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. 2026 Aug 31;65(3):e70190. doi: 10.1111/famp.70190

The Effects of Adverse Childhood Experiences (ACEs) on Change in Emotion Regulation Difficulty in Clinical Couples

Betsy Hughes Barrow 1,✉, Angela B Bradford 1, Justin W Dyer 1, Alyssa Banford Witting 1, Lee N Johnson 1
PMCID: PMC13527539  PMID: 42670295

ABSTRACT

Emotion regulation is central to managing emotions and interactions, making it essential for effective relationship functioning. Because emotion dysregulation contributes to many presenting problems in couple therapy, understanding it within clinical couples is vital, particularly when one or both partners have a history of adverse childhood experiences (ACEs). While the link between ACEs and adult mental and relational challenges is well‐established, research about how ACEs affect the therapy change process is still developing. Most existing research about ACEs has focused on cumulative ACE counts, with less attention to exposure to distinct ACE types (within the family context) and their differential effects on emotion regulation. The current study focuses on emotion regulation difficulty in clinical couples, exploring associations with frequency of exposure to individual ACE types—such as abuse, neglect, and various types of family of origin dysfunction—and levels of emotion regulation difficulty at intake as well as the trajectory of emotion regulation difficulty over 12 sessions of couple therapy. Findings were that emotional maltreatment (abuse and neglect) and mental illness in one's family of origin were associated with higher levels of emotion regulation difficulty at intake. Also, greater frequency of emotional neglect in childhood was associated with faster rates of change in emotion regulation difficulty over 12 therapy sessions. Findings suggest that assessing the frequency of family‐of‐origin adversity may be clinically relevant in couple therapy contexts and that individuals with histories of neglect may experience improvement in emotion regulation within supportive relational environments characteristic of couple therapy.

Keywords: adverse childhood experiences (ACEs), childhood adversity, childhood trauma, couple therapy, emotion regulation, emotional neglect

1. Introduction

The impact of negative family of origin experiences on later life couple processes has become an area of increasing interest. As such, intermediary psychological processes such as emotion regulation that influence couple relationships are an important consideration for clinical work with couples when one or both partners have experienced childhood adversity. Adverse childhood experiences (ACEs) encompass various forms of trauma, including physical or emotional abuse, neglect, and family stressors such as substance abuse and mental illness. Research indicates that these experiences can have significant long‐term effects on individuals, impacting their physical health, mental well‐being (Felitti et al. 1998; Hughes et al. 2017), and relationships throughout life (Eyisoylu and Erdem 2023; Nelson and Wampler 2000; Ogan et al. 2024).

Although previous research has linked ACEs to emotion dysregulation, limited research has examined whether the frequency of exposure to specific ACE types differentially increases the risk (Lacey and Minnis 2020) for emotion regulation difficulty. Additionally, few studies have examined emotion regulation difficulties within clinical couples. Addressing this gap is particularly important for systemic therapists, as both ACEs and emotion regulation difficulty have the potential to affect the therapy change process. Of interest to the current study is whether frequency of exposure to various types of ACEs within a family context (e.g., abuse, neglect, and various household dysfunctions) is associated with (a) initial levels of emotion regulation difficulty reported at the start of therapy and (b) changes in emotion regulation difficulty over the course of 12 sessions of couple therapy.

1.1. Adverse Childhood Experiences

Since the original ACEs study by Felitti et al. (1998), extensive research has examined the effects of cumulative ACEs on various negative outcomes. Studies have consistently indicated a dose–response relationship where more ACEs (a sum of all the individual ACE type items) are positively associated with more mental and physical health risks (Felitti et al. 1998; Hughes et al. 2017). Thus, studies have focused primarily on individuals with higher total ACE counts with less attention given to the impact of different types of ACEs as individual predictors. An assumption of the cumulative ACE approach is that all ACEs have the same impact. However, scholars agree that ACEs vary in their impact and more research is needed to understand which ACEs are more predictive of outcomes (Krinner et al. 2021).

More recently, researchers have called for studies that move beyond simple ACE counts to address ACE severity, impact, timing, and frequency, including the potential weighting of individual ACE types (Lacey and Minnis 2020). Additionally, a debate over dimensional perspectives of childhood adversity has emerged. McLaughlin et al. (2021) suggest categorizing adversity by underlying environmental dimensions such as threat versus deprivation, whereas Pollak and Smith (2021) argue that stress‐related processes are activated not by objective events alone but by individuals' perceptions of those experiences. The present study situates itself in this debate by examining the frequency of exposure to individual ACE types simultaneously rather than summing ACE types into a cumulative score. By treating different ACE types as separate predictors, we focus on how different ACEs influence therapeutic trajectories of change.

