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Description of the MUSP Cohort

Inclusion criteria for original research publications, quality of supporting literature, predictors: maltreatment types, ethical approval, prevalence and co-occurrence of maltreatment subtypes, cognition and education outcomes, psychological and mental health outcomes, addiction and substance use outcomes, sexual health outcomes, physical health, magnitude of effects, abuse, neglect, and cognitive development, psychological maltreatment: emotional abuse and/or neglect, sexual abuse, physical abuse, limitations, conclusions, long-term cognitive, psychological, and health outcomes associated with child abuse and neglect.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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Lane Strathearn , Michele Giannotti , Ryan Mills , Steve Kisely , Jake Najman , Amanuel Abajobir; Long-term Cognitive, Psychological, and Health Outcomes Associated With Child Abuse and Neglect. Pediatrics October 2020; 146 (4): e20200438. 10.1542/peds.2020-0438

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Video Abstract

Potential long-lasting adverse effects of child maltreatment have been widely reported, although little is known about the distinctive long-term impact of differing types of maltreatment. Our objective for this special article is to integrate findings from the Mater-University of Queensland Study of Pregnancy, a longitudinal prenatal cohort study spanning 2 decades. We compare and contrast the associations of specific types of maltreatment with long-term cognitive, psychological, addiction, sexual health, and physical health outcomes assessed in up to 5200 offspring at 14 and/or 21 years of age. Overall, psychological maltreatment (emotional abuse and/or neglect) was associated with the greatest number of adverse outcomes in almost all areas of assessment. Sexual abuse was associated with early sexual debut and youth pregnancy, attention problems, posttraumatic stress disorder symptoms, and depression, although associations were not specific for sexual abuse. Physical abuse was associated with externalizing behavior problems, delinquency, and drug abuse. Neglect, but not emotional abuse, was associated with having multiple sexual partners, cannabis abuse and/or dependence, and experiencing visual hallucinations. Emotional abuse, but not neglect, revealed increased odds for psychosis, injecting-drug use, experiencing harassment later in life, pregnancy miscarriage, and reporting asthma symptoms. Significant cognitive delays and educational failure were seen for both abuse and neglect during adolescence and adulthood. In conclusion, child maltreatment, particularly emotional abuse and neglect, is associated with a wide range of long-term adverse health and developmental outcomes. A renewed focus on prevention and early intervention strategies, especially related to psychological maltreatment, will be required to address these challenges in the future.

Child maltreatment is a major public health issue worldwide, with serious and often debilitating long-term consequences for psychosocial development as well as physical and mental health. 1   In the United States alone, 3.5 million children are reported for suspected maltreatment each year, with an annual substantiated maltreatment rate of 9.1 per 1000 children. 2   Some of the long-term adverse outcomes associated with maltreatment include cognitive disability, anxiety and depression, psychosis, teen-aged pregnancy, addiction disorders, obesity, and cardiovascular disease. 3   Understanding the distinctive impact of differing types of maltreatment may help medical professionals provide more wholistic care and treatment recommendations as well as identify more specific public health targets for primary prevention.

Unfortunately, however, little is known about the long-term effects of differing types of child maltreatment, which include sexual abuse, physical abuse, emotional abuse, and neglect. 4   According to a meta-analysis review, 5   research on child maltreatment has predominantly been focused on sexual abuse, with far less attention paid to psychological maltreatment (emotional abuse and/or neglect) and the co-occurrence of different types of maltreatment. In addition, most of the current evidence is derived from cross-sectional studies, which may be subject to recall bias, 6 – 8   in which an outcome status (such as depression) may influence recall of the exposure (ie, previous maltreatment). Few previous studies have adequately controlled for confounding variables, such as perinatal risk, socioeconomic adversity, parental psychopathology, and impaired early childhood development, which may predispose to both child maltreatment and later adverse health outcomes.

Longitudinal studies offer evidence that is more robust, but these studies are relatively few in number and have generally been limited to certain sociodemographic groups 9   or to specific types of child maltreatment, such as sexual abuse. 1 , 10   Other longitudinal studies have relied on retrospective recall of maltreatment rather than prospectively collected agency-reported data. 11 – 13   In studies in which prospective data have been collected, 7 , 13 – 17   only a few have compared different types of child maltreatment. 7 , 16 , 17  

In this special article, we review findings from the Mater-University of Queensland Study of Pregnancy (MUSP), a now 40-year longitudinal prenatal cohort study from Brisbane, Australia, involving >7000 women and their children. 18   Unique features of the MUSP include its use of a population-based sample, its use of prospectively substantiated child maltreatment reports, and its consideration of different subtypes of maltreatment. In addition, the study design controlled for a wide range of confounders and covariates, including both maternal and child sociodemographic and mental health variables. This combined body of work, which includes numerous publications over the past decade, has documented a broad range of adverse outcomes associated with child maltreatment, including deficits in cognitive and educational outcomes 19 – 21   ; mental health problems, such as anxiety, depression, posttraumatic stress disorder (PTSD), psychosis, delinquency, and intimate partner violence (IPV) 22 – 25   ; substance abuse and addiction 26 – 30   ; sexual health problems 31   ; physical growth and health deficits 32 – 35   ; and overall decreased quality of life. 36  

Our purpose for this special article is to compare the effects of 4 differing types of maltreatment on long-term cognitive, psychological, addiction, and health outcomes assessed in the offspring at ∼14 and/or 21 years of age. Rather than providing a systematic review or meta-analysis of the current literature, which would include diverse study designs and purposes, we report and compare the findings of individual articles that used a common data set and standard methodology to study a broad array of outcomes. We particularly highlight the long-term impact of emotional abuse and neglect, which has received far less attention in the literature.

Between 1981 and 1983, 8556 consecutive pregnant women who attended their first prenatal clinic visit at the Mater Mothers’ Hospital in Brisbane, Australia, agreed to participate ( Fig 1 ). After excluding mothers who did not deliver a singleton infant at the Mater Mothers’ Hospital or withdrew consent, the MUSP birth cohort consisted of 7223 mother-infant dyads, who were followed over 2 decades: at 3 to 5 days, 6 months, 5 years, 14 years and 21 years. Midway through the study, this rich data set was anonymously linked to state reports of child abuse and neglect, which identified some form of suspected maltreatment in >10% of cases. 37   Notified cases, which had been referred from the community or by general medical practitioners, were investigated by the Queensland government child protection agency. Substantiated maltreatment was determined after a formal investigation when there was “reasonable cause to believe that the child had been, was being, or was likely to be abused or neglected.” 38   Substantiated maltreatment occurred when a notified case was confirmed for (1) sexual abuse, “exposing a child to or involving a child in inappropriate sexual activities”; (2) physical abuse, “any non-accidental physical injury inflicted by a person who had care of the child”; (3) emotional abuse, “any act resulting in a child suffering any kind of emotional deprivation or trauma”; or (4) neglect, “failure to provide conditions that were essential for the healthy physical and emotional development of a child,” which encompassed physical, emotional and medical neglect. 37  

Overview of the MUSP enrollment and testing.

We searched PubMed from inception to April 2020 for published MUSP articles in which agency-reported child maltreatment was evaluated as the predictor of a range of outcomes. Studies needed to meet the following criteria for inclusion in the review: (1) notified or substantiated abuse and neglect was listed as a main predictor variable and (2) outcomes included standardized measurements of cognitive, psychological, behavioral, or health functioning. From ∼340 published MUSP studies, we identified 24 articles dealing with child maltreatment, of which 21 included state-reported maltreatment versus self-reported maltreatment data ( n = 3). Nineteen of the 21 articles met all inclusion criteria and were evaluated in this review ( Fig 2 ). One study was excluded because it only examined outcomes associated with sexual abuse. 8   Another article was excluded because its outcome measures were similar to another included study. 29  

Published studies from the Mater-University of Queensland Study of Pregnancy, linking long-term outcomes with specific maltreatment subtypes (adjusted coefficients or odds ratios ± 95% confidence intervals). CES-D, Center for Epidemiologic Studies–Depression Scale; CI, confidence interval; N , number of offspring in sample; N (Mal) , number of offspring who experienced maltreatment. a In different articles adjusting for co-occurrence of maltreatment subtypes was handled in different ways: (1) statistical adjustment: each maltreatment subtype predictor was statistically adjusted for the other maltreatment subtypes (eg, neglect was adjusted for the occurrence of physical, sexual, and emotional abuse) and is reflected in the table’s odds ratios and coefficients; (2) exclusive categories: different combinations of maltreatment types are included in mutually exclusive groups (eg, physical abuse only, physical abuse and emotional abuse only, physical and emotional abuse and neglect [without sexual abuse], etc; see Table 1 ); (3) nonexclusive categories: maltreatment categories may overlap with other categories (eg, any substantiated abuse [sexual, physical, or emotional] versus any substantiated neglect); and (4) none: no statistical adjustments or combined categories were presented for co-occurring maltreatment subtypes. b Adjusted coefficients (95% CI) were reported as statistical association measures rather than adjusted odds ratios. c Cases of notified (rather than substantiated) maltreatment. In the study by Mills et al, 26   a sensitivity analysis was performed after exclusion of unsubstantiated cases of maltreatment. The associations between any maltreatment and substance use were similar to those seen in the original analysis after full adjustment. d Medium effect size, based on magnitude of the adjusted odds ratio (2 ≤ odds ratio ≤ 4). e Large effect size, based on magnitude of the adjusted odds ratio (odds ratio > 4).

Each of the reviewed articles followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for the conduct of cohort studies. 41   The quality of the studies was also evaluated by using a modified version of the Newcastle-Ottawa Scale, which is used to assess the following domains: sample representativeness and size, comparability between respondents and nonrespondents, ascertainment of outcomes, and statistical quality. 42   On the basis of this assessment, all of the MUSP studies were determined to be of low risk of bias, with a score of 4 out of 5 points ( Supplemental Information ).

In all but 2 studies (which used notified maltreatment 21 , 26   ) events were dichotomized and coded as substantiated maltreatment versus no substantiated maltreatment. According to a validated classification of maltreatment types, 43   specific categories and co-occurring forms of childhood maltreatment 44   were used to predict outcomes. In 2 studies, 19 , 20   all types of abuse were combined into 1 category and compared to neglect, whereas in another study, sexual abuse was compared to any combination of nonsexual maltreatment. 21   In 2 other studies, 26 , 40   emotional abuse and neglect (examples of psychological maltreatment) were combined, partly because of overlapping definitional constructs from the government child protection agency (emotional abuse included “emotional deprivation,” and neglect included the failure to provide for “healthy…emotional development”). In all but 2 of the included articles, 25 , 33   co-occurrence of different types of maltreatment was considered, either by examining specific combinations of maltreatment types (in exclusive or nonexclusive overlapping categories) or by statistically adjusting for all remaining types of maltreatment ( Fig 2 ).

All of the odds ratios, mean differences, or coefficients were adjusted for potential confounding variables ( Fig 3 ). All articles adjusted for a variety of sociodemographic variables, such as age, race, education, income, and marital status. Perinatal and/or childhood factors, such as birth weight, gestational age, and breastfeeding status, were used as covariates, particularly in articles in which cognitive and educational outcomes were examined. Psychological and mental health variables (such as internalizing and externalizing behavior problems, maternal depression, chronic stress, or exposure to violence) were primarily included as covariates in mental health outcome studies, especially for psychosis. Addiction studies adjusted for youth and maternal alcohol or tobacco use, among other covariates, and physical health outcome studies adjusted for relevant covariates (such as BMI in a study of dietary fat intake and parental height when studying offspring height). In selected articles, maltreatment subtypes were also statistically adjusted for the other types of maltreatment to determine independent effects.

Covariates used in published articles from the MUSP to adjust for possible confounding. a Race: child’s race, parental race, and maternal or paternal racial origin at pregnancy. b Child age: child age and gestational age. c Maternal age: maternal age at the first visit clinic or at pregnancy. d Maternal education: maternal education (prenatal or at birth). e Family income: annual family income, familial income over the first 5 years or family poverty before birth or over the first 5 years of life, family income before birth, and annual family income. f Maternal marital status and social support: same partner at birth and 14 years and social support at 5 years. g Maternal depression: maternal depression during pregnancy, 3- to 6-month follow-up, or 21-year follow-up; chronic maternal depression. h Maternal alcohol use: maternal alcohol use at 3- to 6-month or 14-year follow-up and binge drinking. i Maternal cigarette use: cigarette use during pregnancy, 6 months postpartum, or at 14-year follow-up. ADHD, attention-deficit/hyperactivity disorder; CES-D, Center for Epidemiologic Studies–Depression Scale; IPV, intimate partner violence. Covariates used in published articles from the MUSP to adjust for possible confounding.

A total of 46 outcomes were assessed at 14 years ( n = 5200) and/or 21 years ( n = 3778) ( Fig 1 ) and were grouped into 5 domains ( Fig 2 ):

Cognition and education outcomes included reading ability and perceptual reasoning measured in adolescence, and, at age 21, receptive verbal intelligence and failure to complete high school or be either enrolled in school or employed; attention problems were measured at both time points.

Psychological and mental health outcomes at 21 years included internalizing and externalizing behavior problems (which were also assessed at 14 years), lifetime anxiety disorder, depressive disorder and symptoms, PTSD, lifetime psychosis diagnosis, psychotic symptoms (such as delusional experience or visual and/or auditory hallucinations), delinquency, experience of IPV or harassment, and overall quality of life.

Addiction and substance use, measured at both time points, included alcohol and cigarette use at 14 and 21 years, and cannabis abuse and/or dependence (including early onset) and injecting-drug use at the 21-year follow-up.

Sexual health was investigated at age 21 in terms of early initiation of sexual experience, having multiple sexual partners, youth pregnancy, and miscarriage or termination.

Physical health outcomes measured at 21 years included symptoms of asthma, high dietary fat intake, poor sleep quality, and height deficits.

The 14-year assessments included a youth questionnaire ( n = 5172) and in-person cognitive testing ( n = 3796). The 21-year visit included an in-person assessment of mental health diagnoses in a subset of the cohort ( n = 2531) with the World Health Organization Composite International Diagnostic Interview (CIDI), which is based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria 45   ( Fig 1 ). All of the questionnaire and interview measures were validated, except for reported frequencies of specific events (ie, pregnancy, number of cigarettes, etc).

Associations were described by using either adjusted odds ratios or mean differences and coefficients, along with the corresponding 95% confidence intervals, and were plotted to visualize and compare the statistical significance of each association across specific outcome categories and types of maltreatment ( Figs 4 – 8 ).

Child maltreatment and cognition and educational outcomes at 14 and 21 years. A, Adjusted coefficients ± 95% confidence intervals. B, Odds ratios ± 95% confidence intervals. * P < .05.

Child maltreatment and psychological and mental health outcomes at 14 and 21 years. A, Adjusted coefficients ± 95% confidence intervals. B, Odds ratios ± 95% confidence intervals. * P < .05.

Child maltreatment and addiction and substance use outcomes at 14 and 21 years (adjusted odds ratio ± 95% confidence interval). * P < .05.

Child maltreatment and sexual health outcomes at 21 years (adjusted odds ratio ± 95% confidence interval). * P < .05.

Child maltreatment and physical health outcomes at 21 years. A, Adjusted odds ratio ± 95% confidence interval. B, Adjusted coefficients ± 95% confidence interval. * P < .05.

