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. Author manuscript; available in PMC: 2023 Oct 1.
Published in final edited form as: J Psychopathol Clin Sci. 2022 Jul 28;131(7):716–726. doi: 10.1037/abn0000772

The Protective Role of Secure Attachment in the Relationship between Experiences of Childhood Abuse, Emotion Dysregulation and Coping, and Behavioral and Mental Health Problems among Emerging Adult Black Women: A Moderated Mediation Analysis

Nicole K Gause 1,2, Jessica M Sales 3,4, Jennifer L Brown 1,5,6, William E Pelham III 7, Yu Liu 8, Stephen G West 9
PMCID: PMC9560963  NIHMSID: NIHMS1821746  PMID: 35901415

Abstract

Objective:

To determine the extent to which secure attachment moderates the effects of previous child abuse history on the intermediate variables (putative mediators) of emotion dysregulation and coping, which, in turn, influence adult behavioral heath and mental health problems.

Method:

440 Black women (M age = 20.33, SD = 1.88) were selected from the baseline data collection of a large randomized trial. Study participants had consumed alcohol, had had unprotected sex in the past 90 days, and either reported abuse prior to age 18 or no lifetime history of abuse. Women completed measures of sociodemographics, abuse history, attachment security, coping, emotion dysregulation, psychological functioning, risky sexual behavior, and substance use problems.

Results:

At low attachment security, the conditional indirect effects of childhood abuse through the intermediate variable, coping, were statistically significant for all dependent variables except proportion condom use and perceived stress. At high attachment security, none of the conditional indirect effects through coping achieved statistical significance. High attachment security also mitigated the conditional indirect effects of childhood abuse through the intermediate variable, emotion dysregulation, reducing the magnitude of the relationship with trait anger, depression, marijuana problems, and perceived stress by about 50%.

Conclusions:

These results demonstrate the potential mitigating effects of secure attachment on the relationship between childhood abuse history and select behavioral and mental health problems through the intermediate variables of coping and emotional dysregulation.

Keywords: attachment security, childhood abuse, emotion dysregulation, coping, Black women

General Scientific Summary:

This study shows that the behavioral and psychological consequences of previous abusive experiences in a sample of Black emerging adult women may occur via their impact of abuse on emotion dysregulation and coping. Secure adult attachment may be a protective factor that attenuates the effects of prior abuse on emotion dysregulation and coping and their effects on behavioral and mental health problems.

Emerging adulthood (ages 18-25) is a critical period for the onset of longer-term mental and behavioral health issues. Rates of problematic substance use and high-risk sexual practices (Anda et al., 2006), as well as mental (Edwards et al., 2003) and physical health issues (Thompson et al., 2015) are elevated among young adults with a history of child abuse (physical, sexual, or emotional/psychological maltreatment occurring between ages 0-17; Centers for Disease Control and Prevention [CDC], 2020). In the United States (U.S.) more than three million cases of child abuse are reported each year (U.S. Department of Health & Human Services [HHS] et al., 2021). Girls experience higher rates of victimization than boys (CDC, 2014), and Black children experience elevated rates relative to children of other racial/ethnic groups (HHS et al., 2021).

Black girls are susceptible to a range of socioeconomic and structural risk factors for child abuse (e.g., low income, caregiver risk factors, inadequate services; Brown et al., 1998). Higher rates of exposure to risk factors, according to Concentrated Risk Theory, result from the systems of inequality and oppression that operate within marginalized contexts (Putnam-Hornstein et al., 2013). Black girls are not only more likely to be victims of child abuse; they also experience worse outcomes of child abuse (Widom et al., 2013), and encounter more barriers to accessing resources and services (Epstein et al., 2017).

As Black girls enter young adulthood, numerous conditions disproportionately affect them relative to women of other racial/ethnic identities. Black women are no more likely than White women to engage in sexual risk behaviors (e.g., unprotected sex; Pfleiger et al., 2013), consume alcohol or binge drink (Boyd et al., 2003), or use marijuana (Keyes et al., 2015). Yet, relative to White women, Black women experience higher incidence rates of HIV and other sexually transmitted infections (STIs; CDC, 2019), are more likely to meet criteria for an alcohol (Witbrodt et al., 2014) or a cannabis use disorder (Wu et al., 2016), and may be more likely to experience negative consequences of substance use (Mulia, Greenfield, & Zemore, 2009). Prevalence rates for mental health issues are equal or lower for Black relative to White women (Alvarez et al. 2019), but Black women encounter more barriers to mental heath care (Substance Abuse and Mental Health Services Administration [SAMHSA], 2015), leading to greater severity and persistence of mental health issues (Cook et al., 2017).

