ORIGINAL RESEARCH

published: 22 October 2021

doi: 10.3389/fpsyt.2021.728280

Childhood Maltreatment Predicts

Specific Types of Dysfunctional
Attitudes in Participants With and
Without Depression
Raj Jugessur 1,2† , Yan Zhang 1,2† , Xuemei Qin 1,2 , Mi Wang 1,2 , Xiaowen Lu 1,2 , Jinrong Sun 1,2,3 ,
Qiangli Dong 1,2 , Liang Zhang 1,2 , Jin Liu 1,2 , Yumeng Ju 1,2 , Mei Liao 1,2 , Ping Wan 4 ,
Edited by: Hua Guo 4 , Futao Zhao 4 , Bangshan Liu 1,2* and Lingjiang Li 1,2*
Miao Qu, 1
National Clinical Research Center for Mental Disorders, Department of Psychiatry, The Second Xiangya Hospital of Central
Capital Medical University, China
South University, Changsha, China, 2 Mental Health Institute of Central South University, China National Technology Institute
Reviewed by: on Mental Disorders, Hunan Technology Institute of Psychiatry, Hunan Key Laboratory of Psychiatry and Mental Health,
Suqian Duan, Changsha, China, 3 Affiliated WuTaiShan Hospital of Medical College of Yangzhou University, Yangzhou Mental Health Centre,
King’s College London, Yangzhou, China, 4 Zhumadian Psychiatric Hospital, Zhumadian, China
United Kingdom
Weijia Gao,
Zhejiang University, China Background: Studies have shown a strong association between childhood
*Correspondence: maltreatment (CM) and major depressive disorder (MDD). Dysfunctional attitudes
Bangshan Liu
(DAs) play a crucial role in the development of MDD. In this study, we aimed to
[email protected]
Lingjiang Li investigate whether (1) DAs are associated with CM, (2) specific CM types predict
[email protected] specific types of DAs, and (3) higher childhood trauma counts (CTCs) predict more DAs.
† These authors have contributed Methods: One hundred seventy-one MDD participants and 156 healthy controls (HCs)
equally to this work
were enrolled for the study. CM was assessed retrospectively with the Childhood Trauma
Specialty section: Questionnaire. DAs were evaluated using the Chinese version of the Dysfunctional
This article was submitted to Attitude Scale–Form A (C-DAS-A). A series of analyses, including multiple analyses of
Mood and Anxiety Disorders,
covariance and hierarchical regression analyses, were used in this study to examine
a section of the journal
Frontiers in Psychiatry the hypotheses.
Received: 21 June 2021 Results: The proportion of CM was 60.2% in the MDD group and 44.2% in the HC
Accepted: 16 September 2021
Published: 22 October 2021
group. The 2×2 analysis of covariance results showed no interaction effect between
Citation:
CM and MDD on C-DAS-A total score. When the factor scores replaced the C-DAS-A
Jugessur R, Zhang Y, Qin X, Wang M, total score, a similar trend was observed. Within the MDD group, emotional abuse (EA)
Lu X, Sun J, Dong Q, Zhang L, Liu J,
predicted two forms of DAs: self-determination type and overall DAs; physical neglect
Ju Y, Liao M, Wan P, Guo H, Zhao F,
Liu B and Li L (2021) Childhood (PN) was predictive of attraction and repulsion-type DAs. Higher childhood trauma counts
Maltreatment Predicts Specific Types significantly predicted more types of DAs in the MDD group.
of Dysfunctional Attitudes in
Participants With and Without Conclusion: DAs are a trait feature of CM. EA and PN predict specific types of DAs in
Depression. MDD patients. Higher CTCs predict more DAs in MDD patients.
Front. Psychiatry 12:728280.
doi: 10.3389/fpsyt.2021.728280 Keywords: childhood maltreatment, dysfunctional attitudes, MDD, polyvictimization, depression

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Jugessur et al. Childhood Maltreatment Predicts Dysfunctional Attitudes

