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. 2019 Nov 23;13(4):455–467. doi: 10.1007/s40653-019-00296-8

The Impact of Maltreatment on Internalizing Symptoms for Foster Youth: an Examination of Spirituality and Appraisals as Moderators

Stephanie K Gusler 1,✉, Yo Jackson 2, Shaquanna Brown 3
PMCID: PMC7683671  PMID: 33269045

Abstract

Research shows that exposure to child maltreatment increases the risk of internalizing symptoms for youth, and that youth in foster care are at a particularly high risk of symptoms. However, not all youth who experience maltreatment evidence maladjustment, making the link between exposure and mental health outcomes unclear and creating a need to examine what factors buffer against symptomatology. A sample of youth in foster care was used to provide a new examination of the relation between child maltreatment exposure and internalizing symptoms, to test the possible moderating effects of both appraisals and spirituality, and examine differences between children and adolescents. Participants were 486 youth in foster care (M age = 13; 204 children; 282 adolescents). Youth completed self-report measures through the SPARK project (Studying Pathways to Adjustment and Resilience in Kids). Although appraisals and spirituality were not significant moderators, significant main effects emerged. For children, regression analyses showed that maltreatment exposure and lower scores on spiritual prosocial attitudes accounted for the majority of the 21% of the variance in internalizing symptoms. For adolescents 28% of the variance in internalizing symptoms was accounted for by greater maltreatment exposure, lower scores on spiritual prosocial attitudes, higher scores on relationship with a God/Higher Power, and more negative appraisals of stressful life events. The current study provides support for cognitive-based interventions for adolescents aimed at increasing appraisal flexibility and suggests that both children and adolescents could benefit from the development of prosocial attitudes often tied to spirituality but could be reinforced in additional settings.

Keywords: Children, Adolescent, Maltreatment, Mental health, Foster youth, Spirituality

Childhood maltreatment, consisting of neglect, physical abuse, sexual abuse, and/or emotional abuse is associated with an array of mental health problems for children and adolescents (Jaffee 2017). In particular, prior research has found internalizing problems (i.e., problems resulting from feelings and thoughts within the child rather than overt outward behaviors), such as depression and anxiety, to be more prevalent among youth who have experienced maltreatment, than those who have not (Cohen et al. 2001). For example, Cohen and colleagues (Cohen et al. 2001) found that among their sample of children with histories of physical abuse or neglect, about 20% had a diagnosis of major depressive disorder and about 60% had a diagnosis of an anxiety disorder compared to a rate of about 2% and 20% respectively for those who had not experienced maltreatment. These results illustrate the risk of internalizing problems for youth who are exposed to maltreatment.

Furthermore, this risk is particularly great for youth in foster care, where maltreatment exposure has reached a severity level requiring removal from their home of origin. Similar to youth who have experienced maltreatment but not been placed in foster care, youth in care have been shown to have higher rates of anxiety, depression, and low self-esteem than youth in the general population (Carbone et al. 2007). Specifically, research has shown foster youth to have twice to three times the prevalence rate of depression, when compared to youth not in care (dos Reis et al. 2001; McMillen et al. 2005). This risk may also be above and beyond that of youth who experience maltreatment but are not placed into care. For example, Lawrence et al. (2006) found that internalizing symptoms increased significantly more for youth who were placed in foster care (from pre-foster care placement to release from foster care) than youth who experienced maltreatment but were not placed in care. However, not all foster youth who experience child maltreatment evidence internalizing problems (Jackson et al. 2014). Thus, it is critical for research to examine what factors may protect against symptomatology, which can inform treatment as well as policy.

Although many avenues for study are possible, research has started to turn its focus to dispositional protective characteristics of maltreated youth that may be relevant to reducing internalizing symptoms. Among this literature, promising research has indicated that youths’ appraisals of stressful life events as well as spirituality may be associated with lower levels of internalizing symptoms following maltreatment (Kim 2008; Leeson and Nixon 2011). Most of this research, however, has examined these constructs individually and thus, little is known about the possible interaction of appraisals and spirituality on youths’ internalizing symptoms in the aftermath of maltreatment. The current study uses a sample of youth in foster care, to provide a new examination of the relation between child maltreatment exposure and internalizing symptoms and to test the possible moderating effects of both appraisals and spirituality.

Spirituality

In prior research (e.g., Cotton et al. 2006), spirituality is often defined through individual feelings and perceptions and structured religious behaviors. These components are often utilized in examining spirituality as a coping mechanism for all youth, including those not exposed to maltreatment, and have been associated with low levels of internalizing symptoms and risky behaviors such as unprotected sex or substance use (Cotton et al. 2006). This broad definition of spirituality, including spiritual feelings and perceptions as well as behaviors, has also been used in literature examining coping mechanisms for those exposed to childhood maltreatment (Gall 2006).

More specifically, this research has found that spirituality can take the form of both negative and positive coping (Gall 2006). For example, some research suggests that among girls who have experienced maltreatment, those who rated spirituality more highly (e.g., attended religious services often, prayed frequently, and rated faith and beliefs in God as important) had lower levels of internalizing symptoms than those who rated their spirituality lower (Kim 2008). However, Gall (2006) also found that certain aspects of spirituality can also be associated with fewer internalizing symptoms among adult victims of childhood sexual abuse, while other aspects of spirituality are associated with more internalizing symptoms. Specifically, spiritual beliefs of the importance of seeking God’s help, forgiveness, and love were associated with fewer depressive symptoms. Conversely, greater “spiritual discontent” or “anger and dissatisfaction with God” was associated with greater depressive symptoms (p. 833).

