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. 2020 Mar 14;13(4):429–441. doi: 10.1007/s40653-020-00305-1

Internalizing, Externalizing Problems and Psychiatric Hospitalizations: Examination of Maltreatment Chronicity and Coping Style in Adolescents in Foster Care

Lindsay Huffhines 1,2,✉, Yo Jackson 3,4, Katie J Stone 3
PMCID: PMC7683672  PMID: 33269043

Abstract

Child maltreatment is associated with internalizing and externalizing problems in adolescents, as well as psychiatric hospitalizations, which represent severe mental health difficulties and substantial burden on individuals and the health care system. These negative outcomes are especially prevalent in youth in foster care. Not all youth exposed to maltreatment, however, demonstrate poor mental health outcomes. Additional factors, such as maltreatment chronicity and coping style, may help explain why some (but not all) youth develop major psychiatric problems. The purpose of the present study was to examine how maltreatment chronicity and coping style were associated with internalizing, externalizing, and psychiatric hospitalizations, and whether coping style moderated the relation between maltreatment chronicity and mental health in a sample of foster adolescents. Participants were 283 adolescents ages 12–19 residing in foster care. Youth reported on maltreatment, coping, and mental health; caregivers reported on mental health. Psychiatric hospitalizations were obtained from medical records. Youth who experienced more maltreatment had higher caregiver- and self-reported internalizing, and more psychiatric hospitalizations. Youth who approached problems directly had lower caregiver-reported internalizing and externalizing, while youth who dealt with stressors alone had higher self-reported internalizing and externalizing, and more psychiatric hospitalizations. Youth who avoided facing their problems had less psychiatric hospitalizations. Further, a significant interaction revealed that youth with more maltreatment who avoided problems had less psychiatric hospitalizations, suggesting that avoiding problems may be more protective for youth with the most chronic abuse and neglect. Findings highlight the importance of examining both maltreatment and coping.

Keywords: Child abuse, Foster care, Coping, Psychopathology, Resilience

Child maltreatment has long been recognized as a significant public health problem due to its long-term effects on mental health. Specifically, maltreatment is linked to internalizing problems in childhood, which in turn are associated with depression and anxiety disorders across the lifespan (Masten and Cicchetti 2010), as well as with externalizing problems, which increase the risk for aggression and substance abuse later in life (Narayan et al. 2015). Further, maltreatment exposure and subsequent mental illness has been linked to psychiatric hospitalizations, such that 61% of psychiatrically hospitalized youth report a history of maltreatment, a costly outcome, both personally and financially (Boxer and Terranova 2008). Moreover, a history of psychiatric hospitalizations in adolescence is associated with a myriad of mental health problems in adulthood and death before middle age (Gyllenberg et al. 2010).

Despite finding that many youths exposed to maltreatment also develop internalizing or externalizing problems, this outcome is not automatic, as evidence also suggests that some maltreated youth display few mental health problems (Bolger and Patterson 2001; Luthar et al. 2014). Although it is possible several factors account for this multifinality, a few factors seem specifically relevant to explaining the variance in mental health outcomes. For instance, chronicity of maltreatment exposure is considered an important determinant of mental health (English et al. 2005; Hahm et al. 2010).

Youth exposed to maltreatment, especially those in foster care, experience a wide range of maltreatment types, and perhaps more importantly, some variance in how often abuse and neglect occur (Finkelhor et al. 2011; Higgins and McCabe 2000). For example, in a sample of 272 youth in foster care who reported on neglect exposure, 54.4% reported experiencing 1–5 different events, 9.9% endorsed 6–11 different events, and 7% endorsed more than 11 different events (Gusler and Jackson 2017). In addition, for physical abuse, 61% of these participants endorsed 1–5 different events, 24.2% endorsed 6–11 different events, and 4.1% endorsed more than 11 different events. Regarding psychological abuse, 37.5% endorsed 1–5 different events, 40.5% endorsed 6–11 different events, and 14.1% endorsed more than 11 different events. Finally, 31.7% endorsed 1–5 different sexual abuse events and 8.3% endorsed 6 or more different events. These results suggest that most participants experienced multiple types of maltreatment, and many different events both within and across types.

Past research shows that ongoing and repeated exposure to maltreatment, as compared to the experience of a single event no matter the type of abuse, is associated with worse mental health outcomes in youth (Miller et al. 2011). Yet research on the relation between child maltreatment and mental health rarely conceptualizes maltreatment in a way that accounts for its chronicity and variability. Thus, when research findings describe youth as exposed to maltreatment or not, the findings likely provide an incomplete view of youths’ experiences. Reducing their exposure to a dichotomous variable (e.g., exposed to sexual abuse or not) may not capture the actual experience of maltreatment, namely how often it occurred or how often one experiences other types of abuse.

Furthermore, youth coping style, or the way that one manages stress, is another potential explanation for mental health differences in youth exposed to maltreatment. That is, it may not only be the maltreatment, but what youth do after the maltreatment to manage their feelings and behaviors that is relevant to the development of mental health problems. The present study utilized a comprehensive framework for coping, the Dual Axis Model of Coping (Hobfoll et al. 1994). The Dual Axis Model of Coping overcomes criticisms of previous conceptualizations of coping, including coping being measured on a unitary continuum, being restricted to one or two methods, or being inadvertently gender biased (Lopez and Little 1996). Rather this model posits that coping style varies along two dimensions and allows for a less gender-biased assessment. The first dimension involves action, or what one does in response to a stressor; this is similar to the approach versus avoidance coping strategies commonly found in the literature. Hobfoll et al. (1994) used the terms direct and indirect coping to describe approach and avoidance, respectively. The second dimension involves sociability, or whether one approaches stressors alone or solicits the help of others (i.e., asocial and prosocial, respectively). Thus far, most research on the role of coping in youth post-maltreatment exposure examines approach/direct or avoidance/indirect strategies (Garcia 2010).

