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. Author manuscript; available in PMC: 2021 Jun 3.
Published in final edited form as: Issues Ment Health Nurs. 2020 Sep 23;42(6):555–563. doi: 10.1080/01612840.2020.1820121

Health Correlates of Abuse History and Moderating Effect of Parenting Stress for Mothers with Mental Disorders

Jessica R Williams a, Brian E McCabe b, Lila de Tantillo c, Kristin Levoy d, Victoria Behar-Zusman e
PMCID: PMC8020494  NIHMSID: NIHMS1686608  PMID: 32965137

Abstract

Parenting stress is common and may lead to worsening health, particularly in the context of other risk factors such as mental disorders or a history of abuse. This study investigated how parenting-related stress impacts the effect of abuse experiences on health among mothers with mental health disorders. Survey data was analyzed from 172 predominantly Hispanic mothers receiving outpatient behavioral health services. Most (80.2%) mothers had experienced abuse. Those reporting childhood abuse had 3.82 greater odds of experiencing abuse in adulthood. Findings demonstrated worse health outcomes among those experiencing abuse in both childhood and adulthood and those with a greater number of abuse experiences. Caregiving load intensified the relationship between abuse and anxiety and sleep disturbance. Parenting self-agency intensified the relationship between abuse and cigarette use. These findings have important implications for mental health nursing practice by identifying parenting-stress as an important target for interventions to improve health among women with histories of abuse and mental health disorders.

Introduction

Individuals with mental disorders are particularly vulnerable to the long-term health consequences of abuse (Chartier et al., 2009; Subica et al., 2012), and this vulnerability is exacerbated in situations of high stress (Yim & Kofman, 2019). Parenting stress is a common occurrence that may lead to worsening health outcomes. Despite this, little is known about how parenting stress may impact the health of mothers, particularly when other risk factors are present such as mental disorders and a history of abuse. To address this gap, this study examined the moderating effects of parenting stress on the relationship between abuse history and health among mothers with mental disorders.

People who have mental disorders are more likely to have experienced abuse than the general population (Khalifeh et al., 2015). This may be because abuse contributes to or exacerbates the development of mental disorders, or because individuals vulnerable to mental disorders are also more likely to be exposed to abuse. The prevalence of adult abuse experiences among women receiving mental health services is estimated to be 30–63% (Oram et al., 2013), compared to 25% among women in the general population (Smith et al., 2018). Estimates of lifetime abuse (i.e., both adult and childhood abuse) among women receiving substance abuse treatment range from 60 to 75% (El-Bassel et al., 2000; Keyser-Marcus et al., 2015; Lincoln et al., 2006).

The health consequences of abuse, both in childhood and adulthood, are well documented. Findings from a meta-analysis suggest causal relationships between experiences of child abuse and adult depression, anxiety, substance use, and obesity (Norman et al., 2012). Other studies have found links between child abuse, pain, and sleep disturbance (Afifi et al., 2016; Miller-Graff et al., 2015). Intimate partner violence in adulthood has been found to increase risk for heart disease (Breiding et al., 2008; Vives-Cases et al., 2011), high cholesterol, joint disease, smoking, binge drinking (Breiding et al., 2008), pain (Vives-Cases et al., 2011), and depressive symptoms (La Flair et al., 2012). Moreover, studies have demonstrated a dose-dependent relationship between abuse and adverse health outcomes (Afifi et al., 2016; Miller-Graff et al., 2015; Norman et al., 2012). For example, girls who experience abuse in childhood are at risk for re-victimization in adulthood (Cannon et al., 2010; Herrero et al., 2018; Ports et al., 2016; Relyea & Ullman, 2017; Whiting et al., 2009), which compounds their risk for depression (Ouellet-Morin et al., 2015), pain, and fatigue (Campbell et al., 2008). Fewer studies account for the cumulative effects of abuse across the lifespan, while also considering varying forms of abuse (physical, sexual, emotional/psychological) exposure.

