ترومای انباشتی دوران کودکی و ناسازگاری روانی کودکان مورد آزار جنسی قرار گرفته شده در کره: اثرات میانجی تنظیم احساسات

The purpose of the present study was to identify the mediating effects of emotion regulation on the association between cumulative childhood trauma and behavior problems in sexually abused children in Korea, using structural equation modeling (SEM). Data were collected on 171 children (ages 6–13 years) referred to a public counseling center for sexual abuse in Seoul, Korea. Cumulative childhood traumas were defined on the basis of number of traumas (physical abuse, witnessing domestic violence, neglect, traumatic separation from parent, and sexual abuse) and the severity and duration of traumas. Children were evaluated by their parents on emotion regulation using the Emotion Regulation Checklist and internalizing and externalizing behavior problems using the Korean-Child Behavior Checklist. SEM analyses confirmed the complete mediation model, in which emotion dysregulation fully mediates the relationship between cumulative childhood traumas and internalizing/externalizing behavior problems. These findings indicate that emotion regulation is an important mechanism that can explain the negative effects of cumulative childhood traumas and that there is a need to focus on emotion regulation in sexually abused children exposed to cumulative trauma.

It has been widely reported that trauma experienced during childhood can seriously affect children's psychological development and adjustment (Cicchetti et al., 1995, Cloitre et al., 2005 and Schwarz and Proctor, 2000). Physical abuse, sexual abuse, neglect, witnessing domestic violence, and traumatic separation from a parent are typical examples of childhood interpersonal traumas that have a negative impact on self-concept, attachment, cognitive development, and emotional development (Briere and Rickards, 2007, Cicchetti et al., 1995 and Cloitre et al., 2009). These interpersonal traumas may frequently be experienced in a cumulative manner during childhood, and children who have undergone more than one kind of trauma are expected to experience more severe psychological maladjustment. Many studies have focused on the negative consequences of the experience during childhood of multiple traumas or polyvictimization (Ackerman et al., 1998, Briere et al., 2008, Cloitre et al., 2009, Deblinger et al., 1989 and Fergusson et al., 2008). In clinical groups composed of abused children, those who experienced both physical abuse and sexual abuse showed higher rates of posttraumatic stress disorder (PTSD) than those who experienced just one type of abuse, and they also tended to show higher rates of psychiatric diagnoses and comorbidity (Ackerman et al., 1998, Deblinger et al., 1989 and Fergusson et al., 2008). Studies on community samples have also found that suicide and alcohol problems among youth are often associated with cumulative interpersonal traumas (Luster & Small, 1997). Cloitre et al. (2009) conducted studies with a group of adults who had experienced childhood traumas, such as physical abuse, neglect, emotional abuse, or separation from the mother. The adults who were exposed to more multiple type traumas in childhood were found to have higher rates of PTSD, internalizing/externalizing problems, and dissociation. Cumulative childhood trauma, but not adulthood trauma, also predicted more complex symptoms in adult. Choi and Oh (2013) reported that sexually abused children who had experienced multiple interpersonal traumas were significantly more likely to have multiple psychiatric diagnoses than those who had not experienced multiple interpersonal traumas, even after statistically controlling for the effects of sexual abuse characteristics and environmental and post-incident factors. What, then, is the mechanism through which cumulative childhood traumas cause the more severe psychological maladjustment? Emotion regulation has received attention in research as a possible mediating factor between childhood trauma and its negative sequelae (Kim and Cicchetti, 2009, Schwarz and Proctor, 2000 and Shields and Cicchetti, 2001). Emotion regulation has been conceptualized as the ability to modulate emotional arousal in one's interaction with the environment (Cicchetti et al., 1995). Thus conceptualized, the construct goes beyond the simple ability to restrain behaviors. It includes not only the ability to flexibly and voluntarily respond to environmental demands (i.e., to empathize or express emotions appropriately depending on the particular situation) but also the ability to regulate arousal, whether it be a negative or a positive emotion (Cole, Martin, & Dennis, 2004). It has been suggested that childhood trauma can damage one's capacity for emotion regulation, and that difficulty in emotion regulation is the key mechanism underlying the psychological sequelae of childhood