ORIGINAL RESEARCH

published: 24 March 2017

doi: 10.3389/fpsyg.2017.00449

Manifestation of Trauma: The Effect

of Early Traumatic Experiences and
Adult Attachment on Parental
Reflective Functioning
Pamela San Cristobal, Maria P. Santelices * and Daniel A. Miranda Fuenzalida

Psychology, Pontificia Universidad Catolica, Santiago, Chile

There are many risk factors that make the transition to parenthood difficult, even in the
best of circumstances. One such risk factor is the experience of parental childhood
trauma, which has the potential to affect the parent/child relationship, both in terms of
attachment style parental reflective functioning. This study aims to expand on the line
of research concerned with the effects that trauma has once that child transitions into
adulthood and into parenthood by looking at the role that the experience of trauma and
adult attachment has in relation to parental reflective functioning. This study assessed
mothers (N = 125) by using the CTQ (childhood experience of trauma), ECR (adult
attachment), and the PRFQ (parental RF). Our study found that in the presence of physical
Edited by:
Nuno Conceicao,
neglect, insecure attachment had a particularly deleterious effect on maternal reflective
Universidade de Lisboa, Portugal functioning. This relationship was not as strong in the absence of physical neglect.
Reviewed by:
Keywords: childhood trauma, adult attachment, parental reflective functioning, prementalization
Tamara Fischmann,
Sigmund-Freud-Institut, Germany
Xiao Zhou,
Tel Aviv University, Israel
EARLY EXPERIENCES OF TRAUMA AND THE ATTACHMENT
*Correspondence:
SYSTEM
Maria P. Santelices
msanteli@uc.cl The experience of trauma during childhood has been the subject of many empirical studies and
its effects well documented, affecting different domains of mental health, and general wellbeing
Specialty section: (Lieberman and Van Horn, 2008; Spratt et al., 2012). Consequently, clinical and empirical interest
This article was submitted to continues to drive research on the effects of trauma on subsequent generations, as it has proven
Psychology for Clinical Settings, to be more complex than previously thought. As a result, there has been specific focus on the
a section of the journal parent/child relationship and how trauma specifically affects parenting in adult survivors of child
Frontiers in Psychology abuse and neglect (Bottos and Nilsen, 2014). Research in this area has important implications in
Received: 11 September 2016 terms of how different service providers approach survivors of traumatic experiences in terms of
Accepted: 09 March 2017 parenting, attachment styles, and early childhood interventions, as childhood maltreatment is more
Published: 24 March 2017 likely to occur during essential moments of childhood development and its long-term effects can
Citation: be especially adverse in these particular areas (Ford and Courtois, 2009).
San Cristobal P, Santelices MP and Attachment theorists have posited that early relational experiences in childhood directly
Miranda Fuenzalida DA (2017)
affects the organization of the attachment system, providing the working models on which
Manifestation of Trauma: The Effect of
Early Traumatic Experiences and Adult
later relationships will eventually be developed (Fonagy et al., 2002; Slade et al., 2005). In this
Attachment on Parental Reflective context, exposure to childhood trauma, specifically trauma perpetrated by primary caretakers or
Functioning. Front. Psychol. 8:449. under their care, can be detrimental to children’s attachment (Carlson et al., 1989). Insensitive
doi: 10.3389/fpsyg.2017.00449 caregiving and maltreating behaviors have been implicated in the development of attachment

Frontiers in Psychology | www.frontiersin.org 1 March 2017 | Volume 8 | Article 449

