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Associations Between Four Types of Childhood Neglect and Personality Disorder Symptoms During Adolescence and Early Adulthood: Findings of A Community-Based Longitudinal Study
Associations Between Four Types of Childhood Neglect and Personality Disorder Symptoms During Adolescence and Early Adulthood: Findings of A Community-Based Longitudinal Study
Associations Between Four Types of Childhood Neglect and Personality Disorder Symptoms During Adolescence and Early Adulthood: Findings of A Community-Based Longitudinal Study
Jeffrey
and
Data from
physical,
were
ciated with increased risk for PDs and with elevated PD symptom
during adolescence and early adulthood, after age, sex,
levels
childhood
physical
or
ne
glect,
From Columbia University and the New York State Psychiatric Institute (J.G.J. E.M.S. P.C.,
J.B.), and Fordham University (D.P.B.).
This study was supported by NIMH grant MH-36971 to Dr. Cohen.
Address correspondence to Jeffrey G. Johnson, PhD, Box 60, New York State Psychiatric In
,
171
JOHNSON ET AL.
172
large proportion
of
report
Brodsky, Cloitre,
more
although
investigation,
hood
neglect
that childhood
neglect is more
physical or sexual abuse (National Center on Child
Abuse and Neglect, 1995), much more research has investigated childhood
physical and sexual abuse than neglect (Straus, Kinard, 6k Williams, 1995;
Wolock 6k Horowitz, 1984). Thus, although childhood physical and sexual
abuse have been hypothesized to play a role in the etiology of PDs (Laporte 6k
Guttman, 1996; Paris, 1997), childhood neglect has not played a prominent
role in etiological theories. Nonetheless, research has indicated that many
adults with PDs report a history of childhood neglect (e.g., Arbel 6k
vices than childhood
Stravynski, 1991;
reports of low childhood parental care by patients with PDs are associated
with some types of PD symptoms (Norden et al., 1995), and that childhood
neglect is associated with attachment difficulties (Bowlby, 1982; Gauthier,
Stollak, Messe, 6k Aronoff, 1996) and antisocial behavior (Robins, 1966;
Widom, 1989).
are
are
known to have
subsequent
experienced
childhood mal
possible
etiology
to
of
(Paris, 1997).
childhood
173
and
passive-aggressive
Unfortunately,
the
PDs in
of "environmental weaknesses"
men.
too
global
neglect, and a
number of PDs were too low in prevalence to be included in the analyses re
ported by Drake et al. (1988). Luntz and Widom (1994) reported that young
adults who experienced childhood abuse or neglect had a higher prevalence
to
permit
an
measure
assessment of the
specific
was
effects of childhood
lar, increased risk for antisocial PD, and they did not investigate the associ
ation between childhood maltreatment and other PDs. Thus, many
neglect
during
recently reported findings indicating that childhood abuse and
neglect are associated with elevated PD symptom levels (Johnson, Cohen,
We have
may
a more
play
in
the
METHOD
PARTICIPANTS AND PROCEDURE
The
participants
in the
738
randomly sampled
dren (367 males and 371 females) who were between the ages of 1 and 10 in 1975
and who resided in one of two counties in the State of New York (Kogan, Smith, &
Jenkins, 1977). In 1975, mothers were interviewed in their homes about family envi
ronment and child charactenstics. During each of three follow-up surveys that took
place in 1983, 1985-1986, and 1991-1993, parents and youths were interviewed re
garding parental behavior, the parent-child relationship, demographics, and men
tal health. At each assessment, written informed consent was obtained from youths
and their parents after the study procedures were fully explained.
The 738 families in the present study were a subsample of 776 families inter
viewed in 1983 who participated in follow-up assessments in 1985-1986 and
1991-1993. The 1983 sample was a close match to the area population of children in
this age range, according to the United States Census data on family income and
structure (Cohen & Cohen, 1996), and the geographic area selected for this study is
representative of the Northeastern region of the U.S. with regard to a wide range of
JOHNSON ET AL.
174
TABLE 1
Demographic
Characteristics of the
Sample Offspring
Mean
Standard
Range
(years)
(years)
Deviation
Age
1975
6.1
1-10
1983
13.8
9-18
2.57
1985-1986
16.1
12-20
2.74
1991-1993
22.0
18-28
2.72
2.79
(%)
Ethnicity
Caucasian
90
African Amencan
Other
Birth Order
First
40
Second
26
Later
34
Residence
Rural Communities and Small Towns
Large
Towns
53
8
Central Cities
12
Suburban Communities
26
Education
Less Than
High
demographic
School
Diploma
variables.