An abundance of research demonstrates the crucial role that chronic stress plays in health (e.g., Park & Iacocca, 2014; Schneiderman et al., 2005). Based on the model of allostasis (McEwen & Stellar, 1993), when an individual experiences stress, physiological and behavioral responses are initiated to adapt to the stressor in order to maintain stability. When a person is exposed to chronic stress, allostatic load, or “wear and tear” on the body, can accumulate and result in adverse health effects. This model is commonly used to explain the relationship between abuse and negative health outcomes, where abuse history (a stressor) contributes to chronic activation of the allostatic systems (i.e., central nervous system, immune system) leading to progressive wear and tear (Crofford, 2007; Danese & McEwen, 2012). Mental health disorders can further increase vulnerability to the negative effects of stress by reducing an individual’s ability to adapt to stress. Given the increased vulnerability individuals with mental health disorders and abuse histories have to the negative consequences of stress, it is critical to understand sources of stress that may worsen this vulnerability as targets for intervention.

Parenting stress is a common, but understudied, source of stress that may exacerbate the effects of abuse on health. Researchers have demonstrated that mothers who have experienced abuse experience greater parenting stress (Ammerman et al., 2013). Sources of parenting stress for these mothers include problems enacting their parenting roles (Cohen et al., 2008; Zalewski et al., 2013; Zvara et al., 2015) having less confidence in parenting (Seltmann & Wright, 2013), and harboring feelings of guilt or fears over the possibility of losing custody of their children (Rhodes et al., 2010). Moreover, mothers with mental health problems are more likely to be raising children who have emotional or physical health problems of their own (Hser et al., 2014; Turney, 2012), further elevating the potential for parenting stress.

While research has typically focused on the effects of parenting stress on child outcomes, fewer studies have focused on how parenting stress may also impact a parents’ health. As such, there remains a dearth of knowledge about how parenting-related stressors impact the health of mothers, particularly when other known risk factors are present such as mental disorders and a history of abuse. Thus, the purpose of this study was twofold. First, we examined the cumulative effects of abuse on mothers with mental disorders. Specifically, we examined the relationships between life-stage abuse profiles (abuse in childhood, adulthood, or both) and abuse forms (physical, sexual, emotional/psychological) with health and risk behavior outcomes. We tested the following hypotheses: 1) mothers who experienced abuse during both childhood and adulthood will have more health and risk behavior problems than those who experienced abuse only in childhood or adulthood, controlling for monthly income, having a partner/spouse, and primary type of treatment (mental health or substance abuse); 2) there will be a direct association between the number of abuse forms and adverse health and risk outcomes, controlling for monthly income, having a partner/spouse, and primary type of treatment (mental health or substance use). Second, we explored the impact of parenting-related stress as a moderator of the relationships between mother’s experiences of abuse and maternal health outcomes, using three indicators of parental stressors: low parenting self-agency, child-related hassles, and caregiving load. This was an exploratory analysis aimed at providing a foundation for future research. Greater knowledge of the health effects (mental and physical) of abuse across life-stages, and the interplay of abuse history with parenting-related stressors can inform targeted trauma-informed services for mothers with mental disorders, whose treatment and recovery have a profound effect on their own wellbeing as well as that of their children.

Methods

Study design

This investigation is a secondary analysis of baseline (pre-intervention) data from a randomized clinical trial (clinical-trials.gov ID NCT02702193; Kim & Mitrani, 2019) testing a family-strengthening home health intervention as an enhancement to behavioral (mental health or substance abuse) services for mothers with minor children (<18 years old).

Participants

Participants were recruited from local community-based, outpatient behavioral health agencies for mental health or substance abuse. Inclusion criteria of the parent study required that potential participants be mothers receiving outpatient behavioral health services and have at least monthly contact with one or more of their children under age 18. Participants were compensated $50 for the initial assessment.

