The Gerontologist Advance Access published November 21, 2013 The Gerontologist Cite journal as: The Gerontologist doi:10.1093/geront/gnt136
© The Author 2013. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: [email protected].
Caring for My Abuser: Childhood Maltreatment and Caregiver Depression Jooyoung Kong, MSW,*,1 and Sara M. Moorman, PhD2 2
1 Graduate School of Social Work, Boston College, Chestnut Hill, Massachusetts. Department of Sociology and Institute on Aging, Boston College, Chestnut Hill, Massachusetts.
*Address correspondence to Jooyoung Kong, MSW, Graduate School of Social Work, Boston College, 140 Commonwealth Avenue, Chestnut Hill, MA 02467. E-mail: [email protected] Received May 31, 2013; Accepted October 8, 2013 Decision Editor: Rachel Pruchno, PhD
Purpose of the Study: This study examined depressive symptoms among adult survivors of childhood maltreatment who provided care to their former abusive/neglectful parents. We also investigated the extent to which four coping styles—problem-focused coping, emotion-focused coping, positive social support, and negative social support—moderated the association between childhood maltreatment and depressive symptoms of the caregivers. Design and Methods: Among 1,001 filial caregivers from the 2003–2005 wave of the Wisconsin Longitudinal Study, 18.6% of respondents reported verbal, physical, or sexual abuse in childhood; 9.4% reported neglect in childhood. Ordinary least squares regression models were estimated. Results: Persons who had a history of parental abuse showed significantly more frequent depressive symptoms when providing care to their abusive parent(s) compared with caregivers who had not experienced parental abuse. Those who had been neglected had significantly more frequent depressive symptoms than caregivers who did not report neglect. Additionally, the use of emotion-focused coping was more strongly associated with more frequent depressive symptoms among abused caregivers than among caregivers with no history of abuse. Implications: This vulnerable group of caregivers should be recognized in the development and implementation of support services for family caregivers at the state and national levels. In direct practice settings, when assessing caregiver stress and burden, the history of childhood maltreatment needs to be taken into account.
Key Words: Caregiving, Child abuse and neglect, Coping styles, Depressive symptoms, Stress process model
The federal Child Abuse Prevention and Treatment Act (CAPTA) defines child abuse and neglect as: “Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act, which presents an imminent risk of serious harm” (CAPTA Reauthorization Act of 2010). Recent data on child maltreatment reported that 9.1 out of every 1,000 U.S. children experienced abuse or neglect from their caretaker(s) in 2011 (National Child Abuse and Neglect Data System, 2011). This high prevalence rate is especially concerning because experiences of child abuse or neglect can lead to intra- and interpersonal problems throughout the life course (Afifi, Boman, Fleisher, & Sareen, 2009; Ethier, Lemelin, & Lacharite, 2004). Little is known, however, about adult survivors of childhood maltreatment who become caregivers for their previously abusive or neglectful parent(s). A substantial body of literature links caregiving to adverse mental health outcomes, such as high levels of stress, depression, and anxiety (Amirkhanyan & Wolf, 2006; Katerndahl & Parchman, 2002). We speculate that this may be even more true of filial caregivers who were abused or neglected as children.
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This study is intended to begin to fill this gap in the literature. Two primary goals of the current study were (a) to examine the levels of depressive symptoms in adult survivors of childhood maltreatment who provide care to their childhood abusers or neglectors and (b) to evaluate the extent to which various coping styles moderate the relationship between abuse or neglect as a child and depressive symptoms as a caregiver. We analyzed data from 1,001 adult children caring for their parents, and our conclusions are based on the Stress Process Model (SPM; Pearlin, Lieberman, Menaghan, & Mullan, 1981). By enhancing the understanding of the stress process of formerly abused or neglected filial caregivers, this study will provide theoretical and empirical evidence for social work interventions. SPM SPM studies have shown how stressors, psychological stress outcomes, and intervening mediators are interconnected in a causal process (Pearlin, 1989; Pearlin et al., 1981). Particularly, the SPM has been used extensively as a conceptual framework to explain caregivers’ health and psychosocial outcomes (Pearlin, Mullan, Semple, & Skaff, 1990). In the caregiving context, stressors refer to the objective and subjective indicators of caregiving demand and burden. Objective indicators include the care recipient’s cognitive status, problem behaviors, and level of functional disability (Mausbach et al., 2012). Subjective indicators are caregivers’ feelings of overload, the closeness of the relationship between caregiver and care recipient, and subjective appraisal of their own difficulty (Son et al., 2007). Stress outcomes involve inhibition of caregivers’ well-being in terms of their physical or mental health or social functioning, including disruption in usual activities, incidence of injuries, disorders in the digestive and cardiovascular systems, depression, and anxiety (Pearlin, 1989; Pearlin et al., 1990). In the SPM, stressors do not invariably result in stress outcomes. Rather, coping strategies and social support may intervene (Pearlin et al., 1981). Folkman and Lazarus (1980, p. 223) define coping as “the cognitive and behavioral efforts made to master, tolerate, or reduce external and internal demands and conflicts among them.” Coping serves to either manage or alter the person-environment relationship, which is known as problemfocused coping, or to regulate stressful emotions,
