Part II: Vulnerabilities and Risk Factors for Psychopathology

1. Part II: Vulnerabilities and Risk Factors for Psychopathology

2. Child Maltreatment and Risk for Psychopathology Chapter 5 Sara R. Jaffee and Andrea Kohn Maikovich-Fong

3. Terminological and Conceptual Issues • Prevalence Rates of Maltreatment Among Subgroups • Children under the age of 4 years represent approximately one third of victims (U.S. Department of Health and Human Services, 2011). • Maltreatment rates are highest among African American, Native American/Alaska Native, and multiethnic youth, and lowest among Asian youth. • Minority children are disproportionately represented in the child welfare system because minority families experience high rates of poverty and other social stressors rather than pervasive bias in the child welfare system (Drake et al., 2011).

4. Maltreatment and Children’s Risk for Psychopathology • Maltreatment and Risk for Externalizing Psychopathology • Maltreated children and adolescents are at higher risk of attention deficit/hyperactivity disorder, conduct disorder, oppositional defiant disorder, delinquency and antisocial behavior. • Risk for externalizing problems extends into adulthood and may include elevated rates of antisocial personality disorder, self-reported crime, and criminal arrests. • Findings with respect to drug and alcohol use have been mixed. • The relationship between externalizing problems and child maltreatment varies as a function of age and sex.

5. Maltreatment and Children’s Risk for Psychopathology • Maltreatment and Risk for Internalizing Psychopathology • Maltreated children and adolescents are at higher risk of major depressive disorder, anxiety disorders, posttraumatic stress disorder (PTSD), and trauma symptoms. • Risk for internalizing problems extends into adulthood and may include elevated rates of major depressive disorder, depressive symptoms, anxiety disorders, borderline personality disorder. • Victims of child maltreatment are at elevated risk for suicide in adolescence and adulthood and engage in elevated rates of self-injury.

6. Maltreatment and Children’s Risk for Psychopathology • Does the Association Between Maltreatment and Psychopathology Reflect Reverse Causation? • Evidence consistent with the hypothesis that maltreatment was a cause of children’s antisocial behavior (Jaffee et al., 2004). • Abuse was associated with changes over time in children’s antisocial behavior. • A dose-response relationship between the severity of the abuse and the severity of children’s antisocial behavior. • Genetic factors accounted for a small and statistically nonsignificant portion of the variation. • Abuse remained a significant predictor of children’s antisocial behavior controlling for parental antisocial behavior.

7. Etiological Formulations • Biological Mechanisms • Epigenetic effects of maltreatment • Maltreatment may lead to psychopathology by triggering epigenetic mechanisms that regulate gene expression in the central nervous system. • Maltreatment and limbic-hypothalamic pituitary adrenal (LHPA) axis function • Maltreatment may dysregulate the LHPA axis due to chronic activation from stressors. • LHPA axis dysregulation has been implicated in a range of mental disorders including depression, anxiety disorders, and conduct disorder (Arborelius, Owens, Plotsky, & Nemeroff, 1999).

8. Etiological Formulations • Structural and functional changes in the brain • Maltreatment increases risk for depression by altering dopaminergic circuitry projecting to the basal ganglia. • Maltreated versus nonmaltreated children are selectively attentive to cues for anger, as evidenced, for example, by greater activation of the right amygdala and anterior insular bilaterally to angry faces. • Hyperattention to threat mediates the association between a history of maltreatment and current symptoms of anxiety (Shackman et al., 2007).

9. Etiological Formulations • Cognitive, Behavioral, and Socioemotional Processes • Externalizing problems • Attribute hostile intent to others’ behavior and respond in an aggressive manner. • Maltreated youth have difficulty regulating their own emotions leading to peer rejection. • Maltreated preschoolers also have difficulty with emotion understanding. • More positive beliefs about violence, which leads to antisocial peer groups and increases their risk for violent behavior.

10. Etiological Formulations • Internalizing problems • Sexual abuse in particular has been linked with a range of problems in self-functioning, defined in terms of self-coherence, self-continuity, self-affectivity, and self-agency (Stern, 1985). • Some studies show that abused and neglected youth report elevated symptoms of dissociation compared with nonmaltreated youth (Macfie, Cicchetti, & Toth, 2001). • Others have found that sexually abused and neglected children are more likely to develop an external locus of control, with perceived external control accounting substantially for their elevated symptoms of internalizing problems (Bolger et al., 2001).

11. Moderators of Maltreatment on Risk for Psychopathology • Characteristics of the Maltreatment • Maltreatment subtype • Maltreatment chronicity • Developmental timing • Characteristics of the Individual • Sex • Race • Personality characteristics • Genotype • Characteristics of the Environment • Neighborhood • Social support • Family environment

12. Clinical Treatment of Maltreated Children • The strongest empirical support is for trauma-focused cognitive behavioral therapy • Dynamic play therapy for children with sexual behavior problems and their caregivers (group therapies) • Cognitive processing therapy • Eye movement desensitization and reprocessing therapy • Multisystemic therapy • Parent-child interaction therapy

13. Conclusion • Basic research: Would benefit from more longitudinal research is needed to better understand the course of resilience and dysfunction over time. • Biology research: Would benefit from larger and more representative samples. • Research on psychological sequelae of maltreatment: Would benefit from research designs that allow for stronger causal inferences about potential mediators of maltreatment. • Multilevel perspective research: Is needed to trace the effects of maltreatment on pathways from genes to brain to behavior. • Clinical research: More research is needed to better evaluate treatment efficacy for maltreated children, to improve access to services and the quality of services for maltreated children, and to understand why some maltreated children respond better to treatment than others.