Coping Style and Internalizing, Externalizing Symptoms

Compas and colleagues (2017) conducted a meta-analysis of 212 articles that examined coping in relation to internalizing and externalizing symptoms in children and adolescents; findings indicated that approach/direct coping was significantly negatively associated with both internalizing and externalizing symptoms, such that greater use of approach/direct coping was associated with fewer symptoms (Compas et al. 2017). These findings reveal that at least in typical populations, approach/direct coping is associated with improved mental health. This association appears somewhat less clear in studies of maltreated youth, such that Clarke (2006) completed a meta-analysis of studies of life stressors, including maltreatment, and found that youth who used approach/direct coping strategies in response to controllable stressors (e.g., argument with a friend) had significantly fewer externalizing symptoms than those who used approach/direct coping in response to uncontrollable stressors (e.g., sexual abuse).

Many studies suggest that avoidant/indirect strategies may lead to worsening symptoms. For example, the meta-analysis by Compas et al. (2017) showed that avoidant/indirect coping was significantly positively associated with both internalizing and externalizing symptoms, such that greater use of avoidant/indirect coping was related to higher levels of symptoms. Similarly, in a sample of sexually abused youth, reliance on avoidant/indirect coping strategies was associated with more internalizing and externalizing symptoms (Tremblay et al. 1999). Further, avoidant/indirect coping was a mediator between sexual abuse and severity of stress-related symptoms, including depression, fear, posttraumatic stress, dissociation, anger, sexual problems, and less emotional stability (Bal et al. 2003). Caples and Barrera (2006) also found that avoidant/indirect coping mediated relations between sexual abuse and internalizing symptoms in adolescents, with those endorsing more avoidant/indirect coping displaying more symptoms. However, avoidant/indirect coping does not always lead to maladaptive outcomes for youth exposed to maltreatment. In fact, one study found that the use of avoidant/indirect coping moderated the relation between maltreatment and trauma symptoms in adolescent girls in foster care (Elzy et al. 2013). Specifically, girls with high levels of maltreatment exposure demonstrated fewer trauma symptoms, including depression and anxiety, if they endorsed high levels of avoidant/indirect coping. Interestingly, there was no significant relation between maltreatment exposure and approach/direct coping in the prediction of trauma symptoms.

Coping Style and Psychiatric Hospitalizations

Few studies have examined how coping strategies are associated with maltreatment exposure for youth who have been hospitalized for psychiatric reasons. One study examined maltreatment and coping in 105 psychiatrically hospitalized adolescents who were exposed to physical abuse only, sexual abuse only, both physical and sexual abuse, and those who had no abuse history (Cohen et al. 1996). Results showed that those who had experienced more severe sexual abuse used more avoidant/indirect and asocial coping strategies (i.e., isolation, social withdrawal) compared to those who experienced less severe sexual abuse or were not sexually abused (Cohen et al. 1996). Further, those who had experienced both sexual and physical abuse reported more avoidant/indirect and asocial coping strategies than those who had experienced sexual abuse only. Importantly, findings also indicated that psychiatric disorders and suicidal behavior of adolescents differed based on coping style, but not maltreatment history, with avoidant/indirect and asocial coping related to more psychiatric diagnoses and behavior problems. Results suggest that coping style may significantly influence youths’ psychiatric symptoms; however, given the cross-sectional design of the study, it is also possible that the severity of symptoms for hospitalized youth may have led to greater avoidance/indirect coping.

A more recent study found that experiencing a high number of stressful life events within the past month increased the risk of attempting suicide by seven times, while using an avoidant/indirect coping strategy increased the risk by nearly 23 times (Mathew and Nanoo 2013). These findings further suggest the importance of measuring coping alongside maltreatment history when examining emotional and behavioral functioning. In addition, risk of psychiatric hospitalization itself, which may be a proxy for more severe psychopathology, has not yet been examined in concert with maltreatment and coping.

Current Study

The present study adds to the literature on maltreatment, coping, and mental health in several ways. First, this study included maltreatment chronicity rather than maltreatment type alone, providing a more comprehensive picture of a youth’s exposure than in most past research. Second, this study utilized a comprehensive framework for coping, the Dual Axis Model of Coping (Hobfoll et al. 1994), in order to examine how participants’ coping actions in response to stressors (i.e., direct/approach, indirect/avoidance) and sociability (i.e., approaches stressors alone [asocial] or solicits the help of others [prosocial]) relate to maltreatment and mental health outcomes. Third, mental health was measured by both caregiver-report and adolescent-report on a well-validated measure, as well as psychiatric hospitalizations, the latter serving as a marker of severe psychopathology (Gyllenberg et al. 2010). Finally, the results provide a new contribution by examining how coping style is related to internalizing, externalizing, and psychiatric hospitalizations in foster youth, a population that is rarely included in coping research. This is not a small issue given the high risk for maladjustment commonly found in youth exposed to maltreatment, and especially youth in foster care (Jones and Morris 2012). Given that youth in foster care reside in different environments (foster homes vs. residential facilities), experience placement changes, and reside in care for different lengths of time, the current study also included these variables as covariates. Indeed, in a previous study with this sample, placement instability was associated with youth mental health problems independent of maltreatment type, severity, or frequency (McGuire et al. 2018).

