CHILDHOOD TRAUMA AND COGNITIVE (IN)FLEXIBILITY:

IMPLICATIONS FOR ANXIETY AND DEPRESSION

A Dissertation

Presented to the Faculty of

Pacific Graduate School of Psychology

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Palo Alto University
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In Partial Fulfillment of the

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Requirements for the Degree of

Doctor of Philosophy in Clinical Psychology

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by

Justin A. Davich

June, 2020

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 CHILDHOOD TRAUMA AND COGNITIVE (IN)FLEXIBILITY:

IMPLICATIONS FOR ANXIETY AND DEPRESSION

Justin A. Davich
Pacific Graduate School of Psychology, Palo Alto University, 2020

Childhood trauma is associated with increased instances of anxiety and depression, yet the

mechanisms by which childhood trauma impacts psychopathology remains poorly understood.

Cognitive inflexibility plays a significant role in the emergence and maintenance of affective

phenomena (e.g., negative cognitive style, rumination, and emotion regulation) and may help to

clarify the relationship between childhood adversity and psychopathology. The present study

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tested the effects of childhood trauma and both subjective and objective cognitive flexibility, and

their interactions on symptom dimensions of depression and anxiety. Path analyses were used to
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evaluate the hypothesized relationships between childhood trauma, cognitive flexibility, and
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symptoms of anxiety and depression in adults with varying degrees of depression and/or anxiety.

The present findings indicated that childhood trauma and cognitive inflexibility predicted

elevated levels of anxiety and depression, and that the relationship between childhood trauma
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and elevated symptoms of anxiety and depression was moderated by cognitive inflexibility.

More specifically, the moderation path analyses demonstrated that low levels of subjective

cognitive flexibility and fast set-shifting abilities moderate the relationship between childhood

trauma and increased symptoms of depression and/or anxiety. Taken together, findings suggest

that poor cognitive flexibility may be a cognitive mechanism by which childhood trauma impacts

depression and anxiety. The level of cognitive flexibility may be an important factor to consider

during case conceptualization and treatment planning prior to and throughout the course of

treatment. Understanding the level of cognitive flexibility in clients may be a helpful clinical

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marker indicating the degree to which a treatment will effectively reduce psychological distress,

especially in adults who have a history of childhood trauma.

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 © Copyright 2020

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by
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All Rights Reserved

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 Childhood Trauma and Cognitive (In)flexibility: Implications for Anxiety and Depression

This dissertation by Justin A. Davich, directed and approved by the candidate’s committee, has

been accepted and approved by the Faculty of Pacific Graduate School of Psychology, Palo Alto

University in partial fulfillment of the requirements for the degree of

DOCTOR OF PHILOSOPHY

IN CLINICAL PSYCHOLOGY

June 10, 2020

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Risa Dickson, Ph.D.
Vice President for Academic Affairs

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Dissertation Committee:
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______________________________________________
Stacie L. Warren, Ph.D.
Chair
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______________________________________________
Rowena Gomez, Ph.D.
Committee Member

______________________________________________
Matthew Cordova, Ph.D.
Committee Member

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 ACKNOWLEDGMENTS

This dissertation is dedicated to my beloved wife, Amanda, and to our children Jayden

and Austin. I would also like to dedicate it to my parents and siblings. I love you all para siempre

jamas. I am grateful for your love and support in helping me remain grounded and kindling my

continued curiosity in life.

I would also like to acknowledge mentors who helped me through this process and share

a special thanks to my dissertation committee, Stacie Warren, Ph.D., Rowena Gomez, Ph.D., and

Matthew Cordova, Ph.D. Each of you played a critical role in guiding me to this point and

beyond.

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Thanks also to Wendy Heller, Ph.D. (Department of Psychology, University of Illinois at
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Urbana-Champaign) and to Gregory A. Miller, Ph.D. (Department of Psychology, University of

California, Los Angeles).