Participants for
to
were
family income,
not
wel
fare support, urbanicity, or race, but they were more likely to be male (60% as com
pared to 48% of the sample with maltreatment data) and their mothers had fewer
12.26 years as compared to 12.64 years in the families
years of education (mean
with maltreatment information). Demographic characteristics of the sample are pre
sented in Table 1 Further information regarding the study methodology is available
=
Kogan
et
al., 1977).
from the
assess
diagnoses
were
drawn
Diag
through
on
consensus
the available
among
one
symptoms,
a=
175
respectively.
With
regard
to
.87.
assess
88
(93.6%) of the 94
DSM-IV PD
diagnostic
were
criteria.
administered to
sessed
1985-1986.
tered to the
youths'
mothers in
1975,
1983, and
which
1985-1986.
Because
some
participants
were
something
that
that
of cognitive
this subscale
was a
.77. The
physical neglect
subscale
was
comprised of 6
items
(e.g., "Has your child ever been immunized against diptheria, polio, measles, Ger
man measles, and mumps?"; "Very poor cleanliness and upkeep of the interior living
[interviewer rating]"), assessing three out of five areas of physical
quarters,
that
were
as
neglect
reliability
(e.g., "I allow
internal
much marijuana
subscale
an
neglect
as
he
or
she
176
JOHNSON ET AL.
neglect
that
liability of a
childhood
were
=
identified
by Straus
neglect
subscales
was a
reliability
an
internal
re
.82.
could not go to school as a result, or needed medical attention; (2) they had been left
without an adult caretaker before age 10; and (3) any older person who
overnight
was
not
boy/girlfriend
sexually.
ever
touched them
sexually
or
older person
RESULTS
The
Neglect
and
Personality
177
Disorders
During Adolescence
or
of Childhood
Types
Cognitive
Neglect
25
(3.4)
Emotional
21
(2.8)
Physical
24
(3.3)
Supervision
38 (5.6)
95
(12.9)
Paranoid
27
(3.7)
Schizoid
20 (2.7)
Personality
Disorder
During
Adolescence
Early
or
Adulthood
Schizotypal
34 (4.6)
71
(9.6)
Borderline
21 (2.8)
Histrionic
24
(3.3)
Narcissistic
44
(6.0)
Any
DSM-iY Cluster B
76 (10.3)
Avoidant
28 (3.8)
Dependent
Obsessive-Compulsive
23
53 (7.2)
(3.1)
7(1.0)
Depressive
15
Passive-Aggressive
38 (5.1)
Any
DSM-IV
using the
sums
(2.1)
180 (24.4)
assess
ne
glect
were
Analyses
of Covariance (ANCOVAs)
were
conducted to
investigate
the
asso
adolescence and
early
tively skewed, but were sufficiently approximate to normal distributions to
permit ANCOVAs to be conducted. As Table 3 indicates, paranoid PD symp
toms during adolescence and early adulthood were associated with a his
tory of childhood emotional neglect after offspring age and sex, childhood
physical and sexual abuse, childhood cognitive, physical, and supervision
neglect, and co-occurring PD symptoms were controlled statistically. Sup
plemental analyses indicated that schizoid and schizotypal PD symptoms
adulthood
assessed
were
as a
continuous variable.
ne-
JOHNSON ET AL.
178
Personality
PD Cnteria Pres
Disorder
ent
Among Those
Not Neglected
(PD)
Personality
PD Cnteria Present
Among
Victims
of Emotional
Neglect
Increase in
Fd
PD
Symptom
Levels
643)
Mean {SD)
(IV =21)
Mean (SD)
Paranoid
0.82
(0.81)
1.48
(1.04)
80
Schizoid
0.91
(0.81)
1.45
(1.15)
59
1.69
(0.90)
2.17
(1.02)
28
4.47ag
50
13.53cgh
(JV
Schizotypal
Any Cluster
(%)
la^i"*1
8.10b
(1.92)
5.10(2.51)
Borderline
1.04 (0.96)
1.64(1.22)
58
6.08a
Histnonic
1.55
1.83 (1.05)
18
0.94
1.37 (1.14)
2.02
(1.53)
47
4.99a
3.96
5.50 (3.22)
39
5.76a
11.23
3.41
Narcissistic
Any
Cluster B
(1.05)
(2.48)
Avoidant
0.76
(0.80)
1.36(1.23)
79
Dependent
1.08
(0.98)
1.71
(1.58)
58
Obsessive-Compulsive
0.77(0.71)
0.81
(0.77)
2.61
3.88 (3.18)
49
Any Cluster
C PD
(1.87)
Depressive
0.70 (0.81)
0.52
Passive-Aggressive
0.82
(0.84)
1.21
11.51
(5.97)
Any
PD
><05; bp<
Analyses
eReported
.01;
"p
<
7.70b
0.03
9.23b
(0.78)
1.18
(1.10)
48
3.12
16.21 (9.17)
41
10.33cg
.005.
