Sleep quality and psychological resilience mediate the association between child maltreatment and externalizing and internalizing problems: A longitudinal study based on an early adolescent cohort

doi:10.21203/rs.3.rs-5011106/v1

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Sleep quality and psychological resilience mediate the association between child maltreatment and externalizing and internalizing problems: A longitudinal study based on an early adolescent cohort

https://doi.org/10.21203/rs.3.rs-5011106/v1

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Child abuse (CM) is considered to be an important risk factor for adolescent externalizing and internalizing problems (EIPs), but the mediating factors that mediate the relationship between the two are different. The purpose of this study was to explore the mediating role of sleep quality and psychological resilience in CM and adolescent EIPs, and to explore the timing of these two mediating variables. Longitudinal data were collected from all the 7th grade students (N = 1814) in a middle school in Huaibei City, Anhui Province. Baseline data were collected in September 2019, followed by two follow-up visits every other year. The main data collected include general demographics, CM, sleep quality, psychological resilience, and EIPs. Correlation analysis was performed using SPASS. Chain mediation analysis in Mplus. There was an association between any two of the four variables of CM, sleep quality, psychological resilience and EIPs. Mediation analysis showed that both sleep quality and psychological resilience independently mediated the association between CM and adolescent EIPs. In addition, when sleep quality and mental resilience continuously mediated the association between CM and EIPs in adolescents, they explained 2.5% (CM-sleep quality-psychological resilience-EIPs) and 2.1% (CM-psychological resilience-sleep quality EIPs) of the CM-EIPs association.

Adolescent

child abuse

sleep quality

psychological resilience

externalizing and internalizing problems

mediation analysis

Both internalizing problems and externalizing problems have negative effects on children's current physical and mental health and subsequent development, and the exploration of risk factors for these two problems is an important topic in the field of public health[1]. Externalizing problems are considered to be a variety of behavioral symptoms, including conduct disorders, hyperactivity symptoms, and aggression[2]. And internalizing problems usually refer to internal symptoms such as anxiety, depression, and sadness, which can comprehensively reflect the psychological and behavioral disorders of children and adolescents[3]. Research has shown that the prevalence of externalizing and internalizing problems (EIPs) among high school students in various states of the United States is 17.8% -34.4%[4], and teenagers are clearly a group with a high incidence of EIPs. The gender difference is that girls tend to exhibit more internalizing problems while boys have more severe externalizing problems[5]. The existence of EIPs is not conducive to maintaining good interpersonal relationships among adolescents and can increase their risk of suicide[6, 7]. Children and adolescents who exhibit high levels of EIPs typically have poorer long-term economic and social outcomes in adulthood[8]. The research conclusions on the causes or risk factors of EIPs are not unified, and child maltreatment (CM) is considered one of the most important risk factors for the emergence and development of EIPs[9, 10].

CM refers to the abuse and neglect suffered by children from their caregivers, which includes five categories: emotional abuse, physical abuse, sexual abuse, physical neglect, and emotional neglect[11]. CM can significantly harm the physical and mental health of adolescents, increasing the burden of adverse health outcomes[12]. According to attachment theory, CM may increase attachment insecurity[13], which can reduce a child's willingness to express emotions and lead to various internalizing problems such as anxiety and depression[14]. In addition, abused children may develop negative coping patterns in the early stages of their lives due to the inability to effectively communicate with the abuser[15], and negative behaviors are more likely to develop into externalizing problems that persist for a considerable period of time[16]. A related biological explanation is that CM stimulation causes neurotransmitters and intracellular signaling dysfunction, so that the nervous system regulated behavior and emotional control is abnormal[17]. A study in China showed a significant positive correlation between CM and internalizing problems (r = 0.284, p < 0.001) and externalizing problems (r = 0.353, p < 0.001) in adolescents[18]. The current risk factor of CM as an EIPs has been widely confirmed[18–20], but the mediating factors involved in the above associations (especially multiple mediators) are rarely mentioned. Therefore, it is necessary to further explore the mechanisms underlying the association between CM and EIPs.

