A particularly vulnerable pediatric group that is of substantial concern to mental health professionals is youth who have experienced maltreatment and who have been removed from home (1). These individuals often endure multiple traumatic events in addition to the stressors of foster care placement, school instability, and loss of social support networks (2). As such, maltreated youth are at substantial risk for multifaceted psychiatric problems that most commonly include symptoms of posttraumatic stress disorder and depression (3). These symptoms can impair cognitive and social functioning and exacerbate anger, anxiety, and somatic complaints, among other problems [e.g., (4)]. Minoritized maltreated youth, and in particular multiracial maltreated youth, are at increased risk for these mental health challenges, thus requiring diverse research samples (5).

Investigations of primary connections between child maltreatment and posttraumatic and depressive symptoms have centered on the key role of emotional dysregulation, a transdiagnostic construct involving difficulty recognizing, evaluating, modifying, and managing emotions in personal and socially acceptable ways (6). Some deficits related to emotional dysregulation apply more generally to posttraumatic and depressive challenges, such as excessive reactivity to stimuli, problems in threat and reward processing, and interference in learning and goal attainment (7). Other deficits related to emotional dysregulation apply more specifically to posttraumatic and depressive challenges, such as those involving under-regulation (e.g., distress, irritability/anger, hypervigilance) or over-regulation (e.g., thought suppression, avoidance) (8).

Research with respect to the specific mechanisms surrounding the role of emotional dysregulation in posttraumatic and depressive symptoms, and particularly among a highly vulnerable group such as maltreated youth, remains only emergent. Two mechanisms that may help explain this relationship include expressive suppression and cognitive reappraisal. Expressive suppression involves inhibiting the outward expression of emotion; cognitive reappraisal involves reframing an emotion-eliciting situation to modify its impact (9). Expressive suppression is associated with reduced positive affect and increased negative affect, whereas cognitive reappraisal is associated with greater experience and expression of positive emotions (10, 11). Expressive suppression is thus considered to be a more maladaptive coping strategy, whereas cognitive appraisal is considered more adaptive (12). Both strategies, however, may be influenced by contexts such as type of trauma, attachment, cultural identity, and developmental status, among other factors [e.g., (13)]. Although expressive suppression and cognitive reappraisal have been linked to posttraumatic and depressive symptoms in adults, little is known with respect to these mechanisms in maltreated youth.

The present study examined expressive suppression and cognitive reappraisal among a highly diverse set of youth that had experienced traumatic maltreatment events sufficient enough to warrant removal from home. Expressive suppression was expected to positively predict total and cluster (i.e., intrusion, avoidance, alterations in cognition and mood, and alterations in arousal and reactivity) symptoms of posttraumatic stress as well as depressive symptoms. Conversely, cognitive reappraisal was expected to negatively predict each of these symptom groups.

ES emerged as a significant positive predictor of depression symptoms, total PTSD symptoms, and PTSD symptom cluster symptoms. ES items collectively predicted RCADS total depression scores [adj. R² = 22.9%, F(4, 120) = 10.23, p < 0.001] and PTSD-RI total scores [adj. R² = 26.0%, F(4, 121) = 11.99, p < 0.001]. Items 2 (keep feelings to oneself) and 4 (careful not to show happiness) contributed significantly to both models, and particularly the latter. Items 6 (control feelings) and 9 (careful not to show feeling bad) did not contribute significantly to the models. ES items collectively predicted PTSD-RI cluster scores: intrusion [adj. R² = 19.9%, F(4, 121) = 8.79, p < 0.001], avoidance [adj. R² = 8.6%, F(4, 121) = 3.94, p = 0.005], alterations in cognitions and mood [adj. R² = 26.6%, F(4, 121) = 12.31, p < 0.001], and alterations in arousal and reactivity [adj. R² = 20.8%, F(4, 121) = 9.19, p < 0.001]. Item 4 contributed significantly to each model. Item 2 also contributed significantly to alterations in cognitions and mood and alterations in arousal and reactivity. Items 6 and 9 did not contribute significantly to any of the models. Post-hoc hierarchical regressions were conducted following control of gender, age, race/ethnicity, and type of maltreatment, and findings were confirmed. No significant interaction effects were found.

CR emerged as a significant positive predictor of total PTSD symptoms and some PTSD symptom cluster symptoms, but not of depression symptoms. CR subscale items collectively predicted PTSD-RI total scores [adj. R² = 7.3%, F(6, 126) = 2.720, p = 0.016]. Item 1 (think something different when want to feel happier) contributed significantly to the model. CR items also collectively predicted symptoms of intrusion [adj. R² = 9.2%, F(6, 126) = 3.234, p = 0.005] and alterations in cognition and mood [adj. R² = 5.7%, F(6, 126) = 2.322, p = 0.037], but not of avoidance or alterations in arousal and reactivity. Only Item 1 contributed significantly to both models. Post-hoc analyses were conducted following control of gender, age, race/ethnicity, and type of maltreatment. Findings were confirmed with the exception of Item 1’s contribution to alterations in cognitions and mood. The expected overall inverse relationship was thus not found, but specific interactions are noted next.