Previous studies evaluating the differential effects of different types of childhood adversity have primarily focused on fixed outcomes with some mixed findings. In a study of 79 healthy adults, frequency of exposure to several types of childhood adversity was assessed. Abuse was calculated by combining the emotional, physical, and sexual abuse subscales, and neglect was calculated by combining the emotional and physical neglect subscales. Abuse was associated with emotion regulation difficulty, and emotion regulation difficulty mediated the relationship between abuse and pre‐sleep arousal, daily hassles, and reported difficulties with executive functioning (Tinajero et al. 2020). Another study investigating effects of different types of childhood trauma on emotion regulation in patients with alcohol use disorder found that frequency of exposure to childhood emotional abuse was positively associated with anxiety. In turn, anxiety was positively related to emotion dysregulation, and emotion dysregulation was negatively associated with pain tolerance (Zaorska et al. 2020). Furthermore, Myroniuk et al. (2025) found that different types of maltreatment relating to threat vs. deprivation shaped emotional functioning and regulation in different ways. Sexual abuse was associated with more emotional reactivity and less stability in adulthood. Emotional neglect showed the strongest and most pervasive effects, characterized by muted positive emotional dynamics and more intense and persistent negative emotions. In contrast, emotional abuse showed no unique effects after controlling for neglect. In line with this finding, exposure to neglect—alone or along with other forms of maltreatment—predicted reduced emotional sensitivity to affective words in a longitudinal study of 427 emerging adults (Warmingham et al. 2023).

While developing research has explored distinct effects of childhood maltreatment (specific to abuse and neglect) on emotion regulation, less is known about how the frequency of exposure to these and other ACE types influences emotion regulation. Given that 61% of adults in North America report having experienced at least one ACE (Centers for Disease Control and Prevention [CDC] 2021), it is vital to understand how frequency of exposure to abuse, neglect, and other types of family dysfunction influences adult relationship processes such as emotion regulation difficulty (Poole et al. 2018).

1.2. Emotion Regulation

The ability to regulate emotion, which is closely linked to positive mental health, is considered essential for emotional and relational wellbeing and theoretically increases one's ability to manage or resolve emotionally provoking events and interactions (Mikulincer and Shaver 2007) through strategies implemented either before or after an emotional response (Gross and John 2003). In contrast, emotional dysregulation includes difficulty understanding emotions, managing emotional reactions, and using emotions to support goal‐directed behaviors (Gratz and Roemer 2004). Consequently, emotional dysregulation has been associated with mental and relational distress (Hu et al. 2014) and cuts across many mental health disorders including depression, anxiety, eating disorders (Mares et al. 2024), posttraumatic stress disorder (Russo et al. 2023), and personality disorders (Haliczer et al. 2021). Increasingly, emotion regulation has been suggested as a transdiagnostic target for treatment and intervention (Sloan et al. 2017).

Recently, more research has focused on the relationship between emotion dysregulation and ACEs. Although emotion regulation difficulty has been well‐established as a mediator between childhood trauma and psychological distress (Rudenstine et al. 2019), emerging evidence suggests that emotion regulation difficulty may characterize a psychological process that not only links ACEs with adult mental and physical health challenges (Cloitre et al. 2019) but also with adult interpersonal difficulties (Poole et al. 2018). This underscores the importance of investigating emotion regulation in the context of couple therapy and is consistent with a recent finding indicating that ACEs for men and women were predictive of their own struggles with emotion regulation in therapy (Xu et al. 2025). Additionally, a study of expectant women suggested a risk chain where an anxious attachment style in adulthood influenced the relationship between childhood emotional maltreatment and couple functioning through emotion dysregulation and depressive symptoms (Cao et al. 2020).

1.3. Couple Relationships

Although the importance of emotion regulation to mental and relational health has been well established, relatively few studies have investigated emotion regulation within treatment‐seeking couples, using data from both partners. Among those that have, most have highlighted the importance of emotional regulation to couple relationship well‐being. VanBoxel et al. (2024) examined how difficulties with emotion regulation influence relationship satisfaction among clinically distressed couples enrolled in an Emotionally Focused Therapy (EFT) protocol. Their findings align with a recent study suggesting a link between greater difficulty with emotion regulation and lower relationship satisfaction in clinical couples at the start of therapy (VanBoxel et al. 2024). Additionally, various aspects of emotion dysregulation such as difficulties with impulse control, lack of emotional awareness, and limited emotion regulation strategies have been negatively associated with relationship satisfaction in couples (Xu et al. 2023). Emotion dysregulation was also found to mediate a negative association between family of origin conflict and relationship maintenance in a study of 114 couples (Ogan et al. 2024). Of interest to the current study is whether the frequency of exposure to different ACE types contributes to variation in emotion regulation difficulty at the start of therapy and rates of change over 12 sessions of therapy for individuals enrolled in couple therapy with their partner.

Research Question 1: Does the frequency of exposure to specific ACE types predict levels of emotion regulation difficulty reported by individuals at the start of couple therapy?

Research Question 2: Does the frequency of exposure to specific ACE types contribute to rates of change in emotion regulation difficulty for individuals over 12 sessions of couple therapy?