known as emotion-focused coping (Folkman & Moskowitz, 2004). Problem-focused coping involves active efforts oriented toward confronting the problem, whereas emotion-focused coping is oriented toward reducing tensions and negative emotions. Certain types of emotion-focused coping strategies (e.g., avoidance) are consistently associated with poor stress outcomes; much has been reported on the detrimental effects of avoidance coping in relation to psychological well-being of caregivers (Mausbach et al., 2012; Powers, Gallagher-Thompson, & Kraemer, 2002). Other types of emotion-focused coping and problemfocused forms of coping, however, are sometimes associated with positive outcomes, depending on the situational context or a person’s appraisal of stressful events (Folkman & Moskowitz, 2004). Social support can be defined as “the access to and use of individuals, groups, or organizations in dealing with life’s vicissitudes” (Pearlin et al., 1981, p. 340). Much research has shown that social support plays a protective role by attenuating stress outcomes. However, negative interactions and unhelpful support from significant others predict psychological distress, such as depression, anxiety, and anger (Ha, 2010; Lincoln, 2008). Pearlin and his colleagues, who coined the term SPM and developed its theoretical framework, exclusively refer to these intervening factors (i.e., coping and social support) as “mediators.” However, SPM researchers have examined not only the mediating effects of the intervening factors, but also their moderating effects on the manifestations of stress. The difference between mediation and moderation is that mediators explain, in whole or in part, the relation between stressors and stress outcomes, whereas moderators affect the strength and/or direction of the relation between stressors and stress outcomes (Baron & Kenny, 1986). In this study, we focused on examining the moderating effects of coping strategies and social support in order to investigate the efficacy of coping strategies that these abused or neglected caregivers use in response to stressors. Long-Term Effects of Childhood Maltreatment Adult survivors of childhood abuse and neglect are known to experience more physical health problems, mental health problems, and cognitive impairments than their nonabused or nonneglected counterparts (Afifi et al., 2009; Ethier et al., 2004). Childhood maltreatment also increases a person’s chances of having poor social relationships due to
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The Gerontologist
distrust of others, low self-esteem, and difficulty in forming secure attachments to others (Cook et al., 2005). Furthermore, early maltreatment predicts difficulties in establishing and maintaining intimate partner relationships (Whisman, 2006). Evidently, adult survivors may still experience unresolved trauma issues. These findings also imply that survivors may have less ability or opportunity to seek support or enact positive coping methods when dealing with the stress of caregiving. It is an ironic situation that a dysfunctional parent–child relationship can switch to a care recipient–caregiver relationship later in life. This study attempts to capture the consequences of such a role reversal. Research has shown that relationship quality is one of the significant predictors of outcomes for caregivers. There have been mixed results: Dyadic closeness as an indicator for positive attachment or emotional bond predicts both protective and adverse effects on caregiving outcomes (Fauth et al., 2012). This study is an extension of this line of research because it focuses on the long-term consequences of destructive parent–child relations in childhood. The Present Study The key research questions in this study are the following: (a) How does abusive/neglectful treatment from parents in childhood affect adult children’s mental health when they provide care to their older parents? and (b) How do such filial caregivers process their stress through social support and various coping mechanisms? The situation of providing care to past abusive/neglectful parent(s) serves as a primary stressor, and depressive symptoms serve as a stress outcome. A set of intervening factors—problem-focused coping, emotional-focused coping, positive social support, and negative social support—are examined to understand the extent to which the four coping styles alter the depressive symptoms of the maltreated caregivers. All analyses control for sociodemographic characteristics and health status of the respondents. These measures have been used as covariates of depression in the caregiving literature (Pinquart & Sorensen, 2003) and may also be associated with the experience of prior abuse or neglect (Ethier et al., 2004). Method Data Set The Wisconsin Longitudinal Study (WLS) is a random sample survey of 10,317 men and women
from the birth cohort of 1939 who graduated from Wisconsin high schools in 1957. The graduates were reinterviewed at three different time points: 1975, 1992–1993, and 2003–2005. The data set provides nearly 50 years of records for the graduates, encompassing social background, education, family formation, employment, social participation, health, and aging. This study used data from the 2003–2005 wave when most graduates turned 65 years old. This wave provides information on caregiving as well as retrospective reports on experiences of abuse and neglect in childhood. Almost 85% of living graduates participated in the telephone survey in 2004, and 88% of these participants completed the mailin follow-up questionnaire. Because the major focus of this study is the depressive symptoms of filial caregivers, the 1,001 graduates who reported providing care to their parent(s) constituted the final study sample. The mail-in survey includes the question: “Have you ever given personal care for a period of 1 month or more to a family member or friend because of a physical or mental condition, illness, or disability, not including your spouse?” Among individuals who answered “yes” to this question, respondents who specified that they have given care to “father,” “mother,” or “both parents” were selected for the study sample. Measures Depressive Symptoms.—The dependent variable was depressive symptoms as measured by the 20-item Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977). Each item used an 8-point scale (0–7) to mark the number of days in the past week a respondent had experienced a specific symptom. The maximum possible score was 140, but no caregivers reported such debilitating depressive symptoms. Provided that a respondent answered more than 15 items of the scale, the 20 items were summed to give a single score (α = 0.80). The square root of the depression scores was used in the ordinary least squares (OLS) analyses due to the high skewness of the variable. Experience of Neglect.—The key independent variables were experiences of child abuse and/ or neglect by parent(s). First, child neglect was assessed using the question: “Up until you were 18, how often did you know that there was someone to take care of you and protect you?” The item