It was hypothesized that chronic maltreatment would be positively associated with both internalizing and externalizing scores, and psychiatric hospitalizations. It was also hypothesized that using a direct or prosocial coping style would be negatively related to internalizing, externalizing, and psychiatric hospitalizations, and using an indirect or asocial coping style would be positively related to these outcomes. It was hypothesized that direct or prosocial coping style would moderate the relation between maltreatment chronicity and each mental health outcome, such that youth exposed to chronic maltreatment with high levels of direct or prosocial coping would show lower levels of mental health problems than youth exposed to chronic maltreatment who have low levels of direct or prosocial coping. Similarly, it was predicted that indirect or asocial coping style would moderate the relation between maltreatment chronicity and each mental health outcome, such that youth exposed to chronic maltreatment with high levels of indirect or asocial coping would show higher levels of mental health problems than youth exposed to chronic maltreatment who had low levels of indirect or asocial coping.

Method

Participants

Participants included 283 adolescents ages 12–19 years (M = 15.10, SD = 1.87) enrolled in foster care in a large Midwestern city, and their foster caregivers (50.9% living in foster homes, 49.1% living in residential facilities). Of the children living in foster homes, 19% resided with a biological relative (i.e., kinship care) while 81% resided with unrelated foster caregivers. Regarding caregiver education, 6.7% of foster caregivers had some high school, 20.9% had graduated high school, 8.6% had graduated from trade school or community college, 27.6% had some college, 22.7% had graduated from college, 10.4% had completed graduate school, and 3.1% did not provide educational information. Among residential facility staff, 19.3% had some college, 30.7% had graduated from college, 28.4% had completed graduate school, and 21.6% did not provide educational information. The youth participants experienced between 1 and 46 foster placement changes, with the average number being 10.03 placement changes (SD = 7.51) in their lifetime. On average, adolescents spent 4.69 years (SD = 3.27) enrolled in care, with the shortest time in care being 0.38 years and the longest being 14.48 years. Of the participants, 46.1% were female, with 39.9% of the sample self-identifying as Black or African American, 31.2% as White or Caucasian, 8.7% as Multiracial, 8.7% as Hispanic or Latino, 4.8% as Asian, and 6.7% as another race/ethnicity.

Participants were recruited on behalf of a larger study, the SPARK (Studying Pathways to Adjustment and Resilience in Kids) project, which is a federally funded longitudinal research study designed to investigate maltreatment exposure and the protective and risk processes leading to mental, physical, and academic outcomes in youth placed in out-of-home care. Foster caregivers and youth were recruited through multiple methods, including direct mailings and phone calls, advertisements in newsletters and list-serves for foster families, at community and foster care events, and through referrals from prior SPARK participants. The sample obtained through these recruitment strategies was demographically representative of the larger population of youth in foster care in the county. For more information on the SPARK Project, including details on recruitment strategy, informed consent, data collection procedures, and maintenance of participant confidentiality and safety, see Jackson et al. (2012).

To be included in the study, youth had to be living with the reporting caregiver for at least 30 days prior to study enrollment. Youth who had received a prior diagnosis of intellectual disability or autism spectrum disorder were excluded from the study due to the necessity of youth self-report for data collection.

Procedures

Before recruitment of participants, the primary investigator of the project obtained consent for all youth from the state social service agency. Prior to participation, youth and caregivers were informed about the purpose and nature of the study, the voluntary nature of participation, and limits to confidentiality before they consented and assented to participate. Each participant used an audio-computer assisted self-interview program (A-CASI) on a laptop computer to complete the study measures. Because the A-CASI reads the study measures presented on the computer screen over private headphones, participants were afforded autonomy and confidentiality and it allowed those who needed reading support to better comprehend the questions. Both youth and their caregivers were compensated for their time and participation. The SPARK project was approved by both the university Institutional Review Board and the State’s Department of Social Services Review Board.

Measures

Demographics

Foster caregivers and adolescents were asked to report on several demographic characteristics, including age, gender, and race/ethnicity. Adolescents’ current placement (i.e., foster home, kinship foster home, or residential facility), number of previous foster placements (i.e. placement moves), and the length of time enrolled in foster care were taken from placement records provided by the state social service agency.

Maltreatment

Maltreatment experienced over the course of adolescents’ lives was self-reported using the Modified Maltreatment Classification System (MMCS; English 1997). The MMCS is often used to code child maltreatment case files, but the items have also been used for self-report. Previous research has found that the MMCS reliably and validly identifies the chronicity of maltreatment experiences reported by foster youth, inclusive of the range of maltreatment types (Gabrielli et al. 2017).

Items from the MMCS were reworded to facilitate self-report (e.g., the item “the child was hit or kicked in the face” was changed to “have you ever been hit or kicked in the face?”). Youth were asked about four types of maltreatment: physical abuse, sexual abuse, psychological abuse, and neglect, and the frequency with which each endorsed event occurred.

The physical abuse subscale of the MMCS included 19 items measuring a range of physical abuse events (e.g., “in your lifetime, how often did someone kick or punch you?”). The sexual abuse subscale consisted of 12 items measuring types of sexual abuse experienced throughout the child’s life (e.g., “in your lifetime, how often has anyone forced you to look at their sexual parts?”). The psychological abuse subscale had 26 items addressing psychological maltreatment by someone in the child’s life (e.g., “in your lifetime, how often has anyone ever blamed you for their own problems?”). The neglect subscale had 24 items measuring several neglect events (e.g., “in your lifetime, how often did your caregivers make sure you saw a doctor if you needed one?”). Chronicity of maltreatment was included in the analyses and was calculated by using a sum of the frequency items across abuse types (i.e., physical, sexual, and psychological abuse, and neglect), where 1 = never occurred, 2 = almost never occurred, 3 = sometimes occurred, 4 = often occurred, and 5 = almost always occurred. For example, if a youth reported that one physical abuse event occurred almost always (score of 5) and five physical abuse events occurred sometimes (score of 3), their chronicity score for physical abuse would be 20. Then, the chronicity score for each abuse type was summed to obtain an overall score for maltreatment chronicity. An adolescent’s chronicity score could be high if they endorsed a large number of different abuse events at a low frequency, or a smaller number of different abuse events at a high frequency.

