Emotion Regulation Difficulties mediate the Relationship between Childhood Maltreatment and Perceived Stress in Adulthood

Emotion Regulation Difficulties mediate the Relationship between Childhood Maltreatment and Perceived Stress in Adulthood | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Emotion Regulation Difficulties mediate the Relationship between Childhood Maltreatment and Perceived Stress in Adulthood Gaia Lapomarda, Beatrice Frajo-Apor, Gerald Autengruber, Alex Hofer, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7454105/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Childhood exposure to traumatic events can have enduring negative effects, particularly on stress levels and overall well-being. However, individuals may respond and adapt differently to such experiences. One of the factors that may explain these differences is emotion dysregulation, which refers to difficulties in managing emotional responses and is often linked to interpersonal trauma. This study investigated whether difficulties in emotion regulation mediate the relationship between various early traumatic experiences and stress in adulthood. A sample of 351 university students completed self-report assessments of childhood maltreatment (CTQ), emotion regulation difficulties (DERS), and perceived stress (PSS-10). Structural equation model (SEM) analyses showed that difficulties in specific emotion regulation strategies mediated the effects of emotional traumatic experiences, both abuse and neglect, on perceived helplessness and self-efficacy in adulthood. These findings underscore the lasting impact of emotional trauma and highlight emotion regulation as a key target for interventions aimed at reducing stress in adulthood. Childhood Maltreatment Emotion Dysregulation Stress Structural equation modeling Figures Figure 1 Figure 2 Figure 3 1. Introduction Childhood maltreatments refer to a variety of traumatic events that occur during childhood, including emotional and physical abuse and neglect (Cameron et al., 2018). Meta-analytic evidence indicates that approximately 17.4% of individuals self-report experiences of childhood neglect (Stoltenborgh et al., 2013), while 12.7% report having experienced childhood sexual abuse (Stoltenborgh et al., 2011). Traumatic experiences during childhood have far-reaching consequences (Cicchetti & Toth, 1995), extending beyond immediate harm to include long-term impacts on mental health and overall well-being (Jennissen et al., 2016; World Health Organization, 1999, 2020), as well as disrupted ability to regulate emotions and form stable relationships (Heleniak et al., 2016; McLaughlin & Lambert, 2017). The "Report of the Consultation on Child Abuse Prevention" provides a comprehensive overview of the various types of maltreatment (World Health Organization, 1999), which encompasses Physical Abuse, Emotional Abuse, Sexual Abuse, and Physical and Emotional Neglect. Physical abuse is the actual or potential physical harm resulting from an action or lack of action within a caregiver’s control (Stoltenborgh et al., 2015). Emotional abuse occurs when there is a failure to provide a developmentally appropriate, supportive environment. This encompasses the absence of a primary attachment figure, which is crucial for children to develop a stable and full range of emotional and social competencies. It also includes actions directed at children that cause harm or are likely to harm their physical, mental, or social development, such as denigrating, threatening, intimidating, discriminating, ridiculing, or other non-physical forms of hostile or rejecting behavior (Stoltenborgh et al., 2015). Sexual abuse occurs when children are involved in sexual activity they cannot comprehend, give informed consent for, or are not developmentally prepared to engage in (Stoltenborgh et al., 2015). Finally, the description of Neglect - both physical and emotional - is characterized by a caregiver’s failure to provide for children’s development in areas such as health, education, emotional well-being, nutrition, shelter, and safe living conditions, taking into account the caregiver’s available resources (Stoltenborgh et al., 2015). Increasing awareness of typical child development and the harmful health effects of maltreatment underscores the urgency of addressing this issue. Individuals with a history of childhood maltreatment show a diminished ability to cope with aversive affective states and experience higher levels of perceived stress (Hager & Runtz, 2012; Hong et al., 2018; Vranceanu et al., 2007). An expanding body of research suggests that early life maltreatment is associated with long-term increases in sensitivity to stressful life events, increasing the likelihood of psychopathology and unfavorable health consequences (Scorza et al., 2022). Neurobiological evidence further indicates that maltreated individuals have alterations in stress-susceptible brain regions, hypothalamic-pituitary-adrenal response, and inflammatory marker levels (Nemeroff, 2016; Tarullo & Gunnar, 2006; Teicher et al., 2022). Given the high prevalence and profound impacts of childhood maltreatment, understanding the mechanisms underlying these adverse outcomes is essential (Jennissen et al., 2016). The long-term impacts of childhood maltreatment on stress sensitivity and neurobiological functioning are deeply interconnected with the development of emotional and behavioral difficulties (Dadomo et al., 2022; Grecucci et al., 2023). Children who experience maltreatment face a heightened risk of developing reactive aggression and deficits in regulating emotions (Dvir et al., 2014). Moreover, adults with a history of childhood maltreatment tend to detect less positive emotions and be faster in recognizing negative ones (Bérubé et al., 2023) and show difficulties in many forms of emotion regulation (Heleniak et al., 2016; McLaughlin & Lambert, 2017). Emotion regulation is defined as the processes of monitoring, evaluating, and modifying emotional reactions, particularly their intensity and duration, to achieve specific goals (Gross, 2015; Morawetz et al., 2017, 2020). It involves six dimensions, such as emotional awareness, acceptance, and clarity, the ability to inhibit prepotent responses, engage regulation strategies, and activate goal-directed behavior (Cole et al., 2019). During childhood, responsive parenting and peer interactions play a crucial role in fostering emotion regulation skills. Consequently, experiencing abuse and neglect as a child can hinder the development of proper emotional and interpersonal abilities (Dadomo et al., 2022; Dvir et al., 2014; Grecucci et al., 2023). Emotion dysregulation - often a result of early adversity - is commonly conceptualized as a multidimensional construct that involves the disruption of one or more of the emotion regulation dimensions, leading to (1) a lack of awareness, understanding, and acceptance of emotions, (2) limited access to adaptive strategies for modulating the intensity and/or duration of emotional responses, (3) an unwillingness to experience emotional distress in the pursuit of desired goals, and (4) an inability to control behaviors while experiencing emotional distress (Gratz et al., 2009; Gratz & Roemer, 2004). Emotion regulation plays a crucial role in how individuals evaluate and respond to stressful events, shaping their emotional reactions and expressions (Wang & Saudino, 2011). This developmental link between emotion regulation and stress is particularly important, as children's capacity to manage stress typically improves as they develop better emotional regulation skills (Wang & Saudino, 2011). Given the centrality of emotion regulation in effectively coping with stress, it is particularly concerning that difficulties in emotion regulation can exacerbate pre-existing vulnerabilities, such as impulsivity or behavioral inhibition, thereby contributing to more severe symptoms across various mental disorders (Beauchaine, 2015; Grecucci et al., 2022; Morawetz et al., 2024). Thus, emotion dysregulation serves as a critical mechanism connecting childhood maltreatment to the long-term cognitive, psychological, and health consequences (Beauchaine, 2015; Sheppes et al., 2015; Strathearn et al., 2020). Understanding these connections is crucial for developing effective interventions aimed at mitigating the enduring effects of childhood maltreatment. However, while emotion dysregulation has been identified as a mediator between childhood maltreatment and psychopathologies (Jennissen et al., 2016), the broader relationship between various forms of childhood maltreatment, emotion regulation difficulties, and perceived stress remains underexplored. Gaining a deeper understanding of this mediation is critical for developing targeted interventions that address the complex interplay of factors contributing to the long-term effects of childhood maltreatment. Interestingly, the impact of childhood maltreatment on psychological functioning (Gallo et al., 2018; Godinet et al., 2014) and on the development of psychopathology (Prachason et al., 2024) seems to be different among females and males. As previously mentioned, emotion regulation is a key mechanism that links childhood maltreatment to its long-term consequences (Kerig, 2020), and difficulties in this process are more common among females than males (Herd & Kim-Spoon, 2021; Vanhalst et al., 2018). In fact, the former tend to show a stronger inclination toward self-blame, ruminating, and catastrophizing following an adverse experience. Sex differences also emerge in perceiving stress and coping (Graves et al., 2021), as well as in the physiological stress responses (i.e., cortisol reactivity) (de Veld et al., 2012), with females showing higher levels of stress and stronger cortisol responses than males. Although studies on a variety of topics have highlighted the importance of sex-specific analyses (Glaesmer et al., 2011; Hong et al., 2018; Topitzes et al., 2012), mixed evidence persists, warranting further investigation (Prevoo et al., 2017). Previous studies have examined stress responses as a risk factor for psychopathology, yet relatively little is known about how maltreatment relates to stress perception and regulation strategies that individuals acquire and use. To fill this gap, our study examines the effects of early traumatic experiences on stress in adulthood, with a focus on the mediating role of emotion dysregulation. Specifically, we investigated how difficulties in emotion regulation mediate the relationship between different traumatic experiences, such as abuse and neglect, and later perceived stress as defined by two dimensions: perceived helplessness and self-efficacy. We hypothesized that difficulties in regulating emotions would amplify the impact of early-life traumatic experiences on stress experienced throughout life. Through this study, we aim to provide a deeper understanding of the complex mechanisms linking childhood maltreatment to long-term stress. 2. Methods 2.1. Sample A sample of 351 participants (260 females; mean age 23.13 ± 3.66) completed self-report measures of childhood maltreatment (CTQ), emotion regulation difficulties (DERS), and perceived stress (PSS-10), using LimeSurvey ( https://www.limesurvey.org/ ). Participants were all students at the University of Innsbruck and the Medical University of Innsbruck who were recruited through advertisements. 