Child Abuse Increases Risk of PTSD in Young Adults

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Researchers in New Zealand have found a link between childhood abuse and mental disorders in young adults. The article by Drs. Scott, Smith, and Ellis was published in the July issue of the Archives of General Psychiatry. The authors analyzed data from a nationally representative community survey of 2144 New Zealanders ages 16 to 27. The survey assessed a variety of anxiety, mood, and substance use disorders during the previous year and in the person's lifetime. National child protection agency records were used to identify the 221 young adults who received services as children due to abuse or neglect (child maltreatment). As is standard for this type of study, the results of the analyses were adjusted for demographic and socioeconomic factors (age, sex, ethnicity, education, & income).

The first set of analyses compared adults with and without child protection service records. Those with a history of child maltreatment had a significantly higher risk of having one or more mental disorders both in the previous year and in their lifetimes. The risk of a mental disorder was highest for Posttraumatic Stress Disorder (PTSD) in the previous year. Those with a history of child maltreatment were 5.12 times more likely to have PTSD. They were also 2.41 times more likely to have an anxiety disorder, a mood disorder (1.86), or a substance use disorder (1.71).

The researchers then repeated their analyses after removing people from the comparison group who reported a history of childhood maltreatment in the survey. The risk of developing a mental disorder went up for most of the disorders, but the greatest increase was in the risk for PTSD in the previous year. Those with a history of child maltreatment were nearly 11 times more likely to have PTSD than the comparison group (10.92). To get a sense of how high that is, compare it to the following statistic from the American Heart Association: "People who smoke a pack of cigarettes a day have more than twice the risk of heart attack than people who’ve never smoked."

Most studies of the effects of child maltreatment and adult mental illness use retrospective reports of child abuse by adults. Retrospective reports may be unreliable for several reasons including memory issues and reluctance to disclose abuse. This study avoids that issue by using prospective records of child abuse and neglect. The authors were also able to show that excluding individuals who retrospectively report abuse (without corroborating records) actually strengthened the relationship between child abuse and later mental illness.

Not surprisingly, the authors conclude that there is a need to provide mental health interventions for maltreated children to prevent or reduce the risk of later mental illness. Their results demonstrate the long-term negative effects of child abuse and neglect on mental health. Consistent with the results of other research with children, and retrospective research with adults, their results show that abused children are at high risk for having PTSD in adulthood.

Scott, K., Smith, D., & Ellis, P. (2010). Prospectively Ascertained Child Maltreatment and Its Association With DSM-IV Mental Disorders in Young Adults Archives of General Psychiatry, 67 (7), 712-719 DOI: 10.1001/archgenpsychiatry.2010.71

Child Abuse is the Primary Cause of Infant Homicides

Child abuse of any sort is difficult to understand, but the homicide of infants by caretakers is beyond most people's imagination. A new study sheds some light on who commits these acts.

Fujiwara, T., Barber, C., Schaechter, J., & Hemenway, D. (2009). Characteristics of Infant Homicides: Findings From a U.S. Multisite Reporting System PEDIATRICS, 124 (2) DOI: 10.1542/peds.2008-3675

The study reports on 72 cases drawn from the National Violent Injury Statistics System. The system was developed to provide detailed information from multiple sources--death certificates, coroner/medical examiner reports, police reports, and crime laboratories--to be used for public health research. The purpose of this study was to describe features of different types of infant homicide (under age 2) to inform prevention efforts.

Three-quarters of infant homicides were due to beating/shaking by a caretaker (Type 1). The perpetrator was most often the father (43%) or the mother's boyfriend (30%). In almost all cases, emergency medical treatment was sought by either the abuser or another household member. The authors conclude that Type 1 homicides are impulsive and largely unintentional in nature. However, in most cases there was evidence of prior physical abuse. Their recommendations for prevention are early identification of child abuse and education directed at male caretakers.

In contrast, most Type 2 homicides were committed by women (69%), were intentional, and no medical treatment was sought. The deaths were related to domestic violence, psychosis, other crime, or occurred within 24 hours of birth. There were too few cases of each kind to draw conclusions useful for prevention. A larger study would be needed.