The complex role of spirituality in coping has also been examined previously in foster youth. For example, Jackson et al. (2010) interviewed adolescents in foster care about their spiritual beliefs and found that 86% stated that they felt they gained strength through their belief in God and 84% of adolescents reported feeling that spirituality helped them find meaning in times of adversity. Despite these seeming positive statements about spirituality in their ability to cope with adversity, almost half of the sample also reported feeling angry with God and 42% reported feeling distant from God, thus showing how both positive and negative spiritual attitudes may be prevalent among those who have experienced childhood maltreatment. However, recent research with youth in foster care, has found that one aspect of spirituality, spiritual prosocial beliefs (e.g., trusting, being nice to, and forgiving others), is predictive of fewer internalizing symptoms (Makanui et al. 2018). Thus, demonstrating the need for research with foster youth to include measures of spirituality that encompass multiple domains (e.g., spiritual beliefs about a High Power as well as spiritualty beliefs about others and spiritual behaviors such as prayer).

Lastly, it is important to note that prior research suggests that one’s view of spirituality can depend on chronological age and developmental level (Fowler and Dell 2004). Qualitative research lends support to the notion that children and adolescents may view spirituality differently. For example, when asked what spirituality meant to them, both children and adolescents reported spirituality as somehow being reflective of a relationship with a God or higher power (Spurr et al. 2013). However, children were more likely to define spirituality through behaviors, such as prayer and attendance to religious services, than adolescents who primarily defined spirituality more abstractly as feelings and perceptions about a God or higher power (Spurr et al. 2013). However, it is not clear how or if these different perceptions of spirituality between children and adolescents are related to adjustment in youth.

Appraisals

A similar construct to spirituality is appraisals, as they both involve an individual’s perceptions, how one might make meaning out of life experiences, and both can be connected to mental health outcomes (Kim 2008; Leeson and Nixon 2011). More specifically, appraisals are defined as one’s subjective interpretation of the significance of events and impact to one’s well-being (Lazarus and Follkman 1984). According to the predominant appraisal theory of stress and coping, different interpretations bring about different emotional and behavioral responses (Lazarus and Follkman 1984; Scherer 1999). Thus, variance in appraisals or in how one interprets events that have occurred, has been examined to help explain why some individuals show more severe pathology following maltreatment, whereas others may show fewer mental health symptoms and better adjustment (Leeson and Nixon 2011; Ponnamperuma and Nicolson 2016; Runyon and Kenny 2002).

Prior research has most often assessed appraisals in terms of valence; that is, whether one’s interpretation of an event is deemed as having a positive or negative impact to one’s well-being. Research has shown that those who view stressful life events has having a strong negative impact on their life exhibit greater mental health problems than those that view stressful life events as having a positive/or less negative impact (Leeson and Nixon 2011). For example, among children who have experienced sexual abuse, more negative appraisals of events have been found to be predictive of symptomatology, such as depression, anxiety, and posttraumatic stress symptoms (Bal et al. 2009). Additional research has found that even when controlling for maltreatment severity, negative appraisals of maltreatment were significantly associated with depression, lower self-esteem, and posttraumatic stress disorder (PTSD) symptoms in youth (Leeson and Nixon 2011). Much of the literature on children exposed to maltreatment has examined appraisals specific to maltreatment events. However, additional research shows value in examining appraisals across different potential stressful life events, as these overall styles in appraisals have been correlated with hardiness, optimism, hope (Power and Hill 2010), and anxiety (Hood et al. 2009). As such the current study examines appraisals to multiple stressful life events to capture youths’ appraisal styles, or ways of thinking across life events, as a potential moderator for the relation between maltreatment and internalizing symptoms.

Contrary to research suggesting differences in spirituality among children and adolescents, prior studies have not found significant differences in youths’ appraisal valence based on age (Ellis et al. 2009). For both children (Jackson and Warren 2000) and adolescents (Espejo et al. 2012), negative appraisals are associated with higher levels of internalizing symptoms, but to the authors’ knowledge no single study has examined potential age differences in the role of foster youths’ appraisals in predicting internalizing symptoms. Further, it is important to note, that prior research has utilized Lazarus and Folkman’s appraisal theory (1984) in work with foster youth, both children and adolescents, and found that these youth are able to appraise life events, such as their transition into care, and attempt to making meaning out of events in their life (Mitchell and Kuczynski 2010).

The Interaction Among Appraisals and Spirituality

Although the research to date is promising in terms of its potential to explain some of the findings relative to internalizing symptoms in youth exposed to child maltreatment, thus far most research has examined spirituality and appraisals as separate constructs, in their role as potential buffers to the effects of maltreatment (Kim 2008; Leeson and Nixon 2011). However, in Lazarus and Folkman’s (1984) theory of appraisals, which existing research continues to acknowledge as the leading theory on appraisals and coping, it was posited that beliefs such as spirituality could influence one’s appraisals of stressful life events.

The bulk of research examining this theorized relation between appraisals and spirituality has focused on coping in light of non-maltreatment types of stressors, such as illnesses or aging. (Park et al. 2010). For example, Cowlishaw et al. (2013) studied coping with the stress of aging in older adults (e.g., the decline in physical health), and found that spirituality influenced appraisals of physical and mental health, such that greater spirituality was predictive of more positive appraisals which was then predictive of greater life satisfaction. Similarly, research with women with breast cancer has found that a spiritual belief in “Gods Will” was associated with more positive appraisals of diagnosis and cancer treatment, which was then predictive of greater emotional well-being (Gall and Bilodeau 2017). Therefore, this research with aging adults or adults with illnesses has provided evidence, suggesting an interaction among spirituality and appraisals in coping with stressors.