According to syndemics theory (Singer, 2009), co-risk for multiple health disparities in marginalized populations is due to overlapping risk factors that interact with one another and with unfavorable structural conditions to increase the odds of each adverse behavioral and mental health outcome. Syndemics are intersecting, interconnected epidemics. For instance, in the syndemic of substance use, violence, and AIDS (SAVA; Singer, 2000) as manifest among Black women—substance use problems and depressive symptoms each elevate HIV/STI risk (Jackson et al. 2015). Black women who have experienced interpersonal violence or abuse are at greater risk for substance use problems, engage in more risky sexual behaviors, and have more severe mental health issues. These behavioral health issues all increase the risk for further adverse life experiences (Nydegger et al., 2021). Due to disadvantageous structural and socioeconomic conditions, Black women’s risks are compounded by barriers to accessing adequate care for these conditions (Artiga et al., 2020). Because the epidemics of substance use, mental health, and sexual heath concerns are co-occuring and mutually related, they should be examined together. The current study seeks to examine this syndemic from a developmental perspective by studying the link between childhood abuse history (i.e., abuse that occurred before age 18) and individual-level behavioral and mental health problems (i.e., risky sexual behavior, substance use problems, and internalizing/externalizing symptoms) during emerging adulthood among a sample of urban Black women.

Child Abuse History and Behavioral and Mental Health Problems

The association between child abuse history and elevated internalizing symptoms (e.g., depression) during young adulthood has been well documented (van Vugt et al., 2014). Childhood abuse is associated with higher perceived stress levels during emerging adulthood (Heinze et al., 2017). Externalizing symptoms such as trait anger (the propensity to become angry), have also been linked to childhood abuse among women (Rholes et al., 2016). Caetano et al. (2003) reported an association between childhood abuse and more severe alcohol-related problems (legal, social, dependence) among adult Black women, and childhood abuse has also been linked to more severe problems (e.g., psychological, legal, occupational) related to marijuana use during emerging adulthood (Vilhena-Churchill & Goldstein, 2014). Emerging adult women with a childhood abuse history report elevated sexual risk-taking, including greater numbers of past year sexual partners (Littleton et al., 2014) and lower rates of condom use (Hall et al., 2008). In recent years, research on the consequences of childood abuse has shifted from examining what goes wrong to examining the mechanisms through which abuse results in its consequences. Researchers have also focused on identifying protective factors that prevent or attenuate the problematic outcomes of childhood abuse at later life stages.

Emotion Dysregulation and Coping

Separate studies have shown that the relationship between childhood abuse and elevated internalizing symptoms (i.e., anxiety, depression) during emerging adulthood is mediated by (a) emotion dysregulation (Heleniak et al., 2016) and (b) maladaptive coping (Roubinov & Luecken, 2013). Childhood abuse has been shown to predict sexual risk behavior (Messman-Moore et al., 2010) and marijuana problems (Vilhena-Churchill & Goldstein, 2014), with some studies providing supporting evidence that these effects operate through the potential mediators of either emotional dysregulation or coping. Findings from Ullman et al. (2014) and Vilhena-Churchill and Goldstein (2014) support the inclusion of both emotion dryregulation and coping as simultaneous mediators of the assocation between childhood abuse and behavioral and psychological health problems among Black emerging adult women. We propose that the inability to effectively regulate emotions and the inability to adaptively cope with the sources of distress each uniquely contributute to adverse behavioral and psychological outcomes of childhood abuse (see Squires et al., 2020).

Moderating Effect of Adult Attachment Security

Attachment broadly refers to internalized schemas of relationship dynamics. During emerging adulthood, young adults form adult attachment representations in the context of romantic/sexual partnerships based the foundation of their existing attachment representations (Roisman et al., 2005). Adult attachment is generally described as either secure or insecure. Alink et al. (2009) in a study of young children found that secure attachment may moderate the unfavorable effect of childhood abuse on emotion regulation and coping. However, it is unknown whether secure adult attachment might have a similar moderating effect on the associations between childhood abuse histories and emotion dysregulation and coping among emerging adults.

Study Aims

Emerging adulthood is a unique developmental phase in which the effects of childhood abuse may translate into enduring behavioral and psychological issues. During this period, individuals develop mental models of adult attachment; friends and romantic partners supplant parents and guardians/caregivers as primary attachment figures. Therefore, emerging adulthood presents an opportunity for the potential negative sequelae of childhood abuse to be mitigated by secure adult attachment.

The aims of the present study were: 1) to examine emotion dysregulation and coping as mechanisms by which childhood abuse history contributes to behavioral and psychological health problems among Black emerging adult women; and 2) to determine the extent to which secure attachment moderates the effects of childhood abuse history on emotion dysregulation and coping in moderated mediation models of the following dependent variables: (a) alcohol-related negative consequences; (b) marijuana-related negative consequences; (c) proportion condom use; (d) condom use at most recent vaginal sex; (e) depression; (f) trait anger; and (g) perceived stress.

