Externalizing behavior was examined using the Youth Self Report, but only met two of our quality criteria as it was not assessed temporally after maltreatment and before depression. However, this association was not evident among maltreated boys. Brody et al. Harsh parenting was associated with increased anger, which was in turn associated with poor health generally.
Unfortunately, the authors did not test whether youth anger increased vulnerability to depressive symptoms specifically. However, harsh parenting and depression was significantly and positively correlated. We conducted a systematic review to synthesize existing literature that examined modifiable predictors of depression following maltreatment. We used stringent inclusion criteria so that only sufficiently powered, longitudinal studies were included.
Combined unadjusted and adjusted associations between maltreatment and depression reported here are consistent with effect sizes reported in existing meta-analyses of this association, 5 , 6 , 7 , 33 demonstrating a clear association when focusing solely on prospective, longitudinal data. Adjusting for study size and quality resulted in only small changes in the effect size. As only six of the identified studies examined potential modifiable predictors of depression, it is difficult to draw firm conclusions from this research. There is some initial evidence that low social support increases vulnerability to depression following maltreatment.
Alternatively, other factors relating to maltreatment may make it difficult for children to access social support.
Equally, children with existing high social support appear buffered from the detrimental effects of maltreatment on depression, though this appears more effective for children without the co-occurrence of maltreatment subtypes. Similarly, insecure attachment style was associated with depression in later life, which may be because maltreated children with insecure attachment styles find it difficult to form stable and supportive relationships. That being said, a substantial proportion of children in foster care with insecure attachments to birth parents were able to form secure attachments with foster parents.
Thus, attachment relationships may be modifiable, and therefore a key target for intervention. Indeed, a number of relationship-based interventions already exist for maltreated children, which aim to promote secure attachment, and sensitive and responsive parent—child interactions. Meta-analyses demonstrate that these types of intervention effectively improve attachment security, however, effects on externalizing behaviors are minimal. A wealth of depression research suggests that cognitive biases and vulnerabilities increase risk for depression onset and recurrence.
One of the main psychological therapies to treat depression, cognitive behavioral therapy, specifically targets negative patterns of thought about the self and world to alter unwanted behavioral patters and improve mood.
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Cognitive behavioral therapy is certainly the most well evidenced form of therapy for maltreated children and has specific adaptations for sexual abuse, physical abuse and multiple forms of maltreatment. The current review also found behavioral difficulties, specifically externalizing behaviors, may also be modifiable predictors of depression following maltreatment, but there are currently few interventions for maltreated children aimed at managing difficult behaviors. As externalizing behaviors are highly comorbid with depression, it is, however, unclear whether externalizing problems are on the causal pathway to depression, or are an early manifestation of depression.
More research is needed to understand this relationship, but if behavioral difficulties are causal, then interventions aimed at behavior management may be effective for reducing depression. Limitations of this systematic review, and the individual studies, should be considered. Our inclusion criteria were strict so only well-powered longitudinal studies were included; however, there was great variability in the measures of maltreatment and depression.
Although all included studies were prospective in design, many included retrospective reports of maltreatment, which is likely to result in recall bias.
Accessing official records may be more reliable; however, restricting measures to official records identifies only a small proportion of cases, which may be a biased, unrepresentative subset. Further, many studies assessed depression via clinical interview, but a significant number assessed depression via self-report, which is subject to current mood.
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It is also important to note that there may be an inherent bias in participants with symptoms depression who are willing to take part in prospective, longitudinal research compared with their counterparts who are not willing to partake in research, and therefore results may not be wholly generalizable to the population. However, this is of course somewhat unavoidable in observational research.
Of the six studies to examine modifiable predictors of depression, two utilized official records 20 , 24 and four assessed maltreatment via youth report. We assessed the study quality using the NOS. However, there are no existing checklists specifically designed to assess the quality of risk factors in longitudinal research, which may be on causal pathways between exposure and outcome.
We thus created three quality criteria for assessing modifiable risk factors, but this has not been validated. The lack of quality checklists is a limitation for any scientific field focused on assessing mechanisms in health and disease. The development and validation of such checklists is of academic and clinical importance. Another limitation is that we focused on depression as an outcome, and therefore studies where depression and other psychiatric and physical conditions were comorbid were not included, as these were beyond the scope of this review.
Depression in childhood and adolescence
For example, there have been reports of poor physical and psychological outcomes, including substance abuse, for those who experienced childhood abuse. We also did not search the gray literature for unpublished data, as we included only peer-reviewed studies published in journal articles. Many questions remain regarding future research. Well-designed longitudinal, prospective research investigating and characterizing modifiable predictors in associations between maltreatment and depression are lacking.
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The design of such studies requires careful consideration to elucidate causal mechanisms and identify targets for intervention. For example, measuring and statistically controlling for baseline symptoms is important to understand cyclical relationships and causal links between variables, and to tease apart correlates of exposure and outcome.
A critical question concerns the underlying biological processes that may lead to depression onset following maltreatment exposure, and future studies should seek to ameliorate the biological mechanisms underlying potential modifiable predictors, such as cognitive processes and behavior, using physiological and neuroimaging techniques. It is also currently unclear whether different modifiable predictors may be important for subtypes of abuse, and whether modifiable predictors are gender-specific.
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Just one of the included studies in our review tested for gender differences and reported that for maltreated girls there was a strong association between externalizing symptoms and depression, but this association was not evident in boys. No other studies reported effects by gender, thus we were unable to test overall effects of gender in meta-analyses. However, given the higher prevalence of depression in females, and the emerging idea that mechanisms leading of psychopathology in the context of early-life stress may be sex-specific, 39 it is possible that modifiable predictors of depression following maltreatment may also be gender-specific.
There is an underdeveloped profile of research regarding modifiable predictors of depression following maltreatment from high-quality, sufficiently powered studies. There is initial evidence to suggest that interpersonal relationships, cognitive vulnerabilities and behavioral difficulties may act as modifiable predictors of this association. Identifying and understanding the mechanisms of modifiable predictors of depression among maltreated children may help us to better understand what works, for which children and why. Such research will enhance the development of targeted interventions for maltreated children.
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