partner.
The CATS model postulates that some individuals may grow from CM and establish healthy intimate relationships. In this process, personal (e.g., psychological characteristics, financial resources, education, coping strategies), interpersonal or social (e.g., partner or family support), and societal resources (e.g., legal or welfare systems) can facilitate adaptive coping with CM and its complications and promote successful relationships (Goff & Smith, 2005).
Methodological Issues
In line with the CATS model postulating inter- and intrapersonal effects of CM on RQ (Goff & Smith, 2005), the current review assessed whether studies employed a dyadic design and whether the sample included couples or individuals. Also, to assess the effects of CM on men and women, the gender of the participants was recorded. The sample type (clinical, community, or college sample) was also recorded. The diversity in the population may be underrepresented in college samples. Moreover, compared with nonclinical samples, clinical samples may display greater emotional distress, which is a major mediating factor involved in the link between CM and RQ (Goff & Smith, 2005). Lastly, research in the field of CM and RQ mostly employed cross-sectional designs (for a review, see Li et al., 2019), which are subject to recall bias. The review, therefore, examined the use of prospective versus retrospective cross-sectional designs.
The Current Study
Creating healthy intimate relationships is a major developmental task in adulthood that many CM victims find difficult to achieve (Cole & Putnam, 1992). The CATS model offers a systematic mediating mechanism for the dyadic effects of CM on RQ. It also suggests that personal, interpersonal, and societal resources can protect against the adverse effects of CM on RQ (Goff & Smith, 2005). The current study aims to investigate the status of the extant empirical literature on (a) the effects of different forms of CM on one’s own and one’s partner’s RQ in men and women and (b) mediating and protective factors for these effects. The current study will also evaluate methodological issues in the reviewed studies.
Method
This review focuses on quantitative empirical literature examining the effects of CM on RQ and mediating and protective factors. First, inclusion and exclusion criteria that were consistent with the goals of the review were determined. Inclusion criteria were (1) at least one measure of CM; (2) at least one measure of adult RQ (over the age of 18) as an outcome variable; and (3) CM was committed by the age of 18. Exclusion criteria were (a) clinical trial studies; (b) literature reviews and meta-analyses; (c) qualitative studies, excluded because they are more descriptive in nature and do not formally examine mediating and protective factors; and (d) the outcome variable was IPV, excluded because the effects of CM on IPV have been extensively and recently reviewed (Cascardi & Jouriles, 2016; Kuijpers et al., 2011; Li et al., 2019; Smith-Marek et al., 2015).
Literature Search
The literature search included articles published through October 2019 that were identified using a Boolean operator in a wide variety of database searches. These databases included HBSCO ERIC, Family Studies Abstracts, Violence and Abuse Abstracts, Social Work Abstracts, Medline, Psych Info, and Psych Articles. The initial search was conducted during the winter of 2018 using the following keywords: “Child Abuse” or “Neglect” or “Maltreatment” or “Child Sexual Abuse” or “Child Physical Abuse” or “Child Emotional Abuse” or “Family of Origin” and “Relationship Satisfaction” or “Marital Satisfaction” or “Marital Adjustment” or “Intimate Relationship” or “Communication” or “Couple Interaction” or “Marital Functioning” or “Intimacy.” The search was restricted to articles written in English and, for quality purposes, subjected to external peer review (e.g., dissertations were excluded). I also obtained studies that were not identified in the database searches from the reference lists of previously identified articles and reviews or meta-analyses identified in the initial search. In early 2020, I reran the search for newly released articles that may not have been indexed in the databases. Of the 19 new releases, none met the screening criteria. The search yielded 4,089 articles. After duplication removal (907), all abstracts and titles of the remaining 3,182 items were screened, from which 217 items appeared to meet the inclusion criteria. Next, full articles were reviewed, and 43 articles were carefully chosen based on the inclusion criteria. Once obtained, all articles were vetted again for fit. In the final count, 43 papers were identified.
Coding
The coding system was designed to capture child abuse types, mediating factors, and protective factors. To provide a comprehensive review, the coding of mediating and protective factors included factors presented in the CATS model and other factors that were found in the literature. Specifically, in line with the CATS model, mediating factors included psychological distress, cognitive, behavioral, or biological factors, attachment, and self-regulation. Also, in line with the CATS model, personal, interpersonal, and societal protective factors were coded with subcategories of the research topics. The review did not include demographic factors because a reliable test for these factors requires representative samples, which have rarely been used. Table 1 catalogs the papers included in this review by forms of CM, sample type (i.e., gender, individuals or couples, and community, college, or clinic sample) and size, and mediating and protective factors. Studies were coded also for study design (cross-sectional or prospective) and analysis (dyadic or individual data analysis).
Summary of the Reviewed Studies by Maltreatment Type, Sample Type, and Mediating and Protective Factors.
