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Contents lists available at ScienceDirect

Child Abuse & Neglect

The relationship between adult health and childhood maltreatment, as moderated by anger and ethnic background夽 Kimberly A. Rapoza ∗ , Denise T. Wilson, Wendy A. Widmann, Michelle A. Riley, Thomas W. Robertson, Elizabeth Maiello, Nikisha Villot, Dana J. Manzella, Alberto L. Ortiz-Garcia Mercy College, 555 Broadway, Dobbs Ferry, NY 10522, USA

a r t i c l e

i n f o

Article history: Received 10 April 2013 Received in revised form 16 January 2014 Accepted 21 January 2014 Available online xxx

Keywords: Anger Childhood maltreatment Physical health Psychological well-being Blood pressure

a b s t r a c t Childhood maltreatment, anger, and racial/ethnic background were examined in relation to physical health, psychological well-being, and blood pressure outcomes. This study used data from a diverse sample of African American, Latino, and Caucasian participants (N = 198). Results from a series of multiple regressions indicated anger and total childhood maltreatment were robust predictors of poorer health. Although correlational analyses found maltreatment from the mother and father were associated with poorer health outcomes, when considered as part of the regression models, only a relationship between maltreatment from the mother and physical health was found. Greater anger scores were linked with lower blood pressure, particularly systolic blood pressure. Generally, more psychological and physical symptom reporting was found with greater anger scores, and higher levels of total maltreatment also predicted physical symptoms. The pattern of interactions indicated anger was more detrimental for African American participant’s (and marginally so for Latino participant’s) physical health. Interestingly, interactions also indicated total childhood maltreatment was related to fewer symptoms for Latino participants. Although child maltreatment may be viewed as a moral and/or human rights issue, this study provides evidence that it can also be viewed as a public health issue. Our study demonstrated that known health risk factors such as anger and maltreatment may operate in a different pattern dependent on ethnic/cultural background. The findings suggest health and health disparities research would benefit from greater exploration of the differential impact of certain moderating variables based on racial/ethnic background. © 2014 Elsevier Ltd. All rights reserved.

Introduction Although child maltreatment may be viewed as a moral and/or human rights issue, it can also be viewed as a public health issue. The World Health Organization has classified interpersonal violence as a health issue worthy of placement on the global public health agenda and has noted that understanding and preventing the health consequences associated with experiences of violence is essential for supporting victims, repairing infrastructure, and reducing loss of productivity in society (Krug, Mercy, Dahlberg, & Zwi, 2002).

夽 Funding for this project was provided by grant P20MD002717 from the National Institute on Minority Health and Health Disparities (NIMHD). ∗ Corresponding author. 0145-2134/$ – see front matter © 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.chiabu.2014.01.009

Please cite this article in press as: Rapoza, K. A., et al. The relationship between adult health and childhood maltreatment, as moderated by anger and ethnic background. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.01.009