Although no study has examined the association between spirituality and appraisal valence among maltreated youth, studies of adults using retrospective reports of child abuse or trauma provide some support for the interaction among these variables. For example, Park (2017) examined appraisals and spirituality among a sample of young adults who experience of a broad range of possible traumatic events. Results showed that more negative appraisals of the impact of the traumatic events were correlated with participants’ spiritual coping, such that the more negatively a participant appraised the impact of the event the lower they rated their ability to find strength through their spirituality or faith. Similarly, Gall (2006) found that among adults who had experienced childhood sexual abuse, current reports of negative appraisals of the impact of abuse were associated with lower ratings of spirituality. Additionally, this study found that when entered into a regression model with demographics and abuse characteristics, appraisals of the impact of the abuse and spirituality significantly predicted participants’ anxious, angry, and depressed mood. However, a potential limitation of this past research is that the potential interactions among spirituality and appraisals, which Lazarus and Folkman’s appraisal theory suggests, was not examined.

In addition to appraisal theory’s suggestion of the interaction among spirituality and appraisal, Gall et al. (2005) have also posited a conceptual framework for coping in which spirituality can influence multiple factors pertaining to coping, one being an individual’s appraisal of the stressful or traumatic event. This framework is consistent with research which has suggested that appraisals are a part of the feelings and perceptions component of spirituality (Bryant-Davis et al. 2012). That is, the valence of one’s appraisals may be a product of viewing events through forgiveness and compassion for others or with the belief that the event was a part of God or a Higher Power’s plan (Bryant-Davis et al. 2012). In sum, prior retrospective research and research on aging and illness, appears to show an association between spirituality and appraisals in predicting well-being, which supports appraisal theory’s (1984) and Gall et al.’s (2005) conceptual framework for coping, that describes spirituality as being influential to one’s appraisals of life events. However, no research to date has examined the possible interaction among these variables concurrently in maltreated youth, as a possible buffer against internalizing symptoms.

Current Study

The current study examined not only the connection between maltreatment and internalizing symptoms, but also how appraisals styles (i.e., overall pattern of appraisal valence for non-maltreatment events) and spirituality may moderate the association between maltreatment exposure and symptomatology in a sample of youth in foster care. Furthermore, the current study explored the correlation between spirituality and appraisals and a possible interaction between the variables in predicting internalizing symptoms, to provide a clearer understanding of how these variables may influence each other in buffering against youths’ internalizing symptoms. Additionally, age differences in the impact of appraisals and spirituality in youths’ internalizing symptomatology was systematically examined, as developmentally children and adolescents have been shown to define spirituality differently (Spurr et al. 2013), which may influence the impact spirituality can have on their appraisals of life events.

The current study had six hypotheses. It was first hypothesized that maltreatment would be positively associated with internalizing symptoms for both children and adolescents (H1). Second, spirituality (both relationship with God/Higher Power and prosocial attitudes) was hypothesized to be associated with fewer internalizing symptoms for both children and adolescents (H2). It was also predicted that both spirituality variables would moderate the association between maltreatment exposure and internalizing symptoms (H3). However, it was expected that relationship with God/Higher Power may not moderate this association as strongly as spiritual prosocial attitudes and may even be associated with greater symptoms, given prior research suggesting that youth exposed to maltreatment can have negative spiritual attitudes in the form of having negative feelings towards God or a Higher Power (Gall 2006; Jackson et al. 2010; Reinert and Edwards 2009). Next, the current study predicted that, for children and adolescents, less negative/more positive appraisals of stressful life events would be associated with fewer internalizing symptoms (H4) and that appraisals would buffer the effects of maltreatment exposure and internalizing problems (H5). Lastly, the current study hypothesized that appraisals and spirituality would interact in predicting fewer internalizing symptoms for both children and adolescents, such that the interaction between greater spirituality and less negative appraisals and would be associated with fewer internalizing symptoms (H6).

Method

Participants

Participants were 486 youth living in foster care in a large, Midwest metropolitan area. The sample, which was nearly evenly distributed between males (52.1%) and females (47.9%), was separated in two age groups: children (youth ages 8–12 years of age; M = 10, SD = 1.44, N = 204) and adolescents (youth ages 13–18 years of age; M = 15, SD = 1.46, N = 282) to allow for examination by age groups. Adolescents participants identified their race/ethnicity as follows: Black or African American (37.9%), White or Caucasian (30.9%), Multiracial (7.4%), Asian or Pacific Islander (10.3%), Hispanic/Latino (9.9%), Other (1.8%), and American Indian (0.7%). One participant (.2%) did not identify his or her race/ethnicity. Child participants identified their race/ethnicity similarly, with 55.4% identifying as Black or African American, 29.9% as White or Caucasian, 10.3% as Multiracial, 2.0% as Hispanic, 1.5% as Other, and .9 as not identifying a race/ethnicity.

Youth in the present study had an average of nine placement changes while in foster care and had been in care a minimum of 30 days (M = 9 months). Type of current placement differed among participants, with 48.8% living with a non-biological foster family, 35.7% living in a group home/residential facility, and 15.5% living in foster care with a biological relative.