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was drawn from the well-validated Childhood Trauma Questionnaire (Bernstein et al., 1994). The item does not ask directly about the respondent’s parents. However, supplementary analyses showed that more than 85% of neglected caregivers reported that they lived with both parents most of time up until high school graduation. Therefore, we infer that respondents who did not feel cared for and protected had neglectful parent–child relationships. There were five response choices: “Never,” “rarely,” “sometimes,” “often,” and “very often.” The variable was recoded as a binary variable to deal with the skewness of the item. Those who reported “never,” “rarely,” and “sometimes” were coded as having experienced neglect as children; those who responded “often” and “very often” were coded as having no experience of child neglect. Experiences of Child Abuse.—Each respondent was evaluated for childhood exposure to parental verbal, physical, and sexual abuse. Child verbal abuse was measured using two questions that asked whether a respondent’s (a) father or (b) mother would “insult or swear” at them before age 18. There were four response categories: “not at all,” “a little,” “some,” and “a lot.” Those who reported “some” or “a lot” were counted as having experienced child verbal abuse; “a little” and “not at all” responses were considered having no experience. This is consistent with coding in the prior literature (Springer, 2009). Child physical abuse was assessed based on the response to two questions: “Up until you were 18, to what extent did your (a) father and (b) mother treat you in a way that you would now consider physical abuse?” In this case, those who reported “a little,” “some,” or “a lot” as opposed to “not at all” were coded as having experienced physical abuse as children. Child sexual abuse was measured using two questions: “Up until you were 18, to what extent did your father have oral, anal, or vaginal sex with you against your wishes?” and “Up until you were 18, to what extent did your father treat you in a way that you would now consider sexual abuse?” Those who responded “a little,” “some,” or “a lot” to either question were classified as having been sexually abused by their father. The 2003–2005 WLS data did not assess child sexual abuse by mothers. We wished to isolate the effect of caring for an abusive parent from the effect of having experienced parental abuse but caring for a parent who was not abusive. For example, if a person was abused by
the father but not the mother as a child, providing care to the father may be particularly stressful, whereas caring for the mother may involve normal levels of caregiving stress or depression. Thus, the final child abuse variable had three mutually exclusive categories: (a) no history of child abuse (reference category); (b) verbally, physically, or sexually abused by a parent and caring for that abusive parent; (c) verbally, physically, or sexually abused by a parent but caring for a nonabusive parent (see Table 1 for subsample sizes). In the case that a caregiver reported providing care for both an abusive parent and a nonabusive parent, the person was coded as caring for an abusive parent. Coping.—The 2003–2005 data set provides items assessing respondents’ coping strategies and reactions to their stressful life events based on the COPE scale (Carver, Scheier, & Weintraub, 1989). Principal-axes factor analyses were conducted to identify underlying factors in the items related to the coping styles, which yielded a two-factor solution that worked best both conceptually and empirically (results available from the first author upon request). The solution identified two groups: problem-focused coping and emotion-focused coping variables. Problem-focused coping was measured by summing four questions (α = 0.80): “Generally, when you experience a difficult or stressful event, how often do you (a) concentrate your efforts on doing something about the situation you’re in; (b) take actions to try and make the situation better; (c) try to come up with a strategy about what to do; (d) think hard about what steps to take?” Respondents who skipped any items were coded as missing. Each item was measured on a 4-point Likert scale, ranging from “not at all” (1) to “a lot” (4). Next, emotion-focused coping was measured with nine questions (α = 0.66): “Generally, when you experience a difficult or stressful event, how often do you (a) say things to let your unpleasant feelings escape; (b) criticize yourself; (c) express your negative feelings; (d) blame yourself for things that happened; (e) say to yourself ‘this isn’t real’; (f) give up trying to deal with it; (g) refuse to believe that it has happened; (h) give up the attempt to cope; (i) do something to think about it less, such as going to the movies, watching TV, reading, daydreaming, sleeping or shopping?” All the nine items were coded in the same direction such that a higher score represented a greater use of emotion-focused coping, as per the original citation (Carver et al., 1989). The scale’s reliability coefficient was slightly
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The Gerontologist
Table 1. Characteristics of Filial Caregivers in the Wisconsin Longitudinal Study, 2003–2005 (N = 1,001) Variables Child abuse No history of parental abuse Experienced parental abuse, caring for the abusive parent Experienced parental abuse, caring for a nonabusive parent Child neglect No history of neglect Neglected in childhood Gender Male Female Marital status Married Separated/divorced Widowed Never married Self-reported health Very poor/poor Fair Good Excellent Diagnosis of major illnesses Diabetes Cancer Heart problems Stroke Years of education Total household income (USD) Number of functional limitations Depression (α = 0.80) Problem-focused coping (α = 0.80) Emotion-focused coping (α = 0.66) Positive social support (α = 0.80) Negative social support (α = 0.55)
N
%
N, missing (%)
801 101
81.40 10.26
82
8.33
892 92
90.65 9.35
277 724
27.67 72.33
756 114 67 64
75.52 11.39 6.69 6.39
23 124 625 221
2.32 12.49 62.94 22.26
96 115 130 31
9.59 11.49 12.99 3.10
Mean (SD)
Observed, Min./Max.