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The link between experiences of maltreatment in the family and health are thought to be a result of prolonged exposure to traumatic circumstances that may be long lasting and leave an individual vulnerable to later physical or psychological disorders. For example, one study found early traumatic experiences between ages 6 and 11 were a significant contributor to poor health even in old age (Krause, Shaw, & Cairney, 2004). The present study adds to this body of knowledge by investigating whether a propensity toward negative affective states (i.e., anger) moderates the relationship between childhood maltreatment and adult physical health, blood pressure, and mental well-being. The specific mechanisms through which maltreatment and anger can affect and shape the health and well-being of individuals from different ethnic/racial backgrounds remain relatively underexplored topics of empirical research and will be addressed by this study. Experiences of Child Maltreatment and Health A provocative question is whether experiences of childhood maltreatment can lead to adverse physical and mental health effects years later in adulthood. Researchers have found physical child abuse to be associated with certain adult medical conditions. For example, individuals reporting physical maltreatment during childhood also reported a significantly lower health-related quality of life (Corso, Edwards, Fang, & Mercy, 2008; Repetti, Taylor, & Seeman, 2002). In terms of medical conditions, physical abuse and maltreatment were linked with increased reports of gastrointestinal symptoms, pain, headaches, diabetes, obesity, irritable bowel syndrome (IBS), fibromyalgia, genitourinary symptoms, and respiratory symptoms (Drossman, Talley, Lesserman, Olden, & Barreiro, 1995; Goodwin, Hoven, Murison, & Hotopf, 2003; Sachs-Ericsson, Medley, Kendall-Tackett, & Taylor, 2011). Heckman and Westfield (2006) found combined physical/emotional abuse in childhood was associated with chronic pain and somatic symptoms (e.g., back or muscle pain, dizziness). When emotional abuse was examined independently, it was associated with increased reports of fibromyalgia, chronic fatigue syndrome, IBS, migraine headaches, chronic pain, and dyspepsia (Sansone, Pole, Dakroub, & Bulter, 2006; Talley, Boyce, & Jones, 1998). Few studies have examined a direct relationship between childhood maltreatment and blood pressure related health risks. Springer, Sheridan, Kuo, and Carnes (2007) analyzed population-based survey data from middle-aged adults and concluded physical abuse during childhood was associated with greater odds of depression, high blood pressure, and cardiac risk factors. However, not all research studies have been successful in correlating childhood maltreatment directly to high blood pressure, and the results have been mixed. Studies with adolescents (12–18 years old) found physical childhood maltreatment was unrelated to blood pressure, and witnessed parental violence was linked to higher diastolic blood pressure (Clark, Thatcher, & Martin, 2010). Also noted, studies with younger children (5–13 years old) found witnessed marital violence was associated with increased heart rate and cortisol secretion, but not blood pressure (Saltzman, Holden, & Holahan, 2005). Overall, it is still unclear whether experienced childhood maltreatment contributes to elevated blood pressure in young adults. Children who are maltreated are also at greater risk for poorer psychological functioning in adulthood. Childhood maltreatment has been linked to a wide range of emotional and behavioral problems in adulthood, which include anxiety, depression and posttraumatic stress disorder (PTSD; Kaplow & Widom, 2007; Repetti et al., 2002; Thompson, Kingree, & Desai, 2004). Longitudinal studies of children who suffered interpersonal violence (physical assault, sexual assault, and/or witnessed violence) found an increased prevalence of PTSD, depressive disorders, anxiety, and use of mental health and social services at later life follow-up (Kilpatrick et al., 2003; Yanos, Czaja, & Widom, 2010). The gender of the perpetrator has not often been examined separately as a risk factor for poorer health, despite indications that perpetrator gender is known to impact other areas of functioning. For example, with a female sample, it was found that maternal physical abuse and paternal psychological maltreatment were associated with dissociation symptoms, but only paternal psychological maltreatment was associated with anxiety and depression, and only maternal physical abuse was linked with suicidal ideation (Briere & Runtz, 1988). Thus, the question of whether perpetrator gender differentially impacts physical and psychological health outcomes, although speculative, is warranted. There are few investigations that have examined similarities and/or differences in the impact of maltreatment on health based on racial/ethnic group membership. In one such study a greater prevalence of depression and suicidal attempts was found in both Caucasian and African American adults who reported more childhood maltreatment experiences (Thompson, Kaslow, Lane, & Kingree, 2000). However, the extent to which maltreatment is equally predictive of physical and psychological health outcomes for individuals from different racial/ethnic groups suffers from a lack of empirical scrutiny. The Relationship Between Anger and Health A growing body of evidence indicates that emotional states, whether positive or negative, can impact the cardiovascular and immune systems. Studies have linked anger to immune system function with couples categorized as high total anger showing greater reductions in the percentages of cells which stimulate immune activity and fight bacteria, after a discussion involving conflict (Suinn, 2000). Other studies have found higher anger scores were positively associated with coronary heart disease in a population with normal blood pressure (Williams, Nieto, Sanford, & Tyroler, 2001). When looking more specifically at certain types of trait anger, cardiovascular outcomes differed. Meta-analytic reviews of the literature indicated anger expression had an inverse relationship with systolic and diastolic blood pressure (actually lessening risk for high blood pressure), while anger suppression was attributed more to increased readings on both forms of blood pressure measurement (Schum, Jorgensen, Verhaeghen, Sauro, & Thibodeau, 2003; Suls, Wan, & Costa, 1995). For Please cite this article in press as: Rapoza, K. A., et al. The relationship between adult health and childhood maltreatment, as moderated by anger and ethnic background. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.01.009