Coping

Coping was measured using the Behavioral Inventory of Strategic Control (BISC; Little et al. 2001; Lopez and Little 1996). This measure was developed from an action-theory perspective, and is based on the idea that children’s coping strategies vary along four dimensions of strategic behavioral control: Direct Action, Indirect Action, Prosocial Action, and Asocial Action. Thus, this instrument measures whether children move towards (direct action) or away from a problem (indirect action), and whether they enlist (prosocial) or avoid support (asocial). The BISC also assesses coping strategy across different situations in a child’s life. For example, the BISC asks “When I have problems keeping a good friend…” and the child can select a direct action behavior (“I try to work it out”), an indirect action behavior (“I do something else instead), a prosocial behavior (“I seek out others”) and an asocial behavior (“I think others just get in my way”). Participants indicated their use of each behavior on a five-point Likert scale ranging from “never” to “almost always”. Participants’ scores are averaged to form composite scores for each coping style (i.e., Direct, Indirect, Prosocial, Asocial) ranging from 1 to 5. These composite scores were used for current analyses. The BISC has demonstrated adequate reliability and validity, and low-to-moderate stability (Little et al. 2001; Lopez and Little 1996; Vanlede et al. 2006). The Direct Action (α = .97), Indirect Action (α = .96), Prosocial Action (α = .97) and Asocial Action (α = .98) composites demonstrated excellent internal consistency in the current sample.

Mental Health

Internalizing and externalizing symptoms were measured via foster caregiver- and youth self-report on the Behavior Assessment System for Children, Second Edition (BASC-2; Reynolds and Kamphaus 2004). The BASC-2 assesses youth behavioral and emotional functioning at home and in the community via 144 items on the adolescent report form, and 160 items on the caregiver report form. Responses are measured on a Likert scale, ranging from “never” to “always”, apart from 69 items on the adolescent report form that are in true-false format. The caregiver- and self-report composite scale scores of Internalizing Problems and Externalizing Problems were included in the present study. The caregiver-report Internalizing composite consists of the anxiety, depression, and somatization subscales, while the adolescent self-report Internalizing composite includes the atypicality, locus of control, social stress, sense of inadequacy, anxiety, depression, and somatization subscales. The caregiver-report Externalizing composite includes the hyperactivity, aggression, and conduct problems subscales. The adolescent self-report Externalizing composite includes the inattention/hyperactivity subscale.

The BASC-2 has demonstrated adequate convergent and discriminant validity with other measures of child behavior in a sample of adolescents in a residential treatment facility (Weis and Smenner 2007), and has evidenced good reliability for youth ages 8 and older, with alphas ranging from .89 to .95 (Reynolds and Kamphaus 2004; Weis and Smenner 2007). In the current sample, the caregiver-reported (α = .93) and self-reported (α = .94) Internalizing composite demonstrated good internal consistency, as did the caregiver-reported (α = .94) and self-reported (α = .92) Externalizing composite.

Psychiatric Hospitalizations

All youth were enrolled in Medicaid as their primary medical provider. The Medicaid claims record for each adolescent was provided by the state welfare agency to determine the medical history of the participants, specifically their psychiatric hospitalizations. For the current study, psychiatric hospitalizations that occurred within one year of starting the project were included (the project’s duration was 9 months); total number of psychiatric hospitalizations within this window was used as a dependent variable.

Data Analytic Approach

All analyses were conducted in IBM SPSS Statistics 25. Separate multiple regression analyses were conducted predicting internalizing symptoms, externalizing symptoms, and psychiatric hospitalizations. A hierarchical approach was used to evaluate: (1) whether maltreatment chronicity was uniquely associated with each of these three outcomes and (2) whether coping style moderated these associations. In each model (i.e., internalizing model, externalizing model, and psychiatric hospitalizations model), the outcome variable was regressed on maltreatment chronicity, all four coping styles (i.e., direct, indirect, prosocial, and asocial), and covariates (i.e., age, gender, race/ethnicity, type of placement [residential status], number of placement moves, and length of time in foster care) in order to determine unique effects of the predictors. Next, the multiplicative terms between maltreatment chronicity and one coping style at a time were added to determine if the associations between maltreatment chronicity and mental health outcomes depended on coping style. One interaction term was entered into the regression models at a time in order to limit the number of parameters in the model and increase power to detect interaction effects. Linear regression was used for models assessing internalizing and externalizing symptoms, while Poisson regression was used for the model assessing psychiatric hospitalizations, given that this was non-normal count data. Results of Poisson regressions are reported as risk ratios (i.e., the exponent of the regression coefficient) with 95% CIs. All variables were standardized prior to analyses to aid in the interpretation of the interaction effects. Significant interactions were probed at high (+1 SD) and low (−1 SD) levels of the moderator in order to evaluate the interaction effect, according to standard procedures (Aiken et al. 1991).

Results

Descriptive Statistics

All variables were normally distributed, with skewness and kurtosis within acceptable limits of ±2 (Gravetter and Wallnau 2014). The exception was psychiatric hospitalizations, which was then treated as a non-normal count variable. Means, standard deviations, and frequencies for maltreatment chronicity, coping style, and mental health outcomes are presented in Table 1.

Table 1.

