Abstract

Background: Emotional neglects is the mostly widespread type of childhood experience which is believed to affect the overall psychological adjustment of the child as a result, victims may experience psychological distress with symptoms of low self-esteem, depression and anxiety. There is limited published data on this subject in Tanzania. This study investigates emotional neglect as a risk factor for psychological distress among adolescents in Dar es salaam, Tanzania.

Methods: This was a cross-sectional, community-based study of adolescents that was conducted in randomly selected schools in Dar es salaam, Tanzania. The data collection process started July 2019 and was completed in July 2020. Each participant was contacted and informed about the purpose of the research, confidentiality issues, and reporting of the results. A multistage cluster sampling technique was employed to obtain a required number of the study participants. Kessler psychological distress scale (K10) and the Adverse Childhood Experience (ACE) questionnaires were used to measure the variables under this study.

Results: Out of 3193 participants enrolled in the study, 1543(48.3%) participants were male and 1650(51.7%) were female. The participants’ age ranged from 13 to 18 years old (mean ± standard deviation= 16.44 ± 2.58 years). Childhood emotional neglect was reported in 51.9% of participants. There was a strong positive correlation between childhood emotional neglect and psychological distress during adolescence (r= 0.55, p<0.001).

Conclusion: Finding from this study demonstrated that childhood emotional neglect is prevalent in our setting and is associated with psychological distress during adolescence. Urgent intervention targeting at reducing occurrence of childhood psychological maltreatment is necessary to reduce the incidence of psychological distress among Tanzanian adolescents.

Keywords: emotional neglect; psychological distress; adolescents; Tanzania.

Citation: Mwakanyamale AA, Mbao EH, Sungwa EE. Childhood emotional neglect experiences as a risk factor for psychological distress among adolescents in Dar es Salaam, Tanzania: A community-based cross sectional study. J Clin Images Med Case Rep. 2022; 3(1): 1533.

Background

Emotional neglect involves rejecting, isolating and emotionally disregarding a child. Emotional neglect occurs when there are acts of omission or commission causing harm or pain on the child’s well-being, and this may be reflected as emotional distress or abnormal behavior to the child [1]. The omission and commission acts may occur one at once or both [2]. These actions include isolating, spurning, exploiting, terrorizing, and denying emotional responsiveness on the child [3]. Also it can refer to a repeated pattern of behaviors that express to children that they are worthless, unwanted, unloved, or only of value in meeting parent’s / guardian’s or another’s needs; this leads to lasting damage to their well-being and development [4].

Childhood emotional neglect is the most prevalent form of child maltreatment and is increasingly recognized as an essential component of child maltreatment and the unifying concept that connects cognitive, affective, and interpersonal problems related to physical abuse, sexual abuse, and neglect [5]. �Globally, the prevalence of emotional neglect is approximated to be 36% [6]. According to previous studies the rate of emotional neglect was 11% in the USA, 23% in England, 23% in Canada, and 34% in Australia [7]. The rate was demonstrated to be slightly higher in East Asia and the Pacific Region for 31.3% and 68.5% for Korea and China respectively [8]. Childhood emotional neglect in the country paralyses children personal career integration, national development and achievement of plans laid in a given country [9]. In most of the time, emotion neglect is masked within other form of child maltreatment when they co exit [10]. Emotional neglect can generally be associated with several factors in the environment where a child is either grown or ever experienced at one or more times; these factors are like family interaction/behavior, school interaction, social community, socioeconomic status, guardian demographic [11].

The negative interaction in any of the mentioned arena might result into a psychological trauma to a child. The long standing trauma associated with characteristics and behaviors such as reduced school performance, negative self-esteem, suicidal behavior, drug abuse and some more other forms of mental disorders [12].

Studies conducted in Asian countries have reported that many children are exposed to high levels of emotional neglect [13]. Experiences from Tanzania show that parents often employ harsh emotional discipline practices and believe that they do not harm their children [14]. Many studies have evaluated the relationship between childhood emotional neglect and behavioural problems [15]. Findings from these studies suggest that individuals with childhood emotional neglect have psychological distress during adolescence [16]. Childhood emotional neglect experiences include parental acts that negatively affect mental health and development [17]. Previous studies have reported a strong positive correlation between emotional neglect and psychological distress [18,19]. This correlation between emotional neglect and psychological distress is derived by the fact that emotional neglect in children can negatively affect the cognitive, social and emotional development of a child [20]. Studies have shown that emotional neglect has a negative impact on a child’s well-being and healthy development, especially in relation to psychological distress [21]. Many studies on emotional neglect in childhood have been conducted in the developed countries, especially the U.S. and Europe [6,7]. Emotional neglect, is extremely common in Dar es salaam, Tanzania yet not as broadly researched as sexual and physical abuse [22,23]. Despite the fact that many studies have focused on maltreatment in childhood, there is limited published data that define emotional neglect as a risk factor for psychological distress among adolescents in Dar es salaam, Tanzania.

