Impact of Child Maltreatment on Attachment and Social Rank Systems: Introducing an Integrated Theory

TRAUMA, VIOLENCE, & ABUSE 1-14 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1524838015584354 tva.sagepub.com

Leon Sloman1 and Peter Taylor2

Abstract Child maltreatment is a prevalent societal problem that has been linked to a wide range of social, psychological, and emotional difficulties. Maltreatment impacts on two putative evolved psychobiological systems in particular, the attachment system and the social rank system. The maltreatment may disrupt the child’s ability to form trusting and reassuring relationships and also creates a power imbalance where the child may feel powerless and ashamed. The aim of the current article is to outline an evolutionary theory for understanding the impact of child maltreatment, focusing on the interaction between the attachment and the social rank system. We provide a narrative review of the relevant literature relating to child maltreatment and these two theories. This research highlights how, in instances of maltreatment, these ordinarily adaptive systems may become maladaptive and contribute to psychopathology. We identify a number of novel hypotheses that can be drawn from this theory, providing a guide for future research. We finally explore how this theory provides a guide for the treatment of victims of child maltreatment. In conclusion, the integrated theory provides a framework for understanding and predicting the consequences of maltreatment, but further research is required to test several hypotheses made by this theory. Keywords social rank system, attachment system, involuntary defeat strategy, involuntary winning strategy, psychopathology, child maltreatment

Introduction There has been a lot of discussion of the causes and effects of child maltreatment, but what we still lack is a comprehensive account of the psychobiological mechanisms that intervene. We explore how to conceptualize mechanisms whereby early experiences of maltreatment lead to an increased vulnerability to a variety of psychological difficulties in adulthood. We first address the overlapping theoretical perspectives of attachment theory (Bowlby, 1969) and social rank theory (Price & Sloman, 1987; Sloman, Gilbert, & Hasey, 2003; Taylor, Gooding, Wood, & Tarrier, 2011). The attachment and social rank systems are very reactive to child maltreatment. First, children’s loss of trust in others makes it harder to comfort and reassure them (Erikson, 1950) and second, the imbalance of power leaves them feeling helpless, hopeless, and disempowered (Gilbert, 2000). Within this article, we introduce a framework for understanding the consequences of maltreatment in terms of the interaction between the attachment and the social rank systems. It is important that any new theory can give rise to testable hypotheses. With this in mind, the goals of the article are to provide an overview of this theory and to consider the novel hypotheses that can be drawn from this theory that require

empirical testing. These hypotheses will serve to illustrate the theory and provide a guide for future research. We commence by undertaking a narrative review of the relevant literature, which is structured around the components of the theory. After an overview of the impact of maltreatment, we will discuss these systems and show how considering the interaction between attachment and social rank illuminates the adverse consequences of child maltreatment and provides a basis for therapeutic intervention.

The Nature of Child Maltreatment The term child maltreatment covers psychological, physical, and sexual abuse, neglect, and failure to provide basic needs (Gilbert, 2009; Radford et al., 2011). These often coexist 1

Centre for Addiction and Mental Health, University of Toronto, Toronto, Canada 2 Institute of Psychology, Health and Society, University of Liverpool, England Corresponding Author: Leon Sloman, Centre for Addiction and Mental Health, 80 Workman Way, Toronto, Ontario, Canada M6 J 1H4. Email: [email protected]

2 (Felitti et al., 1998; Radford et al., 2011). Recent prevalence rates estimates based on self-report (official statistics may underestimate prevalence) suggest that abuse is common, with estimated rates across different countries of 3.7–16.3% for physical abuse, 4.9% for severe emotional abuse, and 5–30% for sexual abuse (gender is an important factor affecting prevalence in the latter case; Gilbert, 2009). Likewise neglect is also prevalent with rates of 3–6% (physical neglect, absence of care, or supervision) reported (Christoffersen, Armour, Lasgaard, Andersen, & Elklit, 2013; May-Chahal & Cawson, 2005). Early experiences of maltreatment lead to poorer adjustment in a variety of domains. These include an increased risk of mental health problems (e.g., depression, posttraumatic stress disorder [PTSD], suicidality, and substance abuse), physical health problems (e.g., obesity and pain), and risky behaviors (e.g., inappropriate sexualized behaviors) in both the short and the longer term (Gilbert et al., 2009; Maniglio, 2009; Radford et al., 2011). Every type of maltreatment is an independent risk factor for future types of debilitation. Furthermore, the Adverse Childhood Experiences study has identified a dose–response relationship between child maltreatment and numerous risk factors for premature death in adults (Felitti et al., 1998). Notably, there does not appear to be clear evidence of a specific relationship between types of maltreatment and particular outcomes (e.g., a sexual-abuse syndrome; Edgardh & Ormstad, 2000). Different forms of maltreatment often have a similar long-term outcome, although some recent studies do suggest specific pathways (Sitko, Bentall, Shevlin, O’Sullivan, & Sellwood, 2014). Within the current article, we largely focus on the common effects of maltreatment but note that unique effects of specific forms of maltreatment may also be operating. We first consider the social rank system in understanding the consequences of maltreatment.

