INTRODUCTION
Depression was the leading cause of disability worldwide. Existing research showed that depression originated in adolescence [1]. Lifetime prevalence of depression among adolescents (13-18 years old) was reported to be almost 11% [2,3]. Depression was more pervasive in adolescents as the sub-clinical stage of depressive disorder. A report from 2018 showed that more than 20% of adolescents in China aged 10-15 years old suffered from depression [4]. Therefore, studying depression was especially necessary to explore the pathogenesis, prevention, and intervention of depression among early adolescents.
Childhood maltreatment was a critical risk factor for depression [5,6]. Previous studies had shown that childhood maltreatment throughout childhood could lead to increase risk of developing depression [7,8]. Moreover, types of childhood maltreatment were identified to have different impact on depression. A recent systematic review found that 26.6% of Chinese children had suffered physical abuse, 19.6% had experienced emotional abuse, 26.0% had experienced emotional neglect and 8.7% had suffered sexual abuse [9]. Emotional abuse consisted of behaviors towards children such as rejection, isolation, terrorization, ignorance, corruption, verbal assault, and over-pressuring behavior [10]. Emotional neglect implied a failure of the parents or caregivers to provide a child with the emotional and psychological nurturing that was required for normal development [11]. There had been relatively less research attention on emotional abuse and neglect (EAN), compared with physical or sexual abuse and physical neglect [12]. In addition, among the four sub-types of childhood maltreatment, the influences of EAN in childhood were becoming stronger and increased the risk of depression with age [13]. However, only a limited number of researches investigated the effects of EAN, and less was known about the continued effects of EAN during adolescence. Furthermore, there were various mediating variables (cognitive, emotional, and relational factors) [14] in the relationships between EAN and depression and need to explore potential mechanisms underlying these relationships.
This study used attachment theory [15] as theoretical frameworks for understanding the developmental psychopathology associated with EAN [16]. Attachment theory proposed that individual characteristics were more likely to develop within the context of a secure parent-child attachment [17]. Specifically, experiences of parental sensitivity were encoded by children into an internal working model encompassing views of the self, others, and the nature of relationships that influenced developmental adaptation [18]. EAN likely interfered with the development of a secure attachment bond, and the consequent insecure attachment patterns could help to explain the associations between EAN and mental health. EAN destroyed a child’s sense of self and personal security [19], which was hypothesized to provide the foundation for later individual differences in personality development. Thus, attachment theory claimed that early attachment security could influence individual characteristics (e.g., temperament) and predicted more optimal socioemotional outcomes.
Neuroticism, one of the major temperamental basic personality traits, implied negative affectivity or negative emotionality [20]. The empirical evidence regarding EAN increased the risk of developing maladaptive personality traits had been documented in previous research [21]. Research had shown that EAN was consistently associated with high neuroticism [22]. Neuroticism was significantly correlated with higher levels in depression and appeared to be the most powerful predictor of depression [23]. These studies above consistently revealed that the neuroticism could be a mediating factor between EAN and depression.
But not all individuals who experienced unpleasant events in childhood would become troubled adolescents. Some protective factors may have worked in helping prevent EAN from developing into depression. Resilience as the protective factors played an important role in those relationships. Resilience was an interactive concept that referred to a relative resistance to environmental risk experiences or the overcoming of stress or adversity [24]. Based on “kindling” hypothesis [25] and sensitizing effect [26] of resilience, EAN set up a heightened sensitivity to adversities or negative events in the future, such that minor events may evoke a depressive response [27]. However, not all EAN led to depression. “Steeling” effect [24] and stress inoculation theory [28] hold that an individual’s psychological and physiological ability would be strengthened when they were exposed to moderate levels of stress. Certain individual and contextual factors may ameliorate the relationships between risk factors and mental health status of adolescents [29,30]. Given previous research, perhaps resilience played a crucial role in the relationships between personality traits and depression. However, considering that neuroticism was the risk factor for depression, psychological resilience may be the protective factor for depression. Combined with the theory of the buffering effect of psychological resilience [31], this study hypothesized that psychological resilience could play a moderating role between neuroticism and depression, more specifically, psychological resilience could reduce the risks of depression among highly neurotic individuals. Currently, few studies had explored these relationships in adolescents, and the effects of personality traits and psychological resilience on depression onset were unclear. Thus, this study would provide a new perspective on prevention and intervention of adolescent depression (The hypotheses and effects were explained in detail in the Supplementary Material).