This study investigated emotional neglect as a risk factor for psychological distress among adolescents in Dar es salaam, Tanzania.

Methods

Study design

A cross-sectional, community-based study was conducted at randomly selected secondary schools in Dar es salaam, Tanzania between July 2019 and July 2020.

Study participants

A total of 3193 students participated in this study. 1543(48.3%) participants were male and 1650(51.7%) were female. The participants’ age ranges from 13 to 18 years old.

Data collection method and tool used

The instruments that were used are two different questionnaires to measure the variables under the study. The questionnaire had items from two main following instruments: Kessler psychological distress scale (K10) and the Childhood Trauma Questionnaire (CTQ).

Childhood Trauma Questionnaire (CTQ) were used in the assessment of emotional neglect.

These scales consisted of a sum of 7 items used to measure emotional neglect CTQ is a measurement tool that demonstrates good reliability and validity among university students [24]. In the international settings, the measures of emotional neglect have demonstrated reliability and validity, due to that, they are highly used by the Centre for Disease Control. [25]

The Kessler Psychological Distress scale (K10) it is globally used to measure non-specific psychological distress in the anxiety depression spectrum. It was developed by Professors Kessler and Mroczek in 1992. The K10 consists of 10 questions about psychological distress.

Again, it is designed to quantify the frequency and severity of anxiety.

Not only that, it is also used to quantify depression-related symptoms experienced during the four weeks before screening. This scale has been validated cross-culture and is a fundamental instrument for international surveys of World Health Organization (WHO). In this scale, an increased likelihood of a psychological disorder is indicated by high scores on the scale [26].

During data collection process, respondents were asked the question: “How often did you feel: 1) tired out for no good reason; 2) nervous; 3) so nervous that nothing could calm you down; 4) hopeless; 5) restless or fidgety; 6) so restless you could not sit still; 7) sad or depressed; 8) so depressed that nothing could cheer you up; 9) everything was an effort; 10) worthless, during the past month?” Each of the ten items in the question was scored from 1 to 5 on a Likert-type scale.

Items were rated on a five-point ordinal scale. All of the time was indicated by score 5, most of the time, it was score 4, some of the time was score 3, a little of the time was score 3, and none of the time was indicated by score 1. The total K10 score for each respondent was realized as a total of all 10 items. The scores ranged from 10 to 50.

The score under 20 was considered normal meaning that there is no stress, score 20-24 indicated mild mental disorder (mild stress), score 25-29 indicated moderate mental disorder (moderate stress), while score 30 and over indicated a severe mental disorder (severe stress).

Sampling technique

A multistage cluster sampling technique was employed to obtain the required number of study participants. A sampling frame from the list of school students from randomly selected schools in was prepared and used to draw up the sample. From the sampling frame, study units were sampled through the simple random method until the required sample was obtained.

Study variables

In the study there were two variables, independent and dependent variables. Emotional neglect was the independent variable, while the dependent variables constitute psychological stress.

Quality assurance and control

To ensure quality in this research all techniques, systems and resources were arrayed to give assurance about data collection process, data handling and data analysis. This research translated all questionnaire from its original language English to Swahili language so that all students in Dar es salaam, Tanzania understood the questions, questionnaire was submitted to students by a well-trained research assistant the responsibilities of those involved in the field for data collection.

Research plan was made known to all research team and data was handling in confidential manner. Researcher read the filled questionnaires and ensures completeness. Soon after collection, data was coded entered in software Statistical Package for Social Science (SPSS) and second cleaning were done.

Validity and reliability

Data collection tools were checked for validity and reliability. In reliability all questionnaires were checked for the extent of yielding the same results on repeated administration of the tool. The Cronbach’s alpha was used to check internal consistence coefficient alpha is an internal consistency index designed to be used in tests which contain items which have no right answer.

All tools adopted for data collection. The Kessler Psychological Distress scale Cronbach’s Alpha was used to measure the internal consistence of the instrument and construct validity was measured by CFI.