2. Method

2.1. Procedures for Data Collection

The proposed study utilizes data from the Marriage and Family Therapy Practice Research Network MFT‐PRN, an online, outcome‐based client monitoring system (see Johnson et al. 2017). As part of the system, clients' complete questionnaires before beginning therapy and throughout the course of therapy. Two batteries of assessments are given to clients. For this study, we used data from the battery of assessments given to clients at intake and before every 4th session thereafter until the 12th session. ACEs and demographic information were collected at intake. Emotion regulation data were collected at intake and every 4th session (i.e., prior to sessions 1, 4, 8, and 12).

2.2. Sample

The sample for this study included 411 couples (822 individuals) who attended couple therapy sessions between June 2018 and December 2023 at clinics in the United States that were part of the Marriage and Family Therapy Practice Research Network (MFT‐PRN; Johnson et al. 2017). Within our sample, 790 partners identified as heterosexual, three partners identified as homosexual, and 29 partners identified as bisexual. Based on sex assigned at birth, 410 individuals reported male, 411 reported female, and 1 reported intersex. Only couples who received the Difficulty with Emotion Regulation Scale (DERS) assessment and who reported at least one ACE within the couple dyad were eligible to be included in the study. See Table 1 for additional demographic characteristics. All study procedures were approved by the Brigham Young University Internal Review Board for the protection of human subjects, protocol IRB2023‐246.

TABLE 1.

Descriptive statistics of demographic variables.

Variables Mean years SD Range
Age 29.05 9.64 18–72
Percentages
Race
Amer Indian or Alaska Native 0.36
Asian 2.55
Black or African American —
White 80.29
Hispanic or Latino 8.27
Native Hawaiian/Other Pacific Islander 0.49
Multiracial 8.07
Sexual orientation
Heterosexual 96.09
Gay/Lesbian 0.37
Bisexual 3.55
Yearly household income
Under $30,000 42.70
Between $30,000–$59,999 27.00
Between $60,000–$89,999 13.51
$90,000 and above 30.78
Education
Junior High School or Less 0.36
High School/GED 29.32
Vocational/Tech School 4.14
Associate Degree 21.05
Bachelor's Degree 32.60
Graduate/Professional Degree 12.53
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Note: N = 411 couples (822 individuals).

2.3. Measures

2.3.1. Adverse Childhood Experiences

ACEs were assessed at the start of therapy using a questionnaire developed from the Behavioral Risk Factor Surveillance System (BRFSS) ACE module (CDC 2018). The questionnaire includes 11 potential adverse childhood experiences: emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, parental domestic violence, alcohol or drug abuse in the home, household depression or mental illness, suicide of a family member or attempted suicide by self or a family member, incarceration of a household member, and parental separation or divorce. Respondents reported whether each event had occurred in their family of origin by responding “yes” or “no” to questions about whether they had experienced each individual ACE item. Examples of items include “Did your parents or adults in your home ever swear at you, insult you, or put you down?” and “Did your parents or adults in your home ever hit, beat, kick, or physically hurt you in any way? (Does not include spanking).” “Yes” answers resulted in respondents receiving additional questions about frequency and impact. Frequency items were used for this study and were rated on a 4‐point Likert scale from once or twice (1) to almost always (4). These items were recoded to a 5‐point Likert scale to retain information about variability in exposure while also including individuals with no exposure. As such, we recoded each ACE frequency item to include a value of zero for no exposure. This allowed us to model frequency of exposure from never (0) to almost always (4) within each ACE type rather than using a dichotomous exposed/not exposed variable. We treated these recoded variables as continuous predictors because they were created to examine whether greater frequency of exposure was associated with increased emotion regulation difficulty.

2.3.2. Difficulties With Emotional Regulation

Difficulty with emotional regulation was assessed at intake and again at every fourth session. The Difficulty in Emotion Regulation Scale (DERS) is a well‐established measure, and the DERS‐Short Form (SF) version (used for this study) shows strong concordance with the full 36‐item DERS measure. Internal consistency for the DERS‐SF was found to be excellent, with reliability above 0.80 (Gratz and Roemer 2004). For the current sample, Cronbach's alpha was 0.87 at Sessions 1 and 4 and 0.88 at Sessions 8 and 12. Participants respond to 18 items on a 5‐point Likert scale from almost never (1) to almost always (5). Examples of items are: “When I'm upset, I have difficulty controlling my behaviors” and “When I'm upset, my emotions feel overwhelming.” All items are summed, and scores can range from 18 to 90. Higher scores indicate more difficulty in emotion regulation. A score of 39 or more on the DERS‐short form has been linked with clinical levels of distress (Burton et al. 2022).

2.3.3. Controls

Because emotion regulation is associated with income (Côté et al. 2010), age (Oriyama et al. 2025), and gender (Bilge and Balaban 2023), we initially included these as covariates. Age, income, and gender were self‐reported. Gender was represented as a binary variable (1 = female, 2 = male), and income was represented with 10 dummy‐coded variables ranging from (< 10,000) to (100,000+).