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example, Goldstein, Edelberg, Meier, and Davis (1988) found general expressed anger was inversely associated with both systolic and diastolic blood pressure readings, while expressed anger in the family context was inversely associated with systolic pressure. Anger has also been linked to the manifestation of other health problems. In terms of general health ailments (e.g., headaches, loss of appetite, upset stomach, complaints of pain, fatigue) trait anger was found to be positively associated with increased reports of symptoms in teenagers (Mahon, Yacheski, & Yacheski, 2000). Several lines of evidence also support a positive relationship between anger and the development of psychological distress such as depression, low self-esteem, irritability, and anxiety (Gross & John, 2003; Kopper & Epperson, 1996). This finding would suggest that negative parent–child relationships resulting in adverse experiences or maltreatment during childhood, when coupled with maladaptive anger regulation, significantly increase the risk for psychological disorders (Wolfe, Scott, Wekerle, & Pittman, 2001). The Relationship Between Anger and Maltreatment Generally, the earlier maltreatment occurs in a child’s life, the more likely the child will fail to achieve important developmental milestones. These include the development of self-regulation, emotional regulation and social peer based relationships (Kim & Cicchetti, 2010). Gilliom, Shaw, Beck, Schonberg, and Lukon (2002) noted anger might sometimes help to establish adaptive interpersonal relationships. However, dysregulated anger and a lack of appropriate self-regulation and pro-social behavioral strategies may lead to the breakdown of relationships. For example, Gilliom and colleagues found negative emotionality (i.e., hostility and punitiveness) between the caregiver and child was linked to reported behavioral problems and poorly controlled anger in preschool. Emotional dysregulation resulting from childhood abuse experiences is one mechanism that might provide a viable link between childhood maltreatment and negative health outcomes. Although inappropriate anger, hostility, and aggression in early childhood and adulthood have been linked with multiple forms of childhood abuse (Herrenkohl, Klika, Herrenkohl, Russo, & Dee, 2012; Loos & Alexander, 1997) and detrimental effects on physical health (Salovey, Rothman, Detweiler, & Steward, 2000), there can be great variability in outcomes and adjustment for children with maltreatment histories. Dumont, Widom, and Czaja (2007) found heterogeneity in adult and adolescent adjustment for children with documented histories of physical abuse, neglect, and sexual abuse (about half of the children were found to be resilient in adolescence and onethird remained so in adulthood). In a sample comprised of maltreated and non-maltreated children, Flores, Cicchetti, and Rogosch (2005) found maltreated children with better ability to regulated behavioral, affective and cognitive expressions evidenced greater resiliency. However, maltreated children found to under or over ego-control had worse outcomes. This heterogeneity in adjustment influenced by emotional regulation capabilities may indicate multiple processes by which childhood maltreatment may impact adult health. It is not clear though that the relationship between anger, maltreatment, and health would be the same across different ethnic groups. For example, one study utilizing a predominately African American sample did not find a direct relationship between anger, physical abuse, neglect, and internalizing problems (i.e., anxiety, depression, withdrawal, and somatic complaints) in pre-school children, although such relationships were present for externalizing behaviors (Bennett, Sullivan, & Lewis, 2005). As noted, this study builds on prior work in the areas of physical and mental health. We hypothesize that increased reports of anger or maltreatment will be associated with poorer health outcomes. This study also questions whether maltreatment is more detrimental to health, depending on the gender of the perpetrator, a question that as of yet is underexplored. The literature has not fully examined the potential moderating role of anger. We suggest that anger modifies the relationship (i.e., protects against or increases risk) between childhood maltreatment and adult health. Additionally, there are few investigations that have examined the utility of such predictors as moderators for individuals from different racial/ethnic backgrounds, which is surprising given strong evidence that the prevalence of disease and mortality between Caucasian and African Americans is one of the largest differences in health statistics (Whitfield, Weidner, Clark, & Anderson, 2002). Methods Sample There were initially 253 participants, but only responses from ethnic groups large enough in numbers for analyses were used in this study (i.e., African American, Caucasian, Latino), which totaled 198. The sample (for those reporting) was 33% men and 63% women. The most frequent age range selected was between 18 and 25 (79%). The sample, as per self-classification, was African American (49%), Caucasian (30%), and Latino (21%). The participants, as per self-report, were predominately single (50%) and born in the United States (83%). The most frequent categories self-selected for social-economic status (SES) were middle (47%) or working (32%) class. Procedure Participants were recruited from a non-traditional college, where students were primarily older, working while obtaining a degree, and commuters. An initial screening was done to exclude individuals based on certain medical conditions and Please cite this article in press as: Rapoza, K. A., et al. The relationship between adult health and childhood maltreatment, as moderated by anger and ethnic background. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.01.009

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medication usage (i.e., diabetes, severe head trauma, angina, coronary heart disease, stroke, alcohol/drug abuse, high blood pressure medication, and cholesterol lowering medication). Informed consent and a packet of questionnaires was given to each individual in a campus lab, followed by measurement of their blood pressure. A debriefing form and honorarium were given at the completion of the study. Internal Institutional review board approval was obtained, and APA ethical guidelines were followed for the study. Measures Physical and Psychological Health Questionnaire: The Memorial Symptom Assessment Scale (Portenoy et al., 1994) was utilized to assess the combined average frequency (0 = did not have to 4 = almost constantly) and distress (1 = slight to 4 = very severe) caused by 32 symptoms over a 6 month period. The measure can be broken down into physical (i.e., immune and gastrointestinal problems) and psychological (i.e., anxiety and depressive) symptom subscales. Portenoy and colleagues found a Cronbach alpha of .88 for the measure overall. This study found Cronbach alphas of .83 for the psychological subscale and .79 for the physical subscale. Anger: Anger was assessed using a shortened version of Siegel’s (1986) Multidimensional Anger Inventory (MAI). The measure utilized a 5-point Likert Scale (1 = completely not descriptive to 5 = completely descriptive), with a greater score indicating greater anger. Siegel has reported good test re-test reliability (r = .75), high internal consistency (alpha = .89) and good concurrent validity. However, this study found a low Cronbach alpha of .64, after deletion of 4 items, to improve the total anger scales internal consistency. Childhood Maltreatment: The Conflict Tactic Scales (CTS2; Straus, Hamby, Boney-McCoy, & Sugarman, 1996) was used to assess maltreatment experienced during childhood. The measure assessed the frequency and intensity of specific parental behaviors from the mother and father toward the participant during the worst year of childhood they remembered. Composite scores were created for total aggression received from each parent and total maltreatment experienced overall. The scoring mechanism used midpoints for occurrence (ranging from 0 = never occurred to 25 = more than 20 times in the past year), with a higher score indicating more experiences of maltreatment. The measure was found by Straus and colleagues to have high reliability (psychological aggression scale = .79 and physical assault scale =. 86) and good construct and discriminant validity. This study found Cronbach alphas of .91 for the maltreatment from the mother subscale, .88 for the maltreatment from the father subscale, and .91 for the total maltreatment scale. Results Descriptive Statistics Descriptive data for all measures were calculated. Participants had a mean score of 8.88 (SD = 5.87) for physical symptoms, 8.57 (SD = 4.61) for psychological well-being, 112.87 (SD = 13.65) for systolic blood pressure, and 70.98 (SD = 9.23) for diastolic blood pressure. For the predictor variables participants reported a mean score of 21.25(SD = 4.94) on anger, 58.37 (SD = 79.88) on maltreatment from the mother, 43.87 (SD = 73.84) on maltreatment from the father, and 99.81 (SD = 134.39) for total maltreatment. Average reported Body Mass Index (BMI) was 25.49 (SD = 5.39). Correlational Analyses Psychological well-being was positively associated with anger (r = .39, p < .001), total maltreatment scores (r = .20, p < .01), mother’s maltreatment (r = .18, p ≤ .01), father’s maltreatment (r = .16, p < .05), and physical symptoms (r = .63, p < .001), but negatively associated with systolic blood pressure (r = −.186, p ≤ .01) and diastolic blood pressure (r = −.15, p < .05). Physical health was positively associated with anger (r = .37, p < .001), total maltreatment scores (r = .31, p < .001), mother’s maltreatment (r = .32, p < .001), and father’s maltreatment (r = .22, p < .01). Anger was positively associated with total maltreatment scores (r = .15, p < .05) and mother’s maltreatment (r = .19, p < .01), but negatively associated with systolic blood pressure (r = −.20, p < .01) and diastolic blood pressure (r = −.15, p < .05). Regression Analyses A series of hierarchical multiple regressions were conducted, with physical symptoms and psychological well-being as the dependent variables. All predictor variables were centered. Based on the heterogeneity of the sample demographic factors such as age, SES, gender, ethnicity, and BMI were controlled for in analyses. For all the regression equations Step 1 contained the demographic variables with gender (coded female = 1 and male = 0), age, BMI, SES, and ethnicity (with two variables coded African American ethnicity [African American = 1, other group = 0] and Latino ethnicity [Latino = 1, other groups = 0], which made Caucasian the reference group). Step 2 contained the maltreatment and anger variables. Step 3 evaluated potential interactions between the aforementioned variables and ethnicity and interactions between anger and the maltreatment variables. A moderator is a variable that influences the direction or strength of an association between two variables, and when an interaction between variables exists the impact of one variable depends on the level of the other variable (Baron & Kenny, Please cite this article in press as: Rapoza, K. A., et al. The relationship between adult health and childhood maltreatment, as moderated by anger and ethnic background. 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Table 1 Summary of hierarchical regression analyses with total maltreatment scores on physical and psychological health. Variables entered