Measures

Child Maltreatment

Youth self-reported on maltreatment history using questions derived from the Modified Maltreatment Classification System (English 1997), which is an empirical supported system for capturing the complexity of maltreatment by including a variety of types of possible maltreatment experiences which are shown to be impactful to youth’s behavioral and emotional health (English et al. 2005). Questions assessed youths’ exposure to four specific types of maltreatment, by assessing the frequency of each item endorsed. Twelve items asked about sexual abuse, including contact and non-contact sexual abuse (e.g., “In your lifetime, has anyone gotten you to touch their private parts or bottom in some way?”; “In your lifetime, how often did an adult make you look at something sexual, like pictures or a movie?”), 19 items asked about physical abuse (e.g., “In your lifetime, did someone hit you with something dangerous like a baseball bat or a shovel?”), 15 items asked about psychological abuse (e.g., “In your lifetime, has anyone ever threatened to abandon or leave you forever?”), and 22 items asked about neglect (e.g., “In your lifetime, did your parents leave you at home alone after dark?”). The maltreatment items, across type asked about abuse from a parent or older adult, in attempts to encompass experienced abuse from caregivers in addition to parents.

For the purposes of the current study, a total maltreatment score was calculated by summing the number of maltreatment items youth endorsed across all items on the four maltreatment types, with the possible minimum score being 0 and the possible maximum score being 68. The decision was made to sum participants maltreatment exposure across types to capture the total experience of possible maltreatment experiences and to account for poly-victimization (e.g., the experience of multiple types of maltreatment), which is highly prevalent among foster youth (Gusler and Jackson 2017). Participants’ summed maltreatment score ranged from 0 to 60 (M = 15.91, SD = 11.10) child maltreatment exposures in their lifetime, with higher values indicating greater maltreatment exposure. For children the range of maltreatment scores was from 0 to 48 and for adolescents, the range was from 0 to 60.

Spirituality

Youth completed the Youth Spirituality Scale (YSS; Sifers et al. 2012), a self-report instrument designed to assess spirituality among children and adolescents of various spiritual and religious backgrounds. The YSS consists of 20-items rated on a scale ranging from 1 “Never” to 5 “Always.” Higher scores indicated higher levels of spirituality. The YSS has demonstrated good internal reliability and convergent validity in previous research (Sifers et al. 2012). For the purposes of the current study, two subscales of the YSS were used. These subscales were found to have the strongest factor structure and were the two subscales recommended for use in the Sifers and colleagues (Sifers et al. 2012) measurement paper for the YSS. These two subscales were Relationship with God and Relationship with Others, both of which capture feelings and perceptions as well as structured spiritual behaviors. The Relationship with God subscale consists of eight items which capture both individual feelings and perceptions (e.g., “How sure are you that there is a God or Higher Power?”) and quantitative religious behaviors (e.g., “How often do you pray, meditate, or talk to God or a Higher Power?”) related to a relationship with a Higher Power. The Relationship with Others subscale consists of eight items assessing spirituality centered prosocial attitudes and behaviors (e.g., “How often do you try to forgive people?” “How often do you try to do the right thing?”). The Cronbach’s alpha for the Relationship with God subscale was .92 and the alpha for the Relationship with Others subscale was .80, suggesting good internal reliability for each subscale.

Appraisal

Participants completed the Life Events Checklist (LEC; Johnson and McCutcheon 1980), a self-report instrument used to assess youths’ appraisals of their stressful life events. The LEC consists of 46 different life events, to which youth respond on a scale from 1 “Never” to 5 “Almost Always” indicating their exposure to the events. Previous research has found the LEC to have strong internal reliability and test-retest correlations (Brand and Johnson 1982). On average, youth endorsed experiencing 29 different life events. Given that it is not likely that youth can reliably appraise each of their 29 events separately, groups of similar events were created to ease the burden on the participants. Four categories were created: family (e.g., “How often have any of your family members has a serious injury/illness?”), peer (e.g., “How often have any of your friends hit, pushed, or hurt one another?”), academic (e.g., “How often have you had arguments or had a hard time getting along with your teachers/coaches?”), and physical events (e.g., “How often have you been in an accident or natural disaster?”). For each of these categories, youth were asked two questions: a) thinking about all of these events, what effect did these events have on you at the time, and b) thinking about all of these events, what effect do these events have on you now. Youth responded to these questions on a scale of 1 “Very Bad” to 5 “Very Good.” This method for capturing youth’s appraisal’s is consistent with appraisal theory’s description of appraisals as subjective interpretations of the impact of effect of events (Lazarus and Folkman 1984) and is similar to methods employed by other researchers such as Kira and colleagues (Kira et al. 2008).

The correlation between these two appraisal items of the current study was significant r = .63. Appraisal valence was calculated by obtaining the mean of the two items across the four categories of events, to obtain a measure of one’s appraisal style across events, which prior research has found correlated with internalizing problems (Hood et al. 2009). Higher scores indicated more positive style of interpreting life events.

Internalizing Symptoms

Youth completed the Behavioral Assessment System for Children-2 (BASC-2; Reynolds and Kamphaus 2004), an instrument assessing emotional and behavioral health in children and adolescents. The BASC-2 consists of 150-items rated on a scale ranging from 1 “Never” to 5 “Almost Always.” The current study used self-report for Internalizing Problems (e.g., anxiety and depression), with T-score at or above 70 indicating clinical significance of symptoms. The internalizing composite was created as the sum of scores for the anxiety and depression subscale. For adolescents, T-scores ranged from 34 to 97 (M = 57, SD = 12), and 14.8% of adolescent participants had clinically significant scores. For children, T-scores ranged from 34 to 87 (M = 55, SD = 10), and 8.5% of child participants had clinically significant scores. For the current study, the Internalizing composite had an alpha of .94 for the child-self report version and an alpha of .95 for the adolescent self-report version.