Data collection and ethical considerations

Bilingual research personnel conducted all interviews in a private setting, most of which occurred at the participants’ homes. Research staff administered questionnaires in interview format and documented responses with a secure web-based research management software system (e-Velos). Participants were interviewed in either English (n = 96, 56%) or Spanish (n = 75, 44%) according to their preference. All measures were available in English and Spanish from the developers or from past research, translated using forward and back translation methods.

Information on informed consent was provided to all participants and written consent was obtained from participants prior to engaging in study activities. The university’s Institutional Review Board approved the study (IRB number: 20111132) and a certificate of confidentiality was granted by the National Institutes of Health.

Measures

Demographics

Participants self-reported demographic information including age, race/ethnicity, socio-economic characteristics (i.e., years of education, employment status, monthly family income < $1000), household characteristics (i.e., has spouse/partner, total number of minor children, number of minor children living in the household, age of children), and type of outpatient behavioral health services, including primary reason for treatment (i.e., psychosis, mood/anxiety disorder, substance use disorder, other/unreported). For analysis, we used monthly family income, having a spouse/partner, and primary type of treatment as control variables.

Abuse history

Experiences of abuse during childhood and adulthood were measured using the Violence Assessment, a measure developed for an HIV risk reduction efficacy trial (Peragallo et al., 2005), and refined in a subsequent study (Gonzalez-Guarda et al., 2008). The measure consists of six dichotomous (yes/no) questions regarding sexual, physical, and emotional/psychological abuse, of which three items refer to childhood experiences (prior to age 18), and three items refer to adulthood experiences (at age 18 or later). We used responses to this measure in two ways. First, we identified four mutually exclusive categories of life-stage abuse profiles: (1) never experienced, (2) childhood only, (3) adulthood only, and (4) both adulthood and childhood – resulting in a 4-level categorical variable. Second, we created a single continuous variable of abuse forms (ranging from 0 to 6) by adding the number of items endorsed. Although this is not a psychometric scale, it had acceptable internal consistency, α = .80.

Health indicators

We measured nine health indicators to capture various aspects of psychological health, physical health, and health risk behaviors.

Psychological health.

Anxiety and depression were examined as indicators of psychological health, using the short forms of the Patient-Reported Outcome Measurement Information System (PROMIS) Anxiety and Depression instruments (Cella et al., 2010). Each measure contains eight items with responses based on a 5-point Likert scale (Never, Rarely, Sometimes, Often, and Always) about the past 7-day period. The Anxiety measure includes items such as “I felt uneasy” and “I felt nervous.” The Depression measure includes items such as “I felt hopeless” and “I felt like a failure.” In this sample, the Cronbach’s alpha of the Anxiety measure, α = .95, and of the Depression measure, α = .94, demonstrated excellent reliability.

Physical health.

Fatigue, pain, sleep disturbance, physical function and obesity were examined as indicators of physical health, using corresponding subscales from the PROMIS 29 measure (Cella et al., 2010). This consisted of 17 Likert-format questions in which higher scores indicate worse health, except for physical function, which was reverse-coded. The internal consistency of the subscales in the present study was excellent (fatigue α = .90, pain α = .95, sleep disturbance α = .89, and physical function α =.92). Obesity was calculated using direct measurements of the participant’s weight and height (BMI=weight [kg] divided by height [m] squared). BMI guidelines consider a BMI less than 18.5 kg/m2 as underweight, BMI of 18.5 to < 25.0 falls within the normal range, between 25 to < 30 kg/m2 as overweight, and 30 kg/m2 or greater is categorized as obese (Centers for Disease Control and Prevention, 2020). There is missing data on BMI for 9 women, due to pregnancy or because they declined to have BMI assessed. For this study, we used a single obesity variable coded as obese vs. not obese, with obese constituting those participants with a BMI of 30 kg/m2 or higher, and not obese including all others below this benchmark.

Health risk behaviors.

Substance use and cigarette use during the three months before the assessment was measured with the Addiction Severity Index Lite (Cacciola et al., 2007). For analyses, these variables were coded as substance use (any alcohol intoxication or illicit drug use vs. no alcohol intoxication or illicit drug use) and cigarette use (any use vs. no use) in the past three months.

