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Aging & Mental Health
Vol. 14, No. 4, May 2010, 489–501
The long-term impact of childhood abuse on internalizing disorders among older adults:
The moderating role of self-esteem
Natalie Sachs-Ericsson
a
*, Mathew D. Gayman
b
, Kathleen Kendall-Tackett
c
, Donald A. Lloyd
d
,
Amanda Medley
a
, Nicole Collins
a
, Elizabeth Corsentino
a
and Kathryn Sawyer
a
a
Department of Psychology, Florida State University, Tallahassee, FL, USA;
b
Cecil G. Sheps Center for Health Services
Research, University of North Carolina, Chapel Hill, NC, USA;
c
Department of Pediatrics, School of Medicine,
Texas Tech University, Amarillo, TX, USA;
d
Department of Sociology, Florida State University, Tallahassee, FL, USA
(Received 13 May 2009; final version received 26 June 2009)
Objectives: First, to determine if childhood experiences of abuse have an impact on internalizing
disorders (e.g., anxiety and depressive disorders) among older adults. Second, we wish to determine if
self-esteem plays a role in explaining the relationship between abuse and internalizing disorders.
Method: First, we conducted an analysis on a population sample of participants aged 50 years or older (mean
age ¼67 years; SD ¼10.3) assessed at two time points, three years apart (Wave 1, N¼1460; Wave 2, N¼1090).
We examined the relationship between reports of childhood abuse (physical, emotional, and sexual) and
internalizing disorders. Second, we determined the role self-esteem played in explaining the relationship.
Results: We found that childhood experiences of abuse assessed at Wave 1 predicted the number of DSM-IV
internalizing disorders occurring three years later. Demonstrating the specificity of self-esteem; we found
self-esteem, but not emotional reliance, to moderate the relationship between abuse and internalizing disorders
such that childhood abuse had more negative effects on those with low self-esteem compared to those with higher
self-esteem. Contrary to prediction, self-esteem did not mediate the relationship between abuse and internalizing
disorders.
Conclusion: The negative effects of childhood abuse persist for many years, even into older adulthood. However,
contrary to the findings in younger adults, self-esteem was not correlated with childhood abuse in older adults.
Moreover, childhood abuse only had a negative effect on those who had low self-esteem. It may be through the
process of lifespan development that some abused individuals come to separate out the effects of abuse from their
self-concept.
Keywords: older adults; childhood abuse; self-esteem; internalizing disorders
Introduction
Child abuse is a major life stressor that has important
consequences for several indices of mental health in
adults (Sachs-Ericsson, Verona, Joiner, & Preacher,
2006). However, the majority of studies examining the
negative consequences of abuse have focused on
adolescents and young adults. While there have been
studies of general population samples, few population
studies have focused predominately on older adults. In
the current study, we examined the influence of
childhood abuse on the occurrence of internalizing
disorders (e.g., anxiety and depressive disorders) in a
population of adults aged 50 years and older (mean
age ¼67 years; SD ¼10.3). First, we wished to estab-
lish whether childhood abuse had far-reaching effects
in increasing rates of internalizing disorders, even for
the adults over the age of 50 years. Second, we wished
to determine the mechanisms (i.e., low self-esteem) by
which early abuse may influence the psychiatric func-
tioning in older adults.
A growing body of literature has established an
association between childhood abuse and an array of
negative outcomes. However, many studies on abuse
have been based on clinical samples or identified cases
of abuse. These samples may include the most severe
cases of abuse and thus may not be representative of
the general population. Thus, general population
samples may further our understanding of the negative
outcomes of abuse. Several epidemiological studies
have documented the association between abuse and
negative health and psychiatric outcomes (Cromer
& Sachs-Ericsson, 2006; Sachs-Ericsson, Blazer, Plant,
& Arnow, 2005; Sachs-Ericsson, Kendall-Tackett, &
Hernandez, 2007). However, it is important to note
that most population studies showing an association
between childhood abuse and psychiatric disorders
have been, for the most part, based on cross-sectional
samples, in which conclusions regarding temporal
order cannot be made. Few longitudinal studies have
examined the relationship between child abuse and
mental health. Those that have been conducted have
also primarily focused on young adults and have been
predominantly based on samples selected from docu-
mented cases of abuse. These studies most likely
comprise the more severe cases of abuse; thus, these
studies’ findings may over-estimate the association
between abuse and mental health outcomes and may
not generalize to the population as a whole.
*Corresponding author. Email: sachs@psy.fsu.edu
ISSN 1360–7863 print/ISSN 1364–6915 online
ß2010 Taylor & Francis
DOI: 10.1080/13607860903191382
http://www.informaworld.com
Furthermore, it is not clear if results from such studies
are applicable to older adults.
In the current study, assessing retrospective reports
of childhood abuse at baseline (Wave 1), we examined
the frequency of one year DSM-IV internalizing
disorders assessed three years later in a population
sample of adults aged 50 years and older (mean
age ¼67 years; SD ¼10.3) (Table 1). We also examined
the potential mediating/moderating effects of
self-esteem in the abuse–mental health relationship,
as previous studies have suggested that low self-esteem
can influence the impact of child maltreatment on
internalizing health disorders (Collishaw et al., 2007;
Rutter, 2007).
Childhood abuse and internalizing disorders
Early experiences of abuse may be one mechanism that
underlies the development of internalizing disorders
(Sachs-Ericsson et al., 2006). For example, adults with
histories of sexual, physical, or emotional abuse are at
increased risk for developing depression (Danielson,
de Arellano, Kilpatrick, Saunders, & Resnick, 2005),
anxiety disorders, post-traumatic stress disorder
(PTSD) (Molnar, Buka, & Kessler, 2001; Spataro,
Mullen, Burgess, Wells, & Moss, 2004), and internaliz-
ing disorders in general (Sachs-Ericsson et al., 2006).