Method

Participants & Procedure

Participants were recruited (January 2012-February 2014) via community outreach in a large Southeastern U.S. city. Participants were screened for eligibility to enroll in a randomized HIV-risk reduction intervention trial and provided written informed consent prior to baseline assessment (N = 560; Mage = 20.58, SD = 1.89 for the full randomized sample). The sample included cisgender Black women, ages 18-24, who met the following inclusion criteria: neither married nor pregnant, consumed alcohol on at least 3 separate occasions within the past 90 days, and had unprotected vaginal sex with a male within the past 90 days. To create distinct childhood abuse and non-abuse groups, the subsample used in the present analyses was restricted to women in the baseline measurement sample of the randomized trial who either (a) reported some form of abuse prior to age 18 (N = 159) or (b) reported no abuse had occurred during their lifetime (N = 281).1 The Emory University Institutional Review Board approved all study procedures (Study Name: Reducing Alcohol-Related HIV Risk in African American Females (N-Liten); Protocol Number: IRB00048502). Only the baseline assessment data collected via audio computer-assisted self-interview (ACASI) prior to randomization were included in the current study. For baseline assessment participation rate and study incentives, see DiClemente et al. (2021).

Measures

Sociodemographics

Sociodemographic measures were collected on all participants (see supplement).

Abuse History

Participants responded (yes/no) to the following questions: (a) Have you ever been emotionally abused? (threatened, called names, etc.); (b) Have you ever been physically abused? (hit, punched, kicked, slapped, etc.); (c) Has anyone ever forced you to have vaginal sex when you didn't want to?; and (d) Has anyone ever forced you to have anal sex when you didn't want to?. A second set of questions asked the age(s) at which the abuse had occurred. We identified a childhood abuse group (N = 159) who reported experiencing some form of abuse prior to age 18, but who did not report current abuse.2 We also identified a non-abuse comparison group (N = 281) who reported never experiencing any form of abuse. Given that multiple forms of abuse often co-occur (Berzenski & Yates, 2011), and based on previous research which has demonstrated similar findings for the effects of different types of abuse on condom use (Brown et al., 2014), symptoms of depression, and substance use (Cohen et al., 2017) among emerging adults, abuse history = 1 represented any form of prior abuse and abuse history = 0 represented no prior abuse.3

Adult Attachment Security

Participants rated the following description of secure attachment (on a four-point scale from 1 = Not at all like me to 4 = Very much like me), which was adapted from the Relationship Questionnaire (RQ; Bartholomew & Horowitz, 1991): “It is easy for me to be close to people. I feel okay asking people for help and know that they will usually help me; when people ask me for help they can count on me, I do not worry about being alone and do not worry about others not liking me.” Higher scores indicate a more secure adult attachment style. Bartholomew and Horwitz provide evidence of the validity of this item.

Emotion Dysregulation

The 18-item Emotion Dysregulation subscale of the Shedler-Westen Assessment Procedure (SWAP-200; Shedler & Westen, 2004) was used to measure emotion dysregulation. An example item is “Sometimes when I'm upset, the world feels strange, unfamiliar, or unreal.” Participants responded to each item on a five-point scale (from 1 = Not true to 5 = Very true). Higher sum scores indicate more severe emotion dysregulation. Subscale reliability (coefficient α = .95 in the present sample; test re-test reliability r = .87, Blagov et al. 2012) is good; validity is indicated by significant correlations with borderline (r = .48) and histrionic (r = .51) personality disorders.

Coping

Participants completed an abbreviated subset of 10 items from the Coping Orientation to Problems Experienced (COPE) Inventory (Carver et al., 1989), which included three items from the Active Coping subscale, three items from the Denial subscale, and four items from the Behavioral Disengagement subscale. Participants rated each item a four-point scale (from 1 = I usually don’t do this at all to 4 = I usually do this a lot). Ratings for the Denial and Behavioral Disengagement Scale were reverse coded, and summed with ratings of the Active Coping items for a composite score. Higher scores indicated more adaptive coping and less maladaptive coping. Carver et al. (1989) reported coefficient α = .62, .71, and .63 for the Active Coping, Denial, and Behavioral Disengagement subscales, respectively. Carver et al. provided evidence of convergent and discriminant validity for each subscale. Coefficient α for the composite scale was .77 in the present sample.

Negative Consequences of Substance Use

Problems Related to Alcohol Use.

The Rutgers Alcohol Problem Index (RAPI; White & Labouvie, 1989) was used to assess negative consequences of alcohol use on daily functioning, as well as tolereance, withdrawal, and whether others think the respondent has a problem with alcohol.4 The 23 RAPI items assessed how often within the last year participants experienced various consequences as a result of alcohol use. An example item is “Neglected your responsibilities”. RAPI items were rated on a four-point scale (from 0 = Never to 3 = More than 6 times), which combined the “3 = 6-10 times” and “ 4 = more than 10 times” response options included in the standard RAPI rating scale. Higher RAPI sum scores indicated experiencing more negative consequences of alcohol use. Evidence for the reliability (coefficient α = ..92) and validity of the RAPI is presented in Shono et al. (2018). Coefficient α = .96 for the RAPI.