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 TABLE OF CONTENTS

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ACKNOWLEDGMENTS ........................................................................................................... 6

LIST OF TABLES ...................................................................................................................... 9

LIST OF FIGURES ..................................................................................................................... 10

CHAPTER

I. INTRODUCTION.................................................................................................................... 11

Childhood Trauma and Psychopathology ................................................................................... 14

Childhood Trauma and Cognition ............................................................................................... 19

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Cognition and Psychopathology .................................................................................................. 24
Mechanisms Linking Childhood Trauma and Psychopathology................................................. 28
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Present Study ............................................................................................................................... 32
Hypotheses .................................................................................................................................. 34
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II. METHODS ............................................................................................................................. 35

Experimental Design ................................................................................................................... 37

Measures ...................................................................................................................................... 38
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Questionnaires ...................................................................................................................... 38
CTQ ................................................................................................................................. 38
BRIEF-A.......................................................................................................................... 39
MASQ-AD and MASQ-AA ............................................................................................ 39
PSWQ .............................................................................................................................. 40
Neuropsychological Measures ............................................................................................. 40
Cognitive Flexibility Measures ....................................................................................... 40
Plus-Minus Task .............................................................................................................. 40
D-KEFS Trail Making Test ............................................................................................. 41
Data Analyses .............................................................................................................................. 41
Descriptives .......................................................................................................................... 41
Principal Components Analysis ........................................................................................... 42

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 Structural Equation Modeling .............................................................................................. 42

III. RESULTS .............................................................................................................................. 44

Hypothesis 1 ................................................................................................................................ 48
Hypothesis 2 ................................................................................................................................ 48
Hypothesis 3 ................................................................................................................................ 48
Hypothesis 4 ................................................................................................................................ 48
Hypothesis 5 ................................................................................................................................ 48
Post Hoc Results................................................................................................................... 57

IV: DISCUSSION ....................................................................................................................... 70

Post Hoc Results................................................................................................................... 77

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Study Strengths & Limitations ............................................................................................. 79
Research and Clinical Implications ...................................................................................... 81
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Future Directions .................................................................................................................. 83

REFERENCES ............................................................................................................................ 86
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APPENDIX ................................................................................................................................. 105
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 LIST OF TABLES

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1. Sample 1 Demographics Table ........................................................................................ 36

2. Sample 2 Demographics Table ........................................................................................ 37

3. PCA Analysis for Objective Cognitive Flexibility (CF) ................................................. 45

4. Descriptive Statistics for Variables of Interest ................................................................ 46

5. Zero-Order Correlations .................................................................................................. 47

6. Moderation Analysis for Childhood Trauma x Subjective CF ........................................ 50

7. Moderation Analysis for Childhood Trauma x Objective CF ......................................... 53

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8. Moderation Analysis for Physical Neglect x Subjective CF ........................................... 59
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9. Moderation Analysis for Physical Abuse x Objective CF............................................... 61

10. Moderation Analysis for Physical Neglect x Objective CF ............................................ 63

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11. Moderation Analysis for Emotional Abuse x Objective CF ........................................... 66

12. Moderation Analysis for Emotional Neglect x Objective CF ......................................... 68

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 LIST OF FIGURES

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1. Proposed Moderation Path Model ................................................................................... 34

2. Moderation Path Model for Subjective CF ..................................................................... 51

3. Plot of 2-way interaction of Childhood Trauma and Subjective CF ............................... 52

4. Moderation Path Model for Objective CF ....................................................................... 54

5. Plot of 2-way interaction of Childhood Trauma and Objective CF on MASQ-AD8 ...... 55

6. Plot of 2-way interaction of Childhood Trauma and Objective CF on MASQ-AA ........ 56

7. Plot of 2-way interaction of Physical Neglect and Subjective CF on MASQ-AD14 ...... 60

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8. Plot of 2-way interaction of Physical Abuse and Objective CF on MASQ-AA ............. 62
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9. Plot of 2-way interaction of Physical Abuse and Objective CF on MASQ-AD8 ........... 62

10. Plot of 2-way interaction of Physical Neglect and Objective CF on MASQ-AA ........... 65
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11. Plot of 2-way interaction of Physical Neglect and Objective CF on MASQ-AD8 ......... 65

12. Plot of 2-way interaction of Emotional Abuse and Objective CF on MASQ-AD8 ........ 67

13. Plot of 2-way interaction of Emotional Neglect and Objective CF on MASQ-AA ........ 69
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Childhood Trauma and Cognitive (In)flexibility: Implications for Anxiety and Depression

