Child Psychiatry Hum Dev (2017) 48:610–618
DOI 10.1007/s10578-016-0687-7
ORIGINAL ARTICLE
Child Abuse and Psychiatric Co-morbidity Among Chinese
Adolescents: Emotional Processing as Mediator and PTSD
from Past Trauma as Moderator
Man Cheung Chung1 · Zhuo Sheng Chen2
Published online: 4 October 2016
© Springer Science+Business Media New York 2016
Abstract  This study investigated whether child abuse
was associated with psychiatric co-morbidity in a group of
Chinese adolescents, and whether this association would
be mediated by emotional processing difficulties and mod-
erated by the severity of PTSD from other traumas in the
past. Four hundred seventy-four adolescents participated in
the study. They completed the Childhood Trauma Ques-
tionnaire–Short Form, General Health Questionnaire-28,
the Posttraumatic Stress Diagnostic Scale, and Emotional
processing scale-25. The results showed that after adjusting
for the total number of traumatic events and how long ago
the most traumatic event occurred, child abuse was associ-
ated with psychiatric co-morbidity. This association was
not moderated by the severity of PTSD from past traumas
but mediated by emotion processing difficulties. To con-
clude, adolescents who experience child abuse can develop
emotional processing difficulties which in turn impact on
psychiatric symptoms. Experience of past trauma does not
influence these psychological processes.
Keywords  Child abuse · Emotional processing ·
PTSD · Mediation · Moderation
Man Cheung Chung
man.chung@cuhk.edu.hk
1 in the community and 60 to 90 % within clinical outpatients
Department of Educational Psychology, Faculty of
Education, The Chinese University of Hong Kong, Ho Tim
Building, Shatin, NT, Hong Kong
2
Institute of Psychology, Chinese Academy of Sciences,
Beijing, China
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Introduction
The prevalence rate for child abuse among adolescents can
range from 17 to 71 % [1–3], some of whom (13 % in one
study) have experienced multiple abuses (e.g. physical and
sexual abuse and neglect) [4]. Child abuse is associated with
a range of psychiatric symptoms [5] including depression,
suicidal tendency, hopelessness, hostility, substance abuse,
conduct disorder and general anxiety disorder [2, 6, 7].
Adolescents who have a history of childhood abuse tend to
have a low level of health-related quality of life [8], family
cohesive problems, attention difficulty and daily stress [9].
They also tend to be more prone to delinquency, posttrau-
matic stress disorder and dissociation than those who have
not [10].
Types of abuse seem to be related to specific psychiat-
ric co-morbidity. For example, emotional abuse and neglect
are associated with anxiety, depression, anger, poor psy-
chological functioning [11], interpersonal problems [12]
and dissociation [13]. Sexual abuse is also associated with
depression. Additionally, it is associated with posttraumatic
stress disorder, conduct disorder, eating disorder, substance
abuse, panic disorder, borderline personality disorder and
suicidality [14, 15].
Two observations are noteworthy in examining the effect
of child abuse on psychiatric co-morbidity. The first is that
in addition to child abuse, based on data from both Western
and Eastern (Malaysia) samples, adolescents experiencing
potentially traumatic events of other kinds (Polyvictimiza-
tion) is common [1, 16, 17] ranging from 25 to 60 % or more
[18]. Before turning16, 1 in 4 children is likely to experience
traumas other than abuse including assault, domestic vio-
lence, and bullying [19]. Before entering adulthood, almost
80 % of adolescents will have experienced at least one other
Child Psychiatry Hum Dev (2017) 48:610–618
trauma including accident (20 %), and death of someone
close (almost 20 %) [20]. Polyvictimization is associated
with elevated psychiatric symptoms, risk-taking behaviour
[2, 17–19, 21, 22], physical health symptoms, obesity and
impaired immunity [23]. Compared with those of single
traumas, adolescents who had experienced multiple abuses
and other traumas were worse in symptom severity [6].
Posttraumatic stress disorder (PTSD) can result from
these other traumatic events for adolescents [24]. The
prevalence rates for full-PTSD were 22 and 51 % and for
partial-PTSD were 32 and 35 % in two separate studies [25,
26]. The number of traumatic events was positively corre-
lated with the severity of PTSD symptoms [25]. In essence,
this amounts to a cumulative traumatic effect. When trauma
types increase, the odds ratios for psychiatric symptoms
also increase [27]. PTSD is not that which can be ignored
among adolescents and its severity may moderate the effect
of child abuse on psychiatric symptoms. To the best of our
knowledge, this has not been investigated systematically in
literature.