The Social Rank System Price (1967) threw light on the evolutionary function of defeat reactions by noting similarities between depressed patients and long-tailed macaques that have just lost hierarchical encounters. He proposed that states of depression, anxiety, and irritability are the emotional correlates of behaviors that are necessary for the maintenance of the dominance hierarchy in social groups. Price later proposed that the ideas of inferiority, unworthiness, withdrawal, loss of self-esteem, and other characteristic features of depression were exquisitely designed to discourage the individual from continuing the competitive struggle and either submit or flee. This reduces the chances of injury or death. Such characteristics signal a ‘‘no-threat,’’ subordinate status to conspecifics. Other labels have been used, but we call the reaction to defeat the Involuntary Defeat Strategy (IDS). It is involuntary because it is automatic, and it is a strategy because it is designed to fulfill an adaptive function. The IDS can be contrasted with the Involuntary Winning Strategy (IWS; Sloman & Sturman, 2011), which is triggered by agonistic victory and success. The euphoria associated with the IWS promotes a shift from the adversarial mind-set to feelings

TRAUMA, VIOLENCE, & ABUSE of benevolence, which promote reconciliation with the loser. The IWS may motivate us to greater effort, when we strive to succeed in order to feel the euphoria associated with the IWS. Shame is particularly characteristic of a persistent IDS. While definitions of shame vary, a key element is the sense that other’s view oneself as flawed or inferior (Gilbert, 1997; Kim Thibodeau, & Jorgensen, 2011; Wiechelt, 2007). Shame can be viewed as part of a hard-wired affect system (the IDS) that has its origins as an evolved response signaling a loss of rank or ‘‘loser’’ status within early social groups (Kim et al., 2011; Wiechelt, 2007). Pride/shame could be thought of as a single emotional continuum (Weisfeld & Wendorf, 2000).

The Attachment System Bowlby (1969) conceptualized the attachment system as a psychobiological system that functions to keep the child safe by maintaining proximity to the caregiver. The perceived accessibility and responsiveness of the attachment figure contributes to a sense of security for the child. Where there is a lack of availability, the attachment system is triggered resulting in behaviors (e.g., distress and proximity seeking) that operate to increase the availability of the attachment figure once more. Attachment theory states that infants develop distinct sets of expectations concerning attachment relationships, based on their caregiving experiences, which form the basis of a cognitive Internal Working Model. This develops within the context of early attachment relationships and influences an individual’s future expectations and attachment behaviors (Bretherton & Munholland, 1999). Early attachment relationships are believed to influence how individuals relate to others during adulthood, including how individuals experience and regulate affective states (Shaver & Mikulincer, 2011). Early relationships therefore influence the ability to self-soothe and regulate emotions in later life (Cassidy, 1994; Shaver & Mikulincier, 2010).

The Impact of Maltreatment upon the Social Rank System Within humans, failure and loss of status activate the IDS (Rohde, 2001; Sloman, 2008). A mildly active IDS is common, accounting for the unpleasant experience that follows events such as the rejection of an academic paper or being spurned by a romantic partner. An activated IDS carries subjective feelings of failed struggle, giving-up, and feeling at the bottom of the ladder (Gilbert & Allan, 1998), and descriptions of abuse bear marked similarities to the characteristics of agonistic defeats. We argue that abusers trigger a pattern of reaction in the victim that is akin to the IDS and abuse of a child can be construed as an agonistic defeat. Research outlines this dynamic; the abuser is often older and larger than the victim, perceived as more powerful, and asserting their will upon the victim, while the victim experiences feelings of powerlessness and helplessness (Morrow & Smith, 1995; Rudd & Herzberger, 1999). Another way the IDS and abuse reaction are alike is that

Sloman and Taylor both demonstrate kindling. Early abuse can lead to a lasting vulnerability to distress and disorder. Likewise, we theorize that the IDS, when overstimulated at an earlier point in time, can be triggered again by a smaller amount of stimulation so that repeated triggering leads to escalation even after a number of years (Post & Weiss, 1998). As with the IDS more generally, brief experiences of shame may be adaptive, facilitating self-monitoring and highlighting possible social transgression (Wiechelt, 2007). However, where escape is blocked, or there is too much anger or resentment to accept defeat, this prevents the IDS from being deactivated so that IDS activation and associated feelings of shame become chronic. This occurs frequently in cases of abuse, where the child is unable to fight back and submission does not stop the abuse so that the IDS cannot be deactivated. While effective functioning of the IDS reduced the risk of physical injury in early man, persistent ineffective functioning of the IDS contributes to depression and other forms of psychopathology (Taylor et al., 2011). IDS dysfunction would be predicted to manifest in extreme dominant (e.g., aggression, bullying) and submissive behavior in children experiencing abuse. There is evidence that such behaviors are elevated in children who have experienced maltreatment (Shields & Cicchetti, 2001), although these behavioral problems appear more pronounced in those who have been abused versus those who have faced only neglect (Hildyard & Wolfe, 2002). Maltreated female preschool children also experienced less pride following success and more shame following failure than nonmaltreated children (Alessandri & Lewis, 1996), suggesting an underlying dysfunction in the social rank system (although different effects were observed in boys). Moreover, these dysfunctional patterns may persist for long periods. In a longitudinal study of children experiencing sexual abuse, the majority (63%) experienced heightened levels of shame around the time of the discovery of the abuse (Feiring & Taska, 2005), and a substantive 39% of those in the high shame group were still experiencing elevated shame levels 6 years later. Feiring, Simon, and Cleland (2009) also highlight the stability over time of shame following abuse. Notably, although Stuewig and McCloskey (2005) did not find a relationship between sexual abuse and shame, they employed a measure of shame that relied on judgments around hypothetical scenarios, which may be too removed from reality to trigger the social rank system. Studies in adult clinical and nonclinical populations demonstrate that a history of abuse is associated with higher levels of current shame (Fowke, Ross, & Ashcroft, 2012; Webb, Heisler, Call, Chickering, & Colburn, 2007). It should be noted, however, that these findings largely rely on selfreport measures of shame, which may be prone to biases such as respondents conflating shame and similar emotions such as guilt (Tangney & Dearing, 2002). In qualitative research into adult survivor’s accounts of psychological (emotional) maltreatment, shame has also emerged as a dominant theme (Harvey, Dorahy, Vertue, & Duthie, 2012). Other emerging themes also reflected characteristics