CHAPTER I

INTRODUCTION

Though it is well established in extant literature that childhood maltreatment is

consistently underreported (MacDonald et al., 2016), the number of children impacted has risen

steadily in recent years (U.S. Department of Health & Human Services (USDHHS),

Administration for Children and Families (ACF), Administration on Children, Youth and

Families (ACYF), Children’s Bureau (CB, 2018). In 2018, the Children’s Bureau published data

indicating that the number of child maltreatment referral reports received by the Child Protective

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Services (CPS) had increased from 3.57 million in 2012 to 4.1 million in 2016. What is most
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concerning is that these 2016 CPS reports implicate approximately 7.4 million children, only 3.5

million (47.2%) of whom received an investigation and/or alternative response. In terms of

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different types of childhood maltreatment, the following types of trauma were indicated in these

reports along with their prevalence: neglect (74.8%), physical abuse (18.2%), sexual abuse

(8.5%), and psychological maltreatment (6.9%). Lastly, 28.5% of children who experienced
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childhood trauma were under the age of 3 (USDHHS, ACF, ACYF, CB, 2018). In addition to the

alarmingly widespread nature of childhood maltreatment and trauma, extant research has also

shown the significant impact of childhood trauma on the development of cognitive and affective

functioning (Cross, Fani, Powers, & Bradley, 2017).

Originally, trauma was conceptualized as a surgical wound in that the skin that when

ruptured caused a “catastrophic global reaction in the entire organism” (Leys, 2000, p. 19).

However, the field’s understanding of trauma has markedly shifted since then to include

traumatic stress and its impact on both physical and psychological well-being (Cross et al.,

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2017). According to the Diagnostic and Statistical Manual of Mental Disorders (5th edition,

DSM-5), traumatic events consist of, but are not limited to, threatened or actual physical assault,

threatened or actual sexual violence, being kidnapped, or held hostage (American Psychiatric

Association; APA, 2013). Other types of interpersonal trauma may include childhood physical

and emotional abuse and/or neglect, as well as childhood sexual abuse (Bernstein & Fink, 1997).

It is also important to note that childhood trauma is used interchangeably in the literature with

childhood maltreatment, childhood adversity, and adverse childhood experiences.

Research has shown that childhood trauma is related to poor health outcomes in

adulthood. More specifically, individuals with a history of childhood trauma have exhibited

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deficits in executive function and emotion regulation (Chapman et al., 2004; Cougle, Timpano,
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Sachs-Ericsson, Keough, & Riccardi, 2010; Dube et al., 2001; Hopfinger, Berking, Bockting, &

Ebert, 2016; Nikulina & Widom, 2013; Sachs-Ericsson, Spann et al., 2012; St. Clair et al., 2015;
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Turner & Butler, 2003; Vares et al., 2016; Verona, Joiner, & Preacher, 2006). However, the

mechanisms by which childhood trauma affects adult cognition and mood remain poorly

understood. The term mechanism is defined as a complex system containing a number of parts
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that interact with one another resulting in an emergent outcome (Glennan, 2002; Sharp, Miller, &

Heller, 2015). An example of a mechanism being an interaction of a number of parts is

demonstrated in Sharp et al.’s (2015) explanation that the interaction between core affect and

executive inflexibility is a mechanism of anxious apprehension. The present study

conceptualized the term mechanism as a moderation. The proposed dissertation sought to

integrate several lines of research with the goal of understanding why some individuals who

experience childhood adversity develop mood and anxiety disorders in later in life. In particular,

this dissertation reviewed the following associations supported by previous research: childhood

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trauma and the development of mood and anxiety disorders in adults, childhood trauma and

cognitive deficits, and finally, cognitive deficits and mood and anxiety disorders (Gibb et al.,

2001; Hankin, 2005; Hopfinger et al., 2016; Kaysen, Scher, Mastnak, & Resick, 2005; Kim, Jin,

Jung, Hahn, & Lee, 2017).