Self-report was used, as prior research has found that youth are the most reliable reporters on their internalizing symptoms (Volpe et al. 1999). Prior research has also found the BASC-2 to have good psychometric properties, including excellent internal consistency and construct validity (Reynolds and Kamphaus 2004).

Placement Changes

Due to participants being in foster care, and on average, having a larger number of placement changes (M = 9), correlations among placement changes and primary study variables were examined to determine if this variable needed to be controlled for. Information on the number of placement moves was drawn from Department of Social Services records.

Procedures

Participants in the current study were part of the SPARK project (Studying Pathways to Adjustment and Resilience in Kids), a large, federally funded research project investigating mental health outcomes among youth exposed to child maltreatment. The larger project is longitudinal, but for the purposes of the current study, only data at the first time point was used in analyses. The SPARK project was approved by the researchers’ institutional review board and the state social service agency, which provided consent for youth to participate in the study. As part of the informed consent process, researchers provided participants with a full explanation of the study as well as researchers’ roles as mandated reporters of current suicidality, homicidality, or reports of child maltreatment. Youth completed questionnaires through an audio-computer assisted self-interview (A-CASI). The A-CASI software visually and auditorily presented each question on a computer screen, to participants who wore headphones. This presentation of questions was used to help reduce the impact of reading difficulties. Upon completion of the survey, youth completed a debriefing process and were compensated for their time. For more information on the project, including recruitment strategies, see Jackson et al. (2012).

Results

Among participants, over 98% endorsed experiencing at least one maltreatment event in their lifetime. Ninety percent of youth reported experiencing at least one form of physical maltreatment, 92.4% experienced at least one form of emotional maltreatment, 69.9% experienced at least one form of neglect, and 45.5% experienced at least one form of sexual maltreatment. A significant portion of the sample experienced more than one type of abuse, with 32.3% endorsing experiencing all four types of maltreatment (e.g., physical, emotional, neglect, and sexual), 42.6% experiencing three types of maltreatment, 17.3% experiencing two types of maltreatment, 6.2% experiencing one type of maltreatment, and 1.6% reporting experiencing no maltreatment.

Table 1 describes the means and standard deviations among primary study variables for children and adolescents and any statistical differences between the age groups. Independent samples, t-tests show that adolescents reported significantly greater maltreatment exposure than did children. Adolescents also reported greater internalizing symptoms than children, but the mean internalizing symptoms for both adolescents and children fell below the clinical range. Adolescents also had a greater number of placement changes than children. Further, children reported higher scores on both spirituality variables and more positive appraisals of stressful life events than adolescents.

Table 1.

Means and standard deviations for children and adolescents

Children (N = 204) Adolescents (N = 282)
Mean SD Mean SD t
Maltreatment Exposure 13.39 9.25 17.67 11.93 −4.48**
Spirituality: Relationship with God 4.24 .65 3.62 .86 8.44**
Spirituality: Relationships with Others 4.10 .58 3.85 .51 4.82**
Appraisal valence 4.26 .56 3.78 .65 8.63**
Number of Placements 8.09 5.52 10.38 7.39 2.90**
Internalizing 55 10 57 12 −2.54*
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*p < .05 **p < .01

Correlations among study variables for children and adolescents are listed in Table 2. For both children and adolescents, greater maltreatment endorsement was associated with more negative appraisals and more internalizing symptoms, than less endorsement of maltreatment. Also, for both children and adolescents, more positive appraisals of stressful life events and higher scores on the spirituality subscale, Relationship with Others, were associated with fewer internalizing symptoms. Further, for both children and adolescents, Relationship with God was positively associated with Relationship with Others, and higher scores on Relationship with God and Relationship with Others were associated with more positive appraisals of life events. Placement changes were not significantly correlated with any primarily study variables for children or adolescents and were therefore not included in regression analyses.

Table 2.

Correlations among variables

Correlations among variables for children (N = 204)
1 2 3 4 5 6
 1. Maltreatment Exposure –
 2. Spirituality: Relationship with God −.20** –
 3. Spirituality: relationship with Others −.30** .81** –
 4. Appraisal Valence −.30** .35** .48** –
 5. Number of Placements .13 −.17 −.09 .08 – .10
 6. Internalizing .44** −.22** −.30** −.25** .09 –
Correlations among variables for adolescents (N = 282)
1 2 3 4 5 6
 1. Maltreatment Exposure –
 2. Spirituality: Relationship with God −.10 –
 3. Spirituality: Relationship with Others −.06 .66** –
 4. Appraisal Valence −.23** .34** .38** –
 5. Number of Placements .07 .12 −.05 .09 – −.01
 6. Internalizing .38** −.05 −.23** −.36** −.01 –
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*p < .05 **p < .01

Several group differences, between children and adolescents, emerged from these correlations. First, for children, but not adolescents, maltreatment was significantly negatively correlated with both spirituality variables, such that greater maltreatment endorsement was associated with lower scores on Relationship with God and Relationship with Others’ subscales. Additionally, greater scores in Relationship with God was associated with fewer internalizing symptoms for children, but this pattern or results was not seen for adolescents.