The MUSP was approved by the Human Ethics Review Committee of The University of Queensland and the Mater Misericordiae Children’s Hospital. Ethical approval was obtained separately from the Human Ethics Review Committee of The University of Queensland for linking substantiated child maltreatment data to the 21-year follow-up data.

In this cohort of 7214 children ( Fig 1 ), 7.1% ( n = 511 children) experienced at least 1 episode of substantiated maltreatment. Substantiated sexual abuse was reported in 2.0% ( n = 147), physical abuse in 4.0% ( n = 287), emotional abuse in 3.7% ( n = 267), and neglect in 3.7% of cases ( n = 269) ( Table 1 ). Almost 60% of the children with substantiated maltreatment had multiple substantiated episodes (293 children; range: 2–14 episodes per child; median: 3 episodes per child 37   ). Of the 3778 young adults included in the 21-year follow-up, 4.5% ( n = 171) had a history of substantiated maltreatment, 39   including sexual abuse ( n = 53), physical abuse ( n = 60), emotional abuse ( n = 71), and neglect ( n = 89).

More than half of the children who experienced substantiated maltreatment were reported for ≥2 co-occurring maltreatment types ( Table 1 ). Of the substantiated sexual abuse cases, 57.1% of the children experienced ≥1 additional maltreatment types (84 of 147); for physical abuse, this proportion was 79.1% (227 of 287); for emotional abuse, 83.5% (223 of 267); and for neglect, 73.6% (198 of 269). In particular, emotional abuse and neglect co-occurred, with or without other types of maltreatment, in ∼59% of cases. 46  

Nonexclusive and Exclusive Categorization of Child Maltreatment Subtypes (Single and in Combination) Within the MUSP Cohort

Abuse (a combined category) and neglect were both associated with significantly lower cognitive scores at both 14 and 21 years, as well as with negative long-term educational and employment outcomes in young adulthood. 19 , 20   This was after adjusting for factors such as the child’s race, sex, birth weight, breastfeeding exposure, and age; family income; and maternal education and alcohol and/or tobacco use ( Fig 3 ). Specifically, proxy measures of IQ, such as reading ability and perceptual reasoning, at age 14 years were adversely associated with both substantiated abuse and neglect. 19   Sexual abuse was associated with attention problems in adolescence, whereas nonsexual maltreatment was associated with attention problems at both time points. 21   Young adults who experienced substantiated child maltreatment had reduced scores on the Peabody Vocabulary Test at 21 years. In terms of educational outcomes in young adulthood, both abuse and neglect manifested a threefold to fourfold increase in odds of failing to complete high school and a twofold to threefold increase in the likelihood of being unemployed at age 21 years 20   ( Figs 2 and 4 ).

During adolescence, physical abuse, emotional abuse, and neglect were all significantly associated with both internalizing and externalizing behavior problems, although this was not the case for physical abuse notifications without co-occurring emotional abuse or neglect. 22   After adjustment for relevant sociodemographic variables, the associations with emotional abuse and neglect remained significant at 21 years. 39   No statistically significant association was found between sexual abuse and these behavior problems at either time point.

Psychological maltreatment in childhood was associated with all of the other 15 psychological and mental health outcomes in young adulthood, except for delinquency in women. This was true after adjustment for sociodemographic variables and psychological and mental health problems (such as attention-deficit/hyperactivity disorder, aggressive behavior problems, and maternal depression or adverse life events, in the case of psychosis and/or IPV exposure outcomes) ( Fig 3 ). Specifically, both emotional abuse and neglect were significantly associated at 21 years with all of the following outcomes: anxiety, depression, PTSD, psychosis (with some exceptions), delinquency in men, and experiencing IPV and harassment (except for neglect). 22 – 25 , 39   Emotional abuse and neglect were the only maltreatment subtypes associated with a significant decrease in quality-of-life scores. 36  

The only mental health outcomes associated with sexual abuse were clinical depression, lifetime PTSD, and experiencing physical IPV. 8 , 25 , 39   Physical abuse was associated with externalizing behavior problems and delinquency (in men), internalizing behavior problems and depressive symptoms, experience of IPV, and PTSD 22 , 24 , 25 , 39   ( Figs 2 and 5 ).

Overall, emotional abuse and/or neglect were associated with all categories of substance use and addiction at both 14 and 21 years, whereas physical and sexual abuse were associated with surprisingly few substance abuse outcomes. Specifically, childhood emotional abuse and neglect were associated with adolescent substance use at age 14, including alcohol use and smoking. 26   This was after adjustment for sociodemographic factors and youth and maternal drug use. The association with cigarette and alcohol use persisted from adolescence to adulthood. The category of "any cigarette use" was the only addiction outcome associated with all 4 types of maltreatment. 40   At 21 years, emotional abuse and neglect were both associated with the early onset of cannabis abuse after adjustment for maternal stress and cigarette use. Additionally, physical abuse, emotional abuse, and neglect all revealed increased odds of cannabis dependence at age 21, with early onset associated with physical abuse and neglect. 28   In contrast, only emotional abuse significantly predicted injecting-drug use in young adult men, after adjustment for maternal alcohol use and depression, whereas all types of substantiated childhood maltreatment were associated with injecting-drug use in women. 27   Sexual abuse was not associated with any addiction or substance use outcome except for cigarette use at 21 years ( Figs 2 and 6 ).

All forms of maltreatment were significantly associated, at 21 years, with early onset of sexual activity and subsequent youth pregnancy. This was after adjustment for factors such as gestational age, youth psychopathology, and drug use. Neglect was the only type of maltreatment associated with having multiple sexual partners and was the maltreatment type most strongly associated with most other sexual health outcomes, especially youth pregnancy. Pregnancy miscarriage was modestly associated with emotional abuse, whereas termination of pregnancy was not associated with any maltreatment subtype 31   ( Figs 2 and 7 ).

Reduced adult height at 21 years, adjusted for parental height, was associated with all maltreatment subtypes except sexual abuse (which was not associated with any of the physical health outcomes). At 21 years, physical abuse was also associated with high dietary fat intake, a risk factor for obesity (adjusted for BMI), and poor sleep quality in men (adjusted for psychopathology and drug use). Asthma at 21 years revealed a modest association with emotional abuse. The combined category of any maltreatment was also associated with high dietary fat intake ( Figs 2 and 8 ).

To estimate the magnitude of potential effects of child maltreatment on long-term outcomes, other studies have used a number of statistical techniques. In one Australian study that used the MUSP and other data sets, the population attributable risk of child maltreatment causing anxiety disorders in men and women, was estimated to be 21% and 31%, respectively, and 16% and 23% for depressive disorders. 46   Similarly, in the MUSP study on cognitive and educational outcomes of maltreated youth, the population attributable risk of child maltreatment leading to “failure to complete high school” was 13%, and 14% for “failure to be in either education or employment at 21 years.” 20  

Based on one published metric of effect size using the magnitude of the adjusted odds ratio, 47   77% of the statistically significant associations in this review were considered to have a medium to large effect size (odds ratio ≥2), including 10% with a large effect size (odds ratio >4) ( Fig 2 ).

In summary, over the past decade, the MUSP has revealed that child maltreatment is associated with a broad array of adverse outcomes during adolescence and young adulthood, including the following:

deficits in cognitive development, attention, educational attainment, and employment;

serious mental health problems, including anxiety, depression, PTSD, and psychosis, as well as delinquency and the experience of IPV;

substance use and addiction problems;

sexual health problems; and

physical health limitations and risk.

These results were seen after adjustment for a broad range of relevant sociodemographic, perinatal, psychological, and other risk factors ( Fig 3 ). Many of the studies also adjusted for the other subtypes of child maltreatment and demonstrated that specific maltreatment types were closely associated with particular outcomes.

Significant cognitive delays and educational failure were seen for both abuse and neglect across adolescence and adulthood. In another study, the authors concluded that preexisting cognitive impairments at 3 or 5 years may explain this association, rather than maltreatment per se. 16   However, other research has revealed that children neglected over the first 4 years of life show a progressive decline in cognitive functioning, which is associated with a significantly reduced head circumference at 2 and 4 years of age. 48   In rodent models, contingent maternal behavior is linked with infant cognitive development, and possible mechanisms include increases in synaptic connections within the hippocampus 49   and reduced apoptotic cell loss. 50   Prolonged maternal separation, in contrast, is associated with impaired cognitive development in rodent and primate models. 51 , 52  

One of the most striking conclusions from this review was the broad association between emotional abuse and/or neglect and adverse outcomes in almost all areas of assessment ( Fig 2 ). In stark contrast, physical abuse and sexual abuse were associated with far fewer adverse outcomes. Overall, quality of life was lower for those who had experienced emotional abuse and neglect but not for those who had experienced physical or sexual abuse. Although emotional abuse and neglect often co-occur with other types of maltreatment, 46   the associated outcomes were generally robust even after statistical adjustment or separation into differing maltreatment categories ( Fig 2 ).

Emotional abuse and neglect in early childhood may lead to psychopathology via insecure attachment, 53 , 54   which has been associated with externalizing behavior problems 55   and impaired social competence. 56 , 57   Emotional neglect, in particular, may lead to deficits in emotion recognition and regulation, as well as insensitivity to reward, 3   potentially influencing social and emotional development. Neglected children are less able to discriminate facial expressions and emotions, 58   whereas youth who have been emotionally neglected show blunted development of the brain’s reward area, the ventral striatum. 59   Reduced reward activation may predict risk for depression, 59   addiction, 60   and other psychopathologies. 61  

Neglect was also associated with the early onset of sexual activity, multiple sexual partners, and youth pregnancy, even after adjustment for other maltreatment subtypes. This suggests that neglect may result in compensatory efforts to obtain sexual intimacy, consistent with other studies revealing higher rates of unprotected sex 62   and adolescent pregnancy in neglected children. 63   In the animal literature, female rodents that experience maternal deprivation tend to have an earlier onset of puberty and increased sexual receptivity, leading to elevated reproductive activity to help offset an environment of higher offspring risk. 64 , 65  

As observed elsewhere, 66   sexual abuse was associated with early sexual experimentation and youth pregnancy as well as symptoms of PTSD and depression. Risky sexual behaviors were independent of other types of maltreatment but were not specific for sexual abuse. An additional MUSP study comparing self-reported and agency-notified child sexual abuse revealed consistent associations with major depressive disorder, anxiety disorders, and PTSD. 8   The absence of associations with other adverse outcomes, however, may be, in part, due to the lower prevalence of substantiated sexual abuse, especially at the 21-year follow-up.

Outcomes associated with physical abuse differed from those associated with sexual abuse, with increased odds of externalizing behavior problems, and delinquency in men. Jaffee 3   suggests that physical abuse, in particular, may lead to a hypervigilance response to threat, including negative attentional bias, disproportionate to relatively mild threat cues. Studies have revealed that physically abused children show selective attention to anger cues, 67   have difficulty disengaging from them, 58 , 68   and are more likely to misinterpret facial cues as being angry or fearful. 69  

Although these studies demonstrated significant associations between maltreatment and a range of long-term outcomes, association does not equal causality. The causal mechanisms proposed above are tentative and may relate to multiple types of maltreatment.

Other limitations should also be considered. Firstly, selective attrition of socioeconomically disadvantaged and maltreated young people was evident in the MUSP cohort ( Supplemental Information ). However, based on multiple imputation calculations and inverse probability weighting of MUSP data, 18 , 70   differences in the rate of loss to follow-up, for both dependent and independent variables, made little difference to either the estimates or their precision, mirroring findings from other longitudinal studies. 71   In addition, the findings were mostly unchanged when using propensity analysis, which is used to assess the effects of nonrandom sampling variation by analyzing the probability of assignment to a particular category within an observational study given the observed covariates. 72   Specifically, the sample was weighted so that it better resembled sociodemographic characteristics at baseline to minimize bias from differential attrition in those with greater socioeconomic disadvantage.

Secondly, differences in the prevalence of specific maltreatment subtypes might have influenced the statistical power to detect true effects, particularly regarding sexual abuse ( Table 1 ).

Finally, the co-occurrence of different types of maltreatment may have impacted the ability to accurately predict the associations between specific types of maltreatment and outcomes. Other studies have revealed that emotional abuse and neglect, in particular, are more likely to co-occur with each other and with other types of maltreatment. 73   However, even in those articles that statistically adjusted for other co-occurring maltreatment subtypes, the associated outcomes linked with emotional abuse and/or neglect were generally robust. In articles that did not adjust for these co-occurrences, some of the strongest associations were still observed for emotional abuse and/or neglect.

Child maltreatment, particularly psychological maltreatment, is associated with a broad range of negative long-term health and developmental outcomes extending into adolescence and young adulthood. Although these data do not establish causality, neurodevelopmental pathways are likely influenced by stress and early social experience through epigenetic mechanisms, which may affect gene expression and regulation and, ultimately, behavior and development. 3 , 74  

Understanding the developmental roots of these adverse outcomes may motivate physicians to more systematically inquire about early-life trauma and refer patients to more appropriate treatment services. 75 , 76   Even more importantly, early intervention and prevention programs, such as prenatal and infancy nurse home visiting, 77   have demonstrated, in randomized clinical trials, diminished rates of child abuse and neglect. 78 , 79   Long-term benefits to the offspring include decreased childhood internalizing problems, 80   reduced antisocial behavior and substance abuse in adolescence, 81   and improved cognitive skills extending into young adulthood. 80 , 82   Supporting at-risk parents and young children should thus be an urgent priority.

Dr Strathearn conceptualized and designed the original study linking the Mater-University of Queensland Study of Pregnancy data set with substantiated reports of child maltreatment, drafted the special article, and reviewed and revised the manuscript; Dr Giannotti assisted in drafting the manuscript and prepared all tables and figures; Drs Mills, Kisely, and Abajobir conceptualized and wrote the original research articles summarized in this article; Dr Najman was the original principal investigator of the Mater-University of Queensland Study of Pregnancy; and all authors critically reviewed the manuscript for important intellectual content and approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Partially supported by the US National Institute on Drug Abuse (R01DA026437). The content is solely the responsibility of the authors and does not necessarily represent the official views of this institute or the National Institutes of Health. Funded by the National Institutes of Health (NIH).

Composite International Diagnostic Interview

intimate partner violence

Mater-University of Queensland Study of Pregnancy

posttraumatic stress disorder

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Preventing child maltreatment: Key conclusions from a systematic literature review of prevention programs for practitioners

Affiliations.

• 1 Bob Shapell School of Social Work, Tel Aviv University, Ramat Aviv, 69978, Israel. Electronic address: [email protected].
• 2 Bob Shapell School of Social Work, Tel Aviv University, Ramat Aviv, 69978, Israel.
• PMID: 34087537
• DOI: 10.1016/j.chiabu.2021.105138

Child maltreatment (CM) is a worldwide social problem and there is a large consensus that its prevention is of crucial importance. The current literature review highlights CM prevention studies that target practitioners, with the aim of assessing the knowledge in this area, informing future efforts and benefiting the international task of mitigating CM. Specifically, the study presents key conclusions from prevention programs evaluated in peer-reviewed journals from the last decade selected using the PRISMA systematic literature review guidelines. Out of the 26 manuscripts that discussed prevention programs targeted at practitioners, 20 programs were identified. While sexual abuse prevention programs were the most common, followed by programs addressing general child maltreatment, only two studies addressed child physical abuse. More than a third of the prevention programs were interdisciplinary, while healthcare providers had the highest number of specifically tailored programs. The discussion addresses the considerable lack of detail in the relevant manuscripts and urges future efforts to further elaborate on necessary details to enable other researchers and practitioners to better assess and determine the congruence between child maltreatment research and prevention programs. Additionally, some methodological issues in the included manuscripts, such as the lack of control groups and the related challenges, are discussed.