San Cristobal et al. The Manifestation of Trauma

insecurity and disorganization (van IJzendoorn and Bakermans- process and resolve the trauma, mentalization is one of the
Kranenburg, 2009). In this context, we use the definition of areas at risk of being compromised. Consequently, Lieberman
trauma as defined by Bernstein et al. (2003) which includes et al. (2015) have written extensively on the repeated dynamic
physical abuse and/or neglect, emotional abuse and/or neglect, found in the clinical work concerning parents who have survived
and sexual abuse. Children exposed to maltreatment have traumatic experiences and their tendency to experience their
been found to be less likely to be securely attached, and children as objects of transference, projecting onto them their
more likely to fall under an insecure-disorganized attachment own unmet needs from their childhood (Lieberman and Van
classification (van IJzendoorn and Bakermans-Kranenburg, Horn, 2008).
2009). Child development that takes place in the context of
Exposure to insensitive, maltreating, or neglectful caretaking maltreatment can be complex and varies in its effects, though
can affect a child’s sense of safety and security, essential to the mentalization is not compromised in all cases, there have been
development of secure attachment (Cyr et al., 2010). In these mentalizing problems associated to the experience of childhood
contexts, a child can perceive their caretaker, their primary trauma. Some of these include, difficulty understanding
attachment figure, as a potential source of distress (Hesse and emotional expressions and social cues, less symbolic play,
Main, 2006). As such, attachment working models have shown limited empathy for others, poor affect regulation, and
to remain generally constant over time, affecting attachment difficulty identifying internal states (Ringel, 2011). Findings
representations later on into adulthood. show that exposure to various traumatic experiences can
Transitioning into parenthood is a period of reorganization of lead to an absence of adequate parental mentalization of
the self that carries with it inherent difficulties and can trigger the child’s experiences, ultimately affecting the way the child
memories and experiences associated to childhood (Lieberman comes to understand himself and his surroundings (Fonagy,
and Van Horn, 2008; Fonagy, 2015). As a result, the attachment 1993). Seligman (2014) highlights that reflective thinking is
system is constantly activated resulting from different parent- important in order to feel secure in the world and find a
child dynamics. The exposure to trauma in early childhood, sense of coherence. In contrast, when this is lacking, the world
namely abuse or neglect, has the potential to derail a parent’s becomes a scary and unsafe place in which internal states
capacity to attend to their children, especially in moments cannot be made sense of or trusted and the behaviors of others
of distress and has been found to impact their children’s become unpredictable and threatening. As a result, deficits in
attachment style. Cues given by children when needing their mentalization have been associated to labile self-organization,
caretakers can be misinterpreted by parents with a history low self-esteem, isolation and fear, and in the worst of cases can
of child abuse or neglect as threatening and overwhelming, be linked to psychopathology (Fonagy et al., 2002; Seligman,
and can lead to perceptual distortions that inhibit the child’s 2014).
needs from getting met and the parent’s capacity to respond The development of reflective functioning takes place within
appropriately (Lieberman et al., 2015). This delineates the the context of a parent’s own early attachment experience (Ensink
pioneering work by Fraiberg et al. (1975) that spoke to the et al., 2016). As a result, the experience of early childhood
“presence” of past traumatic experiences in the relational trauma can affect an adult’s reflective functioning and in the
dynamics between caregiver and child. Finally, it is important transition to parenthood can potentially affect parental reflective
to note that the experience of trauma alone does not necessarily functioning as well. Parental reflective functioning is defined
lead to insecure attachment styles, however the experience of as a parent’s capacity to hold and reflect on their child’s inner
trauma that is not resolved or worked through has shown experiences, attributing mental states to behaviors and having the
to lead to increased insecurity of attachment in children of capacity to reflect on their own internal experience associated to
parents who have experienced trauma early on (Berthelot et al., their child’s behaviors (Fonagy et al., 2002; Slade, 2008). Insofar
2015). as reflective functioning is developed in terms of the parent’s
developmental context, so too is parental reflective functioning,
PARENTAL REFLECTIVE FUNCTION which is inherently connected to the parent’s own experiences
with their parental and attachment figures (Slade, 2008). As
Parental reflective functioning is understood as the capacity to a result, parental experience of trauma is a potential factor
perceive and interpret human behavior in terms of intentional influencing a parent’s reflective functioning capacity. However,
mental states, such as, needs, desires, goals, beliefs, etc., findings in this area have been mixed and suggest a more
mentalization is imperative for healthy human development and nuanced and complex relationship between early childhood
more importantly, it is born out of the parent/child relationship trauma, parental reflective functioning, and attachment style
(Fonagy et al., 1991, 2002; Ringel, 2011). Though human beings (Schwerdtfeger and Nelson Goff, 2007). For example, a recent
are born with the mechanisms that enable mentalization, it is a study by Ensink et al. (2014) indicates that the experience
skill developed through mutual interactions between the child of childhood trauma alone doesn’t necessarily compromise a
and his caregiver. Through parental modeling, children learn parent’s ability to respond to their child’s attachment needs,
to identify their own affects and cognitions and those of others rather, a parent’s capacity to mentalize about their own trauma
in order to communicate them and empathize appropriately histories appears to significantly contribute to their capacity
(Fonagy et al., 2002). When this relationship becomes altered to tend to and satisfy their children’s attachment needs and
by the experience of traumatic events without the means to provide reflective caregiving. Ensink et al. (2014) have found

Frontiers in Psychology | www.frontiersin.org 2 March 2017 | Volume 8 | Article 449

