Does adult attachment style mediate the relationship between childhood maltreatment and mental and physical health outcomes?

Attachment theory has been proposed as one explanation for the relationship between childhood maltreatment and problematic mental and physical health outcomes in adulthood. This study seeks to determine whether: (1) childhood physical abuse and neglect lead to different attachment styles in adulthood, (2) adult attachment styles predict subsequent mental and physical health outcomes, and (3) adult attachment styles mediate the relationship between childhood physical abuse and neglect and mental and physical health outcomes. Children with documented cases of physical abuse and neglect (ages 0-11) were matched with children without these histories and followed up in adulthood. Adult attachment style was assessed at mean age 39.5 and outcomes at 41.1. Separate path models examined mental and physical health outcomes. Individuals with histories of childhood neglect and physical abuse had higher levels of anxious attachment style in adulthood, whereas neglect predicted avoidant attachment as well. Both adult attachment styles (anxious and avoidant) predicted mental health outcomes (higher levels of anxiety and depression and lower levels of self-esteem), whereas only anxious adult attachment style predicted higher levels of allostatic load. Path analyses revealed that anxious attachment style in adulthood in part explained the relationship between childhood neglect and physical abuse to depression, anxiety, and self-esteem, but not the relationship to allostatic load. Childhood neglect and physical abuse have lasting effects on adult attachment styles and anxious and avoidant adult attachment styles contribute to understanding the negative mental health consequences of childhood neglect and physical abuse 30 years later in adulthood.

Intergenerational transmission of child abuse and neglect: real or detection bias?

The literature has been contradictory regarding whether parents who were abused as children have a greater tendency to abuse their own children. A prospective 30-year follow-up study interviewed individuals with documented histories of childhood abuse and neglect and matched comparisons and a subset of their children. The study assessed maltreatment based on child protective service (CPS) agency records and reports by parents, nonparents, and offspring. The extent of the intergenerational transmission of abuse and neglect depended in large part on the source of the information used. Individuals with histories of childhood abuse and neglect have higher rates of being reported to CPS for child maltreatment but do not self-report more physical and sexual abuse than matched comparisons. Offspring of parents with histories of childhood abuse and neglect are more likely to report sexual abuse and neglect and that CPS was concerned about them at some point in their lives. The strongest evidence for the intergenerational transmission of maltreatment indicates that offspring are at risk for childhood neglect and sexual abuse, but detection or surveillance bias may account for the greater likelihood of CPS reports.

Child abuse and neglect and intimate partner violence victimization and perpetration: a prospective investigation.

This paper describes the extent to which abused and neglected children report intimate partner violence (IPV) victimization and perpetration when followed up into middle adulthood. Using data from a prospective cohort design study, children (ages 0-11) with documented histories of physical and sexual abuse and/or neglect (n=497) were matched with children without such histories (n=395) and assessed in adulthood (Mage=39.5). Prevalence, number, and variety of four types of IPV (psychological abuse, physical violence, sexual violence, and injury) were measured. Over 80% of both groups - childhood abuse and neglect (CAN) and controls - reported some form of IPV victimization during the past year (most commonly psychological abuse) and about 75% of both groups reported perpetration of IPV toward their partner. Controlling for age, sex, and race, overall CAN [adjusted odds ratio (AOR)=1.60, 95% CI [1.03, 2.49]], physical abuse (AOR=2.52, 95% CI [1.17, 5.40]), and neglect (AOR=1.64, 95% CI [1.04, 2.59]) predicted increased risk for being victimized by a partner via physical injury. CAN and neglect also predicted being victimized by a greater number and variety of IPV acts. CAN and control groups did not differ in reports of perpetration of IPV, although neglect predicted greater likelihood of perpetrating physical injury to a partner, compared to controls. Abused/neglected females were more likely to report being injured by their partner, whereas maltreated males did not. This study found that child maltreatment increases risk for the most serious form of IPV involving physical injury. Increased attention should be paid to IPV (victimization and perpetration) in individuals with histories of neglect.

Do the long-term consequences of neglect differ for children of different races and ethnic backgrounds?