Note. CSA = child sexual abuse; CPA = child physical abuse; CEA = child emotional abuse; CEN = child emotional neglect; CPN = child physical neglect.
Results
Table 1 shows that all forms of CM were tested in relation to RQ, either directly or indirectly, including CEA (11), CPA (13), CSA (26), CPN (3), CEN (3), or total CM (9). Of the 43 articles, 17 used a sample of only women and 26 studies used a sample of men and women, 10 of which used samples of couples. The majority of the studies used community samples (27), although some used college students (10) or clinical samples (6).
Our review yielded 17 articles testing mediating factors and 18 articles testing protective factors. Five domains of mediating factors were identified as follows: psychological distress (seven) cognitive factors (six), behavioral problems (five), insecure adult attachment (five), and self-regulation (two). Protective factors included three personal characteristics, including gender (eight), coping strategies (three), and emotion regulation (three), and three interpersonal resources, including parental support (one), attachment style to a parent (one), and partner characteristics (one).
The vast majority of the studies used a cross-sectional design (34) and a few studies (nine) used a longitudinal design, four of which measured childhood abuse prospectively. Lastly, only nine studies employed dyadic data analysis, whereas the rest used individual-level data analysis.
Association Between CM and RQ by Type of Abuse
CEA
The link between CEA and lower marital satisfaction has been shown in several cross-sectional studies in newlywed couples (Perry et al., 2007) and women involved in an intimate relationship (Bigras et al., 2015). CEA also predicted lower communication quality for women only. Women who experienced CEA were more domineering and distant in their interactions with their romantic partners (Paradis & Boucher, 2010). Moreover, each partner’s greater CEA was associated with their own and their partner’s lower relationship satisfaction (Maneta et al., 2015; Riggs et al., 2011).
In contrast, a longitudinal study that followed newlywed couples for 2 years found that CEA predicts a greater decrease in marital satisfaction only in men (DiLillo et al., 2009). Furthermore, the link between CEA and marital dissatisfaction was nullified once controlling for CSA and CPA (Bradbury & Shaffer, 2012) as well as adult attachment, relationship length, and gender (Riggs & Kaminski, 2010).
CPA
Several studies indicated that CPA is linked with a range of relationship difficulties including ineffective communication, lower intimacy, and less relationship stability in men and women who turned to mental health services (Larsen et al., 2011). Moreover, assessments of CPA from birth to the age of 17.5 in a low socioeconomic status (SES) sample predicted lower relationship competence, a composite of self-reported relationship satisfaction, interviews assessing relationship functioning, and observed couple communication in ages 20–32. Also in the same study, the chronicity of CPA and maternal abuse (compared with paternal or nonparental abuse) predicted lower RQ. This was true even after controlling for gender, ethnicity, SES, and maternal education (Labella et al., 2017). In another study, spouses reporting CPA rated their partners’ communication as less supportive and more negative compared to spouses without a history of abuse (Whisman, 2014). Similarly, in a large sample of couples, if at least one partner reported CPA, both partners rated their own and their partner’s communication as more negative compared with couples without a history of abuse (Busby et al., 2011).
Other studies found the effects of CPA on RQ only in men. CPA in men was associated with communication problems, including being more domineering, distant, and self-sacrificing (Paradis & Boucher, 2010), as well as with greater marital conflict (Belt & Abidin, 1996) and lower relationship satisfaction (DiLillo et al., 2009).
When controlling for sexual abuse, CPA did not predict marital dissatisfaction concurrently (Whisman, 2006) or over time in newlyweds (DiLillo et al., 2009). Furthermore, surprisingly, a prospective study using court records of CPA and neglect found that physically abused boys, but not girls, were more likely than their nonabused counterparts to rate their romantic relationships as high in warmth and support (Colman & Widom, 2004).
CSA
CSA exposure or severity is a significant risk factor for lower satisfaction in men (Dunlop et al., 2015; Hunter, 1991; Tardif-Williams et al., 2017; Whisman, 2006) and women (DiLillo & Long, 1999; Lassri et al., 2018). Women reporting CSA indicated more avoidance of intimacy and less disclosing personal concerns, more control, and lower care of their intimate partners (Mullen et al., 1994). CSA predicted a 2.2-fold increase in the odds of low care (Fleming et al., 1999). CSA is associated with both the victims’ and their partners’ lower marital satisfaction and more volatile conflict resolution style (Knapp et al., 2017).
In a prospective study, reports of CSA at the ages of 18–21 predicted lower RQ in men and women at age 30 (Friesen et al., 2010). Also, a study using hospital records of CSA found that genital penetration, oral, or anal assaults in childhood predicted lower marital satisfaction in women (Liang et al., 2006). Another prospective study used court-substantiated CSA records and found that sexually abused girls, but not boys, reported on less warm and supportive relationships compared to nonabused girls (Colman & Widom, 2004).