There is a high comorbidity among anxiety and
depression (Brown & Barlow, 1992; Kessler et al. 1998;
Krueger, 1999). It has been suggested that these
patterns of comorbidity represent meaningful covar-
iance. Specifically, Krueger and colleagues identified a
two-factor model of common mental disorders, with an
internalizing factor representing mood and anxiety
disorders. This dimensional model suggests that each
factor (or cluster of related disorders) represents a
common underlying process of psychopathology
(Krueger et al. 2002; Krueger, McGue, & Iacono,
2001). Building on this conceptualization, one hypoth-
esis is that anxiety and depressive disorders are
comorbid because they share common vulnerabilities.
In this study, we investigated negative self-concept,
specifically, self-esteem, as a likely sequela of abuse
which is a potential psychological vulnerability factor
to internalizing symptoms.
Abuse has been found to be associated with several
internalizing disorders. Depression is common among
adult survivors of childhood physical and sexual abuse
(Goldberg, 1994; Levitan et al., 1998; Molnar et al.,
2001; Roosa, Reinholtz, & Angelini, 1999;
Sachs-Ericsson et al., 2006; Turner & Muller, 2004;
Zuravin & Fontanella, 1999). Studies using longitudi-
nal designs and based on identified abused samples
have shown this association. For example, researchers
(Spatz-Widom, DuMont, & Czaja, 2007) examined
whether abused and neglected children followed up
into young adulthood were at an elevated risk of major
depressive disorder (MDD) compared with matched
control subjects. In this study, child abuse and neglect
were associated with an increased risk for current
MDD (odds ratio [OR], 1.51) in young adulthood.
Lifetime MDD was also greater among children who
experienced physical abuse (OR, 1.59) or multiple
types of abuse (OR, 1.75). However, few studies have
examined this association in older adults.
Anxiety disorders have also been found to be
associated with a history of childhood abuse and, in
particular, PTSD. In one study (Widom, 1999), victims
of substantiated child abuse were matched with
Table 1. Characteristics of older sample at Wave 1 by abuse status.
Characteristics
Overall (N¼1460) Abused (N¼105) Non-abused (N¼1355)
For X
2
p-value
Mean (SD) or
frequency
Mean (SD)
or frequency
Mean (SD)
or frequency
Gender 42.4% Female 72.3% Female 56.4% Female X
2
¼10.12 0.001
Age 67.12 (10.28) 63.46 (8.72) 67.41 (10.34) F¼9.49 0.002
Screened as disabled 45.5% Yes 65.3% Yes 44.0% Yes X
2
¼16.97 p50.001
Instrumental
Activity limitations
11.26 (6.22) 13.22 (5.94) 11.09 (6.22) F¼1.17 0.28
Education (years) 11.45 (4.40) 11.91 (4.74) 11.42 (4.37) F¼1.58 0.21
Household income 4.99 (3.99) 6.31 (4.59) 4.88 (3.92) F¼4.51 0.03
Family-of-origin
employment problems
7.2% parents
didn’t have a job
14.8% parent
didn’t have a job
6.7% parent
didn’t have a job
X
2
¼8.67 0.009
Childhood abandonment
Never abandoned 84.9% 60.9% 86.8% X
2
¼80.415 p50.001
Sometimes abandoned 10.8% 21.8% 9.9%
Often abandoned 3.7% 12.6% 3.1%
Frequently abandoned 0.5% 4.8% 0.2%
Parents abused substances 6.1% Yes 29.1% Yes 6.7% Yes X
2
¼0.000 p50.001
Self-esteem
a
8.29 (3.50) 8.32 (3.00) 8.29 (3.54) F¼2.89 0.09
Emotional reliance
b
9.78 (4.27) 8.98 (4.17) 9.84 (4.28) F¼0.60 0.44
Internalizing disorders 0.05 (0.28) 0.12 (0.45) 0.04 (0.26) F¼26.46 p50.001
Notes:
a
Higher score indicates higher self-esteem.
b
Higher score indicates higher emotional reliance.
490 N. Sachs-Ericsson et al.
non-abused controls and followed into young adult-
hood. Childhood victimization was associated with
increased risk for current and lifetime PTSD. Nearly a
third or more of the childhood victims of sexual abuse
(37.5%), physical abuse (32.7%), and neglect (30.6%)
met DSM-III-R criteria for lifetime PTSD. In a
cross-sectional population-based study (Schneider,
Baumrind, & Kimerling, 2007), childhood sexual,
physical, and emotional abuse were associated with
increased risk for mental health problems. In particu-
lar, exposure to all three types of child abuse was
linked to a 23-fold increase in PTSD. Finally, a
meta-analysis of 37 studies published between 1981
and 1995, and involving 25,367 people, demonstrated
an average weighted effect size for PTSD of 0.40 and
for depression of 0.44 (Paolucci, Genuis, & Violato,
2001).
The influence of child abuse in older populations
While research is limited, unfortunately, it appears that
the negative effects of childhood abuse may last a
lifetime. A handful of studies have been conducted
which show that there is an apparent relation between
abuse experienced in childhood and negative outcomes
in older adulthood. For example, Talbot et al. (2009)
found that childhood sexual abuse victims were at a
higher risk for medical illness burden, worse physical
function, and greater bodily pain as compared to
people who had not been abused, in those aged 50
years and over. In a study that examined 21,000 adults
aged 60 and over, individuals who had experienced
childhood physical and sexual abuse were at a higher
risk for poor physical and mental health (Draper et al.,
2008).
Self-esteem and abuse
A large body of evidence demonstrates an association
between traumatic stress exposure and self-esteem
(Cheng & Lam, 1997; Kreger, 1995; Lo, 2002;
Youngs, Rathge, Mullis, & Mullis, 1990). Traumatic
childhood events may have greater consequences on
the development of one’s self-esteem given that this is
an important developmental period in the life course.