Scant research has examined how children of different races or ethnic backgrounds manifest consequences of neglect. We examined multiple domains of functioning (academic/intellectual, social/behavioral, and psychiatric), three theories (racial invariance, double jeopardy, and resilience), and potential confounding variables. Children with documented cases of neglect (ages 0-11) and matched controls without such histories were followed up and interviewed in adulthood (N = 1,039). The sample was 47.3% female, 62.4% White, 34.3% Black, and 3.4% Hispanic. Black and White neglected children showed negative consequences for IQ, reading ability, and occupational status compared to controls. Compared to same race and ethnic group controls, neglected White children showed extensive mental health consequences, Black children showed more anxiety and dysthymia, and Hispanic children showed increased risk for alcohol problems. Black and White neglected children differed in risk for violence compared to same race controls: Neglected Black children were arrested for violence two times more often than Black controls, whereas neglected White children were more likely than White controls to report engaging in violence. Findings provide some support for each theory (racial invariance, double jeopardy, and resilience). Understanding the factors that account for similarities and differences in consequences requires further investigation. Implications for research and policy are discussed.

A prospective investigation of physical health outcomes in abused and neglected children: new findings from a 30-year follow-up.

OBJECTIVES: We investigated whether abused and neglected children are at risk for negative physical health outcomes in adulthood. METHODS: Using a prospective cohort design, we matched children (aged 0-11 years) with documented cases of physical and sexual abuse and neglect from a US Midwestern county during 1967 through 1971 with nonmaltreated children. Both groups completed a medical status examination (measured health outcomes and blood tests) and interview during 2003 through 2005 (mean age=41.2 years). RESULTS: After adjusting for age, gender, and race, child maltreatment predicted above normal hemoglobin, lower albumin levels, poor peak airflow, and vision problems in adulthood. Physical abuse predicted malnutrition, albumin, blood urea nitrogen, and hemoglobin A1C. Neglect predicted hemoglobin A1C, albumin, poor peak airflow, and oral health and vision problems, Sexual abuse predicted hepatitis C and oral health problems. Additional controls for childhood socioeconomic status, adult socioeconomic status, unhealthy behaviors, smoking, and mental health problems play varying roles in attenuating or intensifying these relationships. CONCLUSIONS: Child abuse and neglect affect long-term health status-increasing risk for diabetes, lung disease, malnutrition, and vision problems-and support the need for early health care prevention.

The role of childhood neglect and childhood poverty in predicting mental health, academic achievement and crime in adulthood.

This study examines the roles of childhood neglect and childhood poverty (family and neighborhood) in predicting Posttraumatic Stress Disorder (PTSD), Major Depressive Disorder (MDD), academic achievement, and crime in young adulthood. Using existing data from a prospective cohort design study, 1,005 children with documented histories of neglect (N = 507) and matched controls (N = 497) were interviewed in young adulthood (mean age 29). Official criminal histories were also used to assess outcomes. Data were analyzed using logistic and ordinary least squares regressions and hierarchical linear modeling (HLM) to control for neighborhood clustering. Results from HLM revealed that childhood neglect and childhood family poverty uniquely predicted PTSD and adult arrest, MDD was predicted only by childhood family poverty, and a significant interaction between childhood family poverty and childhood neighborhood poverty predicted academic achievement for the control group only. Childhood neglect, childhood family poverty, and childhood neighborhood poverty each contribute to poor outcomes later in life. While interventions should be developed for neglected children to prevent negative outcomes, the current findings suggest that it is also important to consider the ecological context in which these children are growing up.

A prospective examination of service use by abused and neglected children followed up into adulthood.