The characteristics of CSA are also major predictors of RQ. CSA exposure increases the odds for marital discord, indexed by less warm and more controlling relationships, for all CSA victims by 4.01, but for victims of genital CSA by 4.14 and for victims of intercourse CSA by 4.74 (Romans et al., 1997). Also, women without a history of CSA reported greater relationship satisfaction when compared with women reporting contact CSA, but not when compared with women reporting noncontact CSA (Feinauer et al., 1996). Furthermore, CSA that ended at an older age was associated with lower relationship satisfaction in women (Wright et al., 2007), but there was no difference in marital satisfaction when comparing extra- versus intrafamilial rape, or isolated CSA events versus continuing abuse (Whisman, 2006).
Despite the above findings linking CSA with lower RQ, other studies indicated otherwise. CSA was not linked to marital dissatisfaction in a clinical sample of married women (Holeman & Myers, 1998) and other cross-sectional or longitudinal studies (DiLillo et al., 2009; Labella et al., 2017; Testa et al., 2005). Other studies provided mixed findings. When compared with a CSA group, women indicating no CSA reported greater past, but not current RQ (Davis et al., 2001). Moreover, the effects of CSA on women’s relationship satisfaction were nullified once controlling for adult attachment style and relationship length (Riggs & Kaminski, 2010).
Neglect
Studies assessing the effects of physical or emotional neglect on RQ are scarce. Emotional neglect is associated with lower marital satisfaction and predicted a decline in marital satisfaction in a 2-year follow-up assessment in newlywed couples (DiLillo et al., 2009). Furthermore, emotional neglect in male and female students was significantly associated with being nonassertive and submissive in intimate relationships (Paradis & Boucher, 2010). Lastly, a prospective cohort study found that physically neglected girls, but not boys, were less likely than their nonneglected counterparts to report lower RQ (Colman & Widom, 2004).
Total CM
A total composite of CM history, comprised of at least two forms of CM, has been linked with women’s (Zamir & Lavee, 2014, 2015, 2016) and men’s lower RQ and predicts a decline in women’s marital satisfaction over the first years of marriage (Nguyen et al., 2017). Women who experienced CPA, CSA, or CEA are six times more likely to report more arguments compared with a nonabused group (McCarthy & Taylor, 1999). Also, a history of CM is associated with more problems in intimacy for female students (DiLillo et al., 2007). In one study, if at least one partner indicated sexual and/or physical CM, the marital satisfaction of couples undergoing treatment was lower (Nelson & Wampler, 2000). However, no such dyadic effects were observed between CSA or CPA and marital satisfaction in newlywed couples (Nguyen et al., 2017), and total CM was not associated with one’s intimacy and affection in a cross-sectional study of women (Rellini et al., 2012).
Mediating Factors
Psychological distress
Several studies identified psychological distress as a mediating factor. Psychological distress partly mediated the links between CPA and low RQ and satisfaction with intimacy in men and women (Dunlop et al., 2015; Tardif-Williams et al., 2017). Other studies indicated that only in men, psychological distress accounted for the link between CPA and lower marital satisfaction concurrently (Godbout et al., 2006) and over the first 2 years of marriage (DiLillo et al., 2009).
When testing the relationship between total CM and lower intimacy in past relationships, psychological distress served as a mediator only in women (DiLillo et al., 2007). Also, only in women, CSA was associated with greater psychological distress, which in turn was associated with lower relationship satisfaction (Godbout et al., 2006). When controlling for childhood adversities and violence in the family of origin, retrospective reports on CSA were associated with a more negative perception of childhood events. The latter was associated with more depression and more emotional flooding during conflicts, which in turn was associated with lower satisfaction in men and women (Walker et al., 2009).
Different patterns between genders were also found in research on CEA. Broad psychological distress or paranoia mediated the link between CEA and lower marital satisfaction only in men (Godbout et al., 2006; Perry et al., 2007). However, in newlywed women, greater obsessive–compulsive tendencies and hostility mediated the link between CEA and lower marital satisfaction (Perry et al., 2007).
Cognitive factors
Two studies failed to find a significant mediating effect of self-esteem in the link between CM and marital outcomes. These results were evident when testing the link between CSA, CPA, or CEA and relationship communication in a retrospective study on women (McCarthy & Taylor, 1999). Also in a longitudinal study tracking individuals from birth to the age of 30, the link between CSA severity and lower marital satisfaction was not mediated by self-esteem assessed at age 15 (Friesen et al., 2010). However, dysfunctional self-capacities, specifically identity impairment (i.e., incapacity for self-awareness and identity diffusion), significantly mediated the association between exposure to CEA and poorer dyadic satisfaction in women (Bigras et al., 2015). Additionally, self-criticism mediated the link between CSA and a decline in relationship satisfaction across 6 months in Israeli women (Lassri et al., 2018).