3 of subordinate rank, including a tendency toward self-inhibition, withdrawal from others, and the tendency to dichotomize others into roles characterized by subordinate and dominant status. Submissive behavior and negative social comparison, which can be viewed as behavioral and cognitive components of shame, respectively, correlate with reports of childhood abuse in undergraduates (C ¸ elik & Odaci, 2012). Research into trauma in adulthood provides evidence that appraisals characterized by perceptions of giving-up and powerlessness are predictive of the subsequent development of PTSD (see review by Taylor et al., 2011). Based on the observed relationship between abuse and proxy indicators of an active IDS (e.g., shame, withdrawal, and submission), the following hypothesis can be made: Hypothesis 1: The level of IDS activation in children with experiences of abuse will be positively associated with stronger feelings of shame. Directly testing this relationship will, however, require a valid and reliable measure of the IDS (see Sturman, 2011). Thus, theoretically, the conceptualization of abuse as an extreme and ongoing agonistic defeat accounts for the emergence of shame. A power imbalance is a feature of all abuse, but there may nonetheless be variation in victim’s awareness and experience of this imbalance that, at least partly, accounts for variation in reactions to abuse. For example, as has been noted for trauma in adulthood, some individuals may hold on to a greater sense of having maintained their psychological autonomy, resisting mentally even where physical resistance is not possible (Ehlers, Maercker, & Boos, 2000). Notably, both crosssectional and longitudinal studies demonstrate that, where such traumas are experienced as a defeat, the development of disorders like PTSD is more likely (see review by Taylor et al., 2011). Molnar, Buka, and Kessler (2001) provide evidence that greater chronicity is associated with poorer outcomes. From a social rank perspective, greater chronicity amplifies the kindling effect through repeated IDS activation, which renders the system more sensitive to reactivation. Increased sensitivity of the IDS response might have been a valuable adaptation in environments characterized by high risk from conspecifics (e.g., during times of famine or limited resources) but are of little value in the context of abuse, where the individual has no means of escape. Hypothesis 1 is consistent with earlier theories of the impact of abuse that posit a link between abuse and shame (e.g., Feiring, Taska, & Lewis, 1996; Finkelhor & Browne, 1985). In Feiring, Taska, and Lewis’ (1996) theory, they emphasize the importance of the attributions young people make about abuse in contributing to experiences of shame. While the importance of these attributional factors is supported by research (Feiring, Taska, & Chen, 2002), it does not seem to fully account for the ubiquity of shame following abuse (e.g., high prevalence reported by Feiring & Taska, 2005). We therefore postulate that, when abuse is experienced as agonistic defeat, shame is

4 more likely to emerge. Self-blaming attributions are therefore viewed as a secondary consequence of the abuse, co-occurring with the emergence of shame. Indeed, self-blame can be understood as a manifestation of the cognitive component of shame that emerges with the activation of the IDS. However, these possibilities are yet to be supported by research. Establishing the temporal sequence of these processes is methodologically complex and will require prospective designs. What social rank theory adds is a strong rationale for why feelings of shame would emerge in these circumstances even when, from a rationale standpoint, the victim is in no way responsible for what has occurred. The social rank theory also explains why this emotion is so aversive, as it relates to extreme agonistic failure and core goals around survival and identity (Kemeny, Gruenewald, & Dickerson, 2004). It also accounts for why shame is associated with behavioral tendencies toward concealment and withdrawal, which are evolved defensive strategies triggered by IDS activation. One reason for avoiding agonistic interactions with others who are too powerful and for trying to avoid ignominious defeat is to avoid feeling shame. Our susceptibility to shame may therefore sometimes be adaptive, even when we do not experience shame. However, the abused child does not have the option of avoiding defeat.

Impact of Maltreatment Upon the Attachment System It is well established that maltreatment can impair the functioning of the attachment system. For example, an abusive caregiving relationship may create a conflict whereby the caregiver is both frightening/abusive and a source of safety/comfort (Hesse & Main, 2006). In these circumstances, the child may come to rely on suboptimal attachment strategies and behaviors, such as the freezing and stereotyped action seen in disorganized attachment styles (Van Ijzendoorn, Schuengel, & Bakermans Kranenburg, 1999). These early relational experiences may become stamped onto the child in the form of an internal working model (Bretherton & Munholland, 1999), characterized by the internalization of negative attachment experiences, which leave individuals ill equipped for managing future relationships and emotions (Balbernie, 2001; Riggs, 2010). These insecure or disorganized attachment patterns may, in turn, lead to difficulties in emotional regulation that leave the individual vulnerable to subsequent psychopathology (e.g., Riggs, 2010; Stirling & Amaya-Jackson, 2008). Meta-analyses support this relationship between child maltreatment and the risk of an insecure or disorganized attachment in children (Cyr, Euser, Bakermans-Kranenburg, & Van Ijzendoorn, 2010; Van Ijzendoorn et al., 1999). All forms of childhood abuse and neglect are related to insecure attachment in adulthood (Hildyard & Wolfe, 2002; Pierrehumbert et al., 2009; Riggs & Kaminski, 2010; Rumstein-McKean & Hunsley, 2001; Varia & Abidin, 1999). In a nationally representative sample of U.S. households, physical abuse, sexual abuse, and neglect were shown to be predictors of insecure attachment patterns (Mickelson, Kessler, & Shaver, 1997). Attachment patterns demonstrate mild to moderate stability over time,

TRAUMA, VIOLENCE, & ABUSE showing that while earlier attachment patterns often predict later ones, there remains a high degree of unexplained variance (Van Izjendoorn et al., 1999; Weinfield, Whaley & Egeland, 2004). However, maltreatment in childhood may produce more rigidly insecure attachment patterns (Weinfield et al., 2004). Studies in adult populations may be open to bias because of a reliance on retrospective accounts of maltreatment, but there may be more false negatives than false positives (Fergusson, Horwood, & Woodward, 2000). Most studies, although not all (Varia & Abidin, 1999), do not distinguish between maltreatment perpetrated by a caregiver, which would be more disruptive for attachment, as compared with maltreatment from another source.

