Disentangling the mental health impact of childhood abuse and neglect
Introduction
In recent decades, the deleterious effects of maltreatment on child development and wellbeing have been well documented (Cicchetti & Toth, 2005; McCrory, De Brito, & Viding, 2012). Nevertheless, understanding the causes of heterogeneity in individuals’ responses to maltreatment continues to represent an important challenge for researchers and practitioners alike (Afifi & Macmillan, 2011). One factor that may contribute to such individual heterogeneity is the type of maltreatment experienced; that is, whether distinct forms of abuse and neglect are associated with increased risk for specific mental health problems. To date, however, the empirical literature has been largely inconsistent. While a number of studies have reported generic, non-specific associations between types of maltreatment and individual outcomes, including anxiety, depression, suicide risk, rule-breaking and substance use (e.g. Green et al., 2010, Norman et al., 2012; Torchalla, Strehlau, Li, Schuetz, & Krausz, 2012; Vachon, Krueger, Rogosch, & Cicchetti, 2015), others have provided evidence for differential effects, with the most consistent evidence relating to the impact of physical abuse on externalizing difficulties. Specifically, a number of studies based on child and adult populations have reported a unique association between history of physical abuse and multiple outcomes related to externalizing difficulties, including conduct problems, impulsivity, anger, aggression, disruptive and delinquent behaviours as well as number of violent offences committed (Cohen, Brown, & Smailes, 2001; Litrownik et al., 2005; Petrenko, Friend, Garrido, Taussig, & Culhane, 2012; van der Put, Lanctot, de Ruiter, & van Vugt, 2015). Still another set of studies has suggested that the number of maltreatment types experienced – rather than the specific type itself – may be a more informative predictor of mental health outcomes, whereby exposure to a higher number of maltreatment types linearly predicts greater symptom severity (i.e. cumulative effects; Arata, Langhinrichsen-Rohling, Bowers, & O'Brien, 2007; Finkelhor, Ormrod, & Turner, 2007; Finkelhor, Ormrod, & Turner, 2009; Lauterbach & Armour, 2016). As such, it remains unclear whether maltreatment effects are driven by what is common to all maltreatment types (i.e. shared variance) versus what is specific to a particular maltreatment type (i.e. unique variance). Further research is needed to disambiguate these influences, as the presence of differential effects may carry important implications for risk assessment, treatment formulation and the development of more targeted prevention strategies.
Much of what is known regarding maltreatment effects has come from studies that have focused on specific forms of abuse or neglect in isolation. However, it is increasingly evident that maltreatment types are significantly correlated, so that experience of one form of maltreatment increases the likelihood of another one also being experienced (Arata et al., 2007, Herrenkohl and Herrenkohl, 2009, Higgins and McCabe, 2003). Furthermore, available data on prevalence estimates suggests that children often experience multiple forms of maltreatment while growing up (Dong et al., 2004, Finkelhor et al., 2007; Turner, Finkelhor, & Ormrod, 2010). Consequently, a failure to consider all maltreatment types is likely to be problematic and result in an overestimation of effects attributed to individual forms of maltreatment, as it assumes that these forms occur independently from one another (Fallon et al., 2010, Herrenkohl and Herrenkohl, 2009, Higgins and McCabe, 2001). To this end, a growing number of studies have begun to examine multiple forms of maltreatment concurrently (e.g. Lau et al., 2005, Petrenko et al., 2012, Torchalla et al., 2012; Lewis, McElroy, Harlaar, & Runyan, 2016; Lauterbach and Armour, 2016, Villodas et al., 2012). While some consistent findings have emerged, particularly with regards to the unique effect of physical abuse on externalizing difficulties (Cohen et al., 2001, Litrownik et al., 2005, Petrenko et al., 2012, van der Put et al., 2015), evidence of other unique effects has been more equivocal. For example, an independent effect of sexual abuse on internalizing and externalizing problems has been observed in some studies (e.g. Lewis et al., 2016), but not others (e.g. Vachon et al., 2015). In addition to sampling and measurement differences, mixed findings in the literature may stem from considerable variations across studies in factors such as (i) the number of maltreatment types assessed, (ii) the analytical strategy employed, and (iii) the type of covariates included (Arata et al., 2007, Higgins and McCabe, 2001, Petrenko et al., 2012).
Firstly, studies examining multiple forms of maltreatment concurrently have often varied in the number of maltreatment types assessed. While physical and sexual abuse have featured predominantly within these studies, the inclusion of other maltreatment types has been more inconsistent, particularly with regards to emotional abuse. In some cases, emotional abuse has been excluded on the basis that it may be inherent to all other forms of maltreatment and may not represent a unitary construct (e.g. Petrenko et al., 2012). In other cases, emotional abuse has been examined separately and has been found to be a significant independent contributor to mental health difficulties (e.g. Arata et al., 2007). It is important to clarify the nature and scope of effects associated with emotional abuse, particularly as it has been shown to be as a highly prevalent yet often overlooked form of maltreatment (Rees, 2010).