Regression Analyses

Regression analyses were used to examine the interactions among maltreatment exposure, appraisal scores, and spirituality variables, each of which were mean centered. Analyses were completed in separate models for children and adolescents.

Table 3 shows the results of these regression analyses for children’s internalizing symptoms. Step one shows that for children, there was a main effect where greater maltreatment exposure was associated with greater internalizing symptoms (H1). Additionally, lower scores on Relationship with Others was associated with greater internalizing symptoms (H2). No other significant main effects where present in step one (H4), indicating that maltreatment and lower scores on Relationship with Others accounts for the majority of the 21% of the variance in internalizing symptoms shown in step one. In step-two, there were no significant interactions among maltreatment exposure, spirituality variables, and appraisals of stressful life events (H3, H5, H6).

Table 3.

Summary of regression analysis predicting child internalizing symptoms

Internalizing (N = 204)
Variable b SE Β 95% CI
Step 1
 Maltreatment Exposure .36 .08 .33** .20–.51
 Spirituality: Relationship with God 2.73 2.31 .13 −1.82-7.29
 Spirituality: Relationship with Others −4.42 1.95 −.25* −8.27- -.57
 Appraisal Valence −.41 1.50 −.02 −3.36-2.55
 R2 .21**
Step 2
 Maltreatment Exposure X Relationship with God −.14 .27 −.08 −.68–.39
 Maltreatment Exposure X Relationship with Others −.06 .25 −.03 −.56–.44
 Maltreatment Exposure X Appraisal −.02 .13 −.01 −.28–.23
 Relationship with God X Appraisal 3.67 3.86 .15 −3.94-11.29
 Relationship with Others X Appraisal −2.96 3.47 −.12 −9.80-3.88
 ΔR2 .02
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All variables were mean centered

*p < .05. **p < .01

Table 4 shows the results of the regression analyses for adolescents’ internalizing symptoms. Step one, which accounted for 28% of the variance in internalizing symptoms, shows that for adolescents, like in the child group, greater maltreatment exposure and lower scores on Relationship with Others were associated with greater internalizing symptoms (H1 and H2), but unlike the child group, negative appraisals and higher scores on Relationship with God were associated with greater internalizing symptoms (H2 and H4). In step-two, there were no significant interactions between maltreatment, spirituality variables, and appraisals (H3, H5, and H6).

Table 4.

Summary of regression analysis predicting adolescent internalizing symptoms

Internalizing (N = 282)
Variable b SE Β 95% CI
Step 1
 Maltreatment Exposure .28 .05 .29** .18–.39
 Spirituality: Relationship with God 5.10 1.46 .29** 3.10–8.83
 Spirituality: Relationship with Others −6.70 1.57 −.30** −9.80- -3.60
 Appraisal Valence −5.36 1.04 −.30** −7.40- -3.31
 R2 .28**
Step 2
 Maltreatment Exposure X Relationship with God −.17 .11 −.11 −.39–.05
 Maltreatment Exposure X Relationship with Others .18 .14 .10 −.09–.46
 Maltreatment Exposure X Appraisal −.05 .09 −.03 −.22–.12
 Relationship with God X Appraisal −2.82 2.28 −.10 −7.32-1.68
 Relationship with Others X Appraisal .79 2.43 .03 −4.00-5.57
 ΔR2 .01
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All variables were mean centered

*p < .05. **p < .01

Discussion

The current study examined appraisals and spirituality as potential buffers for the relation between maltreatment exposure and internalizing symptoms, and included several important methodological steps intended to better reflect the experience of child maltreatment. That is, youths’ lifetime maltreatment experiences, across multiple types of maltreatment, were assessed, thereby, addressing limitations of prior maltreatment research that has focused on single subtypes of maltreatment (Kobulsky et al. 2017; Newbury et al. 2018). The current study also further explored differences in children versus adolescents, recognizing potential developmental differences in study variables.

Results did show significant differences between children and adolescents for most variables. Specifically, adolescents reported greater maltreatment exposure and internalizing symptoms than did children. However, this could be explained by age, in that adolescents may have had more time to be exposed to maltreatment experiences than younger children. Additionally, this greater maltreatment exposure could help account for adolescents reporting greater internalizing symptoms, or this difference could be explained by the developmental onset of internalizing symptoms such as depression being more prevalent in adolescence than childhood (Zahn-Waxler et al. 2000). Furthermore, children reported higher scores on both spiritualty variables (e.g., relationship with a God/Higher Power and spiritual prosocial attitudes) and reported less negative/more positive appraisals than did adolescents. These differences may be contributed in part to children reporting fewer maltreatment experiences and less internalizing problems than adolescents, and spirituality variables and appraisals were significantly correlated with maltreatment and internalizing problems. Therefore, results of regression analyses, described below, were helpful in teasing apart age-related differences or similarities, controlling for the impact of each study variable.

Specifically, results of regression analyses revealed that for both children and adolescents, a greater number of maltreatment experiences were associated with greater internalizing symptoms, supporting the first hypothesis of the current study (H1) and aligning with the bulk of prior research (McMillen et al. 2005; White et al. 2007). Regressions also showed interesting main effects of appraisals and spirituality along with differences in effects between children and adolescents.