Secondly, there is a paucity of research looking at the
effect of emotional processing difficulties among abused
adolescents, with the exception of one study alluding to
the fact that child abuse and neglect were associated with
increased emotional problems among Chinese adolescents
[28]. Child abuse can change the neural system governing
emotion regulation [29, 30] thereby increasing sensitivity to
emotional conflict [31]. As adults, they continue to have dif-
ficulties regulating and processing emotion [32–34]. They
also tend to avoid negative emotional expressions [35].
These emotional difficulties would, in turn, lead to problems
in interpersonal skills [32], self-concept and the concept of
others [36], psychological disorders (e.g. disordered eating)
[37], obesity [38] and extreme stress not otherwise specified
[39]. In other words, child abuse leads to emotional pro-
cessing difficulties which in turn affect the severity of psy-
chiatric co-morbidity among adolescents. Put another way,
emotional processing difficulties could mediate the effect
of child abuse on psychiatric symptoms. Systematic stud-
ies investigating this are also lacking in literature, although
evidence exists to support emotional processing difficulty
acting as a mediator among the adult population [40].
What has been said sets the theoretical model for the cur-
rent investigation. Figure 1 depicts that the effect of child
abuse on psychiatric symptoms is moderated by the severity
of PTSD from other traumas and is mediated by emotional
processing difficulty. It echoes the self-trauma theory [41]
suggesting that child abuse affects self-capacities especially
in the area of emotional regulation or self-regulation of
emotion. As a result, victims of abuse are at risk for ele-
vated emotional distress which motivates them to protect
themselves by avoiding or dissociating themselves from it,
in effect not processing the distressing emotion. This is a
611
Emotional
processing
PTSD from
past trauma
Child abuse
Psychiatric
co-
morbidity
Fig. 1  The hypothesized model with PTSD from past traumas mod-
erating and emotional processing mediating the path between child
abuse and psychiatric co-morbidity
form of premature inhibition of processing in which victims
avoid thinking about the abuse and try to escape the emo-
tional arousal associated with it. Repetitive processing like
this will lead to the process becoming automatic. Conse-
quently, emotional arousal and deliberate attempts to avoid
it are no longer necessary [42]. However, the unresolved and
unprocessed distressing feelings accumulate in the body and
later cause disturbance in the physiological and neurologi-
cal system giving rise to health or psychological difficulties
[43], anxiety and depression [44], and negative affects [45].
This study aimed to examine (1) whether there would be
a link between child abuse and psychiatric co-morbidity,
(2) whether this link would be mediated by emotional pro-
cessing difficulty and moderated by the severity of PTSD
from other traumas among a group of secondary school
adolescents in China. Guided by the preceding literature,
we hypothesized that the effect of child abuse would be
positively associated with psychiatric co-morbidity. We also
hypothesized that the severity of PTSD from other trauma
and emotional processing difficulty would moderate and
mediate respectively the effect of child abuse on psychiatric
co-morbidity.
Methods
Procedure
Four hundred and seventy-four adolescents (M  = 291,
F = 183) were recruited from three vocational schools in a
city in China. These schools were located in three different
areas of the city. Thus, the adolescents in the schools came
from families with diverse socio-economic backgrounds.
Upon the approval of the schools, the research assistant
identified the classes that students meeting the inclusion
criteria attended and presented the purpose of the study to
them. Students were reassured that information collected
would be kept anonymous and that they were entitled to
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withdraw from the study any time they wished without giv-
ing a reason. Students provided their assent to the study
before participation. They completed the questionnaires
described in the “Measures” section. The inclusion criteria
were that (1) they were between 13 and 19 years old, and (2)
they were not receiving special needs education. The first
criterion was based on Erikson’s age range for adolescence.
The second criterion was based on the school records and
confirmed by the class teacher. All the questionnaires went
through the back translation procedure. Ethical approval
was sought from the Panyu Education Center in China.
