Child maltreatment and depression: A meta-analysis of studies using the Childhood Trauma Questionnaire

Abstract

Background

Researchers have documented that child maltreatment is associated with adverse long-term consequences for mental health, including increased risk for depression. Attempts to conduct meta-analyses of the association between different forms of child maltreatment and depressive symptomatology in adulthood, however, have been limited by the wide range of definitions of child maltreatment in the literature.

Objective

We sought to meta-analyze a single, widely-used dimensional measure of child maltreatment, the Childhood Trauma Questionnaire, with respect to depression diagnosis and symptom scores.

Participants and setting

192 unique samples consisting of 68,830 individuals.

Methods

We explored the association between total scores and scores from specific forms of child maltreatment (i.e., emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect) and depression using a random-effects meta-analysis.

Results

We found that higher child maltreatment scores were associated with a diagnosis of depression (g = 1.07; 95 % CI, 0.95–1.19) and with higher depression symptom scores (Z = .35; 95 % CI, .32–.38). Moreover, although each type of child maltreatment was positively associated with depression diagnosis and scores, there was variability in the size of the effects, with emotional abuse and emotional neglect demonstrating the strongest associations.

Conclusions

These analyses provide important evidence of the link between child maltreatment and depression, and highlight the particularly larger association with emotional maltreatment in childhood.

Introduction

Depression is a significant public health concern; indeed, major depressive disorder (MDD) is the leading cause of disability worldwide (World Health Organization, 2017). Understanding the etiology of depression, in particular mutable factors that may play a causal role, is critical for reducing risk for this recurrent and debilitating disorder (Liu, 2017). Prospective studies have documented that greater adversity in childhood is associated with more chronic depression (Klein & Kotov, 2016), more severe depression (Rhebergen et al., 2012), and a longer time to remission (Fuller-Thomson, Battiston, Gadalla, & Brennenstuhl, 2014). The role of early adversity in increasing risk for the subsequent development of depression is substantial; in fact, Kessler et al. (2010) estimated that almost 25 percent of population-attributable risk is due to early adversity.

Among early adverse experiences, child maltreatment is a particularly potent risk factor for depression. Previous meta-analyses examining child maltreatment and depression have found that experiencing any form of maltreatment (treated statistically as the presence or absence of maltreatment) was associated with more than a two-fold increase in risk for depression in adulthood (Li, D’Arcy, & Meng, 2016), and with the development of chronic, or recurrent, depression (Nanni, Uher, & Danese, 2012). Although sexual abuse has received the most empirical attention (see Liu, 2017), it is noteworthy that different types of maltreatment frequently co-occur (Petersen, Joseph, & Feit, 2014). Thus, rather than focus on a single type of maltreatment, it is important to characterize the relation between different types of child maltreatment and depression. This perspective is supported by the emerging theory that early experiences that are characterized by threat (e.g., abuse) have different effects on the emergence of psychopathology than do early experiences characterized by a lack of species-expected input (e.g., neglect; Humphreys & Zeanah, 2015). Further, although physical, sexual, and emotional abuse have all been linked to depression (Mullen, Martin, Anderson, Romans, & Herbison, 1996), their different prevalence rates (Edwards, Holden, Felitti, & Anda, 2003), and their differential links to depressogenic features (e.g., low self-esteem following emotional abuse; Mullen et al., 1996), underscore the importance of careful examination of different forms of maltreatment with depression.

Previous meta-analyses examining the association between maltreatment and depression are informative. However, while important, all are limited either by small numbers of available studies (e.g., 8 for Li et al., 2016; 12 for Infurna et al., 2016; 16 for Nanni et al., 2012) or by considerable variability in how child maltreatment was operationalized (e.g., Norman et al., 2012), which limits comparisons across studies. Given that different definitions, informants, and thresholds for characterizing maltreatment are likely to result in different patterns of findings, there is value in prioritizing the meta-analysis of studies that use a common measure to assess maltreatment. In one such example, Infurna et al. (2016) conducted a meta-analysis of studies using the Childhood Experience of Care and Abuse interview (CECA; Bifulco, Brown, & Harris, 1994). They also restricted their inclusion criteria to studies that required a clinical diagnosis of depression. This increased confidence in their conclusions has a trade-off, which is that only 12 studies met inclusion criteria; this limited their ability to conduct moderator analyses. Moreover, experiences of maltreatment, as well as characterization of depression, may better be considered along a dimension (i.e., people vary in the severity of their maltreatment experiences [Humphreys & Zeanah, 2015; King, Humphreys, & Gotlib, 2019; McLaughlin, Sheridan, & Lambert, 2014] and depression can be represented both dimensionally and categorically [Ruscio & Ruscio, 2000]).

Thus, we sought to meta-analyze studies that assessed maltreatment experiences on a continuous scale using the Childhood Trauma Questionnaire (CTQ; Bernstein et al., 2003; Bernstein & Fink, 1998). The CTQ is the most widely used measure of this construct; it has been shown to have acceptable internal consistency, test-retest reliability, and strong convergence with interviews that assess child trauma (Bernstein et al., 1994). The CTQ assesses five types of maltreatment experiences (i.e., emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect) using a Likert-scale approach to assess the severity of each type of experience. By assessing maltreatment using a dimensional approach, and by using a single assessment measure (i.e., the CTQ), our meta-analysis maximizes consistency in the measurement of child maltreatment and increases confidence in the effect size estimates in relation to depression; moreover, this meta-analysis includes the largest set of studies and number of unique participants assessed using a single measure to date. Further, unlike prior meta-analyses that vary in the forms of maltreatment that were considered in their assessments, our approach allows us not only to probe associations between depression and overall maltreatment, but also to assess specific types of maltreatment measured at the same time using the same scale. Such an approach will yield insight into whether models indicating that the type of maltreatment or deviation from an expectable environment are differentially associated with depression (including neglect versus abuse; see Humphreys & Zeanah, 2015; McLaughlin & Sheridan, 2016; McLaughlin et al., 2014; or emotional maltreatment versus physical or sexual maltreatment). Finally, by including studies that examined depression using either a group-based approach (e.g., diagnoses) or a continuous approach (e.g., depression symptom scores), we can examine the strength and specificity using two widely used approaches to the assessment of depression.