N, missing (%)
13.59 (2.19) 60,231.89 (83,327.79) 1.40 (1.66) 14.51 (14.10) 12.92 (2.54) 16.23 (3.65) 7.80 (1.81) 3.21 (1.36)
12/20 0/710,000 0/7 0/97 4/16 8/32 2/10 2/10
0 (0) 0 (0) 13 (1.30) 22 (2.20) 51 (5.09) 41 (4.10) 21 (2.10) 23 (2.30)
17 (1.70)
17 (1.70)
0 (0)
0 (0)
8 (0.80)
1 (0.10)
Notes: Descriptive statistics are reported prior to correction for skew, standardization, and multiple imputation. Higher mean scores indicate greater depressive symptoms and greater use of each coping strategy.
low. However, confirmatory factor analysis indicated that all the items had a strong loading (above 0.30) on a single factor (Carver et al., 1989). Social Support.—This study distinguished between the positive and negative aspects of social support. For the positive aspect, two questions were summed (α = 0.80): “How much do your friends and relatives other than your spouse and children (a) make you feel loved and cared for and (b) are willing to listen to you?” Negative social support was assessed with the two questions (α = .55): “How much do your friends and relatives other than your spouse and children (a) make too many demands on you and (b) are critical of what you
do?” The low reliability of the negative social support measure is not surprising considering that alpha is highest when a scale has a large number of items that are unidimensional (Cortina, 1993). This scale has two items that measure different dimensions of negative support (i.e., criticism and demands). Further, this two-item scale has been widely used in published work (Ha, 2010). Each item was measured on a 5-point Likert scale, ranging from “not at all” (1) to “a lot” (5). Respondents who skipped any items were coded as missing. Covariates.—We controlled for sociodemographic characteristics including gender, marital status (married, separated/divorced, widowed,
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never married), education (in years), and household income (square rooted to correct skewness). Informed by the previous literature (Schafer & Ferraro, 2012), we also included three measures of current health. These were self-reported health status (very poor, poor, fair, good, excellent), functional limitations (count of seven possible difficulties), and diagnosis of any of four major illnesses (diabetes, cancer, heart disease, and/or stroke). Data Analysis First, bivariate analyses were conducted to compare the levels of depressive symptoms, coping strategies, and social support between abused caregivers and their nonabused counterparts, and between neglected caregivers and their nonneglected counterparts. Next, a series of OLS regression models were estimated with depressive symptoms as the outcome variable. In Model 1, the abuse and neglect variables, as well as the sociodemographic and health variables, were the independent measures. In Model 2, the coping strategies and social support were added to examine their effects on depressive symptoms. Model 3 examined whether caregiver depression was contingent upon the coping strategies and social support by adding multiplicative interaction terms. The coping strategies and social support variables were mean centered before creating the interaction terms (Aiken & West, 1991). Complete data were provided by 90.5% of participants. The summed scale of problem-focused coping had the most missing data (n = 51; 5.1% of cases). To handle incomplete data, we conducted multiple imputation by chained equations in Stata
12.0. We generated 20 data sets with imputed values. As von Hippel (2007) suggested, we included our dependent variable in the imputation model and then deleted its imputed values in the analyses. Results Sample Characteristics Table 1 presents the descriptive statistics for all variables in the analyses. The majority of respondents (76.7%) cared for their mothers only; 195 caregivers (19.5%) cared for fathers only. Only 38 caregivers (3.8%) cared for both parents. Among the caregivers, 18.6% had experienced some type of parental abuse, and 9.4% reported neglect in childhood. Mean comparisons indicated that abused caregivers, either providing care to their abusive or nonabusive parent, had more frequent depressive symptoms than nonabused caregivers. Neglected caregivers also showed significantly more frequent depressive symptoms than the nonneglected caregivers (see Table 2; see Table 3 for correlations between variables). Multivariate Analyses A summary of regression results is presented in Table 4. Model 1 examined the main effects of child abuse and neglect on caregivers’ depressive symptoms. For those who experienced any type of abuse in childhood, caring for the abusive parent was associated with more frequent depressive symptoms (b = 0.38, p < .05). In addition, providing care to a neglectful parent was associated with more frequent depressive symptoms (b = 0.51, p
© The Author 2013. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: [email protected].