Parenting stress

Three indicators of parenting stress were examined, parenting self-agency, child-related hassles, and caregiving load.

Parenting self-agency.

The Parenting Self-Agency Measure (Dumka et al., 1996) assessed with five items how frequently a mother perceived she acts confidently in her parental role, e.g., “I feel sure of myself as a parent.” Responses were on a five-point scale, from 1 almost never or never to 5 almost always or always. In this sample, the measure had acceptable internal consistency, Cronbach’s α = .79.

Child-related Hassles.

A single item was used from the Hassles Scale, a measure originally developed to evaluate the impact of minor hassles and uplifts of everyday life and serve as a predictor of concurrent and subsequent psychological symptoms and adaptational outcomes (Kanner et al., 1981). This scale has been used in our previous studies with similar samples (e.g., Burns et al., 2008; Mitrani et al., 2011). Respondents are asked to indicate which items among a list of potential “hassles” had affected them in the past month and, of those, to denote their severity as Somewhat severe, Moderately severe, or Extremely severe. For analysis, we coded child-related hassles as 0 if the mother reported no hassle with children, and as 1 if the mother reported any level of hassle with children, due to skewedness of the data.

Caregiving load.

A composite variable was used to measure caregiving load, which has been used in previous research (Matsuda et al., 2020) with mothers in our sample. To create this composite, one point was assigned for each of the following indicators from mother-reported data: (1) each child living with the mother, (2) each child (living with the mother) with an internalizing T-score ≥ 65, (3) each child with an externalizing T-score ≥ 65, and (4) each child with a medical condition. Child internalizing and externalizing problems were assessed with the Child Behavior Checklist (CBC; Achenbach & Rescorla, 2001) for children age 6–18 years, and with the preschool version of the Child Behavior Checklist (CBCP; Achenbach & Rescorla, 2000) for children age 2–5 years. These scales had strong internal consistency in this sample, Internalizing α = .82, Externalizing α = .91, in older children; and Internalizing α = .89; Externalizing α = .95, in younger children. To assess medical condition, mothers responded to a list of 15 common medical conditions including asthma, autism, cerebral palsy, diabetes, epilepsy, and heart defects, and other non-specified conditions. This measure was adapted from the Caregiver Strain Questionnaire developed by Brannan et al. (1997).

Analyses

Analyses had three control variables: monthly income, having a partner/spouse, and primary type of treatment (mental health or substance use). To test Hypothesis 1 (experiencing abuse during both childhood and adulthood is associated with more adverse health), we used Generalized Linear Model (GZLM) for each outcome variable, i.e., analogues to ANCOVA for continuous outcomes and logistic regression for dichotomous outcomes. GZLM is a statistical technique that flexibly combines multiple distributions of both independent and dependent variables. Post-hoc tests using the Sidak correction were used to determine which of the four levels of the independent variable were different. To test Hypothesis 2 (association between the number of forms of abuse and health indicators), we used partial correlations to examine the link between the continuous abuse variable and each dependent variable.

We then explored whether the three indicators of parenting stress—parental self-agency, child-related hassles, and caregiving load—moderated the relationships between each of our abuse variables and each of the dependent variables. We used analyses that had the parenting stress x abuse interaction terms, separately for each outcome, in GZLM, which allowed for a continuous or categorical moderator for both ANOVA and logistic regression models and controlling for the same covariates. All analyses were conducted using SPSS 26 (IBM, Armonk, NY).