Spirituality

The second hypothesis (H2), that greater spirituality would be associated with fewer internalizing symptoms for both children and adolescents was partially supported. Results showed that for both children and adolescents, greater endorsement of the importance of spiritual prosocial attitudes was predictive of fewer internalizing symptoms. This result is consistent with research using a foster youth sample, of children and adolescents, which also found spiritual prosocial beliefs being predictive of fewer internalizing symptoms (Makanui et al. 2018). However, for adolescents, greater endorsement of the importance of a relationship with God or a Higher Power was actually predictive of greater internalizing symptoms, in the regression analysis.

There are multiple implications from these results. First, results highlight the importance of examining spirituality as a multifaced construct, and not just a total score, as different conceptualizations of what spirituality is may be associated with different outcomes. Additionally, the results highlight the importance of reinforcing positive prosocial attitudes that are often reinforced by spiritual beliefs, such as forgiveness and doing right by others, regardless of level of maltreatment exposure. Furthermore, although contrary to the hypothesis, the finding that a relationship with God or a Higher Power was associated with greater internalizing symptoms in adolescents, may be consistent with prior work on negative spiritual coping, which often focuses on anger or discontentment with a Higher Power and has most commonly included samples of adults and adolescents (Gall 2006; Jackson et al. 2010; Reinert and Edwards 2009). Therefore, present results suggest that adolescents may be more prone to this negative spiritual attitude than children. Additionally, prosocial attitudes, but not a relationships with God/Higher power was found to be a protective factor, being associated with fewer internalizing symptoms, which has important implications for all youth, not only youth with spiritual beliefs and backgrounds, as the prosocial attitudes measured such as forgiveness and doing right by others can be reinforced and taught in non-spiritual as well as spiritual settings.

Furthermore, the current study found that for both children and adolescents, neither spirituality variables significantly moderated the impact of maltreatment exposure on internalizing symptoms, contrary to the third hypothesis (H3). Instead results suggested that the main effects of spirituality seen for children and adolescents are irrespective of amount of maltreatment exposure. This is inconsistent with prior research that has found the importance of spirituality (Kim 2008) or spiritual support (Gall 2006) to be associated with fewer internalizing symptoms among those exposed to maltreatment, but not placed into foster care. The inconsistency could be because this prior research did not include foster youth, the majority of whom experienced multiple types of maltreatment and maltreatment experiences that rose to a severity or frequency level necessitating removal from their homes. Therefore, the current sample may have more maltreatment exposure or less variability in the amount of exposure than samples of previous studies. Additionally, there may be factors specific to the foster care experience that were not examined in the current study but may account for the differences found between the results of the current study and prior research with those exposed to maltreatment.

Further, most previous studies did not examine spirituality through the same measure as used in the current study (Gall 2006; Kim 2008). Therefore, although prior research also examined beliefs and behaviors related to spirituality, each study did so using different measurements with variations on these aspects of spiritualty which may have obscured the relation between the different components of spirituality and internalizing symptoms. For example, the current study did not directly assess for spiritual support, as was found to be the primary facet of spirituality associated with fewer symptoms in Gall’s (2006) study of adults exposed to childhood maltreatment.

Appraisals

Supporting prior work that has demonstrated the important role of appraisal valence in internalizing symptoms (Bal et al. 2009; Runyon and Kenny 2002), regression analyses showed that more positive/less negative appraisals were associated with fewer internalizing symptoms for adolescents. This partially supporting the fourth hypothesis of the current study (H4). However, this result was not true for the child subsample. It is possible that this difference in results between children and adolescents could be because children, overall, had more positive appraisals of stressful life events than did adolescents. As such, adolescents may be more likely to appraise life events more negatively than children (e.g., reporting that events had a “very bad” impact on them, then and now) and these negative appraisals may then be associated with adolescents’ report of higher levels of internalizing symptoms. Specifically, the appraisal bias model of cognitive vulnerability to depression (Mehu and Scherer 2015), demonstrates how one developing a bias in their appraisal styles (e.g., appraising most life events as being strongly negative) may contribute to a cognitive vulnerability increasing the risk for mental health concerns such as depression. This result demonstrates the importance of those working with adolescents to assess appraisals and help promote cognitive flexibility in one’s appraisals of life events or situations. Further, this result demonstrates developmental differences between children and adolescents in terms of their appraisal style, across stressful events, which has not been demonstrated in previous research (Hood et al. 2009) but may help explain the increased risk for internalizing symptoms as youth exposed to childhood maltreatment reach adolescence (Cohen et al. 2001).

The fifth hypothesis that appraisals would moderate the impact of maltreatment on internalizing symptoms was not supported (H5). Although more positive/less negative appraisals were predictive of fewer internalizing symptoms in adolescents and correlations showed that more positive/less negative appraisals were associated with less internalizing symptoms for children and adolescents, appraisal valence did not buffer against the impact of maltreatment on internalizing symptoms. Similar to the null results for spirituality as a moderator, appraisal may not have significantly moderated the relation between maltreatment and internalizing symptoms due to the sample endorsing high prevalence and multiple types of maltreatment, thus having less variability in maltreatment exposure than studies that used community samples.