San Cristobal et al. The Manifestation of Trauma

that for parents who have experienced child abuse and neglect different from one person to another, and yet is often grouped
(CA&N), mentalization concerning trauma was associated to into a single construct.
investment in pregnancy, positive feelings toward pregnancy, In this line, it seems plausible to hypothesize that emotional
and quality of relationship to partner. This research suggests maltreatment has especially deleterious effects on maternal
that for women who have experienced CA&N, the capacity reflective functioning because of the very nature of emotional
to mentalize about traumatic events is particularly important, maltreatment and there have been some empirical findings that
rather than mentalizing capacities in general (Berthelot et al., have backed up this hypothesis. For example, Rogosch et al.
2015). However, despite what research is still discovering on (1995) found that households characterized by emotionally labile
the mechanisms behind how trauma affects the mother/child caregiving proved to be unpredictable, thus affecting the child’s
relationship, the effects of trauma on maltreated children can ability to anticipate behaviors and assess consequences. Fear
potentially compromise the way they understand themselves and is also an important factor in households in which there is
others, risking the development of mentalization (Cicchetti et al., emotional maltreatment in that an environment colored by fear
2003). This study specifically aims at taking a closer look at adult is not conducive to the expression on mental states and reflective
survivors of CA&N in terms of how parenting is influenced by capacities (Fonagy et al., 2002, 2007). In general, children who
the experience of childhood trauma and the potential effects on have experienced CA&N have been found to use less mental
their offspring. references, as they have been modeled in some cases not to do
so and/or have been given messages that are at odds with their
own experiences, leading to confusion, and distrust toward their
DIFFERENT TYPES OF TRAUMA internal states (Cloitre et al., 2006). This is especially alarming in
light of the fact that emotional maltreatment is potentially one
Though trauma can be an all-encompassing construct that of the most underreported forms for maltreatment experienced
includes a spectrum of different experiences, we define trauma by young children (Trickett et al., 2009). If this indeed are
as abuse endured during childhood in terms of physical neglect some of the experiences of children with the experience of
or abuse, emotional neglect or abuse, and sexual abuse. These CA&N, it leads to the question that is relevant for this study,
experiences all have the potential to have profound effects which is what happens when these children are themselves
on a person, however it is important to understand the parents?
different effects that different types of trauma can have, as it
is relevant both clinically and empirically. For example, child CURRENT STUDY
abuse reporting laws often define child abuse by the physical
symptoms that a child can present, when symptoms associated Following this theoretical line, this study seeks to contribute
to emotional trauma can be more complex and sometimes to the research focused on the survivors of trauma and its
invisible, yet underreported or identified. Understanding the effects on parenting. While many studies have been focused on
effects of different types of trauma can also shed light onto the the immediate impact that trauma has during childhood, few
intergenerational aspect of trauma when working with families studies have focused on the long term effects that childhood
who have extensive histories of trauma from one generation to trauma has into adulthood and in parenthood, both in terms
another. A recent study by Bottos and Nilsen’s (2014) was the of adult attachment, and reflective functioning (RF; Ensink
first to take a close look at the relationship between distinct types et al., 2014). This study seeks to describe the relationship that
of traumatic experiences and the experience of depression in the experience of childhood trauma has on adult attachment
adult survivors of abuse and its effect on maternal mentalization and parental reflective functioning, as these three constructs
and the development of theory of mind in their offspring. are related and influence each other in various ways. Firstly,
Their findings highlighted the deleterious effects the experience we hypothesize that insecure attachment will be related to
of childhood trauma can have on survivors of CA&N and higher prementalization, whereas secure attachment style will
on their children. Bottos and Nilsen’s (2014) study specifically not. As a construct, reflective functioning was developed within
highlighted the deleterious effects that emotional maltreatment the context of attachment theory. Studies on the relationship
had, in comparison to physical and sexual abuse. In their study, between RF and attachment style have found the two to be
parental childhood experience of emotional maltreatment was intricately related, parental RF has not been the exception.
found to be a significant predictor of children’s mentalization Through the use of the Adult Attachment Interview, studies
outcomes. Lastly, another important contribution by Bottos and have found that parents who rated high on RF tend to be
Nilsen’s (2014) study is their finding regarding the interplay securely attached adults and have children who are securely
between depression, CA&N, reflective functioning, and theory attached as well (Slade, 2005). In fact, it is thought that the
of mind. They found that the experience of maternal depression intergenerational transmission of attachment style is transmitted
in conjunction with emotional maltreatment had the most through the parent’s RF capacity (Fonagy et al., 2002). Lower
significant effects on reflective functioning and on their children’s PRF will be measured by levels of prementalization, where higher
development of theory of mind. In summary, this particular study prementalization is indicative of lower PRF and vice versa.
expands on an area of research that also interests the authors Our second hypothesis is that emotional abuse and emotional
of this study in its differentiation between different types of negligence will yield higher levels of insecure attachment style
traumatic experiences, as the experience of trauma can be very and prementalization in comparison to the other types of trauma

Frontiers in Psychology | www.frontiersin.org 3 March 2017 | Volume 8 | Article 449

San Cristobal et al. The Manifestation of Trauma

assessed (physical abuse, physical neglect, and sexual abuse). the requirements of the Ethics Committee of the Universidad
This hypothesis derives from recent literature that highlights Católica, Chile.
that emotional abuse is an underlying factor at the root of
other forms of abuse (Bottos and Nilsen, 2014). While all forms
of abuse are aggressions toward the well-being of children, Measures
trauma-related literature has highlighted that emotional abuse Maternal Experience of Childhood Trauma
during childhood can deeply fragment an individual’s sense To assess for maternal trauma during childhood, the participants
of self, attachment representations, and mentalizing capacities were asked to complete the Child Trauma Questionnaire (CTQ)
(Bottos and Nilsen, 2014). Emotionally abusive and negligent developed by Bernstein et al. (2003). The CTQ assesses for past
contexts deprive children of adults that help them make sense of, experiences of trauma and specifically measures physical abuse,
reflect on, and create a coherent narrative of life events, especially physical neglect, emotional abuse, emotional neglect, and sexual
traumatic ones, ultimately compromising their own RF abilities abuse. The CTQ is a self-report questionnaire that measures 5
(Ensink et al., 2014). categories of childhood trauma experience, including emotional,
Recent studies suggest a more nuanced profile of adults physical, and sexual abuse as well as emotional and physical
with a history of childhood trauma, both in terms of neglect. Each subscale is measured in 5 items rated on a 5-
attachment classification and RF capacities. For example, point Likert scale from 1 (never true) through 5 (very often
Ensink et al. (2014) and Stovall-McClough et al. (2008) true).
both found that in a non-clinical sample of women a
significant number of participants with the experience of Experiences in Close Relationships (ECR)-Adult
child abuse and neglect had secure attachment suggesting Attachment (Brennan et al., 1998)
that more research is needed in this area, especially studies This instrument measures the individual’s attachment style in
that include non-clinical samples in order to illuminate the the context of romantic partnership. This instrument allows
nuanced effects that childhood traumatic experience have into us to measure adult attachment on a continuum focusing on
adulthood. two dimensions: avoidance (inconformity with intimacy and
dependency) and anxiety (fear of separation and abandonment).
It is composed of 36 items, measured on a Likert scale with a
METHODS possible score from 1 to 7 (1 = completely disagree and 7 =
completely agree). Scores indicate 4 types of attachment styles:
Participants Secure (low avoidance, low anxiety), Preoccupied (low avoidance,
The participants for this study belong to secondary data from high anxiety), disengaged (high avoidance, low anxiety), and
the FONDECYT 1130786 project which took place in Santiago, fearful (high avoidance, high anxiety). Both dimensions have
Chile. There were 125 participants who were evaluated during the confidence indictors of 0.94 and 0.91 via Cronbach’s Alpha.
year 2014–2015 in daycare centers belonging to JUNJI. Generally, Chilean studies using this measure show a reliability of 0.87
parents and children who attend JUNJI daycare centers belong to for avoidance and 0.85 for anxiety (Rivera, 2006). This study
a medium-low socioeconomic stratum of Chilean society. There used the version of the ECR validated in Chile in 2012 by
is a high number of single mothers within this population and Spencer, Guzman, Fresno, & Ramos which consists of 12 items
many of the children who participated are under the care of other and has a adequate reliability (Alpha’s Secure = 0.64 / Alpha’s
family members like grandmothers/grandfathers, uncles/aunts, unsecure = 0.78).
cousins, etc. One-hundred and 56 participants were initially
recruited, but only 124 participants finished the battery of
Parental Reflective Function
assessment.
The Parental Reflective Functioning Questionnaire- PRFQ
(2009) was created by Luyten, Mayes, Sadler, Fonagy, Nicholis,
Procedure Crowley, Vesper, Mobley, Stewart, Close, & Slade. This is a
As previously mentioned, the data obtained for this study is 39-item, self-report measure which were translated in Mexico
secondary data belonging to the FONDECYT project #1130786. with a inter-judge verification conducted in Chile. It consists
In order to obtain this data contact was initially established of three subscales which measure the caregiver’s curiosity about
with JUNJI centers after they were presented with the study their child’s mental states and how they relate mental states
in which they were invited to participate after signing the to behavior, resulting in a measure of low, medium, or high
appropriate consent forms. Once the consent forms were parental reflective functioning. Each item in the PRFQ are
obtained from the director of the centers, parents and caregivers given up to 7 points in a Likert type scale. On this scale 1
were invited to participate after signing the appropriate consent point indicates complete disagreement and 7 points indicate
forms as well. Later, a sociodemographic questionnaire was complete agreement. The prementalization scale consists of non-
given to the parents and caregivers to complete, followed mentalizing items. The mental states subscale consists of items
by the other measures. The children who participated in the evaluating the inability to recognize mental states that are not
FONDECYT project #1130786 also filled out questionnaires, transparent. The third subscale was designed to measure interest
but for the purposes of this study, these assessments were and curiosity in the parent regarding his/her child’s mental
not incorporated. The procedures included all comply with states.