Results

Participant characteristics

Table 1 shows characteristics of the 172 study participants. Participants had a mean age of 35.27 (SD=8.93) and most identified as Hispanic (n=137, 79.7%). The average number of years of education was 12 (SD=3.04), which equates approximately to completing high school. Half (n=86) reported a monthly family income of less than $1,000. The mothers in our sample had a mean number of 2.15 minor children (SD=1.32; range 1–7), with a mean number of children in the household of 1.5 (SD=1.21; range 0–6). The children had an average age of 8.36 years (SD=4.39). Almost four out of five (77.9%, n=134) participants reported at least one form of abuse (physical, sexual, emotional/psychological) during their lifetime, with 13.4% (n=23) reporting childhood abuse only, 18.0% (n=31) adulthood abuse only, and 46.5% (n=80) experiencing abuse in both childhood and adulthood. Mothers who reported childhood abuse had greater likelihood of adulthood abuse, χ2 (df=1) = 15.98, p < .001, OR = 3.82, compared to those who did not experience abuse during childhood. Additional descriptives for health outcomes are presented in Table 2.

Table 1.

Participant characteristics (N = 172).

Characteristic M SD n %
Age, years 35.27 8.93
Race/Ethnicity
 Hispanic 137 79.7
 Black 22 12.8
 White non-Hispanic/other 13 7.6
Socio-economic characteristics
 Education, years 12.00 3.04
 Employed 40 23.3
 Monthly family income < $1000 86 50.0
Household characteristics
 Has spouse/partner 71 41.3
 Minor children (total) 2.15 1.32
 Minor children (living in household) 1.50 1.21
 Age of children 8.36 4.39
Mental health treatment 106 61.6
 Psychosisa 53 50.0
 Mood/anxiety disordera 24 22.6
 Substance use disordera 10 9.4
 Other/unreporteda 19 17.9
Substance abuse treatment 66 38.4
 Substance use disordera 43 65.2
 Mood/anxiety disordera 9 13.6
 Psychosisa 6 9.1
 Other/unreporteda 8 12.1
Life-stage abuse profiles
 Any lifetime abuse 134 77.9
 Never experienced 38 22.1
 Childhood abuse only 23 13.4
 Adulthood abuse only 31 18.0
 Childhood and adulthood abuse 80 46.5
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a

Proportion of disorders is calculated separately for women in each type of treatment.

Table 2.

Associations between life-stage abuse profiles and health indicators.

Health indicators Never experienced (n = 34) Childhood only (n = 23) Adulthood only (n = 31) Childhood and adulthood (n = 80) χ2 p
M SD M SD M SD M SD
Anxiety 58.04 15.12 56.77 11.71 57.88 11.99 62.85 11.57 10.73 .013
Depression 53.71 12.16 51.23 10.70 54.67 11.25 58.53 10.02 12.57 .006
Fatigue 49.84 11.41 54.13 12.17 51.94 11.81 56.02 11.24 10.26 .016
Pain 51.31 12.06 51.15 11.39 52.15 11.35 55.81 11.10 7.04 .071
Sleep disturbance 51.27 11.59 54.33 11.51 52.47 12.35 58.81 11.12 16.54 .001
Physical function 49.64 9.83 49.08 9.83 48.22 10.64 47.92 9.51 2.86 .414
n % n % n % n % χ2 p
Obesity 14 41.2 13 56.5 17 54.8 27 33.8 6.96 .073
Substance use 1 2.9 2 8.7 2 6.5 19 23.8 5.54 .136
Cigarette use 9 26.5 13 56.5 6 19.4 25 31.3 8.78 .032
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Note. χ2 test shows whether there was a significant difference between any of the four groups in the GZLM analysis. Bold denotes significant differences between one of four levels: never experienced, childhood only, adulthood only, and both childhood and adulthood. Post-hoc tests using the Sidak correction are described in text. Percentages are calculated using the n of each level, not overall sample size. Analyses controlled for monthly income, having a partner/spouse, and primary type of treatment (mental health or substance use).