Of note, nearly half of the Type 1 homicides were caused by shaking. Young adult males with little or no experience can find it difficult to care for a baby that continually cries. Some will shake a baby out of frustration and anger to stop it crying without realizing the damage shaking will cause. Not all shaken babies die, but survivors' injuries may include severe brain damage, blindness, learning disabilities, and physical impairments.

One hospital-based prevention education program directed at both parents has been successful in reducing the number of cases, and the program has been replicated elsewhere (Upstate New York Shaken Baby Syndrome Education Program). The basic elements of this and other prevention education are to raise awareness of injuries caused by shaking and teach caretakers how to soothe a crying baby and cope with their own frustration.

For more information: The National Center on Shaken Baby Syndrome

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This post was featured in Grand Rounds Vol. 5 No. 51, comes to Paramedicine! « Medic999

Ten Common Causes of Child Trauma Due to Violence

I started this post several weeks ago to answer the question "What are the most common causes of child trauma?" It was much harder than I expected. The task of reviewing statistics wasn't just comparing apples to oranges. It was, instead, like comparing the ingredients of a fruit salad. The statistics varied greatly, in part, due to differences in research design:

• Some studies reported how many children experienced traumatic events in one year while others reported lifetime experience (incidence vs prevalence).
• Some included only children or adolescents while others asked adults to report on their entire childhood.
• Most focused on one type of trauma (for example child sexual abuse) rather than a wider range of traumatic experiences.
  
• Most weren't large enough or representative enough of the entire nation to draw firm conclusions. (Unfortunately, few researchers are able to obtain the funding needed to conduct large, representative studies.)
• Those that relied on victim reports to child welfare or law enforcement weren't able to estimate the number of victims who had not reported.
  

There are several ways to estimate how many children have experienced trauma. One way is to ask about a short period of time (incidence) rather than a person's entire childhood (prevalence). Some advantages of this approach is that it relies less on memory, and it is easier to compare different ages. Otherwise, when asked if an event has ever occurred, more teenagers are likely to report an experience than younger children simply because they've had more years for it to have happened.

A disadvantage is that the results do not reflect the full magnitude of a problem which is often better represented by an estimate of prevalence. For example, a familiar childhood statistic such as "one out of four girls experience sexual victimization before age 18" will be higher than the number of girls victimized in one year. Still, the advantages can outweigh the disadvantages when comparing rates across various traumatic experiences within different age groups, and a one-year snapshot of new cases can be more useful for current policy and service delivery.

My list is limited to child trauma caused by violence because there has been more research done for it than for other traumas (such as disaster or accidental injury). I selected a single study that included a wide range of violence-related victimizations by David Finkelhor and colleagues designed to address many of the issues listed above.

Finkelhor, D., Ormrod, R., Turner, H., & Hamby S. L. (2005). The Victimization of Children and Youth: A Comprehensive, National Survey Child Maltreatment, 10 (1), 5-25 DOI: 10.1177/1077559504271287


Their study included:

• a large, nationally representative sample of children ages 2 to 17
• younger children (through interviews with their parents)
  
• a comprehensive list of child abuse and other victimization experiences
• examined the number of victims for each trauma during one year
• relied on direct reports rather indirect statistics collected by reporting agencies
• reported how many children experienced multiple traumas

Of the 34 different direct and indirect victimizations included in the study, I've selected the top ten I believe best fit the criteria needed to diagnose PTSD. I converted population rates (number per 1000) to percentages more familiar to most readers. I've also included the definition of each trauma used in the study.

1. Bullying - 22% - A peer picked on child (for example, by chasing, grabbing hair or clothes, or making child do something he or she did not want to do).

2. Assault with injury - 10% - Someone hit or attacked child, and child was physically hurt when this happened. (Hurt means child felt pain the next day, or had a bruise, a cut that bled, or a broken bone.) No weapon was used.

3. Assault with a weapon - 8% - Someone hit or attacked child on purpose with something that would hurt (like a stick, rock, gun, knife or other thing).