Physical health Step 1

1

BMI Age Gender African American Latino SES

2

Total anger Total maltreatment

3

Anger × Mal. Anger × Af. Am. Anger × Latino Mal. × Latino Mal. × Af. Am.

Model

F value R2 F value R2

† * ** ***

Psychological well-being

Step 2

Step 3

Step 1

Step 2

Step 3

ˇ

t value

ˇ

t value

ˇ

t value

ˇ

t value

ˇ

t value

ˇ

t value

.03 −.09 .17 −.02 .11 −.23

.40 −1.20 2.37* −.22 1.10 −3.04**

.02 −.05 .16 .01 .12 −.12

.24 −.80 2.36* .13 1.31 −1.58

.04 −.09 .13 −.04 .08 −.11

.55 −1.29 1.93† −.41 .91 −1.56

−.002 −.03 .16 −.23 −.03 −.22

−.02 −.45 2.19* −2.41* −.28 −2.94**

−.006 −.003 .14 −.19 .002 −.11

−.10 −.04 2.18* −2.25* .02 −1.57

−.001 .005 .15 −.19 −.01 −.12

−.02 .07 2.21* −2.21* −.12 −1.60

.30 .24

4.33*** 3.34***

.04 .44 .20 .23 .19 −.29 −.16

2.90** .09 2.90** .09

6.78*** .24 16.81*** .15

.27 3.45***

.37 .16

2.57** 2.01* 1.68† −2.54** −1.62

5.50*** .31 2.86** .06

5.50*** 2.29*

.37 .23 .06 .06 −.08 −.09 −.04

3.63** .11 3.63** .11

8.17*** .28 19.43*** .17

2.58** 1.76† .79 .49 −.68 −.77 −.41

5.14*** .29 .49 .01

p < .10. p < .05. p ≤ .01. p ≤ .001.

16

Physical Symptoms

14 12 10 Low Anger

8

High Anger

6 4 2 0 Low Maltreatment

High Maltreatment

Fig. 1. Graphical depiction of the interaction between total anger scores and total maltreatment scores on physical symptoms.

1986). Based on computational tools developed by Preacher, Curran, and Bauer (2006) significant interaction effects were probed by conducting a simple slopes analysis. Graphs were plotted based on techniques by Dawson (2013) in which the simple regression line for the low (−1SD) and high (+1SD) values of the moderator on the dependent variable were plotted against the low (−1SD) and high (+1SD) values of the predictor variable proposed to be moderated. The regression model for physical health, utilizing total maltreatment scores (see Table 1), was significant, F(13,176) = 5.50, p < .001. In Step 1, gender (ˇ = .17, p < .05) and SES (ˇ = −.23, p < .01) were significant predictors of physical symptoms, indicating females and lower SES participants reported more symptoms. In Step 2, gender (ˇ = .16, p < .05), anger (ˇ = .30, p < .001), and total maltreatment (ˇ = .24, p ≤ .001) were significant. In Step 3, the interaction between anger and total maltreatment (ˇ = .20, p ≤ .01) was significant. The simple slope effects of maltreatment at conditional values of anger were significant at the mean and +1SD. The graph of the interaction between total anger scores and total maltreatment scores (see Fig. 1) depicts that high levels of maltreatment are associated with more physical symptoms at high levels of reported anger. However, at low levels of maltreatment, higher anger expression was associated with fewer reported symptoms. African American ethnicity was a significant moderator when interacting with anger (ˇ = .23, p < .05; see Fig. 2), and Latino ethnicity was marginally significant when interacting with anger (ˇ = .19, p < .10). The simple slope effects of African American ethnicity at conditional values of anger were not significant. Trends in patterns could be discerned, however, from graphical exploration of interaction outcomes (only the interaction for African Americans is depicted). At high levels of anger African American individuals reported more symptoms than other ethnic groups, but at low levels of anger they Please cite this article in press as: Rapoza, K. A., et al. The relationship between adult health and childhood maltreatment, as moderated by anger and ethnic background. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.01.009

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16

Physical Symptoms

14 12 10 Not African American

8 6 4

African American

2 0 Low Anger

High Anger

Fig. 2. Graphical depiction of the interaction between African American ethnicity and anger on physical symptoms.