2.4. Preliminary Analysis

We examined patterns of missingness by using Little's (1988) test of Missing Completely at Random (MCAR), including all DERS variables and study covariates in the analysis. Results were nonsignificant, χ 2(204) = 214.82, p = 0.29, indicating that the data were consistent with the assumption of MCAR. The number of participants providing data at each session decreased over time, with 822 individuals at intake to 273 individuals providing data at Session 12. This pattern is consistent with attrition in longitudinal clinical outcome research. Analyses were conducted in Mplus using the robust maximum likelihood estimator (MLR), which provides standard errors and fit statistics even when data are not evenly distributed. Missing data were handled using full information maximum likelihood (FIML), which takes into account all available observations and does not require complete data at every time point (Enders 2022).

Given that the sample comes from couple therapy clients where both partners provided data, there is the potential for non‐independence. We accounted for this non‐independence by nesting individuals within couples (clustering by dyad). This nesting structure allowed us to appropriately manage the shared variance between partners.

2.5. Main Analyses

To address the research questions, we utilized Mplus 8.10 (Muthén and Muthén 2023) to fit a latent growth curve model nested within couples. At the within‐couple level, we estimated a latent intercept and slope using DERS data from Sessions 1, 4, 8, and 12 as indicators. We allowed the intercept and slope to covary. This unconditional model (with no controls and no predictors) was estimated to assess the average rate of change, average intercept, and variance in the slope and intercept (Robson and Pevalin 2016). We then regressed the latent intercept and slope on the controls and ACE types. The estimated means of the intercept and slope were modeled at the between‐couple level.

3. Results

3.1. Univariate and Bivariate Statistics

Descriptive statistics and bivariate associations between study variables and demographics were estimated using STATA 18 (StataCorp 2023). Variables showed skew toward fewer ACEs. See Table 2 for descriptive statistics of the study variables. See Table 3 for a summary of the bivariate associations among the study variables. Emotional abuse, emotional neglect, and household mental illness were associated with emotion regulation difficulty at Sessions 1, 4, 8, and 12. Suicide or attempted suicide by self or a family member was associated with emotion regulation difficulty at Sessions 1, 4, and 12, and parental domestic violence was associated with emotion regulation difficulties at Sessions 1, 4, and 8.

TABLE 2.

Summary of descriptive statistics for the study variables.

Variables M SD
Emotional abuse 0.97 1.31
Physical abuse 0.35 0.83
Sexual abuse 0.13 0.48
Emotional neglect 0.73 1.25
Physical neglect 0.08 0.46
Parental domestic violence 0.15 0.57
Substance use or abuse 0.29 0.92
Household mental illness 1.23 1.44
Suicide or attempted 0.27 0.73
Incarcerated 0.09 0.39
Parental separation/divorce 0.32 0.73
Emotion regulation 1 41.39 11.06
Emotion regulation 4 40.97 10.75
Emotion regulation 8 40.62 10.62
Emotion regulation 12 39.63 10.57
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Note: N = 822 individuals (411 couples).

Abbreviations: Emotion regulation #, Emotion regulation difficulty at session #; Incarcerated, incarcerated household member; Substance use or abuse, substance use or abuse in the home; Suicide or attempted, suicide of family member or attempted suicide by self or family member.

TABLE 3.

Summary of bivariate (pairwise) associations of the study variables.

Variables 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
1. Emo abuse 1.000
2. Physical abuse 0.525* 1.000
3. Sexual abuse 0.169* 0.214* 1.000
4. Emo neglect 0.531* 0.373* 0.225* 1.000
5. Phys neglect 0.263* 0.245* 0.233* 0.314* 1.000
6. Dom violence 0.340* 0.396* 0.246* 0.302* 0.247* 1.000
7. Substance use 0.185* 0.152* 0.185* 0.205* 0.286* 0.315* 1.000
8. Mental illness 0.208* 0.134* 0.141* 0.256* 0.196* 0.147* 0.209* 1.000
9. Suicide/attempt 0.155* 0.150* 0.180* 0.205* 0.128* 0.153* 0.193* 0.263* 1.000
10. Incarcerated 0.171* 0.130* 0.237* 0.163* 0.174* 0.292* 0.315* 0.072* 0.118* 1.000
11. Divorce 0.241* 0.186* 0.202* 0.341* 0.271* 0.285* 0.353* 0.147* 0.202* 0.239* 1.000
12. Emo reg S1 0.243* 0.112* 0.035 0.294* 0.071* 0.080* 0.051 0.218* 0.074* 0.062 0.022 1.000
13. Emo reg S4 0.224* 0.112* 0.061 0.267* 0.051 0.122* 0.076 0.215* 0.115* 0.011 0.022 0.759* 1.000
14. Emo reg S8 0.172* 0.025 0.029 0.259* 0.111* 0.111* 0.088 0.276* 0.097 0.093 0.039 0.763* 0.789* 1.000
15. Emo reg S12 0.265* 0.114 0.017 0.285* 0.103 0.117 0.076 0.297* 0.181* −0.003 0.108 0.704* 0.729* 0.797* 1.000
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Note: Adverse childhood experience (ACE) information was gathered at Session 1.