INTRODUCTION METHODS
Childhood maltreatment (CM) is deviant behavior toward an The set of data used for this study derives from a longitudinal
underage that causes harm or entails a risk of causing harm project to scrutinize the psychological and biological mechanisms
in physical, sexual, and emotional aspect. Several CM forms of MDD (hypothalamic–pituitary–adrenal axis function and
are recognized: emotional abuse (EA), physical abuse (PA), magnetic resonance imaging study of trauma-related depression,
sexual abuse (SA), and neglect [emotional neglect (EN) and registration no. ChiCTR1800014591).
physical neglect (PN)] (1). It constitutes a global threat leading One hundred seventy-one participants with MDD were
to significant health concerns. Worldwide, one of two children enrolled from inpatient and outpatient departments of the
is a victim of any form of CM (2). They lead to severe Zhumadian Psychiatric Hospital (Henan, China), and 156
long-term consequences not limited to work and relationship participants were recruited from the local area through flyers for
difficulties, disappointing academic performance, and impaired a healthy control (HC) group. The enrolment procedure started
mental health, including major depressive disorder (MDD) in January 2013 and ended in December 2018. An eligibility
(3–5). Individuals who underwent CM exhibit psychological criterion was set for the two groups, and two well-trained
consequences and disruptions in neurobiological mechanisms; psychiatrists supervised the process.
the stress system is affected, and there is impeded brain The enrolment criteria set for the MDD group was as follows:
connectivity, primarily in the frontal brain cortex (6, 7). (1) age 18–60 years, (2) diagnosed with MDD and medication-
Depression is one of the leading causes of psychiatric free for not <2 weeks, (3) diagnosis of MDD confirmed by two
morbidity globally (8); documentation of its association with CM well-trained psychiatrists using the Structured Clinical Interview
is not scarce in the medical literature (9, 10). Some reported that for Diagnostic and Statistical Manual of Mental Disorders, Fourth
MDD was twice likely in individuals with CM (11). CM has a Edition, (4) 24-item Hamilton Depression Rating Scale score
varying effect on depression onset (12), course and response to (HAMD24 ) ≥20 (23), and (5) consent form signed by the patient.
treatment, and other attributes (10, 13). When considering the The exclusion criteria set was as follows: (1) comorbid Axis I
individual types of CM, EA increases the risk of depression twice or II or a history of bipolar disorder; (2) history of head injury,
as likely as PA (14); others suggested EN significantly predicts neurological disorders, or other internal illnesses; (3) history of
depression, whereas EA correlates with depression severity (15). substance abuse or dependence except for tobacco dependence;
Under Beck’s views of depression, a negative self-schema may and (4) having suicidal tendencies or ideation. As for the HC
be acquired during childhood due to scarring life events. Those group, the inclusion criteria set was as follows: (1) age 18–
are not limited to abuse and neglect. The negative self-schemas 60 years, (2) HAMD24 score <8, and (3) signed consent form
remain quiescent unless triggered by stressors (16). Those by the participant. The HC group’s exclusion criteria were as
negative self-schemas, commonly referred to as dysfunctional follows: (1) history of any psychiatric disorders; (2) history of
attitudes (DAs), are ubiquitous negative thought processing styles substance abuse or dependence except for tobacco dependence;
that affect one’s belief about oneself, the world, and the future; and (3) history of head injury, neurological disorders, or other
they are at the core of depressive pathologies. Several studies internal illnesses.
thoroughly investigated the impact of DAs in depression patients.
They constitute a considerable risk and poorer prognosis of Measures
depression (10), as well as being a long-term predictor for relapse Depression
(17) and decreased effectiveness to antidepressant therapy (18). A 24-item HAMD24 was used to assess depression. It is a
The relationship between CM and MDD is moderated by DAs commonly used clinician-rated questionnaire (23). The scale
(19, 20). However, not all individuals with DAs will develop was translated by the Shanghai Mental Health Center, and it
depressive disorders, leading us to contemplate whether DAs summed up to have a good reliability and validity in the Chinese
are a trait resulting from CM. Also, as the individual types of community. The scale consists of 24 items: 12 items were rated
CM have varying effects on depression, could it be possible for 0–4, nine items were rated 0–2, and three items were rated 0–3.
the specific CM types to forecast global DAs and specific DAs? Hence, the total score ranges from 0 to 75. A cutoff score of at
Nevertheless, this relationship is unexplored. Only a few studies least 20 signifies moderate depression (24).
partly address the question. In a study involving a sample of
women, the researcher suggests a significant association between Anxiety
EA and DAs (19). Another researcher suggests a significant A 14-item Hamilton Anxiety Rating Scale (HAMA14 ) was used
association between childhood neglect (CN) and DAs (20). The to assess anxiety among the participants. It is a clinician-rated
amount of DAs influences the threshold of an adverse event to questionnaire consisting of 14 items. Each item is rated on a range
onset depression; the higher the DAs grade, the lesser the adverse of 0 (absent) to 4 (severe). The total score ranges from 0 to 56
event’s threshold (21, 22). We therefore hypothesized that the (25). The Chinese version of the HAMA14 summed up to have a
more the specific CM types present, the more the DAs. good reliability and validity in the Chinese community (26).
In this study, we hypothesized that (1) DAs are associated
with CM, (2) specific types of CM can predict specific types of Dysfunctional Attitudes
DAs, and (3) higher childhood trauma counts (CTCs) can predict The Dysfunctional Attitude Scale was used to assess cognitive
more DAs. vulnerabilities. The Chinese version of the Dysfunctional

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Jugessur et al. Childhood Maltreatment Predicts Dysfunctional Attitudes