Measures
Childhood Trauma Questionnaire–Short Form (CTQ) [46]
provides a brief, standardized, validated instrument for
assessing abuse and neglect, with five subscales: emotional
abuse, physical abuse, sexual abuse, emotional neglect and
physical neglect. Adolescents were asked to answer on a
5-point Likert scale from “never true” [1] to “very often
true” [5]. CTQ has been validated based on adolescent and
adult populations. Good internal consistency was reported
with alpha reliabilities ranging from 0.70 to 0.93 and retest
reliabilities ranging from 0.66 to 0.94. One study looking
at Chinese college students demonstrated a good retest reli-
ability (0.71) and Cronbach’s α (0.60) for the total score
[47]. Based on the current sample, the Cronbach’s α for the
total score was 0.85.
The General Health Questionnaire-28 (GHQ-28) [48]
aims to estimate the likelihood of adolescents being diag-
nosed as suffering from general psychiatric morbidity
at interview. The questions are scored using the scoring
method of 0-0-1-1, which counts the number of symptoms
and avoids the problems of middle-user response bias. As
the total GHQ score exceeds the recommended cutoff point
of 4, the probability for adolescents to be diagnosed as suf-
fering from a general psychiatric disorder increases. As we
analysed the mean scores of the GHQ-28, however, the rat-
ing scale of 1-2-3-4 was used for preventing the problem of
information loss. In PTSD research, the GHQ-28 has been
recommended as a standardized questionnaire to measure
global dysfunction and diagnose co-morbid psychological
disorders associated with PTSD [49]. The questionnaire
yields four subscales which are somatic problems, anxiety,
social dysfunction and depression. Reliability coefficients
ranged from 0.78 to 0.95 [50]. GHQ-28 has recently been
validated in a study based on a sample of Chinese adoles-
cents (Cronbach’s α score for the total score = 0.94) [51].
Based on the current sample, the Cronbach’s α was 0.91 for
the total score.
The Posttraumatic Stress Diagnostic Scale (PDS) [52]
aims to assess PTSD, based on DSM-IV criteria. The first
part of PDS focuses on a range of previous traumatic events
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Child Psychiatry Hum Dev (2017) 48:610–618
throughout life that adolescents may have experienced.
If adolescents had experienced more than one traumatic
event, they were asked to identify the one which was most
traumatic. The second part assesses PTSD symptoms that
resulted from this most traumatic event. Adolescents were
asked to rate the severity of the symptoms according to the
rating scale: 0 = not at all, 1 = once a week or less/once in a
while, 2 = 2 to 4 times a week/half the time, 3 = 5 or more
times a week/almost always. Based on the PDS diagnostic
criteria, adolescents were classified into three groups: full-
PTSD (meeting the threshold for all criteria), partial-PTSD
(meeting at least one symptom in each of the three PTSD
symptom clusters [re-experiencing, avoidance and hyper-
arousal symptoms]) [53] or no-PTSD (not meeting the diag-
nostic criteria). This scale has shown good reliability and
validity and good agreement with the Structured Clinical
Interview for Diagnosis (kappa = 0.65, agreement = 82 %,
sensitivity = 0.89 and specificity = 0.75). PDS was used and
validated in a recent study based on a group of Chinese ado-
lescents (Cronbach’s α score for the total score = 0.95) [51].
Based on the sample of the current study, the Cronbach’s α
for PTSD total was 0.95.
Emotional processing scale-25 (EPS-25) [54] aims to
identify emotional processing difficulties. The scale contains
five factors with 3 (avoidance, suppression, unregulated
emotion) assessing emotional control and dysregulation.
Impoverished emotion is another factor examining difficul-
ties including differentiating feelings from illness and flat
emotion. Unprocessed emotions are felt to be intrusive,
controlling and overwhelming. Adolescents’ responses
were scored according to their experiences of emotional
processes on a scale of 0 = completely disagree to 9 = com-
pletely agree. EPS-25 was validated from a whole range of
samples including youths. Internal reliability for the overall
scale is high (α = 0.92) and the reliability for the subscales
ranged from (α = 0.70 to 0.80). Based on Chinese univer-
sity students, one study revealed good internal consistency
(0.85), Cronbach’s α (0.65 to 0.77) for the subscales and
test–retest reliability (0.75 to 0.87) [55]. The Cronbach’s α
for the total score of the current sample was 0.92.
Data Analysis Plan
Descriptive statistics were used to describe the data initially.