For example, in a longitudinal study, children who
experienced maltreatment were found to have lower
levels of self-esteem compared to matched controls
(Bolger, ChaPatterson, & Kupersmidt, 1998). A study
of college students (Lopez & Heffer, 1998) examined
the impact of physical abuse on self-esteem and social
competence. After controlling for ethnicity and socio-
economic status, those who have been physically
abused had the lowest self-concept. Another study
(Schuck & Widom, 2001) found that survivors of
childhood abuse had significantly lower self-esteem
than their non-abused counterparts and were signifi-
cantly more likely to report that they felt worthless.
The researchers concluded that the experience of
physical abuse led to a perception of lower parental
support, which led to low self-esteem. In a
meta-analysis of the relationship between child sexual
abuse and adult psychological adjustment, results
indicated statistically significant relationships between
the experience of child sexual abuse and subsequent
difficulties in psychological adjustment as measured by
psychological symptomatology, depression, and
self-esteem (Jumper, 1995). However, no study to our
knowledge has examined the association of childhood
abuse to self-esteem in older adults. It would be of
interest to determine if the effects of childhood abuse
on self-esteem found among young adults persist into
later life.
Possible mechanisms
Coping resources, such as self-esteem, are invariably
tied to the social relationships and interactions humans
have with each other. There are several possible
mechanisms by which childhood abuse may decrease
self-esteem, which in turn increases the risk for
psychopathology. There has been some evidence that
childhood abuse confers risk for development of a
negative cognitive style (Gibb, 2002), which is a risk
factor for depression (Alloy et al., 1999) and inter-
nalizing disorders in general (Sachs-Ericsson et al.,
2006).
Negative cognitive style (Abramson, Metalsky, &
Alloy, 1989) has been defined as a characteristic way of
attributing the causes of negative life events to stable
and global factors and making self-critical judgments
of one’s character (e.g., ‘I am worthless’) (Alloy et al.,
2004; Seligman, Abramson, Semmel, & von Baeyer,
1979), as well has having dysfunctional attitudes and
maladaptive self-schemas (e.g., negative self-concepts)
(Beck, 1987). Thus, one aspect of a negative cognitive
style can be operationalized as having a self-critical
style or low self-esteem (Beck, 1983; Blatt, 1974).
Individuals who develop low self-esteem may have
been influenced by their interpretations of why the
abuse occurred. Among abused individuals, interpreta-
tions of self-blame are associated with a negative
attritional style, self-criticism, and low self-esteem and
are known risk factors for internalizing disorders
(Sachs-Ericsson et al., 2006). However, the specificity
of a negative self-concept as a mediator/moderator of
the abuse–mental health association has not been well
examined.
In addition to negative self-concept, there are other
factors, specifically interpersonal dependence (or emo-
tional reliance), that have been identified as vulnera-
bility markers for internalizing disorders. Indeed,
emotional reliance has been identified by several
prominent theorists as a vulnerability marker for
depression (Beck, 1983; Blatt, 1974). Emotional reli-
ance involves the need for others’ approval for the
feeling of self-worth (Turner, Taylor, & Van Gundy,
2004). Dependent characteristics reflect extreme
Aging & Mental Health 491
distress in relation to the loss or abandonment of a
significant other, or a strong need for approval
(Zuroff, Blatt, Sanislow, Bondi, & Pilkonis, 1999).
Victims of childhood abuse may come to rely on the
appraisals of others for their sense of self-esteem. In
addition, relying on others’ appraisal can have negative
consequences for mental health. Indeed, there is
evidence that emotional reliance is directly related to
mental health, such that higher levels of emotional
reliance are associated with depressive symptoms
(Turner et al., 2004). Thus, both a self-critical style
associated with low self-esteem and a dependent
interpersonal style, or emotional reliance, have been
posited as important vulnerability markers for depres-
sion (Blaney & Kutcher, 1991; Blatt, 1974). Indeed,
independent effects of emotional reliance and a nega-
tive self-concept on depression have emerged in some
studies (Mongrain, Lubbers, & Struthers, 2004), but
few have investigated the extent to which self-esteem,
in contrast to emotional reliance, serves as a mediator/
moderator of the relationship between childhood abuse
and internalizing symptoms (Sachs-Ericsson et al.,
2006). However, in our previous work based on a
general population sample (Sachs-Ericsson et al.,
2006), we found that self-criticism, but not dependency
traits, partially mediated the relationship between
abuse and internalizing symptoms. We concluded
that a negative self-concept played a more potent role
than dependency because abuse either directly or
indirectly conveys to the child that he or she is of less
worth. Once internalized, such thoughts (e.g., ‘I’m
worthless’) are an important vulnerability marker for
internalizing disorders. No studies, to our knowledge,
have examined these relationships among older adults.
In the current study we have theorized that low
self-esteem, rather than emotional reliance, would play
a role in the development of internalizing disorders
among abused individuals. This is because the negative
self-cognitions that underlie low self-esteem are likely
directly or indirectly supplied to the child by the abuser
(e.g., ‘You are of little worth’). Specifically, in the
current study of older adults we expect that the
negative influence of abuse would be greater for
those with low self-esteem, but not high emotional
reliance, because the specific self-critical attributions
associated with low self-esteem would play a more
central role in the development of internalizing
disorders in comparison to emotional reliance.
Indeed, research has found an association between
negative self-concept, attributional style, childhood
abuse, and psychopathology. For example, in a study
of college-aged women (McCauley et al., 1997), the
authors concluded that the psychopathology among
adults who suffered emotional abuse in childhood is
produced by the detrimental effect of abuse on
personality and takes the form of immature defense
organization and damaged self-representation. In
another study (Feiring, Taska, & Chen, 2002),
abuse-specific internal attributions were consistently
related to higher levels of psychopathology and in
particular PTSD. Shame also was an important
predictor of symptom level and mediated the relation-
ship between abuse-specific internal attributions and
PTSD symptoms. In addition, self-esteem has been
shown to moderate (Southall & Roberts, 2002; Turner
et al., 2004) and mediate (Cheng & Lam, 1997) the
effects of social stress on depression.