Interaction of Spirituality and Appraisals

Lastly, analyses examined, but did not support an interaction between spirituality and appraisals in predicting internalizing symptoms. Bivariate correlations did show that higher levels of self-reported spirituality, including relationship with God or a Higher Power and spiritual prosocial attitudes, were associated with more positive appraisals for children and adolescents. However, results indicated that these variables did not interact in accounting for internalizing symptoms. This is contrary to Lazarus and Folkman’s (1984) theory of appraisal and Gall et al.’s (2005) conceptual framework for coping, which both suggested that spirituality is a construct that may influence one appraisals of life events, which thereby may impact emotionality. The current study’s significant correlations but nonsignificant interaction effects may suggest that for children and adolescents, these constructs are related, but it is perhaps not until adulthood that one’s spiritual beliefs can allow them to make meaning out of life events, creating more positive appraisals and potentially fewer internalizing problems. This would be supported by prior research, which suggested an interaction effect, being done with adult samples (Gall 2006; Park 2017). Therefore, although not conclusive, the present findings suggest that although associated, appraisal valence and spirituality, in combination, do not predict internalizing symptomatology for youth in foster care.

Limitations and Future Directions

The current study provides a number of novel results expanding knowledge on how spirituality and appraisals are associated and differences between maltreated adolescents and children in terms of the impact of maltreatment, appraisal valence, and spirituality on internalizing symptoms. However, the study is not without limitations. In particular, the current study used measures of self-report retrospective recall to assess children’s maltreatment experiences and appraisals of life events, which can lead to socially desirable responding, misremembering and forgetting events, and reporter bias. Nonetheless, self-report of maltreatment experiences is commonly used and a widely accepted means of assessing maltreatment exposure (Kim and Cicchetti 2010). It is important to note that although providing a good start, much of the research on child maltreatment has been limited in that it assesses childhood experiences through adult retrospective reports (Newbury et al. 2018), case file summaries that contain only exposure that could be substantiated, or an exclusive focus on one subtype of abuse or maltreatment (e.g., physical) rather than assessing all possible forms maltreatment (Kobulsky et al. 2017). These are significant limitations, as individuals have a better memory of events when asked about them closer to when the event occurred in their childhood or adolescence (Fergusson et al. 2011). Also, research has consistently shown that most children who experience maltreatment are more likely to experience multiple forms than one form in isolation (Finkelhor et al. 2007). Although recall bias could still be a problem, the current study attempted to manage issues of prior research by asking youth directly about their possible cumulative maltreatment experiences. Also, despite this potential for reporter bias, prior research has indicated that youths’ report of internalizing symptoms is more reliable than that of teachers or caregivers (Volpe et al. 1999), and that youth would likely know more about their views of spirituality, appraisals of life events, and prior maltreatment experiences than their foster or residential home caregivers. Further, the current study was cross-sectional in nature, so causal interpretations are not able to be drawn from the results. Additionally, foster youth were the focus of the current study given their high exposure to maltreatment and risk for internalizing symptoms, but using this sample also limits the generalizability of the results. Lastly, it is important to note that the percentage of children (8.5%) and adolescents (14.5%) in the current sample that had clinically elevated symptoms was low. This may represent a limitation of the current study, as it is possible that participating youth had factors contributing to fewer internalizing symptoms or youth could have been underreporting symptoms. This may have also impacted the lack of a significant correlation between placement changes and internalizing symptoms, which runs contrary to prior research showing a correlation between caregivers’ reports of youths’ internalizing symptoms and placement changes (Aarons et al. 2010). Lastly, although the YSS is designed to be used with youth of various religious and spiritual backgrounds, the current study did not assess for youths’ religious backgrounds, and further research will be needed to determine in one’s religious identity/background would impact the association between spirituality variables measured in the current study and internalizing symptoms.

In light the noted limitations, the present findings suggest multiple directions for future research. First, the findings highlight the need for future research examining age-based differences between children and adolescents with respect to their maltreatment experiences and symptomology as well as factors that might differentially moderate the association between maltreatment and symptomatology. Second, the current study shows that more research is needed to understand the multiple aspects that make up one’s spirituality and examine how each aspect may be differentially associated with positive versus negative spiritual coping. The results show that more work is needed to understand the role of appraisals in adolescents’ internalizing symptoms and what factors contribute to the development of more negative appraisals as one progresses through childhood into adolescence. Further research is needed to examine if the pattern of results in the current study is also seen in maltreated youth, not in foster care, to determine if the results generalize to youth with maltreatment histories who are not in care. Lastly, future research should consider examining specific aspects of maltreatment, such as age of onset of abuse and severity of abuse, which may impact study variables.

In the current study, attitudes towards spirituality and appraisal styles for stressful life events were shown to be important in predicting some mental health concerns for youth in foster care. Current results also provide support for cognitive-based interventions aimed at directly addressing the residual cognitive schemas related to stressful life events. Encouragingly, trauma-focused interventions, such as trauma-focused cognitive behavioral therapy (TF-CBT), aim to help clients restructure their maladaptive appraisals of the traumatic event and its sequelae (Dittmann and Jensen 2014). However, results suggest the importance of not only addressing trauma-specific appraisals but also adolescents’ appraisals of multiple life events, and promoting greater flexibility across appraisals may reduce a cognitive vulnerability for internalizing problems (Mehu and Scherer 2015). Additionally, results suggest that both children and adolescents could benefit from the development of prosocial attitudes, and while these are often taught in spiritual settings, topics such as forgiveness and kindness to others can also be addressed in therapeutic or counseling settings. Further, one of the most prominent implications of the current study is the attention drawn to the need for more work aimed at addressing what factors contribute to greater pathology among youth exposed to maltreatment and what factors may mitigate the relation between maltreatment and pathology.

Acknowledgements

The current project was made possible by funding from the National Institutes of Mental Health, RO1 grant MH079252-03.

Compliance with Ethical Standards

Conflict of Interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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