Within-subject ANOVA was used to examine the within-
subject effects between the subscales of questionnaires.
Correlation coefficients including point biserial correlations
(rbp) were carried out to examine the relationship between
adolescents’ demographic variables and psychiatric co-mor-
bidity. PROCESS, a modelling tool for mediation and mod-
eration analysis, was used [56]. Bias-corrected bootstrapping
was used to generate confidence intervals which addressed
the problem of power resulting from the asymmetric and
Child Psychiatry Hum Dev (2017) 48:610–618 613

non-normal sampling distributions of an indirect effect [57]. differed significantly from each other (p < 0.001) except for
The bootstrapping sampling (n = 1000) distributions of the unprocessed and improvised emotions.
indirect effects were produced by selecting a sample of cases In terms of PTSD from past traumas, sudden death of
from the complete data set and calculating the indirect effects someone close was the traumatic event reported most fre-
in the resamples. Point estimates and confidence intervals quently (17 %). Otherwise, events included accident (9 %),
(95 %) were estimated for the indirect effects. When zero physical assault (4 %), natural disaster (3 %) and life threat-
was not contained in the confidence interval, point estimates ening illness (3 %). On average, the most traumatic event
of indirect effects were then considered to be significant. occurred just over 1 year ago (mean = 13.27 in months,
Expectation Maximization (EM) algorithm [58] was used to SD = 32.58). The total number of traumatic events that hap-
replace the missing data. Less than 5 % of responses were pened in their lives was 0.83 (SD = 1.67).
missing due to participants omitting questionnaire items. On the basis of the Posttraumatic Stress Diagnostic Scale,
Regression imputation has been shown to be a valid method 19 % met the diagnostic criteria for full-PTSD; 22 % partial
in dealing with missing data [59]. and 59 % no-PTSD. At the time of the study, the adoles-
cents reported that the severity of PTSD symptoms had been
persistent for 3 months or more. Looking at psychiatric co-
Results morbidity, there were significant within-subject effects for
symptoms [Greenhouse-Geisser: F(2.85, 1352.38) = 166.70,
Four hundred and seventy-four adolescents (M = 291, F = 183) p < 0.001, η2 = 0.26]. Pairwise comparisons with Bonferroni
were recruited from 3 vocational schools in a city in China. adjustment showed that social dysfunction and depression
They were on average 15.39 (SD = 0.67) years old ranging differed significantly from each other (p < 0.001). Ninety-
from 14 to 18. Table 1 shows the means and standard deviations two percent met the cutoff for GHQ-28 cases. It is notewor-
of measures on child abuse, emotional processing difficulties, thy that PTSD was a distinctively different psychological
PTSD following past traumas and psychiatric co-morbidity. construct from psychiatric co-morbid symptoms (Collinear-
There were significant within-subject effects for types of ity: tolerance = 0.55, 0.44, 0.75, 0.61 and VIF = 1.80, 1.24,
child abuse [Greenhouse-Geisser: F(1.96, 931.01) = 290.42, 1.33 and 1.62 for somatic problems, anxiety, social dysfunc-
p < 0.001, η2 = 0.38] and emotional processing difficulties tion and depression respectively).
[Greenhouse-Geisser: F(3.60, 1706.91)  = 88.62, p < 0.001, To address the two research questions, correlation coeffi-
2
η  = 0.15]. Pairwise comparisons with Bonferroni adjustment cients including point biserial correlations (rbp) were carried
showed that all child abuse and emotional processing types out to ascertain whether demographic variables would relate
to outcomes. PTSD research suggests that “victim variables”
are related to PTSD severity which in turn might influence
Table 1  The means and standard deviations of measures on child distress outcomes [60, 61]. The results showed that the total
abuse, posttraumatic stress following past traumas, psychiatric co-
morbidity and emotional processing
number of traumatic events experienced was correlated with
psychiatric co-morbidity (r = 0.18, p < 0.001). Summing up
Mean SD the total number of traumatic events meant losing sight of
Physical abuse 6.12 2.31 qualitative differences in trauma responses. To make an
Emotional abuse 7.03 3.62 attempt to address this issue, following recent literature
Sexual abuse 5.34 1.26 [62], the traumatic events were classified into interpersonal
Emotional neglect 11.86 6.14 and single or non-interpersonal trauma. Adopting the defi-
Physical neglect 8.18 3.18 nitions from recent studies [63, 64], interpersonal trauma
Re-experiencing 1.65 2.92 was defined as an assault experienced directly from another
Avoidance 2.09 3.86
person, examples of which were robbery, physical or sexual
Hyperarousal 1.55 2.96
abuse/assault, assault with weapon, and domestic violence.