Keywords: Child maltreatment (CM); Education; PRISMA; Prevention; Systematic literature review; Welfare.

Copyright © 2021 Elsevier Ltd. All rights reserved.

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• Systematic Review
• Child Abuse* / prevention & control
• Physical Abuse

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• Systematic Review
• Published: 25 September 2020

Social determinants of health and child maltreatment: a systematic review

• Amy A. Hunter 1 , 2 , 3 &
• Glenn Flores 3 , 4  

Pediatric Research volume  89 ,  pages 269–274 ( 2021 ) Cite this article

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Child maltreatment causes substantial numbers of injuries and deaths, but not enough is known about social determinants of health (SDH) as risk factors. The aim of this study was to conduct a systematic review of the association of SDH with child maltreatment.

Five data sources (PubMed, Web of Science Core Collection, SCOPUS, JSTORE, and the Social Intervention Research and Evaluation Network Evidence Library) were searched for studies examining the following SDH: poverty, parental educational attainment, housing instability, food insecurity, uninsurance, access to healthcare, and transportation. Studies were selected and coded using the PICOS statement.

The search identified 3441 studies; 33 were included in the final database. All SDH categories were significantly associated with child maltreatment, except that there were no studies on transportation or healthcare. The greatest number of studies were found for poverty ( n  = 29), followed by housing instability (13), parental educational attainment (8), food insecurity (1), and uninsurance (1).

Conclusions

SDH, including poverty, parental educational attainment, housing instability, food insecurity, and uninsurance, are associated with child maltreatment. These findings suggest an urgent priority should be routinely screening families for SDH, with referrals to appropriate services, a process that could have the potential to prevent both child maltreatment and subsequent recidivism.

SDH, including poverty, parental educational attainment, housing instability, food insecurity, and uninsurance, are associated with child maltreatment.

No prior published systematic review, to our knowledge, has examined the spectrum of SDH with respect to their associations with child maltreatment.

These findings suggest an urgent priority should be routinely screening families for SDH, with referrals to appropriate services, a process that could have the potential to prevent both child maltreatment and subsequent recidivism

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Child maltreatment is a pervasive public health problem in the United States (US). 1 Comprised of acts of commission and omission by a parent or other caregiver (e.g., physical abuse, sexual abuse, and various forms of neglect), 2 child maltreatment is a substantial cause of pediatric injury and death. In 2018, nearly 700,000 childhood victims of nonfatal maltreatment were identified, and an estimated 1770 children died. 1 The combined human and institutional cost attributed to maltreatment morbidity and mortality in the US is estimated to be $124 billion annually. 3

The World Health Organization defines social determinants of health (SDH) as “the conditions in which people are born, grown, work, live, and age, and the wider set of forces and systems shaping the conditions of life.” 4 These conditions are shaped by the distribution of resources, and connect facets of the physical, social, and built environment associated with health outcomes. 5 Among the most commonly recognized SDH (economic stability, education, neighborhood and built environment, health and healthcare, and social and community context), 6 poverty is a major and often overarching factor. Poverty also has been identified as a known risk factor for child maltreatment. 7 Thus, identifying how poverty and other SDH are associated with child maltreatment is a necessary step to develop effective interventions for maltreatment prevention and treatment, and mitigating the risk of associated physical and psychological injury.

Not enough is known about the association of SDH with child maltreatment. Four published systematic reviews have included analyses that examined the relationship between a single or two SDH and maltreatment. Two included socioeconomic status, 8 , 9 one included socioeconomic status and parental educational attainment, 10 and the fourth included immigration status. 11 No published systematic reviews (to our knowledge), however, have examined the spectrum of SDH with respect to their associations with child maltreatment. Therefore, the aim of this study was to conduct a systematic review of the associations of SDH (including poverty, housing insecurity, food insecurity, uninsurance, healthcare access, and transportation) with child maltreatment.

Inclusion criteria

Studies were selected using the PICOS approach for inclusion and exclusion. 12 , 13 The a priori inclusion criteria for studies were as follows: (1) English-language studies, (2) children 0–18 years old living in the US, (3) peer-reviewed, (4) observational and experimental designs, (5) outcome measures reported for at least one form of maltreatment, and 6) exposure measures for at least one SDH. The exclusion criteria were: (1) specific SDH could not be identified, and (2) conference presentations (e.g., abstracts, posters, or oral presentations).

The outcome of interest was child maltreatment, defined by the Child Abuse Prevention and Treatment Reauthorization Act of 2010 as “at a minimum, any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm.” 2 Included studies were assessed for the associations of selected SDH—including poverty, food insecurity, housing instability, parental educational attainment, child uninsurance, transportation barriers, and access barriers to healthcare—with child maltreatment. These SDH were chosen because they are domains hypothesized to be most likely associated with child maltreatment and were addressed in a recently published SDH screening instrument used for testing interventions effective in reducing SDH and improving child and caregiver health. 14 Immigration status was not included because of the recent publication of a systematic review examining the association of this SDH with child maltreatment. 11

Data sources

Five data sources were searched through March 2020: (1) PubMed, (2) Web of Science Core Collection, (3) SCOPUS, (4) JSTORE, and (5) the Social Intervention Research and Evaluation Network Evidence Library. All searches contained the following terms: (“Child Abuse”[Mesh] OR “child abuse”[tw] OR “child maltreatment”[tw] OR “child mistreatment”[tw] OR “child neglect”[tw]) AND (“Social Determinants of Health”[Mesh] OR “social determinants of health”[tw] OR “social class”). Searches for terms related to specific SDH varied. A sample search strategy (SCOPUS) can be found in Supplementary Table S 1 (online) .

An effort-to-yield measure of search precision, number needed to read (NNR) was calculated by taking the inverse of the precision of the searches. Precision was calculated by dividing the number of included studies by the number of screened studies, after removal of duplicates. NNR quantifies the number of articles that would be needed to be read before finding one that meets the established inclusion criteria. Dependent on the subject and inclusion criteria, this number provides insights into the time and resources needed for replication, or to conduct a similar study.

Selection of studies

All studies were stored on a Microsoft Excel document detailing the reasons for inclusion or exclusion.

Data abstraction

A codebook was developed using Microsoft Excel. Variables included study characteristics (year of publication, study design and population size, duration, data sources, and level[s] of analysis), sociodemographic characteristics of the study population (child age, racial composition, and sex), SDH under investigation, child maltreatment type (sexual, physical, psychological, neglect, multiple forms, and other), and measures of study quality.

Study quality

A modified version of the Downs and Black checklist was used to assess study quality (Supplementary Table S 2 ). 15 Each item was scored as no (0) or yes (1). The sum of all items ranged from 1 to 8, with higher scores representing a lower risk of bias.

Data synthesis

The criteria for SDH and definitions of child maltreatment varied by study. Therefore, we were unable to combine endpoints in a meta-analysis. Data synthesis at the level of the individual, family, and community were used to analyze included studies.

Study registration

The study protocol was registered with PROSPERO (CRD42020166969).

Study characteristics

Our initial search yielded 3441 studies. After screening by titles and abstracts, 118 met the initial inclusion criteria. Following a full review of 118 studies, 33 were included in the final analysis. The process for selecting included studies is presented in Fig.  1 . Search precision was 0.0096 and the NNR was 104. The characteristics of included studies are presented in Table  1 . Included studies were published from 1978 to 2020. 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 Nine studies used national data, 16 , 23 , 27 , 30 , 36 , 38 , 42 , 43 , 47 and the remaining studies used data from individual states, including 14 from the Midwest, 17 , 18 , 19 , 20 , 25 , 26 , 28 , 29 , 31 , 33 , 39 , 40 , 41 , 45 four from the South, 21 , 22 , 32 , 37 four from the Northeast, 34 , 35 , 46 , 48 one from the West (California), 24 and one from the Pacific (Alaska). 44 Of these studies, 5 conducted chart reviews, 7 used cohort study designs, 7 used a cross-sectional design, and 14 conducted ecological analyses. Included studies assessed the relationship between SDH and child maltreatment at the levels of the individual, zip code, county, and census tracts.

a Studies may have been excluded for multiple reasons.

Study outcomes

Twenty-nine studies explored the association of poverty with child maltreatment. 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 47 Poverty was found to be consistently and strongly associated with maltreatment, with all but three studies identifying a significant association between either familial or community-level poverty and child maltreatment. 16 , 18 , 21 Across studies, poverty was defined by county, 45 neighborhood, 41 familial/household income, 17 , 18 , 19 , 20 , 23 , 28 , 41 , 42 , 43 socioeconomic status, 44 poverty rate, 21 , 27 , 35 , 40 unemployment, 16 , 17 , 21 , 31 , 32 , 34 , 36 , 40 percentage of families living below the federal poverty level, 24 , 28 , 31 , 32 , 33 , 36 , 37 , 38 , 39 children living in poverty, 17 , 47 receipt of public assistance, 19 , 25 , 31 , 40 composite impoverishment scores, 26 and self-reported acute financial challenges. 22

In some studies, the relationship between poverty and maltreatment differed by abuse type. For example, one study found that neighborhood poverty was associated with all three forms of child maltreatment, but to different degrees. 38 Another study indicated that financial problems were strongly associated with neglect and abandonment, but the association was less pronounced for sexual abuse. 21

Associations between poverty and maltreatment varied by race/ethnicity. A study comparing predominantly white and black neighborhoods found that the association between poverty and child maltreatment was strongest in whites. 25 Research linking multiple sources of data showed that black children living in poverty were twice as likely to be reported for needs-based neglect than their white counterparts. 26 A recent study showed that when income was held constant, white race was strongly associated with both sexual abuse and neglect, and black race was associated with physical abuse. 27

Housing instability

Thirteen studies examined the relationship between housing instability and child maltreatment. 16 , 18 , 20 , 21 , 23 , 26 , 28 , 29 , 32 , 33 , 34 , 40 , 46 Most studies revealed that housing instability is associated with child maltreatment. Among these studies, the definition of housing stability varied, and included percent vacancy, 21 , 26 , 32 , 33 , 40 rates of foreclosure and delinquency, 16 , 18 , 34 hazardous living conditions, 29 and instability/mobility (>1 move per year). 20 , 23 , 28 Only one study examined homelessness, performing an analysis of hospital and pediatric ambulatory records of children <18 years old. 46 After matching families on income, homeless children were found to have higher rates of maltreatment-related emergency-department (ED) visits and child maltreatment than their nonhomeless counterparts. One study found that displacement due to foreclosure, eviction, or mortgage delinquency was associated with maltreatment investigations. 34 Two studies documented that housing instability/mobility (>1 move per year) was associated with child protective service (CPS) reports and maltreatment risk. 20 , 23

Two studies found no association between housing insecurity and child maltreatment. 18 , 28 In the first, housing instability consisted of an aggregate measure of material hardship, including difficulty paying rent, eviction, or having experienced any utility shutoff in the previous year. 18 In the second, housing instability was measured by residential mobility. 28

Several studies reported differences in the association between housing stability and child maltreatment type. Two identified an association between the percent of vacant housing in communities and sexual abuse. 21 , 32 Another study found that hazardous housing conditions were associated with neglect, but not physical abuse; a history of housing instability increased the strength of this association. 29 One study found that mortgage delinquency was associated with traumatic brain injury and other forms of physical abuse. 20

Food insecurity

Just one study examined the relationship between food insecurity and child maltreatment. 30 An analysis of a national sample from the Fragile Families and Childhood Wellbeing Study revealed that, compared with food-secure households, food-insecure households experienced increased rates of total parental aggression (7% vs. 20%, respectively). Controlling for maternal characteristics did not attenuate this association.

Parental educational attainment

Eight studies considered the relationship between parental educational attainment and child maltreatment. 17 , 18 , 20 , 24 , 25 , 32 , 41 , 42 The results of most studies indicate that low parental educational attainment is associated with child maltreatment. Parental educational attainment was defined as high-school completion in six studies, 17 , 18 , 20 , 32 , 41 , 42 maternal education level in one, 25 and completion of postsecondary education in the last. 24 Two studies found no association. 18 , 24 Notably, one of these studied failed to report victim and perpetrator demographic characteristics (age, sex, or race/ethnicity), 18 and the other relied on self-reported data. 24

Uninsurance

One study was identified that examined the association of the child lacking health insurance with child maltreatment. 48 This study reported that a higher proportion of preadolescent children seen in the ED with suspected sexual child abuse were uninsured, compared with a control group of children seen in the ED with upper-limb fractures, at 52% vs. 1%, respectively. No statistical analyses, however, were conducted, nor is it clear whether there was matching of cases and controls by age, sex, or other relevant characteristics.

The search did not reveal any studies that examined the associations of transportation or access to healthcare with child maltreatment.

Multiple studies document that SDH, including poverty, housing instability, food insecurity, low parental educational attainment, and child uninsurance, are significantly associated with child maltreatment. A recent systematic review also concluded that although the immigrant parental status is associated with a lower likelihood of overall child maltreatment, it may be associated with a higher risk of child neglect and neglectful supervision. 11 Taken together, these findings suggest that an urgent priority, therefore, should be to routinely screen families for SDH in inpatient and outpatient settings and in CPS, and to address identified SDH with referrals to appropriate services. This screening and referral process could have the potential to not only prevent child maltreatment by reducing or eliminating the SDH before they result in maltreatment, but might also decrease the risk of maltreatment recidivism in families in which maltreatment already has occurred. The American Academy of Pediatrics, American Academy of Family Physicians, and the National Academy of Sciences, Engineering, and Medicine all have endorsed SDH screening and service referral. 49 , 50 , 51 Several studies document that patients and caregivers are comfortable with completing SDH screening. 52 , 53 , 54 , 55 , 56 Addressing SDH by referral to such services as case managers, social workers, housing vouchers, medical–legal partnerships, and parent mentors, already has been shown to reduce hospitalizations, improve housing quality and stability, enhance economic security, improve healthcare outcomes, insure more uninsured children, increase the quality of care, empower parents, and save money for society, 57 thereby holding great promise as interventions that may prove effective in ultimately reducing or preventing child maltreatment.

Poverty was the SDH for which the greatest number of studies documented an association with child maltreatment. Although few studies have investigated the temporal relationship between poverty and child maltreatment, 8 there is evidence that families living in poverty are more likely to be reported to CPS for neglect. 58 Poverty sequelae, such as inability to feed, clothe, or house a child, overlap with the definition of child neglect, so it is important to distinguish intentional neglect from family challenges related to living in poverty. Differential or alternative response is one CPS approach that addresses maltreatment reports by attending to unmet family needs. 59 An analysis of the effectiveness of this form of intervention has shown that families living in poverty benefit most from this approach. 60 To date, this response has been implemented at the individual and family levels. Extending differential or alternative response to the community level may be an effective strategy for families living in impoverished neighborhoods, where racial biases in child maltreatment reports and investigations have been identified.