of Covariance. controlling for offspring age. sex, and physical or sexual abuse (df= 1. 662).
by youths' mothers during prospective interviews or documented in New York State records.
^This
association remained
gleet.
significant
Because there
childhood
neglect,
few
were
cases
after
are
with
was
PD
were
associated with
than
dichotomous variable.
Symptoms of
Cluster A PDs
1 79
Personality
Prevalence of PD
Disorder (PD)
Prevalence of PD
Among Those
Not Neglected
Victims
of Emotional
Among
in
Adolescence
Odds
95%
Ratio
Confidence
Interval
Neglect
Paranoid
3.0%
(19/643)
9.5%
(2/21)
3.46
0.75-15.92
Schizoid
2.6%
(17/643)
9.5%
(2/21)
3.87
0.84-17.98
Schizotypal
Any Cluster A
3.9%
(25/643)
4.8%
(1/21)
1.24
0.16-9.58
8.2%
(53/643)
19.0%
(4/21)
2.61
0.85-8.07
Borderline
2.0%
(13/643)
9.5% (2/21)
5.10
1.08-24.21
Histrionic
3.0%
(19/643)
9.5%
(2/21)
3.46
0.75-15.92
PD
Narcissistic
5.0%
(32/643)
14.3% (3/21)
3.18
0.89-11.36
9.2%
(59/643)
14.3% (3/21)
1.65
0.47-5.77
Avoidant
3.1%
(20/643)
14.3%
(3/21)
5.19abd
1.41-19.07
Dependent
3.0%
(19/643)
4.8%
(1/21)
1.64
0.20-12.88
Obsessive-Compulsive
0.9%
(6/643)
0.0%
(0/21)
Any Cluster C
6.4%
(41/643)
14.3%
(3/21)
2.45
0.69-8.65
Depressive
1.9%
(12/643)
0.0%
(0/21)
Passive-Aggressive
3.9%
(25/643)
14.3%
(3/21)
4.12
1.14-14.91
(140/643)
42.9% (9/21)
2.69acd
1.11-6.52
Any
Any
Cluster B PD
PD
PD
21.8%
for childhood
cognitive, emotional,
PD
and
co-occurring
symptoms (see Table 5) Supplemental analyses indicated
that schizoid and narcissistic PD symptoms during adolescence and early
adulthood
sessed
were
as a
it
was as
continuous variable.
Childhood
and
after
JOHNSON ET AL.
180
Physical Neglecte
Early Adulthood
TABLE 5. Childhood
Adolescence and
Personality
and
Personality
PD Cnteria Present
Disorder (PD)
Among Victims of
Physical Neglect
(JV
Mean
Paranoid
F*
% Increase
in PD
Symptom
Levels
24)
(SD)
1.35(1.06)
65
8.54cg
Schizoid
1.40(0.96)
54
6.68ag
Schizotypal
2.38
(1.20)
41
10.61cg
5.12(2.50)
50
14.87cgh
Any
Cluster A PD
Borderline
1.73(1.31)
66
Histnomc
1.92(1.05)
24
1.57
Narcissistic
2.00 (1.37)
46
5.43a
5.65 (3.34)
43
7.47b
Avoidant
1.15(0.92)
51
4.24ag
Dependent
1.67(0.88)
55
6.15a
Obsessive-Compulsive
1.21
(0.92)
57
7.71b
4.02 (2.07)
51
10.60cg
Any
Any
Cluster B PD
Cluster C PD
Depressive
0.92
Passive-Aggressive
1.12
Any
PD
y<
.05;
Dp<
"p<
.01,
8.56c
(0.86)
31
1.02
(0.90)
37
2.02
16.83 (8.20)
46
14.00cg
.005.