Problems Related to Marijuana Use.

Adapted from the RAPI, the Marjuana Problem Index (MPI) assesses negative consequences of marijuana use during the past year. Twenty-three MPI items were identical to the RAPI, but with “marijuana” replacing “alcohol,” “smoking” replacing “drinking,” and “high” replacing “drunk.” Six additional items assessed other problems associated with marijuana use, for example, “noticed that your memory was not as good as it used to be.” All MPI items were rated on a four-point scale (from 0 = Never to 4 = More than 6 times). Higher sum scores on the MPI indicated more negative consequences of marijuana use. Coefficient α = .96 and MPI scores significantly correlated with frequency of marijuana use, r = .44, p < .001, in the present sample

Risky Sexual Behaviors

Proportion Condom Use.

Proportion condom use for vaginal sex (past 3 months) was calculated as the number of self-reported times a condom was used during vaginal sex divided by the number of self-reported vaginal sex episodes in the past 3 months.

Condom Use at Most Recent Vaginal Sex.

Participants reported (yes/no) whether or not they had used a condom the very last time they had vaginal sex.

Psychological Functioning

Trait Anger.

Participants completed the 15-item Trait Anger subscale (T-Anger) items of the State-Trait Anger Scale (STAS; Spielberger et al., 1983). Each item (e.g., “I have a fiery temper”) was rated on a four-point scale from 1 = Almost never to 4 = Almost always. Higher sum scores indicated higher levels of trait anger. Spielburger et al. (2009) provide evidence for the reliability (α = .87) and validity of the T-Anger subscale (e.g., significant correlations with hostility). Coefficient α = .94 in present sample.

Depression.

The 8-item Center for Epidemiologic Studies—Depression Scale (CES–D; Santor & Coyne, 1997) was used to determine how often participants experienced various clinical indiators of depression (e.g., “ I thought my life had been a failure”) within the past week. Each item was rated on a four-point scale (from 1 = Less than 1 day to 4 = 5-7 days). Higher sum scores indicated more frequent depressive symptoms during the past week. Santor and Coyne (1997) present evidence for the reliability and validity of the CES-D; Makambi et al. (2009) reported coefficient α = .89 in a sample of Black women. Coefficient α = .91 in present sample.

Perceived Stress.

Participants completed an abbreviated version of the African-American Womens Stress Scale (AWSS; Watts-Jones, 1990). The 13 items assess common sources of stress among Black women (e.g., racial discrimination, personal health, financial troubles). Participants responded to each item on a six-point rating scale (from 0 = Does not apply to 5 = Extreme stress) to indicate how stressful they found the stressor to be. They completed an item in which they reported their overall stress level on a five-point scale from 1 = No stress to 5 = Extreme Stress. Higher sum scores indicated greater overall levels of perceived stress. Coefficient α = .92 in present sample.

Data Analyses

Figure 1 portrays the path diagram representing our hypothesized model. We used procedures suggested by MacKinnon (in press) to estimate a moderated-mediation model with two intermediate (putative mediator) variables. We performed an initial check of whether secure attachment moderated the effect of abuse on coping and emotional dysregulation using multiple regression (Aiken & West, 1991). We then used structural equation modeling (SEM) to estimate the hypothesized path model for each of the eight dependent variables using Mplus 8.6 (Muthén & Muthén, 1998-2021). We estimated both (a) the average indirect effect for the mediational model and (b) the conditional indirect effects at high (very much secure = 4) and low (not at all secure = 1) levels of secure attachment, together with their 95% confidence intervals. 95% confidence intervals were constructed using percentile bootstrapping for all dependent variables except the binary variable (condom use at last vaginal sex). Unstandardized path coefficients with bootstrap standard errors are reported given the interest in the effect of the binary predictor, childhood abuse history, and in its indirect effect on these dependent variables. For the binary dependent variable of condom use at last vaginal sex, the 95% confidence interval was calculated using Sobel’s (1982) method. The path coefficients in the logistic regression model for the binary dependent variable are on the log-odds scale.

Figure 1. Hypothesized Moderated Mediation Model.

Figure 1

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Note. For each moderated mediation model, age and highest education were included as covariates for coping, emotion dysregulation, and the dependent variables, but are omitted from the figure to enhance clarity.

All study variables had complete data (N = 440), except for proportion condom use (n = 431), MPI total score (n = 332), and education level (n = 436). We used full information maximum likelihood estimation to address missing data (Enders, 2010), permitting the full subsample to be included in the analyses. We utilized robust adjustment of the maximum likelihood estimator (MLR) to adjust the standard errors of path coefficients for non-normality (Muthén & Muthén, 1998-2021). The two predictors, childhood abuse history and adult attachment security, and the two covariates, age and highest education, and the residuals of the two intermediate variables, coping and emotion dysregulation, were allowed to correlate (not depicted in Figure 1).