The study results underscore several unanswered questions regarding the association between SDH and child maltreatment. First, it is unclear whether transportation barriers or impaired access to healthcare are associated with child maltreatment, given that no studies were identified on these SDH. Second, because the definitions for each SDH varied considerably within and across studies (especially for poverty), it is unclear whether more consistent SDH definitions would yield different findings. Third, because males as caregivers and heads of household were under-represented and often excluded from some study populations, 20 , 23 , 25 , 33 an unanswered question is whether there are associations of paternal educational attainment and other male-caregiver SDHs with child maltreatment. Although single mothers have been identified as an at-risk population for maltreatment perpetration, it is equally important to examine the role that men play in maltreatment. In a previous analysis, the first author identified men as the predominant perpetrator in 58% of cases of fatal maltreatment in the US. 61 Results of our study emphasize the need for research inclusive of male caregivers, to identify and mitigate risk factors before they escalate to maltreatment fatalities. Fourth, most studies focusing on sexual abuse were primarily limited to female populations, 32 despite evidence that male children also are victims of sexual abuse. There is an urgent need to investigate how SDH perpetuate or protect against sexual abuse in male children, so that prevention efforts can be tailored by sex. Finally, because most studies combined maltreatment into one aggregate category, an unanswered question is what are the associations of SDH with specific maltreatment categories. It has been posited that each maltreatment type has a unique etiology, and lumping these types into one category likely attenuates the ability to identify meaningful associations. Although few studies in this systematic review disaggregated by maltreatment categories, those that did found significant differences in maltreatment risk according to the SDH examined.

Based on the study findings, a research agenda is proposed to address key issues regarding the association of SDH with child maltreatment. Research is needed to address the aforementioned identified research gaps, including studies on transportation barriers, impaired access to healthcare, consistently defined SDH, SDH for male caregivers, and the associations of SDH with specific maltreatment categories and male victims of sexual abuse. Studies are needed to determine whether there is a direct association between the number of SDH and the risk of maltreatment, and whether the presence of multiple SDH can synergistically increase maltreatment risk. Research is urgently needed to determine whether SDH screening and referral to appropriate services result in SDH reduction and elimination as well as decreases in or the prevention of child maltreatment and maltreatment recidivism.

Limitations and strengths

Certain study limitations should be noted. First, as with all systematic reviews, the quality of this analysis is limited by the scientific rigor of included studies. Second, studies were selected based on the search criteria. It is possible that relevant literature was missed because of the heterogeneity of terms used to describe the various SDH and child maltreatment. Third, many included studies were cross-sectional or ecological, preventing the ability to draw conclusions about the temporal relationship between SDH and child maltreatment. Fourth, many data sources for the included studies used administrative data derived from CPS. In most instances, these records only included reports of maltreatment that were screened in and accepted for either an investigation or alternative response. As a result, these data sources likely exclude many cases of maltreatment, given evidence demonstrating equivalent risk of incidence and recurrence between maltreatment reports and substantiations. 28 , 38

SDH, including poverty, parental educational attainment, housing instability, food insecurity, and uninsurance, are associated with child maltreatment. These findings suggest that an urgent priority should be routinely screening families for SDH, with referrals to appropriate services, a process that could have the potential to prevent both child maltreatment and subsequent recidivism. Unanswered questions include whether SDH are associated with specific maltreatment categories and male victims of sexual abuse, and whether transportation barriers, impaired access to healthcare, consistently defined SDH, and SDH for male caregivers are associated with child maltreatment. A proposed research agenda includes addressing these unanswered questions; determining whether there is a direct association between the number of SDH and the risk of maltreatment, and whether the presence of multiple SDH can synergistically increase maltreatment risk; and investigations on whether SDH screening and referral to appropriate services result in SDH reduction and elimination, as well as decreases in or the prevention of child maltreatment and maltreatment recidivism.

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Amy A. Hunter

Department of Public Health Sciences, University of Connecticut, Farmington, CT, USA

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Amy A. Hunter & Glenn Flores

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Hunter, A.A., Flores, G. Social determinants of health and child maltreatment: a systematic review. Pediatr Res 89 , 269–274 (2021). https://doi.org/10.1038/s41390-020-01175-x

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Received : 30 June 2020

Revised : 09 September 2020

Accepted : 10 September 2020

Published : 25 September 2020

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Child maltreatment, cognitive functions and the mediating role of mental health problems among maltreated children and adolescents in Uganda

• Herbert E. Ainamani   ORCID: orcid.org/0000-0001-7290-7232 1 , 2 ,
• Godfrey Z. Rukundo 3 ,
• Timothy Nduhukire 4 ,
• Eunice Ndyareba 5 &
• Tobias Hecker 6  

Child and Adolescent Psychiatry and Mental Health volume  15 , Article number:  22 ( 2021 ) Cite this article

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Child maltreatment poses high risks to the mental health and cognitive functioning of children not only in childhood but also in later life. However, it remains unclear whether child maltreatment is directly associated with impaired cognitive functioning or whether this link is mediated by mental health problems. Our study aimed at examining this research question among children and adolescents in Uganda.

A sample of 232 school-going children and adolescents with a mean age of 14.03 ( SD  = 3.25) was assessed on multiple forms of maltreatment using the Maltreatment and Abuse Chronology Exposure—Pediatric Version (pediMACE). Executive functions were assessed by the Tower of London task and working memory by the Corsi Block Tapping task, while mental health problems were assessed using the Child PTSD Symptom Scale for PTSD and the Center for Epidemiological Studies Depression Scale for Children (CES-DC).

In total, 232 (100%) of the participant reported to have experienced at least one type of maltreatment in their lifetime including emotional, physical, and sexual violence as well as neglect. We found a negative association between child maltreatment and executive functions (β = − 0.487, p  < 0.001) and working memory (β = − 0.242, p  = 0.001). Mental health problems did not mediate this relationship.

Conclusions

Child maltreatment seems to be related to lower working memory and executive functioning of affected children and adolescents even after controlling for potential cofounders. Our study indicates that child maltreatment the affects children’s cognitive functionality beyond health and well-being.

Child maltreatment which is defined as any act of abuse or neglect by a parent, caregiver or a community member that results in harm, potential harm, or threat of harm to a child has been remarked as one of the greatest global public health concerns [ 1 ]. Child maltreatment may include, emotional, physical, and sexual violence as well as neglect [ 1 , 2 , 3 ]. Estimates on the prevalence of violence against children in low- and middle-income countries (LMICs) show that a minimum of 50% of children in Asia and Africa between the ages of 2 and17 experience violence in their upbringing [ 4 ]. Various studies in Africa have shown that there is high level of child abuse in varying samples of children and adults [ 5 ]. Child maltreatment, has also been documented in East-African families, e.g., in Tanzania more than 90% of the children reported to have experienced violent discipline by parents [ 6 ] and different forms of maltreatments by teachers [ 7 ].While in Kenya, severe forms of child sexual abuse was reported [ 8 ] with key perpetrators being relatives (29%).

Similarly, studies in Uganda have reported that children and adolescents experienced violence very frequently [ 9 , 10 , 11 ]. For example, physical and emotional violence have been experienced by 98% of children, sexual violence by 76% and economic violence by 74% [ 10 ].

Child maltreatment does not only inflict physical pain on the affected children but also poses a major risk to cognitive impairment in both childhood and adulthood [ 12 , 13 , 14 ]. In support of the above findings, the toxic stress theory implicates exposure to early childhood adversity for altering the neuro-endocrinal immune system, which renders individual vulnerability to all forms of functional impairments and disease [ 15 ]. A systematic review of cognitive function after childhood trauma concluded that cognitive abnormalities may be linked to neuro-psychological and neurological impacts [ 16 ]. Studies with both animals and humans show that exposure to adverse experiences in early life affects brain regulation and endocrine responses to stress [ 17 , 18 , 19 ]. In fact, a number of studies on neuropsychological impairments have observed a significant disruption in prefrontal cortex that plays an important role in executive functioning following exposure to trauma and subsequent PTSD diagnosis [ 20 , 21 , 22 , 23 , 24 , 25 ]. Moreover, previous studies have documented how exposure to continuous stress affects hippocampal volume resulting from constant increase in glucocorticoid hormone which is released as the brain seeks to mitigate negative effects of stress. Stress in turn seems to affect the functionality of human memory and learning [ 18 , 26 , 27 , 28 ].

Therefore, it is not surprising that a systematic review on the impact of child maltreatment on later cognitive functions reported that children with experiences of child maltreatment performed poorly on tasks of working memory, attention, episodic memory and executive functions [ 29 ]. In line with these findings, other studies mostly from high income countries showed that as a consequence of adverse childhood experiences many affected children and adolescents suffer from cognitive deficiencies [ 25 , 30 , 31 ]. For example, child abuse was found to be associated with delayed language development, cognitive development, and a lower intelligence quotient [ 12 , 32 ]. A systematic review indicated that maltreated children performed poorly on tasks requiring executive functions, working memory and attention [ 33 ].

In addition to the high risk of cognitive impairment associated with child maltreatment, studies in high income countries have also found a strong association between maltreatment and mental health problems [ 34 , 35 , 36 ]. Others have repeatedly found links between maltreatment, PTSD, depression, impairments of prefrontal cortex functioning and dysregulation of HPA [ 37 , 38 , 39 , 40 ]. Furthermore, a negative effect of PTSD symptoms severity on cognitive functions but not trauma, has been frequently reported [ 24 , 41 , 42 ].

The described association between maltreatment and impaired cognitive functioning, maltreatment and mental health problems, as well as mental health problems and impaired cognitive functioning raise the question whether the association between child maltreatment and cognitive functions may be mediated by mental health problems [ 12 , 43 ]. A review of maltreatment studies recommended further studies that control for the mediation effect of psychiatric co-morbidities [ 32 ]. In line with this recommendation and other previous findings, it remains unclear whether child maltreatment is directly associated with impaired cognitive functioning or whether this link is mediated by mental health problems. Moreover, most of the studies testing this link have been conducted in high income-countries. Only one study in Tanzania showed that the relation between child maltreatment and cognitive functioning was mediated by internalizing mental health problems. The other existing studies in low- and middle-income countries, in which violence against and maltreatment of children is much more common, have either examined cognitive impairment among people living with HIV [ 44 , 45 , 46 ], refugees [ 41 ] and the elderly [ 47 ] but not among children and adolescents with a history of maltreatment.

To close this gap, our study sought to examine the relationship between child maltreatment and cognitive functioning (working memory and executive functions) and the mediating role of mental health problems (PTSD symptom severity and depressive symptoms) among maltreated children and adolescents in Southwestern Uganda. We hypothesized that child maltreatment would be negatively correlated with (a) working memory and (b) executive functions, and (c) that these relations would be mediated by mental health problems.

Participants

In total, 232 children and adolescents (52% male) with a mean age of 15 years ( SD  = 2.95) participated in our study. Overall, boys were older than girls and the majority ( n  = 145, 63%) attended primary school (Table 1 ). In total, 101 (44%) participants were living with their mothers as primary caregivers, 40 (17%) were under the primary care of their grandparents, 21 (9%) were primarily cared for by their fathers and 21(9%) were cared for by their siblings, while 30 (13%) indicated other relatives as their main primary caregivers. Only 19 (8%) participants were cared for by another person. Overall, 103 (44%) participants reported to have lived in more than two families in their lifetime.

Study setting and design

This was a cross-sectional study in which 232 children and adolescents between the ages of 8 to 18 studying at two primary schools and one secondary school located in the districts of Mbarara and Rubanda in Southwestern Uganda. The three schools were chosen because they were mainly supported by nonprofit organizations and were expected to have enrolled at-risk children in terms of maltreatment experiences. On average, the enrollment per each school was at 300 (n = 900) children with a total number of 305 children recorded as the most at risk of child maltreatment. Southwestern Uganda is mainly inhabited by Bantu and Nile Hamites ethnic groups. Most residents live in rural areas, where the local economy is primarily characterized by subsistence economy with high levels of food and water insecurity [ 48 , 49 ].

Recruitment and sampling procedure

Data were collected between June 2018 and May 2019. The social workers within the schools helped to locate children and adolescents with a known history of maltreatment in their schools. Only children below the ages of 18 were recruited. We interviewed all children that were identified by the school social workers until there were no more potential participants. Two counsellors and one psychologist conducted the interviews.

The interviewers went through 1-week training in the psychological assessment and practiced the assessment in joint interviews to accomplish high inter-rater reliability. Generally, each interview took 45–60 min in a private setting within the school premises.

Ethical considerations

Ethical clearance was obtained from the Mbarara University of Science and Technology Research Ethics Committee (MUST-REC) under approval number 07/02-18 and the Uganda National Council for Science and Technology (UNSCT) under approval number SS 4928.

Additionally, we sought permission from the school Head Teachers who introduced us to the school social workers. Before the interviews, information on the content, procedures, risks, the right to withdraw, and confidentiality were explained to the participants. Written informed consent (signature or fingerprints) of the legal guardian were obtained. In addition, children and adolescents provided their assent before participating in the study. Each family received two bars of soap as a token of appreciation for taking part in the study. Children with severe symptoms of mental health problems were referred to the nearest health facilities for specialized psychological treatment.

All instruments were translated into Runyankole-Rukiga and back translated to English in a blind written form to ensure the original meaning was not lost. Face to face interviews included socio-demographic information, such as age, gender, educational level and having stayed in two or more homes.

• Child maltreatment

Child maltreatment and other adversities encountered at home were assessed using the Maltreatment and Abuse Chronology of Exposure—Pediatric Version (pediMACE). This tool was the child-appropriate version of the Maltreatment and Abuse Chronology of Exposure [ 50 ]. The pediMACE consists of 45 dichotomous (yes/no) questions, measuring witnessed or self-experienced forms of childhood maltreatment throughout one’s lifetime. We summed up all the questions to a total child maltreatment score (possible range: 0 to 45) that was subsequently used in the analysis.

Exposure to traumatic events

Exposure to traumatic events was assessed using a 15-item checklist on the revised version of the Child PTSD Symptoms Scale for DSM-5—Self-Report (CPSS-VSR) [ 51 ]. With response to yes or no, children were assessed on their exposure to severe natural disasters, severe accidents, being robbed or threatened, being slapped or knifed, seeing relative being beaten or slapped and many others. The scale provides the participants with an opportunity to mention any other traumatizing event that could have been experienced. We summed up all the 15 items to come with a total score that was subsequently used in the analysis.

Mental health problems

We used the CPSS-VSR also to assess the PTSD symptoms severity [ 51 ]. This is a 20-item scale that assesses the occurrence and frequency of PTSD symptoms in relation to the most distressing event experienced by an individual. Participants were asked to rate the frequencies of listed symptoms during the previous 2 weeks on a 5-point Likert scale from 0 (not at all/only once) to 4 (almost every week). A total sum score was calculated. A cut off score of 31 indicated a probable PTSD diagnosis [ 52 ]. This scale has good psychometric measures and showed good psychometric properties, e.g. a Cronbach alpha of 0.92 and test retest reliability of r = 0.93 [ 53 ]. In the current study the Cronbach alpha was 0.86.

Furthermore, we assessed for depressive symptoms using the Center for Epidemiological Studies Depression Scale for Children (CES-DC) [ 54 ]. This is a 20-item self-report depression inventory with total scores ranging from 0 to 60. Each response to an item is scored as: 0 = “Not at All” 1 = “A Little” 2 = “Some” 3 = “A Lot”. Items 4, 8, 12, and 16 are phrased positively, and thus were inverted prior to the calculation of the total score. Higher CES-DC scores indicate higher levels of depression. Scores above 15 have been suggested to indicate significant depressive symptoms in children and adolescents [ 55 ]. However, in this study, we used an adopted cut-off score [ 56 ]. Owing to the cultural context in East Africa, the authors set the cut-off point of probable depression at > 30 [ 53 ]. In the Rwandan study, CES-DC was validated and showed good psychometric properties: Cronbach alpha of 0.86 and test–retest reliability of r = 0.85. In the current study, the Cronbach alpha was 0.87.