2.2. Measures Childhood Trauma Questionnaire - Short Form (CTQ) Childhood maltreatment is here defined as exposure to traumatic experiences during childhood. Participants completed the German version of the Childhood Trauma Questionnaire - Short Form (Klinitzke et al., 2012). The CTQ is a retrospective, 28-item self-report scale that assesses the frequency of maltreatment experiences during childhood, including abuse and neglect. The items are rated on a 5-point Likert scale ranging from 1 (never true) to 5 (very often true), and explore five dimensions of maltreatment: (1) Emotional Abuse - verbal assaults or any humiliating or demeaning behavior directed at a child by an adult (e.g., “People in my family said hurtful or insulting things to me”), (2) Physical Abuse - bodily assaults on a child by an adult that created a danger of or led to harm (e.g., “People in my family hit me so hard that it left me with bruises or marks”), (3) Sexual Abuse - sexual contact or conduct between a child and an adult (e.g., “Someone tried to touch me in a sexual way, or tried to make me touch them”), (4) Emotional Neglect - failure of caretakers to provide for a child’s basic physical needs, including food, shelter, clothing, safety, and health care (e.g., “People in my family looked out for each other”), and (5) Physical Neglect - failure of caretakers to meet children’s basic emotional and psychological needs, including love, belonging, nurturance, and support (e.g., “I had to wear dirty clothes”). Difficulties in Emotion Regulation Scale (DERS) Participants completed the German version of the Difficulties in Emotion Regulation Scale (Ehring et al., 2013). The DERS is a 36-item self-report scale measuring difficulties within the following dimensions of emotion regulation: awareness and understanding of emotions, acceptance of emotions, the ability to engage in goal-directed behavior and refrain from impulsive behavior when experiencing negative emotions, and access to emotion regulation strategies perceived as effective for feeling better (Gratz & Roemer, 2004). Specifically, six subscales are defined: (1) Non-acceptance of emotional responses (e.g., “When I’m upset, I become angry with myself for feeling that way”), (2) Difficulty engaging in goal-directed behaviors (e.g., “When I’m upset, I have difficulty focusing on other things”), (3) Impulse control difficulties (e.g., “When I’m upset, I become out of control”), (4) Lack of emotional awareness (e.g., “When I’m upset, I acknowledge my emotions”), (5) Limited access to emotion regulation strategies (e.g., “When I’m upset, I believe that I will remain that way for a long time”), and (6) Lack of emotional clarity (e.g., “I am confused about how I feel”). The items are rated on a 5-point Likert scale ranging from 1 (almost never) to 5 (almost always). The scale is composed of 6 dimensions: non-acceptance of emotional responses, difficulty engaging in goal-directed behavior, impulse control difficulties, lack of emotional awareness, limited access to emotion regulation strategies, and lack of emotional clarity. Perceived Stress Scale (PSS-10) Participants completed the German version of the Perceived Stress Scale (Schneider et al., 2020), a 10-item self-report scale that assesses the degree to which, in the last month, individuals perceived situations in their lives as uncontrollable, unpredictable, and overloaded. It is represented by two subscales: Perceived Helplessness - measuring individuals’ perceived difficulty in controlling circumstances or emotions (e.g., “In the last month, how often have you been upset because of something that happened unexpectedly?”), and Perceived Self-Efficacy - measuring individuals’ perceived ability to handle problems (e.g., “In the last month, how often have you felt confident about your ability to handle your personal problems?”). Items are rated on a 4-point scale from 0 (never) to 4 (very often). 2.3. Statistical Analysis All data were entered and analyzed in R (R Core Team, 2022). Following an initial exploration of descriptive statistics for the sample, we conducted preliminary analyses to examine potential sex and age differences in the variables of interest. Because the variables didn’t follow a normal distribution, non-parametric analyses were computed (i.e., Mann-Whitney U test adjusted with the Benjamini-Hochberg method). Also, bivariate correlation analysis using Pearson’s coefficient was computed to explore the relationships among these variables. Next, we employed structural equation modeling (SEM) with observed variables to investigate the direct and indirect associations between traumatic childhood experiences, emotion dysregulation, and perceived stress. Specifically, path analyses were conducted using the lavaan package (version 0.6–18) in R, employing maximum likelihood estimation with robust standard errors (MLR) and applying the Yuan-Bentler scaled test statistic to account for non-normality. The traumatic childhood experiences were modeled as exogenous variables and measured by five distinct observed variables, which were computed as the mean of items from each CTQ subscale (Emotional abuse, Physical abuse, Sexual abuse, Emotional neglect, Physical neglect). Emotion dysregulation was modeled as an endogenous mediator variable and composed of six observed variables, each representing the composite score of the six dimensions of DERS (Nonacceptance of emotional responses, Difficulty engaging in goal-directed behaviour, Impulse control difficulties, Lack of emotional awareness, Limited access to emotion regulation strategies, Lack of emotional clarity). Perceived stress was modeled as an endogenous variable measured with the two PSS-10 subscales of Helplessness and Self-efficacy. Sex and age were included as covariates in the model. Specifically, a two-step SEM approach was employed. In the first model (Model 1), total scores from the DERS and PSS-10 were used to test a general mediation model including all five traumatic childhood experiences subtypes from the CTQ. Based on the pattern of results and consistent with recommendations for model parsimony and statistical power (McCoach, 2003; Taris et al., 2020), non-significant predictors were removed. In the second step, Model 2 was specified as a more detailed model, and both the DERS and PSS-10 were disaggregated into their respective subscales to explore more nuanced mediation pathways. Following common best practices in SEM for psychological research (Kline, 2023), we also specified free covariances among the CTQ subscales, the DERS subscales, and between the two PSS-10 subscales, to capture shared variance among related constructs. Model fit was evaluated using the following indices: Comparative Fit Index (CFI; values > .90), Tucker-Lewis Index (TLI; values > .90), Root Mean Square Error of Approximation (RMSEA; values < .06), and Standardized Root Mean Square Residual (SRMR; values < .08). 3. Results 3.1. Descriptive analysis Table 1 shows the descriptive statistics for all variables. Preliminary analyses of the contribution of demographic characteristics to the variables of interest revealed that females reported more experiences of Emotional abuse (W = 14968, p < .001) and Sexual abuse (W = 13639, p = .002) than males. In addition, females reported more Non-acceptance of emotional responses (W = 14260, p = .003), Impulse control difficulties (W = 14450, p = .001), and Limited access to emotion regulation strategies (W = 14096, p = .006) compared to males. Lastly, females also reported higher perceived stress overall (W = 13737, p = .02), specifically more Perceived helplessness (W = 13856, p = .01) than males. Age significantly predicted Perceived self-efficacy (t(350) = 2.26, p = .02), Impulse control difficulties (t(350) = -2.22, p = .02), and Lack of Emotional Clarity (t(350) = -4.95, p < .001), meaning that the older the participants the greater the sense of self-efficacy, and the lower the difficulties in these two dimensions of emotion regulation. No significant interaction effect between sex and age was observed. Total (N = 351) Females (N = 260) Males (N = 91) M SD Range M SD Range M SD Range CTQ Emotional Abuse 9.21 4.54 5-23 9.77 4.79 5-23 7.59 3.21 5-22 Physical Abuse 5.54 1.61 5-16 5.59 1.7 5-16 5.41 1.29 5-13 Sexual Abuse 5.84 2.37 5-24 6.01 2.6 5-24 5.34 1.41 5-16 Emotional Neglect 9.69 4.2 5-23 9.77 4.37 5-23 9.47 3.68 5-19 Physical Neglect 6.62 2.15 5-16 6.73 2.3 5-16 6.29 1.59 5-11 DERS Non-acceptance of emotional responses 17.12 6.15 6-30 17.69 6.17 6-30 15.48 5.81 6-30 Difficulties in goal-directed behaviors 15.83 5.04 5-25 16.16 4.93 5-25 14.88 5.27 5-24 Impulse control difficulties 13.84 5.61 6-30 14.38 5.72 6-30 12.27 5 6-26 Lack of emotional awareness 14.41 4.65 6-29 14.22 4.46 6-26 14.95 5.15 6-29 Limited access to emotion regulation strategies 22.16 7.82 8-40 22.84 7.79 8-40 20.22 7.6 9-37 Lack of emotional clarity 12.87 4.79 5-25 12.93 4.76 5-25 12.69 4.9 5-25 Total 96.22 26.37 38-164 98.23 26.38 38-164 90.49 25.63 47-147 PSS-10 Perceived Helplessness 20.06 4.95 8-30 20.45 4.9 8-30 18.97 4.95 10-29 Perceived Self-Efficacy 12.66 2.75 6-20 12.5 2.66 6-19 13.12 2.97 7-20 Total 31.4 7.21 13-48 31.94 7.08 13-48 29.85 7.38 16-44 Table 1 Descriptive statistics for Variables of Interest. CTQ=Childhood Trauma Questionnaire; DERS=Difficulty in Emotion Regulation Scale; PSS-10=Perceived Stress Scale The correlogram in Figure 1 displays the correlations among the various psychopathological variables examined in this study. Bivariate relationships between variables were assessed using Pearson correlations adjusted for multiple comparisons (Holm-Bonferroni correction), with the significance level set at α = .05. The results supported the links between childhood trauma, difficulties in emotion regulation, and perceived stress. Emotional Abuse and Emotional Neglect appeared to be key trauma-related predictors of both impaired emotion regulation and heightened stress. Specifically, Emotional Abuse and Emotional Neglect were most strongly associated with Limited access to emotion regulation strategies (CTQ_Emotional abuse: r =.38, CTQ_Emotional neglect: r =.37) and also with Nonacceptance of emotional responses, Difficulties in goal-directed behavior, and Difficulties in impulse control (CTQ_Emotional abuse: r =.26, .29, .33, CTQ_Emotional neglect: r =.27, .27, .30). Perceived helplessness was positively associated with all DERS subscales, while Perceived self-efficacy showed negative associations. Emotional Abuse and Emotional Neglect were also correlated with higher Perceived helplessness (CTQ_Emotional abuse: r = .35, CTQ_Emotional neglect: r =.28) and lower Perceived self-efficacy (CTQ_Emotional abuse: r = -.32, CTQ_Emotional neglect: r = -.30). 3.2. Path analysis Model 1: Total Emotion Regulation Difficulties as Mediator The initial structural model tested whether total difficulties in emotion regulation (DERS total score) mediated the relationship between various subtypes of maltreatment (CTQ subscales) and perceived stress (PSS-10 total score) in adulthood. The model demonstrated acceptable fit to the data (robust χ²(5) = 21.17, p = .001; robust CFI = 0.981; TLI = 0.865; RMSEA = 0.095, 90% CI [0.056, 0.139]; SRMR = 0.040). Among the five trauma subtypes, Emotional neglect emerged as the strongest predictor of emotion dysregulation, exerting a significant direct effect on DERS total scores (b = 1.80, p < .001). Emotional abuse showed a marginal effect (b = 0.76, p = .072), while Physical abuse, Sexual abuse, and Physical neglect did not significantly predict emotion regulation difficulties. In turn, greater difficulties in emotion regulation were strongly associated with increased perceived stress (b = 0.16, p < .001). Two trauma subtypes - Emotional abuse (b = 0.25, p = .004) and Sexual abuse (b = 0.26, p = .014) - had significant direct effects on perceived stress. In contrast, Emotional neglect showed no direct effect on stress, but its indirect effect through emotion dysregulation was significant (b = 0.29, p < .001), indicating a pattern of full mediation. No significant indirect effects were found for the remaining trauma types. Altogether, the model explained 20.1% of the variance in emotion regulation difficulties and 44.1% in perceived stress. Importantly, female sex was significantly associated with greater exposure to Emotional abuse (b = −2.18, p < .001), Sexual abuse (b = −0.68, p = .002), and Physical neglect (b = −0.44, p = .044) than male, but it did not have a direct effect on emotion regulation or stress in this model. Full results are provided in Table S1 (Supplementary Materials). Model 2: Specific Emotion Regulation Difficulties and Perceived Stress Dimensions To expand on these initial findings, in Model 2, we broke down both emotion dysregulation and perceived stress into their respective