4. Exposure to shooting, bombs, riots - 6%
Child was in a place (in real life) where child could see or hear random shootings, terror bombings, or riots.

5. Non-sexual genital assault - 5% - A peer tried to hurt child's private parts on purpose by hitting or kicking.

6. Robbery by nonsibling- 4% - A nonsibling (peer or adult) used force to take something away from child that child was carrying or wearing.

7. Physical abuse by caregiver - 4%
An adult in child's life hit, beat, kicked, or physically abused child in any way.

8. Witness domestic violence - 4% - Child saw one parent get hit (for example, slapped, hit, punched, or beat up) by another parent, or parent's boyfriend or girlfriend.

9. Sexual assault - 3% - Someone touched child's private parts when unwanted, make child touch their private parts, or forced child to have sex. Or attempted any of these acts.

10. Murder of someone close - 3% - Someone close to child (for example, family member, friend, or neighbor) was murdered.

There are some surprises here. Bullying was the most common. Significant numbers of children in the United States have been exposed to shootings, bombs, or riots. Many children have had someone close to them murdered though perhaps this shouldn't be surprising given the U.S.'s high murder rate.

In this article, I've focused on the number of children in the United States who experience trauma related to violence. In future articles, I will address other forms of child trauma such as disaster or serious accidents. I will also, from time to time, provide an in-depth look at items in the list including what is known about rates of PTSD and other negative consequences.
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This post was featured in Doc Gurley » Grand Rounds, Vol. 5, No. 44: Mystery!

Child Sexual Abuse Fact Sheet

The National Child Traumatic Stress Network recently updated their Child Sexual Abuse Fact Sheet - For Parents, Teachers, and Other Caregivers. It provides an overview of symptoms, disclosure, myths and facts, and safety education.

Myths and Facts

Myth: Child sexual abuse is a rare experience.

Fact: Child sexual abuse is not rare. Retrospective research indicates that as many as 1 out of 4 girls and 1 out of 6 boys will experience some form of sexual abuse before the age of 18. However, because child sexual abuse is by its very nature secretive, many of these cases are never reported.

Myth: A child is most likely to be sexually abused by a stranger.

Fact: Children are most often sexually abused by someone they know and trust. Approximately three quarters of reported cases of child sexual abuse are committed by family members or other individuals who are considered part of the victim’s “circle of trust.”

Prevention Tips for Parents

• Teach children accurate names of private body parts.

• Avoid focusing exclusively on “stranger danger.” Keep in mind that most children are abused by someone they know and trust.

• Teach children about body safety and the difference between “okay” and “not okay” touches.

• Let children know that they have the right to make decisions about their bodies. Empower them to say no when they do not want to be touched, even in non-sexual ways (e.g., politely refusing hugs) and to say no to touching others.

• Make sure children know that adults and older children never need help with their private body parts (e.g., bathing or going to the bathroom).

• Teach children to take care of their own private parts (i.e., bathing, wiping after bathroom use) so they don’t have to rely on adults or older children for help.

• Educate children about the difference between good secrets (like surprise parties—which are okay because they are not kept secret for long) and bad secrets (those that the child is supposed to keep secret forever, which are not okay).

• Trust your instincts! If you feel uneasy about leaving a child with someone, don’t do it. If you’re concerned about possible sexual abuse, ask questions.

Protecting Your Child From Sexual Abuse

There are a multitude of resources for parents on preventing child sexual abuse. Unfortunately, many focus on teaching children about "stranger danger" when in actuality, most abusers are known to children and their families. Many are family members themselves--parents, step-parents, older siblings, cousins, uncles, aunts, and grandparents. Others are trusted adults who take care of children (daycare providers, babysitters) and those who work with children (teachers, coaches, youth ministers, and private music, dance or martial arts instructors).

Most parents assume that professionals who work with children pass background checks. Unfortunately, background checks only pick-up convicted sex offenders or those proven to be abusers by child protective services. Abusers who move from state to state may be missed. Religious institutions, sports leagues, and other private organizations often don't require background checks, and no one monitors private instructors.