Sleep quality refers to individual satisfaction with multiple aspects of their sleep experience[21]. Adolescents are more sensitive to emotional and mental issues[22], and good sleep can improve their neurobehavioral function[23]. Through traumatic stress pathways, CM may reduce sleep quality by affecting amygdala function[24]. Given that cumulative CM may lead to sleep problems in adolescents[25], a meta-analysis involving 26 studies found that adolescents with a history of CM were 3.9 times and 3.2 times more likely to experience insomnia and nightmares, respectively, compared to adolescents without a history of CM[26]. In addition, sleep problems are closely related to emotional and behavioral problems in children and adolescents. There is longitudinal research evidence to suggest that there is a positive correlation between adolescent sleep problems and baseline and slope internalizing problems[27]. In conducting linear and nonlinear correlation analysis, multiple sleep problems are significantly correlated with EIPs in adolescents[28]. Other studies have found that sleep problems mediate the association between CM and partial EIPs (such as suicidal ideation) in adolescent[29].

Psychological resilience is thought to be a protective factor in reducing the negative effects of CM[30]. Psychological resilience refers to an individual's ability to maintain or improve mental health when exposed to stress in life and thereafter[31]. A literature review that primarily included longitudinal studies found that high-level exposure to CM can lead to sustained low-level psychological resilience[32]. A case-control study in China claims that there is a particularly significant negative correlation between emotional abuse and emotional neglect in participants and psychological resilience[33]. In the group of CM victims, psychological resilience is considered a protective factor for EIPs[34, 35]. The results of randomized controlled trials indicate that interventions focused on psychological resilience are effective in addressing EIPs in both children and adolescents[36]. A cross-sectional study further concluded that the association between CM and EIPs is mediated by resilience[37].

In addition, there is a certain correlation between psychological resilience and sleep quality[38]. Arbinaga investigated the relationship between sleep quality and psychological resilience in dance students[39]. They found that students who reported low sleep quality had lower resilience scores than those who reported high sleep quality. A cross-sectional study in Oman suggests that regular sleep can significantly predict good psychological resilience[40]. Unfortunately, there is still a lack of longitudinal research on sleep quality and psychological resilience.

Based on the above evidence, we hypothesize that sleep quality and psychological resilience may have a continuous mediating effect in the association between CM and EIPs. We established a theoretical hypothesis model (Fig. 1). Corresponding hypothesis: 1) Sleep quality mediates the association between CM and EIPs. 2) Psychological resilience mediates the association between CM and EIPs. 3) Sleep quality and psychological resilience continuously mediate the relationship between CM and EIPs. 4) The order of the two mediating (sleep quality and psychological resilience) variables does not affect the significance of the chain mediation effect between CM and EIPs.

Participants and Procedures

The participants of this study were from the Chinese Early Adolescent Cohort (CEAC), which included all Seventh grader from a high school in Huaibei City, Anhui Province, China as of September 2019. Complete the baseline data survey and subsequent follow-up evaluation in the form of a questionnaire. Follow ups were conducted using the same procedure at 12 months (wave 2, Sep 2020) and 24 months (wave 3, Sep 2021) after the baseline survey (wave 1, Sep 2019). We collected CM information and general demographic information in wave 1, distributed 1814 questionnaires, and finally collected 1784 valid questionnaires. In wave 2, sleep quality and mental resilience were assessed, this time 1,751 participants received questionnaires, of which 72 participants did not provide information on sleep quality or mental resilience, and 1679 valid questionnaires were obtained. In wave 3, the EIPs were measured. 1655 questionnaires were distributed this time, among which 50 did not provide information on EIPs, and 1605 were valid. The response rate for the first wave of surveys was greater than 98%, and the response rate for the two follow-up visits was between 96% and 98%. The main reason for non-response at the beginning of each data collection was that some participants were absent or had dropped out of school on the day of data collection. The number of participants ultimately included in the study was 1605. The data collection process is shown in Fig. 2. The entire data collection process obtained informed consent from students and their parents, and the Biomedical Ethics Committee of Anhui Medical University (ethical approval no. 20180083) approved this study.