subdomains, offering a more detailed understanding of the underlying pathways (see Figure 3). We kept only Emotional abuse, Emotional neglect, and Sexual abuse as predictors, based on the significant paths that emerged in Model 1. Removing such paths enhances parsimony, statistical power, and prevents biased parameter estimates that may arise from including irrelevant predictors in structural equation modelling (McCoach, 2003; Taris et al., 2020). This refined model demonstrated an excellent fit to the data (robust χ²(3) = 3.92, p = .271; robust CFI = 0.999; TLI = 0.988; RMSEA = 0.029, 90% CI [0.000, 0.097]; SRMR = 0.014), indicating that the structure effectively captured the observed relationships. Both Emotional abuse (b = 0.14, p = .016) and Sexual abuse (b = 0.18, p = .017) had significant direct effects on Perceived helplessness. None of the trauma subtypes showed significant direct effects on Perceived self-efficacy. Emotional abuse also had a significant indirect effect on Perceived helplessness (b = 0.14, p = .002), primarily via increased Difficulties in engaging in goal-directed behavior and Limited access to emotion regulation strategies, supporting a partial mediation. Emotional neglect showed a significant indirect effect (b = 0.15, p = .004), largely mediated by Lack of emotional clarity and Limited access to emotion regulation strategies, indicating full mediation through emotion regulation processes. Sexual abuse did not show any significant indirect effect on Perceived helplessness. Similar patterns were observed for Perceived self-efficacy. Emotional abuse was negatively related to Perceived self-efficacy via indirect pathways (b = −0.06, p = .013), particularly through Lack of emotional clarity and Limited access to emotion regulation strategies. Emotional neglect also had a significant negative indirect effect on Perceived self-efficacy (b = −0.11, p < .001) via Lack of emotional awareness and Limited access to emotion regulation strategies. Sexual abuse did not show any significant indirect effects on this dimension of stress either. Overall, the expanded model explained 43.4% of the variance in Perceived helplessness and 44.3% in Perceived self-efficacy, highlighting the central role of specific emotion regulation mechanisms in shaping the impact of early emotional trauma on perceived stress in adulthood. Female sex remained significantly associated with greater exposure to Emotional abuse and Sexual abuse, and sex also predicted higher scores in Nonacceptance of emotional responses (b = −1.71, p = .020), suggesting more difficulties in this domain in females than males. Age was negatively associated with Lack of emotional clarity (b = −0.36, p < .001), suggesting slightly better regulation with age. Full results are provided in Table S2 (Supplementary Materials). 4. Discussion This study aimed to examine how traumatic childhood experiences influence perceived stress in adulthood and whether this relationship is mediated by emotion dysregulation, controlling for variation in sex and age. Initial analyses of the contribution of demographic characteristics revealed sex and age differences in trauma exposure, emotion dysregulation, and stress. Females reported significantly more emotional and sexual abuse, greater emotion regulation difficulties (non-acceptance, impulse control, limited strategy access), and higher perceived helplessness than males. Age was positively associated with perceived self-efficacy and negatively related to impulse control difficulties and emotional clarity problems, suggesting greater regulatory capacity with age. These results allowed us to account for demographic influences when examining the mediating role of emotion dysregulation. The observed correlations further indicated that emotional abuse and neglect were consistently associated with greater emotion regulation difficulties and higher perceived stress, particularly high helplessness and low self-efficacy. These patterns supported our theoretical model and justified the use of structural equation modelling to examine potential mediating pathways and the overall structure of these relationships. Following previous studies (Kim & Cicchetti, 2010; Zhang et al., 2022), emotion dysregulation partially mediated the relationship between childhood maltreatment and perceived stress, accounting for sex and age variation. In the path analysis, Emotional neglect emerged as a key predictor of emotion dysregulation that, in turn, increased perceived stress. Emotional abuse also predicted higher perceived stress both directly and indirectly, suggesting that the consequences of such traumatic experiences are both immediate and mediated by regulatory dysfunction. In contrast, Sexual abuse showed a strong contribution to the increased perceived stress later in life, regardless of emotion regulation abilities. More specifically, having limited access to emotion regulation strategies and difficulties in engaging in goal-directed behaviors, as well as less clarity and awareness of the emotional experiences, significantly amplified the long-term effect of emotional maltreatment on perceived stress, resulting in increased feelings of helplessness and reduced self-efficacy. Individuals can flexibly use emotion regulation strategies based on the situation, aligning them with changes in external circumstances and/or the individual's perceptions of them (Blanke et al., 2020; Elkjær et al., 2022). Emotion regulation flexibility can lead to more or less adaptive outcomes (e.g., the ability to achieve goals), influencing well-being (Aldao et al., 2015; Rammensee et al., 2023). According to the attachment theory, children living in abusive and neglectful environments experience insecure attachment (Greenman et al., 2024; Toof et al., 2020), which prevents them from learning appropriate strategies to manage emotions (Brenning & Braet, 2013) and cope with stress (Mikulincer & Shaver, 2019). Thus, our findings on the mediating role of emotion regulation difficulties may reflect a tendency for inflexible responses in individuals who experienced trauma in childhood. This inflexibility can intensify the negative impact of trauma over time, leading to greater perceived helplessness (i.e., difficulties in controlling circumstances) and reduced self-efficacy (i.e., ability to handle problems). In line with the learned helplessness model (Miller & Norman, 1979), organisms exposed to a situation where they experience unavoidable harmful stimuli (e.g., unavoidable shock) may fail to avoid such stimuli in the future when escape becomes possible (i.e., they learn “helplessness”). A revised approach proposed by Boddez and colleagues (2022) suggests that rather than learning passivity, organisms may learn controllability (Boddez et al., 2022; Duda & Joormann, 2022), meaning that prior experience with controllability could shape the perception of control later (Ly et al., 2019). Extending this mechanism would then result in a generalization of the sense of helplessness learned during unavoidable and uncontrollable maltreatment situations, reducing the perception of possible control over circumstances and increasing perceived stress (Duda & Joormann, 2022; Lieder & Goodman, 2013). Hence, there is evidence supporting integrated control beliefs, which are related to how children learn to cope with stress (Compas et al., 1991; Jenzer et al., 2019), and several studies highlighted that an altered perception of control may contribute to the development of affective disorders and the exacerbation of perceived stress (Gallagher et al., 2014; Ly et al., 2019; McEwen, 2000; Schweizer et al., 2020). This perspective can improve our understanding of the link between trauma, emotion regulation, and stress (Weems & Silverman, 2006) and is particularly relevant when considering the consequences of exaggerated and prolonged emotional reactions to stressful situations. Under such conditions, stress can contribute to the development of various types of psychopathology (Slavich, 2016b, 2016a), and the ability to cope effectively with stress can help prevent negative consequences for mental well-being (Dijkstra & Homan, 2016). For example, individuals who do not feel competent to avoid threatening situations (low self-efficacy) may experience anxiety (Weems & Silverman, 2006). Similarly, the perception of self as having an insufficient ability to cope with situations and not having control over social situations (high helplessness) is associated with higher degrees of social anxiety (Thomasson & Psouni, 2010). This also corroborates the findings of a recent study that investigated the dynamics of coping behavior and psychological distress across different phases of the COVID-19 pandemic within an adult general population sample and revealed that maladaptive coping strategies were consistently linked to increased psychological distress, whereas adaptive strategies were associated with decreased psychological distress (Schurr et al., 2024). It is worth noting that, in our sample, women reported a higher frequency of early-life maltreatments (both emotional and physical) and showed more compromised emotion regulation abilities (nonacceptance of emotional responses). Cutler and Nolen-Hoeksema (1991) first proposed sex differences in the effects of childhood trauma, arguing that females are more inclined to blame themselves for stressful life events (e.g., maltreatment), making them more vulnerable to low self-esteem and mental health problems. Furthermore, while abuse is likely to impact both sexes negatively, the symptoms of the trauma may differ (e.g., internalized disorders in females and externalized disorders in males) (Hanson et al., 2008). These results highlight the importance of considering sex when studying affective variability in the effects of early-life trauma (Prevoo et al., 2017). A noticeable finding of this study is the stronger and more consistent effect of emotional trauma, both abuse and neglect, compared to physical trauma. This aligns with a growing body of evidence indicating that emotional maltreatment may be as harmful, or even more so, than physical forms of abuse (Dye, 2020; Spinazzola et al., 2014). First, emotional trauma directly disrupts the development of core self-regulatory capacities (Warmingham et al., 2023). Emotionally neglectful environments fail to model and validate emotional experiences, impeding the child’s ability to recognize, understand, and manage emotions (Eilert & Buchheim, 2023). Also, emotional abuse, through denigration, hostility, or rejection, may actively distort a child’s self-concept and emotional security (Baugh et al., 2019). Second, physical abuse typically occurs in episodes and receives external support, while emotional trauma usually manifests chronically and subtly, making it more challenging to detect and report. This often results in deeper effects on self-regulation and stress appraisal systems (Osborne et al., 2022). Our findings that specific emotion regulation difficulties, such as limited access to adaptive strategies, difficulty engaging in goal-directed behavior, and reduced emotional clarity and awareness, mediate the impact of emotional abuse and neglect on perceived stress align closely with the Research Domain Criteria (RDoC) project (Cuthbert & Insel, 2013; Fernandez et al., 2016). Within the RDoC framework, emotion regulation processes are situated at the intersection of the negative valence systems (e.g., heightened threat sensitivity in maltreated individuals) and cognitive control systems (e.g., goal-directed behavior under emotional strain). The mediators identified in our models map directly onto these domains, suggesting that early maltreatment may disrupt processes central to both affective and cognitive control. This reinforces the value of RDoC as a lens for understanding how emotion regulation operates as a transdiagnostic mechanism linking adversity to stress-related psychopathology (Aldao, 2016; Fernandez et al., 2016; Morawetz et al., 2024). 