Self-esteem in the life course of older adults
Among older adults, high self-esteem is considered to
be one indicator of successful aging (Baltes & Baltes,
1990), in part because of its link to life satisfaction and
psychological well-being (Markus & Herzog, 1992).
Markus and Herzog (1992) propose that the
self-concept determines how individuals will respond
to experiences and events in old age. Furthermore, low
self-esteem among elderly individuals has been found
to be associated not only with poorer mental health,
but also with poorer physical health and functioning
(Hunter, Linn, & Harris, 1981–1982). Among older
adults, part of successful aging may entail the ability,
through the life course, to come to terms with earlier
negative life events such that these negative events
come to have less effect on self-concept. Thus, unlike
younger populations, in which a moderate to strong
association between abuse and low self-esteem has
been documented, we might expect among older adults
to find more variability in the association between
child abuse and self-esteem, and thus weaken the
association between abuse and self-esteem.
The current study
In the current study, we examined the association
between retrospective reports, at baseline, of childhood
abuse (physical, emotional, and sexual), and the
subsequent occurrence of the number of one year
DSM-IV internalizing disorders assessed three years
later in a population of older adults (50þ, mean age 67
years). Despite the fact that abuse occurred decades
earlier, we hypothesized that abuse would predict
increased rates of internalizing disorders. While there
have been several cross-sectional studies showing an
association between childhood abuse experiences, neg-
ative self-concepts and internalizing disorders, there
have been few population studies examining the
association between retrospective reports of abuse,
and subsequent internalizing disorders and the role
that self-esteem plays in the maintenance of internaliz-
ing disorders over time. Furthermore, no studies, to
our knowledge, have observed these relationships
among older adults. In the current study, we expected
that those who have been abused would have lower
levels of self-esteem, and that self-esteem will both
mediate and moderate the association between abuse
and subsequent internalizing disorders. Specifically,
we predicted that self-esteem will explain, in part,
the association between childhood abuse and
492 N. Sachs-Ericsson et al.
internalizing disorders. Regarding the moderating
hypothesis, we expected that childhood abuse will
have a greater negative impact on those who have
lower self-esteem compared to those who have higher
levels of self-esteem. In order to evaluate the specificity
of self-esteem in the relationship between childhood
abuse and internalizing disorders, we also tested these
hypotheses using emotional reliance as a potential
mediator/moderator, another known risk factor for
depression.
Method
Sample
The data employed in this study were from The
Physical Health and Disability Study a two-wave
(Wave 1 and Wave 2) panel study of Miami-Dade
County residents that included a substantial over-
sampling of individuals with a physical disability. The
sampling methods have been described in detail else-
where (Gayman, Turner, & Cui, 2008; Turner, Lloyd,
& Taylor, 2006). Briefly, a total of 10,000 randomly
selected households were screened with respect to
gender, age, ethnicity, disability status, and language
preference. Using this sampling frame, the study
sample was drawn such that there were equal numbers
of women and men, equal numbers of people screened
as having a physical disability and those not having a
physical disability, and equivalent numbers of the four
major ethnic groups comprising more than 90% of all
Miami-Dade County residents (non-Hispanic Whites,
Cubans, non-Cuban Hispanics, and African
Americans). It is important to note that these
proportions departed only slightly from those for the
county as a whole.
The oversampling of physically disabled partici-
pants was conducted for reasons unrelated to the
current research questions. However, because disability
and poorer physical functioning is associated with both
child abuse and increased internalizing disorders, these
variables were controlled for in the current analyses.
Interviews
Well-trained and predominantly bilingual interviewers
administered computerized questionnaires in either
English or Spanish as preferred by each participant.
The majority of interviews took place in the homes of
participants. However, a small number of interviews
were conducted at alternative sites or by telephone
when requested by the participants.
A total of 1986 first-wave interviews were com-
pleted in 2000–2001 (82% success rate). A total of 1086
adults who were screened for having no physical
disability and 900 individuals who screened as having a
disability were included. The oversampling of indivi-
duals with a physical disability and the fact that
the nondisabled participants were group matched
on race/ethnicity, gender, and age resulted in a
greater proportion of older respondents than in the
general population. Ages in the sample ranged from 18
to 93 years, with a median of 59 years (the median age
of the general population of Miami-Dade County in
2000 was 35.6 years; see Census, 2000, Summary File 1,
Table P13). Given this discrepancy in ages and the
oversampling of individuals with a physical disability,
it cannot be claimed that the sample was representative
of the Miami-Dade County population. Conclusions
based on this study must keep this limitation in mind.
Importantly, for the current study we included only
older adults. Thus, we identified a subsample of the
population who were 50 years of age or older. This
population subsample will be described in greater
detail below.
Second-wave interviews of 1495 Wave 1 partici-
pants were completed approximately three years later
(82.5% success rate). A total of 1362 study participants
provided valid data. This included 55.9% women,
21.7% non-Hispanic Whites, 25.3% Cuban
Americans, 18.8% non-Cuban Hispanics, and 34.1%
African Americans.
Measures
The survey included baseline measures of retrospective
reports of childhood abuse experiences (including
emotional, physical, and sexual abuse) and assessed
participants’ level of self-esteem. Three years later
participants were re-interviewed, and one year
DSM-IV diagnoses, including internalizing disorders
(e.g., mood and anxiety disorders), were obtained.
Demographic variables
A comprehensive psychosocial section obtained parti-
cipants’ demographic information, including partici-
pants’ age, gender, years of education, and family
income.
Internalizing disorders
In the current study, at Wave II, participants’ one year
DSM-IV psychiatric diagnoses were assessed using the
semi-structured Composite International Diagnostic
Interview (CIDI) (World Health Organization, 1990)
conducted by highly trained and closely supervised
interviewers. The reliability and validity of the CIDI
has been established in prior work (Wittchen, 1994).