A potential cognitive mechanism (i.e., moderating variable) by which childhood trauma

may impact psychopathology in adulthood is cognitive flexibility. Cognitive flexibility

represents a top-down process by which an individual is able to disengage from an irrelevant task

or mental set and shift to an adaptive task or mental set in order to successfully meet changing

situational demands (Carbonella & Timpano, 2016; Johnco, Wuthric, & Rapee, 2015; Miyake &

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Friedman, 2012; Nikulina & Widom, 2013; Spann et al., 2012). Studies have demonstrated that
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negative cognitive style, rumination, and emotion regulation partially mediate the relationship

between childhood trauma and psychopathology (Gibb et al., 2001; Hankin, 2005; Hopfinger et
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al., 2016; Huh, Kim, Lee, & Chae, 2017; Kaysen et al., 2005; Kim et al., 2017), and that

cognitive flexibility is related to each of these mediators (Davis & Hoeksema, 2000; Malooly,

Genet, & Siemer, 2013; McRae, Jacobs, Ray, John, & Gross, 2012; Schmeichel & Tang, 2015;
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Vergara-Lopez, Lopez-Vergara, & Roberts, 2016). One potential explanation for why each

variable partially mediated the relationship between childhood trauma and psychopathology

could be that the variables (i.e., negative cognitive style, rumination, and emotion regulation) had

cognitive flexibility in common. Furthermore, deficits in cognitive flexibility have been shown in

adolescents and adults with a history of childhood trauma (Nikulina & Widom, 2013; Spann et

al., 2012). Individual differences in cognitive flexibility may offer an explanation for why some

adults with childhood trauma experience increased psychopathology whereas others do not.

Individuals with childhood trauma who experience reduced cognitive flexibility may experience

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increased distress due to difficulties shifting away from maladaptive thoughts and/or negative

emotional experiences. This inflexible style of thinking may lead to rumination and/or worry as

well as to increased symptoms of anxiety and/or depression. On the other hand, increased levels

of cognitive flexibility may be a protective factor for individuals with childhood trauma because

they are able to flexibly shift from a maladaptive to an adaptive thought and/or positive

emotional experience, which could serve to prevent increased anxiety and/or depression

symptoms.

Understanding how cognitive flexibility impacts childhood trauma and psychopathology

in adulthood may provide new insights for research and clinical practice. If the level of cognitive

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flexibility impacts the direction and/or strength of the relationship between childhood trauma and
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anxiety and/or depression, this may open a new avenue of research and clinical practice by

highlighting the need for a cognitive treatment method focused on improving an individual’s
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level of cognitive flexibility. Increasing cognitive flexibility may help reduce cognitive and

affective consequences of childhood trauma on an individual’s symptoms of anxiety and/or

depression. The present study will test whether and how cognitive flexibility moderates the
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relationship between childhood trauma and symptoms of anxiety and depression.

Childhood Trauma and Psychopathology

Research demonstrates a high prevalence of childhood trauma in individuals who have

been diagnosed with or are experiencing symptoms of one or more mood disorders (Chapman et

al., 2004; Cougle et al., 2010; Dube et al., 2001; Sachs-Ericsson et al., 2006; St. Clair et al.,

2015; Turner & Butler, 2003; Vares et al., 2016). For instance, childhood abuse appears to be

more prevalent in individuals with anxiety disorders than without anxiety disorders (Stein et al.,

1996). Major depressive disorder (MDD) is more likely to be diagnosed for patients with anxiety

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disorders who have a history of childhood abuse versus patients without child abuse (Safren,

Gershuny, Marzol, Otto, & Pollack, 2002). Additionally, childhood emotional, physical, and

sexual abuse have been linked to higher rates of internalizing disorders (i.e., increased symptoms

of depression, generalized anxiety disorder (GAD), phobia, social phobia, post-traumatic stress

disorder (PTSD), and panic disorder (PD; Sachs-Ericsson et al., 2006)). Lastly, in one

longitudinal study early life events predicted the onset and course of depression (Friis, Wittchen,

Pfister, & Lieb, 2002). Specifically, negative life events, low social class, and family-related

stressful life events all predicted the onset of depression. Conversely, positive life events

predicted improvement in depression and total number of life events was related to depression

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stability (Friis et al., 2002). Although these findings are not causal, it appears that childhood
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trauma is a transdiagnostic risk factor for the development, symptom severity, and course of

mood disorders (Cross et al., 2017; Friis et al., 2002; Sachs-Ericsson et al., 2006; Safren et al.,
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2002; Stein et al., 1996).