Transperancy and Openness

This study was not preregistered. The codebook, dataset, and analysis code for this study have been made available; see (https://osf.io/xbtyj/). Please note that bootstrapping produces small differences in the standard errors and the p-values of the results depending on the seed that is used for the random number generator.

Results

Characteristics of Key Study Variables: Means, Standard Deviations, and Correlations

A full sociodemographic description of the current subsample ( N = 440), as well as detailed descriptive statistics on childhood abuse history is provided in Table S1 in the supplemental materials. Table 1 presents the means, standard deviations, and correlations of all key study variables based on full information maximum likelihood estimation. Pearson correlations provided an initial look at the linear relationships between abuse history, attachment security, and the intermediate and dependent variables.

Table 1.

Correlations, Means, and Standard Deviations of Study Variables

1 2 3 4 5 6 7 8 9 10 11
1. Childhood Abuse History --
2. Adult Attachment Security 0.018 -
3. Coping −0.148 ** 0.048 -
4. Emotion Dysregulation 0.403 *** 0.003 −0.393 *** -
5. T-Anger 0.352 *** −0.012 −0.356 *** 0.572 *** -
6. CES-D 0.364 *** −0.06 −0.369 *** 0.426 *** 0.399 *** -
7. Proportion Condom Use −0.034 −0.043 −0.098 † 0.055 −0.06 0.029 -
8. Condom Use Last Encounter −0.109 * −0.088 † −0.123 ** 0.015 0.006 −0.015 0.508 *** -
9. RAPI 0.295 *** −0.037 −0.302 *** 0.293 *** 0.423 *** 0.358 *** −0.052 −0.081 † -
10. MPI 0.293 *** 0.014 −0.263 *** 0.323 *** 0.358 *** 0.303 *** 0.012 −0.009 0.725 *** -
11. AWSS 0.396 *** 0.082 † −0.228 *** 0.383 *** 0.288 *** 0.451 *** −0.023 −0.074 0.217 *** 0.220 *** --
Mean 281 (n) 2.809 29.839 40.827 29.825 13.066 0.335 155 (n) 12.82 18.437 36.759
SD 36.1 (%) 1.164 4.524 17.738 10.801 5.819 0.307 35.2 (%) 14.609 18.63 15.552
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Note. Values shown are Full Information Maximum Likelihood estimates based on the full sample (N = 440) correcting for missing data on proportion condom use and MPI. Childhood abuse history and condom use at last encounter are both binary variables. T-Anger = Trait Anger subscale of the State-Trait Anger Scale; CES-D = Center for Epidemiologic Studies—Depression Scale; RAPI = Rutgers Alcohol Problem Index score; MPI = Marijuana Problem Index; AWSS = abbreviated version of the African-American Womens Stress Scale.

***

p < .001

**

p < .01

*

p < .05

†

p < .10

Check on Moderator Effects

Underlying our moderated mediation model is a hypothesized interaction in which adult attachment security would mitigate the negative effects of childhood abuse history on coping and emotion dysregulation. Following Aiken and West (1991), we coded the binary variable childhood abuse history (1 = yes; 0 = no), centered adult attachment security, and reported unstandardized regression coefficients (bs). Adult attachment security interacted with childhood abuse history to predict both coping (for interaction, b = 0.805, z = 1.979, p = .048) and emotion dysregulation (for interaction, b = −3.501, z = −2.304, p = .021). Figure 2 depicts these two interaction effects, supporting the hypothesized moderation of the effects of childhood abuse history by adult attachment security.

Figure 2. Moderator Analysis.

Figure 2

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Note. Childhood abuse history predicting (a) coping and (b) emotion dysregulation at low (= 1) and high (= 4) levels of adult attachment security. High attachment (= 4) in blue; low attachment (= 1) in red. The chilhood abuse history × adult attachment security interaction was significant for both coping and emotional dysregulation. Error bars represent +/− 1 standard error for the estimated mean. Original scales: coping (10 to 40); emotion dysregulation (18 to 90).

***p < .001.

Tests of Moderated Mediation Model

The hypothesized moderated mediation model depicted in Figure 1 was tested separately for each of the seven dependent variables. We inspected standardized residuals and did not detect appreciable misfit in any part of the models; χ2 (2, N = 440) values ranged from 0.23 to 3.38, all ps > .05 (McDonald & Ho, 2002; West et al. in press). Table 2 reports the direct effect of childhood abuse history on each dependent variable and the average indirect (putative mediated) effect for the moderated mediation model, together with their 95% confidence intervals. Confidence intervals that do not include 0 indicate a statistically significant effect. Of central interest, the average indirect effect through the intermediate variable, coping, was statistically significant for four dependent variables (T-Anger, CES-D, RAPI, MPI).The average indirect effect through the intermediate (mediator) variable, emotional dysregulation, was statistically significant for four of the dependent variables (T-Anger, CES-D, MPI, AWSS). Neither average indirect effect was significant for proportion condom use or (binary) condom use at last encounter.