Caring for My Abuser: Childhood Maltreatment and Caregiver Depression Jooyoung Kong, MSW,*,1 and Sara M. Moorman, PhD2 2
1 Graduate School of Social Work, Boston College, Chestnut Hill, Massachusetts. Department of Sociology and Institute on Aging, Boston College, Chestnut Hill, Massachusetts.
*Address correspondence to Jooyoung Kong, MSW, Graduate School of Social Work, Boston College, 140 Commonwealth Avenue, Chestnut Hill, MA 02467. E-mail: [email protected] Received May 31, 2013; Accepted October 8, 2013 Decision Editor: Rachel Pruchno, PhD
Purpose of the Study: This study examined depressive symptoms among adult survivors of childhood maltreatment who provided care to their former abusive/neglectful parents. We also investigated the extent to which four coping styles—problem-focused coping, emotion-focused coping, positive social support, and negative social support—moderated the association between childhood maltreatment and depressive symptoms of the caregivers. Design and Methods: Among 1,001 filial caregivers from the 2003–2005 wave of the Wisconsin Longitudinal Study, 18.6% of respondents reported verbal, physical, or sexual abuse in childhood; 9.4% reported neglect in childhood. Ordinary least squares regression models were estimated. Results: Persons who had a history of parental abuse showed significantly more frequent depressive symptoms when providing care to their abusive parent(s) compared with caregivers who had not experienced parental abuse. Those who had been neglected had significantly more frequent depressive symptoms than caregivers who did not report neglect. Additionally, the use of emotion-focused coping was more strongly associated with more frequent depressive symptoms among abused caregivers than among caregivers with no history of abuse. Implications: This vulnerable group of caregivers should be recognized in the development and implementation of support services for family caregivers at the state and national levels. In direct practice settings, when assessing caregiver stress and burden, the history of childhood maltreatment needs to be taken into account.
Key Words: Caregiving, Child abuse and neglect, Coping styles, Depressive symptoms, Stress process model
The federal Child Abuse Prevention and Treatment Act (CAPTA) defines child abuse and neglect as: “Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act, which presents an imminent risk of serious harm” (CAPTA Reauthorization Act of 2010). Recent data on child maltreatment reported that 9.1 out of every 1,000 U.S. children experienced abuse or neglect from their caretaker(s) in 2011 (National Child Abuse and Neglect Data System, 2011). This high prevalence rate is especially concerning because experiences of child abuse or neglect can lead to intra- and interpersonal problems throughout the life course (Afifi, Boman, Fleisher, & Sareen, 2009; Ethier, Lemelin, & Lacharite, 2004). Little is known, however, about adult survivors of childhood maltreatment who become caregivers for their previously abusive or neglectful parent(s). A substantial body of literature links caregiving to adverse mental health outcomes, such as high levels of stress, depression, and anxiety (Amirkhanyan & Wolf, 2006; Katerndahl & Parchman, 2002). We speculate that this may be even more true of filial caregivers who were abused or neglected as children.
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This study is intended to begin to fill this gap in the literature. Two primary goals of the current study were (a) to examine the levels of depressive symptoms in adult survivors of childhood maltreatment who provide care to their childhood abusers or neglectors and (b) to evaluate the extent to which various coping styles moderate the relationship between abuse or neglect as a child and depressive symptoms as a caregiver. We analyzed data from 1,001 adult children caring for their parents, and our conclusions are based on the Stress Process Model (SPM; Pearlin, Lieberman, Menaghan, & Mullan, 1981). By enhancing the understanding of the stress process of formerly abused or neglected filial caregivers, this study will provide theoretical and empirical evidence for social work interventions. SPM SPM studies have shown how stressors, psychological stress outcomes, and intervening mediators are interconnected in a causal process (Pearlin, 1989; Pearlin et al., 1981). Particularly, the SPM has been used extensively as a conceptual framework to explain caregivers’ health and psychosocial outcomes (Pearlin, Mullan, Semple, & Skaff, 1990). In the caregiving context, stressors refer to the objective and subjective indicators of caregiving demand and burden. Objective indicators include the care recipient’s cognitive status, problem behaviors, and level of functional disability (Mausbach et al., 2012). Subjective indicators are caregivers’ feelings of overload, the closeness of the relationship between caregiver and care recipient, and subjective appraisal of their own difficulty (Son et al., 2007). Stress outcomes involve inhibition of caregivers’ well-being in terms of their physical or mental health or social functioning, including disruption in usual activities, incidence of injuries, disorders in the digestive and cardiovascular systems, depression, and anxiety (Pearlin, 1989; Pearlin et al., 1990). In the SPM, stressors do not invariably result in stress outcomes. Rather, coping strategies and social support may intervene (Pearlin et al., 1981). Folkman and Lazarus (1980, p. 223) define coping as “the cognitive and behavioral efforts made to master, tolerate, or reduce external and internal demands and conflicts among them.” Coping serves to either manage or alter the person-environment relationship, which is known as problemfocused coping, or to regulate stressful emotions,