In contrast to emotional abuse and neglect, childhood physical and sexual abuse have

received much attention in the literature (Cougle et al., 2010; Lindert, Von Ehrenstein, Grashow,
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Gal, Braehler, & Weisskopf, 2014; Safren et al., 2002; Stein et al., 1996). One plausible

explanation for this discrepancy is that physical and sexual abuse often leave behind physical

markers and are thus more easily identifiable than the invisible wounds wrought by emotional

abuse/neglect (Glaser, 2002). In terms of mental health, research has demonstrated that specific

traumatic experiences may be more related to one disorder than another (Gibb, Butler, & Beck,

2003; Martins et al., 2014). More specifically, childhood physical, emotional, and sexual abuse

are positively related to both anxiety and depression, but the correlation is larger between

physical abuse and anxiety (Gibb et al., 2003) and between emotional abuse and depression

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(Kendler et al., 2000; Martins et al., 2014). The relationship between trauma type and incidence

of anxiety and depression has mixed support in the literature as some studies have replicated

these distinct associations, whereas other findings do not demonstrate a significant difference

between anxiety and depression depending on childhood trauma type (Gibb et al., 2003; Spertus,

Yehuda, Wong, Halligan, & Seremetis, 2003; van Veen, Wardenaar, Carlier, Spinhoven,

Penninx, & Zitman, 2013). A potential explanation for these mixed findings could be the

researchers’ different methods of collecting information regarding childhood trauma (e.g.,

different self-report questionnaires as well as semi-structured interviews), and psychopathology

(e.g., different self-report questionnaires about symptoms or symptom dimensions, and

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structured interviews assessing diagnostic classification; Kendler et al., 2000; Spertus et al.,
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2003; van Veen et al., 2013). As demonstrated in these findings, different types of childhood

trauma may be differently related to anxiety and depression. In addition to distinguishing the
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effects of various trauma types on anxiety and depression, exploring gender differences can help

to further elucidate and clarify these relationships.

Several studies have identified gender differences in the relationship between childhood
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trauma and anxiety and depressive disorders (Cougle et al., 2010; Stein et al., 1996). Prior to

reviewing these findings, it is important to note that women are twice as likely as men to

experience anxiety and depression (Heim, Newport, Mletzko, Miller, & Nemeroff, 2008; Kessler

Maeng & Milad, 2015; Tolin & Foa, 2006). Research has shown that for women, SAD, PD, and

PTSD were related to childhood sexual abuse, whereas childhood physical abuse was only

related to SP and PTSD (Cougle et al., 2010). Amongst women with depression, those who had

experienced five or more adverse childhood experiences (ACEs) were at five times greater risk

for dysthymia and six times more at risk for MDD than women without ACEs (Chapman et al.,

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2004). In men with depression, those with a history of five or more ACEs were between two and

three times more at risk for dysthymia and MDD than men without ACEs (Chapman et al.,

2004). For men, SAD has been related to both childhood physical and sexual abuse, while PTSD

was related to childhood physical abuse alone (Cougle et al., 2010). Other associations remain

less clear; for instance, the relationship between childhood sexual abuse and anxiety disorders in

men remains relatively unknown, due to low base rates and potential underreporting (i.e., only

4.3% of men reported childhood sexual abuse; Cougle et al., 2010; Stein et al., 1996). In

summary, across men and women, research demonstrates a strong dose-response relationship

between childhood adversity and increased rates of depressive disorders; however, the

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relationship appeared to be more robust for women than men (Chapman et al., 2004). Moreover,
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emotional abuse demonstrated the strongest relationship to dysthymia and MDD in both men and

women (Chapman et al., 2004). Overall, the reviewed research to date supports that significant
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relationships exist between trauma type and mood and anxiety disorders.

As reviewed above, childhood trauma is associated with internalizing disorders. Anxiety

and mood disorders share many overlapping symptoms (e.g., difficulty concentrating, fatigue,
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restlessness) as well as affective experiences (e.g., elevated negative affect, repetitive negative

thought). Given the degree of symptom overlap between anxiety and mood disorders and the

variability of trauma type predicting a specific anxiety or mood disorder, targeting specific

symptom dimensions rather than categorical diagnoses might be a more fruitful approach to

understanding how childhood trauma contributes to the development of psychopathology. The

present dissertation proposes to investigate cognitive flexibility as a moderator between

childhood trauma and internalizing disorders by using symptom dimensions to operationalize

anxiety and depression. Such a strategy may provide a more targeted explanation of the long-