Attitude Scale–Form A (C-DAS-A) was used for the study. It is group (10.23 years) was lower than in the HC group (11.12 years).
a self-reporting scale designed to evaluate DA’s rectitude (27). The male proportion was also lower in the MDD group (male
This scale has good reliability and validity in Chinese MDD 43.9%) than that in the HC group (male 45.5%).
samples (28, 29). The Chinese version of the scale includes 40 Within the MDD group, the mean age at onset of depression
items and encompasses eight subscales. The total score ranges was 31.74 years. The average number of episodes of depression
from 40 to 280, with higher the total score, the more DAs. was 2.03. There was no statistical significance in age and gender
The eight subscales are vulnerability, attraction and repulsion, between MDD and HC groups (p > 0.05). Both HC/CM+ and
perfectionism, compulsion, seeking applause, dependence, self- HC/CM− had more years of education compared to MDD/CM+
determination attitude, and cognition philosophy (28). More and MDD/CM− . The MDD/CM+ group had higher mean scores
details about the C-DAS-A questionnaire and the nature of the in HAMD24 , HAMA14 , C-DAS-A total, and CTQ total than the
several factors involved can be found in our other articles (30, 31). MDD/CM− group, and they were all significant (p < 0.001).
Clinical and demographic characteristics are shown in Table 1.
Childhood Maltreatment The prevalence of CM types and CTC is shown in Table 2.
CM was assessed using the Childhood Trauma Questionnaire The prevalence of CM in our sample was 52.5%, whereas 60.2%
(CTQ). It is a retrospective assessment tool consisting of five of the MDD group reported CM. PN (43.1%) had the highest
factors for maltreatment, and it is evaluated through 28 items in prevalence in the sample, in the MDD (49.7%) and the HC
the questionnaire. It accounts for maltreatment before the age of (35.9%) groups. SA (8.8%) was the least prevalent form of
16 years, and it is summed up to have good reliability and validity CM among the MDD group, whereas EA (3.2%) was the least
in the Chinese community. The five factors for CM assessed are common in the HC group.
EA, PA, SA, EN, and PN. Participants were identified as positive Most participants (52.9%) reported at least one type of CM
for CM if any one of these factors exceeded their cutoff score from the sample, whereas 28.1% reported at least two types of
as mentioned: EA > 12, PA > 9, SA > 7, EN > 14, and PN > CM, 7.3% reported at least three types of CM, 2.7% reported at
9 (32–34). The CTC was defined as the sum of the total CTQ least four types of CM, and 0.3% reported all types of CM.
factors exceeding their respective cutoff scores. Its minimal score A higher proportion of participants in the MDD group
is therefore 0, whereas the maximal score is 5. reported having experienced maltreatment in the past. Similarly,
the proportion for the subtypes of CM was higher in the MDD
Data Analytic Plan group than that in the HC group. As for CTC, the HC group’s
SPSS version 25.0 was used for the analytic procedure and a proportion was higher than the MDD group for scores 0, 1, and
p = 0.05 (two-tailed) for statistical significance. χ 2 tests and 5, whereas the reverse was observed with CTC scores 2, 3, and 4.
independent t-tests were used to check for group differences
for categorical variables and continuous variables, respectively,
in the MDD and HC groups. To test our first hypothesis, that Effect of Diagnosis and CM on C-DAS-A
is, DAs are associated with CM; we used a 2×2 analysis of Total and Subscale Scores
covariance (ANCOVA) of the diagnosis and CM on C-DAS-A Table 3 shows the results of a 2×2 ANCOVA (factor 1: diagnosis
total score with age, sex, and education as covariates; post-hoc and factor 2: CM) on C-DAS-A total and subscale scores with
analyses followed it. The same procedure was repeated with the age, gender, and education as covariates. No significant two-way
eight C-DAS-A subscale scores as the dependent variable. interaction effect of CM and diagnosis was found for C-DAS-
For our second hypothesis, a hierarchical regression analysis A total score while controlling for covariates (F = 1.20, p =
was used to estimate the different CM types’ influence magnitude 0.275, partial η2 = 0.004). Therefore, an analysis of the main
on C-DAS-A total score first. Then, the eight various C-DAS-A effects and the Bonferroni post-hoc test were performed for CM
subscale scores replaced the C-DAS-A total score. The procedure and diagnosis (35). The main effect of CM showed a statistically
was run in the two groups, MDD and HC groups, independently. significant difference in unweighted adjusted marginal mean
Afterward, we assessed whether higher CTCs lead to more (36, 37) C-DAS-A total score for those who had CM (145.57) vs.
DA, that is, our third hypothesis, by running a hierarchical those without CM (134.03) was 11.542 [95% confidence interval
regression analysis of CTC on C-DAS-A total score followed by (CI), 5.83–17.25; p < 0.001]. As for the main effect of diagnosis,
its substitution with the eight different DAS factor scores. The it showed a statistically significant difference in unweighted
process was run separately in the MDD and HC groups. adjusted mean C-DAS-A total score for those of the MDD group
(154.10) vs. those of the HC group (125.50). The difference was
RESULTS 28.60 (95% CI, 23.04–34.16; p < 0.001).
There was no statistically significant two-way interaction
Demographic/Clinical of CM and diagnosis while controlling for covariates, on C-
Information/Prevalence of CM, CM Types, DAS-A subscale scores, except for C-DAS-A dependence. These
and CTC statistically significant interactions were interpreted through
Three hundred twenty-seven participants fulfilled the eligibility analysis of main effects and Bonferroni post-hoc analyses of CM
criteria, including 171 MDD and 156 HC participants. The mean and diagnosis. The main effect of CM had statistically significant
age of the MDD group (35.06 years) was higher than the HC adjusted marginal means in the following C-DAS-A subscales:
group (34.62 years). The average years of schooling in the MDD vulnerability (1.497, p = 0.009), attraction and repulsion (2.717,