4.1. Limitations and Future Directions Our findings should be interpreted in light of some limitations. The cross-sectional design limits the ability to draw inferences about directionality and causality among variables. Furthermore, results may have been influenced by social desirability bias in the use of self-report measures. Future studies should benefit from using longitudinal, multi-method designs to investigate the specific ways in which maltreatment interferes with the acquisition of healthy stress responses. Evidence suggests that the characteristics of maltreatment may have different implications for specific coping and emotion regulation strategies (Milojevich et al., 2019). Therefore, studies may also explore various forms of emotion regulation to deepen their significance and associations with psychological consequences, as well as collect details on maltreatment histories (e.g., type, timing, duration) using reliable and valid measures. It should also be noted that we exclusively investigated students of a health-related subject (medicine, psychology). Selecting a sample in this way limits the generalizability of the obtained results. Finally, the influence of socio-economic status and the interaction with pre-existing traits (e.g., personality, anxiety trait, self-compassion) should be further explored to understand their possible role in the observed outcomes (Barlow et al., 2017). 5. Conclusion These findings highlight the crucial role of emotion regulation in connecting early traumatic experiences with stress perception in adulthood. They support a model suggesting that emotionally abusive or neglectful environments impair regulatory processes, which then increase vulnerability to stress. Importantly, the specific emotion regulation pathways identified present promising opportunities for intervention. Therapeutic strategies that focus on improving clarity and awareness, encouraging goal-directed coping, and increasing access to effective emotion regulation techniques may be particularly beneficial for adults who have experienced childhood maltreatment. Additionally, longitudinal studies are needed to gain deeper insights into the causal relationship between childhood trauma, emotion regulation, and adult stress outcomes, paving the way for more effective early interventions. Declarations Funding statement The authors received no financial support for the research, authorship, and/or publication of this article. Declaration of conflicting interest The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Ethics approval This study was conducted in accordance with the principles of the Declaration of Helsinki. Approval was granted by the University Ethics Committee (90/2022). Consent to participate All participants provided written informed consent prior to participating. Consent for publication Informed consent for publication was provided by the participants. Author Contribution CM and AH participated in the conceptualization, design, and coordination of the study, and reviewed the draft of the manuscript; GL performed the statistical analyses, participated in the interpretation of the data, and drafted the manuscript; BFA and GA participated in the design of the study and reviewed the draft of the manuscript. All authors read and approved the final manuscript. Data Availability https://osf.io/6z8dq/ References Aldao, A. (2016). Introduction to the Special Issue: Emotion Regulation as a Transdiagnostic Process. Cognitive Therapy and Research , 40 (3), 257–261. https://doi.org/10.1007/s10608-016-9764-2 Aldao, A., Sheppes, G., & Gross, J. J. (2015). Emotion Regulation Flexibility. Cognitive Therapy and Research , 39 (3), 263–278. https://doi.org/10.1007/s10608-014-9662-4 Barlow, M. R., Goldsmith Turow, R. E., & Gerhart, J. (2017). 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18:13:56","extension":"xml","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":115277,"visible":true,"origin":"","legend":"","description":"","filename":"804224125109425d84895e970b3f58681structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7454105/v1/5bd165e04b2e5b142167ead6.xml"},{"id":94582428,"identity":"91d24bb4-135e-4347-9189-dac9bdc865fe","added_by":"auto","created_at":"2025-10-28 18:13:07","extension":"html","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":125543,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7454105/v1/a889925bef2ccd71be7131e9.html"},{"id":94583864,"identity":"39f8b213-c0d4-461d-8f9e-0950fcb12917","added_by":"auto","created_at":"2025-10-28 18:14:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":90624,"visible":true,"origin":"","legend":"\u003cp\u003eRelationships among childhood traumatic experiences, emotion dysregulation, and perceived stress. CTQ=Childhood Trauma Questionnaire; DERS=Difficulty in Emotion Regulation Scale; PSS=Perceived Stress Scale\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7454105/v1/e6735f3ffc81bcd58212b9c7.png"},{"id":94582639,"identity":"280b545c-1c4f-4db7-aefd-10a548299703","added_by":"auto","created_at":"2025-10-28 18:13:20","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1201250,"visible":true,"origin":"","legend":"\u003cp\u003eStructural equation model (Model 1) linking childhood trauma subtypes to total perceived stress via general emotion regulation difficulties. Rectangles are observed subscale scores (CTQ=Childhood Trauma Questionnaire; DERS=Difficulty in Emotion Regulation Scale; PSS=Perceived Stress Scale). Solid arrows show significant direct effects (* \u003cem\u003ep \u0026lt;\u003c/em\u003e .05, ** \u003cem\u003ep \u0026lt;\u003c/em\u003e .01, *** \u003cem\u003ep \u0026lt;\u003c/em\u003e.001). Specifically, red arrows are significant paths from CTQ to PSS-10; light blue arrows are significant paths from CTQ to DERS; green arrows are significant paths from DERS to PSS-10. Dashed arrows are nonsignificant paths. Dotted curves indicate within-domain covariances. Numbers on arrows are unstandardized regression coefficients. Age and sex were included as covariates in the model; for clarity, their paths are not displayed.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7454105/v1/ab41c6919c5191d8e4b47e2a.png"},{"id":94583245,"identity":"77cb5083-4ea4-4434-9c9c-729f0ab52659","added_by":"auto","created_at":"2025-10-28 18:13:56","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2861226,"visible":true,"origin":"","legend":"\u003cp\u003eStructural equation model (Model 2, based on the significant paths that emerged in Model 1) linking childhood trauma subtypes to perceived helplessness and perceived self-efficacy via each of the DERS subdomains. Rectangles are observed subscale scores (CTQ=Childhood Trauma Questionnaire; DERS=Difficulty in Emotion Regulation Scale; PSS=Perceived Stress Scale). Solid arrows show significant direct effects (* \u003cem\u003ep \u0026lt;\u003c/em\u003e .05, ** \u003cem\u003ep \u0026lt;\u003c/em\u003e .01, *** \u003cem\u003ep \u0026lt;\u003c/em\u003e.001). Specifically, red arrows are significant paths from CTQ to PSS-10 subscales; light blue arrows are significant paths from CTQ to DERS subscales; green arrows are significant paths from DERS to PSS-10 subscales. Dashed arrows are nonsignificant paths. Dotted curves indicate within-domain covariances. \u0026nbsp;Numbers on arrows are unstandardized regression coefficients. Age and sex were included as covariates in the model; for clarity, their paths are not displayed.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7454105/v1/91b41d8d512e9838cab1c812.png"},{"id":94598435,"identity":"dc8bd692-94fb-4926-823f-cf2135aefe93","added_by":"auto","created_at":"2025-10-28 18:53:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3907816,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7454105/v1/fc059f01-1729-412d-8557-2dcb58a9396f.pdf"},{"id":94583416,"identity":"250148e8-ee21-4cf5-b03c-f1837463a25d","added_by":"auto","created_at":"2025-10-28 18:14:02","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":33272,"visible":true,"origin":"","legend":"","description":"","filename":"TraumaERStressSupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-7454105/v1/83d04cf2c1d84a3965863996.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Emotion Regulation Difficulties mediate the Relationship between Childhood Maltreatment and Perceived Stress in Adulthood","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eChildhood maltreatments refer to a variety of traumatic events that occur during childhood, including emotional and physical abuse and neglect (Cameron et al., 2018). Meta-analytic evidence indicates that approximately 17.4% of individuals self-report experiences of childhood neglect (Stoltenborgh et al., 2013), while 12.7% report having experienced childhood sexual abuse (Stoltenborgh et al., 2011). Traumatic experiences during childhood have far-reaching consequences (Cicchetti \u0026amp; Toth, 1995), extending beyond immediate harm to include long-term impacts on mental health and overall well-being (Jennissen et al., 2016; World Health Organization, 1999, 2020), as well as disrupted ability to regulate emotions and form stable relationships (Heleniak et al., 2016; McLaughlin \u0026amp; Lambert, 2017). The \"Report of the Consultation on Child Abuse Prevention\" provides a comprehensive overview of the various types of maltreatment (World Health Organization, 1999), which encompasses Physical Abuse, Emotional Abuse, Sexual Abuse, and Physical and Emotional Neglect. \u003cem\u003ePhysical abuse\u003c/em\u003e is the actual or potential physical harm resulting from an action or lack of action within a caregiver\u0026rsquo;s control (Stoltenborgh et al., 2015). \u003cem\u003eEmotional abuse\u003c/em\u003e occurs when there is a failure to provide a developmentally appropriate, supportive environment. This encompasses the absence of a primary attachment figure, which is crucial for children to develop a stable and full range of emotional and social competencies. It also includes actions directed at children that cause harm or are likely to harm their physical, mental, or social development, such as denigrating, threatening, intimidating, discriminating, ridiculing, or other non-physical forms of hostile or rejecting behavior (Stoltenborgh et al., 2015). \u003cem\u003eSexual abuse\u003c/em\u003e occurs when children are involved in sexual activity they cannot comprehend, give informed consent for, or are not developmentally prepared to engage in (Stoltenborgh et al., 2015). Finally, the description of \u003cem\u003eNeglect\u003c/em\u003e - both physical and emotional - is characterized by a caregiver\u0026rsquo;s failure to provide for children\u0026rsquo;s development in areas such as health, education, emotional well-being, nutrition, shelter, and safe living conditions, taking into account the caregiver\u0026rsquo;s available resources (Stoltenborgh et al., 2015). Increasing awareness of typical child development and the harmful health effects of maltreatment underscores the urgency of addressing this issue.\u003c/p\u003e\u003cp\u003eIndividuals with a history of childhood maltreatment show a diminished ability to cope with aversive affective states and experience higher levels of perceived stress (Hager \u0026amp; Runtz, 2012; Hong et al., 2018; Vranceanu et al., 2007). An expanding body of research suggests that early life maltreatment is associated with long-term increases in sensitivity to stressful life events, increasing the likelihood of psychopathology and unfavorable health consequences (Scorza et al., 2022). Neurobiological evidence further indicates that maltreated individuals have alterations in stress-susceptible brain regions, hypothalamic-pituitary-adrenal response, and inflammatory marker levels (Nemeroff, 2016; Tarullo \u0026amp; Gunnar, 2006; Teicher et al., 2022). Given the high prevalence and profound impacts of childhood maltreatment, understanding the mechanisms underlying these adverse outcomes is essential (Jennissen et al., 2016).