For the purposes of this study, we examined
diagnostic information relevant to the internalizing
syndromes (including diagnoses of MDD, dysthymia,
generalized anxiety disorder, phobia, social phobia,
PTSD, and panic disorder). We used a diagnostic
count variable (number of one year DSM internalizing
disorders) at the three year follow-up (e.g., Wave 2) as
the dependent measure.
Childhood abuse items
At baseline the list of traumatic events included
questions about being raped, molested, and
Aging & Mental Health 493
physically abused. It is also important to note that the
PTSD module, in which the abuse items were
embedded, has been shown to have good validity and
reliability (Kessler, 2000).
Sexual abuse. The list of negative life events included
the following sexual abuse items: (1) (Rape) ‘Did you
ever have sexual intercourse when you didn’t want to
because someone forced you or threatened to harm
you if you didn’t?’ (2) Molestation: ‘Were you ever
touched or made to touch someone else in a sexual way
because they forced you in some way, or threatened to
harm you if you didn’t?’ Participants were then asked
the age at which this abuse first occurred. Those who
reported that the abuse occurred before the age of 15
were coded one ‘Yes, childhood sexual abuse’, the
remaining participants were coded two ‘No, childhood
sexual abuse’.
Physical abuse. Participants were asked, ‘Were you
regularly physically abused by one of your parents,
step-parents, grandparents, or guardians?’ Those who
reported that such abuse occurred before the age of 15
were coded one ‘Yes, childhood physical abuse’, the
remaining participants were coded two ‘No, childhood
physical abuse’.
Emotional abuse. Participants were asked the follow-
ing; ‘Were you regularly emotionally abused by one of
your caretakers?’ Those who reported that the abuse
occurred before the age of 15 were coded one ‘Yes,
childhood emotional abuse’, the remaining partici-
pants were coded two ‘No, childhood emotional
abuse’.
Abuse scale. A variable was created to identify the
number of abuse experiences reported. The scale
ranged from zero ‘No childhood abuse’ to three
‘Experienced all three types of abuse’ (e.g., sexual,
physical, or emotional). This abuse scale was then used
as a predictor variable of internalizing disorders.
Covariates in analyses
Disability and activity limitations
Because this study oversampled for individuals who
had physical limitations, we controlled for the presence
or absence of physical limitations as well as the severity
of the effect of the limitation on functioning. Persons
who self-confirmed that they had a physical disability
are coded as one, otherwise coded as 0.
Our analyses controlled for degree of limitations
estimated by a relatively comprehensive measure of
activities of daily living. The items for this measure
were drawn from an array of previously employed
indices (Fries, Spitz, Kraines, & Holman, 1980; Jette,
1980; Jette & Deniston, 1978; Katz, Downs, Cash, &
Grotz, 1970; Lawton & Brody, 1969; Nagi, 1976;
Rosow & Breslau, 1966) selected to capture difficulties
related to the performance of instrumental activities of
daily living (IADL) and physical mobility across a
continuum varying from no impairment (1) to severe
impairment (5).
For example, items included: Can you prepare your
own meals? Can you do your housework? Can you
dress and undress yourself? Can you get in and out of
bed? Can you take a bath or shower? Can you get to
the bathroom on time? Can you climb up stairs?
Participants used the following response scale: one
(Easily), two (With Difficulty But Without Help), three
(With Special Equipment But No Help), four (With
Help From Someone), and five (Completely Unable to
Do This).
This study also controlled for several
family-of-origin variables known to be associated
with abuse, including childhood abandonment experi-
ences, economic difficulties in childhood, and parental
substance misuse, as these can also lead to negative
sequela similar to those caused by abuse (Felitti et al.,
1998; Kenny & McEachern, 2000).
Family-of-origin variables
Childhood separation–abandonment
Several variables were identified as potential correlates
of childhood abuse. Parental abandonment was
assessed with the following four items. Participants
were asked to indicate if they had: (1) Ever been sent
away from home or kicked out of the house because
you did something wrong? (2) Were you ever aban-
doned by one or both of your parents? (3) As a child,
did you ever live in an orphanage, foster home, a group
home, or were you a ward of the state? (4) Were you
ever forced to live apart from one or both of your
parents? (Yes/No). It is important to note that these
items, to some extent, may represent a type of
emotional abuse. Thus, the relationship between this
variable and internalizing disorders is of interest in the
context of the current work.
Family history of substance symptoms
Participants were asked about parental substance
abuse. Specifically, participants were asked, ‘Did
either of your parents drink or use drugs so often or
so regularly that it caused problems for the family?’
(Yes/No).
Potential mediators
Self-esteem
A subset of Rosenberg’s (1979) measure is employed in
order to assess self-esteem. The Rosenberg Self-Esteem
Scale (RSE) is an attempt to achieve a unidimensional
measure of global self-esteem. It was designed to be a
Gutman scale, which means that the RSE items were to
494 N. Sachs-Ericsson et al.
represent a continuum of self-worth statements ranging
from statements that are endorsed even by individuals
with low self-esteem to statements that are endorsed
only by persons with high self-esteem. Respondents are
presented with six items that include statements such
as, ‘You feel that you have a number of good qualities’
and ‘All in all, you are inclined to feel that you are a
failure’. Response categories range from ‘strongly
agree’ to ‘strongly disagree’ on a 5-point scale. All
responses are coded so that higher values equate to
greater self-esteem. Cronbach’s was 0.79.
Emotional reliance
One of the factors of interpersonal dependency,
emotional reliance on others, was assessed using the
scale developed by Hirschfeld et al. (1977) and is based
on attachment theory and object relations. The four
items measured concerns and fears related to loss or
abandonment by others. For example, (1) The idea of
losing a close friend is terrifying to you, or (2) You
would feel helpless if you were deserted by someone
you love. Participants used a 5-point Likert-type scale
to respond anchored by ‘strongly agree’ to ‘strongly
disagree’. Emotional reliance characteristics reflect
extreme distress in relation to the loss or abandonment
of a significant other, or a strong need for approval.