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Jugessur et al. Childhood Maltreatment Predicts Dysfunctional Attitudes

TABLE 1 | Demographics and clinical information of major depressive disorder (MDD) and healthy control (HC) groups.

Item MDD p1 HC p2 P3

CM+ CM− CM+ CM−

(n = 103) (n = 68) (n = 69) (n = 87)
Mean ± SD Mean ± SD Mean ± SD Mean ± SD

Age (years) 34.61 ± 9.42 35.74 ± 10.08 0.459 36.09 ± 9.30 33.45 ± 8.96 0.074 0.672
Gender (male/female) 41/62 34/34 — 28/41 43/44 — 0.387
Education (years) 9.55 ± 3.29 11.26 ± 3.52 0.001 10.26 ± 3.37 11.80 ± 3.68 0.008 0.024
HAMD24 32.01 ± 7.67 31.00 ± 6.80 0.379 1.79 ± 1.89 1.06 ± 1.61 0.011 0.000
HAMA14 18.54 ± 6.32 17.96 ± 6.17 0.551 1.55 ± 2.14 1.01 ± 1.73 0.084 0.000
C-DAS-A total 159.11 ± 25.50 149.37 ± 29.13 0.022 133.13 ± 22.83 117.40 ± 22.72 0.000 0.000
CTQ 48.12 ± 9.20 32.16 ± 4.46 0.000 44.94 ± 8.81 30.64 ± 4.10 0.000 0.000
Episodes 1.98 ± 1.18 2.10 ± 1.53 0.556 — — — —
Onset age (years) 31.35 ± 10.09 32.36 ± 10.30 0.537 — — — —
Current history 5.20 ± 11.00 3.50 ± 3.16 0.217 — — — —
Total history 41.14 ± 50.01 42.32 ± 53.13 0.883 — — — —

Data are presented as mean ± SD. Bold values indicate statistical significance. MDD, major depressive disorder; HC, healthy control; CM, childhood maltreatment; BMI, body mass
index; HAMD24 , 24-item Hamilton Rating Scale for Depression; HAMA14 , 14-item Hamilton Anxiety Rating Scale; p1 , statistical significance of MDD group; p2 , statistical significance
for HC group; p3 , statistical significance of MDD and HC groups.

TABLE 2 | Prevalence of childhood maltreatment and factors in the sample.

MDD HC MDD+HC χ2 p

n % n % n %

Childhood maltreatment 103 60.2 69 44.2 172 52.6 8.380 0.004

Emotional abuse 16 9.4 5 3.2 21 6.4 5.137 0.023
Physical abuse 16 9.4 8 5.1 24 7.3 2.145 0.143
Sexual abuse 15 8.8 10 6.4 25 7.6 0.664 0.442
Emotional neglect 55 32.2 30 19.2 85 26.0 7.093 0.008
Physical neglect 85 49.7 56 35.9 141 43.1 6.344 0.012
CTC 0 68 39.8 86 55.1 154 47.1 15.596 0.012
1 41 24.0 40 25.6 81 24.8
2 46 26.9 22 14.1 66 20.8
3 10 5.8 5 3.2 15 4.6
4 6 3.5 2 1.3 8 2.4
5 0 0.0 1 0.6 1 0.3

Bold values indicate statistical significance. MDD, major depressive disorder; HC, healthy control; CTC, Childhood trauma count; p, statistical significance of χ2 test.