Biased attribution of a partner’s behavior was not found to underlie the link between CM and low RQ in a retrospective study assessing associations between CSA, CPA, and CEA and communication in women (McCarthy & Taylor, 1999) as well as in a prospective study assessing the effects of CPA and CEA on positive couple communication in adulthood in African American children from low-income families (Gordon Simons et al., 2014).
Finally, CEA in women was associated with their lower ability to accurately identify their partner’s negative emotional state (i.e., empathic accuracy), which in turn was cross-sectionally associated with their own and their partner’s lower marital satisfaction (Maneta et al., 2015).
Behavioral factors
First, risky behaviors play a mediating role in the effects of childhood abuse on RQ. In a study following men and women from birth to the age of 30, the effect of CSA severity on marital satisfaction was fully mediated by greater numbers of sexual partners or cohabiting relationships (controlling for physical punishment in childhood). However, early consensual sexual intercourse or substance abuse did not mediate this effect (Friesen et al., 2010). Another longitudinal study of randomly selected women showed that the severity of CSA was associated with women’s affiliation with more aggressive partners and with a greater number of lifetime sexual partners, which were in turn associated with lower RQ. These results were replicated in three analyses, one cross-sectional and two longitudinal across 1 and 2 years with different partners at each time point (Testa et al., 2005).
Second, hostile behaviors in intimate relationships appeared as a significant mediating factor for relationship dissatisfaction. Psychological aggression mediated the effect of CPA severity on lower marital satisfaction in husbands, but not in wives, over the first 2 years of marriage (DiLillo et al., 2009). Also, CEA was related to poorer marital satisfaction in women through a greater tendency for interpersonal conflicts (Bigras et al., 2015), including an explosive conflict resolution style. Furthermore, this tendency was also associated with lower relationship satisfaction in the partners of these women (Knapp et al., 2017).
Adult insecure attachment
Several studies provided evidence for the central role of adult attachment style in the link between CM and low RQ. An insecure adult attachment style—avoidant or ambivalent—fully mediated the link between retrospective reports of total CM and the quality of past or current communication quality in women (McCarthy & Taylor, 1999). Likewise, a prospective study following African American children from low-income families demonstrated that an insecure attachment style assessed in late adolescence mediates the effects of CPA and CEA on positive couple communication in men and women (Gordon Simons et al., 2014). Furthermore, greater severity of CEA was associated with one’s own higher levels of attachment anxiety and avoidance. In turn, one’s own and one’s partner’s attachment anxiety levels were associated with one’s own lower relationship satisfaction (Riggs et al., 2011).
Other findings revealed an indirect link between concurrent reports of CSA and lower relationship satisfaction through attachment style. CSA exposure in men and women was associated with greater attachment anxiety, which was associated with more emotional distress, which in turn was associated with lower relationship satisfaction (Godbout et al., 2006). However, attachment style was not found to mediate the link between CSA exposure and marital satisfaction in well-functioning Israeli women over 6 months (Lassri et al., 2018).
Self-regulation
The inability to regulate one’s emotions, behaviors, and thoughts was found to be a significant mediating factor. Self-control assessed in late adolescence mediated the prospective effects of CPA and/or CEA on couple communication in emerging adulthood (Gordon Simons et al., 2014). Likewise, emotion regulation, a component of self-regulation, fully mediated the association between CEA and lower relationship satisfaction in young adults, when controlling for gender and relationship duration. However, when controlling for CSA or CPA, only partial mediation was found. Multiple mediator analyses indicated that specific emotion regulation difficulties, namely, nonacceptance of emotions, impulse control difficulties, and lack of emotional clarity, each partially mediated the association between CEA and lower relationship satisfaction. Other emotion regulation skills were not found to be mediating factors, including limited access to emotion regulation strategies and goal-directed behaviors (Bradbury & Shaffer, 2012) and anger management in teenagers (Gordon Simons et al., 2014).
Protective Factors
Personal characteristics
Coping strategies
Three studies assessing the protective effect of specific coping strategies found mixed results. In a clinical sample of married women reporting CSA, greater forgiveness toward the offender was significantly associated with higher levels of marital adjustment (Holeman & Myers, 1998). Furthermore, perceiving benefits from CSA was associated with greater marital satisfaction among women reporting CSA. However, other coping strategies including problem-solving, social support seeking, avoidance, and meaning-making of CSA were not found to be protective factors (Wright et al., 2007).
Surprisingly, some personal resources were found to place women at risk for lower RQ. Specifically, gaining knowledge of CSA was associated with lower marital satisfaction in female survivors of CSA (Wright et al., 2007). Another retrospective study found that the link between greater severity of global CM and lower RQ was evident only in women with a high level of psychological mindedness (i.e., the ability to find relations between thoughts, feelings, and actions in order to understand the source of experiences and behaviors), but not in women reporting low levels of psychological mindedness (Zamir & Lavee, 2014).