16

Physical Symptoms

14 12 10 8

Not Latino

6 4

Latino

2 0 Low Maltreatment

High Maltreatment

Fig. 3. Graphical depiction of the interaction between Latino ethnicity and maltreatment on physical symptoms.

reported fewer physical symptoms than other ethnic groups. Although only the interaction for African American participants is depicted, explorations of the outcomes for Latino participants revealed a similar pattern. At high levels of anger, Latino individuals reported more physical symptoms than other groups, but at low levels of anger they reported fewer physical symptoms than other groups. The interaction between maltreatment and Latino ethnicity (ˇ = −.29, p ≤ .01) was also significant (see Fig. 3). The simple slope effects of Latino ethnicity at conditional values of maltreatment were significant at −1SD and at +1SD. Graphical depiction of the interaction indicated that at high levels of maltreatment, Latino ethnicity was associated with fewer reported symptoms than other groups, whereas at low levels of maltreatment Latino ethnicity was linked with more physical symptoms. The regression model for psychological well-being utilizing the total maltreatment scores (see Table 1) was significant, F(13,176) = 5.14, p < .001. In Step 1, gender (ˇ = .16, p < .05), African American ethnicity (ˇ = −.23, p < .05) and SES (ˇ = −.22, p < .01) were significant predictors, indicating those with a female gender and lower SES reported more symptoms, while those with an African American ethnicity reported fewer symptoms. In Step 2, African American ethnicity (ˇ = −.19, p < .05), gender (ˇ = .14, p < .05), anger (ˇ = .37, p < .001), and maltreatment (ˇ = .16, p < .05) were significant. In Step 3, none of the interactions were significant. The regression model for physical health, utilizing separate parental maltreatment scores (see Table 2) was significant F(17,164) = 3.94, p < .001. In Step 1, gender (ˇ = .18, p < .05) and SES (ˇ = −.27, p < .01) were significant predictors of physical symptoms, indicating females and lower SES participants reported more symptoms. In Step 2, gender (ˇ = .14, p < .05), SES (ˇ = −.15, p ≤ .05), anger (ˇ = .25, p ≤ .001), and total maltreatment from the mother (ˇ = .23, p < .01) were significant. In Step 3, none of the interactions were significant. The regression model for psychological well-being utilizing separate parental maltreatment scores (see Table 2) was significant F(17,164) = 3.32, p < .001. In Step 1, gender (ˇ = .18, p < .05) and SES (ˇ = −.32, p < .01) were significant predictors, indicating those with a female gender and lower SES reported more symptoms. In Step 2, gender (ˇ = .15, p < .05) and anger (ˇ = .35, p < .001) were significant. In Step 3, none of the interactions were significant. The regression model for systolic blood pressure utilizing the total maltreatment scores (see Table 3) was significant, F(13,167) = 2.28, p < .01. In Step 1, SES (ˇ = .28, p < .001) and gender (ˇ = −.15, p ≤ .05) were significant predictors, indicating those with a male gender and higher SES reported more symptoms. In Step 2, SES (ˇ = .25, p < .01) and anger (ˇ = −.16, p < .001) were significant. In Step 3, none of the interactions were significant. Please cite this article in press as: Rapoza, K. A., et al. The relationship between adult health and childhood maltreatment, as moderated by anger and ethnic background. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.01.009

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Table 2 Summary of Hierarchical Regression Analyses with Parental Maltreatment Scores on Physical and Psychological Health. Variables entered

Physical health Step 1

1

BMI Age Gender African American Latino SES

2

Total anger Father maltreatment Mother maltreatment

3

Anger × Father mal. Anger × Mother mal. Anger × Af. Am. Anger × Latino Father mal. × Latino Mother mal. × Latino Father mal. × Af. Am. Mother mal. × Af. Am.