Child maltreatment

The Childhood Trauma Questionnaire-Short Form (CTQ-SF) is used to evaluate CM, which consists of five components: physical abuse, emotional abuse, sexual abuse, physical neglect, and emotional neglect[41]. Each component contains five items with a score of 1–5, with a total score of 5-125. The higher the total score of 25 items, the higher the frequency of exposure to CM. The Cronbach’s value in this study is 0.72.

Sleep Quality

The Pittsburgh Sleep Quality Index (PSQI) questionnaire collects data related to sleep quality from participants in the past month[42]. It consists of seven 3-point Likert scales, with a total score of 0–21. The higher the total score, the poorer the corresponding sleep quality. The Cronbach’s value is 0.72.

Psychological Resilience

The Connor-Davidson Resilience Scale (CD-RISC) is rated based on the feelings of the subjects in the past month[43]. It consists of 25 items, all of which use a 5-point Likert scale with a score range of 0 (completely inconsistent) to 4 (almost consistent) points. The higher the total score (0-100), the stronger the psychological resilience. The Cronbach’s value is 0.79.

Externalizing and Internalizing Problems

The Strengths and Difficulties Questionnaire (SDQ) is used to evaluate the EIPs in adolescents[44]. This scale consists of 25 questions and 5 dimensions of mental health issues (emotional symptoms, peer issues, conduct issues, hyperactivity and inattention, and prosocial behavior). This is a 3-point Likert scale with scores ranging from 0 (incorrect) to 2 (of course correct). Based on the suggestion of Goodman et al., we divided SDQ into two broader subscales[45]: internalizing problems (peer and emotional problems) and externalizing problems (behavioral problems and hyperactive inattention), with higher scores indicating higher levels of difficult behavior. In this study, prosocial behavior was not used independently of EIPs. The Cronbach’s value is 0.71, which is an acceptable level.

Covariates

Based on our previous research[46], part of the information reported by participants in wave 1 was taken as potential covariate. This includes gender, age, family structure (1 = nuclear family, 2 = single parent family, 3 = extended family, 4 = orphan), self-rated family economic status (1 = below average, 2 = moderate, 3 = above average), relationship with parents (1 = average or below, 2 = intimate, 3 = very intimate), number of friends (1 = 2 or less, 2 = 3–5, 3 = 6 or more), and whether they are only children (1 = yes, 2 = no).

Statistical Analysis

Descriptive statistical analysis was performed on all variables included in the study in IBM SPASS STATISTICS (V25.0), with continuous variables described as mean ± standard deviation (SD) and categorical variables described as percentages. Use the person correlation coefficient to analyze the correlation between CM, psychological resilience, sleep quality, and EIPs. Finally, continuous mediation analysis was conducted in Mplus (V8.1). Use mediation models to test hypotheses 1 and 2. Use chain mediation analysis to test hypotheses 3 and 4. All mediation analyses were controlled for covariates. The Bootstrap method was used to test the mediating effect, and 5000 repeated measurements were taken to obtain a 95% confidence interval (CI). If the mediating effect is significant, the 95% confidence interval (CI) does not include 0. The effect sizes of all mediation analyses are standardized estimates.

Participant characteristics

Table 1 presents the characteristic information of the participants. The average age of the participants was 12.49 years (± 0.48), with girls accounting for 39.4%. Among them, 16.0% are only children, 46.0% have a nuclear family, 74.4% think their family's economic situation is average, 29.1% think their relationship with their father is very close, 39.7% think their relationship with their mother is very close, and 33.8% have six or more friends. The average score of CM reported by the subjects in wave 1 was 27.63 points (± 4.89). In wave 2, the average sleep quality score was 4.70 (± 2.84), and the average psychological resilience score was 60.54 (± 16.12). The average total score of EIPs obtained from wave 3 measurement is 9.47 (± 5.47).