Means, SDs, and Frequencies for Maltreatment Chronicity, Coping Style, and Mental Health Outcomes

Maltreatment Chronicity
Mean (SD) Min-Max
Chronicity Sum 17.96 (11.56) 1–60
Coping Style
Mean (SD) Description Min-Max % never % almost never % sometimes % often % almost always
Direct Coping 3.59 (0.66) Often 1–5 0.3 3.0 48.1 37.6 11.0
Indirect Coping 2.70 (0.63) Sometimes 1–5 6.3 27.2 58.8 7.5 0.3
Prosocial Coping 2.96 (.65) Sometimes 1–5 3.3 18.0 61.7 16.2 0.9
Asocial Coping 2.50 (.75) Sometimes 1–5 14.1 29.6 50.3 6.0 0.0
Mental Health Problems
Mean (SD) Description Typical % At-Risk % Clinically Significant %
Caregiver-report Internalizing 63.04 (11.42) At-Risk 37.5 34.5 28.0
Youth-report Internalizing 52.42 (10.84) Typical 75.0 17.8 7.2
Caregiver-report Externalizing 70.19 (13.15) Clin. Sig. 21.8 23.2 55.0
Youth-report Externalizing 57.58 (10.91) Typical 55.0 29.5 15.5
Psychiatric Hospitalizations
0 79.3%
1 17.2%
2 1.4%
3 2.1%
Diagnoses %
89.1 multiple diagnoses: suicidal ideation, psychosis, mood, anxiety, and/or conduct disorders
2.8 suicidal ideation
2.6 mood disorder
0.5 anxiety disorder
1.4 psychotic disorder
3.4 conduct disorder
0.2 substance use disorder
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Results of the bivariate correlations analyses are presented in Table 2. The results indicated a statistically significant, positive correlation between chronicity of maltreatment and asocial coping, youth-reported internalizing and externalizing symptoms, caregiver-reported internalizing symptoms, and psychiatric hospitalizations. Direct coping was negatively correlated with indirect coping and asocial coping, and positively correlated with prosocial coping. Direct coping was also negatively correlated with youth-reported internalizing and externalizing symptoms, and caregiver-reported externalizing symptoms. Indirect coping was positively correlated with prosocial and asocial coping, and with youth-reported internalizing and externalizing, and caregiver-reported externalizing. Prosocial coping was positively correlated with youth-reported externalizing symptoms. Asocial coping was positively correlated with youth-reported internalizing and externalizing, and caregiver-reported externalizing.

Table 2.

Descriptive statistics and correlations of study variables

1 2 3 4 5 6 7 8 9 10
1 Maltreat. chronicity 1
2 Direct coping −.03 1
3 Indirect coping .09 −.29** 1
4 Prosocial coping .06 .44** .23** 1
5 Asocial coping .18** −.32** .58** .02 1
6 Youth internalizing .40** −.27** .38** .09 .53** 1
7 Youth externalizing .23** −.23** .29** .13* .36** .59** 1
8 Caregiver internalizing .21** −.07 .11 .10 .04 .25** .20** 1
9 Caregiver externalizing .06 −.24** .16** −.02 .15* .14* .27** .53** 1
10 Psychiatric hospitalization .26** −.07 −.10 −.05 .01 .15 .25*** .05 .06 1
Mean 17.96 3.59 2.70 2.96 2.50 52.42 57.58 63.04 70.19 .26
SD 11.56 .66 .63 .65 .75 10.84 10.91 11.42 13.15 .59
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Note. *p < .05, **p < .01, ***p < .001

Youth-reported internalizing was positively correlated with youth-reported externalizing and caregiver-reported internalizing and externalizing. Youth-reported externalizing was positively correlated with caregiver-reported internalizing and externalizing, and psychiatric hospitalization. Caregiver-reported internalizing was also positively correlated with caregiver-reported externalizing.

Regression Analyses

A series of multiple regression models were evaluated to examine the direct and two-way interaction effects of maltreatment chronicity and direct, indirect, prosocial, and asocial coping styles on caregiver- and youth- reported internalizing (see Table 3) and externalizing (see Table 4) symptoms, and psychiatric hospitalizations (see Table 5).

Table 3.

Regression models with maltreatment chronicity predicting internalizing symptoms. N = 283

Youth-Report Caregiver-Report
Predictors β SE R2 β SE R2
.43 .15
Age .08 .39 −.11 .52
Gender −.11 1.41 −.12 1.89
Race/Ethnicity .08 .43 −.09 .58
Residential status .05 1.07 .12 1.96
Number of moves −.04 .12 −.02 .16
Time in care −.10 .12 .13 0
Maltreatment chronicity .24*** .06 .17* .08
Direct coping −.15 1.38 −.25** 1.86
Indirect coping .07 1.61 .09 2.16
Prosocial coping .15 1.41 .15 1.89
Asocial coping .40** 1.25 −.18 1.67
Step 2 .02 .01
Chronicity x direct −.06 .10 −.01 .13
Chronicity x indirect .09 .09 −.07 .13
Chronicity x prosocial .03 .10 −.07 .14
Chronicity x asocial .02 .08 .02 .11
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Note. *p < .05, **p < .01, ***p < .001

Table 4.