Cronbach’s was 0.68.
Data analyses
First, we report on demographics of abused and
non-abused participants for our sample of older
adults. Next, a series of hierarchical linear regression
analyses were performed with the internalizing diag-
nostic count as the dependent measure and the
childhood abuse scale inserted into the model as a
predictor, following the inclusion of the covariates.
The covariates included demographic variables
(gender, age, education) and family-of-origin variables
(childhood separation–abandonment, parents’ sub-
stance abuse symptoms, family-of-origin employment
status). Next, self-esteem was entered into the model to
examine whether self-esteem predicted internalizing
disorders. A standardized interaction term including
abuse and self-esteem was then entered in the model to
determine if abuse had a greater effect on mental
health at higher levels of self-esteem compared to the
effects at lower levels of self-esteem. To determine the
specificity of self-esteem as a mediator/moderator of
the relationship between childhood abuse and inter-
nalizing disorders, we examined the effects of a
competing psychosocial resource, emotional reliance,
on the abuse–mental health relationship. Thus, the
above analyses were repeated using emotional reliance
as a predictor variable and also as a potential
moderator of the abuse–mental health relationship.
We then performed mediation analyses to determine
whether self-esteem or emotional reliance mediated the
association between abuse and internalizing disorders.
Finally, in order to determine if any single DSM-IV
internalizing disorder was accounting for the relation-
ship between abuse and the internalizing disorder
count, the regression analyses were repeated using each
specific DSM internalizing disorder separately as the
dependent measure.
Results
In the current population study we conducted analysis
on a subsample of participants who were 50 years of
age or older from The Physical Health and Disability
Study. This included 1460 participants at Wave 1 and
1082 participants at Wave 2. The average age of the
sample at baseline was 67.1 years (10.3). Women
comprised 57.6% of the sample. Race and ethnicity
were as follows: non-Hispanic white (23.6%), Cuban
(26.8%), other Hispanic (13.1%), and African
American (36.5%). It should be noted that there was
a high percentage of Cubans, which is consistent with
the population of South Florida where this study was
conducted.
Among the sample at baseline (N¼1460), 7.2% of
participants reported a history of any childhood abuse
(physical, sexual, or emotional). Specifically, 2.6%
reported being physically abused as a child, 2.4 percent
reported sexual abuse, and 3.9% reported emotional
abuse. The type of sexual abuse reported most often by
the older participants was rape, 3.9% raped and 1.7%
molested, X
2
(N¼1460) ¼18.7, p50.001. More
women than men reported a history emotional abuse,
4.6%, versus 2.6%, X
2
(N¼1460) ¼5.0, p50.001, and
any sexual abuse, 3.6%, versus 1%, X
2
(N¼1460) ¼10.0, p50.001. There were no gender
differences for physical abuse. Those who had been
abused were on average younger than those who had
not been abused, 63.4 years versus 67.4
years, F(1,1450) ¼14.43, p50.001, which could
represent a cohort effect or it may be that abused
individuals do not live as long as those who were not
abused.
Participants who experienced any form of childhood
abuse assessed at baseline (Wave 1) had a greater num-
ber of 1-year internalizing disorders at follow-up (Wave
2), 3 years after baseline, than those without any
childhood abuse, 5% versus 12%, F(1,1082) ¼7.5,
p50.001. Of note, each specific type of abuse assessed
at baseline was correlated with the number of inter-
nalizing disorders assessed three years later including
any sexual abuse r
2
(N¼1082) ¼.1, p¼0.01, physical
abuse r
2
(N¼1082) ¼0.1, p50.01 and emotional abuse
r
2
(N¼1082) ¼0.08, p50.001. Importantly, and incon-
sistent with predictions, analysis showed that childhood
abuse was not correlated with self-esteem.
Adult abuse
It is of interest to note that there were no participants
who reported being physically abused by their parents,
Aging & Mental Health 495
for the first time, after the age of 15 years. There were
six participants who reported experiencing emotional
abuse after the age of 15 years, and there were 41
participants who experienced sexual abuse after the age
of 15 years. Results across all of the analyses, described
below, did not essentially change regardless as to
whether or not we retained or removed these partici-
pants from the study. Thus, we retained in the study
those 47 participants who experienced abuse as an
adult and, for the purposes of the current study, were
defined as not having experienced childhood abuse.
Effects of abuse and self-esteem on 12-month
internalizing disorders for older adults
A hierarchical linear regression analysis was performed
to examine the relationship between abuse and
internalizing disorders among the older adults. There
were 344 participants who were excluded from the
analyses due to missing data. Specifically, among the
1082 participants aged 50 years and over who were
assessed at Wave 2, we had complete data for the
regression analysis on 738 participants. There were 202
participants with data missing on IADL, and there
were 176 individuals for whom we did not have
household income. We conducted all of the following
analyses for a second time but removed the two
variables with missing data, yielding a greater sample
size at (N¼1068). The findings were essentially
the same.
Table 2 summarizes the results. Demographics were
entered in the first step. Younger age, lower household
income, and having problems in IADL predicted the
internalizing disorder count. We then entered
family-of-origin variables, none of which were signif-
icant. In the next step, we entered the scale-of-abuse
experiences. Retrospective reports of childhood abuse
experiences predicted internalizing disorders, even after
the inclusion of demographic and other known risk
factors. In the next step, self-esteem was entered into
the model. We found self-esteem predicted internaliz-
ing disorders. In the final step, we included the
interaction of abuse and self-esteem in predicting
internalizing disorder episodes. The interaction was
significant such that abuse had a greater effect on
those with lower self-esteem than on those with higher
levels of self-esteem. The interaction is depicted in
Figure 1.
Effects of abuse and emotional reliance on
internalizing symptoms
We repeated the analysis but this time included
emotional reliance as the predictor variable instead of
self-esteem. Reliance was unrelated to internalizing
disorders. An interaction between emotional reliance
and abuse predicting internalizing disorders was tested.
The interaction-term was not significant.