Limitations of Social Rank and Attachment Theory Descriptions of reactions to defeat have been inconsistent. For example, Price and Sloman (1987) had a narrower definition than Price (1967). Furthermore, the long-term consequences of the IDS are probably more varied than once thought (Felitti et al., 1998). Social rank theory is also limited in its ability to explain why some people develop one disorder and others develop another (Taylor et al., 2011). As noted, maltreatment is related to a plurality of disorders and social rank theory is limited in its capacity to explain why one individual may experience depression rather than anxiety or psychosis. There is also an overlap between social rank theory and competing theories like learned helplessness theory (Peterson, Maier, & Seligman, 1993), inasmuch as both describe how being trapped in an aversive and uncontrollable environment may contribute to psychological difficulties. Learned helplessness could also, therefore, account for some of the effects of maltreatment. Social rank theory is also less explicit about the cognitive processes involved in individuals’ responses to trauma, for example, the role of attributions, although attempts to link social rank theory to cognitive processes have been made (Swallow, 2000). Critical discussions of attachment theory exist elsewhere (e.g., Rutter, 1995). One limitation of attachment theory is that, similarly to social rank theory, the simplicity of the present delineation of attachment styles does not capture the complexity of responses to trauma and resulting difficulties. Attachment theory also concerns the relationship between child and caregivers and is limited in accounting for the negative impact of maltreatment or hostile interpersonal relationships involving noncaregivers. However, a consideration of the interaction between attachment and social rank theories enables one to better account for the complexity of reactions to trauma.

Interaction Between Attachment and Social Rank Systems It is important to consider both the attachment and the social rank systems in evaluating the consequences of maltreatment because different systems may play a greater or lesser role depending on the nature of the maltreatment. A number of studies support a relationship between more active forms of abuse

Sloman and Taylor and shame (see earlier), but few have looked at the link between neglect and shame. One study examining shame-like reactions to an experimental task in children found that abuse but not neglect was related to shame (Bennett, Sullivan, & Lewis, 2005). We therefore suggest the following: Hypothesis 2: Neglect will have a stronger association with attachment insecurity than with IDS activation within the first 6 months following maltreatment, while physical, sexual, or emotional/verbal abuse will have a stronger relationship with IDS activation. This hypothesis is based upon the theoretical principles of an integrated theory but is yet to be tested empirically. This hypothesis is, however, consistent with the observation of more extreme behavioral problems occurring in young children who have been abused versus those who have been neglected (Hildyard & Wolfe, 2002). As noted, the IDS may be strongly activated following situations of abuse. In cases of neglect, the social rank system may not initially be triggered, but disorganized or insecure attachment patterns may be expected. As different forms of maltreatment often co-occur (Gilbert et al., 2009; Radford et al., 2011), parallel activation of both systems would be expected in many cases. Moreover, intrafamilial abuse often occurs in the context of wider family dysfunction, and so insecure attachment patterns may precede the initiation of the abuse (Alexander, 1992). These factors are liable to present challenges in testing Hypothesis 2. It is also possible for the IDS to be triggered in the absence of overt abuse as in hostile relationships characterized by a power differential and unresponsiveness to a child’s attempts to submit or fight back. Consequently, it may be useful clinically and theoretically to think about abuse in terms of broader relationships and the family system as well as a series of discrete instances. Human attachment theory and social rank theory are conceptually interrelated (Sloman, Gilbert, & Hasey, 2003; Sloman, Atkinson, Milligan, & Liotti, 2002) and empirically intercorrelated, with greater attachment insecurity associated with greater negative social comparison and submissive behavior (Gilbert, McEwan, Hay, Irons, & Cheung, 2007; Irons & Gilbert, 2005). Based on these existing findings, we propose the following: Hypothesis 3: Over time, changes in one system (e.g., attachment or social rank) will be associated with subsequent changes in the other (e.g., social rank or attachment) in a reciprocal fashion. The effective functioning of the attachment system can play a crucial role in deactivating the IDS, reflecting a reciprocal relationship between the attachment and the social rank systems. When one of these two systems is ineffective, the other system may take over, though less well designed to serve this function than the system it replaces. For example, failure to regulate tension in the attachment system may lead individuals to turn to other forms of internal regulation such as dominance and submission (Hilburn-Cobb, 1998). In the context of