Regression models with maltreatment chronicity predicting externalizing symptoms. N = 283

Predictors Youth-Report Caregiver-Report
β SE R2 β SE R2
.22 .19
Age .14 .44 −.03 .61
Gender −.09 1.60 .05 2.24
Race/Ethnicity .07 .49 .02 .69
Residential status .06 1.07 .15 2.32
Number of moves .00 .13 .11 .19
Time in care .08 0 .13 0
Maltreatment chronicity .05 .07 −.09 .10
Direct coping −.28** 1.57 −.28** 2.19
Indirect coping −.02 1.82 .01 2.55
Prosocial coping .27** 1.60 .11 2.24
Asocial coping .25** 1.41 .10 1.98
Step 2 .02 .00
Chronicity x direct .07 .11 0 .15
Chronicity x indirect −.01 .11 −.13 .15
Chronicity x prosocial .12 .11 −.08 .16
Chronicity x asocial −.10 .09 −.03 .13
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Note. *p < .05, **p < .01, ***p < .001

Table 5.

Regression models with maltreatment chronicity predicting psychiatric hospitalizations. N = 283

Predictors Medical Report
β SE R2
.18
Age .08 .10
Gender .15 .41
Race/Ethnicity .02 .02
Residential status .96 .62
Number of moves .05 .03
Time in care 0 0
Maltreatment chronicity .04* .02
Direct coping −.42 .36
Indirect coping −.82* .41
Prosocial coping .75 .46
Asocial coping .77* .28
Step 2 .05
Chronicity x direct 0 0
Chronicity x indirect −.04* .02
Chronicity x prosocial −.01 0
Chronicity x asocial −.01 .01
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Note. *p < .05, **p < .01, ***p < .001

Internalizing Symptoms

Caregiver-report internalizing score was regressed on covariates, maltreatment chronicity, and the four coping styles. The model was significant, F(3, 280) = 2.11, p = .026, with these variables accounting for 19% of the variance in caregiver-report internalizing score. Results indicated that maltreatment chronicity was positively associated with caregiver-report internalizing symptoms, such that greater exposure to maltreatment was associated with higher levels of caregiver-reported internalizing symptoms in youth. Direct coping was negatively associated with caregiver-reported internalizing symptoms, with youth who endorsed using more direct coping having lower levels of caregiver-reported internalizing symptoms. No significant interaction effect was evident.

Adolescent-report internalizing score was regressed on covariates, maltreatment chronicity, and the four coping styles. The model was significant, F(3, 280) = 3.54, p = .000, with these variables accounting for 27% of the variance in adolescent-report internalizing score. Maltreatment chronicity was positively associated with adolescent-report of internalizing symptoms, as it was with caregiver-report. Additionally, asocial coping was positively associated with adolescent-report of internalizing, such that dealing with problems alone and not seeking support was linked to higher levels of internalizing symptoms perceived by the adolescent. No significant interactions were found.

In summary, these findings partially support the hypotheses, with maltreatment chronicity positively associated with both caregiver- and youth self-report of internalizing symptoms, but only direct coping was negatively associated with caregiver-report of internalizing, and only asocial coping was positively associated with youth report of internalizing.

Externalizing Symptoms

Caregiver-report externalizing score was regressed on covariates, maltreatment chronicity, and the four coping styles. The model was significant, F(3, 280) = 2.23, p = .018, with these variables accounting for 20% of the variance in caregiver-report externalizing score. Direct coping was the only significant main effect, such that greater use of direct coping was associated with lower levels of externalizing symptoms. No significant interaction effects were found.

Adolescent-report externalizing score was regressed on covariates, maltreatment chronicity, and the four coping styles. The model was significant, F(3, 280) = 2.55, p = .007, with these variables accounting for 21% of the variance in adolescent-report externalizing score. Direct coping was negatively associated with externalizing symptoms, such that greater use of direct coping was associated with lower levels of externalizing symptoms. Prosocial coping and asocial coping were both positively associated with externalizing symptoms, indicating that both seeking out others for help and avoiding others was related to greater externalizing. No significant interactions were found.

In summary, these findings partially support the hypotheses, given that maltreatment chronicity was unrelated to externalizing symptoms, and only direct coping was associated with caregiver-report, and direct, prosocial, and asocial coping were associated with youth-report, though prosocial coping was in an unexpected direction.

Psychiatric Hospitalizations

Count of psychiatric hospitalizations was regressed on covariates, maltreatment chronicity, and the four coping styles. For every additional maltreatment event experienced, individuals experienced an average of 1.04 more psychiatric hospitalizations (risk ratio = 1.04, 95% CI = 1.01–1.07). For every 1-point increase in indirect coping score, individuals experienced an average of 1.01 less psychiatric hospitalizations (risk ratio = 1.01, 95% CI = 1.00–1.07). For every 1-point increase in asocial coping score, individuals experienced an average of 2.16 more psychiatric hospitalizations (risk ratio = 2.16, 95% CI = 1.24–3.77). Indirect coping significantly interacted with maltreatment chronicity to predict psychiatric hospitalizations (see Table 5). Further examination suggested that at high levels of maltreatment chronicity, high use of indirect coping was associated with decreases in psychiatric hospitalizations while low use of indirect coping was associated with increases in psychiatric hospitalizations; however, at low levels of maltreatment chronicity, indirect coping was not significantly associated with psychiatric hospitalizations (see Fig. 1). No other significant interactions were found.

Fig. 1.

Fig. 1

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Association between maltreatment chronicity and psychiatric hospitalizations at high and low levels of indirect coping

In conclusion, the hypotheses were partially supported, with maltreatment chronicity and asocial coping positively associated with psychiatric hospitalizations; however, indirect coping did not operate as predicted. Results for the indirect coping main effect and moderation effect were in the opposite direction than expected.