Working memory capacity

Corsi-block tapping (CBT) task was used to assess working memory. This neuropsychological test, which has been widely used as a measure of spatial memory in both clinical and experimental contexts for several decades and comes with good psychometric properties shown in validation studies [ 57 , 58 ]. It has also been successfully used in studies within the Great Lakes Region in Central Africa [ 7 , 41 ].The task requires participants to reproduce block-tapping sequences of increasing length in the same or in the reversed order and provides an index of working memory capacity. The Corsi apparatus consisted of nine 2.25 cm 3 black, wooden blocks fixed to a 27.5 cm × 22.8 cm grey, wooden board. The blocks were placed as described in the original test developed by Corsi [ 58 , 59 ]. Each cube was numbered on one side so that the numbers were visible to the interviewer but not to the participant. The participant was seated in front of the interviewer, who subsequently tapped the blocks starting with a sequence of three blocks. Three trials were given per block sequence of the same length. The blocks were touched with the index finger at a rate of approximately one block per second with no pauses between the individual blocks. In the first application of the test after the first half of the interview, the participant had to tap the block sequences in the same order immediately after the interviewer was finished. In the second application at the end of the interview, the participants had to tap the block sequence in reversed order. We computed a total score for both applications (same order and reversed order) by adding the number of correctly repeated sequences until the test was discontinued (i.e., the number of correct trials). The total score ranged from 0 to 21. High performance implied higher working memory capacity.

Executive functions

The Tower of London (TOL) assessed executive functions. The TOL is a classic neuropsychological test for the assessment of executive functions that include planning and problem-solving skills, which has been widely used in diverse cultures [ 41 , 60 , 61 ].

The validation study revealed sound psychometric properties [ 61 ]. The TOL consisted of three wooden pegs, which were fixed on a block of wood and three wooden balls of different colors (black, grey and white) that were placed on the pegs and moved from one peg to another. The participants were shown 12 pictures which depicted the TOL with the balls being placed in different positions on the pegs and were asked to arrange the balls to match the positions on the picture. Each trial started from the same starting positions and varied in difficulty due to the number of moves that were allowed to arrange the balls to match the picture (from two to five). Three attempts were granted for each problem. For each problem up to three points could be earned (if successful in the first attempt). The total sum scores ranged from 0 to 36. Higher grades would mean better performance.

Data analysis

Data were analyzed using SPSS version 23 for Mac. Descriptive statistics were used to compute demographic variables for participants. We z-standardized the two sum scores of PTSD and depressive symptoms severity to compute a mental health problem composite score. Linear regression models were used to test for the association between maltreatment (predictor variable) and the outcome variables of working memory and executive functions. Furthermore, we conducted a simple mediation analysis within the set mediation assumptions that (a) the independent variable would be significantly associated with the dependent variable, (b) the independent variable would be significantly associated with the mediator, and (c) the mediator would be significantly associated with the dependent variable while controlling for the independent variable [ 62 ]. These procedures were followed through the analysis process to estimate the mediating role of mental health problems (mediator variable) on the relationship between child maltreatment and the cognitive domains of working memory and executive functions while controlling for age, years of education and trauma load. As test statistic for the mediating role, we used the Sobel test and non-parametric approach of 5000 bootstraps [ 63 ]. All models fulfilled the necessary quality criteria for linear regression analysis. The residuals did not deviate significantly from normality, linearity or homoscedasticity and no univariate outliers could be identified. The maximum variance inflation factor did not exceed 1.52. Hence, we did not need to take multicollinearity into consideration.

Table 1 displays the descriptive statistics for the main study variables. Overall, 232 (100%) of the participant reported to have experienced at least one type of maltreatment in their lifetime. Female participants experienced more maltreatment types than their male counterparts (see Table 1 ). For example, the majority of participants endorsed having been intentionally pushed by an authority figure (89.7%, n = 208), 89.2% (n = 207) reported having felt that their feelings were not understood by family members. In total, 37.5% of the girls (n = 45,) and 5.4% of the boys (n = 6) indicated that they had been touched in a sexual way (see Additional file 1 : Table S1 for more details). The prevalence of PTSD and depression within our sample was 60% (n = 140) and 39% (n = 91), respectively.

Associations between maltreatment, mental health problems, and executive functions

In a regression model with maltreatment as an explanatory variable and executive functions as the outcome variable while controlling for participant’s age, education in years and trauma load, we found a significant association between maltreatment and executive functions (see Table 2 and Fig.  1 ). The regression model explained 20% of the variability in executive functions. In addition, trauma load and maltreatment significantly correlated with mental health problems (see Table 2 and Fig.  1 ). This model explained 26% of the variance of mental health problems. To investigate whether the association between maltreatment and executive functions was mediated by mental health problems, we conducted a simple mediation analysis with maltreatment as an independent variable and executive functions as dependent variable (Fig.  1 ). When the composite score of mental health problems was added as a mediator variable, the indirect effect of child maltreatment via mental health problems was not significant (see Table 2 , Bootstrap results: B = 0.011, SE = 0.023, 95% CI − 0.036, 0.059).

Mediated regression model ( N  = 232) exploring the mediating influence of mental health problems on the relation between child maltreatment and executive functions. This model indicates that the mental health problems did not mediate the association between child maltreatment and executive functions

Associations between maltreatment, mental health, and working memory

After controlling for age, years of education, and trauma load, maltreatment was significantly associated with working memory (Table 3 and Fig. 2 ). The regression model explained 4% of the variability in working memory. Furthermore, maltreatment and trauma load were significantly associated with mental health problems (Table 3 and Fig. 2 ). The regression model explained 26% of the variations of mental health problems. To investigate whether the association between maltreatment and working memory is mediated by mental health problems, we conducted a simple mediation analysis with maltreatment as independent variable, working memory as dependent variable (Fig. 2 ). When the mental health composite score was added as a mediator variable, the indirect effect of child maltreatment via mental health problems was not significant (see Table 3 , Bootstrap results: B = 0.005, SE = 0.008, 95% CI − 0.010, 0.021).

Mediated regression model ( N  = 232) exploring the mediating influence of mental health problems on the relation between child maltreatment and working memory. This model indicates that mental health problems did not mediate the association between child maltreatment and working memory

In this study, we aimed at examining the association between child maltreatment and the cognitive domains of executive functions and working memory as well as the mediating role of mental health problems in a sample of maltreated children and adolescents in Southwestern Uganda. In line with our hypothesis (a) and (b), we found a negative relationship between child maltreatment and both domains of cognitive functioning after controlling for potential influences, such as age, education, and trauma load. However, in contrast to our hypothesis (c), we did not find an indirect effect via mental health problems.

The finding that child maltreatment was negatively associated with executive functions is in line with previous studies suggesting impairments in executive functions among individuals exposed to child maltreatment [ 29 , 64 , 65 , 66 ]. Furthermore, we found a negative association between child maltreatment and working memory. This observation is also in line with previous findings that found a negative association between child maltreatment and executive functions [ 13 , 67 , 68 , 69 ]. A possible explanation for these negative associations could be the toxic stress theory that implicates exposure to early childhood adversity in altering the neuro-endocrinal immune system, which renders individuals vulnerable to all forms of functional impairments and disease [ 15 , 18 ]. For example, children who have experienced harsh punishments and other forms of maltreatment performed poorly on indicators of self-regulation and other cognitive domains [ 7 , 70 , 71 ]. Differences between maltreated children and non-maltreated children can also be seen in children’s physiology, stress response pathways and cortisol levels [ 72 , 73 ]. With exposure to high levels of maltreatment in our sample, high levels of stress may have negatively impacted hippocampus and the prefrontal cortex functioning. Dense concentration of cortisol receptors in specific brain areas are a possible explanation of cognitive dysfunctioining e.g., in the domains of working memory and executive functions [ 18 , 19 , 74 ]. Based on our own findings and the existing evidence base, including a systematic review [ 29 ], we may conclude that children and adolescents exposed to child maltreatment have a higher likelihood of performing poorly on tasks assessing working memory and executive functions. Our findings therefore lend further support to previous research that children exposed to maltreatment risk impairment in cognitive functions [ 14 , 29 ]. However, it is important to note that most studies on cognitive impairment in individuals exposed to maltreatment are based on cross-sectional data [ 12 , 69 , 75 , 76 ]. Therefore, it remains unclear in literature whether maltreatment leads to poor cognitive functions, whether it co-occurs or whether poor functions increase the risk for maltreatment. Future research should focus on longitudinal, prospective, and experimental studies. For example, randomized controlled studies that implement preventative intervention approaches that reduce maltreatment would offer a unique opportunity to test for causal relations [ 6 ].

Contrary to our hypothesis, we did not find an indirect effect of child maltreatment via mental health problems on cognitive functions. Although our results are partially in line with one study that also did not find an indirect effect of child maltreatment via PTSD on cognitive functions [ 12 ], most studies in high income countries compared individuals with and without mental health problems after trauma exposure [ 77 , 78 ], while others especially in Africa examined the direct association between mental health problems and cognitive functions [ 7 , 41 ]. Overall, the current evidence suggests that mental health problems seem to be linked with poor performance in cognitive functioning [ 79 ]. In our sample, we could not replicate this finding. Our findings, on the other hand, suggest that it is not the mental health problems but the exposure to maltreatment that is linked to poor performance. As most of the above-mentioned studies did not include maltreatment in their analysis, the question remains whether the found associations would hold when including maltreatment in their analysis. However, it is important to consider that our sample was composed of children and adolescents exposed to severe child maltreatment and the found associations may be specific for severely maltreated children. For example, potential effects on the stress response axis may have played a more prominent role [ 31 , 74 ]. Due to the limitation of our cross sectional design further research in Africa and Uganda examining the interplay between child maltreatment, mental health problems, and cognitive functions is needed to fully understand the causal mechanisms that lead to cognitive impairments.

Strength and limitations

Our study examined the relationship between child maltreatment and cognitive functioning and the mediating role of mental health problems among maltreated children and adolescents in Southwestern Uganda. To our knowledge, this is one of the few studies in Africa and other LAMICs that has assessed the mediating role of mental health on child maltreatment and cognitive functions among a sample of maltreated children. Despite our study’s strength, some limitations should be noted: first, the convenience sample does not allow generalizing our findings beyond our specific sample. Secondly, the cross-sectional nature of our study design does not allow us to draw any conclusions about the directionality of our findings. We recommend prospective and experimental studies to shed light on the causal relations. Thirdly, our sample consists of at-risk children. This also limits the possibility to generalize our findings to the general population of children and adolescents. Lastly, it is important to note that biases such as social desirability can never be completely ruled out for subjective reports.

Our findings therefore provide further support to earlier findings, especially from high income countries, that child maltreatment is associated with poor cognitive functioning. Similarly, based on our findings, we advocate for preventive measures to protect children in Uganda and Africa from violence and maltreatment. Programs aimed at equipping parents, caregivers, and teachers with none violent competencies while interacting with children are highly needed in societies where violence against children is still socially accepted. Based on our findings, we advocate for preventing child maltreatment within schools and families to enable more children in Uganda to grow up in a secure environment and to ensure their healthy development. Future studies in Africa should investigate differential associations and consequences of different types of maltreatment on mental health and cognitive functions.

Availability of data and materials

The data sets used and analyzed during the current study are available from the corresponding author on request.

Abbreviations

Post traumatic stress disorder

Low- and middle-income countries

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Acknowledgements

We thank the children and caregivers who participated in this study; the administrators of New Times Nursery and Primary School, Kishanje Highlands High school and Murole Preparatory school. We are grateful to our motivated research assistants; Ninsiima Ainembabazi, Joseph Namanya and Eunice Atuheire for assisting with data collection. We also thank Mr. Chris Brett for proofreading this Manuscript.

HEA acknowledges partial funding from Bishop Stuart University Mbarara-Uganda.

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Herbert E. Ainamani

Department of Psychology, Bishop Stuart University, Mbarara, Uganda

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Godfrey Z. Rukundo

Department of Pediatrics, Kabale University School of Medicine, Kabale, Uganda

Timothy Nduhukire

Department of Educational Psychology, Kabale University, Kabale, Uganda

Eunice Ndyareba

Department of Psychology, Bielefeld University, Bielefeld, Germany

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HEA participated in the conception and design of the study, collected the data, performed data analyses, interpreted the data, and drafted the manuscript. GZR participated in the conception of the study, supervised data collection and revised the manuscript. TN and EN participated in the conception of study and revised the manuscript. TH participated in the conception and design of the study, supervised data analysis and provided substantial revision of the manuscript. All authors read and approved the final manuscript.

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Additional file 1: table s1..

Endorsement of individual items on pediMACE stratified by gender.

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Ainamani, H.E., Rukundo, G.Z., Nduhukire, T. et al. Child maltreatment, cognitive functions and the mediating role of mental health problems among maltreated children and adolescents in Uganda. Child Adolesc Psychiatry Ment Health 15 , 22 (2021). https://doi.org/10.1186/s13034-021-00373-7

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DOI : https://doi.org/10.1186/s13034-021-00373-7

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Longterm Consequences of Childhood Maltreatment

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Part of the book series: Child Maltreatment ((MALT,volume 14))

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Over the past four decades, considerable progress has been made in understanding the long-term consequences of childhood victimization. This chapter is organized around a model that focuses on the cascade of consequences that may develop after childhood experiences of abuse and neglect. This modified ecological model considers the individual in the context of the broader social environment in which he or she functions. The first part reviews the literature on the “cascade of consequences of childhood maltreatment” across multiple domains of functioning, including cognitive and academic, social and behavioral, psychiatric and emotional, and physical health and neurobiological. Where possible, consequences for specific types of childhood maltreatment (physical abuse, sexual abuse, and neglect) are described. Because the negative effects of childhood maltreatment are not inevitable, the next two sections describe research on protective factors that may buffer maltreated children from succumbing to negative consequences and then the important role that contextual factors play in influencing the development of children. The chapter concludes with a discussion of challenges to the field and a brief section on gaps in knowledge and suggestions for future research.

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Acknowledgments

This work was supported in part by grants from NIJ (86-IJ-CX-0033, 89-IJ-CX-0007, and 2011-WG-BX-0013), NIMH (MH49467 and MH58386), Eunice Kennedy Shri ver NICHD (HD40774), NIDA (DA17842 and DA10060), NIAAA (AA09238 and AA11108), NIA (AG058683), and the Doris Duke Charitable Foundation. The opinions, findings, and conclusions or recommendations expressed are those of the authors and do not necessarily reflect those of the US Department of Justice.

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Widom, C.S. (2022). Longterm Consequences of Childhood Maltreatment. In: Krugman, R.D., Korbin, J.E. (eds) Handbook of Child Maltreatment. Child Maltreatment, vol 14. Springer, Cham. https://doi.org/10.1007/978-3-030-82479-2_18

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Peer-reviewed

Research Article

A Systematic Review of Childhood Maltreatment Assessments in Population-Representative Surveys Since 1990

* E-mail: [email protected]

Current address: Public Health Agency of Canada, Government of Canada, 785 Carling Ave., Ottawa, Ontario, K1A 0K9, Canada

Affiliation Public Health Agency of Canada, Government of Canada, Ottawa, Canada

Affiliation Ottawa, Canada

• Wendy Hovdestad, 
• Aimée Campeau, 
• Dawn Potter, 

• Published: May 18, 2015
• https://doi.org/10.1371/journal.pone.0123366
• Reader Comments

Population-representative surveys that assess childhood maltreatment and health are a valuable resource to explore the implications of child maltreatment for population health. Systematic identification and evaluation of such surveys is needed to facilitate optimal use of their data and to inform future research.