known as emotion-focused coping (Folkman & Moskowitz, 2004). Problem-focused coping involves active efforts oriented toward confronting the problem, whereas emotion-focused coping is oriented toward reducing tensions and negative emotions. Certain types of emotion-focused coping strategies (e.g., avoidance) are consistently associated with poor stress outcomes; much has been reported on the detrimental effects of avoidance coping in relation to psychological well-being of caregivers (Mausbach et al., 2012; Powers, Gallagher-Thompson, & Kraemer, 2002). Other types of emotion-focused coping and problemfocused forms of coping, however, are sometimes associated with positive outcomes, depending on the situational context or a person’s appraisal of stressful events (Folkman & Moskowitz, 2004). Social support can be defined as “the access to and use of individuals, groups, or organizations in dealing with life’s vicissitudes” (Pearlin et al., 1981, p. 340). Much research has shown that social support plays a protective role by attenuating stress outcomes. However, negative interactions and unhelpful support from significant others predict psychological distress, such as depression, anxiety, and anger (Ha, 2010; Lincoln, 2008). Pearlin and his colleagues, who coined the term SPM and developed its theoretical framework, exclusively refer to these intervening factors (i.e., coping and social support) as “mediators.” However, SPM researchers have examined not only the mediating effects of the intervening factors, but also their moderating effects on the manifestations of stress. The difference between mediation and moderation is that mediators explain, in whole or in part, the relation between stressors and stress outcomes, whereas moderators affect the strength and/or direction of the relation between stressors and stress outcomes (Baron & Kenny, 1986). In this study, we focused on examining the moderating effects of coping strategies and social support in order to investigate the efficacy of coping strategies that these abused or neglected caregivers use in response to stressors. Long-Term Effects of Childhood Maltreatment Adult survivors of childhood abuse and neglect are known to experience more physical health problems, mental health problems, and cognitive impairments than their nonabused or nonneglected counterparts (Afifi et al., 2009; Ethier et al., 2004). Childhood maltreatment also increases a person’s chances of having poor social relationships due to
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The Gerontologist
distrust of others, low self-esteem, and difficulty in forming secure attachments to others (Cook et al., 2005). Furthermore, early maltreatment predicts difficulties in establishing and maintaining intimate partner relationships (Whisman, 2006). Evidently, adult survivors may still experience unresolved trauma issues. These findings also imply that survivors may have less ability or opportunity to seek support or enact positive coping methods when dealing with the stress of caregiving. It is an ironic situation that a dysfunctional parent–child relationship can switch to a care recipient–caregiver relationship later in life. This study attempts to capture the consequences of such a role reversal. Research has shown that relationship quality is one of the significant predictors of outcomes for caregivers. There have been mixed results: Dyadic closeness as an indicator for positive attachment or emotional bond predicts both protective and adverse effects on caregiving outcomes (Fauth et al., 2012). This study is an extension of this line of research because it focuses on the long-term consequences of destructive parent–child relations in childhood. The Present Study The key research questions in this study are the following: (a) How does abusive/neglectful treatment from parents in childhood affect adult children’s mental health when they provide care to their older parents? and (b) How do such filial caregivers process their stress through social support and various coping mechanisms? The situation of providing care to past abusive/neglectful parent(s) serves as a primary stressor, and depressive symptoms serve as a stress outcome. A set of intervening factors—problem-focused coping, emotional-focused coping, positive social support, and negative social support—are examined to understand the extent to which the four coping styles alter the depressive symptoms of the maltreated caregivers. All analyses control for sociodemographic characteristics and health status of the respondents. These measures have been used as covariates of depression in the caregiving literature (Pinquart & Sorensen, 2003) and may also be associated with the experience of prior abuse or neglect (Ethier et al., 2004). Method Data Set The Wisconsin Longitudinal Study (WLS) is a random sample survey of 10,317 men and women
from the birth cohort of 1939 who graduated from Wisconsin high schools in 1957. The graduates were reinterviewed at three different time points: 1975, 1992–1993, and 2003–2005. The data set provides nearly 50 years of records for the graduates, encompassing social background, education, family formation, employment, social participation, health, and aging. This study used data from the 2003–2005 wave when most graduates turned 65 years old. This wave provides information on caregiving as well as retrospective reports on experiences of abuse and neglect in childhood. Almost 85% of living graduates participated in the telephone survey in 2004, and 88% of these participants completed the mailin follow-up questionnaire. Because the major focus of this study is the depressive symptoms of filial caregivers, the 1,001 graduates who reported providing care to their parent(s) constituted the final study sample. The mail-in survey includes the question: “Have you ever given personal care for a period of 1 month or more to a family member or friend because of a physical or mental condition, illness, or disability, not including your spouse?” Among individuals who answered “yes” to this question, respondents who specified that they have given care to “father,” “mother,” or “both parents” were selected for the study sample. Measures Depressive Symptoms.—The dependent variable was depressive symptoms as measured by the 20-item Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977). Each item used an 8-point scale (0–7) to mark the number of days in the past week a respondent had experienced a specific symptom. The maximum possible score was 140, but no caregivers reported such debilitating depressive symptoms. Provided that a respondent answered more than 15 items of the scale, the 20 items were summed to give a single score (α = 0.80). The square root of the depression scores was used in the ordinary least squares (OLS) analyses due to the high skewness of the variable. Experience of Neglect.—The key independent variables were experiences of child abuse and/ or neglect by parent(s). First, child neglect was assessed using the question: “Up until you were 18, how often did you know that there was someone to take care of you and protect you?” The item