Data analysis and presentation

Statistical Package for Social Sciences (SPSS) version 20.0 (SPSS, Chicago IL, USA) for Windows was used in performing statistical data analysis. Descriptive statistics like mean (+Standard deviation) and ranges on one hand were calculated on continuous variables. On the other hand, on categorical variables, proportions and frequency tables were used to summarize the information. Furthermore, the significance of relationship between the independent variables emotional neglects and dependent variables psychological distress the categorical variables was tested by Chi square (χ2).

Multivariate logistic regression analysis was used to determine whether childhood emotional neglect predicts psychological distress during adolescence period, while the level of significance was considered as p< 0.05.

Ethical consideration

All the participants were informed about the purpose of the study and were ensured that their answers would only be used anonymously for research purposes. There after they were asked if they were willing to participate on a voluntary basis. Thus, informed consent was sought from each participant before they were enrolled into the study. Permission to conduct the study in respective schools was also obtained from school authorities.

Study limitation and delimitation

This study covered few adolescents from Dar es salaam, Tanzania. This might bring difficult in generalization of the results. The researcher increased the sample size to foster variability of the subject which might prove the legacy of generalizing results.

Table 1:Study sample.

Results

The study samples

The sample consisted of 3193 participants. Of which 1650(51.7%) were female and 1543(48.3%) were male adolescents. Out of 3193 participants, 2318(72.6%) experienced emotional neglect during childhood.

Correlation analysis between emotional neglects and gender

The correlation analysis in table 2 shows a strong correlation between emotional neglect and gender (r=0.13, p< 0.01).

Table 2:Correlation analysis among adolescents (gender) and emotional neglect.

Correlation between psychological distress, age, gender of the participants

Table 3 below shows a strong positive correlation between psychological distress and gender (r = 0.51, p< 0.001).

Table 3:Correlation analysis of psychological distress by gender and age groups.

The average psychological distress scores

The average psychological distressscore of adolescents was (22.12 ± 4.734)

Table 4:Psychological distress mean scores.

Correlation between emotional neglect and psychological distress

The findings in Table 5 shows a strong positive correlation between emotional neglect and psychological distress (r= 0.55, p<0.001).

Table 5:Correlation between Emotional abuse and Emotional neglect and Psychological distress.

Linear regression analysis between emotional neglect and psychological distress

A simple linear regression model (Table 6 below) was calculated to predict psychological distress based on emotional neglect; b=0.51, (998) 35.08, p<0.001. A significant regression equation was found (F (1,998)) = 359.893, p<0.001, with R2 of 0.265.

Approximately 26% of the variance in psychological distress can be explained by emotional neglect. Moreover, Psychological distress can be predicted based on emotional neglect; b=-0.86, (998) 41.05, p<0.001.

A significant regression equation was found (F (1,998)) = 7.36, p<0.001, with R2 of 0.007. This means that 0.6% of the variance in psychological distress can be explained by emotional neglect.

Table 6:Linear regression analysis between Emotional neglect and psychological distress.

Prevalence of psychological distress in average scores among adolescents

The average score of psychological distress among adolescents was 25.84 with the minimum score being 10 and maximum score 50.

Table 7:Prevalence of psychological distress in average scores among adolescents

Prevalence of psychological distress among adolescents by gender

Male adolescents showed higher score of severe psychological distress than female adolescents 649 (55.9%). The differences in score between male and female adolescents demonstrated statistical significance with P-value =0.000.

Level of emotional neglects on adolescents with psychological distress

A one-way ANOVA was conducted to compare effect of levels of emotional neglect on the psychological distress score among adolescents. The psychological distress score was statistically significantly different between different levels of childhood emotional neglect among adolescents. F (2, 3190)=54.476, P value=0. 000.

Table 8: Prevalence of psychological distress by gender.

Relationship between emotional neglect and psychological distress

Childhood emotional neglect has significant relationship with adolescents feeling of anxious and depressive symptoms which are known as psychological distress; the correlation analysis of individual variables of emotional neglect has shown significant relationship with psychological distress P<0.00.

Table 9:Prevalence of mean scores in emotional neglect among adolescents with psychological distress.

Table 10:Relationship between Emotional neglect with psychological distress.

