At times our own light goes out and is rekindled by a spark from another person. Each of us has cause to think with deep gratitude of those who have lighted the flame within us.
— Albert Schweitzer
According to the U.S. Department of Health and Human Services (2016), in 2014 there were 3.25 million reports of possible abuse to Child Protection Services. Over 20 percent of these referrals were found to constitute maltreatment, reflecting greater than 700,000 children exposed to significant childhood adversity. Neglect was present in three-quarters of these cases, and physical abuse in 17 percent. Child maltreatment may have a persistent negative impact from childhood on, in spite of opportunities for post-traumatic growth. The long-term health impact of Adverse Childhood Experiences (ACEs) is described in the landmark study from the Centers for Disease Control and Kaiser.
Childhood maltreatment is not a death sentence, however, and many who experience maltreatment go on to be happy, healthy adults, making use of traumatic experience, to an extent, in the service of personal development. Resilience, for example, has been shown to buffer the effect of childhood maltreatment, leading to better outcomes in adulthood (e.g. Poole et al., 2017). Both maltreatment and resilience are important factors in understanding developmental pathways from childhood maltreatment to adult behavior, but they do not tell the whole story. Attachment style, shown in numerous studies to be connected with relationship quality and potential health outcomes, is a significant factor for understanding how childhood maltreatment affects adult health and well-being.
Mistreatment and Attachment Style
To clarify the relationship between childhood maltreatment and adult attachment style, Widom, Czaja, Kazakowski, and Chauhan (2017) conducted research with 650 adults. They were specifically interested in determining whether the type of maltreatment (abuse versus neglect) is associated with future attachment style. In reviewing the literature on maltreatment, attachment, and health outcomes, they note that prior research has suggested that family environment predicts adult attachment style, and that children from abusive homes are more likely to have insecure attachments. Neglect and abuse, and different forms of abuse, have different emotional and psychological meaning.
Neglect may result in the child's feeling unwanted and discarded, for example, whereas, despite being violent and destructive, physical abuse does not necessarily coincide with frank abandonment and rejection. Neglected children do not receive attention at all, whereas abused children do receive attention, albeit in the form of undeserved harsh punishment. While both abuse and neglect are thought therefore to lead to insecure attachment, they may foster different developmental outcomes. Preliminary research has found that avoidant adult attachment is associated with childhood physical abuse, whereas neglect is associated with adult anxious attachment, and that the relationship between different forms of childhood maltreatment may have a more complex relationship with adult attachment, suggesting the need for further study.
The current study
Widom and colleagues (2017) set out to look at adult attachment style and childhood maltreatment type, adult attachment and physical and mental health outcomes, and whether adult attachment style affects the connection between childhood maltreatment and health outcomes. This study is notable because it used a prospective design based on objective measures. Rather than looking at a cross-section of adults and using solely self-report measures, researchers looked at actual data on abuse and health outcomes, in addition to self-report measures, and followed a cohort of participants over a long span of time. Prospective controlled study designs are generally considered to be more robust, and are able to provide a clearer picture of causal relationships.
They recruited a total of 650 participants, 50 percent women, 60 percent white, and with an average age of about 40 years old. They included people without childhood maltreatment as well as those with histories of significant neglect and physical abuse for comparison. In addition, they looked at participants with only one form of abuse or neglect in their analysis in order to focus on the relationships of interest, noting that 11 percent of the sample reported combined abuse and neglect. They identified potential participants for the study by reviewing officially reported cases of abuse or neglect from court cases from the late 1960s and early 1970s, and matched them with similar controls without reported maltreatment. The study was conducted over the course of many years, beginning in the late 1980s and early 1990s, through 2005.
Researchers measured 1) adult attachment style, using the three categories of secure, avoidant, and anxious, with the Relationship Style Questionnaire (RSQ); 2) depression, using the Center for Epidemiologic Studies Depression Scale (CES-D); 3) anxiety, using the Beck Anxiety Inventory (BAI); 4) Self-esteem, using the Rosenberg Scale; and 5) negative health indicators (“allostatic load”) as a composite of nine factors including a) blood pressure, b) high-density lipoproteins (HDL), c) cholesterol to HDL ratio (associated with cardiac risk), d) average blood glucose over time (hemoglobin A1C), e) C-reactive protein (CRP—a measure of inflammation), f) albumin level (a measure of nutritional status), g) creatinine clearance (indicating kidney health), and h) peak air flow (indicating lung function). They controlled for demographic factors, including age, sex, race/ethnicity, and family socioeconomic status, in addition to matching maltreated with non-maltreated controls, in order to reduce variability.
Childhood neglect was correlated with greater depression, childhood physical abuse was correlated with lower self-esteem, and physical abuse predicted anxious attachment style. Anxious and avoidant attachment style predicted depression, anxiety, and lower self-esteem. Childhood neglect predicted anxious and avoidant attachment styles and negative health indicators. Childhood physical abuse predicted anxious attachment, but not avoidant attachment or negative health indicators. Adult anxious attachment style predicted negative health indicators. Childhood neglect predicted negative health indicators, but was not clearly mediated by attachment style. Models of the relationship from neglect and abuse to adult outcomes (path analyses) are included at the end of this post for interested readers.
Overall, this study found that anxious attachment style was a significant contributor to depression, anxiety, and low self-esteem in those with a history of childhood neglect or physical abuse. Avoidant attachment style, however, was not found to be a significant predictor of those outcomes, in this study. Participants with confirmed histories of childhood neglect were more likely to have anxious and avoidant attachment styles. A history of physical abuse did not predict avoidant attachment, as the study authors had hypothesized it would. They found that both forms of insecure attachment style predicted depression, anxiety, and low self-esteem. Insecure attachment may worsen mental-health outcomes, and poor mental health may reciprocally affect attachment adversely.
Only anxious attachment style predicted negative health indicators, and only anxious attachment mediated the relationship between childhood maltreatment and negative mental health outcomes. These are important findings as anxious attachment is the most common form of insecure attachment. Because of this relationship, it may be of special importance to address anxious attachment both in early childhood intervention and as a focus in adult therapeutic settings. While anxious attachment was more clearly related to childhood maltreatment, avoidant attachment was not.
The picture this study illustrates is informative, if partly indeterminate, because avoidant and anxious attachment had both distinct differences and significant overlap—for example, in the high degree of correlation between the two attachment styles. It may be that the attachment landscape as relates to developmental trauma and adult health behavior is more complicated than captured in this study. Clinical measures looked at depression and anxiety, excluding developmental trauma and personality disorders (e.g. Borderline PD). Insecure attachment was analyzed as having only two dimensions. Individuals with a disorganized attachment style would express features of both anxious and avoidant attachment, and it would make sense to look at disorganized attachment styles to clarify the relationship among childhood adversity, attachment style, and adult health outcomes.
Poole JC, Dobson KS, Pusch D. (2017). Childhood adversity and adult depression: The protective role of psychological resilience. Child Abuse & Neglect, Vol. 64, Feb., pp. 89-100.
U. S. Department of Health and Human Services (2016). Child maltreatment 2014. Washington, DC: Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau.
Widom CS, Czaja SJ, Kozakowski SS, Chauhan P. (2017). Does adult attachment style mediate the relationship between childhood maltreatment and mental and physical health outcomes? Child Abuse & Neglect, In Press, https://doi.org/10.1016/j.chiabu.2017.05.002