\u003c/p\u003e\u003cp\u003eThe long-term impacts of childhood maltreatment on stress sensitivity and neurobiological functioning are deeply interconnected with the development of emotional and behavioral difficulties (Dadomo et al., 2022; Grecucci et al., 2023). Children who experience maltreatment face a heightened risk of developing reactive aggression and deficits in regulating emotions (Dvir et al., 2014). Moreover, adults with a history of childhood maltreatment tend to detect less positive emotions and be faster in recognizing negative ones (B\u0026eacute;rub\u0026eacute; et al., 2023) and show difficulties in many forms of emotion regulation (Heleniak et al., 2016; McLaughlin \u0026amp; Lambert, 2017). Emotion regulation is defined as the processes of monitoring, evaluating, and modifying emotional reactions, particularly their intensity and duration, to achieve specific goals (Gross, 2015; Morawetz et al., 2017, 2020). It involves six dimensions, such as emotional awareness, acceptance, and clarity, the ability to inhibit prepotent responses, engage regulation strategies, and activate goal-directed behavior (Cole et al., 2019). During childhood, responsive parenting and peer interactions play a crucial role in fostering emotion regulation skills. Consequently, experiencing abuse and neglect as a child can hinder the development of proper emotional and interpersonal abilities (Dadomo et al., 2022; Dvir et al., 2014; Grecucci et al., 2023). Emotion dysregulation - often a result of early adversity - is commonly conceptualized as a multidimensional construct that involves the disruption of one or more of the emotion regulation dimensions, leading to (1) a lack of awareness, understanding, and acceptance of emotions, (2) limited access to adaptive strategies for modulating the intensity and/or duration of emotional responses, (3) an unwillingness to experience emotional distress in the pursuit of desired goals, and (4) an inability to control behaviors while experiencing emotional distress (Gratz et al., 2009; Gratz \u0026amp; Roemer, 2004).\u003c/p\u003e\u003cp\u003eEmotion regulation plays a crucial role in how individuals evaluate and respond to stressful events, shaping their emotional reactions and expressions (Wang \u0026amp; Saudino, 2011). This developmental link between emotion regulation and stress is particularly important, as children's capacity to manage stress typically improves as they develop better emotional regulation skills (Wang \u0026amp; Saudino, 2011). Given the centrality of emotion regulation in effectively coping with stress, it is particularly concerning that difficulties in emotion regulation can exacerbate pre-existing vulnerabilities, such as impulsivity or behavioral inhibition, thereby contributing to more severe symptoms across various mental disorders (Beauchaine, 2015; Grecucci et al., 2022; Morawetz et al., 2024).\u003c/p\u003e\u003cp\u003eThus, emotion dysregulation serves as a critical mechanism connecting childhood maltreatment to the long-term cognitive, psychological, and health consequences (Beauchaine, 2015; Sheppes et al., 2015; Strathearn et al., 2020). Understanding these connections is crucial for developing effective interventions aimed at mitigating the enduring effects of childhood maltreatment. However, while emotion dysregulation has been identified as a mediator between childhood maltreatment and psychopathologies (Jennissen et al., 2016), the broader relationship between various forms of childhood maltreatment, emotion regulation difficulties, and perceived stress remains underexplored. Gaining a deeper understanding of this mediation is critical for developing targeted interventions that address the complex interplay of factors contributing to the long-term effects of childhood maltreatment.\u003c/p\u003e\u003cp\u003eInterestingly, the impact of childhood maltreatment on psychological functioning (Gallo et al., 2018; Godinet et al., 2014) and on the development of psychopathology (Prachason et al., 2024) seems to be different among females and males. As previously mentioned, emotion regulation is a key mechanism that links childhood maltreatment to its long-term consequences (Kerig, 2020), and difficulties in this process are more common among females than males (Herd \u0026amp; Kim-Spoon, 2021; Vanhalst et al., 2018). In fact, the former tend to show a stronger inclination toward self-blame, ruminating, and catastrophizing following an adverse experience. Sex differences also emerge in perceiving stress and coping (Graves et al., 2021), as well as in the physiological stress responses (i.e., cortisol reactivity) (de Veld et al., 2012), with females showing higher levels of stress and stronger cortisol responses than males. Although studies on a variety of topics have highlighted the importance of sex-specific analyses (Glaesmer et al., 2011; Hong et al., 2018; Topitzes et al., 2012), mixed evidence persists, warranting further investigation (Prevoo et al., 2017).\u003c/p\u003e\u003cp\u003ePrevious studies have examined stress responses as a risk factor for psychopathology, yet relatively little is known about how maltreatment relates to stress perception and regulation strategies that individuals acquire and use. To fill this gap, our study examines the effects of early traumatic experiences on stress in adulthood, with a focus on the mediating role of emotion dysregulation. Specifically, we investigated how difficulties in emotion regulation mediate the relationship between different traumatic experiences, such as abuse and neglect, and later perceived stress as defined by two dimensions: perceived helplessness and self-efficacy. We hypothesized that difficulties in regulating emotions would amplify the impact of early-life traumatic experiences on stress experienced throughout life. Through this study, we aim to provide a deeper understanding of the complex mechanisms linking childhood maltreatment to long-term stress.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Sample\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eA sample of 351 participants (260 females; mean age 23.13\u0026thinsp;\u0026plusmn;\u0026thinsp;3.66) completed self-report measures of childhood maltreatment (CTQ), emotion regulation difficulties (DERS), and perceived stress (PSS-10), using LimeSurvey (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.limesurvey.org/\u003c/span\u003e\u003cspan address=\"https://www.limesurvey.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). Participants were all students at the University of Innsbruck and the Medical University of Innsbruck who were recruited through advertisements.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2. Measures\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eChildhood Trauma Questionnaire - Short Form (CTQ)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eChildhood maltreatment is here defined as exposure to traumatic experiences during childhood. Participants completed the German version of the Childhood Trauma Questionnaire - Short Form (Klinitzke et al., 2012). The CTQ is a retrospective, 28-item self-report scale that assesses the frequency of maltreatment experiences during childhood, including abuse and neglect. The items are rated on a 5-point Likert scale ranging from 1 (never true) to 5 (very often true), and explore five dimensions of maltreatment: \u003cem\u003e(1) Emotional Abuse\u003c/em\u003e - verbal assaults or any humiliating or demeaning behavior directed at a child by an adult (e.g., \u0026ldquo;People in my family said hurtful or insulting things to me\u0026rdquo;), (2) \u003cem\u003ePhysical Abuse\u003c/em\u003e - bodily assaults on a child by an adult that created a danger of or led to harm (e.g., \u0026ldquo;People in my family hit me so hard that it left me with bruises or marks\u0026rdquo;), (3) \u003cem\u003eSexual Abuse\u003c/em\u003e - sexual contact or conduct between a child and an adult (e.g., \u0026ldquo;Someone tried to touch me in a sexual way, or tried to make me touch them\u0026rdquo;), (4) \u003cem\u003eEmotional Neglect\u003c/em\u003e - failure of caretakers to provide for a child\u0026rsquo;s basic physical needs, including food, shelter, clothing, safety, and health care (e.g., \u0026ldquo;People in my family looked out for each other\u0026rdquo;), and (5) \u003cem\u003ePhysical Neglect\u003c/em\u003e - failure of caretakers to meet children\u0026rsquo;s basic emotional and psychological needs, including love, belonging, nurturance, and support (e.g., \u0026ldquo;I had to wear dirty clothes\u0026rdquo;).\u003c/p\u003e\u003cp\u003e\u003cem\u003eDifficulties in Emotion Regulation Scale (DERS)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipants completed the German version of the Difficulties in Emotion Regulation Scale (Ehring et al., 2013). The DERS is a 36-item self-report scale measuring difficulties within the following dimensions of emotion regulation: awareness and understanding of emotions, acceptance of emotions, the ability to engage in goal-directed behavior and refrain from impulsive behavior when experiencing negative emotions, and access to emotion regulation strategies perceived as effective for feeling better (Gratz \u0026amp; Roemer, 2004). Specifically, six subscales are defined: (1) \u003cem\u003eNon-acceptance of emotional responses\u003c/em\u003e (e.g., \u0026ldquo;When I\u0026rsquo;m upset, I become angry with myself for feeling that way\u0026rdquo;), (2) \u003cem\u003eDifficulty engaging in goal-directed behaviors\u003c/em\u003e (e.g., \u0026ldquo;When I\u0026rsquo;m upset, I have difficulty focusing on other things\u0026rdquo;), (3) \u003cem\u003eImpulse control difficulties\u003c/em\u003e (e.g., \u0026ldquo;When I\u0026rsquo;m upset, I become out of control\u0026rdquo;), (4) \u003cem\u003eLack of emotional awareness\u003c/em\u003e (e.g., \u0026ldquo;When I\u0026rsquo;m upset, I acknowledge my emotions\u0026rdquo;), (5) \u003cem\u003eLimited access to emotion regulation strategies\u003c/em\u003e (e.g., \u0026ldquo;When I\u0026rsquo;m upset, I believe that I will remain that way for a long time\u0026rdquo;), and (6) \u003cem\u003eLack of emotional clarity\u003c/em\u003e (e.g., \u0026ldquo;I am confused about how I feel\u0026rdquo;). The items are rated on a 5-point Likert scale ranging from 1 (almost never) to 5 (almost always). The scale is composed of 6 dimensions: non-acceptance of emotional responses, difficulty engaging in goal-directed behavior, impulse control difficulties, lack of emotional awareness, limited access to emotion regulation strategies, and lack of emotional clarity.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePerceived Stress Scale (PSS-10)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eParticipants completed the German version of the Perceived Stress Scale (Schneider et al., 2020), a 10-item self-report scale that assesses the degree to which, in the last month, individuals perceived situations in their lives as uncontrollable, unpredictable, and overloaded. It is represented by two subscales: \u003cem\u003ePerceived Helplessness\u003c/em\u003e - measuring individuals\u0026rsquo; perceived difficulty in controlling circumstances or emotions (e.g., \u0026ldquo;In the last month, how often have you been upset because of something that happened unexpectedly?\u0026rdquo;), and \u003cem\u003ePerceived Self-Efficacy\u003c/em\u003e - measuring individuals\u0026rsquo; perceived ability to handle problems (e.g., \u0026ldquo;In the last month, how often have you felt confident about your ability to handle your personal problems?\u0026rdquo;). Items are rated on a 4-point scale from 0 (never) to 4 (very often).