Second, studies have tended to adopt a categorical approach when assessing the relationship between maltreatment types and mental health outcomes. Often individuals are assigned to discrete categories that index different combinations of maltreatment types and groups are then compared in order to test for differential effects. However, the disadvantage of this approach is that it relies extensively on subjective decisions about what methodology to use in order to derive groups (e.g. person-centred latent class analysis, Witt et al., 2016; hierarchical classification, Lau et al., 2005; severity-based classification; Arata et al., 2007), and how many combinations of maltreatment types to include, both issues that may contribute to differences in findings across studies. Furthermore, the use of discrete categories precludes the possibility of establishing whether maltreatment effects are driven by unique or shared variance between maltreatment types. In contrast, regression approaches can be used to isolate the effects of individual maltreatment types, over and above all other forms of maltreatment. To date, however, few studies have made use of this approach to identify differential effects while including all maltreatment types concurrently (e.g. Arata et al., 2007, Torchalla et al., 2012).
Third, existing studies have varied in the number and type of covariates included. While many studies have not examined potential confounds in the association between maltreatment and mental health outcomes (see Higgins & McCabe, 2001; for a review), some have controlled for differences in demographic characteristics, such as participant age and sex (e.g. Taussig, 2002; Sullivan, Fehon, Andres-Hyman, Lipschitz, & Grilo, 2006). Very few studies have adjusted for socio-economic disadvantage, even though maltreatment is known to cluster in geographical areas characterized by increased poverty, also a predictor of poorer mental health outcomes (Evans & Cassells, 2014). In addition, no study to our knowledge has examined the effects of maltreatment types while controlling for other forms of adversity, such as community violence exposure (CVE; Petrenko et al., 2012). CVE may be a particularly important confound as it has been shown to co-occur with maltreatment (Cecil, Viding, Barker, Guiney, & McCrory, 2014), and also increase risk of negative mental health outcomes (Margolin & Gordis, 2000).
To address these research gaps, we aimed to systematically characterize the unique, shared and cumulative effects of maltreatment types on a broad range of mental health domains within a community sample of high-risk youth (age 16–24). Outcomes examined included multi-informant reports of internalizing problems as well as ratings of externalizing difficulties and trauma-related symptomatology. By controlling for demographic characteristics, neighbourhood deprivation and current levels of community violence exposure we excluded the contribution of these possible confounds in all analyses. Based on previous studies, we predicted that maltreatment types would be significantly interrelated and that youth who experienced multiple forms of maltreatment while growing up would show more severe psychiatric symptoms. In addition, we predicted that few differential effects would be evident when all maltreatment types were examined concurrently, but that physical abuse would be independently associated with externalizing difficulties. No a priori hypotheses were made for other differential effects, as the evidence so far has been largely inconsistent regarding unique vs shared associations between other maltreatment types and psychopathological outcomes.
Section snippets
Participants
The present sample comprised of 204 inner-city youth aged 16–24 years (M = 18.85). Multiple recruitment channels were used in order to include individuals with varying exposure to childhood maltreatment. Of the total sample, 48% (n = 98) were recruited from a children’s mental health charity, who provided comprehensive services to vulnerable inner-city youth (typically via self-referral), the majority of whom were exposed to developmental adversity, such as poverty, childhood maltreatment and
Step 1: descriptive statistics
Associations between maltreatment types and study variables. As shown in Table 1, maltreatment types were not significantly associated with participant sex or level of neighbourhood deprivation (IMD), which may in part reflect the fact that, on average, participants resided in impoverished neighbourhoods, compared to the national average (IMD, 2010). Multiple forms of maltreatment were associated with participant age and ethnicity. Of note, physical abuse was associated with lower IQ.
Discussion
The aim of this study was to systematically characterize the unique, shared and cumulative effects of childhood abuse and neglect on young people’s mental health. Strengths include the analysis of quantitative data on a broad range of maltreatment types, (multi-rated) psychiatric outcomes and confounding factors, based on a sample of youth featuring high rates of adversity. Consistent with prior research, we found that maltreatment types were highly interrelated and frequently co-occurred. The
Conflict of interest
None.
Acknowledgements
We would like to thank the young people, teachers and key workers who have taken part in this project. We are grateful to Feras Abo Anour, Jo Guiney and Yvonne Whelan for their valuable help with data collection. This research was supported by Kids Company charity. CC is supported by the Economic and Social Research Council (grant ref: ES/N001273/1). EV is a Royal Society Wolfson Research Merit Award Holder.
References (68)
- et al.
Differential correlates of multi-type maltreatment among urban youth
Child Abuse & Neglect
(2007) - et al.
Differential adult symptomatology associated with three types of child abuse histories
Child Abuse & Neglect
(1990) - et al.
Assessing community violence: The children’s report of exposure to violence
Journal of the American Academy of Child & Adolescent Psychiatry
(1995) - et al.
The interrelatedness of multiple forms of childhood abuse, neglect, and household dysfunction
Child Abuse & Neglect
(2004) - et al.
Methodological challenges in measuring child maltreatment
Child Abuse & Neglect
(2010) - et al.
Poly-victimization: A neglected component in child victimization
Child Abuse & Neglect
(2007) - et al.
Lifetime assessment of poly-victimization in a national sample of children and youth
Child Abuse & Neglect
(2009) - et al.
Multiple forms of child abuse and neglect: Adult retrospective reports
Aggression and Violent Behavior
(2001) - et al.
What’s in a name? A comparison of methods for classifying predominant type of maltreatment
Child Abuse & Neglect
(2005) - et al.
Does the impact of child sexual abuse differ from maltreated but non-sexually abused children? A prospective examination of the impact of child sexual abuse on internalizing and externalizing behavior problems
Child Abuse & Neglect
(2016)