Discussion

The results of this study showed that the prevalence of childhood emotional neglect was 51.9%, a figure which is comparable with 51% that was reported in Turkey [22], but higher than that observed in many other studies in developed countries [6,7]. The prevalence of childhood emotional neglect in the present study may be under estimated because this form of child maltreatment is mostly under reported to authorities for fear of being arrested by the police. Also, childhood emotional neglect may be ignored and therefore not reported. This is because it’s not easily noticed and cannot be recalled by its victims. It has in many ways been over shadowed by the more visible childhood events, such as abuse and trauma.

The prevalence rates of emotional neglect may also be underestimated because they capture a wide range of parenting behaviours, and there is little to no consensus across studies as to what phenomena should be included [29].

In keeping with what has previously been reported in other studies [30,31], the prevalence of emotional neglect in this study was found to be higher among male participants than their female counterparts. The reason for the underlying vulnerabilities and gender influence on children with emotional neglect is unclear, and this requires further investigation. Despite the fact that emotional neglect is a common form of childhood maltreatment in developing countries such as Tanzania, no participants who had emotional neglect experiences during childhood sought professional treatment attributing this to the lack of awareness and poor knowledge regarding which childhood experiences constitute emotional neglect. This calls for urgent preventive measures to reduce the occurrence of emotional neglect so as to reduce the potential adverse consequences of this form of psychological distress that occurs during adolescence and adulthood.

Emotional neglect is strongly associated with psychological distress in adolescents [32]. This finding agrees with our study, which found that childhood emotional neglect was statistically significantly associated with psychological distress during adolescence. Parenting style plays a crucial role in a child’s social, cognitive and emotional development. A negative parenting style involving emotional neglect may result in psychological distress in adolescents that continues to adulthood [33]. The results reported here agree with previously published studies, demonstrating a negative correlation between childhood exposure to emotional neglect and psychological distress. Children exposed to high levels of emotional neglect have been reported to show high levels of psychological distress during adolescence.

For emotional neglect child, the negative impacts are believed to occur when the child internalizes the harsh treatment, including the negative messages from parents and/or care givers [34]. This results in insecurities, and the child develops maladaptive interpersonal schemas, which lead to dysfunctional behaviours [35]. Children in such situations tend to believe that they are worthless and that the world is unsafe and perceive everybody as abusive [36,37]. Those with psychological distress tend to be more self-conscious and isolate themselves from others [37,38].

Limitations

There are some limitations of the study that should be noted: First, the cross-sectional study design does not allow for the establishment of a causal relationship; therefore, only the association between childhood emotional neglect and psychological distress was established in this study. Second, the study participants included adolescents from randomly selected schools; therefore, the results cannot be generalized to the Tanzania population as a whole. Third, additional consideration should be given to the tendency of participants to under-or over-report incidents of maltreatment. Thus, the results must be interpreted with caution.

Conclusion

Findings from this study demonstrated that childhood emotional neglect experience is prevalent in our setting and statistically significant positively affected psychological distress among Tanzanian adolescents and is associated with high levels of psychological distress during adolescence. The understanding of the interrelatedness of childhood emotional neglect with psychological distress should be considered in the design of studies, treatments, and programs to prevent of childhood emotional neglect and psychological distress. Strategic national educational programs should be implemented to bring awareness of the adverse effects of adverse childhood experience of emotional neglect. Parents, caregivers and teachers will benefit from realizing the effects of adverse childhood experience of emotional neglect and be encouraged to take an alternative method of discipline. It is urged that urgent preventive measures aiming at reducing the occurrence of emotional neglect are necessary to be undertaken to reduce the incidence of psychological distress among adolescents in Tanzania. This can be achieved through education efforts that highlight the negative effects of adverse childhood experience of emotional neglect. Also, parents /care givers and teachers need to be educated about the potential negative consequences of adverse childhood experience of emotional neglect to raise awareness among them as a means of reducing psychological distress in Dar es salaam, Tanzania.

Declarations

Ethics approval and consent to participate: All participants were given information about the study and asked for their voluntary participation. Students were informed about the purpose of the study and ensure them that their answers would only be used anonymously for research purposes on a voluntary basis. Informed consent was sought from each participant before being enrolled into the study. Permission to conduct the study was also obtained from respective school authorities.

Consent to publish: Not applicable.

Availability of data and materials: Not applicable.

Funding: This study had no sources of funding. All operational costs were met by authors.

Competing interests: The authors declare that they have no competing interests.

Acknowledgements: The authors are grateful to all who participated in the preparation of this manuscript. The authors acknowledge the help of the students who participated in this study and the teachers who delivered and collected questionnaires.