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3. Statistical Analysis\u003c/h2\u003e\u003cp\u003eAll data were entered and analyzed in R (R Core Team, 2022). Following an initial exploration of descriptive statistics for the sample, we conducted preliminary analyses to examine potential sex and age differences in the variables of interest. Because the variables didn\u0026rsquo;t follow a normal distribution, non-parametric analyses were computed (i.e., Mann-Whitney U test adjusted with the Benjamini-Hochberg method). Also, bivariate correlation analysis using Pearson\u0026rsquo;s coefficient was computed to explore the relationships among these variables. Next, we employed structural equation modeling (SEM) with observed variables to investigate the direct and indirect associations between traumatic childhood experiences, emotion dysregulation, and perceived stress. Specifically, path analyses were conducted using the lavaan package (version 0.6\u0026ndash;18) in R, employing maximum likelihood estimation with robust standard errors (MLR) and applying the Yuan-Bentler scaled test statistic to account for non-normality. The traumatic childhood experiences were modeled as exogenous variables and measured by five distinct observed variables, which were computed as the mean of items from each CTQ subscale (Emotional abuse, Physical abuse, Sexual abuse, Emotional neglect, Physical neglect). Emotion dysregulation was modeled as an endogenous mediator variable and composed of six observed variables, each representing the composite score of the six dimensions of DERS (Nonacceptance of emotional responses, Difficulty engaging in goal-directed behaviour, Impulse control difficulties, Lack of emotional awareness, Limited access to emotion regulation strategies, Lack of emotional clarity). Perceived stress was modeled as an endogenous variable measured with the two PSS-10 subscales of Helplessness and Self-efficacy. Sex and age were included as covariates in the model. Specifically, a two-step SEM approach was employed. In the first model (Model 1), total scores from the DERS and PSS-10 were used to test a general mediation model including all five traumatic childhood experiences subtypes from the CTQ. Based on the pattern of results and consistent with recommendations for model parsimony and statistical power (McCoach, 2003; Taris et al., 2020), non-significant predictors were removed. In the second step, Model 2 was specified as a more detailed model, and both the DERS and PSS-10 were disaggregated into their respective subscales to explore more nuanced mediation pathways. Following common best practices in SEM for psychological research (Kline, 2023), we also specified free covariances among the CTQ subscales, the DERS subscales, and between the two PSS-10 subscales, to capture shared variance among related constructs. Model fit was evaluated using the following indices: Comparative Fit Index (CFI; values\u0026thinsp;\u0026gt;\u0026thinsp;.90), Tucker-Lewis Index (TLI; values\u0026thinsp;\u0026gt;\u0026thinsp;.90), Root Mean Square Error of Approximation (RMSEA; values\u0026thinsp;\u0026lt;\u0026thinsp;.06), and Standardized Root Mean Square Residual (SRMR; values\u0026thinsp;\u0026lt;\u0026thinsp;.08).\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003ch1\u003e3.1. Descriptive analysis\u003c/h1\u003e\n\u003cp\u003eTable 1 shows the descriptive statistics for all variables. Preliminary analyses of the contribution of demographic characteristics to the variables of interest revealed that females reported more experiences of \u003cem\u003eEmotional abuse\u0026nbsp;\u003c/em\u003e(W = 14968, \u003cem\u003ep \u0026lt;\u003c/em\u003e .001) and \u003cem\u003eSexual abuse\u003c/em\u003e (W = 13639, \u003cem\u003ep =\u003c/em\u003e .002) than males. In addition, females reported more \u003cem\u003eNon-acceptance of emotional responses\u003c/em\u003e (W = 14260, \u003cem\u003ep =\u003c/em\u003e .003), \u0026nbsp;\u003cem\u003eImpulse control difficulties\u003c/em\u003e (W = 14450, \u003cem\u003ep =\u003c/em\u003e .001), and \u003cem\u003eLimited access to emotion regulation strategies\u003c/em\u003e (W = 14096, \u003cem\u003ep =\u003c/em\u003e .006) compared to males. Lastly, females also reported higher perceived stress overall (W = 13737, \u003cem\u003ep =\u003c/em\u003e .02), specifically more \u003cem\u003ePerceived helplessness\u003c/em\u003e (W = 13856, \u003cem\u003ep =\u003c/em\u003e .01) than males. Age significantly predicted \u003cem\u003ePerceived self-efficacy\u003c/em\u003e (t(350) = 2.26, \u003cem\u003ep =\u003c/em\u003e .02), \u003cem\u003eImpulse control difficulties\u003c/em\u003e (t(350) = -2.22, \u003cem\u003ep =\u003c/em\u003e .02), and \u003cem\u003eLack of Emotional Clarity\u003c/em\u003e (t(350) = -4.95, \u003cem\u003ep \u0026lt;\u003c/em\u003e .001), meaning that the older the participants the greater the sense of self-efficacy, and the lower the difficulties in these two dimensions of emotion regulation. No significant interaction effect between sex and age was observed.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"590\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e (N = 351)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemales\u003c/strong\u003e (N = 260)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMales\u003c/strong\u003e (N = 91)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 42px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 42px;\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 52px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 42px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 42px;\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 52px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 42px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 42px;\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 52px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCTQ\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003eEmotional Abuse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e9.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e4.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e9.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e4.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e7.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e3.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003ePhysical Abuse\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e5.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e1.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e5.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e5.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e1.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003eSexual Abuse\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e5.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e2.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e6.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e5.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003eEmotional Neglect\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e9.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e9.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e4.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e9.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e3.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003ePhysical Neglect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e6.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e2.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e6.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e6.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e1.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDERS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003eNon-acceptance of emotional responses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e17.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e6.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e6-30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e17.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e6.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e6-30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e15.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e5.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e6-30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003eDifficulties in goal-directed behaviors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e15.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e5.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e16.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e4.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e14.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e5.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003eImpulse control difficulties\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e13.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e5.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e6-30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e14.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e5.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e6-30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e12.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e6-26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003eLack of emotional awareness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e14.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e4.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e6-29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e14.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e4.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e6-26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e14.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e5.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e6-29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003eLimited access to emotion regulation strategies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e22.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e7.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e8-40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e22.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e7.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e8-40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e20.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e9-37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003eLack of emotional clarity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e12.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e4.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e12.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e4.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e12.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5-25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e96.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e26.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e38-164\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e98.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e26.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e38-164\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e90.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e25.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e47-147\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePSS-10\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003ePerceived Helplessness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e20.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e4.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e8-30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e20.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e8-30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e18.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e4.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e10-29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003ePerceived Self-Efficacy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e12.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e2.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e6-20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e2.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e6-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e13.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e2.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e7-20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e31.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e7.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e13-48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e31.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e7.