To sum up, based on the relationships between EAN and depression, this study hypothesized a moderated mediation model (Figure 1). We aimed to provide insights on how (the mediation role of neuroticism), and under what conditions (the moderator role of psychological resilience), leads to a higher level of depression.
METHODS
Participants
This study was a cross-sectional study that used a random cluster sampling method. We randomly selected four junior middle schools from four different districts in northern city of China in June, 2021. These districts covered various education and socioeconomic developmental levels. Each district was selected one junior middle school. Then the method of cluster sampling was used to invite all of the students of the junior high schools grading 7, 8, and 9 in each junior middle school. In total, 4,166 adolescents responded to the survey, yielding a participation rate of 96.9%. For the present study, adolescents with missing information on the variables assessing EAN, neuroticism, psychological resilience, and depression were removed from the sample (168 adolescents). To ensure the quality of data, adolescents also were removed if they reported that they were older when the event happened than their actual age at the time of the survey (5 adolescents). The final sample size for the present study was 3,993.
Procedure
The study was approved by the School of Public Health Institutional Review Board of the Jilin University and was conducted in accordance with the protocol of the Declaration of Helsinki (ethical approval number: 2021-06-06). One week prior to the survey assessment, school, parents, and students were informed regarding the topic and purpose of the research, and emphasized that students were voluntary and anonymous, and given the right to withdraw from the survey at any point, even after it had started. All participants received information regarding accessing mental health support if they experienced any emotional distress during or after the study. After giving a briefing about study purpose and procedures to each junior high school, consents were obtained from guardians of students. Before the formal survey, the researchers conducted a pre-survey to ensure level of understanding of the participants. The questionnaires were administered in paper-and-pencil format. Participating adolescents took about 30 minutes to complete a series of self-reported questionnaires during their mental health class. To encourage honest responses, all students participated in the study voluntarily, with anonymity and they were informed that their personal information would be strictly confidential.
Measures
EAN was assessed by the Childhood Trauma Questionnaire (CTQ) [32], which was divided into five sub-scales: emotional neglect, emotional abuse, physical neglect, physical abuse, and sexual abuse. The CTQ was 28-item retrospective measure of different types of abuse and neglect for individuals aged 12 or older. Each item was answered with one of five responses (never, rarely, sometimes, often, and very often). Higher scores mean a stronger degree of childhood maltreatment. This study used sub-scales (emotional neglect and emotional abuse) of CTQ, a version adapted to the Chinese cultural context [33], to evaluate the degree of EAN of participants. The Chinese version had been proven to have both high reliability and validity in the Chinese population [34]. In this study, the Cronbach’s alpha of the scale was 0.815 and construct validity was acceptable.
Depression was assessed using the Children Depression Inventory-Short Form (CDI-SF) [35] which was a commonly used to assess the severity of depression between 7 and 17 years old in adolescents. This sale was widely used to investigate the mental health of Chinese adolescents [36]. This self-report scale consisted of 10 items. Each item was presented as a series of three phrases, and respondents were asked to select the phrase that best represents how their feeling. Higher scores indicated more severe depression. The total score ranged from 10 to 30. Depression was defined as a score greater than or equal to 17 [37]. In this study, the Cronbach’s alpha of the scale was 0.808 and construct validity was acceptable.
Neuroticism was measured by using the sub-scales of Chinese Big Five Personality Inventory Brief Version (CBF-PIB) [38]. The CBF-PI-B was developed to assess personality traits of the Chinese population and had been shown to have good psychometric properties for Chinese adolescents [39]. The subscales with neuroticism had eight items and each item was answered on a six-point. High scores indicated higher levels of the neuroticism. In this study, the Cronbach’s alpha of the scale was 0.815 and construct validity was acceptable.
Adolescent psychological resilience was measured by the 27-item resilience scale for Chinese adolescents [40]. Participants rated each statement on a 5-point scale ranging from 1=completely disagree to 5=completely agree. Adequate test-retest reliability and construct validity had been reported for this measure [41]. In this study, the Cronbach’s alpha of the scale was 0.864 and construct validity was acceptable.