p < 0.001), perfectionism (1.321, p = 0.029), seeking applause (37–40). The effects of diagnosis for CM+ (F = 18.635, p < 0.001,
(2.408, p < 0.001), and self-determination (1.440, p = 0.018). partial η2 = 0.135) and CM− (F = 50.832, p < 0.001, partial η2 =
No statistically significant adjusted marginal mean scores were 0.055) were both statistically significant. The effect of CM for the
observed for the main effect of CM in C-DAS-A compulsion MDD group (F = 0.021, p = 0.886, partial η2 = 0.000) was not
and cognition philosophy subscales (p > 0.131). As for the main statistically significant, unlike that for the HC group (F = 9.588,
effects of diagnosis group, there was a statistically significant p = 0.002, partial η2 = 0.029).
adjusted marginal means in all of the eight subscale scores of
C-DAS-A (p < 0.001).
As for C-DAS-A dependence, a statistically significant two- Hierarchical Regression Analysis of CM
way interaction of CM and diagnosis was present while Types on C-DAS-A Total and Subscale
controlling for covariates (F = 4.55, p = 0.034, partial η2 = Scores
0.014). Therefore, an analysis of simple main effects for CM A hierarchical regression analysis was run at three levels to
and diagnosis was performed using a Bonferroni adjustment and determine if CM types improved the prediction of C-DAS-A total
being accepted at the p < 0.025 level for both CM and diagnosis and subscale scores in the MDD and HC groups. At level 1: age,

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Jugessur et al.
TABLE 3 | Analysis of covariance (ANCOVA) of C-DAS-A total and subscale scores with age, gender, and education controlled.

C-DAS-A MDD HC F1 p1 Main effects Main effects Interaction effects

of diagnosis of CM (CM and diagnosis)

CM+ CM− CM+ CM− F2 p2 F3 p3 F4 p4

(n = 103) (n = 68) (n = 69) (n = 87)
Mean ± SD Mean ± SD Mean ± SD Mean ± SD

Total score 159.11 149.37 133.13 117.4 24.71 <0.001 102.44 <0.001 15.83 <0.001 1.20 0.275
± 25.5 ± 29.13 ± 22.83 ± 22.72
Vulnerability 18.59 17.19 15.64 13.92 9.83 <0.001 38.97 <0.001 8.54 0.004 0.10 0.754
± 4.67 ± 4.34 ± 4.81 ± 3.81
Attraction and repulsion 19.18 16.90 14.65 11.30 20.51 <0.001 74.73 <0.001 20.89 <0.001 0.52 0.471
± 5.25 ± 6.05 ± 5.10 ± 4.24
Perfectionism 18.91 18.38 16.10 13.83 8.92 <0.001 38.92 <0.001 4.80 0.029 2.51 0.114
± 5.73 ± 5.50 ± 4.59 ± 4.70
Compulsion 19.26 18.44 16.29 16.10 9.71 <0.001 29.17 <0.001 0.05 0.828 0.68 0.410
± 4.75 ± 4.21 ± 4.12 ± 3.59
Seeking applause 20.44 18.06 17.30 14.48 12.57 <0.001 36.03 <0.001 18.01 <0.001 0.41 0.522
± 5.44 ± 4.95 ± 4.51 ± 4.55
Dependence 19.68 19.34 16.52 14.13 14.95 <0.001 66.28 <0.001 5.22 0.023 4.55 0.034
± 4.65 ± 4.80 ± 3.96 ± 4.48
Self-determination attitude 22.37 21.74 18.81 17.08 10.76 <0.001 52.94 <0.001 5.67 0.018 0.53 0.467
5

± 5.88 ± 5.21 ± 5.03 ± 4.60

Cognition philosophy 20.67 19.32 17.81 16.56 7.94 <0.001 22.73 <0.001 2.29 0.131 0.34 0.853
± 5.32 ± 5.21 ± 4.06 ± 5.15

Data are presented as mean ± SD. Bold values indicate statistical significance. HC, healthy control; CM, childhood maltreatment; C-DAS-A, Chinese version of Dysfunctional Attitude Scale–Form A; F1 , F test value for corrected model;
p1 , statistical significance of corrected model; F2 , F test value for main effects of MDD; p2 , statistical significance for main effects of MDD; F3 , F test value for main effect of CM; p3 , statistical significance of main effect of CM; F4 , F test
value for interaction effect between CM and MDD; p4 , statistical significance of interaction effect between CM and MDD.