To inform researchers of the existence and nature of population-representative surveys relevant to understanding links between childhood maltreatment and health; to evaluate the assessment of childhood maltreatment in this body of work.

We included surveys that: 1) were representative of the non-institutionalized population of any size nation or of any geopolitical region ≥ 10 million people; 2) included a broad age range (≥ 40 years); 3) measured health; 4) assessed childhood maltreatment retrospectively; and 5) were conducted since 1990. We used Internet and database searching (including CINAHL, Embase, ERIC, Global Health, MEDLINE, PsycINFO, Scopus, Social Policy and Practice: January 1990 to March 2014), expert consultation, and other means to identify surveys and associated documentation. Translations of non-English survey content were verified by fluent readers of survey languages. We developed checklists to abstract and evaluate childhood maltreatment content.

Fifty-four surveys from 39 countries met inclusion criteria. Sample sizes ranged from 1,287-51,945 and response rates from 15%-96%. Thirteen surveys assessed neglect, 15 emotional abuse; 18 exposure to family violence; 26 physical abuse; 48 sexual abuse. Fourteen surveys assessed more than three types; six of these were conducted since 2010. In nine surveys childhood maltreatment assessments were detailed (+10 items for at least one type of maltreatment). Seven surveys’ assessments had known reliability and/or validity.

Conclusions and Implications

Data from 54 surveys can be used to explore the population health relevance of child maltreatment. Assessment of childhood maltreatment is not comprehensive but there is evidence of recent improvement.

Citation: Hovdestad W, Campeau A, Potter D, Tonmyr L (2015) A Systematic Review of Childhood Maltreatment Assessments in Population-Representative Surveys Since 1990. PLoS ONE 10(5): e0123366. https://doi.org/10.1371/journal.pone.0123366

Academic Editor: Paula Braitstein, Indiana University and Moi University, UNITED STATES

Received: July 14, 2014; Accepted: February 22, 2015; Published: May 18, 2015

Copyright: © 2015 Hovdestad et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: The authors have no support or funding to report.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Child maltreatment has been defined by the Public Health Agency of Canada as neglect, exposure to intimate partner violence, emotional maltreatment, physical and sexual abuse [ 1 ]. The American Centers for Disease Control similarly defines child maltreatment as abuse or neglect of someone under age 18 years by any person in a custodial role [ 2 ]. Child maltreatment is recognized as a serious problem around the world. Cumulative childhood prevalence estimates range from 1% (intrusive sexual abuse of boys) to 35% (assaults including serious threats), depending on the maltreatment type, respondents’ gender, the geographical region, and other factors [ 3 ]. These may be underestimates, given that some interviewees with previously documented maltreatment provide false negatives [ 4 – 7 ]. Adults with histories of childhood maltreatment are more likely than those without such histories to experience a variety of negative health outcomes, and these associations persist when effects due to variables such as income are statistically controlled [ 8 – 10 ]. A wide variety of population-representative surveys are relevant to health, whether they focus on health behaviours (e.g., alcohol use, sexual behaviour), on specific health outcomes, or on social issues with health implications (e.g., criminal victimization). If such surveys include childhood maltreatment measures, they can illuminate the long-term population health implications of the maltreatment of children.

Although causality cannot be inferred from cross-sectional surveys, it has been recently argued that retrospective population-representative community based surveys have an important role to play in understanding child maltreatment [ 11 ]. Such surveys also allow the study of health-relevant outcomes that may be undocumented (e.g., re-victimization, untreated illness), in administrative medical and social services databases. In addition, they allow the exploration of research questions that are potentially difficult to address with child samples due to ethical and reporting requirements [ 12 , 13 ]. Nonetheless, population-representative surveys are usually limited to the non-institutionalized population with a fixed household address and may be limited to fluent speakers of the dominant regional language. These exclusions may cause underestimation of the strength of the associations between adversity-related predictor and health outcome variables [ 14 , 15 ]. Although concerns have been raised about the use of retrospective reports of childhood maltreatment [ 5 ], arguments by Kendell-Tackett and Becker-Blease [ 16 ] and analyses of data from New Zealand, American, British, and German samples are reassuring [ 9 , 17 – 19 ]. Recent work has found, for example, that psychological adjustment is related to adverse childhood experiences in the same way whether adversity is assessed prospectively or retrospectively [ 19 ].

Some issues with using population representative surveys as a means to understand child maltreatment and population health are specific to the surveys’ childhood maltreatment assessments. For example, the definition of a type of maltreatment may be left to the respondents (e.g., “Were you ever physically abused?”) rather than being defined by specific behaviours. Items to assess maltreatment may be of unknown reliability and validity. Some types of child maltreatment (e.g., neglect, emotional abuse) are studied less often than others [ 3 ] and surveys’ inclusion of multiple types of childhood maltreatment is also an important issue.

Spurred in part by earlier reports of issues encountered in efforts to include childhood maltreatment and other highly personal questions in health surveys [ 20 – 22 ] and following from earlier reviews [ 23 , 24 ], this is a systematic review and evaluation of the childhood maltreatment assessments in population-representative surveys with any health content, worldwide, since 1990. The first objective is to provide a resource that informs health researchers of the existence and nature of surveys that assessed childhood maltreatment in order to facilitate secondary data analyses. The second objective is to describe and evaluate childhood maltreatment assessments that have been used on earlier population-representative surveys. This paper is intended as a resource to facilitate planning of future surveys in Canada and worldwide. To the best of our knowledge no similar resource exists.

This systematic review was done according to PRISMA guidelines (see S1 PRISMA Checklist ).

Search Strategy

Fig 1 shows our means of including surveys. We began by searching citation databases to identify peer-reviewed articles that used data from relevant surveys (January 1990-March 2014). Cinahl, Embase, ERIC, Global Health, MEDLINE, PsycINFO, Scopus, Social Policy and Practice were searched with assistance from a librarian.

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Unshaded boxes represent database searches of peer-reviewed articles. Shaded boxes represent sources of included surveys.

https://doi.org/10.1371/journal.pone.0123366.g001

A sample search string was: ((TITLE-ABS-KEY-AUTH((survey* W/3 health) OR (representati* W/3 survey*) OR (household* W/3 survey*) OR (general* W/3 survey*) OR (morbid* W/3 survey*))) AND TITLE-ABS-KEY((child* AND victimization) OR (child* W/3 abuse*) OR (child* W/3 neglect*) OR (child* W/5 assault*) OR (child* W/2 violence) OR (child W/3 maltreat*) OR (child* AND punishment*) OR (pumitiv* W/3 experienc*) OR (child* AND witness* AND violen*))) OR (((TITLE-ABS-KEY-AUTH((survey* W/3 health) OR (representati* W/3 survey*) OR (household* W/3 survey*) OR (general* W/3 survey*) OR (morbid* W/3 survey*)))) AND (TITLE-ABS-KEY(national* AND child*)) AND (TITLE-ABS-KEY(victimizat* OR victimisat* OR (child* W/3 abus*) OR (child* W/3 maltreat*) OR (child* W/3 neglect*) OR (domest* W/3 violenc*) OR (domest* W/3 violent*) OR (famil* W/3 violen*) OR (partner* W/3 violen*) OR (sex* W/3 assault*) OR (sex* W/3 abus*) OR (sex* W/3 maltreat*) OR (psycholog* W/3 assault*) OR (psycholog* W/3 abus*) OR (psycholog* W/3 maltreat*) OR (emotion* W/3 assault*) OR (emotion* W/3 abus*) OR (emotion* W/3 maltreat*) OR ((witness* OR expos* OR exposed*) AND violen*) OR "physical punishment" OR punitive OR "physical abuse"))).

In the initial search, two teams of two reviewers independently screened titles and abstracts. After this training phase, titles and abstracts were screened by one reviewer. Inclusion criteria for articles identified in this way were as stated below. Five additional steps were taken to identify relevant surveys not described in the 99 included articles. Excluded articles were re-checked as articles pertaining to subpopulations did, at times, utilize representative surveys. Internet searches were performed using titles of all included surveys to ensure additional cycles that met criteria were not overlooked. Internet searches were conducted using an abbreviated list of search strings to identify potential new surveys. A list of included surveys was shared with two electronic discussion forums populated by child maltreatment experts. Communication with experts led to the identification of additional relevant surveys. Finally, we searched reference lists from included and excluded articles, along with references from research bibliographies on survey websites.

Additional materials pertaining to reliability and validity of surveys’ childhood maltreatment assessments were obtained by other Internet searching (using key words from each survey title in combination with “reliability” and “validity”).

Survey Selection

Population representative surveys including assessment of both childhood maltreatment and health were eligible for inclusion. We defined population representative surveys as those which were described that way by users of the data (i.e., authors of articles), which had been sampled and weighted in order to accurately reflect the members of the entire population.

We defined childhood maltreatment as respondents’ experiences before age 18 years involving family or caregiver-related emotional or physical neglect, emotional or physical abuse. The initial review protocol specified assessments specific to childhood exposure to intimate partner violence but was adapted to include violence within the family in which victims and/or perpetrators were unspecified (See S1 Protocol ). We included any sexual abuse before age 18, not exclusively acts committed by a caregiver. Our choices here with regard to how to define childhood maltreatment reflect our child welfare and public health informed understandings that child sexual abuse (where a child is a person under age 18 years) is different from other forms of child maltreatment. Sexual assault of children, especially girls, is common, and has important health impacts whether the perpetrators are intra- or extra-familial. Some forms of child maltreatment (e.g., neglect, emotional abuse) can only occur within ongoing relationships. Sexual abuse is different, in that strangers and acquaintances can and do victimize children this way.

No minimum quality criteria were applied to childhood maltreatment assessments; items posed to survey respondents only needed to correspond to any one of the five maltreatment subtypes [ 1 ].

Health was defined broadly, including mental and physical health, self-esteem, health care utilization, alcohol or substance use, injury, and re-victimization (but not violence perpetration nor experience of criminal sanctions). Fourteen non-English surveys were included because the survey was described in an English article (see search strategy) or because communication with survey administrators and/or article authors was possible. Surveys were included if they were representative of the household population of a sovereign nation or if they were representative of a distinct geopolitical region of at least 10 million people. Due to our broad public health focus and the need to limit the scope of the review, surveys were excluded if respondent ages spanned less than 40 years (e.g., adolescents and young adults only) or if respondents were representative only of a subpopulation (e.g., women).

Data Collection Process.

The complete instruments were obtained for review for all but seven of the included surveys. For the seven surveys, experts confirmed that questions pertaining to childhood maltreatment were repeated verbatim from earlier cycles for which the complete instruments had been obtained, or provided excerpts containing the childhood maltreatment content. Survey methods, geographical coverage information, maltreatment type, and characteristics of the maltreatment assessment measures (e.g., reliability, validity) were extracted from research and methods articles, survey websites (where available), survey instruments, and from personal communications with survey administrators and data users. Survey instruments were searched for additional child maltreatment content not described in associated articles. Five checklists were developed and adapted as necessary to reflect concepts used on surveys to assess childhood maltreatment. The key shared domains of our five checklists were item count, self-defined maltreatment, behaviours constituting maltreatment, and indicators of severity. The checklists correspond exactly to the column headings, used below. Our use of checklists to describe and evaluate surveys’ childhood maltreatment assessment is in keeping with earlier recommendations that the best tools are simple checklists, specific to the content, with a small number of key domains [ 25 ]. Better quality of childhood maltreatment assessment was indicated by use of multiple rather than single items, behaviourally-specific rather than self-defined items, use of items with known reliability and validity, and assessment of multiple rather than single types of childhood maltreatment. Survey instruments and associated documentation were reviewed independently by at least two authors to ensure that all relevant content was accurately extracted. At all stages of data extraction, disagreements were rare and were resolved by discussion to consensus.

Table 1 summarizes the 54 included surveys, conducted in 39 countries. The table presents the surveys in chronological order, with multi-cycle surveys grouped together. The majority of surveys were conducted in high income countries (e.g., the United States, Canada, several European countries), followed by middle to low-middle income countries (e.g., Brazil, China), and a low income country (i.e., Uganda). The Ugandan survey was conducted as part of the Gender, Alcohol and Culture International Study (GENACIS). More surveys were conducted in the United States than any other country (43%). The sample sizes ranged from 1,287–51,945 and the response rates from 15%-96%. Sexual abuse was assessed most often, followed by physical abuse, exposure to family violence, emotional abuse, and neglect. Four American surveys included all five types of childhood maltreatment: the National Comorbidity Survey (NCS), the Behavioral Risk Factors Surveillance System (BRFSS) California 2008, 2009, and the second cycle of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC2).

https://doi.org/10.1371/journal.pone.0123366.t001

As shown in Tables 2 – 6 , for all types of childhood maltreatment some surveys included items relying on respondents’ self-definition (e.g., “As a child, did you ever witness parent/guardian abuse by their spouse/partner?”). Self-definition was most common with sexual abuse (48%), and nine of the 48 surveys assessing sexual abuse included exclusively a self-definition item. Single-items were used to assess exposure to family violence and emotional abuse over 50% of the time. Detailed assessments of childhood maltreatment (+10 items) were usually of sexual abuse (23% of surveys that included sexual abuse) with one of these (National Violence Against Women Survey) also assessing physical abuse in detail. NESARC2 assessed neglect with more than 10 items and also assessed the other four types of maltreatment with six or more items. The majority of the surveys included assessment of various aspects of maltreatment severity such as frequency, immediate harm, perpetrator identity, and age at occurrence.

https://doi.org/10.1371/journal.pone.0123366.t002

https://doi.org/10.1371/journal.pone.0123366.t003

https://doi.org/10.1371/journal.pone.0123366.t004

https://doi.org/10.1371/journal.pone.0123366.t005

https://doi.org/10.1371/journal.pone.0123366.t006

Table 2 describes 13 surveys that assessed neglect. Items assessing respondents’ experiences of going without food and other necessities and of having unmet medical needs were most common, followed by items about emotional neglect such as lack of attention and absence of close relationships with caregivers.

Table 3 describes 15 surveys that assessed respondents’ experiences of emotional abuse. Most surveys assessed verbally abusive behaviours such as insults, swearing at, cursing at or doing or saying something to spite or hurt feelings.

Table 4 describes 18 surveys that assessed exposure to family violence. Common behaviours included exposure to a family member being slapped or hit, being pushed, shoved or grabbed, or having something thrown at them. Six surveys dealt with aspects of being exposed to the emotional abuse of another family member in the form of threats of harm.

Table 5 describes 26 surveys that assessed physical abuse. The behaviours assessed most often were: slapped or hit, beaten up, hit with an object, and burned or scalded.

Table 6 describes 48 surveys that assessed sexual abuse. The behaviours assessed most often were rape (oral and/or anal and/or vaginal penetration) followed by molestation.