Analyses of Covanance, controlling for offspring age, sex. and physical or sexual abuse (df 1. 662).
eReported by youths' mothers during prospective interviews or documented m New York State records.
Mean DSM-IV PD criteria met at interviews conducted during adolescence and early adulthood.
^This association remained significant after controlling for other forms of childhood neglect.
^his association remained statistically significant after controlling for other PD svmptoms that were signifi
cantly associated with childhood physical neglect.
=
neglect
was
associated with
sive-aggressive
statistically
for
increased
adolescence
PDs
during
offspring age
and
sex.
or
risk
early
Cluster B
and pas
controlling
physical and sexual
physical neglect, and for
for childhood
co-occurring
for
adulthood after
PDs.
lescence
were
or
conducted to
as
result of
regard
to associations
Personality
Physical Neglect
Disorder
(PD)
181
Personality Disorders
in Adolescence and
Prevalence of PD
Odds
95% Confidence
Among Victims of
Physical Neglect
Ratio
Interval
Paranoid
S 3%
(2/24)
2.99
0.65-13.62
Schizoid
4.2% (1/24)
1.60
0.20-12.55
Schizotypal
Any Cluster
A PD
Borderline
Histrionic
4.94acef
1.57-15.54
25.0% (6/24)
3.71ace
1.41-9.75
12.5% (3/24)
6.92ace
4 2%
Narcissistic
Any Cluster
Avoidant
Dependent
5.02bce
1.76-14.32
3.29ace
1.26-8.63
12.5% (3/24)
4.45
1.23-16.15
1.43
0.18-11.13
20.S%
Depressive
(1/24)
(5/24)
12.5%
.Any PD
45.8% (11/24)
.05;
p<
4.62
0.53-39.93
3.86ace
1.37-10.87
3.53
0.99-12.63
3.04bde
1.33-6.93
0.0% (0/24)
Passive-Aggressive
*p<
0.18-11.13
25.0% (6/24)
4.2% (1/24)
Cluster C PD
1.83-26.14
1.43
(1/24)
20.S% (5/24)
4.2%
Obsessive-Compulsive
Any
16.7% (4/24)
(3/24)
.01.
cDetermined by Fisher's
Exact Test.
Determined
by Chi-Square Test.
eLogistic regression analyses indicated that this association remained statistically significant after control
ling for offspring age and sex, for documented childhood physical or sexual abuse, and for childhood cogni
tive, emotional, or supervision neglect.
Logistic regression analyses indicated that this association remained statistically significant after
controlling for other PDs that were significantly associated with childhood physical neglect.
were
that,
glect
identified
reported
by
controlled
statistically.
was
mented childhood
cases
of
It should be noted
above, there
as
more severe
than the 75
Antisocial PD
was
only assessed
participants were
18 years old in 1983 and 1985-1986. Therefore, separate analyses were con
ducted to investigate whether the four types of childhood neglect were associ
early
adulthood.
Findings
JOHNSON ETAL.
182
TABLE 7.
Supervision Neglect
and Earlv
and
Personality
Adulthoodf
Personalitv Disorder
PD Critena Present
(PD)
Among Victims of
Supervision Neglect
(JV 38)
=
Mean
F*
Increase in PD
Symptom Levels
(%)
(SD)
25.17cgh
Paranoid
1.47
(1.22)
79
Schizoid
1.11
(0.82)
22
2.88
Schizotypal
2.12 (1.22)
25
6.54ag
4.70
38
16.44cg
18.76cgh
Any Cluster
A PD
(2.60)
Borderline
1.86(1.45)
79
Histnomc
2.00(1.26)
29
5.48ag
Narcissistic
2.07
(1.60)
51
13.29cg
18.97cg
Any
Cluster B PD
5.92 (3.57)
49
Avoidant
1.12 (1.01)
47
8.50cg
Dependent
1.50
(1.28)
39
6.62ag
Obsessive-Compulsive
0.97 (0.78)
26
1.84
3.59
(2.43)
38
9.76cg
Depressive
1.11
(1.39)
59
5.91ag
Passive-Aggressive
1.45 (1.31)
77
17.31cgh
16.76 (8.72)
46
25.34cg
Any
Any
Cluster C PD
PD
Hnis
association remained
cantly
that
were
signifi
DISCUSSION
The
neglect
was
(Drake etal., 1988; Luntz & Widom, 1994) and with findings indicating that
patients with PDs are more likely than individuals without PDs to report
histories of childhood
neglect (e.g.,
see
Arbel &
Norden etal.,
183
TABLE 8. Childhood Supervision Neglect and Risk for Personality Disorders in Adolescence
and
Early
Adulthood
Personality
Disorder (PD)
Prevalence of