References

1. S. Longman-Mills et al. Psychological maltreatment and its relationship with substance abuse among university students in kingston, jamaica maus-tratos psicológicos e sua relação com o abuso de substâncias entre estudantes universitários em kingston, jamaica, Artig. Orig. Texto Context. Enferm. 2015; 24: 63-68.
2. S. A. Sumner, J. A. Mercy, J. Saul, N. Motsa-nzuza, G. Kwesigabo, and R. Buluma, et al. Prevalence of Sexual Violence Against Children and Use of Social Services -Seven Countries. 2007–2013. 64(21): 2007–2013, 2015.
3. D. Glaser. Emotional abuse and neglect (psychological maltreatment): A conceptual framework. Child Abuse Negl. 2002; 26(6- 7): 697–714.
4. P. Stiefelhagen. How emotional abuse can cause illness. MMW Fortschr. Med. 2015; 157(5): 20.
5. E. Paul and J. Eckenrode. Childhood psychological maltreatment subtypes and adolescent depressive symptoms. Child Abuse Negl. 2015; 47: 38–47.
6. D. P. Bernstein et al., Initial reliability and validity of a new retrospective measure of child abuse and neglect. Am. J. Psychiatry. 1994; 151(8): 1132–1136.
7. V. J. Felitti et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am. J. Prev. Med. 1998; 14(4): 245–258.
8. A. Han, G. Wang, G. Xu, and P. Su, A self-harm series and its relationship with childhood adversity among adolescents in mainland China: A cross-sectional study,” BMC Psychiatry. 2018; vol. 18, no. 1, p. 28.
9. H. Ward and R. Brown, “Assessing Parental Capacity to Change when Children are on the Edge of Care : An overview of current research evidence Research report,” 2014; no. pp. 1–193.
10. G. Arslan, “Psychological maltreatment, emotional and behavioral problems in adolescents: The mediating role of resilience and self-esteem,” Child Abuse Negl. 2016; vol. 52, pp. 200–209.
11. F. Meinck, L. D. Cluver, and M. E. Boyes, “Household illness, poverty and physical and emotional child abuse victimisation : Findings from South Africa ’s first prospective cohort study,” ???, 2015; pp. 1–13.
12. K. Sesar, I. Zivcic-Becirevic, and D. Sesar, “Multi-type Maltreatment in Childhood and Psychological Adjustment in Adolescence: Questionnaire Study Among Adolescents in Western Herzegovina Canton.” cmj. 2008; vol. 49, no. 2, pp. 243–256.
13. B. A. Dachew, A. Fekadu, T. Kisi, N. Yigzaw, and T. A. Bisetegn, “Psychological distress and associated factors among prisoners in North West Ethiopia: Cross-sectional study.,” Int. J. Ment. Health Syst. 2015; vol. 9, no. 1, p. 39.
14. United Republic of Tanzania: Ministry of Health and Social Sevices, “National managment guidelines for the health sector response to and prevention of gender-based violence,” Minist. Heal. Soc. Serv., no. 2011; pp. 1–81.
15. R. C. Kessler et al., “Screening for serious mental illness in the general population.,” Arch. Gen. Psychiatry. 2003; vol. 60, no. 2, pp. 184–189.
16. K. Qamar, M. R. B. Kiani, A. Ayyub, A. A. Khan, and M. Osama, “Higher stress scores for female medical students measured by the Kessler Psychological Distress Scale (K10) in Pakistan.,” J. Educ. Eval. Health Prof. 2014; vol. 11, p. 27.
17. Y. Dessie, J. Ebrahim, and T. Awoke, “Mental distress among university students in Ethiopia: A cross sectional survey,” Pan Afr. Med. J. 2013; vol. 15, p. 95.
18. G. Rubinstein, “The big five and self-esteem among overweight dieting and non-dieting women,” Eat. Behav. 2006; vol. 7, no. 4, pp. 355–361.
19. O. Karakus, “Relation Between Childhood Abuse and Self-esteem in Adolescence,” Int. J. Hum. Sci. 2012; vol. 9, no. 2.
20. A. Drapeau, D. Beaulieu-Prévost, A. Marchand, R. Boyer, M. Préville, and S. Kairouz, “A life-course and time perspective on the construct validity of psychological distress in women and men. Measurement invariance of the K6 across gender,” 2010.