Frontiers in Psychology | www.frontiersin.org 4 March 2017 | Volume 8 | Article 449

San Cristobal et al. The Manifestation of Trauma

Sociodemographic Characteristics RESULTS

Sociodemographic characteristics were taken through a
questionnaire completed by participants. The questionnaire The results are presented in the following three sections.
included items related to maternal age, child’s age, and maternal Firstly, we report the descriptive statistics and correlations
educational level. for all measures included in the model. Second, we show
seven regression models in order to test the hypotheses
Sociodemographic characteristics. presented in this paper. Third, we show a seventh
model that estimates the moderation role of physical
Variable n Mean Std. Dev. Min Max
negligence.
Child’s age 124 44.65323 3.737406 36 54 From the results presented in Table 1, it can be inferred that
Mother’s age 124 29.68551071 6.551071 19 47 the variables considered in the model exhibited reasonable levels
of variability. All of the correlations indexes were, as expected,
Child_Sex Frequency Percent Cum. positively related to prementalization (except in the case of secure
autonomous attachment style) and all means were significantly
Male 62 50.41 50.41 different from zero.
Female 61 49.59 100 Table 2 shows the results of the regression models estimating
the hypotheses. Model 1 shows that only insecure attachment is
Maternal educational level Frequency Percent Cum. related to the adult prementalization scores. This specific result
indicates that adults with insecure early attachment show higher
No response 2 1.61 1.61 inabilities to recognize the mental states of their children (higher
Did not complete middle school 4 3.23 4.84 prementalization). On the other hand, secure attachment did not
Completed middle school 8 6.45 11.29 show this effect. Models 2, 3, 4, and 5 shows that any kind of
Did not complete high school 19 15.32 26.61 negligence or abandonment was related with prementalization.
Acquired high school degree 55 44.35 70.97 Model 6 estimates the joint effect of variables. In this model,
Did not complete college 27 21.77 92.74 controlling for negligence and abandonment yielded a positive
Acquired college degree 8 6.45 99.19 effect in terms insecure attachment, which is a similar effect to
1 0.81 100 the one observed in model 1. Up to this point, results indicate
that the unique relevant dimension is attachment, particularly
insecure attachment style.
Model 7 shows the moderation effect of physical negligence
DATA ANALYSES in the relationship between insecure attachment and
prementalization. The general result indicates that the strength
The analyses were conducted using regression models in of relationship between both variables changes depending on
order to estimate the lineal relationship among variables, the specific type of negligence. Particularly, when the declared
furthermore, the non-linear relationships were estimated using physical negligence is zero the effect of insecure attachment on
interaction models. The Stata software was used to carry out the prementalization was non-significantly different from zero (0.20,
descriptive correlational and regression models. Finally, in order p = 0.409). However, when the declared physical negligence is
to graphically show the interaction effects, we used marginal higher (1) the effect of insecure attachment on mentalization is
estimation Stata 14 module. positive (−0.20 + 0.34 = 0.14, p = 0.030).
The equations used were the following: In order to check the collinearity, the variance inflation
factor (VIF) was estimated. The average of VIF was 1.55
indicating that the independent variables are not collinear.
(Prem) = a + b1_(Ins.Attach) + b2_(Sec. Attach) (1) Furthermore, normality was estimated using Shapiro Wilks test,
(Prem) = a + b1_(P. Abandonment) (2) which indicates that the residuals are non-normal (W = 0.944;
p < 0.01). This indicates that these results must be interpreted
(Prem) = a + b1_(E. Abandonment) (3) considering this assumption’s violation. Nevertheless, it is not
(Prem) = a + b1_(P. Negligence) (4) possible to observe severe outliers, indicating that the non-
(Prem) = a + b6_(E. Negligence) (5) normality is not a severe violation. Additionally, in order to
(Prem) = a + b1_(Ins.Attach) + b2_(Sec. Attach) + handle potential effects of outliers, a robust regression was
estimated (model 8). Results indicate that the observed effects are
b3_(P. Abandonment) + b4_(E.Abandonment) + robust.
b5_(P. Negligence) + b6_(E. Negligence) (6) Figure 1 shows a graphical representation of the moderation
(Prem) = a + b1_(Ins.Attach) + b2_(Sec. Attach) + effect. On the one hand, the marginal estimation indicates that
at lower levels of physical negligence the fitted line is almost
b3_(P. Abandonment) + b4_(E.Abandonment) +
flat. This means that when participants did not report physical
b5_(P. Negligence) + b6_(E. Negligence) + negligence, prementalization is almost the same at different levels
b7_(Ins.Attach*P.Negligence) (7) of insecure attachment. While on the other, when participants