Emotion regulation
Emotion regulation, when defined and measured as mood repair, reduced the link between total CM and low RQ in married and/or cohabitating Israeli women (Zamir & Lavee, 2016). However, when emotion regulation was indexed by difficulties to regulate emotions (Rellini et al., 2012) or by difficulties in emotional awareness (i.e., identifying and labeling emotions), it did not moderate the link between total CM and lower relationship satisfaction (Zamir & Lavee, 2015), affection, and intimacy (Rellini et al., 2012).
Gender
Some studies indicated that CM contributes more strongly to communication problems in males than in females (Paradis & Boucher, 2010). Also, in newlywed couples, the association between CPA severity and lower marital satisfaction was significantly stronger for husbands than for wives, and CEA and neglect predicted a greater decline in marital satisfaction for husbands than for wives over the first 2 years of marriage (DiLillo et al., 2009). In contrast, a study tracking low-SES newlywed couples found that only wives’ CSA and/or CPA predict a greater decrease in marital satisfaction over the first years of marriage (Nguyen et al., 2017). Other studies did not detect gender difference in the links between CSA and relationship dissatisfaction (Dunlop et al., 2015) or CPA and marital problems (Larsen et al., 2011) as well as between CEA and one’s own and one’s partner marital dissatisfaction (Riggs et al., 2011).
Interpersonal resources
Parental attachment
Greater severity of documented CSA in girls predicted lower marital satisfaction in women who retrospectively reported poor maternal attachment during adolescence, but not in women recalling more positive maternal attachment (Liang et al., 2006).
Prenatal support
Adults reporting CSA and unsupportive parenting following CSA disclosure reported lower levels of relationship satisfaction when compared to survivors reporting supportive parenting following disclosure of CSA or when compared to a nonabused group (Godbout et al., 2014).
Characteristics of the partner
One study that tested the moderating effects of partner characteristics on the association between child abuse and low RQ found no evidence for protective effects. The partner’s depression level, observed couple interaction, IPV, substance abuse, and SES did not moderate the effects of CSA and/or CPA on changes in RQ across 27 months in low-income newlywed couples (Nguyen et al., 2017).
Discussion
This review summarized 43 studies showing how different forms of CM predict a range of relationship difficulties. Based on the reviewed studies, five mediating and six protective factors for RQ were identified. In total, the reviewed studies indicated that all types of CM are linked with lower RQ (Belt & Abidin, 1996; Lassri et al., 2018; Perry et al., 2007; Zamir & Lavee, 2016) in men and women (Larsen et al., 2011; Whisman, 2006). This link was evident in community (Bigras et al., 2015; DiLillo et al., 2009; Labella et al., 2017), college (Paradis & Boucher, 2010; Zamir & Lavee, 2015), and clinical samples (Larsen et al., 2011; Liang et al., 2006), and when using cross-sectional (Belt & Abidin, 1996; Perry et al., 2007; Zamir & Lavee, 2016) and longitudinal study designs (DiLillo et al., 2009; Labella et al., 2017).
The above findings are in line with the CATS model (Goff & Smith, 2005), which postulates that any form of CM can predict lower RQ in both men and women. Given that much of the research on the effects of CM on RQ was focused on CSA in women, more research should be conducted for other types of abuse and especially neglect. Despite the high prevalence of childhood neglect, to date, it is the least studied type of CM. Neglect often co-occurs with other forms of CM, and it is also associated with symptoms of trauma (Turner et al., 2019).
The CATS model posits that emotional, cognitive, behavioral, and biological trauma-related symptoms are central mediating factors through which CM hinders dyadic functioning (Goff & Smith, 2005). First, psychological distress emerged as a significant mediator underlying the link between different forms of CM and low RQ for men and women (Tardif-Williams et al., 2017; Walker et al., 2009). Second, the review found that some cognitive problems, including identity impairment (Bigras et al., 2015), self-criticism (Lassri et al., 2018), and empathic inaccuracy (Maneta et al., 2015), mediated the link between CEA or CSA and low RQ. However, neither self-esteem (Friesen et al., 2010; McCarthy & Taylor, 1999) nor attributions regarding the romantic partner mediated the association between CSA, CPA, or CEA and low RQ in retrospective or prospective studies in men or women (Gordon Simons et al., 2014; McCarthy & Taylor, 1999). Third, behavioral problems, including risky behaviors, mediate the effects of CSA on RQ for both men and women (Friesen et al., 2010; Testa et al., 2005). Also, aggressive or hostile behaviors mediated the effects of CSA and CEA on women’s marital satisfaction (Bigras et al., 2015; DiLillo et al., 2009; Knapp et al., 2017).