Abbreviations: Divorce, parental separation or divorce; Dom violence, parental domestic violence; Emo abuse, emotional abuse; Emo neglect, emotional neglect; Emo reg S#, emotion regulation difficulty at session number; Incarcerated, incarcerated household member; Mental illness, household mental illness; Phys neglect, physical neglect; Substance use, substance use or abuse in the home; Suicide/attempt, suicide of family member or attempted suicide by self or family member.

*

p < 0.05.

3.2. Multivariate Results

The unconditional model showed good model fit: χ 2 (5) = 1.58, p = 0.90, RMSEA = 0.00, CFI = 1.00, TLI = 1.00, SRMR = 0.01 (Hu and Bentler 1995). The average intercept for individuals' emotion regulation difficulty was 41.45 (p < 0.001). The average rate of change over 12 sessions of therapy was = −0.23 (p < 0.001), indicating that, on average, individuals' levels of emotion regulation difficulty decreased by 0.23 at each session of therapy. Over 12 sessions of therapy, there was an average 2.76 reduction in emotion regulation difficulty.

The intercept and slope were negatively correlated (r = −0.32, p < 0.001), indicating that individuals with higher baseline emotion regulation difficulty experienced steeper declines over time. To evaluate baseline dependency, we conducted a sensitivity check, regressing the slope on the intercept. Baseline severity significantly predicted change and accounted for approximately 10% of the variance in slope. Notably, residual slope variance remained significant (p = 0.003), showing that reductions over time were not fully attributable to initial severity.

Next, controls and predictor variables were added predicting the intercept and slope. Because age, gender, and income have been associated with emotion regulation, we initially controlled for these variables; however, there were no significant associations with gender, age, or income levels between 30,000 to 39,999, 50,000 to 59,999, and 80,000 to 89,999. In order to test whether these non‐significant controls were necessary to the model, we used a chi‐squared difference test to compare an unconstrained model (with all controls added) and a model with age, gender, and nonsignificant income ranges constrained to be zero. The difference between the models did not reach the critical chi‐square value (∆χ 2(10) = 14.62, p = 0.05), meaning the constrained model did not have worse fit. In the interest of parsimony, we retained the constrained model and removed non‐significant controls. There was a significant association with income for individuals reporting a yearly household income between 10,000 to 29,999, 40,000 to 49,999, 70,000 to 79,999, and 90,000+, therefore we controlled for these income ranges in our model. The final model showed good fit: χ 2(66) = 91.70, p = 0.02, RMSEA = 0.02, CFI = 0.98, TLI = 0.97. See Figure 1. Controlling for ACE types and significant income levels, the average intercept for individuals' emotion regulation difficulty was 38.25, SE = 0.72, p < 0.001. The average rate of change over 12 sessions of therapy was −0.22, SE = 0.08, p < 0.01 indicating that, on average, individuals' levels of emotion regulation difficulty decreased by 0.22 at each session of therapy. Over 12 sessions of therapy there was an average 2.64 reduction in emotion regulation difficulty.

FIGURE 1.

FIGURE 1

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Conditional model (constrained). N = 411 couples. For readability, controls are not depicted, and only significant paths are shown. *p < 0.05, **p < 0.01, ***p < 0.001.

Additionally, four ACE types predicted levels of emotion regulation difficulty at the start of therapy: emotional abuse (B = 1.06, SE = 0.38, p < 0.01, β = 0.14), emotional neglect (B = 2.09, SE = 0.38, p < 0.001, β = 0.27), household mental illness (B = 1.14, SE = 0.26, p < 0.001, β = 0.17) and parental separation or divorce (B = −1.56, SE = 0.61, p < 0.05, β = −0.12). Emotional abuse, emotional neglect, and household mental illness were all associated with higher levels of emotion regulation difficulty reported at the start of therapy. Conversely, higher levels of parental separation or divorce were associated with lower levels of emotional regulation difficulty at intake.

Only one ACE type significantly influenced the rate of change in emotion regulation difficulty. Emotional neglect had a significant effect on the average rate of change in emotion regulation difficulty (B = −0.09, SE = 0.04, p < 0.05, β = −0.28). When individuals were 1 point higher in emotional neglect, they decreased an additional 0.09 to the average rate of change in emotion regulation difficulty at each session. Because the average rate of change was −0.22, this means that for every point higher in emotional neglect, participants decreased 0.31 points in emotion regulation difficulty at each session. All standardized and unstandardized estimates of predictors have been provided. See Table 4.

TABLE 4.

Standardized and unstandardized estimates of predictors.