Relationship between control variables and health indicators

Monthly income over $1,000 was negatively associated with pain, b = −3.93, SE=1.71, p = .021. Having a partner was negatively associated with fatigue, b = −4.17, SE=1.89, p = .027, and sleep disturbance, b = −3.79, SE=1.92, p = .048, and positively associated with physical functioning, b=3.45, SE=1.58, p = .029. Being in substance use treatment compared to mental health treatment was negatively related to anxiety, b = −5.12, SE=2.11, p = .015, depression, b = −3.90, SE=1.81, p = .032, and pain, b = −5.74, SE=1.91, p = .003, and positively associated with physical functioning, b=4.61, SE=1.64, p = .005, and substance use, b=1.69, SE=0.56, p = .003.

Relationships between abuse histories and health indicators

Hypothesis 1: Maternal health correlates of life-stage abuse profiles

Table 2 presents associations between life-stage abuse profiles and maternal health indicators. Controlling for monthly income, having a partner, and primary type of treatment, the life-stage abuse profile groups had significant differences in anxiety, χ2 (df=3) = 10.73, p = .013, depression, χ2 (df=3) = 12.57, p = .006, fatigue, χ2 (df=3) = 10.26, p = .016, sleep disturbance, χ2 (df=3) = 16.54, p = .001, and cigarette use, χ2 (df=3) = 9.07, p = .028. Results of post-hoc tests (not reported in table) using the Sidak correction showed that the group who experienced abuse in both childhood and adulthood had higher anxiety (p = .041), depression (p = .019), fatigue (p = .026) than those with abuse in childhood only; and more cigarette use (p = .018) than those with abuse in adulthood only. The group that experienced abuse in both childhood and adulthood had greater sleep disturbance than those who never experienced abuse (p = .016) and those with abuse in adulthood only (p = .016).

Hypothesis 2: Maternal health correlates of the number of abuse forms

Controlling for monthly income, having a partner, and primary type of treatment, the number of abuse forms was positively correlated with anxiety, r = .31, p < .001, depression, r = .27, p = .001, fatigue, r = .29, p = .001, sleep disturbance, r = .32, p = .001, pain, r = .24, p = .004, and substance use, r = .28, p < .001

Parenting stress as moderator of the relationship between abuse and maternal health

Moderation of life-stage abuse profiles

Table 3 presents results for analyses examining parenting stress as a moderator of the relationship between life-stage abuse profiles and maternal health indicators. Caregiving load moderated the relationship between the life-stage abuse profiles and anxiety, χ2 (df=3) = 14.62, p = .002, and sleep disturbance, χ2 (df=3) = 9.46, p = .024. Specifically, higher levels of caregiving load intensified the relationships between anxiety and having experienced abuse in childhood only, b=5.43, SE=1.85, p = .003, adulthood only, b=5.97, SE=1.66, p < .001, and abuse in both childhood and adulthood, b=3.87, SE=1.50, p = .010 (results not reported in table). Higher levels of caregiving load also intensified the relationships between sleep disturbance and abuse in adulthood only, b=4.48, SE=1.58, p = .005, and abuse in both childhood and adulthood, b=2.93, SE=1.43, p = .040 (results not reported in table)

Table 3.

Interactions between parental stress, life-stage abuse profiles, number of abuse forms, and health indicators.

Health indicators Life-stage abuse profiles Number of abuse forms
Parenting self-agency Child-related hassles Caregiving load Parenting self-agency Child-related hassles Caregiving load
χ2 p χ2 p χ2 p χ2 p χ2 p χ2 p
Anxiety 5.18 .159 0.25 .968 14.62 .002 1.80 .180 0.38 .540 0.31 .581
Depression 4.50 .212 1.26 .739 7.78 .051 1.50 .220 0.44 .509 0.35 .552
Fatigue 1.47 .688 1.87 .601 3.83 .281 1.01 .316 3.59 .058 0.00 .981
Pain 1.58 .664 2.44 .487 3.81 .283 0.48 .487 2.07 .151 1.37 .242
Sleep dist. 3.93 .270 0.34 .952 9.46 .024 0.24 .627 0.41 .523 0.99 .319
Physical Fx. 0.25 .969 0.53 .913 5.06 .168 0.06 .805 0.94 .333 1.29 .256
Obesity 3.40 .334 1.99 .575 0.91 .824 0.21 .645 0.66 .415 0.71 .398
Sub. use 0.60 .897 0.00 1.000 2.39 .496 1.09 .295 0.65 .420 0.30 .587
Cigarette use 4.50 .212 0.27 .966 1.90 .593 4.15 .042 0.57 .452 0.09 .762
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Note. χ2 test shows whether there was a significant interaction in the GZLM analysis. Bold denotes significant interactions, which are interpreted in text. Analyses controlled for monthly income, having a partner/spouse, and primary type of treatment (mental health or substance use). Sleep dist. = Sleep disturbance; Physical Fx. = physical functioning; Sub. Use = substance use.