Frontiers in Psychology | www.frontiersin.org 5 March 2017 | Volume 8 | Article 449

San Cristobal et al. The Manifestation of Trauma

TABLE 1 | Correlation among variables.

1 2 3 4 5 6 7

1 Pre-mentalisation
2 Insecure attachment 0.312**
3 Secure autonomous attachment −0.109 0.100
4 Physical abandonment 0.050 0.148 0.033
5 Emotional abandonment 0.035 0.273** −0.034 0.590**
6 Physical negligence 0.048 0.224* −0.114 0.315** 0.491**
7 Emotional negligence 0.160+ 0.238* −0.228* 0.309** 0.418** 0.624**

Mean 2.516 3.006 4.940 1.453 1.789 1.486 1.939

Estandar deviation 1.216 1.337 1.402 0.775 0.949 0.541 0.932

** p < 0.01, * p < 0.05, + p<0.10.

TABLE 2 | Regression model.

(1) (2) (3) (4) (5) (6) (7) (8)

Insecure attachment 0.30** 0.30** −0.20 −0.20

(3.78) (3.66) (−0.41) (−0.83)
Secure autonomous attachment −0.12 −0.11 −0.11 −0.11
(−1.70) (−1.41) (−0.16) (−1.44)
Physical abandonment 0.08 0.08 0.05 0.05
(0.56) (0.62) (0.75) (0.33)
Emotional abandonment 0.05 −0.13 −0.10 −0.10
(0.39) (−0.38) (−0.52) (−0.62)
Physical negligence 0.11 −0.21 −1.26* −1.26**
(0.54) (−0.43) (−2.31) (−2.63)
Emotional negligence 0.21 0.18 0.18 0.18
(1.80) (0.24) (1.21) (1.41)
Insecure x physical negligence 0.34* 0.34*
(2.19) (2.37)
Constant 2.23** 2.40** 2.44** 2.35** 2.11** 2.21** 3.65** 3.74**
(5.20) (10.34) (10.43) (7.36) (8.46) (4.12) (4.14) (4.18)
Observations 125 125 125 125 125 125 125 125
R-squared 0.116 0.003 0.001 0.002 0.026 0.135 0.164 0.168
F-test (p-values) 0.00 0.58 0.70 0.59 0.07 0.01 0.00 0.00

t-statistics in parentheses ** p<0.01, * p<0.05.

reported higher levels of physical negligence, the inability to trauma which has shown that one form of maltreatment often
recognize the mental states of their children varied significantly coexists with multiple other forms of maltreatment (Trickett
in the different levels of insecure attachment. For example, a et al., 2009). As Bernstein et al. (2003) point out, it is often difficult
participant that reported 3 points in physical negligence showed to disentangle one form of trauma from others and due to the
significantly lower levels of prementalization at level 1 of insecure nature of trauma, it can be challenging to adequately capture
attachment and showed very high levels of prementalization at the trauma phenonemnon in the assessment process, particularly
level 7 of insecure attachment. when it comes to differentiating abuse from neglect. However,
the CTQ-SF, yields considerable discriminate validity between
DISCUSSION the constructs even though they are highly interrelated (Bernstein
et al., 2003).
The results of this study yield interesting implications. Firstly, The next set of results found in this study pertain to
we see that maternal experience of physical abandonment, the relationship found between insecure attachment and the
emotional abandonment, physical negligence, and emotional prementalization scale. Healthy reflective functioning has been
negligence were significantly correlated amongst each other. This found time and time again to be born out of relationships
is congruent with the literature regarding the experience of characterized by secure attachment (Fonagy et al., 2002; Allen

Frontiers in Psychology | www.frontiersin.org 6 March 2017 | Volume 8 | Article 449

San Cristobal et al. The Manifestation of Trauma

FIGURE 1 | Moderation effect between physical negligence and insecure attachment.