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term effects of childhood trauma above and beyond anxiety and depression disorders (Clark &

Watson, 1991; Cougle et al., 2010; Dunlop et al., 2015; Infurna, Reichl, Parzer, Schimmenti,

Bifulco, & Kaess, 2016; van Veen et al., 2013). The tripartite model of anxiety and depression is

a theory that proposes grouping symptoms of anxiety and depression into three dimensions

(Clark & Watson, 1991). First, the general distress dimension accounts for shared symptoms

between anxiety and depression. Second, the physiological arousal dimension is specific to

anxiety and is also known as anxious arousal. Third, the anhedonic depression dimension

consists of symptoms of low positive affect specific to depression (Clark & Watson, 1991).

Finally, research has shown another dimension that is related to anxiety known as anxious

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apprehension, also known as worry, which is a form of negative repetitive thought concerning
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future threats and their potential negative outcomes (Nitschke, Heller, Imig, McDonald, &

Miller, 2001). Research using symptom dimensions has demonstrated significant positive
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associations between childhood physical abuse and increased anxious arousal, as well as between

emotional and sexual abuse and increased general distress and anxious arousal, and finally

between emotional neglect and increased general distress, anhedonic depression, and anxious
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arousal (van Veen et al., 2013). Operationalizing anxiety and depression through anxious

arousal, anxious apprehension, and anhedonic depression measures may provide a clearer

explanation of the long-term effects of childhood trauma and cognitive flexibility above and

beyond categorical diagnoses.

In addition to its association with anxiety and depression, childhood trauma has also been

related to suicidality (APA, 2013; Dube et al., 2001). In 2015, suicide accounted for 44,193

deaths in the United States (Centers for Disease Control and Prevention [CDC], 2018) and is

noted to be one of the top ten leading causes of death (CDC, 2018). Research has shown that

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individuals with a history of childhood trauma are two to five times more likely to attempt

suicide than those without a history of childhood trauma (Dube et al., 2001). Other research has

demonstrated a link between emotional abuse and increased severity of depressive symptoms,

including suicidal ideation (Martins, Von Werne Baes, De Carvalho Tofoli, & Juruena, 2014). In

sum, childhood trauma, regardless of type, appears to have a deleterious effect on a person’s

ability to adaptively regulate their emotions, potentially causing increased distress as well as

suicidal thoughts and behaviors. One potential explanation for the relationship between

childhood trauma and mood and anxiety disorders that has been proposed is cognitive

functioning.

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Childhood Trauma and Cognition
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Research indicates that individuals with a history of childhood trauma experience deficits

in executive function (Cross et al., 2017; Nikulina & Widom, 2013; Spann et al., 2012).
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Executive function is a set of higher-order processes that regulate an individual’s thoughts and

actions in everyday life (Miyake & Friedman, 2012). General childhood maltreatment has

predicted deficits in multiple areas of executive function, such as cognitive flexibility, response
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inhibition, working memory, problem solving, attention, processing speed, and nonverbal

reasoning in adults (Brandes et al., 2002; Navalta, Polcari, Webster, Boghossian, & Teicher,

2006; Stein, Kennedy, & Twamley, 2002; Twamley, Hami, & Stein, 2004). Understanding

processes of executive function, such as cognitive flexibility, in adults with childhood trauma

may provide a potential explanation for the strength of the relationship between childhood

trauma and psychopathology.

Miyake and Friedman (2012) highlighted different processes of executive function that

have received notable attention in the literature. Miyake’s model of executive function targets

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three components: updating of working memory (continuous monitoring and quick addition or

removal of information in working memory), shifting (the ability to disengage from an irrelevant

task and alternate attention flexibly to a relevant task), and inhibition (the ability to limit a

predominant response tendency; Miyake & Friedman, 2012). Processes involved in cognitive

flexibility comprise shifting and inhibition (Carbonella & Timpano, 2016; Johnco et al., 2015;

Lee & Orsillo, 2014; Miyake & Friedman, 2012; Nikulina & Widom, 2013; Spann et al., 2012).