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was drawn from the well-validated Childhood Trauma Questionnaire (Bernstein et al., 1994). The item does not ask directly about the respondent’s parents. However, supplementary analyses showed that more than 85% of neglected caregivers reported that they lived with both parents most of time up until high school graduation. Therefore, we infer that respondents who did not feel cared for and protected had neglectful parent–child relationships. There were five response choices: “Never,” “rarely,” “sometimes,” “often,” and “very often.” The variable was recoded as a binary variable to deal with the skewness of the item. Those who reported “never,” “rarely,” and “sometimes” were coded as having experienced neglect as children; those who responded “often” and “very often” were coded as having no experience of child neglect. Experiences of Child Abuse.—Each respondent was evaluated for childhood exposure to parental verbal, physical, and sexual abuse. Child verbal abuse was measured using two questions that asked whether a respondent’s (a) father or (b) mother would “insult or swear” at them before age 18. There were four response categories: “not at all,” “a little,” “some,” and “a lot.” Those who reported “some” or “a lot” were counted as having experienced child verbal abuse; “a little” and “not at all” responses were considered having no experience. This is consistent with coding in the prior literature (Springer, 2009). Child physical abuse was assessed based on the response to two questions: “Up until you were 18, to what extent did your (a) father and (b) mother treat you in a way that you would now consider physical abuse?” In this case, those who reported “a little,” “some,” or “a lot” as opposed to “not at all” were coded as having experienced physical abuse as children. Child sexual abuse was measured using two questions: “Up until you were 18, to what extent did your father have oral, anal, or vaginal sex with you against your wishes?” and “Up until you were 18, to what extent did your father treat you in a way that you would now consider sexual abuse?” Those who responded “a little,” “some,” or “a lot” to either question were classified as having been sexually abused by their father. The 2003–2005 WLS data did not assess child sexual abuse by mothers. We wished to isolate the effect of caring for an abusive parent from the effect of having experienced parental abuse but caring for a parent who was not abusive. For example, if a person was abused by
the father but not the mother as a child, providing care to the father may be particularly stressful, whereas caring for the mother may involve normal levels of caregiving stress or depression. Thus, the final child abuse variable had three mutually exclusive categories: (a) no history of child abuse (reference category); (b) verbally, physically, or sexually abused by a parent and caring for that abusive parent; (c) verbally, physically, or sexually abused by a parent but caring for a nonabusive parent (see Table 1 for subsample sizes). In the case that a caregiver reported providing care for both an abusive parent and a nonabusive parent, the person was coded as caring for an abusive parent. Coping.—The 2003–2005 data set provides items assessing respondents’ coping strategies and reactions to their stressful life events based on the COPE scale (Carver, Scheier, & Weintraub, 1989). Principal-axes factor analyses were conducted to identify underlying factors in the items related to the coping styles, which yielded a two-factor solution that worked best both conceptually and empirically (results available from the first author upon request). The solution identified two groups: problem-focused coping and emotion-focused coping variables. Problem-focused coping was measured by summing four questions (α = 0.80): “Generally, when you experience a difficult or stressful event, how often do you (a) concentrate your efforts on doing something about the situation you’re in; (b) take actions to try and make the situation better; (c) try to come up with a strategy about what to do; (d) think hard about what steps to take?” Respondents who skipped any items were coded as missing. Each item was measured on a 4-point Likert scale, ranging from “not at all” (1) to “a lot” (4). Next, emotion-focused coping was measured with nine questions (α = 0.66): “Generally, when you experience a difficult or stressful event, how often do you (a) say things to let your unpleasant feelings escape; (b) criticize yourself; (c) express your negative feelings; (d) blame yourself for things that happened; (e) say to yourself ‘this isn’t real’; (f) give up trying to deal with it; (g) refuse to believe that it has happened; (h) give up the attempt to cope; (i) do something to think about it less, such as going to the movies, watching TV, reading, daydreaming, sleeping or shopping?” All the nine items were coded in the same direction such that a higher score represented a greater use of emotion-focused coping, as per the original citation (Carver et al., 1989). The scale’s reliability coefficient was slightly
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The Gerontologist
Table 1. Characteristics of Filial Caregivers in the Wisconsin Longitudinal Study, 2003–2005 (N = 1,001) Variables Child abuse No history of parental abuse Experienced parental abuse, caring for the abusive parent Experienced parental abuse, caring for a nonabusive parent Child neglect No history of neglect Neglected in childhood Gender Male Female Marital status Married Separated/divorced Widowed Never married Self-reported health Very poor/poor Fair Good Excellent Diagnosis of major illnesses Diabetes Cancer Heart problems Stroke Years of education Total household income (USD) Number of functional limitations Depression (α = 0.80) Problem-focused coping (α = 0.80) Emotion-focused coping (α = 0.66) Positive social support (α = 0.80) Negative social support (α = 0.55)
N
%
N, missing (%)
801 101
81.40 10.26
82
8.33
892 92
90.65 9.35
277 724
27.67 72.33
756 114 67 64
75.52 11.39 6.69 6.39
23 124 625 221
2.32 12.49 62.94 22.26
96 115 130 31
9.59 11.49 12.99 3.10
Mean (SD)
Observed, Min./Max.