5 relationship violence, ‘‘insecure attachment predisposes individuals to experience a greater need for dominance in relationship to others’’ (Mauricio & Gormley, 2001, p. 1076). Adults with an avoidant insecure attachment habitually regulate affect by defensive attempts to deactivate the attachment system (Shaver & Mikulincer, 2011), including attempts to enhance their self-reliance and trying to show they can cope. One way of achieving this is by competitive success via activation of the dominance system (Hilburn-Cobb, 1998). Instead of seeking reassurance, they compensate for their low self-esteem by presenting themselves as strong and capable of rising to challenges. From a psychodynamic perspective, the polarity between a secure and an insecure attachment, in early childhood, is related to Erikson’s proposed conflict between a ‘‘sense of basic mistrust’’ and a ‘‘sense of trust’’ (Erikson, 1950). Similarly, the polarity between the impact of success versus repetitive failure on the IDS system shares similarities with Erikson’s second stage of ‘‘autonomy versus shame and doubt.’’ In the second stage, success experiences strengthen the child’s sense of autonomy, while child maltreatment reinforces a sense of shame and doubt. To date, only a few studies have examined both the social rank and the attachment system in relation to psychopathology. Weisman, Aderka, Marom, Hermesh, and Gilboa-Schechtman (2011) conclude that both attachment and IDS measures are independent predictors of emotional problems, while in another study the IDS mediated the relationship that attachment security has with depression and anxiety (Irons & Gilbert, 2005). It has been argued that attachment is more closely linked to depression and social rank is more closely related to anxiety (Aderka, Weisman, Shahar, & Gilboa-Schechtman, 2009), but these results are questionable because other expected relationships between social rank variables were not replicated in this study. Moreover, it is argued elsewhere that the attachment and social rank systems jointly determine both depression and anxiety (Sloman, Farvolden, Gilbert, & Price, 2006). These studies were cross-sectional and so do not clarify how attachment and social rank interact over time. The relationship between social rank and attachment systems outlined here is seen as a dynamic one making it difficult to draw conclusions based on a single snapshot. The reliance on self-report measures also raises the possibility that significant relationships were, in part, due to shared method bias, although relationships were typically moderate to large and so unlikely to be fully explained by this. In considering the relationship between the social rank and the attachment systems, it is helpful to consider the functioning of these systems in optimal circumstances. During normal growth and individuation, the child faces developmental and agonistic challenges (e.g., facing criticism from a peer or failing in an academic setting). The briefly activated IDS promotes the disengagement from a thwarted goal and acceptance of the defeat. Mild residual dysphoria is regulated through adequate soothing and reassurance, resulting from a secure attachment pattern. Successful regulation interactions make it easier to

6 reassure the child on future occasions leaving the young person able to pursue new challenges and goals. In the context of maltreatment, the IDS is ineffective as withdrawal, submission, flight, or even fighting back may not be an option, so activation becomes chronic. Characteristics of the maltreatment, such as its chronicity or severity, are important in determining the extent of IDS activation. The individual, who is unable to deactivate their IDS, may fight on and respond to continued defeat with increasing shame, helplessness, and inferiority (Sloman, 2008). It is a challenge for an attachment figure to provide adequate reassurance and soothing in this context, even when they are not the abuser, without becoming frustrated, hopeless, and discouraged themselves. Moreover, in the case of intrafamilial maltreatment, the child is in double jeopardy, as the maltreatment will have prevented the formation of a secure attachment pattern. Consequently, the young person struggling with extreme feelings of shame, inferiority, or helplessness will find it difficult to regulate them. For example, the child with an avoidant attachment style may suppress emotions and avoid attempts to seek soothing or reassurance altogether and the child of an ambivalent attachment figure may focus on heightened displays of affect and distress for fearing of losing the attachment figure (Cassidy, 1994), or lack any coherent strategy for obtaining support as with a disorganized pattern (Carlson, Barnett, Cichetti, & Braunwald, 1989). These insecure attachment patterns are the optimal strategies to adopt considering the adverse situations faced by the young person, but they become problematic, preventing effective seeking or reassurance and soothing from other potential caregivers who may be nonabusive as may be the case when children are adopted out of a birth family following maltreatment (Carlson et al., 1989). Unable to make use of the attachment system to regulate feelings, the young person becomes reliant on the social rank system to take over this function. In the longer term, this leads to oppositional and challenging, or overly submissive, behavior. The latter is characterized by an overly sensitive IDS, prone to reactivation, giving rise to renewed feelings of shame, helplessness, and frustration. As discussed, such individuals may be prone to problematic interpersonal behaviors (e.g., excessive dominance, avoidance, or submissiveness), which undermine subsequent relationships and so maintain the insecure/disorganized attachment pattern. In this way, the functioning of the social rank system and attachment system are closely interrelated. Overreliance on an IDS, which is sensitive to reactivation, increases the risk of future psychopathology. This overview of the integrated model is displayed diagrammatically in Figure 1. It is assumed that a wide variety of external factors impact upon the functioning of the attachment and social systems and the relationship between them, including aspects of the individual’s family and peer systems as well as wider social and cultural factors. For example, even where a young person is exposed to extrafamilial abuse, but has an otherwise supportive family, a secure attachment may be eroded as caregivers struggle to manage the subsequent behavioral and emotional

TRAUMA, VIOLENCE, & ABUSE sequelae of the child’s IDS. In this situation, factors such as whether or not the maltreatment is disclosed (Ullman, 2003), and the level of stigma surrounding those who are maltreated (Deblinger & Runyon, 2005), may further affect the ability of attachment figures to remain attuned and attentive to the young person. Research will be required to explore these possibilities.

Impact of Disruptions of Attachment and Social Rank Systems It has been suggested that child maltreatment has three areas of impact, (1) disturbances of self: This comprises low self-worth, self-hatred, sexual dysfunction, and self-injury; (2) interpersonal problems: This includes promiscuity, revictimization, alcohol/substance abuse, marital difficulties, and social withdrawal; and (3) affect dysregulation; This includes depression, anxiety states, guilt/shame, self-blame, and powerlessness (Alexander, 1992; Pollock, 2001). The dysregulation of the attachment and social rank systems contributes to problems in each of these three areas. Notably, this range of effects accounts for the wide variety of emotional and behavioral difficulties that have been linked to trauma. The internal working model that follows maltreatment may represent the self as unworthy of support/care and others as unresponsive/unsupportive (Alexander, 1992), while an overly sensitive IDS may regularly leave the individual feeling powerless and inferior relative to others. Regarding interpersonal consequence, when maltreatment leads to an insecure attachment between the child and the significant adults, the child develops a mistrustful attitude, which is related to their internal working model of others (Mikulincer & Nachshon, 1991) that is likely to lead to social withdrawal and other interpersonal problems. Similarly, child abuse may impact the social rank system by contributing to oversubmissiveness. The attachment and social rank systems are therefore likely to be involved in many of the core signs of severe child maltreatment. Both the attachment and the social rank systems are normally involved in affect regulation. The child’s inability to obtain reassurance, while being maltreated, or following maltreatment is likely to lead to a greater arousal of the fight–flight reaction and a stimulation of the hypothalamic–pituitary– adrenal (HPA) axis (Levitan, Hasey, & Sloman, 2000), which undermines the attachment system’s ability to reduce anxiety and tension. Winning agonistic encounters and success activates the IWS, generates euphoria, and reduces anxiety (Sloman, Sturman, & Price, 2011), while defeat and failure activate the IDS and generate negative affect, shame, and powerlessness. Affect can therefore be regulated by avoiding challenge, accepting defeat, or winning, but as a rule none of these are options for those facing maltreatment.