Cognitive flexibility consists of the inhibition of irrelevant internal or external stimuli and

flexibly shifting to a relevant task or mental set to successfully meet new demands (Johnco et al.,

2015; Lee & Orsillo, 2014). Cognitive flexibility has been previously investigated using

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neuropsychological tests to evaluate the underlying construct known as shifting, in which
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inhibition plays an implicit role (e.g., Delis-Kaplan Executive Function System [D-KEFS] Trail

Making Test; D-KEFS Verbal Fluency Test; Wisconsin Card Sorting Task [WCST]; Lieberman,
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Gorka, Sarapas, & Shankman, 2015; Nikulina & Widom, 2013; Spann et al., 2012).

Deficits in executive function at a young age could have detrimental and enduring effects

on the development of executive function into adulthood (Danese et al., 2017; Deary, Pattie, &
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Starr, 2013; Pesonen et al., 2013; Richards & Wadsworth, 2004). Longitudinal research has

tested the stability of intact cognitive ability and intelligence as well as the enduring effects of

deficits in cognitive functioning (e.g., executive function, IQ, processing speed, and memory),

demonstrating that intelligence and cognition remain consistent from age 11 to 90 (Deary, Pattie,

& Starr, 2013). Other longitudinal studies have tested executive function in participants who

have histories of childhood trauma (Danese et al., 2017; Pesonen et al., 2013; Richards &

Wadsworth, 2004), finding that childhood trauma was related to cognitive impairment that

persisted into middle adulthood for both women and men (Richards & Wadsworth, 2004) as well

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as late adulthood for men (Pesonen et al., 2013). In contrast, another study found that adults who

experienced trauma between the ages of 3 and 11 demonstrated poor performance on tests of

executive function (e.g., cognitive flexibility), processing speed, memory, and intelligence

during adolescence and adulthood (Danese et al., 2017). Although these findings demonstrated

the potentially enduring effects of cognitive deficits, the outcome appeared to be a result of

individuals’ cognitive abilities at 3 years of age, prior to the reported childhood trauma,

controlling for the socioeconomic status of their families (SES; Danese et al., 2017). One

potential explanation for this finding is that the participants had experienced adversity prior to

the time period the study had assessed (i.e., three years of age onwards). Regardless, research

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demonstrates a relationship between childhood trauma and executive function and provides
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greater insight into how resultant deficits can persist across an individual’s lifespan.

Different types of childhood trauma may have diverse effects on executive function,
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independent of psychopathology. For example, physical abuse and neglect have been related to

poor cognitive flexibility in both adolescents and adults (Dannehl, Rief, & Euteneuer, 2017;

Gould et al., 2012; Nikulina & Widom, 2013; Spann et al., 2012). Physical abuse and neglect
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predicted poorer performance in processing speed, emotional processing, verbal learning,

working memory, and executive function in adults aged 30 to 37 with and without depression

(Dannehl et al., 2017; Gould et al., 2012; Nikulina & Widom, 2013). Deficits in cognitive

functions such as cognitive flexibility, processing speed, problem solving, and nonverbal

reasoning remained significant in adults with childhood physical neglect after controlling for

potential confounding variables such as subject demographics, IQ, substance use, and depression

(Nikulina & Widom, 2013). These findings indicate that individuals with a history of childhood

physical abuse and/or neglect may experience increased deficits in cognitive flexibility and other

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areas of cognitive functioning above and beyond what is explained by psychopathology

(Dannehl et al., 2017; Gould et al., 2012; Nikulina & Widom, 2013). Such findings bolster the

conclusion that childhood trauma, and more specifically physical abuse and neglect, may impact

cognitive functioning (e.g., cognitive flexibility) prior to the onset of psychopathology.

Emotional abuse and/or neglect have mixed results in the literature regarding their

relationship with cognitive functioning. Emotional abuse and neglect have been related to

deficits in executive function, processing speed, and emotional processing in adults with and

without depression (Gould et al., 2012). In another study, emotional abuse was related to

enhanced executive function in individuals with and without depression (Dannehl et al., 2017).