Predictor Unstandardized results Standardized results
B SE p 95% CI β SE p 95% CI
Yearly income
< 10,000 −0.033 1.111 0.976 [−2.893, 2.828] −0.001 0.037 0.976 [−0.097, 0.095]
10,000–19,999 0.120 1.080 0.912 [−2.663, 2.902] 0.005 0.042 0.912 [−0.103, 0.112]
20,000–29,999 −0.009 1.154 0.994 [−2.981, 2.964] 0.000 0.042 0.994 [−0.109, 0.112]
40,000–49,999 −0.485 1.293 0.707 [−3.816, 2.845] −0.014 0.037 0.707 [−0.110, 0.082]
60,000–69,999 −0.221 1.649 0.893 [−4.469, 4.026] −0.005 0.039 0.893 [−0.107, 0.096]
70,000–79,999 −0.148 2.177 0.946 [−5.755, 5.459] −0.003 0.043 0.946 [−0.114, 0.108]
90,000+ −1.536 2.547 0.547 [−8.096, 5.025] −0.026 0.044 0.547 [−0.139, 0.086]
Adverse childhood experiences
Emotional abuse 1.059 0.380 0.005 [0.079, 2.039] 0.144 0.051 0.005 [0.011, 0.276]
Physical abuse −0.308 0.593 0.603 [−1.836, 1.219] −0.027 0.051 0.602 [−0.158, 0.105]
Sexual abuse −0.755 0.828 0.362 [−2.888, 1.378] −0.037 0.041 0.361 [−0.143, 0.068]
Emotional neglect 2.094 0.384 0.000 [1.105, 3.083] 0.271 0.048 0.000 [0.148, 0.395]
Physical neglect −0.924 1.101 0.401 [−3.759, 1.912] −0.044 0.053 0.401 [−0.180, 0.091]
Parental domestic violence 0.085 0.757 0.910 [−1.864, 2.034] 0.005 0.045 0.910 [−0.111, 0.121]
Substance use/abuse 0.128 0.468 0.785 [−1.078, 1.333] 0.012 0.045 0.785 [−0.103, 0.128]
Household mental illness 1.143 0.263 0.000 [0.466, 1.820] 0.171 0.038 0.000 [0.072, 0.270]
Suicide or attempted −0.006 0.513 0.990 [−1.328, 1.315] 0.000 0.039 0.990 [−0.0100, 0.099]
Incarcerated household member 0.573 1.119 0.608 [−2.310, 3.457] 0.023 0.045 0.608 [−0.093, 0.140]
Parental separation/divorce −1.563 0.613 0.011 [−3.143, 0.016] −0.119 0.047 0.011 [−0.239, 0.001]
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Note: The intercepts are not standardized.

Abbreviations: β, standardized fixed effect; B, unstandardized fixed effect; CI, confidence interval; Substance use/abuse, substance use or abuse in the home; Suicide or attempted, suicide of family member or attempted suicide by self or family member.

3.3. Post Hoc Analysis

To further examine estimated emotion regulation trajectories for emotional neglect, we conducted a post hoc analysis. We used the Mplus plotting function to visualize estimated means for those who reported neglect at one standard deviation below the mean (which meant no neglect or what we conceptualized as low neglect), those clustered around the mean, and those at or above one standard deviation above the mean. A picture of these estimated slopes was generated using the plot information from Mplus and visualized via Microsoft Copilot. See Figure 2.

FIGURE 2.

FIGURE 2

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Model‐estimated emotion regulation trajectories by level of emotional neglect. Lines represent model‐estimated trajectories predicting emotion regulation difficulties across therapy sessions, derived from Mplus. Emotional neglect was probed at 1 SD below the mean (low neglect), at the mean (moderate neglect), and 1 SD above the mean (high neglect). Values reflect fixed effects estimates. Microsoft copilot was used to generate this image.

4. Discussion

This study underscores the potential long‐term impact of specific ACEs—namely, household mental illness, emotional abuse, and emotional neglect—experienced during childhood. It suggests that more frequent exposure to these experiences may heighten the risk of emotion regulation difficulties in adulthood. Therefore, it may be important to explore these factors and their frequency with individuals seeking couple therapy.

The association between mental illness in the household and increased emotion regulation difficulties in adulthood is consistent with what we know about psychopathology, emotion regulation, and parenting (Zitzmann et al. 2024). Emotion regulation has been regarded as a transdiagnostic characteristic of many mental disorders, and children develop emotion regulation skills through interactions with caregivers (Calkins and Hill 2007). Thus, more frequent exposure to mental illness in the household may influence the development of children's emotion regulation capacities. Supporting this perspective, a systematic review of 23 studies examining parental psychopathology and emotion regulation found that, across clinical and subclinical categories of mental distress, parental difficulties with emotion regulation were associated with more negative parenting practices, less positive parenting, and difficulties with emotion socialization (Zitzmann et al. 2024). The finding linking mental health in the household to emotion regulation in adulthood is interesting in this context, suggesting long‐term effects of this type of family of origin adversity. It is possible that more frequent exposure to mental illness in the home may interfere with children's ability to trust that a primary caregiver will be appropriately responsive and emotionally engaged. A lack of support from a trusted adult in childhood is a common side effect of many ACEs (Vederhus et al. 2022).

The observed association with emotional maltreatment and emotion regulation difficulty in adulthood is consistent with previous findings. A recent systematic review and meta‐analysis of 183 studies comprising 145,317 adults examined childhood maltreatment across several domains of resilience including emotion regulation. This study found childhood maltreatment to be negatively associated with emotion regulation in adulthood, with emotional abuse and neglect showing the largest effect (Fares‐Otero et al. 2025). This understanding may be especially important in the context of adult couple relationships because prior research has suggested that emotional abuse and emotional neglect may account for significant variability in interpersonal problems later in life (Poole et al. 2018).