Role of HPA Axis in child Maltreatment The HPA axis is the main physiological system underlying the stress response and is essential in the regulation of stress and

Sloman and Taylor

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Maltreatment Characteristics: Chronicity, Severity

Carer response: Carer unable to reduce distress/provide soothing and reassurance

Insecure attachment: Anxious and avoidant

Agonistic encounter

Unable to regulate or switch off IDS

IDS active Escape or fighting back not an option, leading to more chronic activation IDS sensitised to re-activation

Ability to self-sooth and seek support: impaired Consequences of ongoing IDS activation: • Perceived Shame, inferiority, helplessness Further impair ability to selfsoothe or be supported by others

Interpersonal behaviour: • Excessive dominance, avoidance, submissiveness Psychopathology E.g., depression, anxiety, interpersonal difficulties

Figure 1. Diagrammatic depiction of the integrated model outlining how the attachment and social rank systems interact in response to abuse. Dashed lines represent a relationship that would operate in optimal circumstances but may not function in the context of maltreatment.

maintenance of homeostasis. Sustained HPA hyper or hypoactivity is linked to a variety of pathophysiological states (Tsigos & Chrousos, 1994). During infancy and early childhood the HPA axis is developing and particularly vulnerable to the impact of social factors (Tarullo & Gunnar, 2006). Child maltreatment has been linked to a persistent sensitization of the HPA system to stress in adulthood (Elzinga, Spinhoven, Berrett, de Jong, & Roelofs, 2010) and increased reactivity of the HPA to pharmacological and psychological challenges (Tarullo & Gunnar, 2006). Heim, Newport, Mietzko, Miller, and Nemeroff (2008) summarize results from a series of clinical studies suggesting that childhood trauma in humans is associated with ‘‘sensitization of the neuroendocrine stress response, glucocorticoid resistance, increased central corticotropin-releasing factor activity, immune activation, and reduced hippocampal volume, closely paralleling several of the neuroendocrine features of depression’’. They conclude that childhood trauma is a substantial risk factor for depression in adulthood. Levitan, Hasey, and Sloman (2000) argued that both the social rank and the attachment systems have a crucial influence on the responses of the HPA system to the stresses of child

maltreatment. A fall in social rank may increase the psychobiological stress response in humans (Levitan et al., 2000) and in nonhuman primates (Sapolsky, 1993; Shively, Laber-Laird, & Anton, 1997). There is evidence that children’s adrenocortical responses are significantly influenced by the quality of maternal care (Roque Varissimo, Oliveira, & Oliveira, 2012). Likewise, there is an altered neuroendocrine stress response in women who have been abused and go on to develop an ‘‘unresolved’’ attachment style (similar to ‘‘disorganized’’), when compared to nonabused women and abused women with other attachment patterns (Pierrehumbert et al., 2009). There is evidence that both social rank and attachment systems determine stress response in nonhuman primates, where social rank and other factors, such as affiliation and social support (the attachment system), jointly determine whether the animal shows the typical stress reaction (Abbott et al., 2003). Thus, while research into how the attachment and social rank systems operate at the level of the HPA axis is still limited, it can be speculated that the HPA axis represents part of the biological circuitry by which problems with the attachment and social rank systems lead to psychological difficulties in those experiencing maltreatment.

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Role of Attachment and Social Rank Systems in the Development of Psychopathology Psychological disorders or difficulties occur from the impact of the social rank and attachment systems on self-concept, affect regulation and interpersonal behavior. Psychological disorders that occur following maltreatment can be understood as representing problems in these three areas, which is true of depression and PTSD (where disturbed affect regulation may often, but not always, be a predominant factor) to borderline personality disorder (where all three areas are implicated). A variety of cultural, social, and personal factors further determine how an individual reacts to stress. For example, those who have experienced maltreatment may deal with stress and extreme affect by an overreliance on maladaptive coping strategies such as substance abuse or dissociation, which may maintain problems over time and contribute to the development of other clinical disorders (Felitti et al., 1998; Stirling & Amaya-Jackson, 2008). One central tenet of the proposed theory is that the relationship between childhood maltreatment and subsequent psychopathology is mediated through the attachment and social rank systems. Hypothesis 4: The relationship between maltreatment and psychopathology will be mediated by the attachment and social rank systems. Although no studies, we are aware of, have explored the joint role of these two systems in mediating the effects of maltreatment on subsequent pathology, numerous studies have explored these systems as individual mediators. Studies have demonstrated that a lack of attachment security, at least partially, mediates the relationship between early maltreatment and subsequent psychological problems (e.g., internalizing symptoms, trauma-related symptoms, and general well-being; Bifulco et al., 2006; Limke, Showers, & Zeigler-Hill, 2010; Muller, Thornback, & Bedi, 2012) and relationship problems (Riggs, Cusimano, & Benson, 2011). While few studies have focused specifically on neglect there is evidence of attachment anxiety and avoidance mediating the relationship between neglect and paranoia (Sitko et al., 2014). There is also evidence that the social rank system mediates the effects of maltreatment upon later psychopathology. Studies in female samples suggest that shame, which we posit results from the continued triggering of the IDS, mediates the effect that childhood abuse has upon subsequent depression and eating disorder pathology (Andrews, 1995; Murray & Waller, 2002). Other research has demonstrated a mediating role for shame in accounting for the link between earlier abuse and interpersonal difficulties later in life (Kim, Talbot, & Cicchetti, 2009). Similarly, a longitudinal study following up a sample of sexually abused children has observed that shame and selfblame mediated the effects of sexual abuse on later dysfunction in romantic and sexual relationships (Feiring, Simon, & Cleland, 2009). Experiences of shame have been found to be predictive of suicidal ideation, anger, and delinquency in

samples of individuals with a history of abuse (Feiring, Miller-Johnson, & Cleland, 2007; You, Talbot, & Conner, 2012). Together these studies support the role of shame as part of the psychological mechanism translating earlier maltreatment into later psychopathology, although their predominantly cross-sectional nature means that caution is required in assuming the direction of these relationships.