Model

F value R2 F value R2

† * ** ***

Psychological well-being

Step 2

Step 3

Step 1

ˇ

t value

ˇ

t value

ˇ

.03 −.10 .18 .01 .12 −.27

.39 −1.26 2.32* .12 1.25 −3.39***

.00 −.05 .14 .02 .12 −.15

.002 −.70 2.03* .23 1.34 −1.97*

.008 −.10 .11 −.03 .10 −.15

.11 −1.33 1.53 −.34 1.03 −1.94*

−.02 .21 .34

−.12 1.05 1.30

.13 .08 .24 .21 −.18 −.17 −.13 −.09

1.15 .65 1.86† 1.67† −.1.14 −.89 −.98 −.51

.25 .06 .23

3.13** .11 3.13** .11

3.39*** .71 2.73**

5.76*** .25 9.91*** .14

t value

3.94*** .31 1.68 .06

Step 2

Step 3

ˇ

t value

ˇ

t value

−.01 −.04 .18 −.18 −.007 −.23

−.19 −.58 2.31* −1.82 −.07 −2.98**

−.02 −.007 .15 −.16 .008 −.12

−.22 −.09 2.13* −1.80† .09 −1.55

.35 .10 .09

4.75*** 1.24 1.06

ˇ

−.39 .94 2.11* −1.58 .11 −1.55

.38 .22 .03

2.17* 1.07 .10

−.02 .09 .03 −.10 −.18 .10 −.03 −.009 3.21** .11 3.21*** .11

6.02*** .26 10.49*** .15

t value

−.03 .07 .15 −.15 .01 −.12

−.16 .73 .22 −.75 −1.14 .53 −.23 −.05

3.31*** .28 .46 .02

p < .10. p < .05. p ≤ .01. p ≤ .001.

Table 3 Summary of hierarchical regression analyses with total maltreatment scores on systolic blood pressure. Variables entered Physical health 1

BMI Age Gender African American Latino SES

2

Total anger Total maltreatment

3

Anger × Mal. Anger × Af. Am. Anger × Latino Mal. × Latino Mal. × Af. Am.

Model

F value R2 F value R2

† * ** ***

Step 1

Step 2

ˇ

t value

.10 .002 −.14 −.05 −.07 .28

1.31 .03 −1.94* −.47 −.74 3.56***

3.21** .11

Step 3

ˇ

t value

ˇ

t value

.10 −.007 −.14 −.05 −.09 .28

1.29 −.09 −1.87† −.50 −.86 3.56**

.12 −.04 −.14 −.05 −.07 .22

1.58 −.50 −1.88† −.48 −.68 2.61**

.30–.16 −.001

−2.05* −.02

−.37 −.07

−2.22* −.48

−.06 .15 .21 −.03 .15

−.59 1.08 1.63 −.22 1.33

2.98** .13

2.28** .16

p < .10. p < .05. p ≤ .01. p ≤ .001.

The regression model for systolic blood pressure utilizing separate parental maltreatment scores (see Table 4) was significant F(17,156) = 1.76, p < .05. In Step 1, SES (ˇ = .29, p < .001) was significant, indicating those with a higher SES reported more symptoms. In Step 2, SES (ˇ = .26, p < .01) was significant. In Step 3, none of the interactions were significant. The regression models for diastolic blood pressure utilizing the total maltreatment variable, F(13,167) = 1.36, p = .19 and separate parental maltreatment variables, F(17,156) = 1.12, p = .34, were not significant.

Please cite this article in press as: Rapoza, K. A., et al. The relationship between adult health and childhood maltreatment, as moderated by anger and ethnic background. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.01.009

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Table 4 Summary of hierarchical regression analyses with parental maltreatment scores on systolic blood pressure. Variables entered Physical health 1

BMI Age Gender African American Latino SES

2

Total anger Father maltreatment Mother maltreatment

3

Anger × Father mal. Anger × Mother mal. Anger × Af. Am. Anger × Latino Father mal. × Latino Mother mal. × Latino Father mal. × Af. Am. Mother mal. × Af. Am.

Model

F value R2 F value R2

† * ** ***

Step 1

Step 2

Step 3

ˇ

t value

ˇ

t value

ˇ

t value

.10 −.01 −.14 −.06 −.07 .29

1.26 −.15 −1.78† −.63 −.72 3.63***

.10 −.03 −.13 −.05 −.07 .26

1.28 −.33 −1.59 −.50 −.73 3.13***

.11 −.05 −.12 .008 −.02 .24

1.36 −.62 −1.51 .07 −.21 2.75**

−.12 .03 −.06

−1.59 .32 −.64

−.30 .35 −.60

−1.64† 1.23 −1.48

−.11 .10 .13 .19 −.16 .22 −.12 .41

−.86 .69 .90 1.31 −.75 .72 −.71 1.52

3.21** .11

2.49** .13

1.76* .18

p < .10. p < .05. p ≤ .01. p ≤ .001.