Neither self-esteem nor emotional reliance partially
mediated the relationship of abuse on internalizing
disorders for older adults
Self-esteem
We wished to determine if self-esteem partially
mediated the relationship between abuse and inter-
nalizing symptoms. To test the criteria needed for
mediation we conducted further analyses.
There are several criteria needed to demonstrate
mediation. Generally speaking, mediation can be said
to occur when (1) the independent variable signifi-
cantly effects the mediator, (2) the independent vari-
able significantly effects the dependent variable in the
absence of the mediator, (3) the mediator has a
significant unique effect on the dependent variable,
and (4) the effect of the independent variable on the
dependent variable is reduced with the addition of the
mediator to the model. To determine if this effect is
significant a Sobel test is then conducted.
In the above analyses, we established a significant
effect of the independent variable (abuse) on the
dependent variable (internalizing symptoms). Next,
however, we conducted further analyses and deter-
mined that independent variable (abuse) did not
predict the potential mediator, self-esteem. Thus, the
criterion necessary for mediation (that the independent
variable predicts the mediator) was not met. Therefore,
self-esteem was not a mediator of the association
between abuse and internalizing disorders.
Emotional reliance
We had already shown that the potential mediator,
emotional reliance, did not predict the dependent
variable, internalizing disorders, which is a require-
ment for mediation. Thus, emotional reliance did not
partially mediate the relationship between child abuse
and internalizing disorders.
Specific internalizing diagnoses
It was of interest to determine if the association between
abuse and internalizing disorders was based on only a
few specific internalizing disorders. Thus, we wished to
determine if childhood abuse predicted each one of the
internal DSM-IV one year diagnoses assessed at Wave
2. A series of regression analyses were completed with
each separate internalizing disorder used as the depen-
dent measure. It is remarkable to note that the scale of
childhood abuse predicted each of the internalizing
diagnoses with one exception, social phobia. Thus, no
one disorder accounted for the observed relationship
between abuse and internalizing disorders.
Discussion
The current study was based on a subsample of the
participants from the Physical Health and Disability
Study; specifically, we included those participants who
were aged 50 years or older. This resulted in 1460
496 N. Sachs-Ericsson et al.
participants at Wave 1 and 1082 participants at
Wave 2. The average age of the sample at baseline
was 67.1 years (10.3). We examined the association
between retrospective reports of childhood abuse
(physical, emotional, and sexual) assessed at Wave 1
and 1-year DSM-IV internalizing disorders assessed at
the 3-year follow-up interview (Wave 2).
First, we found the number of childhood abuse
experiences (sexual, physical, or emotional) assessed at
baseline predicted the number of one year DSM-IV
internalizing disorders occurring three years later.
Further, there was an interaction between abuse and
self-esteem such that abuse had a more negative impact
on those with lower self-esteem than those with higher
self-esteem.
This is one of the first studies on a large sample of
older adults to show that retrospective reports of
childhood abuse predict subsequent episodes of psy-
chiatric disorders. Indeed, given the average age of
these older adults, which was late 60’s, we have shown
that childhood abuse can have long-term consequences
for one’s mental health.
Second, we examined the role self-esteem played in
the association between abuse and internalizing dis-
orders. There is a documented association between
traumatic stress exposure and self-esteem (Cheng &
Lam, 1997; Kreger, 1995; Lo, 2002; Turner et al., 2004;
Youngs et al., 1990). We had hypothesized that abuse
in the presence of low self-esteem would have an
impact on the development of internalizing disorders in
part because of the cognitions associated with low
self-esteem (e.g., ‘I am worthless’). Negative
self-concept, including low self-esteem, is a potential
vulnerability marker for internalizing disorders in part
because low self-esteem is related to a negative
self-representation and a negative cognitive style
which is thought to adversely affect the individual’s
interpretation of stressful life events.
Not surprisingly, we found low self-esteem to
predict internalizing disorders. However, we also
investigated the role of self-esteem in explaining the
abuse–mental health relationship. Specifically, we
examined whether self-esteem was a mediator and/or
a moderator of the relationship between abuse and
internalizing disorders. We found self-esteem to mod-
erate the relationship between abuse and internalizing
disorders such that child abuse had a greater negative
effect on those with lower self-esteem compared to
those with higher self-esteem. Surprisingly, and con-
trary to predictions, self-esteem did not mediate the
relationship between abuse and internalizing disorders.
Thus, higher rates of internalizing disorders among
Table 2. Regression analysis.
Model characteristics
Unstandardized coefficients
Fp-value
95% Confidence interval (CI)
B Standard error Lower bound Upper bound
Step 1 df ¼(6732)
Gender 0.001 0.006 0.020 0.887 0.014 0.012
Age 0.005 0.001 17.240 50.001 0.008 0.003
Screened as disabled 0.013 0.007 3.483 0.062 0.026 0.001
Instrumental activity limitations 0.008 0.002 10.940 50.001 0.003 0.012
Education 0.001 0.003 0.162 0.687 0.007 0.005
Household income 0.008 0.003 6.062 0.014 0.015 0.002
Step 2 df ¼(9729)
Family of origin had employment problems 0.047 0.045 1.057 0.304 0.043 0.136
Scale of childhood abandonment 0.039 0.025 2.452 0.118 0.010 0.088
Parents used substances 0.008 0.047 0.032 0.859 0.084 0.101
Step 3 df ¼(10,728)
Abuse scale 0.110 0.034 10.318 50.001 0.043 0.176
Step 4 df ¼(11,727)
Self-esteem 0.011 0.004 8.423 50.01 0.003 0.018
Step 5 df ¼(12,726)
Interaction self-esteem and abuse 0.035 0.010 13.456 50.001 0.016 0.054
Hi
g
h self-esteemLow self-esteem
Mean internalizing disorders
0.50
0.40
0.30
0.20
0.10
0.00
At least one type of abuse
None
Any abuse
Figure 1. Interaction of abuse and self-esteem. This figure
illustrates that the negative effects of abuse in the develop-
ment of internalizing disorders is dramatically greater for
those with low self-esteem (lowest 20%) compared to those
with higher self-esteem.