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e13-48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e29.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e7.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e16-44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Descriptive statistics for Variables of Interest. CTQ=Childhood Trauma Questionnaire; DERS=Difficulty in Emotion Regulation Scale; PSS-10=Perceived Stress Scale\u003c/p\u003e\n\u003cp\u003eThe correlogram in Figure 1 displays the correlations among the various psychopathological variables examined in this study. Bivariate relationships between variables were assessed using Pearson correlations adjusted for multiple comparisons (Holm-Bonferroni correction), with the significance level set at \u0026alpha; = .05. The results supported the links between childhood trauma, difficulties in emotion regulation, and perceived stress. Emotional Abuse and Emotional Neglect appeared to be key trauma-related predictors of both impaired emotion regulation and heightened stress. Specifically, Emotional Abuse and Emotional Neglect were most strongly associated with Limited access to emotion regulation strategies (CTQ_Emotional abuse: r =.38, CTQ_Emotional neglect: r =.37) and also with Nonacceptance of emotional responses, Difficulties in goal-directed behavior, and Difficulties in impulse control (CTQ_Emotional abuse: r =.26, .29, .33, CTQ_Emotional neglect: r =.27, .27, .30). Perceived helplessness was positively associated with all DERS subscales, while Perceived self-efficacy showed negative associations. Emotional Abuse and Emotional Neglect were also correlated with higher Perceived helplessness (CTQ_Emotional abuse: r = .35, CTQ_Emotional neglect: r =.28) and lower Perceived self-efficacy (CTQ_Emotional abuse: r = -.32, CTQ_Emotional neglect: r = -.30).\u003c/p\u003e\n\u003ch1\u003e3.2. Path analysis\u003c/h1\u003e\n\u003cp\u003e\u003cem\u003eModel 1: Total Emotion Regulation Difficulties as Mediator\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe initial structural model tested whether total difficulties in emotion regulation (DERS total score) mediated the relationship between various subtypes of maltreatment (CTQ subscales) and perceived stress (PSS-10 total score) in adulthood. The model demonstrated acceptable fit to the data (robust \u0026chi;\u0026sup2;(5) = 21.17, \u003cem\u003ep =\u003c/em\u003e .001; robust CFI = 0.981; TLI = 0.865; RMSEA = 0.095, 90% CI [0.056, 0.139]; SRMR = 0.040).\u003c/p\u003e\n\u003cp\u003eAmong the five trauma subtypes, Emotional neglect emerged as the strongest predictor of emotion dysregulation, exerting a significant direct effect on DERS total scores (b = 1.80, \u003cem\u003ep \u0026lt;\u003c/em\u003e .001). Emotional abuse showed a marginal effect (b = 0.76, \u003cem\u003ep =\u003c/em\u003e .072), while Physical abuse, Sexual abuse, and Physical neglect did not significantly predict emotion regulation difficulties. In turn, greater difficulties in emotion regulation were strongly associated with increased perceived stress (b = 0.16, \u003cem\u003ep \u0026lt;\u003c/em\u003e .001). Two trauma subtypes - Emotional abuse (b = 0.25, \u003cem\u003ep =\u003c/em\u003e .004) and Sexual abuse (b = 0.26, \u003cem\u003ep =\u003c/em\u003e .014) - had significant direct effects on perceived stress. In contrast, Emotional neglect showed no direct effect on stress, but its indirect effect through emotion dysregulation was significant (b = 0.29, \u003cem\u003ep \u0026lt;\u003c/em\u003e .001), indicating a pattern of full mediation. No significant indirect effects were found for the remaining trauma types.\u003c/p\u003e\n\u003cp\u003eAltogether, the model explained 20.1% of the variance in emotion regulation difficulties and 44.1% in perceived stress. Importantly, female sex was significantly associated with greater exposure to Emotional abuse (b = \u0026minus;2.18, \u003cem\u003ep \u0026lt;\u003c/em\u003e .001), Sexual abuse (b = \u0026minus;0.68, \u003cem\u003ep =\u003c/em\u003e .002), and Physical neglect (b = \u0026minus;0.44, \u003cem\u003ep =\u003c/em\u003e .044) than male, but it did not have a direct effect on emotion regulation or stress in this model. Full results are provided in Table S1 (Supplementary Materials).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eModel 2: Specific Emotion Regulation Difficulties and Perceived Stress Dimensions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTo expand on these initial findings, in Model 2, we broke down both emotion dysregulation and perceived stress into their respective subdomains, offering a more detailed understanding of the underlying pathways (see Figure 3). We kept only Emotional abuse, Emotional neglect, and Sexual abuse as predictors, based on the significant paths that emerged in Model 1. Removing such paths enhances parsimony, statistical power, and prevents biased parameter estimates that may arise from including irrelevant predictors in structural equation modelling (McCoach, 2003; Taris et al., 2020). This refined model demonstrated an excellent fit to the data (robust \u0026chi;\u0026sup2;(3) = 3.92, \u003cem\u003ep =\u003c/em\u003e .271; robust CFI = 0.999; TLI = 0.988; RMSEA = 0.029, 90% CI [0.000, 0.097]; SRMR = 0.014), indicating that the structure effectively captured the observed relationships.\u003c/p\u003e\n\u003cp\u003eBoth Emotional abuse (b = 0.14, \u003cem\u003ep =\u003c/em\u003e .016) and Sexual abuse (b = 0.18, \u003cem\u003ep =\u003c/em\u003e .017) had significant direct effects on Perceived helplessness. None of the trauma subtypes showed significant direct effects on Perceived self-efficacy. Emotional abuse also had a significant indirect effect on Perceived helplessness (b = 0.14, \u003cem\u003ep =\u003c/em\u003e .002), primarily via increased Difficulties in engaging in goal-directed behavior and Limited access to emotion regulation strategies, supporting a partial mediation. Emotional neglect showed a significant indirect effect (b = 0.15, \u003cem\u003ep =\u003c/em\u003e .004), largely mediated by Lack of emotional clarity and Limited access to emotion regulation strategies, indicating full mediation through emotion regulation processes. Sexual abuse did not show any significant indirect effect on Perceived helplessness. Similar patterns were observed for Perceived self-efficacy. Emotional abuse was negatively related to Perceived self-efficacy via indirect pathways (b = \u0026minus;0.06, \u003cem\u003ep =\u003c/em\u003e .013), particularly through Lack of emotional clarity and Limited access to emotion regulation strategies. Emotional neglect also had a significant negative indirect effect on Perceived self-efficacy (b = \u0026minus;0.11, \u003cem\u003ep \u0026lt;\u003c/em\u003e .001) via Lack of emotional awareness and Limited access to emotion regulation strategies. Sexual abuse did not show any significant indirect effects on this dimension of stress either.\u003c/p\u003e\n\u003cp\u003eOverall, the expanded model explained 43.4% of the variance in Perceived helplessness and 44.3% in Perceived self-efficacy, highlighting the central role of specific emotion regulation mechanisms in shaping the impact of early emotional trauma on perceived stress in adulthood. Female sex remained significantly associated with greater exposure to Emotional abuse and Sexual abuse, and sex also predicted higher scores in Nonacceptance of emotional responses (b = \u0026minus;1.71, \u003cem\u003ep =\u003c/em\u003e .020), suggesting more difficulties in this domain in females than males. Age was negatively associated with Lack of emotional clarity (b = \u0026minus;0.36, \u003cem\u003ep \u0026lt;\u003c/em\u003e .001), suggesting slightly better regulation with age. Full results are provided in Table S2 (Supplementary Materials).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study aimed to examine how traumatic childhood experiences influence perceived stress in adulthood and whether this relationship is mediated by emotion dysregulation, controlling for variation in sex and age. Initial analyses of the contribution of demographic characteristics revealed sex and age differences in trauma exposure, emotion dysregulation, and stress. Females reported significantly more emotional and sexual abuse, greater emotion regulation difficulties (non-acceptance, impulse control, limited strategy access), and higher perceived helplessness than males. Age was positively associated with perceived self-efficacy and negatively related to impulse control difficulties and emotional clarity problems, suggesting greater regulatory capacity with age. These results allowed us to account for demographic influences when examining the mediating role of emotion dysregulation. The observed correlations further indicated that emotional abuse and neglect were consistently associated with greater emotion regulation difficulties and higher perceived stress, particularly high helplessness and low self-efficacy. These patterns supported our theoretical model and justified the use of structural equation modelling to examine potential mediating pathways and the overall structure of these relationships.\u003c/p\u003e\u003cp\u003eFollowing previous studies (Kim \u0026amp; Cicchetti, 2010; Zhang et al., 2022), emotion dysregulation partially mediated the relationship between childhood maltreatment and perceived stress, accounting for sex and age variation. In the path analysis, Emotional neglect emerged as a key predictor of emotion dysregulation that, in turn, increased perceived stress. Emotional abuse also predicted higher perceived stress both directly and indirectly, suggesting that the consequences of such traumatic experiences are both immediate and mediated by regulatory dysfunction. In contrast, Sexual abuse showed a strong contribution to the increased perceived stress later in life, regardless of emotion regulation abilities. More specifically, having limited access to emotion regulation strategies and difficulties in engaging in goal-directed behaviors, as well as less clarity and awareness of the emotional experiences, significantly amplified the long-term effect of emotional maltreatment on perceived stress, resulting in increased feelings of helplessness and reduced self-efficacy. Individuals can flexibly use emotion regulation strategies based on the situation, aligning them with changes in external circumstances and/or the individual's perceptions of them (Blanke et al., 2020; Elkj\u0026aelig;r et al., 2022). Emotion regulation flexibility can lead to more or less adaptive outcomes (e.g., the ability to achieve goals), influencing well-being (Aldao et al., 2015; Rammensee et al., 2023). According to the attachment theory, children living in abusive and neglectful environments experience insecure attachment (Greenman et al., 2024; Toof et al., 2020), which prevents them from learning appropriate strategies to manage emotions (Brenning \u0026amp; Braet, 2013) and cope with stress (Mikulincer \u0026amp; Shaver, 2019). Thus, our findings on the mediating role of emotion regulation difficulties may reflect a tendency for inflexible responses in individuals who experienced trauma in childhood. This inflexibility can intensify the negative impact of trauma over time, leading to greater perceived helplessness (i.e., difficulties in controlling circumstances) and reduced self-efficacy (i.e., ability to handle problems). In line with the learned helplessness model (Miller \u0026amp; Norman, 1979), organisms exposed to a situation where they experience unavoidable harmful stimuli (e.g., unavoidable shock) may fail to avoid such stimuli in the future when escape becomes possible (i.e., they learn \u0026ldquo;helplessness\u0026rdquo;). A revised approach proposed by Boddez and colleagues (2022) suggests that rather than learning passivity, organisms may learn controllability (Boddez et al., 2022; Duda \u0026amp; Joormann, 2022), meaning that prior experience with controllability could shape the perception of control later (Ly et al., 2019). Extending this mechanism would then result in a generalization of the sense of helplessness