Discussion

The purpose of the present study was to expand the knowledge base on how coping may influence mental health for adolescents exposed to maltreatment. Given that some youth in foster care (and youth exposed to maltreatment generally) demonstrate a range of mental health behaviors, both clinical and nonclinical, the present study examined how coping and maltreatment chronicity could account for adjustment. Specifically, the present study is one of the first to examine the interactive effects between maltreatment chronicity and coping styles on mental health outcomes, including psychiatric hospitalizations, of adolescents in foster care. Overall, the results demonstrated that maltreatment chronicity, direct coping, and asocial coping were associated with internalizing symptoms. Direct, prosocial, and asocial coping were associated with externalizing symptoms. Maltreatment chronicity, indirect coping, and asocial coping were associated with psychiatric hospitalizations. Additionally, at high levels of maltreatment chronicity, high use of indirect coping was associated with decreases in psychiatric hospitalizations while low use of indirect coping was associated with increases in psychiatric hospitalizations. The findings generally support the predictions, albeit with a few exceptions, but overall, provide new information on the relation between exposure to maltreatment, coping, and mental health functioning among adolescents in foster care.

Internalizing Symptoms

First, it was hypothesized that chronic maltreatment would be positively associated with internalizing symptoms. This hypothesis was supported, and findings are consistent with previous research that found youth exposed to chronic maltreatment had more caregiver-reported anxiety and depression compared to youth who experienced less frequent maltreatment (Éthier et al. 2004).

It was also hypothesized that direct and prosocial coping would be negatively associated with internalizing symptoms while indirect and asocial coping would be positively associated with internalizing behaviors. These hypotheses were partially supported. Youth who endorsed direct coping had significantly lower levels of caregiver-reported internalizing, but not self-reported internalizing, perhaps in part due to the lower level of self-reported internalizing compared to caregiver report. The results suggest that it may be beneficial to support the use of direct coping skills for youth in foster care, perhaps because attempting to solve problems directly may help one feel empowered, improve self-worth, and feel less anxious generally (Gutierrez 1994; Kendall et al. 2016; Miller Smedema et al. 2010). Alternatively, direct coping may reduce more apparent signs of internalizing in youth, like crying, contributing to caregivers’ impressions that their children have few symptoms.

Further, youth who endorsed asocial coping had significantly higher levels of self-reported internalizing symptoms, but not caregiver-reported internalizing. Avoiding or withdrawing from others is commonly associated with internalizing problems and it is clear that youth who reported not asking others for help perceived their own mental health as more likely to be anxious or withdrawn. This tendency to not ask others for help is consistent with aspects of Beck’s Cognitive Triad theory which suggests that individuals with depression tend to feel that there is nothing that others can do to help (Beck 2002). Perhaps especially for youth in foster care, where caregivers can be transient – the tendency to not reach out may be especially understandable. Some foster youth who experienced abuse or neglect from biological caregivers may have learned to isolate themselves to avoid further abuse, or that asking for help does not get them anywhere. While this strategy was likely adaptive at one point in time, when used frequently, it may contribute to internalizing symptoms, especially for youth who are no longer living with their biological parents. The lack of association between asocial coping and caregiver-reported internalizing symptoms may make sense in that youth who do not tend to reach out to others may be more difficult to read emotionally, thus caregivers may not pick up on internalizing symptoms. Extant literature suggests that difficulties with emotion identification and expression, also known as alexithymia, is significantly associated with asocial or avoidant coping and internalizing symptoms (Bilotta et al. 2016; Mueller and Buehner 2006). Further, alexithymia has been found to account for the association between child maltreatment and internalizing symptoms (Brown et al. 2016). Thus, youth in foster care who use asocial coping strategies may be more likely to exhibit difficulties with emotion expression, thus making it more difficult for caregivers to identify the presence of internalizing symptoms. Contrary to hypotheses, indirect and prosocial coping were unrelated to internalizing symptoms.

Externalizing Symptoms

Next, it was hypothesized that chronic maltreatment would be positively associated with both caregiver- and self-report of externalizing symptoms, but this finding did not emerge in the current sample. Instead, the results suggested that coping styles for youth exposed to maltreatment in foster care may be more important for predicting externalizing than maltreatment exposure itself. Specifically, as hypothesized, direct coping was negatively associated with both caregiver- and self-reported externalizing, consistent with past research demonstrating that youth who used approach (e.g., direct) coping in response to stressors had low externalizing problems (Clarke 2006). Importantly, direct coping was the only variable significantly associated with caregiver-reported externalizing behavior. Results suggest that maltreated youths’ tendency to directly manage situations may reduce their aggression and confrontation, regardless of whether they do this alone or seek others to assist them (i.e., asocial and prosocial coping). Interestingly, indirect coping (i.e., avoidant) was not associated with either youth- or caregiver-reported externalizing, contrary to hypotheses. Past literature suggests that avoidant coping styles have been associated with externalizing problems (Tremblay et al. 1999).

While the past study examined constructs in a sample of sexually abused children (ages 7–12), the present study surveyed maltreated adolescents who may have learned to use other forms of coping strategies to address stressors. Prosocial coping was, however, positively associated with self-reported externalizing, as was asocial coping. Findings on prosocial coping were in an unexpected direction, suggesting that youth who use prosocial coping have significantly more externalizing problems. When youth in foster care rely on prosocial coping and experience a placement and caregiver change, it may be difficult for them to identify adults or others they can trust for support, thus contributing to externalizing problems when they do not know how to cope with situations. That is, they may seek out others, but the result of this approach may not be positive adjustment. Alternatively, foster youth may not have people in their lives who are consistently helpful to them in managing stressors, and seeking out people who provide unhelpful advice may actually contribute to youths’ behavior problems. Given that endorsing asocial coping was also associated with more externalizing problems, withdrawing from others and failing to seek out help may also be problematic. It may be that maltreated youth in foster care need stronger, helpful, and more reliable social networks for this style of coping to be beneficial for mental health. Interestingly, prosocial and asocial coping were not associated with caregiver-reported externalizing.