Aging & Mental Health 497
abused individuals were not the result of abuse causing
low self-esteem.
To test the specificity of self-esteem we also
examined alternative mediators/moderators of the of
the abuse–mental health association. Specifically, we
examined one aspect of interpersonal dependency,
emotional reliance on others, which has also been
found to be a vulnerability marker for depression. As
expected, emotional reliance was not a mediator or a
moderator of the relationship between abuse and
internalizing disorders. One explanation for this speci-
ficity of our findings is that the specific self-critical
attributions associated with low self-esteem, rather than
the dependency associated with emotional reliance, play
a more central role in the development of internalizing
disorders. Our results show the specificity of self-esteem
as a moderator of the relationship between abuse and
mental health problems among adults.
Surprisingly, and in contrast to many other studies
of younger adults, self-esteem was not found to be
associated with childhood abuse. First, differences may
be related to the use of a population sample. Many of
the studies finding the association between abuse and
self-esteem were based on clinical or selected samples
of abused and non-abused individuals. Samples
selected from documented cases of abuse are likely to
comprise the more severe incidences of abuse and may
demonstrate an association between abuse and
self-esteem that does not generalize to the general
population as a whole. Similarly, participants with a
history of abuse who are included in a study obtained
from a utilization sample (e.g., those participants
seeking treatment) may have a stronger association
between abuse and self-esteem than those identified in
a population sample. Importantly, in the current study
participants were older than the general population,
and most studies finding an association between abuse
and self-esteem have been based on children, adoles-
cents, or young adults. Thus, the association between
abuse and low self-esteem found in other studies may
be due in part to the proximity of the childhood abuse
to the assessment of self-esteem. Among older adults,
high self-esteem is considered to be one indicator of
successful aging (Baltes & Baltes, 1990), in part,
because of its link to life satisfaction and psychological
well-being (Markus & Herzog, 1992). It may be that,
through the process of life span development, some
abused individuals come to separate out the effects of
abuse on their self-concept. Indeed, our results showed
that childhood abuse was unrelated to self-esteem
among our older adult sample, and that childhood
abuse, for the most part, only had a negative affect on
those individuals with low self-esteem.
Our findings have direct implications for the
treatment of older adults with a history of childhood
abuse and current internalizing disorders. It may be the
case that clinicians are unaware of the long-term effects
of childhood abuse on older adults. However, findings
from this study show that there are long-term negative
effects that should be addressed in such older adults
and, in particular, in those with low self-esteem.
Identifying the attributions related to low self-esteem
and challenging such cognitions, may influence the
negative effects of abuse on mental health disorders
among older adults. Regardless of abuse history,
targeting self-critical ideation in older adult patients
with anxiety or depressive disorders may help reduce
internalizing symptoms in this population.
In interpreting the findings from this investigation, it
is important to consider several methodological limita-
tions. First, the study relied on self-reports of partici-
pants’ abuse histories that did not incorporate a high
degree of behavioral specificity. Researchers have found
that questions regarding abuse history that incorporate
a high degree of specificity elicit greater rates of
reporting than those that do not. It is possible that the
study results underestimated rates of childhood abuse
because of the lack of specificity of the abuse-related
items. In this regard, childhood abuse experiences may
be more salient to those who were most affected by the
abuse (e.g., those experiencing mental health problems).
Given the lack of specificity of the abuse items, those
least affected by the abuse may be more likely to
under-report abuse experiences. Possible under-
reporting of abuse by those least affected by the abuse
may have enhanced the apparent relationship between
abuse and disorders in the current study. Moreover,
given that the assessed abuse occurred before the age of
15 years, respondents were reporting on events that
occurred, on average, over 50 years ago. The long period
of time between the event and the assessment of the
event may affect the reliability of the reports.
Second, oversampling of persons with a physical
disability in this population study may influence the
rates of both childhood abuse and psychiatric dis-
orders. Specifically, rates may be higher than in a
representative epidemiological sample because disabil-
ity is associated with both abuse and mental health
problems. Thus, we may have overestimated the
association between abuse and internalizing disorders.
Therefore, our study’s results may not generalize to the
population as a whole.
Furthermore, while we concluded that self-esteem
was unrelated to abuse in this older sample, the lack of
association may be due, in part, to a selection effect.
Specifically, those who experienced abuse and have
poorer self-esteem may be less likely to have survived
into older adulthood.
Lastly, the association between childhood abuse
and internalizing disorders may be affected by gender.
Specifically, the sole focus on internalizing disorders
may underestimate the effects of abuse among males
who are known to be more likely to manifest stress
exposure in terms of externalizing problems (i.e.,
substance use problems, intermittent explosive dis-
orders, etc.) (Sachs-Ericsson & Ciarlo, 2000). Because
distress can be expressed both internally and exter-
nally, one promising line of future research could
evaluate the impact of childhood abuse and the
mediating/moderating role of self-esteem using both
498 N. Sachs-Ericsson et al.
internalizing and externalizing disorders as outcome
variables and examining them by gender.
In sum, for older participants we found that the
number of childhood experiences of abuse assessed at
baseline predicted the number of DSM internalizing
disorders occurring within one year of the Wave 2
interview conducted three years later. Also as expected,
self-esteem predicted the number of internalizing
disorders. Importantly, unlike results from younger
populations, self-esteem was not associated with abuse
status. Among older adults, high self-esteem is consid-
ered to be one indicator of successful aging (Baltes &
Baltes, 1990). It may be through the process of lifespan
development that some abused individuals come to
separate out the effects of abuse on their self-concept
and thereby reduce the impact of childhood abuse on
their mental health.
Acknowledgements
This work was supported by Grants R01DA13292 and
R01DA16429 from the National Institute on Drug Abuse to
R. Jay Turner.
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