Childhood Maltreatment and the Subjective Roots of Mental Health Suffering.

Starting from the seminal empirical study on Adverse Childhood Experiences (ACEs) (Felitti et al., 1998), the phenomenon of childhood maltreatment has been progressively acknowledged 1) as epidemiologically relevant also in western societies (Bellis et al., 2019), and 2) as a robust prognostic risk factor for subsequent somatic illnesses and psychopathological outcomes (Hughes et al., 2017). Maltreatment represents one key issue of adverse childhood experiences in terms of both physical, emotional, and sexual abuse and physical and emotional neglect: the concomitant presence of many self-reported ACEs increases in a stepwise progression the risk of subsequent long-term negative health outcomes, suggesting a dose-effect of ACEs and a cumulative risk on the impact of child maltreatment on health. Moreover, some ACEs, and in particular sexual abuse, seem to have the synergistic effect, in the interaction with other ACEs, to increase the overall longitudinal risk for health beyond the sum of effects of each ACE (Briggs et al., 2021).

Assessment of child maltreatment

Recent evidence suggested that the subjective retrospective recall of child maltreatment (as provided, for example, by the ACE questionnaire: Felitti et al., 1998) and the objectivation of child maltreatment poorly agree at a meta-analytical level (κ = 0.19) (Baldwin et al., 2019). Moreover, the subjective experiential side of child maltreatment appears as the central key risk factor for life-course psychopathology rather than the objective side, also in case of ascertained maltreatment based on court records (Danese and Widom, 2020): i.e., only the subjective recall of child maltreatment is longitudinally associated with psychopathological consequences in young adulthood, independently from the presence or not of objective records of the maltreatment itself. Such primacy of the subjective experience of child maltreatment, harbours multiple levels of complexity worth thematizing as regards maltreatment assessment and its scientific investigation (Bifulco and Schimmenti, 2019).

The definition of child maltreatment is per se complex and with different degrees of overt visibility. Single, “macroscopic” episodes of physical or sexual abuse are more easily definable and ascertainable (see Barbara et al., 2021 for an Italian, single-center based retrospective analysis of 1106 cases), than the wide spectrum of (“microscopic”) early relational hidden trauma (Dutra et al., 2009, Schore 2009) determined by a prolonged exposure to a maltreating parenting during early years of life. Such enduring and pervasive micro-traumatism is more difficult to be objectively ascertained, being more easily hidden and concealed within the family system, although is probably not less disruptive than macro-traumatism (i.e., acute traumatic episodes) in its potential impact on mental health. This suggests that also different instruments of child maltreatment assessment (e.g., questionnaires vs. semi-structured standardized interviews) may probably provide not totally homologous findings in terms of depth of analysis and possibility to establish different longitudinal pathways 1) from parent characteristics to child maltreatment and 2) from child maltreatment to negative health outcomes.

For example, the empirical use of interviews as the Childhood Experience of Care and Abuse (Bifulco et al., 1994) permitted to find that parental hostility and rejection of the child may be associated with psychological abuse (e.g., child humiliation, deprivation and terrorization in the context of a highly controlling and sometimes sadistic relationship) and may worsen towards forms of violent punishments (the physical abuse pathway), his/her neglect (the neglect/role reversal pathway), up to the extreme of sexual abuse when the parent totally disregards the child and uses him/her to satisfy dysregulated impulses (Bifulco and Schimmenti, 2019).

Subjective determining and the dynamic psychological components trauma

Long-term mental health consequences of child maltreatment are determined by developmental dynamics characterized by modulating variables such as disorganized attachment and dissociative processes (Liotti, 2004). The early hidden relational trauma may result in a disorganized attachment when the primary caregivers that are necessary for child survival are abusing or neglecting (Granqvist et al., 2017). In this chronic exposure, in which there is a sort of double bind related to a necessary and at the same time harmful caregiver, children lack a secure basis to regulate their internal and affective states and to explore the external world at both the sensory-motor and intersubjective levels: i.e., the early relational trauma involving the relation with primary caregivers represents a developmental constraint for the progressive integration of inner and outer experiences.