Psychiatric Hospitalizations

It was also hypothesized that chronic maltreatment would be positively associated with psychiatric hospitalizations, which was supported by the data. This is in line with previous research showing that a high percentage of youth who have been hospitalized for a psychiatric reason have a history of maltreatment (Boxer and Terranova 2008). This study is the first to demonstrate this link in a sample of foster youth. Further, there was a positive association between asocial coping and psychiatric hospitalizations, as hypothesized. However, a negative association emerged between indirect coping and psychiatric hospitalizations, indicating that youth who endorsed an indirect coping style had less psychiatric hospitalizations. Moreover, a significant interaction revealed that youth with high levels of maltreatment chronicity and low use of indirect coping had more psychiatric hospitalizations in their medical records. Said another way, if an adolescent experiences chronic maltreatment and does not withdraw from or avoid stressors, they may be more at risk for psychiatric hospitalizations.

Indirect coping in the current study may be compared to avoidance coping, which involves attempts to withdraw from or deny the stressor. Many past studies have found an association between a variant of indirect coping and both positive and negative outcomes (Caples and Barrera 2006; Shapiro et al. 2012; Tremblay et al. 1999). It may be that for youth in foster care, it is not always possible or helpful to solve problems head on (e.g., confronting an abusive parent, protesting a placement change), and that doing so may actually result in psychological maladjustment. Consistent with the meta-analysis by Clarke (2006), approach coping strategies were only related fewer mental health symptoms in response to controllable stressors (e.g., an argument with a peer), thus youth in foster care with high maltreatment chronicity may have learned indirect coping strategies, particularly in response to uncontrollable stressors (e.g., physical abuse). Avoiding or withdrawing from the stressor may actually result in better mental health. This idea is consistent with studies by Chaffin et al. (1997) and Elzy et al. (2013), both of whom found that using an avoidance coping strategy was associated with fewer internalizing and externalizing symptoms.

Importantly, coping style may also be influenced by severity of distress. For example, in dialectical behavior therapy (DBT) distraction strategies are recommended over other types of coping when distress is at its most severe, at least until distress has decreased to a level that feels more tolerable (Linehan 2015). Given links between maltreatment and emotion dysregulation in a large body of previous literature (Hébert et al. 2018; Luke and Banerjee 2013; Maughan and Cicchetti 2002), it may be that youth who have experienced abuse and neglect become more dysregulated and experience greater distress even when faced with everyday problems, and thus benefit more from distraction techniques.

Limitations and Implications

Results of the present study should be interpreted within the context of several limitations. While the present study differed from past studies in that it examined youth with multiple forms of maltreatment and measured chronicity of maltreatment, findings may not generalize to maltreated adolescents who have not been placed in foster care. Youth whose abuse is frequent and/or severe enough to warrant placement in out-of-home care may use substantially different coping strategies and have different outcomes than youth whose abuse exposure is more infrequent or mild. Further, time since maltreatment was not considered. Youth may cope differently based on whether maltreatment was relatively recent or many years past. In addition, the current data was cross-sectional, thus it is not possible to determine causal links between variables. Youth should be followed over time to determine how maltreatment and coping affects mental health and psychiatric hospitalizations. Finally, the interaction effect should be interpreted with caution, as the beta coefficient was small. The current hypotheses should be examined in additional samples to determine reproducibility.

Despite these limitations, the current study has several strengths. First, the current study employed a multi-informant method, which reduces the risk of response bias and shared method variance. Second, the current study measured the frequency of maltreatment events across maltreatment types, rather than solely type of maltreatment, given that most youth in foster care experience multiple types of maltreatment. Third, past studies have primarily examined only approach or avoidance strategies; thus, the current study utilized an empirically supported, comprehensive model of coping including direct, indirect, prosocial, and asocial coping styles. Fourth, this is one of very few studies to examine the interaction of maltreatment and coping in a sample of adolescents in foster care. Lastly, this is the first study to examine the impact of maltreatment and coping on psychiatric hospitalizations, an outcome that not only serves as a proxy for more extreme mental health problems but has grave implications for the future mental health of an individual. In summary, the results of the present study provide empirical evidence for how the field might understand the disparities in mental health for maltreated adolescents in foster care.

The results suggest several possible clinical implications. First, it may be useful for mental health providers to consider encouraging the use of direct coping and focus on building this skill, as this style of coping was associated with less internalizing and externalizing, and thus was the most robust finding. It may also be important to build up the social support networks for youth in foster care, given that both prosocial and asocial coping were related to mental health problems. Moreover, mental health providers may want to encourage the use of indirect coping until ensuring that adolescents’ circumstances are safe and stable.

Conclusions

This study substantially contributes to the field by providing a greater understanding of how the combination of maltreatment exposure and coping style impact three important aspects of mental health: internalizing, externalizing, and psychiatric hospitalizations. Given that all but one interaction was non-significant, it appears that for the most part, maltreatment exposure and coping act independently on mental health, rather than in concert, similar to findings from past studies (Tremblay et al. 1999). This study provided evidence that not all youth exposed to maltreatment, even those in foster care, have clinically significant levels of internalizing and externalizing or psychiatric hospitalizations, and that maltreatment chronicity and coping style are important explanatory factors for differing mental health outcomes among youth.

Funding Information

This research was supported by funding from the National Institutes of Mental Health, R01 Grant MH079252–03 awarded to Yo Jackson, as well as funding from the National Institutes of Mental Health, T32 Grant 2T32MH019927–26 awarded to Lindsay Huffhines.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have 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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