Somatic problem 18.31 3.10
Type of trauma in this study was, however, not significantly
correlated with psychiatric co-morbidity (r  = 0.16, ns).
Anxiety 18.02 3.39
Neither were gender (rpb = 0.08, ns) and age (r = 0.06, ns).
Social dysfunction 19.87 2.73
On the other hand, how long ago the most traumatic event
Depression 16.65 3.26
occurred (r = 0.11, p < 0.05) was significantly correlated
Suppression 19.67 8.10
with psychiatric co-morbidity.
Unprocessed emotion 17.73 8.63
Thus, the total number of traumatic events and how long
Unregulated emotion 15.41 8.88
ago the most traumatic event occurred were treated as co-
Avoidance 21.32 8.73
variates in the mediational and moderation analyses. The
Impoverished emotion 18.01 8.78
initial analysis was based on the total scores of PTSD from

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614 Child Psychiatry Hum Dev (2017) 48:610–618

past trauma (moderator) and emotional processing difficulty
(mediator). The results showed that child abuse predicted
psychiatric co-morbidity. The cross-product term (child
abuse X PTSD total) was not significant when the outcome
was psychiatric co-morbidity. The total amount of emotional
processing difficulty mediated the effects of child abuse on
psychiatric co-morbidity (Effect: 0.11, Boot SE: 0.02, Boot
LLCI: 0.07, Boot ULCI: 0.16). These results were consistent
even without these two co-variates adjusted (Effect: 0.09,
Boot SE: 0.02, Boot LLCI: 0.05, Boot ULCI: 0.13).
Further analyses were then carried out to examine which
types of emotion processing difficulty acted as significant
mediators. The results showed that unprocessed, unregulated
and impoverished emotions were the significant mediators.
Increased child abuse was positively correlated with the
three types of emotion processing difficulty (unprocessed,
r = 
0.19; unregulated, r  = 0.26, impoverished, r  = 0.23)
which were in turn associated with increased psychiatric
co-morbidity (unprocessed, r = 0.17; unregulated, r = 0.18,
impoverished, r = 0.37). These analyses also confirmed that
PTSD from past trauma did not moderate the effect of child
abuse on psychiatric co-morbidity (see Table 2).
Discussion
This study aimed to investigate whether there would be a
link between child abuse and psychiatric co-morbidity, and
whether this link would be mediated by emotional processing
difficulty and moderated by the severity of PTSD symptoms
from past traumas among a group of adolescents in China.
After adjusting for the total number of traumatic events and
how long ago the most traumatic event occurred, consis-
tent with the first hypothesis, child abuse was associated
with psychiatric co-morbidity. The second hypothesis was
partially confirmed in that emotional processing difficulties
(unprocessed emotion, unregulated emotion and impov-
erished emotion) mediated the relationship between child
abuse and psychiatric co-morbidity. However, contrary to
the hypothesis, the severity of PTSD symptoms following
past trauma did not moderate the preceding relationship.
The finding on the association between child abuse and
psychiatric co-morbidity provided further evidence for the
detrimental effects of child abuse. Although trauma symp-
toms can vary depending on cultural differences, e.g. col-
lectivism versus individualism [65, 66], the link between
the effect of child abuse on psychiatric co-morbidity in our
Chinese adolescents was consistent with the link established
mostly based on Western samples described in the introduc-
tion and suggests that the effect of child abuse is somewhat
universal.