Moderation of number of abuse forms

Results for the analyses examining parenting stress as a moderator of the relationship between number of abuse forms and maternal health indicators are presented in Table 3. Parenting self-agency moderated the relationship between number of abuse forms and cigarette use, χ2 (df=3) = 4.15, p = .042. Specifically, parental agency was positively related to cigarette use, b=1.74, SE=0.83, p = .036, and the number of abuse forms was positively related to cigarette use, b=2.11, SE=1.05, p = .044, but the parenting self-agency x abuse forms interaction was inversely related to cigarette use, b = −0.44, SE=0.21, p = .042 (results not reported in table)

Discussion

This study expanded the extant literature on women who have experienced abuse by focusing on mothers with mental health disorders and demonstrating that parenting-related stressors add to the health burdens faced by abuse survivors. The findings confirmed the high prevalence and health consequences of abuse among women receiving behavioral health services for mental health or substance abuse disorders. The vast majority of mothers in this sample reported physical, sexual or emotional/psychological abuse in their lifetime, consistent with, and in some cases higher than, prevalence rates of abuse history reported in previous studies among women in behavioral health settings (El-Bassel et al., 2000; Keyser-Marcus et al., 2015; Lincoln et al., 2006; Oram et al., 2013). Similar to other studies demonstrating dose-related health effects of abuse (e.g., Dubowitz et al., 2001), in this study we found the accumulation of abuse experiences to be associated with worse health outcomes for anxiety, depression, fatigue, pain, sleep disturbance and substance use. The strongest of these relationships was with sleep disturbance, corroborating previous literature demonstrating that accumulated abuse is associated with sleep disorders (Hoag et al., 2015; Kajeepeta et al., 2015). Mounting evidence documents the importance of sleep as a determinant of women’s health (Grandner et al., 2010, 2015; Kanagasabai & Ardern, 2015), thus heightening the significance of this finding.

A large body of research examines parenting and child-related outcomes in high-risk families, including families with maternal history of abuse or mental health problems, but very limited research is available on the health outcomes for the mothers themselves. The current study extends the research literature by exploring whether stressors associated with raising children, including raising children with physical and emotional problems, exacerbate the effects of abuse history on maternal health. We found significant interactions between abuse history and two of the parenting stress indicators, caregiving load and parenting self-agency, on anxiety, sleep disturbance, and cigarette use. This exploratory analysis lays the groundwork for hypothesis-driven research testing the stress process among mothers with mental disorders who are abuse survivors. Understanding the modifiable parenting-related factors that affect maternal health can inform interventions aimed at improving the wellbeing of this vulnerable population of mothers, that may also have mutually beneficial effects for their children.

This study also provided additional evidence of the cascading and long-term consequences of child abuse. A note-worthy finding in this study was the high odds of experiencing abuse in adulthood among survivors of child abuse, which was greater than the risk reported in previous studies (Barrios et al., 2015; Cannon et al., 2010; Widom et al., 2014). These findings highlight the potential to improve women’s health through interventions that prevent child abuse, attend to child victims, and address malleable risk/protective factors for experiencing abuse in adulthood among survivors of child abuse (Cloitre et al., 2011; Substance Abuse and Mental Health Services Administration [SAMHSA], 2014).