trauma. Shipman, Zeman, Penza, and Champion (2000) found that sexually abused girls showed less emotional understanding and also more unstable, negative, and dysregulated emotions in comparison to nonabused peers. A similar study with neglected children found that these children have poor understanding of negative emotions (Shipman, Edwards, Brown, Swisher, & Jennings, 2005). Unlike adulthood, childhood is a critical period when the physiological, cognitive, and behavioral mechanisms of emotion regulation are still developing. Therefore, it is possible that the experience of trauma during childhood can fundamentally and structurally impede the development of emotion regulation (Cloitre et al., 2005, Schwarz and Proctor, 2000 and Shields and Cicchetti, 2001). Based on animal experiments and brain image studies, basic science suggests that traumatic events and continuous stress trigger changes in the brain structure related to stress response and emotion regulation (Crowe and Blair, 2008, De Bellis and Van Dillen, 2005 and Gunnar and Quevedo, 2007). Although the detailed mechanisms have not been identified, researchers are making continuous efforts to distinguish the different brain structures and neurobiological results by onset time and type of trauma (Cicchetti and Rogosch, 2001 and Cirulli and Alleva, 2003). On the other hand, it also was suggested that emotion regulation—which is developed by learning or modeling through interaction with a parent or caregiver who understands, empathizes, and soothes emotions—is damaged or underdeveloped through childhood trauma or neglect (Calkins and Hill, 2007 and Cole et al., 1994). There have been studies that directly examined the role of emotion regulation as a mediator between interpersonal trauma and psychological adjustment. For example, Schwarz and Proctor (2000) found that children who were directly victimized by community violence showed higher levels of aggression and that emotion regulation functioned as a mediator between interpersonal trauma and aggression. Emotion regulation was also confirmed as a mediator of the association between childhood trauma and internalizing behavior problems including depression and anxiety (Shields & Cicchetti, 2001). In a study with 215 abused children and 206 non-abused children, Kim and Cicchetti (2009) also reported that emotion regulation not only mediates between trauma and both internalizing and externalizing problems, but also affects behavior problems at one-year post-follow up. They also found that multiple types of maltreatment resulted in more damage to emotion regulation, therefore leading to more serious internalizing and externalizing behavior problems. Findings from previous studies suggested that the negative impact of childhood trauma on psychological adjustment is mediated by impairment in emotion regulation. That is, a traumatic experience is likely to cause difficulties in emotion regulation, which, in turn, lead to psychological problems. We also know from previous studies that multiple traumas are associated with more serious psychological difficulties (Ackerman et al., 1998, Cloitre et al., 2009 and Fergusson et al., 2008). However, little research has been done to date on the specific mechanism involved in the relationship between cumulative trauma and severity of maladjustment. Kim and Cicchetti (2009) reported that children who had experienced multiple maltreatments showed more externalizing behavior problems, suggesting the mediating role of emotion regulation, but they categorized maltreated children on the basis of the number of trauma types experienced (i.e., children with 1 or 2 types of trauma and those with 3 or 4 types of trauma) while the duration and severity of trauma, which are likely to be important factors in cumulative trauma experience, were not considered in their study. Clemmons, Walsh, DiLillo, and Messman-Moore (2007) did attempt to examine both the co-occurrence and severity of abuse type in predicting long-term psychological functioning, but they regarded the two factors as independent variables, not integrating them together as cumulative trauma. The purpose of the current study was to examine interrelationships between cumulative childhood trauma, emotion regulation, and psychological maladjustment, using structural equation modeling (SEM). Emotion regulation was examined as a mediator of the effect that cumulative childhood trauma has on the psychological maladjustment of sexually abused children. It was hypothesized that children with more childhood trauma would have severe emotion dysregulation and difficulties with emotion regulation influenced behavior problems. In the present study, cumulative childhood traumas were defined on the basis of number of traumas as well as the severity and duration of traumas. Psychological maladjustment also covered both internalizing and externalizing behavior problems.