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Some studies did not find any effect of childhood emotional abuse and/or neglect on cognitive
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functioning (Aas et al., 2012; Spann et al., 2012). One potential explanation for the mixed

findings concerning the relationship between childhood emotional trauma and cognitive
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functioning could be methodological differences. For example, different tasks were used to

assess executive function (e.g., D-KEFS Verbal Fluency and Letter Fluency Tests, D-KEFS Trail

Making Test A and B, Modified Card Sorting Test (MCST), Intra-Extra Dimensional Set
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Shifting (IED), the Affective Go-No-Go test (AGN), and WCST; Aas et al., 2012; Dannehl et al.,

2017; Gould et al., 2012; Spann et al., 2012). Although the studies tested cognitive measures that

had common elements of executive function, some measures required distinct cognitive abilities

not shared by all studies (e.g., processing speed, use of feedback, rule acquisition, and

information retrieval from phonological and semantic memory; Aas et al., 2012; Dannehl et al.,

2017; Gould et al., 2012; Spann et al., 2012). Any of these other cognitive abilities could have

been an explanation for the different findings shown for the relationship between childhood

emotional trauma and cognitive functioning. The heterogeneity of participants used across

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various studies may provide another reason for the mixed results. Examples of heterogeneity that

could have impacted the generalizability of findings from the different studies included

differences in age, such as adults (Aas et al., 2012; Dannehl et al., 2017; Gould et al., 2012)

versus adolescents (Spann et al., 2012)] and the percentage of participants who met full criteria

for a diagnosis [100% MDD (Dannehl et al., 2017), 35% MDD and 16.7% PTSD (Gould et al.,

2012), and 59% Schizophrenia spectrum, and 41% Bipolar (Aas et al., 2012)]. In conclusion, the

varying ages and psychopathological characteristics of the participants among studies may be an

explanation for the different findings between childhood emotional trauma and cognitive

functioning.

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The last type of childhood trauma that will be reviewed as it relates to cognitive
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functioning is sexual trauma. Childhood sexual abuse is significantly related to decreases in

cognitive flexibility, executive function, spatial working memory, attention, and verbal working
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memory in adults with and without depression (Dannehl et al., 2017; Gould et al., 2012). Poorer

inhibition, memory problems, and decreased performance on a math scholastic aptitude test

(SAT) were demonstrated in college women with childhood sexual abuse when compared to
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college women without childhood trauma (Navalta et al., 2006). However, in adults over the age

of 50, childhood sexual abuse was related to improved global cognition, memory, executive

function, and processing speed (Feeney, Kamiya, Robertson, & Kenny, 2013). A similar effect

was found in older adults over the age of 65 in which childhood physical, emotional, or sexual

abuse were related to decreased risk of cognitive impairment (Ritchie et al., 2011). Age appears

to be a potential moderator in the relationship between childhood trauma and cognitive

functioning; as adults become older, the negative relationship between childhood trauma and

cognitive functioning appears to improve (Feeney et al., 2013; Ritchie et al., 2011). Potential

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 explanations for why childhood trauma may be related to increased cognitive functioning in

older adults include: effects of childhood trauma may decline with time, and/or the length and

severity of a traumatic experience may influence its impact on cognitive functioning (Ritchie et

al., 2011).

Research has suggested that individuals with a history of childhood trauma not only

experience deficits in cognitive functioning (e.g., cognitive flexibility), but also in emotion

regulation (Cross et al., 2017; Hopfinger et al., 2016). Emotion regulation refers to an

individual’s ability to influence how they experience and respond to their emotions (Dvir, Ford,

Hill, & Frazier, 2014). Studies have also shown that executive function plays a role in regulating

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emotions (Malooly et al., 2013; McRae et al., 2012; Schmeichel & Tang, 2015; Sperduti et al.,
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2017). Cognitive flexibility has been shown to positively correlate with the emotion regulation

strategy of cognitive reappraisal, the ability to reinterpret information in an adaptive manner to

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change an emotional state (Malooly et al., 2013; McRae et al., 2012). Given that poor cognitive

flexibility is associated with emotion regulation difficulties in adults with childhood trauma,

these individuals may develop increased symptom severity in one or more mood and/or anxiety
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disorders. Understanding the processes of executive function (i.e., cognitive flexibility) and how

it may contribute to emotion dysregulation in individuals with a history of childhood trauma may

provide greater insight into the relationship between childhood trauma and increased anxiety and

depression.

Cognition and Psychopathology

A related area of research that may help elucidate the relationship between childhood

trauma and anxiety and depression is cognitive functioning in mood and/or anxiety disorders.

Many forms of psychopathology that are associated with childhood maltreatment (e.g.,

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