Table 1

Basic characteristics of 1605 participants. SD, standard deviation.
Variable	Level	Total(n = 1605)
Age, Mean (SD)		12.49 (0.48)
Gender, n (%)
Female		633 (39.4)
Male		972 (60.6)
Only child, n (%)		257 (16.0)
Family structure, n (%)
Nuclear family		738 (46.0)
Single-parent family		252 (15.7)
Big family		593 (36.9)
Orphan		22 (1.4)
Family economic status, n (%)
	1 (lowest)	181 (11.3)
	2	1194 (74.4)
	3 (highest)	230 (14.3)
Relationship with father, n (%)
	1 (average even worse)	472 (29.4)
	2 (close)	666 (41.5)
	3 (very close)	467 (29.1)
Relationship with mother, n (%)
	1 (average even worse)	298 (18.6)
	2 (close)	670 (41.7)
	3 (very close)	637 (39.7)
Number of friends, n (%)
	1 (no more than 2)	443 (27.6)
	2 (3–5)	620 (38.6)
	3 (no less than 6)	542 (33.8)
Child maltreatment score, Mean (SD)		27.63 (4.89)
Sleep quality score, Mean (SD)		4.70 (2.84)
Psychological resilience score, Mean (SD)		60.54 (16.12)
Externalizing and internalizing problems score, Mean (SD)		9.47 (5.47)

Correlation analysis

Table 2 shows the correlation analysis results of key variables in the mediation model. The results indicate that EIPs are significantly positively correlated with CM and sleep quality, while they are significantly negatively correlated with psychological resilience. Sleep quality is significantly positively correlated with CM, and significantly negatively correlated with psychological resilience. There is a significant negative correlation between psychological resilience and CM.

Table 2

Correlation analysis. The selected control variables are age, gender, only child, family structure, family economic status, relationship with father, relationship with mother and number of friends. **, Correlation is significant at the 0.001 level (2-tailed).
	1	2	3	4
1.Child maltreatment	1
2.Psychological resilience	-0.126**	1
3.Sleep quality	0.246**	-0.384**	1
4.Externalizing and internalizing problems	0.263**	-0.330**	0.400**	1

Mediation analysis

Using a chain mediation model to analyze the mediating role of sleep quality and psychological resilience in the relationship between CM and EIPs, the two mediating variables are divided into Model A and Model B in longitudinal order. The two models and their standardized path coefficients are shown in Fig. 3.

The mediating role of sleep quality - psychological resilience

Table 3 shows the results of mediation analysis based on Model A. The direct effect of CM on EIPs is significant (β = 0.172, p < 0.001). CM was significantly correlated with sleep quality and psychological resilience, sleep quality was significantly correlated with psychological resilience and EIPs, and psychological resilience was significantly correlated with EIPs. Sleep quality (ind1 = 0.014, p < 0.05) and psychological resilience (ind2 = 0.083, p < 0.001) can independently mediate the association between CM and EIPs. CM had significant indirect effects on EIPs through sleep quality and mental resilience in turn (ind3 = 0.025, p < 0.001).

Table 3

The direct, indirect and total effects of sleep quality as the primary mediator in the association between child maltreatment and externalizing and internalizing problems. CM, child maltreatment; SQ, sleep quality; PR, psychological resilience; EIPs, externalizing and internalizing problems; CI, Confidence interval; Ind, indirect effect.
Effect	Pathways	Effect value	95%CI	Effect rate, %	P
	CM → SQ	0.289	(0.236, 0.342)		< 0.001
	CM → PR	-0.069	(-0.128, -0.010)		< 0.05
	SQ → EIPs	0.288	(0.237, 0.339)		< 0.001
	PR → EIPs	-0.208	(-0.255, -0.161)		< 0.001
	SQ → PR	-0.413	(-0.457, -0.368)		< 0.001
Direct effect	CM → EIPs	0.172	(0.123, 0.222)	58.50%	< 0.001
Indirect effect	Ind1: CM → SQ → EIPs	0.014	(0.002, 0.027)	4.76%	< 0.05
	Ind2: CM → PR → EIPs	0.083	(0.062, 0.105)	28.23%	< 0.001
	Ind3: CM → SQ → PR → EIPs	0.025	(0.017, 0.033)	8.50%	< 0.001
Total indirect effect		0.122	(0.094, 0.151)	41.50%	< 0.001