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gender, and education; level 2: HAMA14 and HAMD24 ; and level depressed participants (EA: 9.4% vs. 36.7%; PA: 9.4% vs. 27.6%;
3: EA, PA, SA, EN, and PN were included for the hierarchical SA: 8.8% vs. 25.3%; EN: 32.3% vs. 43.2%; PN: 49.7% vs. 36.2%).
regression analysis in the HC group, whereas in the MDD group, Given our study’s regional concept, China’s rapid economic
two supplementary items were added to level 2: duration of development meant parents have less time to interact with their
current episode and episode counts. As six participants had children physically. As stated by the social development theorist
missing records of the HAMA14 data, they were removed from Vygotsky, children do not develop in isolation; the lack of social
this investigation leading to a new sample size of 168 for the interaction suffered by the children neglected by their caregivers
MDD group and 153 for the HC group. constitutes a social impediment for their cognitive development.
The hierarchical regression analysis of CM types on C-DAS- Beck’s cognitive theory of depression proposed that a
A total and subscale scores within the MDD group is shown in negative self-schema is present before the onset of depression.
Table 4. Within the MDD group, the CM types’ addition to the Those cognitive distortions are results of adverse childhood
model led to a statistically significant 1R2 of 7.9% (p = 0.015) experiences. They remain dormant until triggered by stressors
with an EA standard coefficient of 0.249 in C-DAS-A total score. (16, 41). By demonstrating cognitive differences between
There was a statistically significant 1R2 of 8.2% (p = 0.015) in individuals who underwent CM and the depressed participants,
the C-DAS-A attraction and repulsion score and a statistically this study provides essential support to Beck’s cognitive
significant PN standard coefficient (0.276). In comparison, in theory of depression. We showed that CM predicts DAs in
the C-DAS-A self-determination, the EA (0.262) was statistically both participants with and without depression. Thereby, we
significant, with a 1R2 of 6.9% (p = 0.027). understand that CM predicts some amount of DAs, which
Table 5 shows the hierarchical regression analysis of CM types remain latent. We shared a similar tenet with a study about
on C-DAS-A total and subscale scores within the HC group. Only mood induction. They showed that DAs remain latent unless
PN (0.216) was statistically significant, with a change in R2 of activated (42). We also shared similar results with a survey of
7.7% (p = 0.033) observed in C-DAS-A seeking applause. 155 participants; they found a significant association between
DAs and CM (43). However, only healthy participants with a
Hierarchical Regression Analysis of CTC comparatively lower mean age were involved in that study.
DAs are molded through adverse experiences starting
on C-DAS-A Total and Subscale Scores
from childhood. CM is among the risk factors for cognitive
A hierarchical regression analysis was run to find CTC’s
vulnerabilities (44). Maltreated children make inferences in
predictability on C-DAS-A total and subscale scores in both the
trying to understand maltreatment events. With the repetition of
MDD (n = 168) and the HC (n = 153) groups. At level 1: age,
those events, the children can develop DAs by negative cognitive
gender, and education; level 2: HAMA14 and HAMD24 ; and level
structuring and faulty information processing. Ultimately,
3: CTC were included for the hierarchical regression analysis in
depression is the result when those are triggered (21, 44, 45).
the HC group, whereas in the MDD group, two supplementary
Studies have found that EA and EN had a strong association
items were added to level 2: duration of current episode and
with DAs (46, 47). They are also predictive of future depressive
episode counts. The results are shown in Table 6. C-DAS-A total
episodes (48–50), mediated by DAs (43). Our study is on similar
score had a significant predicted 1R2 of 3.8% (p = 0.010, β =
lines. We found that individuals with EA were likely to develop
0.213) in the MDD group. Other C-DAS-A subscales that showed
more DAs of self-determination attitude type and overall DAs
a significant 1 R2 were as follows: vulnerability (1R2 = 2.5%,
among the depressed participants. It is possible that those two
p = 0.042, β = 0.171), attraction and repulsion (1R2 = 5.4%,
types of DAs might influence the pathway from EA to depression.
p = 0.002, β = 0.253), and seeking applause (1R2 = 3.4%, p
Individuals with DAs of self-determination attitude type are those
= 0.014, β = 0.202). In the HC group, the C-DAS-A attraction
with the thought of casting one’s values in comparison with others
and repulsion score (1R2 = 2.7%, p = 0.036, β = 0.167) led
(e.g., “If I do not do as well as other people, it means I am
to a statistically significant rise with the addition of CTC to
an inferior human being”) (28). A group of researchers shared
the investigation.
similar findings; they discussed the relationship between EA and
depression mediated by DAs (19).
DISCUSSION Failure to cater to a child’s basic needs by caregivers, either
deliberately or unknowingly, defines CN. The child is deprived
Up to our knowledge, this study is among the few to investigate of basic needs, safety, supervision, medical care, physical
DAs as trait features of CM. The reported prevalence rate of CM requirements, and emotional support (1). CN includes PN and
among the depressed participants and HCs was 60.2% and 44.2%, EN. It is the most prominent form of CM worldwide, and its
respectively. Our reported prevalence rate was much higher than high prevalence can be seen in our study. Approximately one
a meta-analysis conducted in 2017. However, the meta-analysis in six children will experience CN (51). Studies have shown
reported a comparatively lower prevalence rate of 45.6% among that CN impedes the development of the corpus callosum areas
depressed participants (15). This discrepancy could be because (52), and those alterations correlate with depression (53–55). An
our study was restricted to one region, and we had a smaller interesting result from our research indicated that PN is bound
sample size. The disparity suggests that CM could be more to more DAs: attraction and repulsion-type DA in the depressed
frequent in some regions. The reported prevalence of specific and seeking applause-type DA in the non-depressed. However,
CM types was comparatively lower, except for PN, within the a study of 155 healthy participants with a mean age of 18.8

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Jugessur et al. Childhood Maltreatment Predicts Dysfunctional Attitudes

TABLE 4 | Hierarchical regression analysis of childhood maltreatment types on C-DAS-A total and subscale scores in the MDD group (n = 168).