et al., 2008). Securely attached parent/child dyads promote the parental detachment from the child’s needs and rights. Rogosch
development of mentalizing capacities from infancy onward et al. (1995) pose that households which are characterized by
and allow the child opportunities to learn and deepen his/her maltreatment convey a lack of RF and can be perceived as
understanding about mental states and eventually apply this an explicit negation of the child’s internal experience which
knowledge within their own social circles (Luyten et al., 2009). leads to confusion in the child between what they experience
Furthermore, attachment style and reflective functioning has internally and how his/her caregivers respond. This ultimately
been found to be intricately linked in that we have come to affects their core sense of self and it becomes increasingly more
understand reflective functionig as the means throught which difficult to understand their own mental states and the mental
attachment patterns are passed on intergenerationally (Fonagy states and desires of those around them, making it difficult to
et al., 1991). In this particular study, the correlation between assess and predict social behaviors of peers and counterparts.
the two is evidenced by the regression model in which we Our findings also show that insecure attachment did not appear
found that insecure attachment predicted the likelihood of the to affect prementalization if there was an absence of physical
parent scoring highly in the prementalization scale of the PRFQ. negligence. However, in the presence of physical negligence,
This subscale consists of items composed of non-mentalizing insecure attachment significantly worsens mentalization capacity
examples, which is further evidence of that insecure attachment (as seen in the increase of prementalization scores). Interestingly,
styles in adults are related to their inability to mentalize this relationship was not present in the other dimensions of
adequately when it comes to those around them. Previous studies trauma captured by this particular instrument. In summary,
have also confirmed these results, for example, Fonagy et al. only the presence of significant physical negligence in the
(1991) and Slade (2005) both found that secure attachment mother’s early childhood experience impacted the extent to
classification through the Adult Attachment Interview has higher which maternal insecure attachment worsened mentalization
RF scores than their securely attached counterparts. capacities.
As a result of a regression modeling we conclude that the As we see in Table 2, lower scores in the physical
presence of insecure attachment and the experience of physical negligence do not alter the relationship between insecure
negligence showed the most damaging effects on reflective attachment and prementalization, however, as the physical
functioning. This can be found in some of the existing literature negligence scores increase, there is a significant increase in the
regarding maltreated children who as a result of traumatic prementalization scores, which leads us to conclude from these
experiences of abuse and neglect with their caregivers, experience results that the mothers who present insecure attachment and
significant disruption in their mentalizing abilities, as these report the experience of physical neglect in their childhood,
households are characterized by unresponsive, unavailable, and were significantly and negatively affected in their reflective

Frontiers in Psychology | www.frontiersin.org 7 March 2017 | Volume 8 | Article 449

San Cristobal et al. The Manifestation of Trauma

functioning. Its seems from these results that the exposure to LIMITATIONS
physical negligence had a particular effect. Physical negligence
seems to play a role in the experience of trauma that is commonly As has been previously noted by other authors who have
associated to other types of traumas and consequences thereafter. conducted studies on the experience of past trauma, it can
For example, in a national study conducted in the United be a challenge to ask a survivor of trauma to accurately
States characterizing adults who experienced physical abuse convey memories of their painful experiences (Bernstein et al.,
during childhood found that neglect was significantly reported 2003). In light of these difficulties, retrospective assessments
in addition to other types of trauma and those who experience can yield important contributions to the work of understanding
neglect showed significantly lower perceived parental support trauma in its various contexts and manifestations. Though
as a child (Sugaya et al., 2012), this is consistent with what the minimizations, normalization, and, in some cases, dissociation,
CTQ was meant to measure in terms of physical neglect in that can play a role in the self-report method of assessing
this construct refers to the child’s parent’s inability to provide trauma, the CTQ-SF incorporates a minimizing/deniability
appropriate parental supervision, putting in jeopardy the child’s scale developed by the authors of the instrument to detect
safety and well-being (Bernstein et al., 2003). Studies have found underreporting.
that abusive and neglectful households are often characterized by
emotional lability and chronic stress stemming from being unable ETHICS STATEMENT
to predict accurately what will trigger their abuser (Sugaya et al.,
2012; Bottos and Nilsen, 2014). The results of our study fall in Pontificia Universidad Católica, Escuela de Psicología, Comité
line with the characterization of physically negligent households de Etica. The parents who participated in this study were given
in that growing up in this context disturbs key developmental a consent form which detailed the type of assessment they
stages, particularly when it comes to mentalization. Physically would partake in and in which they were invited to be part
abusive and negligent households make it especially difficult for of a 5 week group focused on strengthening the attachment
children to predict and assess the antecedents and consequences bond and mentalizing capacities between the parent and child.
of behavior, a key element in the development of mentalization The consent form explicitly stated that their participation was
(Rogosch et al., 1995). Physical negligence is also an overt voluntary, that their information was confidential, and that they
negation of the developing child’s internal experience in that were able to refuse participation at any time during during
these painful experiences are often refuted by the parental the study without consequence. Parents were asked to sign the
figure, making it increasingly difficult for the child to develop consent form after reading it in detail. The preschools to which
an internal dialogue through which to process the trauma, the participants belonged were also asked to sign a consent
layered with the lack of space to communicate about internal form acknowledging that they agreed with the participation of
states with parental figures. In a study focused on the effects their parents. Parents were also informed that the data resulting
of early neglect on children, Spratt et al. (2012) found that of from their initial assessment were confidential and only used
physical abuse, sexual abuse, emotional abuse, and physical or for educational and research purposes. Minors only participated
medical neglect, adults who reported neglect in their childhood with the consent of their caregivers and in the presence of their
showed the strongest association with delays relating to overall caregivers.
language development which depraved them of healthy language,
cognitive, and behavioral development; these children specifically AUTHOR CONTRIBUTION
showed significant social and interpersonal impairment, as they
were not able to effectively communicate, affecting their overall PS: conception and design of work; interpretation of data;
social interactions. Our study sought to focus on the long- drafting of article. MS: data collection; critical revision of article.
term effects of this kind of abuse by examining its effect on DM: data analysis, critical revision of article.
mentalization. Our findings fall in line with findings by Bottos
and Nilsen (2014) in that an often-underreported experience ACKNOWLEDGMENTS
of trauma, in our study physical negligence and in their study,
emotional maltreatment, was found to have significant effects on This study was supported by CONICYT (National Fund for
adult’s qualities related to caregiving. Our findings highlight the Research and Technology), Grant FONDECYT 1130786 and N◦
nuanced and complex effects that these early experiences have on PII PII20150035, with co-funding of the Fund for Innovation
survivors of childhood trauma, however more research is needed and Competitiveness (FIC) of the Chilean Ministry of Economy,
in order to begin to understand the full effects of childhood Development and Tourism, through the Millennium Scientific
trauma through the lifespan. Initiative, Grant N◦ IS130005.