Here are two general resources that I particularly like from the National Center for Missing & Exploited Children to help parents protect their children from sexual abuse and exploitation.

Child Protection

Know The Rules...General Tips for Parents and Guardians

Both publications are also available in Spanish. Hard copies can be ordered at 10 cents a piece with the first 50 copies free.

Parenting Tips to Prevent Child Abuse - Your Tax Dollars at Work

If you are still working on your income taxes, and getting frustrated as a result, it might help to consider what your federal and state tax dollars support. One worthwhile endeavor is the efforts of child protective services to investigate and intervene on the behalf of abused and neglected children across the nation. Although we might have different opinions about paying taxes, I don't believe any of us can really argue against the need to fund these services.

In honor of National Child Abuse Prevention Month, let's review the extent and costs of child abuse and neglect in the United States.

(Warning! Statistics ahead, but only a few.)

Extent

In 2006 (the year the most recent statistics are available), 3.3 million reports were made to child protective services of suspected child abuse or neglect on behalf of 6 million children in the United States. As a result of these reports, 905,000 children were determined to have been abused or neglected. Approximately 64% were neglected, 16% were physically abused, 9% were sexually abused, and 7% were emotionally abused or neglected. An estimated 1,530 children died due to abuse or neglect. Child Maltreatment, 2006, Washington,DC: U.S. Department of Health and Human Services, Administration on Children, Youth, and Families, 2008.

Cost

The direct cost of child abuse and neglect in the United States totals more than $33 billion annually. (This figure includes law enforcement, judicial system, child welfare, and health care costs.) After adding in the indirect costs (special education, mental health care, juvenile delinquency, lost productivity, and adult criminality), the amount is more than $103 billion annually. Ching-Tung Wang and John Holton, Total Estimated Cost of Child Abuse and Neglect in the United States, Washington, DC: Prevent Child Abuse America, 2007.

(End of statistics. That wasn't so bad, now was it?)

It's in all our interests to do what we can to prevent child abuse and neglect. The Children's Bureau of the U.S. Dept. of Health and Human Services provides some resources to do so via it's Child Welfare Information Gateway (along with many more statistics for those inclined).

One set of resources for National Child Abuse Prevention Month is a series of tip sheets for parents and caregivers. All six are available in pdf format individually or as a set. They are also available in Spanish. Titles and descriptions follow.

Bonding With Your Baby

Strong bonds between babies and caregivers help babies' bodies and brains grow. This tip sheet helps parents understand normal infant behavior, the importance of nurturing and attachment, and what parents can do to develop strong bonds with their babies.

Dealing With Temper Tantrums

A young child's tantrums can be stressful for parents. This tip sheet helps parents understand why toddlers have tantrums, what they can do to help prevent tantrums, and how to handle them calmly when they occur.

Connecting With Your Teen

Teens are becoming more independent, but they still need their parents' love, support, and guidance. This tip sheet helps parents understand typical teen behavior. It offers suggestions for how parents can use simple, everyday activities to reinforce their connection with their teens and show they care.

Teen Parents ... You're Not Alone!

Being a teen parent is a 24-hour-a-day job and can feel overwhelming at times. This tip sheet reassures teen parents that these feelings are normal. It offers suggestions for reducing stress, improving parenting skills, and finding help when needed.

Ten Ways to Be a Better Dad

Fathers who spend time with their children increase the chances that their children will succeed in school, have fewer behavior problems, and experience better self-esteem. This tip sheet lists 10 concrete ways that fathers can enhance their involvement in their children's lives.

Raising Your Grandchildren

When children can't be with their parents, a grandparent's home can provide stability and comfort. This tip sheet helps grandparent caregivers understand how their grandchildren may be feeling, how to help children feel safe and secure in their home, and where to find support in their community if needed.

These tip sheets are an example of what's known as universal prevention. They are aimed at everyone, not just parents who are at risk to abuse or neglect their children. The idea is to give all parents and caregivers helpful tips to strengthen their parenting skills and their families. Take a look. You may find you already know most of this, but I'll bet there are some you'd like to practice more often with your own children.