OBJECTIVE: This study sought to determine whether abused and neglected children are more likely than those without childhood maltreatment to use health and social services as adults and whether psychiatric status mediates or moderates the relationship. METHODS: A prospective cohort design was used. Individuals with documented cases of physical and sexual abuse and neglect (ages 0-10) and nonvictimized children matched on age, sex, and race-ethnicity were interviewed in adulthood (mean age 41 years). Past-year service use (general medical, mental health, substance abuse, and social) was assessed during 2003-2004 interviews (maltreated group, N=458; control group, N=349). Psychiatric status (posttraumatic stress disorder [PTSD], drug abuse, and major depressive disorder) was assessed during 1989-1995 (mean age 29) by structured interview. RESULTS: Individuals with histories of childhood abuse and neglect were significantly more likely than their control group counterparts to use mental health services (odds ratio [OR]=1.60, 95% confidence interval [CI]=1.04-2.45) and social services (OR=2.95, CI=2.19-3.97) in adulthood. Psychiatric status in young adulthood (PTSD and major depressive disorder) partially mediated the relationship between childhood maltreatment and use of mental health services, whereas major depression and drug abuse moderated the relationship between maltreatment and use of any services and general medical services. CONCLUSIONS: In adulthood, individuals with documented histories of childhood abuse and neglect are more likely than persons without such histories to use some types of services, and psychiatric status mediates and moderates these relationships. Findings have implications for the provision of services to persons with childhood abuse and neglect.

A prospective investigation of borderline personality disorder in abused and neglected children followed up into adulthood.

Child abuse has been implicated as a risk factor for borderline personality disorder (BPD), yet few prospective longitudinal studies exist. The current study examined whether 500 individuals with documented cases of childhood physical and sexual abuse and neglect were at elevated risk of BPD in adulthood, compared to 396 demographically similar control children. Results indicated that significantly more abused and/or neglected children overall met criteria for BPD as adults, compared to controls, as did physically abused and neglected children. Having a parent with alcohol/drug problems and not being employed full-time, not being a high school graduate, and having a diagnosis of drug abuse, major depressive disorder, and posttraumatic stress disorder were predictors of BPD and mediated the relationship between childhood abuse/neglect and adult BPD. These results call attention to a heightened risk of BPD in physically abused and neglected children and the need to consider multiple pathways to BPD.

Childhood victimization and lifetime revictimization.

OBJECTIVE: To examine the fundamental hypothesis that childhood victimization leads to increased vulnerability for subsequent (re)victimization in adolescence and adulthood and, if so, whether there are differences in rates of experiencing traumas and victimizations by gender, race/ethnicity, and type of childhood abuse and/or neglect. METHODS: Using a prospective cohort design, participants are individuals with documented cases of childhood physical and sexual abuse and neglect from the years 1967 through 1971 and a matched control group. Both groups were interviewed in-person (mean age 39.5 years) in 2000-2002 using a new instrument to assess lifetime trauma and victimization history. RESULTS: Abused and neglected individuals reported a higher number of traumas and victimization experiences than controls and all types of childhood victimization (physical abuse, sexual abuse, and neglect) were associated with increased risk for lifetime revictimization. Significant group (abuse/neglect vs. control) by gender and group by race/ethnicity interactions were found. Childhood victimization increased risk for physical and sexual assault/abuse, kidnapping/stalking, and having a family friend murdered or commit suicide, but not for general traumas, witnessing trauma, or crime victimization. CONCLUSIONS: These findings provide strong support for the need for early intervention with abused and neglected children and their families to prevent subsequent exposure to traumas and victimization experiences.

Long-term effects of child abuse and neglect on alcohol use and excessive drinking in middle adulthood.

OBJECTIVE: The purpose of this study was to determine the long-term effects of child abuse and neglect on alcohol use in middle adulthood. METHOD: Individuals with documented cases of childhood physical and sexual abuse and/or neglect (n = 500) and matched controls (n = 396) from a metropolitan county in the Midwest were followed and interviewed in middle adulthood. Outcomes were Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, diagnoses of alcohol abuse or dependence in young adulthood (age 29) and excessive drinking in middle adulthood (age 40). RESULTS: Women with documented histories of child abuse or neglect reported higher past-year typical quantity (p < .01) and past-month number of days drinking eight or more drinks (p < .05) than nonabused/nonneglected women. Controlling for parental alcohol/drug problems, the effect of child maltreatment on excessive drinking in middle adulthood was not significant for women. For women, the final structural equation model revealed an indirect path through alcohol diagnosis in young adulthood (p < .05) to excessive drinking in middle adulthood (p < .001) but no direct path from child abuse and neglect to excessive drinking in middle adulthood. For men, there were no significant paths from child abuse and neglect to alcohol diagnosis in young adulthood or excessive drinking in middle adulthood. For men and women, parental alcohol/drug problems had a significant indirect effect on the offspring's drinking in middle adulthood (p < .001) through young adult alcohol diagnosis (p < .001). CONCLUSIONS: Consequences of abuse and neglect persist into middle adulthood for women, through continuation of earlier alcohol problems, suggesting the need for interventions throughout the life course. The influence of parental alcohol and drug problems warrants further attention.