Discussion Over the past four decades there has been increased interest in determining the extent that child abuse and maltreatment impact health and psychological well-being. Although child maltreatment may be viewed as a moral and/or human rights issue, this study provides evidence that it can also be viewed as a public health issue. Based on the pattern of correlations, our study found support for a relationship between childhood maltreatment and adverse adult physical and mental health. This replicated prior research, which also found childhood physical and emotional abuse to be linked to various deleterious health outcomes, such as gastrointestinal symptoms, chronic pain, migraines and headaches, diabetes, obesity, IBS, and fibromyalgia (Goodwin et al., 2003; Sachs-Ericsson et al., 2011; Sansone et al., 2006) and vulnerability to depression, anxiety, and psychological distress (Drossman et al., 1995; Penza, Heim, & Nemeroff, 2003). Although Goodwin et al. (2003) found experienced physical child abuse from either the mother or the father was associated with greater odds of gastrointestinal disorders and migraine headaches, few studies have examined perpetrator gender separately as a risk factor for poorer health. The correlational results from this study indicated that maltreatment from either parent was detrimentally linked to poorer adult physical/psychological health. However, when considered as part of the regression models, only a strong direct relationship between maltreatment from the mother and physical health emerged. Why might this be? A greater potential disruption to attachment bonds might underlie this study’s overall findings of a more robust pattern between maternal caregiver maltreatment and health. McEwen (2004) has noted that hormones related to the stress response, such as cortisol and adrenaline, may promote adaptation in the short-term, but when the release is prolonged or when not “turned off” after the event has passed the effects may no longer be beneficial. For example, cortisol is involved in both affective disorder (such as depression) and cardiovascular and immune system functioning. Maunder and Hunter (2001), in a review of the literature, noted that the mother–infant relationship is one that supplies an external physiological regulatory function for the infant and that stress on or loss of this dyadic relationship (certainly from maltreatment) may result in abnormalities in neurotransmitter and hormonal balances, critical for the negative feedback loop needed to attain homeostasis after stressful circumstances. Perhaps maltreatment from the mother provides greater disruption to the development of adaptive physiological regulatory function in response to stressors, leading to greater risk for disease and illness later in the lifespan. Overall, maltreatment from a specific parent did not moderate the relationship between ethnicity and health outcomes. However, it was found that total experienced maltreatment did moderate the relationship between Latino ethnicity and physical health. At high levels of maltreatment, Latino ethnicity was associated with fewer reported symptoms than other groups, whereas at low levels of maltreatment Latino ethnicity was linked with more physical symptoms. One provocative question would be why maltreatment showed less impact on physical symptoms for Latino participants, as compared with other ethnic groups. An explanation of our finding might center on cultural differences in perceptions of the parental role, Please cite this article in press as: Rapoza, K. A., et al. The relationship between adult health and childhood maltreatment, as moderated by anger and ethnic background. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.01.009

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parenting, and discipline. McLoyd, Cauce, Takeuchi, and Wilson (2000), in a multicultural study on family and parenting, noted that the expectations for the parental role might differ for individuals from different ethnic backgrounds. The authors noted the childrearing practices of some ethnic minority parents might not reflect the same values as the European American middle class, with more implementation of hierarchical parenting (i.e., very strict, yet warm and emotionally responsive). It is possible that in our sample, the tactics utilized by Latino parents are regarded as in keeping with the parental role, hence having a lesser long-term impact. McLoyd and colleagues also noted that discipline and physical punishment was more generally accepted in some non-majority ethnic groups and produced different outcomes. For example, although physical discipline predicted greater externalizing problem behaviors in European American children, it did not for African American children. One vein for future research might be a greater exploration of the attributions regarding particular parental disciplinary events and how those perceptions impact health outcomes. Our study found correlational support for a relationship between anger and physical/psychological health symptoms. This replicated well-established findings in the literature, indicating anger can have a negative impact on physical health through placing increased strain on cardiovascular and immune systems (Salovey et al., 2000) and on the development of disorders, such as depression, irritability, and anxiety (Gross & John, 2003). Interestingly, anger showed a robust relationship in both regression models, both directly and as a moderator of total maltreatment and ethnicity. Anger did not play a moderating role between maltreatment and psychological well-being, nor between maltreatment from a specific parents and health outcomes. It did however moderate the relationship between total experienced maltreatment and physical health. Low levels of maltreatment combined with higher levels of anger seemed to actually be protective and related to fewer reported physical symptoms. However, a risk factor for poorer health seemed to be higher levels of maltreatment combined with higher levels of reported anger. Researchers have found evidence that parental maltreatment and harsh discipline in childhood was linked with a greater propensity toward anger and aggression in adulthood (Herrenkohl et al., 2012; Loos & Alexander, 1997). This study demonstrated it is possible that the emotional pain and trauma associated with childhood maltreatment can later manifest in poorer adult health. It has been speculated that childhood maltreatment may create deficits in social information processing, impulse control, and emotion regulation on a neurobiological level, increasing the risk for hostile attributions, negative emotions, and aggression (Chen, Coccaro, Lee, & Jacobson, 2012). This process might, in turn, leave victims vulnerable to the manifestation of health problems, based on the detrimental strain negative emotions place on the cardiovascular and immune systems (Salovey et al., 2000). The regression models on physical health also demonstrated a moderating role for anger on health, particularly as a pattern for African American participants and marginally so for Latino participants. The trends in both interactions taken collectively indicated at higher levels of anger African American and Latino individuals reported more symptoms than Caucasian participants, but at lower levels of anger they reported fewer physical symptoms than Caucasians. The question of cultural and social impact on risk for disease is a particularly important area of research, as Whitfield et al. (2002) noted that even when socio-economic status has been controlled for in analyses, between-group ethnic differences on health disparities have not evaporated. One reason could be that even at higher levels of education or income racial or ethnic minority individuals may still expend more energy coping with challenging environments. Some of the coping mechanisms used to deal with chronic race related stressors might involve anger. For instance, with a sample of 18–47 year old African-American males, Merritt, Bennett, Williams, Edwards, and Sollers (2006) found even greater increases in blood pressure to a non-racist scenario depicting unfair treatment than to the same scenario where racism was made blatant. The authors note that many blatant forms of racism in modern society have been supplanted by subtle forms that contain attribution ambiguity, which nonetheless seem to have detrimental effects on cardiovascular health. Additionally, for participants from an ethnic minority background the experience of anger may carry with it conflicts around the normative acceptability of emotional expression within our culture. Emotional self-regulatory efforts are shaped by cultural background, which encourages or discourages emotional responding, sanctioning the situational circumstance for display (Butler, Lee, & Gross, 2007). Bulter and colleagues noted Western European culture values such as independence and self-expression encourage emotional expression. However, although Western European culture may value emotional expression, the socially acceptable display of anger does not extend to all racial/ethnic groups equally. Gross and John (2003) noted that in the United Sates, European Americans tend to still have more power and social status than ethnic minorities, and this lack of social power for ethnic minorities translates into greater monitoring and control of emotional expression to reduce potential negative consequences from upsetting those in power. Indeed Gross and John found that when questioned, European American participants reported the least use of emotional suppression as a regulatory strategy, as compared with African American, Asian American and Latino participants. Hence it is possible that the trend toward greater detrimental impact of anger for African Americans in this study, and marginally so for Latino participants, is based in some part on the comingling of negative affect, emotional regulation, and suppression. Negative correlational relationships were found between systolic blood pressure, diastolic blood pressure, and anger. Additionally, anger was one of the few significant predictor of systolic blood pressure in the regression models. Evidence linking trait anger to blood pressure has been relatively inconsistent, but two meta-analytic reviews also indicated that although anger suppression seems linked to increased blood pressure, anger expression evidenced an inverse relationship with blood pressure measurement (Schum et al., 2003; Suls et al., 1995). Future research should try to tease out subtle distinctions between anger expression and suppression on blood pressure. Please cite this article in press as: Rapoza, K. A., et al. The relationship between adult health and childhood maltreatment, as moderated by anger and ethnic background. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.01.009