Sociocultural and Sociodemographic Factors It has been observed that sociocultural factors, including religion, ethnicity, or country of origin, influence the distribution of different attachment patterns. For example, in one study, attachment anxiety was most pronounced among those originating from East Asia and lowest among those from India (Agishtein & Brumbaugh, 2013). Likewise, it is likely that responses to agonist encounters may be influenced by sociocultural factors. For example, within religion, perceiving a deity as being more punitive in nature may be associated with a more insecure attachment (Agishtein & Brumbaugh, 2013), but also with a greater tendency to construe relationships in terms of social rank (and proneness toward responding to agonistic encounters with submission), and perhaps a more sensitive IDS system. While we suggest that IDS activation is a common response to maltreatment, a stronger and more chronic response may be expected within the cultural contexts where the system is already sensitized. Authoritarian patterns can characterize both families (Luyckx et al., 2011) and the broader society. There are societies where freedom of speech is not permitted in the political or religious arenas. In these situations, individuals are expected to react in a submissive fashion to those in authority. In cultures where women are relegated to second-class status, women are expected to react to males in a submissive fashion. In these situations, the IDS can be adaptive by promoting the stability of the family or society. However, it can also have maladaptive consequences by leading to maladaptive cycles of frustration, anger, hopelessness, and helplessness and by preventing challenges to those in authority. Examples of gender-based oppression and subordination are found in Saudi Arabia, where women are not supposed to leave home unless accompanied by a close male relative and are not allowed to drive (Al-Atawneh, 2009). A more extreme example is the Taliban in Afghanistan, who violently oppose female education (Marsden, 1998). Gender submission triggers the IDS in women, which may then lead to shame within such settings. An example of positive steps by women to move out of their subordinate status are women in India who are demanding that steps be taken to stamp out maltreatment of women in the family and in society at large. An understanding of cultural factors is important when working with immigrant children who are thought to comprise one third of the public school population in the United States (The Annie E. Casey Foundation, 2007). Ethnicity has been found to have a statistically significant effect on child maltreatment and help seeking, and ethnicity is an important factor in

Sloman and Taylor determining what constitutes child maltreatment (Miller & Cross, 2006). Physical abuse of children has historically been justified because it was believed that severe physical punishment was necessary to discipline, to rid the evil nature, and to educate children (Tomison, 2001). Presently, it is more sanctioned in some cultures than others, although generally not in modern Western society. Fifty years ago, the mainstream judicial and social work systems in the United States were not familiar with traditional Native American value systems regarding childrearing and socialization with the result that child welfare agencies would label native American families as abusive on the basis of criteria that were alien to their culture (Jones, 1995). The Indian Child Welfare Act represented an effort to redress the situation by allowing the tribe instead of courts to address issues of child welfare for Native American children (Allen, 1991). In the United States, African American, Native American, and Hispanics were reported to have higher rates of child maltreatment compared to their White counterparts, but Asian Americans had a much lower rate than their White counterparts. Moreover, Latinos had a lower rate of reported sexual abuse than nonLatinos (Elliott & Urquiza, 2006). Understanding a family’s cultural background enables one to recognize the possibility that what looks like child maltreatment might be attributable to the cultural norms of the family. This does not necessarily imply that one should not intervene but that, if one does, one should intervene in a culturally sensitive fashion. If one undermines the parent’s confidence in their parenting, while trying to protect the child, one may also undermine the parent’s ability to reassure their child or set appropriate limits so that one may end up hurting rather than helping the abused child. One of us (L.S.) has seen many families of children with autism spectrum disorder (ASD), where the parents were competent and conscientious but were investigated by Child Welfare because of suspicion they were abusing their ASD child. Those, who reported them to Child Welfare, failed to recognize that the child’s difficult behavior was biologically based, another example of how maltreatment may be more apparent than real.

Treatment Implications There have been a number of descriptions of therapies focusing on the attachment system (e.g., Johnson, Makinen, & Millikin, 2001). We will illustrate how an intervention that targets the social rank system can ultimately impact the attachment system.

Case Illustration This is a condensation of what transpired over two sessions. Elizabeth was 48 years old, with a history of being verbally abused and neglected as a child, who worked in public relations for a large educational establishment. New management resulted in a political shift, which led to her being fired. When I (L.S.) saw her, she was depressed with suicidal ideation but also a strong determination to fight her dismissal. I proposed that she