Predictors of resilience in abused and neglected children grown-up: the role of individual and neighborhood characteristics.

PURPOSE: This paper examines individual, family, and neighborhood level predictors of resilience in adolescence and young adulthood and describes changes in resilience over time from adolescence to young adulthood in abused and neglected children grown up. METHOD: We use documented cases of childhood physical and sexual abuse and neglect (n=676) from a Midwestern county area during the years 1967-1971 and information from official records, census data, psychiatric assessments, and self-reports obtained through 1995. Analyses involve logistic regressions, replicated with Mplus to test for possible contextual effects. RESULTS: Almost half (48%) of the abused and neglected children in adolescence and nearly one-third in young adulthood were resilient. Over half of those who were resilient in adolescence remained resilient in young adulthood, whereas 11% of the non-resilient adolescents were resilient in young adulthood. Females were more likely to be resilient during both time periods. Being white, non-Hispanic decreased and growing up in a stable living situation increased the likelihood of resilience in adolescence, but not in young adulthood. Stressful life events and a supportive partner promoted resilience in young adulthood. Neighborhood advantage did not exert a direct effect on resilience, but moderated the relationship between household stability and resilience in adolescence and between cognitive ability and resilience in young adulthood. CONCLUSIONS: Ecological factors appear to promote or interfere with the emergence and stability of resilience following childhood maltreatment.

A prospective investigation of major depressive disorder and comorbidity in abused and neglected children grown up.

CONTEXT: Few prospective longitudinal studies have examined the relationship between abuse or neglect in childhood and depression in adulthood. OBJECTIVE: To determine whether abused and neglected children were at elevated risk of major depressive disorder (MDD) and psychiatric comorbidity, compared with matched control subjects, when followed up into young adulthood. DESIGN: Prospective cohort design study. SETTING: Midwestern metropolitan county area. PARTICIPANTS: Children with substantiated cases of physical and sexual abuse and neglect (before the age of 11 years) from January 1, 1967, to December 31, 1971 (n = 676) were matched based on age, race, sex, and approximate family social class with a group of non-abused and non-neglected children (n = 520) and followed up into young adulthood (mean age, 28.7 years). MAIN OUTCOME MEASURES: Between October 20, 1989, and December 22, 1995, 2-hour in-person interviews were conducted, using the National Institute of Mental Health Diagnostic Interview Schedule, Version III Revised, to determine DSM-III-R MDD and other psychiatric diagnoses. RESULTS: Child abuse and neglect were associated with an increased risk for current MDD (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.06-2.14; P< or=.05) in young adulthood. Children who were physically abused (OR, 1.59; 95% CI, 1.00-2.52; P< or =.05) or experienced multiple types of abuse (OR, 1.75; 95% CI, 1.01-3.02; P< or =.05) were at increased risk of lifetime MDD, whereas neglect increased risk for current MDD (OR, 1.59; 95% CI, 1.10-2.29; P<.01). Childhood sexual abuse was not associated with elevated risk of MDD. Kaplan-Meier age-of-onset curves (log-rank statistic, 4.03; df = 1; P=.04) showed earlier onset of MDD for abused and neglected children compared with controls. Among those with MDD, comorbidity was higher for abused and neglected individuals than for controls. CONCLUSION: These results support the need for clinicians to increase efforts to detect and treat depression in physically abused and neglected children.

Major depression and immunity in alcohol-dependent persons.