Table 2.

Results of Moderated Mediation Analysis: Average Indirect Effect and Conditional Indirect Effects at Low and High Values of Secure Attachment

Outcome Variable
T-Anger CES-D Proportion
Condom Use		 Condom Use at Last
Encounter		 RAPI MPI AWSS
Direct effect of childhood abuse history 3.291*
[1.420, 5.245]		 2.881*
[1.801, 3.922]		 −0.047
[−0.113, 0.021]		 −0.658*
[−1.149, −0.167]		 6.613*
[3.651, 9.718]		 7.266*
[3.312, 11.590]		 9.457*
[6.383, 12.472]
Indirect effect of childhood abuse history
Putative Mediator Attachment Security (Putative Moderator)
Coping Low (Not at all secure) 1.004*
[0.304, 1.962]		 0.872*
[0.336, 1.587]		 0.019
[−0.001, 0.048]		 0.191*
[0.009, 0.373]		 1.962*
[0.764, 3.483]		 1.918*
[0.410, 3.710]		 0.974
[−0.065, 2.325]
Average 0.475*
[0.097, 1.018]		 0.413*
[0.104, 0.830]		 0.009
[−0.001, 0.023]		 0.090
[−0.003, 0.183]		 0.929*
[0.235, 1.853]		 0.908*
[0.141, 1.892]		 0.461
[−0.040, 1.103]
High (Very much secure) 0.163
[−0.343, 0.777]		 0.141
[−0.302, 0.647]		 0.003
[−0.008, 0.016]		 0.031
[−0.067, 0.129]		 0.318
[−0.642, 1.476]		 0.311
[−0.733, 1.437]		 0.158
[−0.398, 0.798]
Emotion Dysregulation Low (Not at all secure) 5.518*
[3.404, 7.828]		 1.599*
[0.725, 2.554]		 0.022
[−0.018, 0.068]		 0.011
[−0.260, 0.282]		 1.746
[−0.097, 3.680]		 3.027*
[0.486, 6.034]		 4.382*
[1.982, 7.118]
Average 3.790*
[2.545, 5.188]		 1.098*
[0.491, 1.744]		 0.015
[−0.013, 0.045]		 0.008
[−0.178, 0.193]		 1.199
[−0.070, 2.499]		 2.079*
[0.377, 4.009]		 3.009*
[1.369, 4.872]
High (Very much secure) 2.769*
[1.430, 4.250]		 0.802*
[0.302, 1.438]		 0.011
[−0.009, 0.033]		 0.006
[−0.130, 0.141]		 0.877
[−0.050, 2.031]		 1.519*
[0.270, 3.128]		 2.198*
[0.822, 4.099]
R2 for Average Effect Models
Coping Emotion Dysregulation T-Anger CES-D Proportion
Condom Use		 Condom Use at Last
Encounter		 RAPI MPI AWSS
0.07 0.21 0.38 0.28 0.02 0.06 0.18 0.17 0.23
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Note. Values shown are unstandardized regression coefficients with 95% confidence intervals in brackets, estimated via bootstrapping. For the binary dependent variable condom use at last encounter, bootstrapping is not available in Mplus when estimating using the logit link function. For this binary variable, Sobel (1982) standard errors were used to construct asymptotic confidence intervals. All regression equations control for participant age and highest educational level. T-Anger = Trait Anger subscale of the State-Trait Anger Scale; CES-D = Center for Epidemiologic Studies—Depression Scale; RAPI = Rutgers Alcohol Problem Index score; MPI = Marijuana Problem Index; AWSS = abbreviated version of the African-American Womens Stress Scale. Total N = 440 Reported any form of Abuse before age 18 [N = 159] vs. reported no abuse during lifetime [N = 281].

*

p < .05.

Following Liu, et al. (2017), Table 2 also reports conditional indirect effects through each intermediate variable corresponding to low (1 = not at all secure) and high (4 = very much secure) values on the attachment security scale, together with their 95% confidence intervals. For the low value on the scale, the conditional indirect effects through the intermediate variable, coping, were statistically significant for all dependent variables except proportion condom use and AWSS. For the high value on the scale, none of the conditional indirect effects achieved statistical significance.

With respect to the conditional indirect effects through the intermediate variable, emotional dysregulation, at both the low and high values on the attachment security scale, conditional indirect effects were statistically significant for T-Anger, CES-D, MPI, and AWSS. The magnitude of the conditional indirect effects was substantially decreased at the high relative to the low level of attachment security. The conditional indirect effects through the intermediate variable of emotion dysregulation did not reach statistical significance at any level of attachment security for proportion condom use, condom use at last encounter, or RAPI. Note that the indirect effects reported are unique indirect effects, over and above the indirect effect through the other intermediate variable.5

Discussion

Results of the current study underscore the relationship between childhood abuse and multiple behavioral and mental health problems that may occur among emerging adult Black women, as would be expected from syndemics theory. Although prior research examined the relationship between behavioral and mental health problems and abuse, fewer studies have focused on either the mechanisms underlying this relationship or on resilience to these potential problems. Emerging adult women with histories of childhood abuse are more likely to experience dysregulated affectivity (Teicher et al., 2015) and less likely to utilize adaptive coping responses (Perlman et al., 2016). Our results supported our hypothesis that adult attachment security would attenuate the negative effects of childhood abuse history on coping and emotion dysregulation.