9 felt defeated by the powerful forces she was challenging, and this had triggered a biological reaction that was associated with feelings of helplessness, hopelessness, and depression. I said that this biological reaction, automatically triggered by her perception of defeat, had an adaptive function, namely, to trigger submission and bring the fight to an end. Its evolutionary function was to avoid injury and death, and it served to preserve the stability of the group. After further discussion, it became apparent that she was aware that she had no chance of holding on to her job so that her determination to continue the struggle to keep her job increased the intensity of her IDS. I advised her to accept that she could not win but to devote her efforts to getting a more generous severance package than had been offered. She accepted my advice and was able to obtain a more generous settlement and, a week later, her mood was more positive. Elizabeth’s abuse as a child probably contributed to her feelings of chronic inadequacy and shame and made her terrified of how she would react to further losses, making it impossible for her to accept defeat. She was prepared to continue to fight to keep her job, even though there was no possibility of winning. She therefore needed the therapist’s help to accept defeat and fight for the more modest goal of getting a better settlement. The therapist’s positive reframing of Elizabeth’s negative reactions, by highlighting their adaptive function, served several functions. First, portraying these psychological reactions to defeat as a biological mechanism helped Elizabeth distance herself from these feelings, which made it easier for her to take appropriate steps to deal with the situation. Second, her acceptance of the positive reframing made her feel more hopeful and self-confident. Third was the implicit message that there were alternative responses to the IDS. On a relational level, Elizabeth’s impression that the therapist understood her helped build her trust in the therapist. When the therapeutic intervention lifted Elizabeth’s spirits, this magnified these feelings of trust, which enabled the therapist to be more reassuring reflecting a more secure attachment to the therapist. Finally, there was evidence that Elizabeth’s secure attachment to the therapist was beginning to generalize by enabling her to develop a more trusting relationship with her husband so that both the social rank and the attachment systems came to operate in a more efficient manner. Elizabeth also illustrated how agonistic defeat and her reluctance to accept defeat and give up the fight triggered the IDS and depression. The notion that success experiences are positively motivating is widely accepted, but the IWS theory provides a rationale by describing the features of the IWS and how promoting success deactivates the IDS, a basic goal in treating depression. One way to trigger the client’s IWS is to help the client (e.g., Elizabeth) devise small challenges, which offer a high likelihood of success. The social rank approach can be incorporated into other forms of psychotherapy. Moreover, because the concept of the IDS interfaces with the cognitive therapy approach to depression (Swallow, 2000), the social rank approach and cognitive therapy could be combined in an integrated approach.

10

New Directions A better understanding of the biological changes associated with the IDS and IWS could facilitate the testing of the first four hypotheses presented earlier, which would be facilitated by developing improved methods of measuring the IDS and IWS. Self-report methods of assessing the IDS have been developed (Sturman, 2011) but have not yet been widely adopted by researchers, and the applicability of such measures to children and adolescents (important in testing hypotheses about the shorter term effects of maltreatment) is unclear. Such measures will also need to be sensitive to change, in order to identify shifts in the reactivity of the IDS over time. In addition to questionnaires, other methods for formally assessing the psychological characteristics of abusive relationships need to be explored. Repertory grids, an idiographic assessment tool that can capture the interpersonal dynamics, may be one option (Harter, Erbes, & Hart, 2004). Regarding Hypothesis 2, in particular, research would benefit from testing distinct pathways between specific forms of maltreatment (or maltreatment characteristics) and subsequent mediating pathways (e.g., Sitko et al., 2014). Longitudinal cohort designs, while resource intensive, will also be necessary to track the short- and long-term consequences of maltreatment upon putative psychological mediators (see Hypotheses 3 and 4). In general, more work is required to account for the possible different outcomes of child maltreatment and why some appear to come through relatively unscathed.

Conclusion A consideration of the impact of child maltreatment on the attachment and social rank systems and the interaction between these two systems and the HPA axis enables us to account for the impaired emotion regulation, emergence of shame, overly submissive and dominant behaviors, variety of syndromes such as affective disorder, PTSD, suicidality, risky behavior, and various physical health problems associated with maltreatment. It is important to note a number of areas where further consideration and research would be warranted that were deemed beyond the scope of the current review. First, while the current review focuses on the sequelae of experiencing maltreatment, the integration of the attachment and social rank theories also helps explain the perpetration of maltreatment. For example, an insecure attachment may hamper the development of empathy (van der Mark, van IJzedoorn, & Bakermans-Kranenburg, 2002) and one response or defense against an active IDS is to seek a position of dominance, which will be easier in relation to a child who is weaker than oneself or is stuck in a subordinate role. Second, while we do provide an outline of how some of the ideas of the integrated theory may be incorporated into clinical practice, a full detailing of how this theory may be applied to psychotherapy is beyond the scope of the current article. Third, the proposed integrated theory provides an explanation of how maltreatment can lead to a wide range of clinical outcomes but is still limited in its capacity to account

TRAUMA, VIOLENCE, & ABUSE for why some individuals will experience a particular difficulty (e.g., depression) but not others (e.g., PTSD). Notably, research is currently in the early stages of determining if particular experiences and mechanisms may account for particular symptoms, but recent evidence in this area does exist. For example Sitko and colleagues (2014) report specific pathways where sexual abuse was related to hallucinations while neglect was linked to paranoia. Future research will enable us to develop a better understanding of the consequences of child maltreatment and provide the framework for a more comprehensive plan for the prevention and treatment of the effects of child maltreatment. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies Leon Sloman was born in South Africa and did his medical training at the Royal Free Hospital, London, England, and psychiatric training at McGill University, Montreal. He is now a staff psychiatrist at the Centre for Addiction and Mental Health in Toronto and Associate Professor at the University of Toronto. He has numerous publications in the area of Evolutionary Psychiatry and in particular on Social Rank Theory and on the relation between Social Rank Theory and Attachment Theory and their relevance to mood disorders. He has written about the relation between anxiety and depression. He also studied the relation between mood and gait pattern and found that that they have a significant relationship. His particular focus has been on the clinical implications of his work on social rank, and he and Peter Taylor wrote the present article because they both felt that their field of interest was of particular relevance to the study and treatment of child abuse. Peter Taylor is a Clinical Psychologist and researcher currently working as a lecturer at the University of Liverpool, England. His research includes an interest in attachment theory and the role of emotional states such as shame in the development of psychological problems.