REFERENCES Bernstein, D. P., Stein, J. A., Newcomb, M. D., Walker, E., Pogge, D., Ahluvalia,
T., et al. (2003). Development and validation of a brief screening version
Allen, J. G., Fonagy, P., and Bateman, A. W. (2008). Mentalizing in Clinical of the Childhood Trauma Questionnaire. Child Abuse Neglect 27, 169–190.
Practice. Arlington, VA: American Psychiatric Publishing Inc. doi: 10.1016/S0145-2134(02)00541-0

Frontiers in Psychology | www.frontiersin.org 8 March 2017 | Volume 8 | Article 449

San Cristobal et al. The Manifestation of Trauma

Berthelot, N., Ensink, K., Bernazzani, O., Normandin, L., Luyten, P., and Fonagy, P. Luyten P., Mayes L. C., Sadler L., Fonagy P., Nicholls S., Crowley M., et al.
(2015). Intergenerational transmission of attachment in abused and neglected (2009). The Parental Reflective Functioning Questionnaire-1 (PRFQ-1). Leuven:
mother: the role of trauma-specific reflective functioning. Infant Ment. Health University of Leuven.
J. 36, 200–212. doi: 10.1002/imhj.21499 Ringel, S. (2011). Developing the capacity for reflective functioning through the
Brennan, K. A., Clark, C. L., and Shaver, P. R. (1998). “Self-report measurement reflective process. Clin. Soc. Work J. 39, 61–67. doi: 10.1007/s10615-009-0246-9
of adult attachment: an integrative overview,” in Attachment Theory and Close Rivera, D. (2006). Influencia de Los Estilos de Apego y Habilidades Pro Relacionales
Relationships, eds J. A. Simpson and W. S. Rholes (New York, NY: Guilford), en la Satisfacción y Bienestar Emocional en Relaciones de Pareja, Doctoral Thesis
46–76. not published, Pontificia Universidad Católica de Chile, Santiago, Chile.
Bottos, S., and Nilsen, E. S. (2014). The cross-generational effects of maternal Rogosch, F. A., Cicchetti, D., Shields, T., and Toth, S. L. (1995). “Parenting
maltreatment histories: implications for children’s mentalizing development. dysfunction in child maltreatment,” in Handbook of Parenting, Vol. 4, eds M.
Child Abuse Neglect 38, 1094–1105. doi: 10.1016/j.chiabu.2014.02.012 H. Bornstein (Hillsdale, NJ: Erlbaum), 127–159.
Carlson, V., Cicchetti, D., Barnett, D., and Braunwald, K. (1989). “Finding order Schwerdtfeger, K. L., and Nelson Goff, B. S. (2007). Intergenerational transmission
in disorganization: lessons from research on maltreated infants’ attachments to of trauma: exploring mother–infant prenatal attachment. J. Trauma. Stress 20,
their caregivers,” in Child Maltreatment: Theory and Research on the Causes and 39–51. doi: 10.1002/jts.20179
Consequences of Child Abuse and Neglect, eds D. Cicchetti and V. Carlson (New Seligman, S. (2014). “Attachment, intersubjectivity, and mentalization within the
York, NY: Cambridge University Press), 494–528. experience of the child, the parent, and the provider,” in Infant and Early
Cicchetti, D., Rogosch, F. A., Maughan, A., Toth, S. L., and Bruce, J. (2003). False Childhood Mental Health: Core Concepts and Clinical Practice, eds K. Brand,
belief understanding in maltreated children. Dev. Psychopathol. 15, 1067–1091. B. D. Perry, S. Seligman, and E. Tronick (Arlington, VA: American Psychiatric
doi: 10.1017/S0954579403000440 Publishing), 309–322.
Cloitre, M., Cohen, L. R., and Koenen, K. C. (2006). Treating Survivors of Childhood Slade, A. (2005). Parental reflective functioning: an introduction. Attach. Hum.
Abuse: Psychotherapy for the Interrupted Life. New York, NY: Guilford Press. Dev. 7, 269–281. doi: 10.1080/14616730500245906
Cyr, C., Euser, E. M., Bakermans-Kranenburg, M. J., and Van Ijzendoorn, Slade, A. (2008). “The implications of attachment theory and research for adult
M. H. (2010). Attachment security and disorganization in maltreating and psychotherapy: research and clinical perspectives,” in Handbook of Attachment:
high-risk families: a series of meta-analysis. Dev. Psychopathol. 22, 87–108. Theory, Research, and Clinical Applications, 2nd Edn., eds J. Cassidy and P. R.
doi: 10.1017/S0954579409990289 Shaver (New York, NY: The Guilford Press), 762–782.
Ensink, K., Berthalot, N., Bernazzini, O., Normandin, L., and Fonagy, P. (2014). Slade, A., Grienenberger, J., Levy, D., and Locker, A. (2005). Maternal reflective
Another step closer to measuring the ghosts in the nursery: preliminary functioning, attachment, and the transmission gap: a preliminary study. Attach.
validation of the Trauma Reflective Functioning scale. Front. Psychol. 5:1471. Hum. Dev. 7, 283–298. doi: 10.1080/14616730500245880
doi: 10.3389/fpsyg.2014.01471 Spratt, E. G., Friedenberg, S., LaRosa, A., De Bellis, M. D., Macias, M. M.,