The reviewed studies also identified impaired self-regulation as a mediating factor involved in the link between CPA or CEA and low RQ cross-sectionally and prospectively (Bradbury & Shaffer, 2012; Gordon Simons et al., 2014). Furthermore, adult insecure attachment mediated the associations between CPA, CEA and/or CSA and low RQ for both men and women (Gordon Simons et al., 2014; McCarthy & Taylor, 1999) and also accounted for dyadic effects of CEA on RQ in couples (Riggs et al., 2011). However, this mediation effect was not found over time in high-functioning women (Lassri et al., 2018).
The review supports the CATS model by showing that emotional, cognitive, and behavioral problems are mediating factors through which CM disrupts dyadic functioning (Goff & Smith, 2005). However, other trauma-related symptoms mentioned in the model, such as biological symptoms, were not examined and need further investigation. Moreover, the CATS model posits a causal sequence by which trauma-related symptoms lead to problems in self-regulation and to hostility and insecure attachment to the spouse, which in turn lead to lower relationship satisfaction (Goff & Smith, 2005). However, none of the reviewed studies investigated this sequence in its entirety. That said, the review indicated that attachment and self-regulation are mediating factors in the sequence leading from CM to low RQ. These findings are consistent with the developing concept of complex trauma, which is an ongoing threat in the early caregiving relationship that is expressed not only in emotional, cognitive, behavioral, or biological symptoms but also in attachment insecurities and self-dysregulation (Courtois & Ford, 2012). The current findings stress the need to expand the CATS model by including symptoms of complex trauma as mediating factors for the dyadic effects of CM on RQ.
The review identified six protective factors. First, some findings suggest that personal characteristics such as coping strategies (e.g., forgiving the offender, perceived benefits of abusive experiences, or relationships with others) protect against lower RQ in female CSA victims (Holeman & Myers, 1998; Wright et al., 2007). However, other coping strategies, such as problem-solving, social support seeking, avoidance, or meaning-making, were not found to serve as protective factors. Moreover, coping strategies that were focused on gaining awareness, such as acquiring knowledge about CSA (Wright et al., 2007) or higher psychological mindedness, surprisingly increased the risk for lower RQ in the context of CM. Perhaps increased awareness of painful experiences provokes distress, which spills over and decreases RQ (Zamir & Lavee, 2014). Second, while mood repair reduced the associations between child abuse and low RQ (Zamir & Lavee, 2016), other emotion regulation strategies, such as the ability to recognize and verbalize emotions, did not (Rellini et al., 2012; Zamir & Lavee, 2015). Third, inconsistencies regarding gender emerged as some studies implied that men are more protected from the adverse effects of CSA or CPA on RQ (Nguyen et al., 2017), while others implied that women are more protected (DiLillo et al., 2009; Paradis & Boucher, 2010). Other studies did not find gender differences in the relations between child abuse and RQ (e.g., Larsen et al., 2011). These discrepancies could be due to methodological differences between studies.
At the interpersonal level, positive relationships in the family of origin, such as secure maternal attachment during adolescence (Liang et al., 2006) and supportive parenting following disclosure of CSA, seem to buffer the effects of CSA on marital satisfaction (Godbout et al., 2014). However, there is no evidence for the protective effects of family relations in adulthood. Moreover, partner characteristics such as depression, interaction patterns, aggression, substance abuse, and SES did not moderate the effects of CSA and/or CPA on changes in marital satisfaction over time (Nguyen et al., 2017). These results point to the crucial role of parenting in the resilience of girls exposed to CSA. Further studies are required to unfold protective factors against other forms of CM. Investigations into interpersonal protective factors should include other significant figures such as extended family, siblings, teachers, or friends. It is also crucial to examine whether supportive relationships are as effective in adulthood as they are in childhood. Finally, research on other partner characteristics that are theorized to facilitate healthy relationships in the context of trauma, such as emotional support, co-parenting, and responsiveness (Goff & Smith, 2005), should be conducted.
The CATS model posits that personal, interpersonal, and societal resources can buffer the effects of CM on RQ (Goff & Smith, 2005). The current review identified only personal characteristics and interpersonal resources as protective factors, but not societal factors. Interestingly, some protective factors were considered also as mediating factors. Indeed, emotion dysregulation and insecure attachment are two of the many possible consequences of CM. However, not all children facing adversity will develop these problems. Secure attachment and self-regulation are viewed as protective factors in children who display adaptive development despite the exposure to hardships (Masten & Coatsworth, 1998), and in this review, they were shown to protect against marital difficulties. The relatively small number of studies in the field, the primary focus on CSA, and the mixed findings (e.g., gender, emotion regulation) afford only a limited understanding of the protective process against unhealthy RQ in CM victims. Additional research on protective factors should be expanded to different types of CM and other protective factors at the individual, family, and especially the societal level. Moreover, the mechanisms by which each protective factor mitigates the effect of CM on RQ should be studied.
