Pathways linking childhood maltreatment and adult physical health☆
Introduction
Child maltreatment is a serious public health problem, with nearly 3 million children or 1 child in every 25 in the United States affected in 2005–2006 (Sedlak et al., 2010). A recent community survey involving a large nationally representative sample reported that approximately 32% of girls aged 14–17 had experienced at least 1 form of maltreatment (Finkelhor, Turner, Ormrod, & Hamby, 2009). Several prevalence studies have estimated that between 26% and 32% of women have been sexually abused in the general female population (Briere and Elliott, 2003, Kendler et al., 2000, MacMillan et al., 2001).
A growing body of literature has documented associations between childhood maltreatment and poor physical health in adulthood in both population-based community samples and clinical samples (Goodwin and Stein, 2004, Greenfield, 2010, Wegman and Stetler, 2009). A history of childhood maltreatment is associated with higher rates of medical problems (Sachs-Ericsson et al., 2005, Shaw and Krause, 2002), such as bronchitis and ulcers (Springer, 2009), liver disease (Dong, Dube, Felitti, Giles, & Anda, 2003), poor self-rated health (Bonomi et al., 2007, Thompson et al., 2002), inflammation (Danese, Pariante, Caspi, Taylor, & Poulton, 2007), cardiovascular disease (Batten et al., 2004, Goodwin and Stein, 2004), chronic pain symptoms (Chartier et al., 2007, Davis et al., 2005, Walsh et al., 2007), functional disability (Chartier et al., 2007), and, thus, higher health care utilization in adulthood (Chartier et al., 2007, Walker et al., 1999).
Findings from physiological research suggest that childhood maltreatment may adversely affect the volume and functionality of brain structures including the hippocampus, corpus collosum, and amygdala. Additionally, childhood maltreatment appears to alter neuroendocrinological mechanisms involved in mediating the stress response such as the hypothalamic–pituitary–adrenal axis (Nemeroff, 2004). These early changes predispose vulnerability for developing disorders and health problems in adulthood (Felitti et al., 1998, Hertzman, 1999). Yet, childhood maltreatment may also act indirectly as a catalyst for an array of behavioral, emotional, and social problems that are more proximal causes of morbidity in adulthood (Kendall-Tackett, 2002, Springer, 2009).
To date, only two studies (Chartier et al., 2009, Springer, 2009) have examined the specific mechanisms through which the experience of childhood maltreatment affect adult physical health, and there is limited understanding of the underlying mechanisms linking childhood maltreatment and adult health (Leserman, 2005, Whitaker et al., 2005). Further, previous studies have failed to assess the relative importance of different pathways that may be reciprocally interrelated over time. Given the pervasive effects of child maltreatment across multiple life domains, identifying salient intermediate variables that lie in the causal path between child maltreatment and adult physical health could provide critical points of intervention and, thus, improve prevention efforts aimed at reducing the lifelong burden of childhood maltreatment.
The life-course model provides a framework to understand the link between childhood maltreatment and later adult health by incorporating biological, behavioral and psychosocial pathways operating across an individual's life course in determining adult health (Ben-Shlomo and Kuh, 2002, Braveman and Barclay, 2009). From the life-course model, childhood maltreatment may be linked to adult health through behavioral strategies to cope with maltreatment (i.e., substance use), psychological responses (i.e., depression and anxiety), and subsequent secondary stressors that were triggered by childhood maltreatment (i.e., interpersonal problems; Pearlin, 1989, Springer, 2009), and these various behavioral, psychosocial factors influence health independently, cumulatively, and interactively (Ben-Shlomo and Kuh, 2002, Hertzman, 1999). Converging evidence from prospective and retrospective studies suggests that child maltreatment increases the risk of smoking (Chartier et al., 2009, Spratt et al., 2009), alcohol problems (Gilbert et al., 2009, Horwitz et al., 2001, Lown et al., 2011) and illicit drug use (Min et al., 2007, Widom et al., 2006), all of which have been independently associated with poorer health outcomes (Hall and Degenhardt, 2009, Minnes et al., in press, Nolen-Hoeksema, 2004, Strandberg et al., 2008). Increased risk for developing obesity has also been linked with childhood sexual abuse (Chartier et al., 2009, Noll et al., 2007), physical abuse (Springer, 2009), and neglect (Lissau & Sorensen, 1994). Obesity is a well-known risk factor for poor health and has been related to multiple health problems, poor self-rated health, disability, high emergency department use, high use of health professionals (Chartier et al., 2009) and a variety of medical diagnoses (Springer, 2009).