Moreover, every traumatic event may cause dissociative processes of detachment or of compartmentalization when its threatening potential is perceived as excessively overwhelming by the victim (Brown, 2006, Holmes et al., 2005). Indeed, the notion of psychological trauma involves a key subjective and dynamic component, i.e., the relation between the victim perception of threat during the potential traumatic event and the victim perceived ability of coping with the event itself. This implies a key role for the age of the victim (for defense mechanism, coping skills and trauma-related memorization), the relation with the perpetrator (e.g., intra-family vs. stranger), and the quality of the traumatic events (e.g., isolated severe event vs. chronic exposure), all of which will condition the relevance of the potential traumatic experience for the later development of psychopathology.

Effects on mental health

In this perspective, there is an increasing focus on the role of early severe and ongoing traumatic exposure in multiple longitudinal trajectories leading to heterotypic psychopathological adult outcomes, including post-traumatic stress disorder, dissociative disorders, borderline personality disorder and psychotic disorders. Indeed, traumatic exposure has been historically associated with dissociation since the work of Janet (Scalabrini et al., 2020) and progressively recognized as a trigger for post-traumatic stress-disorders, including specificities of developmental trauma exposure (in terms of PTSD complex as currently included in ICD 11: Spinazzola et al., 2021); moreover, there is increasing consensus and awareness that also non-negligible fractions of patients with borderline personality disorder or psychotic disorders present anamnestically trauma exposures and that these early adverse experiences are involved in their underlying complex etiopathogenetic cascades, leading longitudinally to clinical symptoms through the intermediation of moderating factors, as attachment and dissociative processes (e.g., Liotti, 2004; Lyons-Ruth and Brumariu, 2021).

For example, among possible ACE, childhood emotional abuse and neglect have the largest meta-analytical association with adult borderline personality disorder (Porter et al., 2020), dissociation, emotion dysregulation and PTSD symptoms (as avoidance, numbing and hyperarousal) have a mediating role between developmental trauma and hallucinations (Bloomfield et al., 2021), as well as attachment and mood symptoms have a mediating role between ACEs and psychosis (Sideli et al., 2020).

In sum, objective measures of child maltreatment may catch only the more manifest and acute surface of previous traumatic exposure, while prolonged subacute traumatic exposure secondary to the daily exposure to a maltreating familial environment, remains an elusive a grey zone to objectify; moreover, the traumatic potential of an event is not solely an intrinsic, immanent feature of the objective event but it also depends on the characteristics of the victim: the objective nature of potential traumatic exposure is experienced and felt through a subjective filter dependent on idiosyncratic characteristics of the exposed child, partially explaining why is in the subjective footprint of trauma rather than in its objective nature that is possible to find the roots of mental health suffering (Baldwin et al., 2019).

Preventive policies

This perspective on childhood maltreatment suggests that a primary preventive approach should target modifiable risk factors: for example, among features of ACE in terms of household dysfunction, parent mental illness represents one of the most modifiable risk factor (Poletti et al., 2020). Children of parents with severe mental illness (such as schizophrenia or mood disorders) represent ab initio an at-risk category (Raballo et al., 2021), combining high degrees of presumed genetic liability, higher risk of early environmental adversities (e.g., in utero exposures) and higher risk or poor parenting (up to maltreatment), whose quality is associated with the clinical severity of parent mental illness. For example, a recent meta-analysis of prospective studies found that the higher risk of developing psychosis was conferred by the cumulative effect of facing ACEs together with genetic liability for psychosis (Pastore et al., 2020).

Therefore, families in which parents have a serious mental illness represent a peculiar ecological niche that tend to perpetuate itself along generations due to maintaining factors that pass from one generation to another, including child maltreatment. Parenting is modifiable via tailored supportive interventions (Thanhäuser et al., 2017), therefore children of parents with mental illness should be more considered by preventive policies aimed to promoting a primary prevention of child maltreatment. Unfortunately, neither specific preventive programs for offspring of parents with severe mental illness are systematically implemented in child/adolescent mental health services, nor dedicated supportive programs for parenting are generally available in adult mental health services.

In conclusion, the robust prognostic power of childhood maltreatment as regards subsequent mental health negative outcomes should alert towards the implementation of preventive programs focused on modifiable risk factors as parenting.