These Chinese adolescents were presumably influenced
by a culture of collectivism which emphasizes the impor-
tance of groups such as families. Group membership is
important for self-concept. Well-being results from carrying
out social roles and meeting social obligation. Meanwhile,
restraint in emotional expression is encouraged to ensure
group harmony [65]. Thus, child abuse by a group member

Table 2  Results on moderating and mediating the effect of child abuse on psychiatric co-morbidity
Effect SE t p LLCI ULCI Boot SE Boot LLCI Boot ULCI

Model
Emotion processing – 0.01 11.43 0.00 0.10 0.14 – – –
Child abuse – 0.04 2.87 0.00 0.03 0.19 – – –
PTSD – 0.14 0.77 0.44 −0.17 0.39 – – –
Child abuse X PTSD – 0.00 −0.48 0.62 −0.00 0.00 – – –
No of events – 0.26 1.91 0.05 −0.01 1.04 – – –
Onset of trauma – 0.01 0.01 0.99 −0.02 0.02 – – –
Conditional direct effects of X (child abuse) on Y (psychiatric co-morbidity) at values of the moderator (PTSD)
PTSD
0.00 0.06 0.04 1.54 0.12 −0.01 0.14 – – –
5.40 0.05 0.03 1.62 0.10 −0.01 0.12 – – –
14.51 0.04 0.04 1.16 0.24 −0.03 0.13 – – –
Indirect effect of X on Y
Suppression 0.00 – – – – – 0.00 −0.01 0.01
Unprocessed emotion 0.03 – – – – – 0.01 0.01 0.06
Unregulated emotion 0.05 – – – – – 0.02 0.01 0.10
Avoidance −0.00 – – – – – 0.00 −0.03 −0.00
Impoverished emotion 0.08 – – – – – 0.02 0.05 0.13

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(such as a caregiver) would mean a major assault to the
development of the self-concept and well-being for these
adolescents. Betrayal trauma is a way to capture this strug-
gle [67]. In addition, adolescents’ psychological distress
could be exacerbated by being in a sensitive developmen-
tal period. According to Erikson [68, 69], this is a period
of psychological confusion and instability in which they
try to develop their own identity. Betrayal from their own
caregiver during this sensitive developmental period could
disrupt their self-concept and personality [67] and heighten
sensitivity to emotional conflict [31] and ultimately the
severity of psychiatric co-morbidity [67].
The lack of moderating effect of PTSD from past trauma
on the path between child abuse and psychiatric co-morbid-
ity was surprising. This does not mean, however, that the
phenomenon of cumulative trauma or polyvictimization was
irrelevant for these adolescents, but that it was expressed
unexpectedly. Bivariate correlation showed that PTSD from
past trauma was associated with psychiatric co-morbidity
(r = 0.21, p < 0.001). However, it became non-significant
when it was entered into the moderation analyses. In other
words, for these adolescents, it was not the case that the
effect of their abuse on psychiatric co-morbidity was severe
when the degree of PTSD was high. Neither was it the case
that the effect of abuse had little effect on psychiatric co-
morbidity when the degree of PTSD was low. The results
seemed to support an additive model in that the effects of
PTSD from past trauma and child abuse made independent
or unique contributions to distress outcomes; the clinical
phenomenon of pathogenetic comorbidity [70].
Arguably, this is consistent with one assumption behind
distinguishing externalization and internalization in child-
hood disorder symptoms [71]. The two broad-band clinical
features are separate psychological constructs contributing
to the genesis of each other [72]. Similarly, it is plausible
that symptoms resulting from the abuse and from past trau-
mas other than child abuse could have specific, unique and
direct impacts on the genesis of psychiatric co-morbidity.
In terms of the mediation results, unprocessed emo-
tion, unregulated emotion and impoverished emotion were
mediators for the effect of child abuse on psychiatric co-
morbidity. In other words, for these adolescents, the abuse
impacted their psychiatric symptoms indirectly through the
severity of intrusive and overwhelming distressing emotion
associated with the abuse, difficulty controlling or regulating
emotion, and differentiating feelings. This is consistent with
the postulate that traumas can affect self-regulatory ability
and increase symptom complexity [73]. Developmentally
adverse interpersonal traumas of which child abuse is one
type can distort psychological development especially when
occurring during periods (like infancy or adolescence) in
which foundational self-regulatory capacities are develop-
ing and being consolidated. These self-regulatory capacities
615
include the distortion of regulating bodily and emotional
processes, anxiety and arousal modulation and ultimately
psychological well-being [74].
Focusing on the three emotional processing difficulties
(unprocessed emotion, unregulated emotion and impover-
ished emotion) which mediated the effect of child abuse on
psychiatric co-morbidity, arguably, what underpinned the
first two is lack of control. What underpinned the third emo-
tion is an attempt to cope with distress, i.e. coping by not
allowing oneself to get in touch with one’s internal feelings.