Among Victims
PD
of
10.5%
Schizoid
Interval
(4/38)
3.86adg
1.25-11.99
0.0% (0/38)
Schizotypal
Cluster A PD
Borderline
Histrionic
Narcissistic
Any
95% Confidence
Ratio
Supervision Neglect
Paranoid
Any
Odds
Cluster B PD
10.5%
(4/38)
2.90
0.96-8.83
18.4%
(7/38)
2.51
1.06-5.98
13.2%
(5/38)
7.34cdf
2.47-21.82
7.9%
(3/38)
2.82
0.79-9.97
15.8%
(6/38)
3.58adf
4.03cdfg
1.90-8.54
0.76-9.42
28.9% (11/38)
Avoidant
7.9%
(3/38)
2.67
Dependent
5.3%
(2/38)
1.82
1.40-9.18
Obsessive-Compulsive
0.0% (0/38)
Any Cluster C
4.3%
(1/38)
2.22
0.82-6.00
7.9%
(3/38)
4.51adg
4.64bdfg
4.44cef
1.22-16.71
PD
Depressive
Passive-Aggressive
Any
15.8% (6/38)
PD
*p<.05; bp<-01; cp
55.3%
<
(21/38)
1.78-12.10
2.28-8.64
.005.
Determined
part
to biased memories
was
JOHNSON ET AL.
184
TABLE 9.
and Earlv
Personality Disorder
Emotional
Physical Neglect
Neglect
During Adolescence
Supervision Neglect
(PD)
Paranoid
Symptoms
Symptoms
Schizoid
Disorder
Schizotypal
.Any Cluster A PD
Symptoms
Symptoms
Borderline
Symptoms
Histrionic
Narcissistic
Disorder
Any Cluster B PD
Avoidant
Disorder
Dependent
Obsessive-Compulsive
Any
Cluster C PD
Depressive
Passive-Aggressive
Any
PD
Symptoms
& Disorder
Symptoms
& Disorder
Symptoms
& Disorder
Symptoms
& Disorder
childhood
neglect,
and
after offspring age and gender, childhood physical and sexual abuse, other
co-occurring PD symptoms were controlled statistically.
1997; Ogata etal., 1990), suggest that it may be important for researchers
investigate specific etiological models for each of the different PDs. It is
to
important to note that cognitive neglect was not associated with any PD
symptoms during adolescence or early adulthood. These findings would
appear to suggest that cognitive neglect may not play a role in the etiology
of PDs. However, different findings might have been obtained if cognitive
neglect
maltreatment
nonverbal
as
during early
childhood
if other adults
provide ongoing
neglect also
merit investigation. Different types of childhood neglect may have specific
effects on the course and treatment of PDs, and particular
psychotherapeutic interventions may be uniquely effective in promoting
therapeutic change among individuals with PDs who have experienced spe
cific forms of childhood neglect.
nurturance to the child. Treatment
or
implications
of childhood
physical
neglect is
more
185
neglect (Straus et al., 1995; Wolock & Horowitz, 1984). Thus, childhood
physical and sexual abuse have been hypothesized to play a role in the etiol
ogy of PDs (e.g., Laporte & Guttman, 1996; Paris, 1997). but the hypothesis
that childhood neglect contributes to the development of PDs has not been
included in most theories of the etiology of PDs. Nonetheless, the
present
findings suggest that childhood emotional, physical, and supervision ne
glect may play a role in the etiology of some types of PDs.
It is important to acknowledge that the prevalence of specific PDs and of
specific types of childhood neglect was low, reducing the statistical power of
some analyses involving PD diagnoses. This concern
prompted us to inves
tigate the association between childhood neglect and PD symptoms during
adolescence and early adulthood. Our findings regarding these associations
provide a valuable supplement to our findings involving PD diagnoses be
cause they are less likely to be
adversely affected by low statistical power.
Another
methodological
interviews
used to
concern
childhood
assess
cases
childhood
provided
neglect were
Another
views
concern
were
is that, because
symptoms
predictive
measures
measures
that
were
early 1980s,
then available to
it
was
assess
no
as
longitudinal
research to
use a
physical
sample,
JOHNSON ET AL.
186
comprehensive
spring
assessment of PDs
use
of statistical
nal
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