Analyses revealed a significant interaction for gender [β = −0.27, t(121) = −2.35, p = 0.020] vis-à-vis CR and total PTSD symptoms as well as alterations in cognitions and mood [β = −0.18, t(121) = −2.18, p = 0.031] and alterations in arousal and reactivity [β = −0.28, t(121) = −2.34, p = 0.021]. Simple slope analyses revealed significant positive relationships for males only. Analyses also revealed significant interactions for maltreatment type. CR and sexual maltreatment interacted to predict avoidance [β = −0.20, t(130) = −2.30, p = 0.023], alterations in cognitions and mood [β = −0.19, t(130) = −2.10, p = 0.038], and alterations in arousal and reactivity [β = −0.23, t(130) = −2.52, p = 0.013]. CR and neglect interacted to predict avoidance [β = −0.31, t(130) = −2.30, p = 0.023] and alterations in arousal and reactivity [β = −0.37, t(130) = −2.69, p = 0.008]. CR and psychological maltreatment interacted to predict alterations in cognitions and mood [β = −0.23, t(130) = −2.00, p = 0.048] and alterations in arousal and reactivity [β = −0.27, t(130) = −2.30, p = 0.024]. Simple slopes revealed positive relationships between CR and symptoms for youth who had not experienced these maltreatment types, but nonsignificant relationships for youth who had. Analyses also revealed a significant interaction for age. CR and age interacted to predict intrusion symptoms [β = 0.23, t(130) = 2.06, p = 0.042]; a positive relationship emerged for youth aged <15 years but not for older youth.

The present study examined potential mechanisms (expressive suppression and cognitive reappraisal) vis-à-vis posttraumatic and depressive symptoms in maltreated youth. As expected, expressive suppression emerged as a significant and positive predictor of total and cluster (i.e., intrusion, avoidance, alterations in cognition and mood, and alterations in arousal and reactivity) symptoms of posttraumatic stress as well as depressive symptoms. Conversely, however, the expected inverse direction with respect to cognitive reappraisal and these symptom groups did not emerge overall. Interaction effects revealed a positive relationship regarding cognitive reappraisal with respect to specific groups, notably males, younger youth, and youth who had not experienced sexual maltreatment, vis-à-vis certain subscales.

Expressive suppression findings were manifested specifically with respect to care about showing happiness. Suppression of positive emotions may thus be a particularly important process regarding posttraumatic and depressive symptoms in maltreated youth. This is consistent with literature that supports links between trauma exposure, difficulty regulating positive emotions, and psychopathology (22). Weiss et al. (23) found that difficulties regulating positive emotions predicted PTSD symptom severity beyond the variance accounted for by difficulties regulating negative emotions in women victimized by interpersonal violence. Links between suppression of positive emotions and depressive symptoms have also been identified (24). Results are also consistent with broader literature proposing that the effects of expressive suppression are influenced by contextual factors such as the valence or type of emotion being suppressed [e.g., (25)].

Cognitive reappraisal findings were more nuanced, with unexpected positive effects noted especially for males, younger youth, and youth who had not experienced sexual maltreatment. Maltreated youth demonstrate trauma-related neural alterations that may impact their ability to utilize cognitive reappraisal effectively [e.g., (26)]. Younger youth and males are particularly less likely to use reappraisal flexibly and effectively (27, 28). Ineffective use of cognitive reappraisal can negatively impact self-efficacy and psychological well-being (29). However, cognitive reappraisal has been linked to resilience and greater adjustment among survivors of sexual maltreatment, which is well-known to be especially pernicious among types of maltreatment (30).

Findings from the present study may thus have implications for clinical practice. With respect to assessment, the nuanced findings reveal the need to delve more deeply into specific aspects of these mechanisms, perhaps via open-ended interviews, responses to hypothetical vignettes, and emotion regulation tasks to reappraise emotional stimuli (31). With respect to treatment, expressive suppression may be an important part of daily mindfulness and cognitive-behavioral practices to enhance emotional regulation (32, 33). The present study also offers insight into possible intervention targets for maltreated youth.

Results from the present study may also be relevant to diagnostic definitions of complex PTSD, particularly with respect to relational trauma and disturbances in self-organization that include affective dysregulation, negative self-concept, and disturbances in relationships (34). In addition, conceptual frameworks for interpreting complex PTSD often focus on how prolonged traumatic, relational stressors disrupt the brain’s predictive processing capabilities, particularly with respect to negative self-concept, biased perceptions toward self-criticism, and social prediction errors that produce mistrust and withdrawal (35). Indeed, impaired cognitive reappraisal with problems in social functioning relate to specific neural circuitry patterns of emotional regulation in patients with PTSD (36).

Limitations of the study should be noted, including reliance solely on youth self-report, lack of knowledge of concurrent trauma events, presence of multiple traumas in some cases, and varied assessment times following removal from home. Despite these limitations, the present study offers potential directions for further research. Examples include greater investigation of expressive suppression and cognitive reappraisal across specific demographic groups, maltreatment types, trauma profiles, and developmental phases. In addition, integrating expressive suppression and cognitive reappraisal into transdiagnostic models of psychopathology in youth would seem desirable. Of special importance in this regard would be utilizing such models to better understand how interventions specifically work to reduce counterproductive, and to enhance productive, emotional regulation strategies, particularly for highly vulnerable populations such as maltreated youth (37).