learned during unavoidable and uncontrollable maltreatment situations, reducing the perception of possible control over circumstances and increasing perceived stress (Duda \u0026amp; Joormann, 2022; Lieder \u0026amp; Goodman, 2013). Hence, there is evidence supporting integrated control beliefs, which are related to how children learn to cope with stress (Compas et al., 1991; Jenzer et al., 2019), and several studies highlighted that an altered perception of control may contribute to the development of affective disorders and the exacerbation of perceived stress (Gallagher et al., 2014; Ly et al., 2019; McEwen, 2000; Schweizer et al., 2020). This perspective can improve our understanding of the link between trauma, emotion regulation, and stress (Weems \u0026amp; Silverman, 2006) and is particularly relevant when considering the consequences of exaggerated and prolonged emotional reactions to stressful situations. Under such conditions, stress can contribute to the development of various types of psychopathology (Slavich, 2016b, 2016a), and the ability to cope effectively with stress can help prevent negative consequences for mental well-being (Dijkstra \u0026amp; Homan, 2016). For example, individuals who do not feel competent to avoid threatening situations (low self-efficacy) may experience anxiety (Weems \u0026amp; Silverman, 2006). Similarly, the perception of self as having an insufficient ability to cope with situations and not having control over social situations (high helplessness) is associated with higher degrees of social anxiety (Thomasson \u0026amp; Psouni, 2010). This also corroborates the findings of a recent study that investigated the dynamics of coping behavior and psychological distress across different phases of the COVID-19 pandemic within an adult general population sample and revealed that maladaptive coping strategies were consistently linked to increased psychological distress, whereas adaptive strategies were associated with decreased psychological distress (Schurr et al., 2024).\u003c/p\u003e\u003cp\u003eIt is worth noting that, in our sample, women reported a higher frequency of early-life maltreatments (both emotional and physical) and showed more compromised emotion regulation abilities (nonacceptance of emotional responses). Cutler and Nolen-Hoeksema (1991) first proposed sex differences in the effects of childhood trauma, arguing that females are more inclined to blame themselves for stressful life events (e.g., maltreatment), making them more vulnerable to low self-esteem and mental health problems. Furthermore, while abuse is likely to impact both sexes negatively, the symptoms of the trauma may differ (e.g., internalized disorders in females and externalized disorders in males) (Hanson et al., 2008). These results highlight the importance of considering sex when studying affective variability in the effects of early-life trauma (Prevoo et al., 2017).\u003c/p\u003e\u003cp\u003eA noticeable finding of this study is the stronger and more consistent effect of emotional trauma, both abuse and neglect, compared to physical trauma. This aligns with a growing body of evidence indicating that emotional maltreatment may be as harmful, or even more so, than physical forms of abuse (Dye, 2020; Spinazzola et al., 2014). First, emotional trauma directly disrupts the development of core self-regulatory capacities (Warmingham et al., 2023). Emotionally neglectful environments fail to model and validate emotional experiences, impeding the child\u0026rsquo;s ability to recognize, understand, and manage emotions (Eilert \u0026amp; Buchheim, 2023). Also, emotional abuse, through denigration, hostility, or rejection, may actively distort a child\u0026rsquo;s self-concept and emotional security (Baugh et al., 2019). Second, physical abuse typically occurs in episodes and receives external support, while emotional trauma usually manifests chronically and subtly, making it more challenging to detect and report. This often results in deeper effects on self-regulation and stress appraisal systems (Osborne et al., 2022).\u003c/p\u003e\u003cp\u003eOur findings that specific emotion regulation difficulties, such as limited access to adaptive strategies, difficulty engaging in goal-directed behavior, and reduced emotional clarity and awareness, mediate the impact of emotional abuse and neglect on perceived stress align closely with the Research Domain Criteria (RDoC) project (Cuthbert \u0026amp; Insel, 2013; Fernandez et al., 2016). Within the RDoC framework, emotion regulation processes are situated at the intersection of the negative valence systems (e.g., heightened threat sensitivity in maltreated individuals) and cognitive control systems (e.g., goal-directed behavior under emotional strain). The mediators identified in our models map directly onto these domains, suggesting that early maltreatment may disrupt processes central to both affective and cognitive control. This reinforces the value of RDoC as a lens for understanding how emotion regulation operates as a transdiagnostic mechanism linking adversity to stress-related psychopathology (Aldao, 2016; Fernandez et al., 2016; Morawetz et al., 2024).\u003c/p\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e4.1. Limitations and Future Directions\u003c/h2\u003e\u003cp\u003eOur findings should be interpreted in light of some limitations. The cross-sectional design limits the ability to draw inferences about directionality and causality among variables. Furthermore, results may have been influenced by social desirability bias in the use of self-report measures. Future studies should benefit from using longitudinal, multi-method designs to investigate the specific ways in which maltreatment interferes with the acquisition of healthy stress responses. Evidence suggests that the characteristics of maltreatment may have different implications for specific coping and emotion regulation strategies (Milojevich et al., 2019). Therefore, studies may also explore various forms of emotion regulation to deepen their significance and associations with psychological consequences, as well as collect details on maltreatment histories (e.g., type, timing, duration) using reliable and valid measures.\u003c/p\u003e\u003cp\u003eIt should also be noted that we exclusively investigated students of a health-related subject (medicine, psychology). Selecting a sample in this way limits the generalizability of the obtained results. Finally, the influence of socio-economic status and the interaction with pre-existing traits (e.g., personality, anxiety trait, self-compassion) should be further explored to understand their possible role in the observed outcomes (Barlow et al., 2017).\u003c/p\u003e\u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThese findings highlight the crucial role of emotion regulation in connecting early traumatic experiences with stress perception in adulthood. They support a model suggesting that emotionally abusive or neglectful environments impair regulatory processes, which then increase vulnerability to stress. Importantly, the specific emotion regulation pathways identified present promising opportunities for intervention. Therapeutic strategies that focus on improving clarity and awareness, encouraging goal-directed coping, and increasing access to effective emotion regulation techniques may be particularly beneficial for adults who have experienced childhood maltreatment. Additionally, longitudinal studies are needed to gain deeper insights into the causal relationship between childhood trauma, emotion regulation, and adult stress outcomes, paving the way for more effective early interventions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding statement\u003c/h2\u003e\u003cp\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\u003cp\u003eDeclaration of conflicting interest\u003c/p\u003e\u003cp\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\u003cp\u003eEthics approval\u003c/p\u003e\u003cp\u003e This study was conducted in accordance with the principles of the Declaration of Helsinki. Approval was granted by the University Ethics Committee (90/2022).\u003c/p\u003e\u003cp\u003eConsent to participate\u003c/p\u003e\u003cp\u003e All participants provided written informed consent prior to participating.\u003c/p\u003e\u003cp\u003e Consent for publication\u003c/p\u003e\u003cp\u003e Informed consent for publication was provided by the participants.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eCM and AH participated in the conceptualization, design, and coordination of the study, and reviewed the draft of the manuscript; GL performed the statistical analyses, participated in the interpretation of the data, and drafted the manuscript; BFA and GA participated in the design of the study and reviewed the draft of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003ehttps://osf.io/6z8dq/\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAldao, A. (2016). Introduction to the Special Issue: Emotion Regulation as a Transdiagnostic Process. \u003cem\u003eCognitive Therapy and Research\u003c/em\u003e, \u003cem\u003e40\u003c/em\u003e(3), 257\u0026ndash;261. https://doi.org/10.1007/s10608-016-9764-2\u003c/li\u003e\n\u003cli\u003eAldao, A., Sheppes, G., \u0026amp; Gross, J. J. (2015). Emotion Regulation Flexibility. \u003cem\u003eCognitive Therapy and Research\u003c/em\u003e, \u003cem\u003e39\u003c/em\u003e(3), 263\u0026ndash;278. https://doi.org/10.1007/s10608-014-9662-4\u003c/li\u003e\n\u003cli\u003eBarlow, M. R., Goldsmith Turow, R. E., \u0026amp; Gerhart, J. (2017). 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Associations of childhood neglect, difficulties in emotion regulation, and psychological distresses to COVID-19 pandemic: An intergenerational analysis. \u003cem\u003eChild Abuse \u0026amp; Neglect\u003c/em\u003e, \u003cem\u003e129\u003c/em\u003e, 105674. https://doi.org/10.1016/j.chiabu.2022.105674\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":true,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Childhood Maltreatment, Emotion Dysregulation, Stress, Structural equation modeling","lastPublishedDoi":"10.21203/rs.3.rs-7454105/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7454105/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eChildhood exposure to traumatic events can have enduring negative effects, particularly on stress levels and overall well-being. However, individuals may respond and adapt differently to such experiences. One of the factors that may explain these differences is emotion dysregulation, which refers to difficulties in managing emotional responses and is often linked to interpersonal trauma. This study investigated whether difficulties in emotion regulation mediate the relationship between various early traumatic experiences and stress in adulthood. A sample of 351 university students completed self-report assessments of childhood maltreatment (CTQ), emotion regulation difficulties (DERS), and perceived stress (PSS-10). Structural equation model (SEM) analyses showed that difficulties in specific emotion regulation strategies mediated the effects of emotional traumatic experiences, both abuse and neglect, on perceived helplessness and self-efficacy in adulthood. These findings underscore the lasting impact of emotional trauma and highlight emotion regulation as a key target for interventions aimed at reducing stress in adulthood.\u003c/p\u003e","manuscriptTitle":"Emotion Regulation Difficulties mediate the Relationship between Childhood Maltreatment and Perceived Stress in Adulthood","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-28 16:26:03","doi":"10.21203/rs.3.rs-7454105/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"978e9eb7-d5d0-476c-9ea7-6cfaf9931b55","owner":[],"postedDate":"October 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-10T00:23:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-28 16:26:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7454105","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7454105","identity":"rs-7454105","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}