21. D. Control, “No . 20 : Adverse Childhood Experiences in NSCAW,” 1997; vol. 1997, no. 20, pp. 1–6.
22. T. Hecker, V. S. Boettcher, M. A. Landolt, and K. Hermenau, “Child neglect and its relation to emotional and behavioral problems: A cross-sectional study of primary school-aged children in Tanzania,” Dev. Psychopathol. 2018; pp. 1–15.
23. A. A. Mwakanyamale and Y. Yizhen, “Psychological maltreatment and its relationship with self-esteem and psychological stress among adolescents in Tanzania : A community based , cross-sectional study,” 2019; pp. 1–9.
24. J. Chen, M. P. Dunne, and P. Han, “Child sexual abuse in China: A study of adolescents in four provinces.,” Child Abuse Negl. 2004; vol. 28, no. 11, pp. 1171–1186.
25. J. Chen, “[A retrospective survey in child sexual abuse among 565 university students].,” Zhonghua Liu Xing Bing Xue Za Zhi. 2004; vol. 25, no. 10, pp. 873–877.
26. V. J. Edwards, G. W. Holden, V. J. Felitti, and R. F. Anda, “Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: Results from the adverse childhood experiences study,” Am. J. Psychiatry. 2003; vol. 160, no. 8, pp. 1453–1460.
27. G. Barker et al., “the United Republic of Tanzania Gender-Based Violence and Violence Against Children,” Soc. Sci. Med. 2017; vol. 152, no. June, p. 40.
28. World Health Organization, “Child abuse and neglect by parents and other caregivers,” World Rep. Violence Heal. pp. 2002; 59– 86.
29. K. Hermenau, I. Eggert, M. A. Landolt, and T. Hecker, “Neglect and perceived stigmatization impact psychological distress of orphans in Tanzania,” Eur. J. Psychotraumatol. 2015; 6: 1–9.
30. C. J. Najdowski and K. M. Bernstein, “Child Abuse & Neglect Race , social class , and child abuse : Content and strength of medical professionals ’ stereotypes,” Child Abuse Negl. 2018; vol. 86, no. October, pp. 217–222.
31. D. C. R. Kerr, G. Gini, L. D. Owen, and D. M. Capaldi, “Child Abuse & Neglect Peer teasing experiences of fathers and their children : Intergenerational associations and transmission mechanisms,” Child Abuse Negl. 2018; vol. 86, no. August, pp. 33–44.
32. K. G. Merrill, L. Knight, S. Namy, E. Allen, D. Naker, and K. M. Devries, “Child Abuse & Neglect Effects of a violence prevention intervention in schools and surrounding communities : Secondary analysis of a cluster randomised-controlled trial in Uganda,” Child Abuse Negl. 2018; vol. 84, no. February, pp. 182–195.
33. J. Rudolph and M. J. Zimmer-gembeck, “Child Abuse & Neglect Parents as protectors: A qualitative study of parents ’ views on child sexual abuse prevention,” Child Abuse Negl. 2018; no. March, pp. 0–1, 2018.
34. J. Adams, S. Mrug, and D. C. Knight, “Child Abuse & Neglect Characteristics of child physical and sexual abuse as predictors of psychopathology,” Child Abuse Negl. 2018; vol. 86, no. August, pp. 167–177.
35. L. M. Richter, S. Mathews, E. Nonterah, and L. Masilela, “Child Abuse & Neglect A longitudinal perspective on boys as victims of childhood sexual abuse in South Africa : Consequences for adult mental health,” Child Abuse Negl. 2018; vol. 84, no. September 2017, pp. 1–10.
36. T. Van Veen, K. J. Wardenaar, I. V. E. Carlier, and P. Spinhoven, “Are childhood and adult life adversities differentially associated with specific symptom dimensions of depression and anxiety ? Testing the tripartite model,” J. Affect. Disord. 2013; vol. 146, no. 2, pp. 238–245.
37. A. A. Mwakanyamale, D. P. Wande, and Y. Yizhen, “Multi-type child maltreatment: Prevalence and its relationship with selfesteem among secondary school students in Tanzania,” BMC Psychol. 2018; vol. 6, no. 1, pp. 1–8.
38. J. R. Kuo, P. R. Goldin, K. Werner, R. G. Heimberg, and J. J. Gross, et al. “Journal of Anxiety Disorders Childhood trauma and current psychological functioning in adults with social anxiety disorder,” J. Anxiety Disord. 2011; vol. 25, no. 4, pp. 467–473.