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This study found little support for a positive correlational relationship between childhood maltreatment and blood pressure. One explanation for the lack of significant findings might be the age of our sample. Many of the studies that found a direct or indirect link between maltreatment and blood pressure did so with middle-age participants, or when stratifying the sample by age (Lehman, Taylor, Kiefe, & Seeman, 2009; Springer et al., 2007). Studies with samples under 18 did not find physical maltreatment to be linked with higher blood pressure (Clark et al., 2010; Saltzman et al., 2005). With our young adult sample, it might be too soon to see the ramifications of maltreatment on the cardiovascular system. An additional explanation could be the practical and methodological challenges that surround documentation of ongoing violent episodes (Corso et al., 2008). Other studies obtaining significant results also comingled different forms of abuse (i.e., physical, sexual, and witnessed) when examining the effects on blood pressure (Lehman et al., 2009). It may be the combined influence of many elements in a chaotic family environment are the underpinnings of the relationship between maltreatment and hypertension, rather than one single form of maltreatment. Limitations and Direction for Future Research Kaplow and Widom (2007) found differences in psychological manifestations in adults dependent on the age at which maltreatment occurred. Individuals maltreated before the age of six evidenced higher levels of depression and anxiety symptoms, whereas individuals with an onset of maltreatment later in childhood were at greater risk for externalizing problems as adults. Despite the considerable strengths of this study, it is important to note that the study could not assess differential effects of short-term versus long-term experiences of maltreatment or outcomes dependent on age of onset. In addition, abusive families often are chaotic and characterized by multiple problematic familial relationships (Mollerstrom, Patchner, & Milner, 1992). We do not know if the participants were also raised in homes with intimate partner violence or experienced additional forms of family violence, such as sexual abuse or neglect. Future research might consider whether some of these other familial variables might account for some portion of the observed associations between maltreatment and health. The difference in participant numbers based on gender and the young adult nature of the sample suggest that one should be cautious when generalizing results. Although gender was controlled for in analyses, because of the small number of males, this study did not allow for fully exploring the model’s predictive utility separately by gender. It is also unclear how adequate the model is in explaining variations in health for older adults. Lastly, the reliability for the total anger scale, although within range of acceptability, was low. It is possible then that our study could underestimate the relationship between anger and some of the other study variables. Implications for Prevention Programs and Conclusion One of the strengths of this study was the ability to demonstrate that the detrimental effects of childhood maltreatment often extend beyond childhood into adulthood. This study indicates these effects may manifest as psychological and/or physical symptoms, with maltreatment from the mother being a more robust correlate of poorer physical health. Another strength of our study was in obtaining a diverse sample. This allowed our study to demonstrate that known health risk factors such as anger may operate in a different pattern dependent on racial/ethnic background. These results highlight the complexities of the long-term effect of childhood maltreatment and emphasize the need for more research on interventions targeted to specific ethnic groups. The information gleaned from this study may be utilized by health providers to better serve the needs of student or young adult populations. Effective intervention and prevention programs aimed at addressing anger management or provisions of counseling for those experiencing childhood maltreatment, early on in the adult lifespan, may promote resilience or forestall the development of serious disease later in the life span.

Acknowledgments We would like to thank Drs. Ellen Sperber and Cynthia Porter Rickert for comments on the manuscript. We would also like to thank the following student research assistants: Ruth Rivera, Kaydi Campbell, Stephanie Walpole, Stephanie Ciani, and Marva Mariner.We appreciate the statistical commentary of Michael Giesinger and editorial contributions of Gerald Robertson. References Baron, R. M., & Kenny, D. A. (1986). The moderator–mediator variable distinction in social psychology research: Conceptual, strategic and statistical considerations. Journal of Personality and Social Psychology, 51, 1173–1182. Bennett, D. S., Sullivan, M. W., & Lewis, M. (2005). Young children’s adjustment as a function of maltreatment, shame, and anger. Child Maltreatment, 10, 311–323. Briere, J., & Runtz, M. (1988). Multivariate correlates of childhood psychological and physical maltreatment among university women. Child Abuse & Neglect, 12, 331–341.

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