The mediating role of psychological resilience - sleep quality

Based on model B, the analysis results when psychological resilience is the first mediation in the mediation chain are shown in Table 4. The direct effect (β = 0.172, p < 0.001) and total indirect effect (β = 0.122, p < 0.001) of CM on EIPs are significant. CM has a significant indirect effect on EIPs through sleep quality (ind1 = 0.039, p < 0.001) or psychological resilience (ind2 = 0.062, p < 0.001). Psychological resilience and sleep quality successively mediated the correlation between CM and EIPs (ind3 = 0.021, p < 0.001).

Table 4

The direct, indirect and total effects of psychological resilience as the primary mediator in the association between child maltreatment and externalizing and internalizing problems. CM, child maltreatment; SQ, sleep quality; PR, psychological resilience; EIPs, externalizing and internalizing problems; CI, Confidence interval; Ind, indirect effect.
Effect	Pathways	Effect value	95%CI	Effect rate, %	P
	CM→ SQ	0.215	(0.167, 0.263)		< 0.001
	CM→ PR	-0.188	(-0.250, -0.125)		< 0.001
	SQ→ EIPs	0.288	(0.237, 0.339)		< 0.001
	PR→ EIPs	-0.208	(-0.255, -0.161)		< 0.001
	PR→ SQ	-0.392	(-0.434, -0.350)		< 0.001
Direct effect	CM→ EIPs	0.172	(0.123, 0.222)	58.5%	< 0.001
Indirect effect	Ind1: CM→ SQ→ EIPs	0.039	(0.023, 0.055)	13.27%	< 0.001
	Ind2: CM→ PR→ EIPs	0.062	(0.044, 0.080)	21.09%	< 0.001
	Ind3: CM→ PR→ SQ→ EIPs	0.021	(0.013, 0.029)	7.14%	< 0.001
Total indirect effect		0.122	(0.094, 0.151)	41.5%	< 0.001

This study focuses on middle school students and analyzes the relationship between CM, EIPs, sleep quality, and psychological resilience. The descriptive analysis results indicate a significant correlation between the above variables. Intermediary analysis found that both sleep quality and psychological resilience can mediate the association between CM and EIPs independently or continuously. At the same time, the positions of the two mediating variables (sleep quality and psychological resilience) in this continuous mediation can be swapped.

Firstly, the results of the direct effect indicate a significant positive correlation between EIPs in adolescents and CM, and experiencing more CM indicates more EIPs, which is similar to the results of a recent study[47]. A reduction in the volume of the brain's hippocampus, a region with higher concentrations of glucocorticoid receptors, has been demonstrated in those who experience CM[48, 49], and glucocorticoids increase an individual's susceptibility to EIPs, such as depression, via the hypothalamic-pituitary-adrenal (HPA) axis[50, 51]. The stress model provides another explanation: exposure to early negative life events (such as CM) increases an individual's stress, while high levels of stress increase individual susceptibility to psychological and behavioral problems[52]. Some argue that CM is often associated with lower socio-economic status, and that poor parenting practices are associated with EIPs[53].

Secondly, we found that sleep quality mediates the association between CM and adolescent EIPs, which is consistent with our hypothesis. The impact of CM on sleep quality is persistent and can last up to 50 years[54, 55]. Adolescents who have experienced CM tend to choose adaptive emotional regulation strategies when faced with emotional distress[2], and they take longer to shake off the effects of negative emotions, and sleep quality during this period is significantly affected[56]. Poor sleep quality can lead to a series of EIPs such as emotional disorders and attention deficit hyperactivity disorder (ADHD)[57, 58]. The possible reason is that sleep problems lead to intermittent hypoxia, resulting in increased physical activity[58], reduced social interaction, and emotional disorders, among other psychological and behavioral problems[59].