Implications for practice

This study highlights the complex interrelationships of abuse, mental/physical health outcomes, and parental stress among mothers with mental and substance abuse disorders who are receiving behavioral health services. These findings provide further support for the clinical recommendations for trauma-informed and comprehensive approaches for women in mental health treatment (SAMHSA, n.d.), and highlights the need for trauma-informed family services. These interventions should be designed to address the health consequences of abuse while avoiding re-traumatization (SAMHSA, n.d.), be sensitive to the client’s cultural and social background, and consider family activities, including child caregiving.

Trauma-informed interventions have been shown to improve both physical and mental health outcomes among women with abuse histories. For example, a previous trauma-informed intervention for women with abuse histories seeking mental health treatment significantly improved self-reported physical health; long-term benefits on physical health were realized by way of the improved mental health (e.g. decreased drug use, decreased post-traumatic symptom severity) (Weissbecker & Clark, 2007). Another study showed trauma-informed care was a successful intervention for mothers with multiple issues, including poor nutrition, low physical activity, and the effects of traumatic experiences (Tuck et al., 2017).

Our findings suggest the need for precision health approaches even within trauma-informed treatment. Additional benefits may be realized by incorporating content tailored for mothers experiencing parenting stress. This may include integrated parenting skills and support interventions and mindfulness-based interventions, which have been shown to reduce parenting stress in prior research (Moreland & McRae-Clark, 2018; Rayan & Ahmad, 2018). Interventions for mothers in behavioral health treatment also need to anticipate the likelihood of multiple types of abuse and include components that address the mental and physical health sequelae of abuse, for both mothers and their children. Providers of physical and mental health care for women should ask clients about lifetime experiences of abuse as a routine part of patient histories and physical exams. Women, and mothers in particular, may be reluctant to bring up this information spontaneously because of discomfort or fear of stigma or reprisal, and because they are unlikely to recognize links between abuse and health, especially if the abuse occurred in the distant past (Spangaro et al., 2016).

Limitations and future directions

Limitations in this study warrant caution in interpreting results. First, this is a secondary analysis of data from a study that was not designed to provide a detailed analysis of the health consequences of abuse or the parenting factors that can affect the stress-process for these mothers. Future prospective studies using more robust measures of abuse and parenting stress are needed to further validate the results found in this exploratory study. We operationalized abuse as the respondent’s report of any experience of physical, sexual or emotional/psychological abuse to address the full range of direct abuse experiences. However, this measure of abuse was limited in that it only indicated whether the various forms of abuse had occurred, but not their frequency, chronicity or severity, important features of the abuse experience that influence health outcomes. Therefore, participants with the same abuse scores could have experienced differing levels of abuse severity or frequency, which may have masked more nuanced relationships between abuse and health. A further limitation of this work is that it focuses exclusively on the health consequences of abuse and parenting stress without examining coping mechanisms or other resiliency factors of women or their environments that could inform intervention development. Further research should examine protective factors that could distinguish those women who, even with histories of abuse and high levels of parenting stress, still had relatively good health outcomes. Finally, while most of our study sample identified as belonging to racial/ethnic minority groups (79.7% Hispanic, 12.8% Black) often underrepresented in this type of research, the homogeneity of racial/ethnic composition did not allow us to specifically examine racial/ethnic differences in our study aims. Additional research is needed to understand better how race/ethnicity may interact with abuse history, parenting stress, and health outcomes.

Conclusions

The study demonstrates the deleterious impact of abuse during childhood and adulthood on maternal health, which is compounded by the parental stressors of parenting self-agency and caregiving load, among mothers with mental disorders. Given the high prevalence of abuse history among mothers receiving behavioral health services, providers should routinely assess for history of abuse, utilize tailored trauma-informed approaches to address emotional and physical sequelae of abuse, and seek to mitigate parenting stress to promote maternal wellbeing. Further research is warranted to develop trauma-informed family services for mothers with mental illness who are survivors of abuse.

Footnotes

Disclosure statement

The authors declare no conflicts of interest.

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