Reduced adaptive coping skills mediated the effect of history of childhood abuse on behavioral and mental health problems, but the mediated effect depended on attachment security. Women with a history of childhood abuse endorsed more depressive symptoms, trait anger, and negative consequences of alcohol and marijuana use via the effect of childhood abuse on reduced adaptive coping skills if respondents also reported low or average, but not high, attachment security. In terms of the likelihood of engaging in protective sexual behaviors, for women with a history of childhood abuse who reported low attachment security, the use of less adaptive coping skills was associated with a lower likelihood of having used a condom at their most recent vaginal sexual encounter with a male partner, whereas the use of less adaptive coping skills was not associated with the likihood of condom use among women who reported average or high adult attachment security. Overall, our results indicated that as adult attachment became increasingly secure, the adverse impact of childhood abuse on mental and behavioral health and substance use problems through the use of less adaptive coping skills diminished, suggesting that the adverse effects of childhood abuse were strongly mitigated by a high level of adult attachment security. Based on these findings, secure adult attachment may serve as a protective factor by buffering the negative effects of childhood abuse on mental and behvaioral health, through attenuating the association between childhood abuse and the use of less adaptive coping skills. Attachment may be relevant to coping in that stressful situations activate the attachment system, which organizes behavior toward seeking closeness to supportive attachment figures (Howard & Medway, 2004), or perhaps by the activation of internalized mental models of attachment figures. When adult attachment is secure this may translate into adaptive coping, versus when adult attachment is less secure, which may motivate less adaptive coping (e.g., avoidance, isolation).

The mitigation of the effect of childhood abuse on mental and behavioral health outcomes through emotion dysregulation was far weaker. Regardless of level of attachment security (low, average, or high), among women with a history of childhood abuse, emotion dysregulation was associated with higher levels of trait anger, depressive symptoms, marijuana use problems, and perceived stress. Relative to women who endorsed being “not at all secure” (i.e., low attachment security), those who endorsed high attachment security (“very much secure” based on the description of secure attachment provided) demonstrated weaker associations (~ 50% reduction) between childhood abuse and these measures of mental health and substance use problems through emotion dysregulation. This weaker effect may result from the fact that levels of emotion dyregulation may not necessarily vary in the same way that coping skills do across levels of attachment security among women with a history of childhood abuse. A recent study (Gardner, Zimmer-Gembeck, & Campbell, 2020) identified profiles based on both adult attachment and emotion regulation among emerging adults; suggesting that individuals can be either regulated or dysregulated at both high and low levels of attachment security. They showed that these profiles were associated with coping responses and mental health issues, which aligns with our assertion that perhaps what is more important when considering mental and behavioral health problems is how emotional states or stressors are coped with, rather than the emotional state of dysregulation itself.

Contrary to our hypotheses, there was little evidence of an indirect effect of childhood abuse on proportion condom use or condom use at last encounter through either coping or emotion dysregulation across levels of attachment security. It is possible that insufficient variation in condom use in this sample, potentially due to relationship status, may have interfered with detecting any relationships. The majority (86%) of the sample reported having a boyfriend/main partner (68% of whom did not use a condom the most recent time they had vaginal sex), and the average relationship length among those currently in a relationship was approximately 2 years. Low levels of condom use have been found among Black women with steady sexual partners (Kanu et al., 2009); non-condom use within steady relationships may symbolize trust and commitment, and heterosexual couples may prefer contraceptive methods that more reliably prevent pregnancy, but which do not afford protection from HIV/STI (Wildsmith, Manlove, & Steward-Streng, 2015).

Clinical Implications

From public health and syndemics theory perspectives, given the high prevalence of childhood abuse and its impact on numerous behavioral and mental health problems in this Black community population, health promotion programs for emerging adult women in communities or clinics should include training in emotion regulation and coping skills. Addressing emotion regulation and coping skills during the critical developmental period of emerging adulthood may be of practical utility in reducing behavioral and mental health problems among women who have experienced childhood abuse.