N, missing (%)
13.59 (2.19) 60,231.89 (83,327.79) 1.40 (1.66) 14.51 (14.10) 12.92 (2.54) 16.23 (3.65) 7.80 (1.81) 3.21 (1.36)
12/20 0/710,000 0/7 0/97 4/16 8/32 2/10 2/10
0 (0) 0 (0) 13 (1.30) 22 (2.20) 51 (5.09) 41 (4.10) 21 (2.10) 23 (2.30)
17 (1.70)
17 (1.70)
0 (0)
0 (0)
8 (0.80)
1 (0.10)
Notes: Descriptive statistics are reported prior to correction for skew, standardization, and multiple imputation. Higher mean scores indicate greater depressive symptoms and greater use of each coping strategy.
low. However, confirmatory factor analysis indicated that all the items had a strong loading (above 0.30) on a single factor (Carver et al., 1989). Social Support.—This study distinguished between the positive and negative aspects of social support. For the positive aspect, two questions were summed (α = 0.80): “How much do your friends and relatives other than your spouse and children (a) make you feel loved and cared for and (b) are willing to listen to you?” Negative social support was assessed with the two questions (α = .55): “How much do your friends and relatives other than your spouse and children (a) make too many demands on you and (b) are critical of what you
do?” The low reliability of the negative social support measure is not surprising considering that alpha is highest when a scale has a large number of items that are unidimensional (Cortina, 1993). This scale has two items that measure different dimensions of negative support (i.e., criticism and demands). Further, this two-item scale has been widely used in published work (Ha, 2010). Each item was measured on a 5-point Likert scale, ranging from “not at all” (1) to “a lot” (5). Respondents who skipped any items were coded as missing. Covariates.—We controlled for sociodemographic characteristics including gender, marital status (married, separated/divorced, widowed,
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never married), education (in years), and household income (square rooted to correct skewness). Informed by the previous literature (Schafer & Ferraro, 2012), we also included three measures of current health. These were self-reported health status (very poor, poor, fair, good, excellent), functional limitations (count of seven possible difficulties), and diagnosis of any of four major illnesses (diabetes, cancer, heart disease, and/or stroke). Data Analysis First, bivariate analyses were conducted to compare the levels of depressive symptoms, coping strategies, and social support between abused caregivers and their nonabused counterparts, and between neglected caregivers and their nonneglected counterparts. Next, a series of OLS regression models were estimated with depressive symptoms as the outcome variable. In Model 1, the abuse and neglect variables, as well as the sociodemographic and health variables, were the independent measures. In Model 2, the coping strategies and social support were added to examine their effects on depressive symptoms. Model 3 examined whether caregiver depression was contingent upon the coping strategies and social support by adding multiplicative interaction terms. The coping strategies and social support variables were mean centered before creating the interaction terms (Aiken & West, 1991). Complete data were provided by 90.5% of participants. The summed scale of problem-focused coping had the most missing data (n = 51; 5.1% of cases). To handle incomplete data, we conducted multiple imputation by chained equations in Stata
12.0. We generated 20 data sets with imputed values. As von Hippel (2007) suggested, we included our dependent variable in the imputation model and then deleted its imputed values in the analyses. Results Sample Characteristics Table 1 presents the descriptive statistics for all variables in the analyses. The majority of respondents (76.7%) cared for their mothers only; 195 caregivers (19.5%) cared for fathers only. Only 38 caregivers (3.8%) cared for both parents. Among the caregivers, 18.6% had experienced some type of parental abuse, and 9.4% reported neglect in childhood. Mean comparisons indicated that abused caregivers, either providing care to their abusive or nonabusive parent, had more frequent depressive symptoms than nonabused caregivers. Neglected caregivers also showed significantly more frequent depressive symptoms than the nonneglected caregivers (see Table 2; see Table 3 for correlations between variables). Multivariate Analyses A summary of regression results is presented in Table 4. Model 1 examined the main effects of child abuse and neglect on caregivers’ depressive symptoms. For those who experienced any type of abuse in childhood, caring for the abusive parent was associated with more frequent depressive symptoms (b = 0.38, p < .05). In addition, providing care to a neglectful parent was associated with more frequent depressive symptoms (b = 0.51, p