Self-assessment of family economic status was measured by an item. The item was “What do you perceive as your family economic status?” The degree of family economic status was assessed using a three-point scale (1=good, 2=fair, 3=poor). Although there was only one item, it was widely used to measure family economic status [42].
Statistical analyses
The analyses were performed using IBM SPSS 24.0 software (IBM Corp.). The differences of the score of depression, EAN, and neuroticism in different demographic characteristics were examined by t-test and one-way analysis of variance. Pearson correlation was used to evaluate the bivariate relationships among EAN, depression, neuroticism, and resilience. The mediation model (Model 4) and the moderated mediation model (Model 14) were tested using the PROCESS macro [43]. The indirect effects were tested with bias-corrected bootstrapping (n=5,000) and 95% confidence intervals (CI) for the indices. When a 95% bootstrapped CI did not include zero, it indicated the parameter was statistically significant.
RESULTS
The demographics of subjects and their effects on depression were displayed in Table 1. The prevalence of depression in the overall sample was 41.5%. The final sample (n=3,993) comprised 48.4% female and 51.6% male. In univariate analyses, female and poor family economic status were associated with increased risk of depression (p<0.05). Grade and family economic status were associated with EAN (p<0.05). There were significant differences (p<0.05) among different groups of sex, grader, family economic, and one-child with neuroticism.
Descriptive statistics and correlation analysis were carried out on EAN, neuroticism, depression, and psychological resilience. EAN was positively related to neuroticism (r=0.363, p<0.001) and depression (r=0.442, p<0.001). EAN (r=-0.439, p<0.001), neuroticism (r=-0.572, p<0.001), and depression (r=-0.667, p<0.001) were all negatively associated with psychological resilience (Table 2).
As shown in Table 3, the effect of EAN on depression was positively significant (β=0.44, p<0.001). EAN showed a significantly indirect effect on depression through neuroticism, which suggested a partial mediation of neuroticism. In addition, the proportion of neuroticism’s mediation was 41.7% in the total effect of EAN on depression. We calculated 95% CI based on a 5,000 bootstrap resampling. The indirect effects of EAN on depression through neuroticism (95% CI, 0.18-0.21) were significant, as zero was not contained in the 95% CI.
The results of the moderated mediation model were presented in Table 4. First, the Model 14 test in the application process of this study tested the theoretical hypothesis model. Model 3 was significant (F=1,096.825, p<0.001, R2=0.533). The interaction term between neuroticism and psychological resilience was related to depression, indicating that psychological resilience moderated the relationships between neuroticism and depression.
As the degree of neuroticism increased, the severity of depression also increased. Figure 2 has further revealed that neuroticism was more strongly related to depression at a low level of psychological resilience compared to a high level of psychological resilience (βlow=0.36, βhigh=0.19).
DISCUSSION
Our study reported that the prevalence of depression was 41.5% in adolescents in China, which was higher than that of previous studies. For example, a recent meta-analysis showed that the overall detection rate of depression among Chinese adolescents was 28.4% [44], and the detection rate of adolescent depression worldwide was reported as 37% [45]. These discrepancies in the prevalence of depressive symptoms might partly be due to differences in the ethnic background, age, and sample size of the study participants or assessment scales and cutoff values for depression. Apart from these, our study found that the proportion of Chinese adolescents with depression has demonstrated a rising trend, which may be attributed to the outbreak of the COVID-19 pandemic. Second, our study offered new directions for exploring potential mechanisms underlying the relationships between EAN and depression of adolescents. As expected, the results confirmed the mediating effect of neuroticism in the link between EAN and depression, and this association was moderated by the resilience.
Mediation role of neuroticism
Findings from this study supported our hypothesis, and revealed that neuroticism was partial mediators in the relationships between EAN and depression, and the mediation effect accounted for 41.7% of the total effect of EAN on depression. These results suggested that EAN had considerable effects on neuroticism which could lead adolescents to depression, which was consistent with previous studies [46,47].