Findings also suggest that strengthening security of attachment may be a meaningful prevention or intervention target in addressing a range of problems focused on substance use, sexual health, and psychological wellbeing in emerging adult women. According to the broaden and build cycle of attachment security (Fridrickson, 2001), insecurely attached individuals can be prompted to behave securely temporarily via situational priming (e.g., Cassidy et al., 2009) and more consistently via psychotherapy or transformative satisfying close relationships (Mikulincer & Shaver, 2007). Experts in the treatment of PTSD for adult women who are childhood abuse survivors have demonstrated that efficacious treatment includes: (1) identifying maladaptive interpersonal schemas that developed in abusive contexts and interfere with emotional and interpersonal functioning; and (2) establishing more flexible and adaptive (i.e., secure) interpersonal schemas (Karakurt & Silver, 2014). According to this approach, not only can abused women with insecure attachment develop attachment security, but this process is a mechanism for reducing the effects of abuse by facilitating the development of constructive emotion regulation and coping skills associated with secure attachment (Mikulincer et al., 2003).

Strengths and Limitations

Among the strengths of this study are its large cohort of Black urban young adult women, a group which disproportionately experiences mental and behavioral health disparities. The full baseline cohort was sampled to reflect an at-risk population that had consumed alcohol and had unprotected sex on multiple occasions during the past 90 days. We limited our analyses to those women who experienced abuse during childhood or adolescence versus those who had no lifetime history of abuse to clearly establish that abuse occurred prior to the assessment of the other measured variables. The data were collected with an audio computer-assisted self-interview procedure, maximizing data quality and reliability. Limitations include our reliance on self report measures for each of the variables. Our global measure of abuse only permitted the examination of the timing of abuse, but precluded examination of the impact of other abuse characteristics such as chronicity and type of perpetrator. The abuse measure also required participants to recall childhood experiences of abuse and to recognize those experiences as abusive. Given the high degree of overlap of types of abuse, an extremely large sample size would be needed to provide sufficient statistical power to examine the unique effect of each type of abuse and their combinations on the dependent variables. We were unable to include clinical diagnostic measures and we did not include an assessment of PTSD symptoms. We also did not include a variable to capture experiences of racism, which could potentially account for variability in the intermediate as well as dependent variables. The measurement of the moderator, intermediate, and dependent variables were cross-sectional, thus weakening causal interpretations of the statistical mediational effects: Abuse history was the only variable that clearly preceded the other variables in the model. The data examined in the current study are the baseline data for an HIV preventive intervention trial (DiClemente et al., 2021) that enrolled young Black female urban participants who drink alcohol and have unprotected sex so that findings may not generalize to other populations at lower health risk.

Conclusions

High rates of childhood abuse among this population signal a need for screening for abuse and targeted interventions to address the various adverse effects of abuse. Potential constructs to address in interventions targeting substance use, sexual health and psychological wellbeing among young Black women include attachment security, coping skills, and emotion regulation strategies. Efficacious interventions may have long-term impacts on the developmental trajectories of young women who have experienced abuse, for both behavioral (e.g., substance use, risky sexual behavior) and psychological (e.g., depression) problems.

Supplementary Material

Supplemental Material

Acknowledgments

This research was supported by R01AA018096 from the National Institute on Alcohol Abuse and Alcoholism to Ralph J. DiClemente. Jessica M. Sales was partially supported by P30DA027827 from the National Institute on Drug Abuse to Gene Body and P30AI050409 from the Emory Center for AIDS Research to Carlos Del Rio. Stephen G. West was partially supported by R37DA09757 from the National Institue on Drug Abuse to David P. MacKinnon. These findings were presented as a poster at the 2020 American Psychological Association Annual Convention. We have no conflicts of interest to disclose. This study was not preregistered. The codebook, dataset, and analysis code for this study have been made available; see (https://osf.io/xbtyj/). Please note that bootstrapping produces small differences in the standard errors and the p-values of the results depending on the seed that is used for the random number generator.

Footnotes

1

120 women were excluded from the current sample because they endorsed some form of abuse occurring at or after age 18, making the temporal precedence of constructs less clear. Findings were similar to those reported in the present manuscript when these 120 women were included in the analysis.

2

39 additional women reported abuse both prior to and after age 18, which in some cases was continuing. These women were not included in the analyses so that abuse occurred prior to measurement of other study variables.

3

In the present subsample the correlations between childhood emotional, physical, and sexual abuse ranged from .47 to .61 (ps< .001), with 66% of those reporing any childhood abuse (N = 159) reporting multiple forms of childhood abuse. The 95% confidence intervals for the correlation of the report of each form of abuse with emotional dysregulation and with coping also showed substantial overlap.

4

We also collected data on the Alcohol Use Disorders Identificiation Test (AUDIT). Since this measure is highly correlated with the RAPI (r = .85 in the present sample) and showed similar results to the RAPI, we have only included results pertaining to the RAPI, as it more closely parallels the MPI.

5

Confusion can arise in the interpretation of the indirect (mediated) effects which represent the product of the constituent paths. There is a negative relation between abuse and adaptive coping and a negative relation between adaptive coping and mental health and substance use problems, resulting in a positive indirect effect. There is a positive relation between abuse and emotional dysfunction and a positive relation between emotional dysfunction and mental health and substance use problems, resulting in a positive indirect effect.

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