Included articles contained information about the reliability, validity, or lack thereof, of the childhood maltreatment assessments used in the NCS, the Ontario Health Survey—Mental Health Supplement (OHSUP), NESARC2 and the Korean GSS. Searches for additional materials uncovered evidence for reliability and validity of the childhood maltreatment assessment used on the 2010 survey conducted by the German statistical company, Unabhangiger Service für Umfragen , Methoden und Analysen (USUMA 2010), which used a German version of the well-validated Childhood Trauma Questionnaire [ 116 ]. In addition, the exposure to family violence item on the Canadian Community Health Survey—Mental Health (CCHS 2012) was drawn from a measure with established reliability and validity [ 117 , 118 ], as were the physical abuse and exposure to family violence items on the General Social Survey—2014 [ 117 , 118 ]. Many surveys used items modified from existing measures (e.g., the Conflict Tactics Scale [ 119 , 120 ]).

The objectives of this review were to provide information about the existence and nature of population health surveys that assess childhood maltreatment and to provide an evaluation of those assessments.

Our review allows discussion of some general characteristics of the included surveys. We identified more surveys in later years compared to earlier years that assessed childhood maltreatment and this may reflect either an increasing number of population-representative surveys or an increasing proportion of such surveys that included childhood maltreatment. Given the successful uses of several high profile surveys to explore the long-term health importance of child maltreatment [ 121 , 122 ] and statements about child maltreatment prevention as preventive of chronic disease and other costly health issues [ 123 , 124 ], there may be a new willingness among sponsors of recent surveys to include childhood maltreatment assessment.

In the early 1990s, interview method was predominantly personal, in contrast to surveys conducted since 2009, which were almost all computer-assisted telephone interviews. The only online (web based) surveys that met inclusion criteria were conducted recently (2005–2009). Given evidence that research participants may prefer to disclose victimization using a computer rather than to an interviewer [ 125 ], online surveys may have potential to advance research in this area. However, based on sampling theory and a simulation study, Bethlehem concluded that self-selection web surveys have “no role” in creation of accurate estimates of population characteristics [ 126 ]. Thus, the utility of online surveys for future research in this area is uncertain.

Childhood maltreatment was conceptualized using exclusively self-defined items on eight surveys that assessed sexual abuse, two for physical abuse, and two for exposure to family violence; self-defined items were also sometimes used in concert with behaviour-based items. Enhancing quality by use of items that are behaviour specific (versus those that are self-defined or interpretative) has been previously discussed [ 117 , 127 ].

Despite longstanding calls for use of high quality measures [ 24 ], we found evidence for the reliability and/or validity of the childhood maltreatment assessments on only seven of the 54 included surveys. The Composite International Diagnostic Inventory (CIDI) formed a part of several surveys, and includes a checklist of life events that includes childhood maltreatment. The CIDI has well established validity and reliability [ 128 ], but Kessler et al [ 129 ] have noted the potential difficulties in assessing life adversities with checklists. Further examination of the specific items used in the surveys indicated that few were used in formats identical to those tested for reliability and/or validity; the psychometric properties of nearly all measures were uncertain.

Maltreatment types commonly co-occur, and study of single types in isolation has been decried [ 130 – 132 ]. Assessment of multiple types of maltreatment is important for understanding which forms of maltreatment co-occur and how different forms of maltreatment, and their co-occurrence, are risk factors for later health outcomes [ 130 ]. Although 14 surveys included more than three forms of childhood maltreatment, we found that half the surveys assessed a single type of childhood maltreatment, and almost always that single type was sexual abuse. We confirmed earlier findings [ 133 , 134 ] that sexual abuse is researched more than other types of maltreatment. Note, however, that our definition of sexual abuse was broader than that for other types of maltreatment. Also, the preponderance of sexual abuse assessments on surveys may be explained, in part, by research related to sexual health and HIV transmission risk factors [ 21 ].

Limitations of our work include the following: The total number of surveys identified was not recorded. In keeping with earlier recommendations [ 25 ], our assessment checklist tools were carefully developed, but their reliability and validity have not been tested. Stoltenborgh et al.’s review [ 135 ] noted the inherent conceptual difficulties of the definition and measurement of child neglect; our neglect tool content should in particular be validated by further research.

Although we searched comprehensively, it is unlikely that all existing surveys have been identified, especially non-English ones. We limited our scope by excluding surveys and articles in which the sample was subnational or in which a segment of the population with an age range smaller than 40 years was targeted because they did not meet our definition of representativeness [ 136 , 137 ].

Despite our international perspective, our inclusion criteria may have resulted in selection of material constructed around concerns held predominantly by Western scientists and policy makers. For example, surveys concerned with child morbidity and mortality were excluded [ 138 – 140 ], although such work may be of key concern in low income countries. Items on the neglect checklist may be particularly Western-centric, in that omissions of care and nurturing seen as “neglect” in one culture may not be seen as problematic in another [ 141 ]. Tausig [ 142 ] discussed the importance of methodological factors and cultural contexts in understanding health estimates derived from international surveys, and a similar perspective may be useful in this context considering that most survey assessments of childhood maltreatment originate from one culture.

A final limitation of this review is that some information of potential interest was not coded, such as accessibility of the data for secondary analyses, which cannot be assumed to be straightforward, as noted for example by Thompson and Xiajie [ 143 ]. We did not assess the availability of measures of non-maltreatment childhood adversity (e.g., poverty) nor childhood supportive relationships (except where such measures, reverse coded, could be seen as indicators of emotional neglect) despite evidence that both are important to adult health outcomes [ 144 – 146 ].

This systematic review, enhanced by Internet searches and consultations with experts, represents a unique assessment of 54 diverse population-representative surveys conducted internationally since 1990 that measured both childhood maltreatment and adult health. This study has a number of strengths. Due to a weighty reliance on grey literature, publication bias is probably not an issue. The process we followed enhanced the quality of the review; basing our tools on survey content, as it emerged, allowed for the diversity of content to be represented; coders represented multiple disciplines; disagreements were resolved by consensus. In addition, in terms of content extraction each identified survey was thoroughly searched; our tools captured diverse surveys’ highly varied childhood maltreatment content from within multiple modules (e.g., “post-traumatic stress disorder”, “childhood”, “background information”, “sexual violence”, “life event history”).

The absence of validated measures and failure to assess multiple types of childhood maltreatment are two concerns in this body of work. Important questions for future work are: Can both these concerns be addressed within surveys that must have the minimum possible administrative and response burdens? If not, which concern is more important to address? Evidence indicates that single-item measures of childhood maltreatment are associated with under-reporting. However, other research indicates no clear effect of maltreatment means of assessment on the strength of the relation with health outcomes [ 147 ] and single-item measures of childhood maltreatment predict adult health outcomes [ 137 ].

Routine inclusion of childhood maltreatment assessment on surveys with any health content would allow further understanding of child maltreatment as a risk factor for various adverse health outcomes throughout the lifespan including those with high social costs, such as chronic disease. Our review demonstrates the feasibility of inclusion and provides diverse examples of previous assessments. A future paper will examine the strength of the observed relationships between childhood maltreatment and health outcome measures (e.g., mental illness, chronic illness such as cancer).

Population-representative surveys are a key source of data to inform public policy about child maltreatment as a preventable problem associated with negative health outcomes. To our knowledge this is a unique, comprehensive search and description of health and social surveys and assessment of their childhood maltreatment content. It is our hope that health researchers who recognize the importance of childhood maltreatment will benefit from knowing on what surveys childhood maltreatment items have been included, and the nature of the surveys and of the items.

Supporting Information

S1 prisma checklist. prisma 2009 checklist..

https://doi.org/10.1371/journal.pone.0123366.s001

S1 Protocol. Research Protocol for A Systematic Review of Childhood Maltreatment Assessments in Population-Representative Surveys Since 1990.

https://doi.org/10.1371/journal.pone.0123366.s002

Acknowledgments

The authors gratefully acknowledge the technical assistance of Jasminka Draca.

Author Contributions

Conceived and designed the experiments: WH LT. Wrote the paper: WH AC LT DP. Wrote the protocol, with input from the others: WH. Extracted and categorised the data: AC WH DP LT. Led the evaluative component: LT. Led the analysis of the measures' reliability: DP.

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Childhood maltreatment responsible for up to 40 percent of mental health conditions

A study examining childhood maltreatment in Australia has revealed the shocking burden for Australians, estimating it causes up to 40 percent of common, life-long mental health conditions.

The mental health conditions examined were anxiety, depression, harmful alcohol and drug use, self-harm and suicide attempts. Childhood maltreatment is classified as physical, sexual and emotional abuse, and emotional or physical neglect before the age of 18.

Childhood maltreatment was found to account for 41 percent of suicide attempts in Australia, 35 percent for cases of self-harm and 21 percent for depression.

The analysis, published in JAMA Psychiatry is the first study to provide estimates of the proportion of mental health conditions in Australia that arise from childhood maltreatment.

The researchers said the results are a wakeup call for childhood abuse and neglect to be treated as a national public health priority.

"The results are devasting and are an urgent call to invest in prevention -- not just giving individual support to children and families, but wider policies to reduce stress experienced by families," said Dr Lucinda Grummitt, from the University of Sydney's Matilda Centre, who led the study.

"Investments to address childhood maltreatment have the potential to avert millions of cases of mental disorders in Australia."

The analysis also found that if childhood maltreatment was eradicated in Australia, more than 1.8 million cases of depression, anxiety and substance use disorders could be prevented.

The study also found elimination of childhood maltreatment in Australia would, in 2023, have prevented 66,143 years of life lost (death) and 118,493 years lived with disability, totaling 184,636 years of healthy life lost through mental health conditions.

Researchers examined data that included national surveys provided by the Australian Child Maltreatment Study in 2023 (8500 participants), the Australian National Study of Mental Health and Wellbeing 2020-2022 (15,893 participants) and the Australian Burden of Disease study 2023.

The study made use of analytical methods to investigate the link between child maltreatment and mental health, which isolated other influential factors such as genetics or social environments. This provides stronger evidence that childhood maltreatment causes some mental health conditions.

Mental health conditions are currently the leading cause of disease burden globally and affect 13 percent of the global population. In Australia, suicide is the leading cause of death for young people.

Previous research (independent to the University of Sydney study) found over half (53.8 percent) of Australians experienced maltreatment during their childhood.

Dr Grummitt said there are effective interventions, such as programs to support children experiencing maltreatment or parent education programs, but the most sustainable solution to prevent child maltreatment is policy-driven prevention.

"Policies to alleviate stress experienced by families, such as paid parental leave, affordable childcare, income support like Jobseeker, and making sure parents have access to treatment and support for their own mental health could make a world of difference for Australian children.

"Addressing the societal and economic conditions that give rise to child maltreatment can play a large part in preventing mental disorders at a national level," Dr Grummitt said.

The researchers cite an example in the United States where the introduction of state paid parental leave policies and timely access to subsidised childcare were strongly linked to reduced rates of child maltreatment.

• Mental Health Research
• Chronic Illness
• Children's Health
• Mental Health
• Child Psychology
• Public Health
• Poverty and Learning
• STEM Education
• Child abuse
• Public health
• Environmental impact assessment
• Epidemiology
• Early childhood education
• Substance abuse
• Political science

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Materials provided by University of Sydney . Note: Content may be edited for style and length.

Journal Reference :

• Lucinda Grummitt, Jessie R. Baldwin, Johanna Lafoa’i, Katherine M. Keyes, Emma L. Barrett. Burden of Mental Disorders and Suicide Attributable to Childhood Maltreatment . JAMA Psychiatry , 2024; DOI: 10.1001/jamapsychiatry.2024.0804

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• Published: 08 May 2024

Childhood maltreatment, shame, and self-esteem: an exploratory analysis of influencing factors on criminal behavior in juvenile female offenders

• Xiaomei Chen 1 ,
• Shuang Li 3 &
• Lili Liu 4  

BMC Psychology volume  12 , Article number:  257 ( 2024 ) Cite this article

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This study aimed to investigate the relationships between childhood maltreatment, shame, and self-esteem among juvenile female offenders and to explore the potential influencing factors on their criminal behavior.

Using a stratified cluster sampling method, 1,227 juvenile female offenders from 11 provinces in China were surveyed using the Childhood Trauma Questionnaire (CTQ), Self-Esteem Scale (SES), and a self-developed Shame Questionnaire for Juvenile Offenders. Data were analyzed using descriptive statistics, correlation analysis, chi-square tests, t-tests, and structural equation modeling with mediation analysis.

(1) Childhood maltreatment have a significant potential influencing factors on criminal behavior; (2) Childhood maltreatment was positively correlated with self-esteem( β  = 0.351, p  < 0.001); (3) shame ( β  = 0.042, p  < 0.001) mediate the relationship between Childhood maltreatment and self-esteem (childhood maltreatment → shame → self-esteem (95% Cl: 0.033, 0.052)).

This study demonstrates that childhood maltreatment is a significant predictor of criminal behavior among juvenile female offenders. childhood maltreatment can directly influence of self-esteem, which can also affect juvenile female offenders’self-esteem indirectly through shame. The findings suggest that shame are important variables that mediate the effect of the juvenile female offenders’childhood maltreatment on their self-esteem.

Peer Review reports

Introduction

Child maltreatment remains a pervasive global issue with far-reaching impacts that extend into every corner of society. juveniles, the future of our society, are influenced by a multitude of factors in their growth and development, one of which is their early life experiences. As emphasized by the World Health Organization, child maltreatment includes physical, emotional, and sexual abuse, neglect, and exploitation, all potentially harmful to a child’s overall health [ 1 ]. Moreover, maltreatment of children is not just about acts of commission; it also involves acts of omission, which include neglecting the emotional and physical needs of children [ 2 ]. The impact of child maltreatment on society becomes particularly evident in the context of criminal behavior. Notably, a link between experiencing abuse during childhood and delinquent behavior in adolescence has been observed [ 3 ]. According to existing literature, such traumatic experiences during formative years lead to challenges in interpersonal relationships and might result in maladaptive behaviors [ 4 , 5 ]. These experiences of abuse can have lasting impacts on a child’s psychological and emotional health [ 6 ]. For instance, children who are frequently abused may exhibit serious mental problems, such as psychological trauma, depression, anxiety, suicidal tendencies, violent tendency, and aggression. Among those with a history of abuse, behaviors such as school absenteeism, risky behaviors, and even physical altercations become more prevalent [ 7 , 8 ]. Simultaneously, these behaviors might be their way of coping with traumatic experiences.