Furthermore, the finding that individuals who experienced emotional neglect differed from those who experienced emotional abuse in their trajectories of change in therapy highlights the importance of more precisely understanding what accounts for this distinction. This pattern supports McLaughlin and colleagues' conceptualization of adversity, which differentiates between dimensions of threat versus deprivation and other studies that support this conceptualization (McLaughlin et al. 2021; Myroniuk et al. 2025). For instance, Cohen et al. (2019) examined the relationship between various forms of physical and emotional maltreatment and depressive symptoms in adolescence. Their findings indicated that both emotional abuse and emotional neglect were associated with an increased risk of depressed mood over time; however, only emotional neglect was specifically linked to an elevated risk of developing anhedonia.

Given that emotional abuse is characterized by negative caregiver interpersonal interaction whereas emotional neglect is characterized by the absence of caregiver interpersonal interaction (Cohen et al. 2017), having a caregiver who is emotionally unavailable, unresponsive, or disengaged may shape how individuals experience the therapy process. As such, there is potential value in developing measurement scales that better capture the nuances of neglect, which could inform more targeted interventions. For instance, interventions addressing isolation and enhancing a sense of support may be especially important for individuals who have experienced emotional neglect.

Additionally, the finding that emotional neglect was associated with faster improvement in emotion regulation difficulty over the course of therapy warrants careful consideration. Consistent with resilience research, it is possible that individuals who have experienced neglect may be particularly responsive to supportive contextual factors (Luthar et al. 2000) such as are present in couple therapy. Furthermore, differential susceptibility theory suggests that individuals most negatively affected by adversity may also derive the most benefit from factors such as environmental support (Belsky and Pluess 2009). Given that emotional attunement and relational support are central to couple therapy, these types of corrective experiences may be especially salient for those with histories of neglect.

Accordingly, a strong therapeutic alliance could be an intervention that has the potential to buffer the effects of neglect. Given the evidence that a strong therapeutic alliance is associated with positive outcomes in therapy (Friedlander et al. 2018), it may be that individuals who are emotionally neglected in childhood and bordering on more difficulty in terms of emotion regulation find a greater benefit in couple therapy. Having a therapist be responsive (and altogether “un‐neglectful”) may attenuate the emotional neglect of their past. Additionally, given that couple therapy is focused on improving emotional expression and connection between partners (Jacobson and Christensen 1996), it is possible that individuals with a history of emotional neglect experience more rapid improvement with overt nurturing of emotional processes and increased responsiveness from their partners.

As discussed previously, the significant associations observed for emotional maltreatment and household mental illness are consistent with prior research linking ACEs with emotion regulation difficulties in adulthood; the non‐significant findings for other ACE types may reflect differences in sample characteristics. Much of the existing literature has focused on community‐based samples of individuals, whereas the current study examined treatment‐seeking couples. Additionally, the absence of significant slope effects for most ACE types may suggest that, within couple therapy, improvement in emotion regulation is influenced more by therapeutic processes, alliance, or relational dynamics than by specific ACE histories.

Interestingly, our findings showed that individuals who experienced more parental separation or divorce in childhood reported lower levels of emotion regulation difficulties at the start of therapy. While longitudinal studies have linked parental divorce with increased psychological and relational difficulties in adulthood (Amato and Anthony 2014; Kelly and Emery 2004), numerous contextual factors, such as family conflict and post‐divorce practices, can influence long‐term emotional outcomes for children following divorce (Til Ogut et al. 2021). Additionally, this finding may reflect a suppressor effect, indicating a different relationship between parental separation/divorce and adult emotion regulation when combined with other family‐of‐origin adversity. This unexpected finding warrants further investigation.

Given the strong link between challenges with emotion regulation and various psychological disorders (Mares et al. 2024), the long‐term effects of emotional abuse, emotional neglect, and household mental illness in childhood are critical to consider. Specifically, these types of ACEs should be key considerations for initiatives aimed at educating parents and communities about childhood experiences that increase the risk of emotion regulation difficulty in adulthood. Furthermore, we echo the call by other scholars for additional studies investigating the relationship between childhood neglect and adult emotion regulation (reviewed by Simon et al. 2024).

4.1. Clinical Implications

Such considerations are important for therapists working with couples who have experienced ACEs. These findings underscore the value of assessing for ACEs and frequency of exposure at the beginning of therapy, as certain types of ACEs, when experienced more frequently, may increase couples' risk for emotion regulation challenges. While we cannot determine the effectiveness of therapy for these couples without a comparison group, it is encouraging that partners who began therapy with higher levels of emotional dysregulation are showing signs of improved emotion regulation. This aligns with the VanBoxel et al. (2024) finding that difficulties with emotion regulation did not hinder improvements in relational outcomes for couples over the course of therapy.