UNLABELLED: Altered immunity has been associated with both alcoholism and major depression (MD). We investigated the contribution of MD, as well as alcoholism, to in vitro measures of immunity in inner-city alcohol-dependent (SCID-DSM-III-R) persons and community nonabusers, all otherwise in good health. METHODS: Alcohol-dependent persons at an ambulatory alcohol treatment center who did not abuse other substances were studied along with the comparison sample (total n=122). Enumerative and functional immune measures included leukocyte and lymphocyte subsets, mitogen response, natural killer cell activity (NKCA), and granulocytic phagocytosis. RESULTS: Controlling for alcohol dependence, age, gender, racial background, and medical status, MD was associated with decreased phytohemagglutinin (PHA) responses (p<.03), possibly decreased NKCA (p<.08), and increased circulating monocytes (p<.04). Controlling for MD, age, gender, racial background, and medical status, alcohol dependence was associated with decreased circulating B lymphocytes (p<.02), possibly decreased CD56+ (NK) cells (p<.06), and increased monocytes (p<.04). Responses to concanavalin A and pokeweed mitogen, granulocyte functions, and the composition of other leukocyte and lymphocyte subsets showed no evidence of being associated with MD or with alcoholism (p>.1). Secondary analyses exploring factors such as recent alcohol use, cigarette use, and nutrition suggested that these factors accounted for the altered lymphocyte subsets associated with alcoholism and the possibly decreased NKCA with MD. They did not account for the association of MD with increased monocytes and decreased PHA. DISCUSSION: MD-associated immune changes in alcoholics are modest and consistent with those seen in MD without alcoholism. Some MD- and many alcoholism-associated immune effects appear related to factors such as cigarette use and recent alcohol exposure.

Development and validation of a new instrument to assess lifetime trauma and victimization history.

This article describes a new easy-to-administer and understand, interview-based instrument that systematically and comprehensively assesses a person's Lifetime Trauma and Victimization History (LTVH). The LTVH inquires about 30 traumas and victimization experiences (including general traumas, physical assault/abuse, sexual assault/abuse, kidnapping/stalking, family/friend murdered or committed suicide, witnessed trauma to someone else, and crime victimizations) and age of onset, perpetrator, degree of danger and fear experienced, duration, and frequency of each experience. We present evidence of predictive validity of the LTVH as well as convergent and criterion validity for the child abuse items using information from individuals with documented histories of child abuse and neglect and matched comparisons (without documented histories of childhood victimization). The 896 individuals (mean age = 39.5 years) reported 11,850 traumas or victimization experiences. The LTVH demonstrates good predictive, criterion-related, and convergent validity and a high level of agreement between earlier and current reports of certain types of traumas.

Reactions to research participation in vulnerable subgroups.

This paper describes the extent to which vulnerable individuals (defined by economic, social, psychological, physical health, and child maltreatment status) react to research participation. As part of an ongoing longitudinal study, participants (N=896) completed a lengthy and intrusive in-person interview and provided a small amount of blood through finger pricks. At the end of the interview, participants were asked eight questions about their reactions to the research experience. Vulnerable individuals in general agreed more strongly about having an emotional reaction, but were not less willing to continue to participate. In addition, psychologically vulnerable individuals more strongly agreed they would continue to participate, were treated with respect and dignity, and found their participation meaningful. Compared to whites, nonwhites reported stronger agreement about the meaningfulness of the research and the belief that their responses would be kept private. Like others, individuals vulnerable by virtue of their prisoner status or homelessness (past or current) agreed more strongly about having an emotional reaction to the interview, but otherwise did not differ in their reactions. These results suggest that researchers and institutional review boards should not be deterred from conducting research on sensitive topics with potentially vulnerable populations.

Emotional abuse in children: variations in legal definitions and rates across the United States.

Child emotional abuse has an intangible quality that has resulted in confusion regarding both medical and legal definitions. This retrospective review of emotional, physical, sexual abuse, and neglect rates reported by the National Center for Child Abuse and Neglect Data System revealed a 300-fold variation in the rate of emotional abuse across state boundaries. By contrast, the rates of physical and sexual abuses, which are much easier to define, were significantly more consistent. To better understand the potential reasons for the unique variability of emotional abuse, an analysis of sociodemographic factors was performed and no correlations were found. However, a systematic review of state laws on child emotional abuse revealed that states having inclusive civil and/or inclusive caretaker culpability statutes were more likely to report higher rates of child emotional abuse. This study supports a need for child maltreatment researchers and advocates to develop clear consensus definitions to aid the legal community in adopting uniform inclusive statutes to protect children from emotional abuse.