C-DAS-A 1R2 p for 1R2 Standard coefficient

Emotional abuse Physical abuse Sexual abuse Emotional neglect Physical neglect

Total score 0.079 0.015 0.249 −0.107 −0.038 0.044 0.119

Vulnerability 0.054 0.101 0.230 −0.094 −0.006 0.048 0.059
Attraction and repulsion 0.082 0.015 0.113 −0.075 −0.009 −0.015 0.276
Perfectionism 0.019 0.685 0.118 −0.054 −0.027 0.075 0.000
Compulsion 0.032 0.334 0.131 −0.005 −0.004 −0.048 0.124
Seeking applause 0.049 0.126 0.165 −0.003 −0.003 0.114 0.009
Dependence 0.031 0.400 0.180 −0.114 0.034 −0.121 0.088
Self-determination attitude 0.069 0.027 0.262 −0.155 −0.023 0.001 0.118
Cognition philosophy 0.052 0.115 0.134 −0.064 −0.125 0.162 −0.050

Bold values indicate statistical significance. The 1R2 indicates the changes R2 of the model from level 2 to level 3. The three hierarchies of the regression model were as follows: level
1: age, sex, education; level 2: HAMA14 , HAMD24 , duration of current episodes, episode counts; level 3: childhood maltreatment types. C-DAS-A, Chinese version of Dysfunctional
Attitude Scale–Form A.

TABLE 5 | Hierarchical regression analysis of childhood maltreatment types on C-DAS-A total and subscale scores in the HC group; (n = 153).

C-DAS-A 1R2 p for 1R2 Standard coefficient

Emotional abuse Physical abuse Sexual abuse Emotional neglect Physical neglect

Total score 0.088 0.007 0.048 −0.100 0.044 0.117 0.135

Vulnerability 0.061 0.090 0.151 −0.063 0.087 0.141 −0.032
Attraction and repulsion 0.090 0.011 0.107 −0.010 −0.044 0.220 0.089
Perfectionism 0.060 0.089 0.127 −0.105 0.077 0.136 0.037
Compulsion 0.016 0.749 −0.007 −0.130 0.031 0.021 0.067
Seeking applause 0.077 0.033 0.139 −0.085 0.057 −0.026 0.216
Dependence 0.054 0.098 0.143 −0.009 0.031 −0.113 0.198
Self-determination attitude 0.039 0.269 −0.115 −0.055 0.128 0.052 0.168
Cognition philosophy 0.051 0.123 0.222 −0.078 0.130 0.156 −0.430

Bold values indicate statistical significance. The 1R2 indicates the changes R2 of the model from level 2 to level 3. The three hierarchies of the regression model were as follows: level
1: age, sex, education; level 2: HAMA14 , HAMD24 ; level 3: childhood maltreatment types. C-DAS-A, Chinese version of Dysfunctional Attitude Scale–Form A; HC, healthy control.

TABLE 6 | Hierarchical regression analysis of childhood trauma count on C-DAS-A total and subscale scores in the MDD (n = 168) and the HC (n = 153) groups.

C-DAS-A MDD HC group

(n = 168) (n = 153)
2 2 2
1R p for 1R Standard coefficient 1R p for 1R2 Standard coefficient
for CTC for CTC

Total score 0.038 0.010 0.213 0.011 0.156 0.108

Vulnerability 0.025 0.042 0.171 0.002 0.555 0.048
Attraction and repulsion 0.054 0.002 0.253 0.027 0.036 0.167
Perfectionism 0.010 0.206 0.107 0.002 0.629 0.039
Compulsion 0.012 0.138 0.121 0.000 0.829 −0.017
Seeking applause 0.034 0.014 0.202 0.014 0.137 0.121
Dependence 0.001 0.681 0.035 0.007 0.280 0.084
Self-determination attitude 0.019 0.064 0.150 0.008 0.255 0.090
Cognition philosophy 0.005 0.363 0.076 0.000 0.874 0.012

Bold values indicate statistical significance. The three hierarchies of the regression model in the MDD group were as follows: level 1: age, sex, education; level 2: HAMA14 , HAMD24 ,
duration of current episode, episode counts; level 3: childhood maltreatment types. The three hierarchies of the regression model in the HC group were as follows: level 1: age, sex,
education; level 2: HAMA14 , HAMD24 ; level 3: childhood trauma counts. The 1R2 indicates the changes R2 of the model from level 2 to level 3. C-DAS-A, Chinese version of Dysfunctional
Attitude Scale–Form A; HC, healthy control; CTC, childhood trauma count.