To be specific, individuals who reported more severe EAN also reported with more severe depression during early puberty, which supported the theories of attachment, sensitizing effect and “kindling hypothesis” mentioned in the introduction section. This theory indicated that EAN made neuroendocrine overly sensitive to stress response, and increased sensitivity to proximal stressors, while reducing the threshold of stress that an individual need to develop depression, which eventually could lead to a higher probability of developing depression [48]. Consistent with those theories, crosssectional studies [49], longitudinal studies [50], and meta-analyses [51] all had found that EAN increased the risk of developing depression. At the same time, EAN impaired the emotional and cognitive developments of individuals, which caused individuals to have experienced more negative emotions and de-velop neuroticism personality traits [52]. Neuroticism was a tendency to cope poorly with stress and experience negative feelings of sadness, anxiety, and irritability [53]. It was tempting to speculate that because responsive relationships between children and caregivers are developmentally expected and biologically essential, their absence would activate the body’s stress response systems [54], impede brain development [55] and eventually lead to a maladaptive personality development. These may lead to high neuroticism which corresponds to the defensive domain and negative emotion, further inducing the occurrence of depression in early adolescence.
Moderator role of resilience
In addition, results suggested that neuroticism contributed to the severity of depression while psychological resilience mitigated it, namely, psychological resilience could act as a protective factor against various psychological problems. As a component of positive psychology, psychological resilience was an indication of positive mental health. Psychological resilience was broadly defined as the capacity of individuals exposed to negative events to remain healthy56 and to cope flexibly with challenges in life [57]. Therefore, a resilient individual might have a broader mindset and a more flexible cognitive process, which could be helpful with improving emotional stability and weakening the negative emotions caused by neuroticism [58]. According to the Broaden-and-Build theory, the experiences of positive emotions might broaden individual’s instantaneous thought-action repertories and build lasting personal resources such as physical, intellectual, and social resources to manage future threats [59]. High levels of psychological resilience might enable adolescents to take full advantage of personal positive resources [60] and adapt successfully to adversities [24]. Individuals who could better cope with adversities or stressful events exhibited fewer psychological and behavioral problems [61]. Therefore, a psychologically resilient individual might have a broader mindset and a more flexible cognitive process, which could be helpful with improving emotional stability and weakening negative emotions caused by neuroticism [62]. In other words, psychological resilience may ameliorate the associations of personality traits with depression by exerting the influence of positive emotions.
Policy and prevention
The present study provides insights into how and under what conditions, EAN can cause more severe depression, which enables several practical implications for reducing the risk of developing depression among adolescent students. Adolescence represents a sensitive neuron developmental period for the fostering of lifelong positive mental health [63]. Young people are still in environments where schemas are being shaped and maintained. Prevention could include education to schools and families on positive parenting patterns identified as meeting core needs and associated with positive mental health outcomes [64]. Strengthen family-school communication and promote mutual understanding. Schools can nurture adolescents’ resilience through knowledge and experiential programs involving self-awareness, interpersonal communication, emotion management, and frustration coping. In addition, intensive therapeutic and counseling interventions may be helpful to minimize the effect of abuse on emotional/behavioral problems for children who have suffered previous abusive experiences. Our findings highlight the necessity of implementing targeted prevention interventions customized to individuals with varying resilience states. The family, school, and society should pay more attention to teenagers with maladaptive personality traits and lower psychological resilience. Improving psychological resilience and developing adaptive personality traits may not only contribute to adolescents’ mental health status, preventing them from developing depression but also have lasting effects after they enter adulthood.
Strength and limitations
Strengths of this study included the inclusion and combination of both active (i.e., emotional abuse) and passive (i.e., emotional neglect) forms of emotional maltreatment, exploring the potential mechanisms underlying relationships between EAN and depression, and the use of a largely representative sample. There were several limitations of the study to be considered. First, our study was a cross-sectional design. Mediation analysis was more acceptable for prospective studies than cross-sectional studies, and our results could not determine a definite causal relationship among EAN, neuroticism, and depression. The results should be interpreted in a cautious manner. Lastly, future studies must proactively enquire about the protective factors that might promote resilience in the face of childhood emotional abuse/neglect.
Conclusions
The present study tested a moderated mediation model and found that neuroticism mediated the relationships between EAN and depression. Furthermore, psychological resilience moderated the effect of neuroticism on depression. This study indicated that EAN could lead to depression through neuroticism, and psychological resilience could buffer the negative effect of neuroticism and act as a protective factor against depression. These findings may provide important information related to possible intervention programs with adolescents to help them cope with crises, adversity, and unexpected life changes, such as those associated with the EAN.
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