Next, the resilience of our research center also mediates the association between CM and adolescent EIPs. Research has shown that resilience plays a protective role in the process of internalizing and externalizing issues in children who experience abuse[60], and our analysis results are similar to this. The association between CM and psychological resilience is still controversial. Yoon et al. believe that CM cannot significantly predict resilience[61], which may be related to his consideration of only a single type of abuse. Another study suggests that CM negatively predicts psychological resilience, indirectly affecting emotions[30]. As psychological problems accumulate, it ultimately leads to various EIPs such as conduct disorders and ADHD[19, 62].

Finally, we found that sleep quality and psychological resilience continuously mediate the association between CM and EIPs. CM reduces psychological resilience by reducing sleep quality, ultimately leading to EIPs. Individuals with poor sleep quality are unlikely to have better self-reported mental health status, so the evaluation results of psychological resilience are usually lower[38]. It is worth noting that after swapping the order of the two mediating variables (psychological resilience, sleep quality), the chain mediation effect (CM - psychological resilience - sleep quality - EIPs) remains significant. Similar studies claim that resilience mediates the association between family dysfunction and adolescent sleep quality, and interventions targeting resilience may improve sleep quality[63]. Low elasticity may lead to insomnia through supporting emotions and arousal disorders, which seems to be a vicious cycle: low elasticity leads to poor sleep quality, which in turn leads to low elasticity[64].

This study has the following advantages. Firstly, our data comes from a large sample size (n = 1605) cohort of junior high school students, analyzing the association between CM and EIPs in adolescents, as well as the mediating role of sleep quality and psychological resilience, which increases the reliability of the results. Secondly, we fully controlled for covariates that may be related to EIPs, and standardized the results of the mediation analysis. Thirdly, we explored the impact of the vertical order of two mediating variables on the chain mediated effect.

There are still limitations to this study: firstly, we did not use baseline data on adolescent EIPs, which may result in biased results. Secondly, this study only used the total score of CM and the total score of EIPs for analysis, without considering the individual effects of different types of CM and the impact of CM on a single internalizing/externalizing problem. Next, we will not discuss the gender differences in mediating effects. In addition, most of the research data is self-reported by students, and retrospective collection of CM data may have recall bias. Finally, this study was only conducted among middle school students, and the research findings may not be applicable to the adolescent population, including high school students.

This longitudinal study provides evidence of mediating variables in the association between CM and EIPs among adolescents. The analysis results indicate that both sleep quality and psychological resilience can independently mediate the above associations. In addition, we determined that the sequence of two mediating variables (sleep quality and psychological resilience) before and after swapping will not change the significance of the chain mediation effect. The significance of these findings is that by helping to improve the sleep quality of adolescents and enhancing their psychological resilience, it may prevent or reduce EIPs among those who have experienced CM.

Author Contribution

Faliang Xie and Xinhui Wang: conceptualization, formal analysis, data curation, methodology, validation, visualization, writing - original draft, writing - review & editing. Ting Tang, Fan Wang, Dongxue Zhu, Yingying Tong and Xue Wen: methodology, data curation, validation, writing - review & editing. Puyu Su and Gengfu Wang: conceptualization, investigation, funding acquisition, supervision, writing - review & editing. All the authors agreed to the submission of the manuscript version. Faliang Xie and Xinhui Wang contributed equally to this work.

Acknowledgement

The study was approved by the National Natural Science Foundation of China (grant no. 82173539, 82204071, 81874268). The authors thank all the participants involved in this study and the students and their parents for their cooperation.

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No competing interests reported.

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Sleep quality and psychological resilience mediate the association between child maltreatment and externalizing and internalizing problems: A longitudinal study based on an early adolescent cohort

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Abstract

Figures

Introduction

Methods

Participants and Procedures

Child maltreatment

Sleep Quality

Psychological Resilience

Externalizing and Internalizing Problems

Covariates

Statistical Analysis

Results

Participant characteristics

Correlation analysis

Mediation analysis

The mediating role of sleep quality - psychological resilience

The mediating role of psychological resilience - sleep quality

Discussion

Declarations

Author Contribution

Acknowledgement

References

Additional Declarations

Status:

Version 1