Ensink, K., Normandin, L., Plamondon, A., and Berthelot, N. (2016). Summer, A. P., et al. (2012). The effects of early neglect on cognitive,
Intergenerational pathways from reflective functioning to infant attachment language, and behavioral functioning on childhood. Psychology 3, 175–182.
through parenting. Canad. J. Behav. Sci. 48, 9–18. doi: 10.1037/cbs0000030 doi: 10.4236/psych.2012.32026
Fonagy, P. (1993). Psychoanalytic and empirical approaches to develop- mental Stovall-McClough, K. C., Cloitre, M., and McClough, J. F. (2008). “Adult
psychopathology: can they be usefully integrated? J. R. Soc. Med. 86, 577–581. attachment and posttraumatic stress disorder in women with histories
Fonagy, P. (2015). “Mentalization and development: tracing the developmental of childhood abuse,” in Clinical Application of the Adult Attachment
roots of mentalization” [PowerPoint slides]. Napa Infant-Parent Fellowship Interview, eds H. Steele and M. Steele (New York, NY: Guilford Press),
presentation. 320–340.
Fonagy, P., Gergely, G., Jurist, E., and Target, M. (2002). Affect Regulation, Sugaya, L., Hasin, D. S., Olfson, M., Lin, K., Grant, B. F., and Blanco, C. (2012).
Mentalization, and the Development of the Self. New York, NY: Other Press. Child physical abuse and adult mental health: a national study. J. Trauma. Stress
Fonagy, P., Gergely, G., and Target, M. (2007). The parent-infant dyad and the 25, 384–392. doi: 10.1002/jts.21719
construction of the a. subjective self. J. Child Psychol. Psychiatry 48, 288–328. Trickett, P. K., Mennen, F. E., Kim, K., and Sang, J. (2009). Emotional
doi: 10.1111/j.1469-7610.2007.01727.x abuse in a sample of multiply maltreated, urban young adolescents:
Fonagy, P., Steele, M., Steele, H., Moran, G. S., and Higgit, A. C. (1991). The issues of definition and identification. Child Abuse Negl. 33, 27–35.
capacity for understanding mental states: the reflective self in parent and child doi: 10.1016/j.chiabu.2008.12.003
and its significance in the security of attachment. Infant Ment. Health J. 12, van IJzendoorn, M. H., and Bakermans-Kranenburg, M. J. (2009). “Attachment
201–218. doi: 10.1002/1097-0355(199123)12:3<201::AID-IMHJ2280120307>3. security and disorganization in maltreating families and orphanages,” in
0.CO;2-7 Encyclopedia on Early Childhood Development, eds M. van IJzendoorn, R. E.
Ford, J. D., and Courtois, C. A. (2009). “Defining and understanding complex Tremblay, M. Boivin, and R. D. Peters (Montreal, QC: Centre of Excellence for
trauma and complex traumatic stress disorders,” in Treating Complex Early Childhood Development and Strategic Knowledge Cluster on Early Child
Traumatic Stress Disorders: An Evidence-Based Guide, eds C. A. Courtois and Development), 1–7. Available online at: http://www.child-encyclopedia.com/
J. D. Ford (New York, NY: The Guilford Press), 13–30. documents/van_IJzendoorn-Bakermans-KranenburgANGxp-Attachment.pdf
Fraiberg, S., Adelson, E., and Shapiro, V. (1975). Ghosts in the nursery: (Accessed July, 2016).
a psychoanalytic approach to the problem of impaired infant-
mother relationships. J. Am. Acad. Child Psychiatry 14, 387–421. Conflict of Interest Statement: The authors declare that the research was
doi: 10.1016/S0002-7138(09)61442-4 conducted in the absence of any commercial or financial relationships that could
Hesse, E., and Main, M. (2006). Frightened, threatening, and dissociative parental be construed as a potential conflict of interest.
behavior in low-risk samples: description, discussion, and interpretations. Dev.
Psychopathol. 18, 309–343. doi: 10.1017/S0954579406060172 Copyright © 2017 San Cristobal, Santelices and Miranda Fuenzalida. This is an
Lieberman, A. F., Ghosh Ippen, C., and Van Horn, P. (2015). Don’t Hit My open-access article distributed under the terms of the Creative Commons Attribution
Mommy!: A Manual for Child-Parent Psychotherapy with Young Children License (CC BY). The use, distribution or reproduction in other forums is permitted,
Exposed to Violence and Other Trauma. Washington, DC: Zero to Three. provided the original author(s) or licensor are credited and that the original
Lieberman, A. F., and Van Horn, P. (2008). Psychotherapy with Infants and Young publication in this journal is cited, in accordance with accepted academic practice.
Children: Repairing the Effects of Stress and Trauma on Early Attachment. New No use, distribution or reproduction is permitted which does not comply with these
York, NY: The Guilford Press. terms.

Frontiers in Psychology | www.frontiersin.org 9 March 2017 | Volume 8 | Article 449