The CATS model offers a systemic framework on the intra- and interpartner effects of exposure to CM on RQ (Goff & Smith, 2005), but only a small number of studies adopted a dyadic approach. CEA, CSA, CPA, or total CM were associated with one’s own and one’s partner’s relationship dissatisfaction (Maneta et al., 2015; Nelson & Wampler, 2000; Riggs et al., 2011) and disrupted communication (Busby et al., 2011; Knapp et al., 2017). However, a longitudinal study failed to find such dyadic effects in newlywed couples) Nguyen et al., 2017). Furthermore, the research on mediating and protective factors from a dyadic perspective is lacking. Recent findings indicate that attachment anxiety and empathic inaccuracy associated with one’s own CEA are linked to lower relationship satisfaction in both partners (Maneta et al., 2015; Riggs et al., 2011). Only one study adopted a dyadic perspective to examine protective factors and found no evidence for protective effects of partner characteristics on the RQ of the victim (Nguyen et al., 2017). However, this study was limited to low-SES newlywed couples and to CSA or CPA. It is essential to further explore how different mediating and protective factors in each partner are involved in the dyadic effects of CM on RQ. For example, future studies could explore how secondary traumatization affects the nonabused partner’s RQ or whether protective factors in each partner alleviate the effects of CM on their own and their partner’s RQ.
Methodological Considerations
Several methodological issues emerged during the review of the studies and they should be taken into account when interpreting the findings or conducting future research (see Supplementary Table 3). These issues may explain some of the discrepant findings. First, the majority of the studies used a cross-sectional design. Prospective studies are needed to establish the chronological sequence of the tested variables. For instance, given that marital difficulties can result in psychological distress, it is problematic to examine emotional distress as a mediator of the effects of CM on RQ with a cross-sectional design. Employing prospective longitudinal designs can also clarify the dynamics of mediating and protective processes. Future studies could, for example, examine how the emotional distress of the victim before marriage crosses over and intensifies emotional distress in the partner, which subsequently leads to escalating hostile interactions. Longitudinal designs are also essential because some mediating and protective factors may have different concurrent versus longitudinal effects. For example, it could be that psychological mindedness or emotional awareness, which were not found to be protective factors in cross-sectional studies (Zamir & Lavee, 2014, 2015), connect CM victims with painful internal experiences, thereby disrupting current mental health and RQ. However, being aware of negative emotions may help to resolve emotional issues and thereafter promote RQ in the long run.
Second, most studies examined the effects of CM and mediating or protective factors within a specific group (e.g., women or men; college, clinical, or community samples) or were limited to heterosexual American couples exposed to a specific type of abuse. Such selective samples limit the generalizability of the results and may explain some of the discrepant findings. For example, in community samples, CPA was associated with low RQ in men only (Belt & Abidin, 1996; DiLillo et al., 2009; Paradis & Boucher, 2010), but in low-SES and clinical samples, these associations were shown in both men and women (Labella et al., 2017; Larsen et al., 2011). It could be that high-functioning women have access to resources that protect them against CPA. Future research should include diverse samples in terms of ethnicity, culture, sexual orientation, personal status, level of functioning (e.g., clinical samples), and abuse types.
Third, the reviewed studies used a variety of measures for CM, mediating and protective factors, and RQ, which could also explain some of the conflicting findings. For example, when defining RQ in terms of satisfaction, it was negatively associated with CEA (Bigras et al., 2015; Perry et al., 2007) and CSA (Friesen et al., 2010) in men and women. When measuring RQ in terms of communication, however, it was negatively associated with CEA only in women (Belt & Abidin, 1996; Paradis & Boucher, 2010). Similarly, when assessing RQ in terms of support and warmth, it was negatively associated with CSA only in women (Colman & Widom, 2004). In another example, CPA predicted marital dissatisfaction concurrently and longitudinally through psychological distress only in men (DiLillo et al., 2009; Godbout et al., 2006), but the effect of total CM on intimacy was mediated by psychological distress only in women (DiLillo et al., 2007). Even when using the same measure (the Brief Symptom Inventory—a measure of psychological distress), the global scale score mediated the effect of CEA on RQ only in men (Godbout et al., 2006; Perry et al., 2007), while specific subscale scores (obsessive–compulsive tendencies and hostility) mediated this effect in women (Perry et al., 2007).
Even though the study of CSA indicates that a more exclusive definition produces stronger effects on RQ (Romans et al., 1997), studies adopted a wide range of CM measures (see Supplementary Materials). Most measures were valid and reliable (e.g., The Childhood Trauma Questionnaire), but some were not. It is hard to say whether or how different measures of the same construct explain inconsistent findings because typically studies differ in several methodological aspects. For example, Nguyen et al. (2017) followed low-SES African American newlyweds. Using a single-item measure of CSA or CPA and path analysis, they found a greater decline in marital satisfaction in women. DiLillo et al. (2009) followed a community sample of newlyweds and assessed all types of CM. Using a latent growth model, they found a steeper decline in marital satisfaction in men predicted by CEA and neglect. Another potential issue is that most studies employed retrospective self-report measures of CM, but a few studies utilized prospective documentation of CM based on reports of welfare agencies. However, although retrospective data may be biased by recollection, the adverse effect of CM on RQ was demonstrated using both methods.