The lack of control is understandable given what we said
earlier about these Chinese adolescents being discouraged
to express distress for the sake of keeping group harmony.
In other words, they found themselves having to endure the
effect of these overwhelmingly distressing emotions rather
than allow themselves to gain control over their emotions by
confronting and processing them. Without emotional pro-
cessing, the effect of the abuse lingered over a long period
of time.
This could lead to the emergence of the third emotion
which is a coping strategy. They might have developed a kind
of “alexithymic” state [75] in order to protect themselves by
endorsing an inhibitory mechanism that regulates the flow
of traumatic information [76]. Being unable to differenti-
ate feelings is an attempt to inhibit difficult, intensive and
negative emotions [77, 78] and avoid frightening or intoler-
able feelings [79]. It is therefore not surprising to learn that
betrayal trauma leads to the emergence of dissociation and
difficulties in emotional processing [67]. As was mentioned
in the introduction, the consequence of not allowing these
emotions to be processed is the unresolved and unprocessed
distressing feelings accumulating in the body, causing dis-
turbance in the physiological and neurological system and
later giving rise to health or psychological difficulties [43],
anxiety and depression [44] and negative affects [45].
It is noteworthy that the emotional processing difficulties
of suppression and avoidance had a direct, as opposed to an
indirect, impact on psychiatric co-morbidity (suppression,
r = 0.30, p < 0.001; avoidance, r = 0.28, p < 0.001). This
opens up questions about the roles of emotional processing
strategies. Some seemed to carry the effects of child abuse
onto the distress outcome but others did not. Perhaps this
reflects individual differences in emotional processing. For
example, it has been argued that the way in which we reg-
ulate our emotions is manifested through culture [80] and
influenced by our temperament [81] and personality [82].
It is therefore not inconceivable that certain emotional pro-
cessing difficulties may or may not affect the effect of abuse
on psychiatric co-morbidity among adolescents depending
on their individual differences.
One implication from the findings of the current study for
school principals and parents is that screening for possible
child abuse among adolescent pupils is paramount. Such
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abuse could have a long term impact on their psychologi-
cal well-being which, in turn, could affect their academic
performance. For those who have been identified as having
been abused in the past, opportunity to process distressing
emotions associated with the abuse should be given. What
entails in the procedure for processing these emotions is
beyond the scope of this paper. However, one main com-
ponent is that it be carried out in line with the Chinese col-
lective culture. Otherwise, an adverse effect may occur as
a result of the emotional processing. Also, opportunities
for processing traumatic emotions should not be viewed
as opportunities for treating psychopathologies for adoles-
cents, but as attempts to confront and address maladaptive
coping or protective strategies that these adolescents might
have adopted to deal with emotional exhaustion.
Limitations of the study need to be mentioned. Firstly,
although the PDS is a widely used tool for measuring the
severity of PTSD based on a given list of events, adolescents
could have under-reported the number or type of traumatic
events. Unfortunately, we had no way of verifying this. They
might not have recalled certain traumas since repression of
traumatic memories has been shown to be prevalent dur-
ing childhood or adolescence, although the psychological
mechanisms underlying these memories are controversial
[83, 84]. In other words, the present results could have been
exacerbated by these covert traumatic effects. Secondly, all
adolescents in the present study were selected from voca-
tional schools. Traditionally speaking, these students tend
to have lower academic ability than those in non-vocational
schools. This could have affected the way in which they
understood some of the questions on the measures. Thirdly,
we did not control for the degree of perceived daily stress
among these adolescents. Whether they appraised their cur-
rent academic situation as unpredictable, uncontrollable and
overloading might have affected the degree of psychiatric
co-morbidity. These adolescents might have also encoun-
tered stressful issues pertaining to their parents, school and
wider community as advocated by the developmental con-
textualism framework [85]. Again, whether these factors
might have contributed to overall psychological well-being
is unknown. Lastly, it would have been useful to have some
information on the adolescents’ individual differences, in
terms of cultural beliefs and personality. This might shed
light onto some of their psychological reactions, particularly
concerning emotional processing.
Summary
To conclude, child abuse can impact on emotional process-
ing difficulties which can then affect psychiatric symptoms.
The severity of other past traumas had a limited influence
on this finding.
123
Child Psychiatry Hum Dev (2017) 48:610–618
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