Childhood maltreatment is also associated with increased exposure to adverse life events, including interpersonal difficulties (Cook et al., 2005), family instability (Collishaw, Dunn, O’Connor, Golding, & the ALSPAC Study Team, 2007), and revictimization (Arata, 2002), all of which contribute to additional ongoing life stress (Pearlin, Schieman, Fazio, & Meersman, 2005). Stress is responsible for the etiology and progression of disease and contributes to overall vulnerability to illness by producing a cascade of neuroendocrine, cardiovascular, and immunological changes (Baum and Posluszny, 1999, Kiecolt-Glazer et al., 2002, McEwen, 1998). Few prior studies have examined how subsequent adverse life events and stressors shape the later physical health consequences of childhood maltreatment. Mental health is another possible pathway through which childhood maltreatment can cause adult health problems. Extensive studies have documented an association between childhood maltreatment and a wide range of psychological symptomatology (e.g., Callahan et al., 2003, Min et al., 2007) and psychiatric disorders (e.g., Bryer et al., 1987, Horwitz et al., 2001, Kendler et al., 2000). Population-based studies reported that depressive symptoms (Springer, 2009) and lifetime occurrence of psychiatric disorders (Chartier et al., 2009, Sachs-Ericsson et al., 2005) substantially explained the effects of childhood maltreatment on various indicators of adult physical health. A review by Kiecolt-Glazer et al. (2002) suggested distress-related immune dysregulation as one core biological mechanism explaining health risks associated with negative emotions.
The purpose of the current study is to examine whether health risk behaviors (obesity, drug dependence, and smoking), adverse life events, and psychological distress explain the link between childhood maltreatment and poor adult health (Fig. 1). Using a community-based sample of minority women with low socio-economic status (SES) and substance use history, our study allows investigation of life-course pathways in an understudied population, complementing previous population-based studies (Chartier et al., 2009, Springer, 2009). Incidence of child maltreatment has been documented to be greater in this low SES, substance using population of women (Kubiak, 2005). In the context of low SES and coincident stressors, long term consequences may be greater as well. By applying the life course model to this more traumatized yet underserved group of women, our study will attempt to identify the salient factors unique to this population which can then be used to develop targeted interventions. In a prior study (Min et al., 2007), we demonstrated that childhood maltreatment was a common correlate explaining the association between psychological distress and substance use in adulthood. We hypothesized that women with more severe childhood maltreatment would be prone to morbid obesity, excessive tobacco use, substance dependence, subjected to more adverse life events, and experience higher levels of psychological distress, with these factors compromising their physical health. We also explored the relative contribution of multiple mediators on physical health, since health risk behaviors, adverse life events, and mental health problems may be reciprocally interrelated over time.
Section snippets
Participants & procedure
This study included 279 women drawn from a cohort recruited at childbirth from a large, urban, county, teaching hospital between September 1994 and June 1996. They were participants in a longitudinal prospective study examining the effects of prenatal cocaine exposure on child development (Singer et al., 2004). Pregnant women considered to be high risk for drug use due to lack of prenatal care, behavior suggesting intoxication, history of involvement with the Department of Human Services, or
Sample characteristics
Participants for the current study were 279 women who were primarily African American (n = 233, 84%) and of low SES (n = 272, 98%), measured by the Hollingshead classification IV and V (Hollingshead, 1957). Thirty-nine percent of the sample (n = 108) had not finished high school, with a mean of 11.8 years of education (SD = 1.5). At the 12 year follow-up, the age ranged from 31 to 54 with a mean age of 40.3 years (SD = 5.3); only a quarter of the sample (n = 67) were married; half (n = 131) were employed;
Discussion
The present study examined multiple pathways underlying the relationship between childhood maltreatment and adult physical health in low SES, primarily African-American, relatively young urban women with a history of substance use. Guided by the life-course model, various indicators of health risk behaviors (BMI, lifetime history of drug dependence, current smoking) and psychosocial stress (adverse life events and psychological distress) were examined separately and simultaneously. Our results
Acknowledgements
Thanks are extended to Adelaide Lang, PhD for reviewing early drafts, and Laurie Ellison, LISW, and Paul Weishampel, MA for research assistance.
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