Fourth, the existing research mostly examined the effects of each CM type and each mediating and protective factor in isolation. This makes it impossible to determine whether there are unique and cumulative effects of CM types and mediating and protective factors on RQ. For example, the link between CEA and low RQ was nullified once controlling for CSA and CPA (Bradbury & Shaffer, 2012), which could indicate that it is the shared characteristics of different types of abuse that drive their effect on RQ rather than the unique characteristics of each type of abuse. Also, the effects of CSA, CPA, and CEA on women’s relationship satisfaction were nullified once controlling for attachment style, relationship length, and gender (Riggs & Kaminski, 2010). Testing multifactor models can unfold the interplay between diverse CM types, mediating, and protective factors.
Lastly, the current state of the literature on the dyadic effects of CM on RQ is poor. Examining dyadic processes requires sampling couples and adopting dyadic data analysis methods (Kenny et al., 2006). Dyadic studies will broaden the understanding of how one’s own and one’s partner’s CM history affects the RQ of each partner and help unfold interpersonal processes that explain or buffer such dyadic effects. For example, future studies could examine which of the abused and nonabused partner’s characteristics promote RQ in both partners.
Limitations
This review is limited in several ways. First, the review covers the current knowledge on CM effects on RQ, mediating and protective factors for RQ in the context of CM, and a critical assessment of methodological issues. This review is not a meta-analysis and does not provide quantitative information on the strength of the associations between CM, mediating and protective factors, and RQ. Second, given that most reviewed studies used cross-sectional designs, causality cannot be inferred. Furthermore, retrospective reports, especially on abusive experiences occurring many years ago, are subject to memory bias, which may hinder the reliability of these findings. Third, despite an extensive literature review, it is inevitable that some relevant articles were not detected (e.g., if an article did not match the search keywords). Additionally, for quality purposes, this review is limited to peer-reviewed, published articles. This process omitted other sources of data such as reports or dissertations. Fourth, this review was conducted using stringent, a priori methods. However, because only a single coder (the author) was used, reliability measures for sorting and coding the articles could not be computed, meaning that coder bias cannot be completely ruled out.
Clinical Implications
The literature on mediating and protective factors for healthy intimate relationships following exposure to CM is relatively small, which limits the ability to translate the empirical knowledge to effective prevention programs. Nevertheless, the current review identified several mediating and protective factors that can inform evidence-based prevention interventions (see “Implications for Research” and “Implications for Practice” sections) focused on men and women with histories of child abuse and neglect. The accumulated evidence points to the need to develop comprehensive and ecologically based prevention programs that target mediating and protective mechanisms at the levels of the individual, social ecology (e.g., social support). Specifically, interventions can be organized around mediating factors, including alleviating trauma-related symptoms, such as emotional symptoms, maladaptive self-perception, empathic inaccuracy, or risky behaviors, as well as facilitating healthy couple communication and emotion regulation. Interventions could also target protective factors, such as support from family during childhood or adolescence, and encourage adaptive coping strategies and emotion regulation. Lastly, the emerging data on the dyadic effects of CM on RQ point to the need to involve both partners in therapy and prevention programs.
Implications for Research
Further research is needed on the effects of childhood neglect on RQ. Further research is needed on the dyadic effects of CM on RQ and the mutual effects of mediating and protective factors among intimate partners. Samples should focus on couples instead of individuals and incorporate dyadic data analysis. More studies are needed on mediating and protective factors for healthy RQ following CM. Studies on mediating and protective factors should incorporate multifactor models. Further research is needed on understudied populations, reflecting diversity in ethnic and cultural groups, sexual orientation, personal status, level of functioning, and contexts. Longitudinal designs are essential to understand long-term mechanisms of the effects of CM on RQ and mediating and protective factors.
Implications for Practice
Prevention interventions for RQ should be focused on men and women with CM histories of all kinds and involve both intimate partners. Prevention interventions should target multiple mediating and protective factors at the individual, couple, and societal levels. Interventions should be organized around mediating factors including alleviating trauma-related symptoms, behavioral problems, and emotion regulation. Interventions should target protective factors such as parental support and coping strategies.
Supplemental Material
Supplemental Material, sj-pdf-1-tva-10.1177_1524838021998319 - Childhood Maltreatment and Relationship Quality: A Review of Type of Abuse and Mediating and Protective Factors
Supplemental Material, sj-pdf-1-tva-10.1177_1524838021998319 for Childhood Maltreatment and Relationship Quality: A Review of Type of Abuse and Mediating and Protective Factors by Osnat Zamir in Trauma, Violence, & Abuse
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.
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References
Supplementary Material
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