While emphasizing ACEs that may place partners at risk for emotional dysregulation, these results also suggest that therapy has the potential to improve emotion regulation for individuals in couple relationships and that targeting emotion regulation in therapy may be especially beneficial for couples with a history of emotional neglect. Approaches such as Emotionally Focused Therapy (EFT; specifically adapted for Trauma Survivors), which emphasizes recognizing and sharing emotions with one's partner to foster emotional regulation (Johnson 2002), may be particularly effective for these couples.

Although this study did not investigate the influence of therapeutic alliance, previous research has indicated that the bond between therapist and adult victims of childhood maltreatment may positively influence therapy outcomes (Lawson et al. 2017). Fostering a strong therapeutic alliance—characterized by empathy, attunement, and positive regard—may be especially valuable for individuals who have experienced more frequent childhood neglect. Further research is needed to explore factors such as therapeutic alliance that may influence therapeutic change in emotion regulation with individuals who have experienced emotional neglect.

4.2. Limitations

This analysis utilized longitudinal dyadic data with a clinical sample of couples and suggests that the frequency of exposure to certain types of ACEs is linked to emotion regulation difficulty at baseline and change in emotion regulation difficulty over 12 sessions of couple therapy. The primary aim was to investigate whether individuals' own ACE exposure predicted their emotion regulation difficulty at intake and change in their emotion regulation over time; therefore, cross‐partner influences were not examined. This represents an important consideration for future studies.

The data for this study were self‐reported and ACE frequencies were reported retrospectively. As is common in therapy settings, clients may discontinue treatment for a variety of personal or practical reasons (e.g., scheduling conflicts, improvement, and relocation). Reasons for discontinuation were not systematically recorded; therefore, the causes of attrition in our sample are unknown and the potential for systematic attrition cannot be definitively ruled out. Additionally, while the sample size was large, statistical power in multilevel growth models also depends on slope variability and cluster structure. Given that the variability in change over time was modest, the study may have been less sensitive to detecting small effects on trajectories.

It is also worth noting that, while the present model moves beyond a cumulative ACE approach by exploring frequency of exposure within each ACE type, it still retains a dose–response framework. It aligns with dimensional models conceptually by exploring whether different types of ACEs influence emotion regulation differently. However, it differs in that it focuses on different types of experiences rather than underlying processes. Exploring the perceived impact of ACEs would be a step further toward a dimensional approach and may be a valuable direction for future research aimed at understanding what underlies risk.

Furthermore, although individuals who reported more frequent emotional neglect experienced a faster rate of change over 12 sessions of therapy, this change—while significant—was small, and additional study is needed to assess whether it is clinically meaningful. Currently, there is no reliable change index for the DERS‐SF, making this an important area for further investigation.

Also, we are not able to determine what therapeutic modalities were used with these couples; therefore, we do not know how variations in the therapeutic approach may have affected the change process. Therapeutic modalities that conceptualize emotion as the primary mechanism of change may be more likely to facilitate improvements in emotion regulation. At the same time, common factors such as therapeutic alliance may play a beneficial role for individuals with a history of emotional neglect, suggesting that the effects of both modality and alliance in couple therapy warrant further study.

Moreover, while data were collected from clinics across the United States and included individuals from various socioeconomic backgrounds and education levels, only 20% of our sample identified as non‐white. Future studies should aim for more racially diverse samples, especially since ACEs are more prevalent in minority populations and families with low socioeconomic status.

Finally, due to the skewness of our sample toward fewer ACEs, the reported instances of certain types of ACEs may have been insufficient to achieve statistical significance. This limited representation may have hindered our ability to detect meaningful differences associated with some types of abuse and family of origin dysfunction. Consequently, our findings should be interpreted with caution, as a lack of significant results for some ACEs may not accurately reflect their actual impact on emotion regulation in the population.

Although we acknowledge limitations, these findings underscore the importance of understanding the emotional and relational processes that carry the effects of emotional maltreatment into adulthood and the need for future studies that investigate ACEs differently than the cumulative ACE count approach.

5. Conclusion

This analysis aimed to investigate whether the frequency of exposure to different types of ACEs influenced levels of emotion regulation difficulty at the start of therapy and the trajectory of change in emotion regulation difficulty over 12 sessions of couple therapy. Findings suggest that emotional maltreatment (abuse and neglect) and mental illness in the household (experienced by one or both partners) are associated with higher levels of emotional regulation difficulty in individuals at the start of therapy. Also, emotional neglect was associated with individuals' improving faster in levels of emotion regulation difficulty over 12 sessions of therapy. Overall, this study highlights the effects of the frequency of exposure to different ACE types on emotion regulation difficulty in adulthood and the potential for systemic therapy to address emotion dysregulation problems in couples who have experienced ACEs. While promising, further research is needed in this area.

Funding

This work was supported by BYU School of Family.

Conflicts of Interest

The authors declare no conflicts of interest.

Acknowledgments

An AI language model, Chat GPT, developed by Open AI, was used to assist with grammar and clarity in this manuscript.

Data Availability Statement

Research data are not shared.

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