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Jugessur et al. Childhood Maltreatment Predicts Dysfunctional Attitudes

years found that physical maltreatment was not related to DAs. summary, our study provided new insights into the clinical
In their research, physical maltreatment englobed PA and PN. field. Specific types of DAs might influence the relationship
Their selection of only healthy participants makes it difficult for between MDD and CM. Furthermore, we also concluded that
us to weigh up our depression group results. Nevertheless, we the higher the CTCs, the more DA types in participants with
could compare the findings of our control group. The reason and without depression. Screening and prevention of CM by
behind this discrepancy could be the merging of PA and PN related authorities, caregivers, medical professionals, and parents
into one category (43), as PA was reported not to be associated are imperative to break the chain. EA or PN typically deserves
with DAs (19). CN was found to be predictive of DAs among better attention; they may be potential markers to screen for
depressed participants in a study (20), partly supporting our depression. Research has shown that psychotherapy alone or
findings for PN. in combination with antidepressants is best suited in depressed
Exposure to one form of trauma in childhood potentially patients who underwent CM (61). Cognitive–behavioral therapy
elevates the risk of experiencing several forms of trauma over (CBT), personalized trauma–focused CBT, and child–parent
time. Polyvictimization is the term used to describe individuals psychotherapy are recommended. The forms of DA associated
who experienced potentially traumatic events such as the known with depression found in our study should to be focused on to
components of CM, bullying, and witnessing adverse events address ongoing or future depressive episodes.
such as parent substance abuse, domestic violence, and others
(56, 57). It is a robust predictor of short- and long-term mental DATA AVAILABILITY STATEMENT
health problems not limited to depression (14, 58). Like a few,
we also used the CTQ to assess an aspect of polyvictimization. The raw data supporting the conclusions of this article will be
They found a “dose-dependent” relationship between collective made available by the authors, without undue reservation.
CM types and the odds of being diagnosed with depression
(59, 60). Our study added a new scope in polyvictimization; we ETHICS STATEMENT
further assessed which type of DA is more likely in depressed
and non-depressed individuals. With increased CTCs, DAs of The studies involving human participants were reviewed and
vulnerability type, attraction and repulsion type, and seeking approved by the Ethics Committee of the Second Xiangya
applause type and overall DAs were predicted in depressed Hospital of Central South University and Ethic Committee of
patients. In those without depression, increased CTCs predicted the Zhumadian Psychiatric Hospital. The patients/participants
DAs of attraction and repulsion type. Our results were in line with provided their written informed consent to participate in
the titration model of the cognitive vulnerability. It states that a this study.
lesser threshold of adverse events is required when more negative
cognitive styles are present to onset depression (21, 22). AUTHOR CONTRIBUTIONS
LIMITATIONS LL, YZ, and BL co-designed the topic. BL, JS, MW, XL, QD,
LZ, JL, YJ, PW, HG, FZ, and YZ are responsible for participant
A couple of limitations concerning this study should be noted. recruitment and data collection. RJ and BL co-conducted the
First, the nature of our research is a hurdle to make reverse statistical analyses. RJ wrote the initial draft of the manuscript.
causality inferences. We could not show the direct causality BL contributed important revisions to the manuscript.
of DAs associated with CM and account for time exposed to All authors contributed to the article and approved the
CM. Second, the retrospective assessment of CM using the submitted version.
CTQ is subject to recall biases. Also, some forms of CM such
as SA might be underreported in fear of shame and social
detriment. Third, polyvictimization is best assessed using the FUNDING
Juvenile Victimization Questionnaire (JVC) (57). As most of the
This study was supported by the National Science and
JVC components overlapped with the CTQ, we adopted the latter
Technologic Program of China (2015BAI13B02), the Defense
for our study’s purposes. Two researchers endorsed the same
Innovative Special Region Program (17-163-17-XZ-004-005-01),
method (59, 60). They assessed polyvictimization by grading the
the National Natural Science Foundation of China (81171286,
severity of the individual CTQ factors. We used a dichotomous
91232714, and 81601180). The funding sources had no role in the
format for each factor of the CTQ; either presence or absence
study design, data collection and analysis, interpretation of the
could be the outcome, ignoring the severity of the CTQ factors.
data, preparation and approval of the manuscript, and decision
to submit the manuscript for publication.
CONCLUSIONS
Our group of researchers brought up the novel idea to examine ACKNOWLEDGMENTS
the type of DAs predicted by CM types, and we are the only
to explore the types of DA predicted by higher CTCs. In We thank all participants for participating in this study.

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Jugessur et al. Childhood Maltreatment Predicts Dysfunctional Attitudes

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