In China, childhood maltreatment is a significant influencing factor in juvenile criminal behavior [ 9 , 10 ]. Studying the relationship between childhood maltreatment and criminal behavior in the Chinese context is unique and necessary, mainly reflected in three aspects. First, the collectivistic cultural characteristics of China may make childhood maltreatment more easily concealed, and victims are less willing to seek help, leading to more severe psychological consequences and criminal risks. Second, China’s relatively inadequate laws and policies in preventing and dealing with childhood maltreatment may exacerbate victims’ psychological trauma and criminal risks. Finally, China’s rapid social transformation and modernization may increase the risk of childhood maltreatment while bringing more uncertainties and challenges to juveniles, increasing their psychological vulnerability and criminal risks. Research shows that among juvenile offenders, theft, group fighting, provocative disturbance, robbery, rape, and intentional injury are the most common criminal behaviors, accounting for 76.5% of all criminal behaviors [ 11 ]. Therefore, conducting research on the relationship between childhood maltreatment and criminal behavior in the Chinese context can reveal the influence of cultural characteristics, legal policies, and social transformation factors, providing important theoretical and practical basis for improving relevant policies, preventing and intervening in childhood maltreatment and its resulting criminal behavior. At the same time, it also helps to fill the research gap in this field in China and provide empirical evidence from a Chinese perspective for cross-cultural research. However, when studying juvenile delinquency, few studies focus on female juvenile offenders. They may have unique experiences and challenges that differ from male offenders [ 12 ]. The underrepresentation of female juvenile offenders in scholarly research is a significant gap that our study aims to address. Historically, the majority of studies in juvenile delinquency have centered on male populations, leading to a skewed understanding of the factors contributing to criminal behavior and the effective interventions needed for rehabilitation. This gender bias overlooks the unique socio-cultural, psychological, and environmental factors influencing female adolescents’ pathways into criminal behavior. Female juvenile offenders often face distinct challenges and vulnerabilities compared to their male counterparts. Research indicates that girls are more likely to experience certain forms of trauma, such as sexual abuse, which can have profound impacts on their psychological development and lead to different coping mechanisms, including delinquent behavior [ 13 , 14 ]. Furthermore, societal norms and gender expectations can exacerbate the stigma and shame associated with female delinquency, influencing their self-esteem and identity formation [ 15 ]. Understanding the specific needs and experiences of female juvenile offenders is crucial for developing targeted interventions that address the root causes of their criminal behavior and support their rehabilitation and reintegration into society.

In recent years, there has been an increasing focus on understanding the specific relationship between childhood maltreatment and juvenile delinquency. Research findings indicate a positive correlation between these two factors, with individuals who experienced physical abuse during childhood being more likely to exhibit aggressive behavior during adolescence [ 16 ]. This highlights the importance of prevention and intervention measures targeting childhood physical abuse to mitigate its impact on later criminal activities. Related studies have explored the relationship between early traumatic experiences and criminal behavior, primarily focusing on male prisoners. However, their research findings suggest that the impact of early trauma may also have significant implications for criminal behavior among female juveniles [ 17 ]. Some researchers investigated the link between childhood emotional abuse and potential aggressive behavior in early adulthood. Their study emphasizes the importance of mentalization abilities as a mediating factor in this relationship. Mentalization refers to the ability to understand the mental states underlying human behavior, which may be crucial for female juveniles in processing the impact of emotional abuse and avoiding the development of criminal behavior [ 18 ]. Furthermore, research has highlighted the role of gender in the impact of abuse, as female participants exhibited BDSM-type sexual addiction, self-attacking behaviors, and alcohol abuse [ 19 ]. This case study emphasizes the need for gender-specific interventions and support systems for female juveniles who have experienced abuse and violence. The “life course perspective” model suggests that childhood abuse indirectly increases the propensity for criminal behavior later in life by exacerbating juvenile delinquency. When juvenile offenders are labeled by society, this initial deviance may be reenacted in later life, leading to the recurrence of criminal behavior [ 20 ].

The process of being socially labeled intensifies feelings of social exclusion, thereby reducing opportunities for behavioral correction or reintegration into society [ 21 ]. This negative cycle makes it more likely for abused juveniles to continue engaging in criminal activities in adulthood. While the life course perspective model emphasizes the indirect pathway from childhood abuse to criminal behavior in adulthood through juvenile delinquency, we must recognize that various factors can mediate the direct link between these two variables. Individual coping mechanisms, the presence of social support systems, and access to effective interventions can all play a role in mitigating the long-term negative effects of abuse [ 22 ]. This implies that not all individuals who experience childhood maltreatment will follow a criminal trajectory, as positive factors at the societal, familial, and individual levels can intervene and alter the course of criminality. The relationship between childhood maltreatment and criminal behavior among female juveniles is a complex process involving the interaction of multiple factors, encompassing both direct influences and indirect effects through juvenile delinquency. The studies reviewed in this literature review highlight the importance of considering the specific forms of maltreatment, such as physical and emotional abuse, as well as the role of gender in shaping the psychological and behavioral outcomes of maltreatment. Consistent with the proposal, we formed our hypothesis 1 as follows: Childhood maltreatment is an important influencing factor in the criminal behavior of juvenile female offenders.

Childhood maltreatment, including various forms of abuse and neglect, is considered a significant risk factor for a range of adverse outcomes, including low self-esteem. Self-esteem is defined as an individual’s overall subjective evaluation of their own worth and plays a crucial role in psychological well-being and social functioning. Shen (2009) investigated the combined impact of interparental violence and child physical abuse on juvenile self-esteem, and the results showed that both forms of abuse experienced during childhood had long-term detrimental effects on self-esteem in adulthood [ 23 ]. This finding highlights the compound impact of various forms of abuse on an individual’s self-perception and worth, emphasizing the need for comprehensive interventions targeting multiple forms of maltreatment. Additionally, The study sampled emerging adults from low socioeconomic backgrounds and examined the relationship between childhood maltreatment and various adverse psychological outcomes, including reduced self-esteem [ 24 ]. Their research adds to the literature linking childhood maltreatment to negative psychological outcomes, highlighting the importance of considering socioeconomic factors when examining the impact of abuse on self-esteem. Furthermore, study found a negative correlation between childhood maltreatment and self-esteem [ 25 ]. Researchers further explored the correlation between self-esteem and child abuse. The study found that psychological abuse and neglect were negatively correlated with self-esteem, which in turn was associated with various forms of internalizing and externalizing behavior problems [ 26 , 27 , 28 ]. In addition, study explored the protective role of self-related resources, such as self-esteem and self-compassion, in the relationship between childhood maltreatment and subjective well-being in early adulthood [ 29 ]. Collectively, the research findings emphasize the significant impact of childhood maltreatment on self-esteem. Based on the above discussion, by combining the aforementioned hypotheses, this study proposes the following hypothesis 2: Childhood maltreatment has a significant impact on self-esteem in juvenile female offenders.

In recent years, research on childhood shame has become increasingly rich, with numerous studies demonstrating that experiences of shame have profound effects on individual psychological health and self-perception, and are also closely related to childhood maltreatment. A study investigated the direct link between childhood maltreatment and the development of shame, demonstrating that these experiences largely contribute to subsequent shame [ 30 ], And further explored the relationship between childhood maltreatment and shame by examining how maladaptive schemas mediate this link [ 31 ]. Their research findings suggest that maladaptive schemas formed due to abuse heighten sensitivity to shame and guilt, which in turn affects emotion regulation and self-esteem. Some researchers explored the psychological pathways from childhood maltreatment to depression and crime, highlighting the process of juvenile shame transforming into guilt and self-blame [ 32 , 33 ]. There are also some studies explored the broader societal impact of shame, examining its relationship with racism, social anxiety, and bullying victimization [ 34 , 35 ]. These studies indicate that shame not only stems from direct abuse but can also be exacerbated by social threats to an individual’s relationships and status, further impacting self-esteem and psychological well-being. This research emphasizes the importance of considering the social context in which shame arises and its far-reaching effects on individual well-being. Several studies focused on specific populations, such as individuals with psychosis, investigating the impact of socially induced shame, self-blame, and low self-esteem [ 36 , 37 ]. These studies provide deeper insights into how internalized shame and self-esteem mediate the relationship between stigma, emotional distress, and recovery in individuals with psychosis, highlighting the central role of shame in the experience of mental health challenges. The reviewed research suggests that shame plays a crucial role in the relationship between childhood maltreatment and various psychological outcomes, including self-esteem. The internalization of shame often stems from maladaptive schemas and social pressures, significantly impacting an individual’s self-esteem, emotional well-being, and behavioral patterns. Recognizing the central role of shame in these dynamics is essential for developing targeted interventions to mitigate the long-term effects of childhood maltreatment and promote resilience and recovery. Based on the above analysis, we propose hypothesis 3: Shame mediates the relationship between childhood maltreatment and self-esteem in juvenile female offenders.

In summary, this study aims to uncover childhood maltreatment as an important influencing factor in juvenile female offenders’ criminal behavior, as well as its relationship with self-esteem and shame, and to examine the mediating effect of shame in the relationship between childhood maltreatment and self-esteem, thereby analyzing the sociopsychological mechanisms of juvenile female offenders’ criminal behavior. This study plans to establish a mediation model to deeply explore the influence of sociopsychological mechanisms such as childhood maltreatment, self-esteem, and shame on the criminal behavior of juvenile female offenders. The research results will help provide targeted recommendations for the prevention and intervention of childhood maltreatment and reduce the long-term negative impact of abuse. Additionally, the research results will provide a basis for the psychological treatment and rehabilitation of female offenders, aiding in the design of intervention programs focusing on self-esteem and shame. Furthermore, this study will also provide references for reducing the risk of recidivism among female offenders and formulating effective rehabilitation and re-socialization strategies.

Participants and procedure

China contains 681 prisons, due to the large number of prisons this study randomly selected 11 provinces prisons, which contain 3 prisons in west of China,4 prison in east of China prison and 4 central prisons of China. From June to July 2023, Paper questionnaires were distributed to juvenile female offenders in these 11 provinces, yielding a total of 1,321 responses. All of the questionnaires are received back, after selected all those questionnaires 1,227 valid responses were obtained, resulting in a questionnaire validity rate of 92.88%, the invalid questionnaires contains unclear answers and blurry messages, and deleted all those questionnaires.

Among the participants, the majority were non-only children (84.27%), with most having an educational level of junior high school or below (59.90%). The majority resided in rural areas (48.90%), came from families where the parents were in their first marriage (68.05%), and had moderate family economic conditions (56.07%). The most common offenses were sexual crimes and fraud (19.64% and 23.88%, respectively), with the majority of crimes being committed in groups (60.64%).

Before the study, informed consent was obtained from departmental and prison leaders as well as the juvenile female offenders themselves. The survey was conducted in a group format, led by two psychology postgraduate students in each prison area. A standardized introduction was used to ensure all participants clearly understood the purpose and process of the survey. The entire survey took approximately 15 min to ensure necessary information was collected efficiently. This study was approved by the Ethics Review Committee of Nanshan Hospital of Shandong Province (Approval Number: [2023-07-X105]). All of the procedures were performed in accordance with the Declaration of Helsinki and relevant policies in China. All participants agreed to participate voluntarily, with informed consent when they fled in the survey.

Demographic questionnaire

We used a self-compiled demographic questionnaire to survey: Only child status (Yes/No), Place of origin, Education Level, Type of Residence, Parental Marital Status(Intact/Remarried/Single Parent), Types of Crime(Property Crime/ Violent Crime/ Sexual Crime /Other), Family’s Economic Status in the Local Area(Better Off/Average/Below Average/Poor).

Childhood trauma questionnaire (CTQ)

The Childhood Trauma Questionnaire (CTQ) developed by Bernstein (1998) [ 38 ] and later translated and modified into Chinese by Zhao Xingfu (2004) [ 39 ] was used. Designed to measure maltreatment experiences before the age of 16, this questionnaire serves as a screening tool to identify individuals with childhood abuse and neglect experiences. The questionnaire comprises five sub-questionnaires with five items each: emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect. Scoring ranges from “never"=1 to “always"=5. Out of 28 questions, 25 assess the questionnaire’s main components, and 3 identify individuals denying childhood issues. The total score of the sub-questionnaires ranged from 0 to 25, with higher scores indicating more severe abuse. The Cronbach’s alpha coefficients of the subscales ranged from 0.79 to 0.92, indicating good reliability.

Self-esteem scale (SES)

The Self-Esteem Scale (SES), developed by the Rosenberg, is used to assess juveniles’ overall sense of self-worth and self-acceptance. It consists of 10 items, each rated on a four-point scale: 1 indicates “strongly agree,” 2 indicates “agree,” 3 indicates “disagree,” and 4 indicates “strongly disagree.” Items 3, 5, 8, 9, and 10 are reverse-scored. The total score ranges from 10 to 40, with higher scores indicating higher levels of self-esteem [ 40 ]. In this study, the Cronbach’s alpha coefficient for the scale was 0.86.

Shame questionnaire for juvenile offenders

The Shame Questionnaire for Juvenile Offenders, a self-developed questionnaire, was used in this study. The questionnaire consists of 17 items, each rated on a 5-point scale ranging from 1 (completely disagree) to 5 (completely agree). It includes three dimensions: cognitive shame, emotional shame, and behavioral shame. Higher scores indicate higher levels of shame among juvenile female offenders. In this study, the fit indices of a confirmatory factor analysis model of the scale were RMSEA = 0.06, TLI = 0.90, and CFI = 0.91. The Cronbach’s alpha coefficients for the overall questionnaire and its three dimensions were 0.86, 0.82, 0.81, and 0.72, respectively. The split-half reliabilities were 0.71, 0.78, 0.77, and 0.81, respectively.

Statistical analysis

This study has adopted IBM SPSS22.0 statistical software for all data analyses. After the questionnaires were collected, all the data have been processed as follows: (1) Exploratory factor analysis was performed on all scales by SPSS22.0; (2) internal consistency was tested for all scales by SPSS22.0; (3) the Harman single-factor method has been adopted for the common method deviation test; (4) descriptive statistics, such as statistical means (M), standard deviations (SD), maximum and minimum values, and the Cronbach’salpha were computed; (5) Pearson correlation analysis to explore the relationship between childhood maltreatment, shame, and self-esteem; (6) T-tests were used to analyze relationship between the types of crime committed and the types of childhood maltreatment experienced, chi-square analyses were performed; (7) a Structural Equation Modelling (SEM) approach was employed to test the theoretical model in the current study. PROCESS version 3.3 macro was used to construct the structural equations and to test the mediating effects [ 41 ]. The accepted level of significance was p  < 0.05.

Data processing and common method bias test

In this study, common method bias was controlled through anonymous surveys and reverse scoring of some items. To further assess this bias, Harman’s single factor analysis method was used. The analysis revealed five factors without rotation, accounting for 59.95% of the total variance. The first factor explained 33.41% of the variance, below the 40% threshold, indicating that the data were not significantly affected by common method bias [ 42 ].

Descriptive statistics of variables

The study participants consisted of 1,227 female juveniles deprived of liberty due to various criminal offenses, as recorded in the reviewed files. Table  1 reveals that the most common type of offense was property crime, accounting for 33.98% ( n  = 417), followed by sexual crimes at 26.49% ( n  = 325), violent crimes at 7.91% ( n  = 97), and other types of crimes at 31.62% ( n  = 388). However, the majority of these juveniles were exposed to negative elements within their marginalized family and educational environments. As depicted in Table  1 , the percentage of family context issues (parental marital status and domestic abuse) was higher than other contexts. This was followed by school educational context (dropout rates), and lastly socio-economic context (poor economic conditions and living in marginalized and inappropriate environments), indicating that these risk factors contribute to the criminal behavior among female juvenile offenders.( Table  1 ).

Types and degrees of childhood maltreatment in female juvenile offenders

Table  2 presents the percentage distribution of types of childhood maltreatment based on the degree experienced by the female juvenile offenders studied. Significant percentages were observed at moderate and high levels, indicating the presence of maltreatment among these juveniles. Indeed, in Table  2 , it can be seen that there is a prevalence of moderate to high degrees of emotional abuse, sexual abuse, physical neglect, and emotional neglect among the female juvenile offenders.

Comparison between types of crime and types of childhood maltreatment

Table  3 presents the results of the analysis of differences between types of crime and types of childhood maltreatment. Significant differences were found among the four groups in terms of emotional abuse ( p  < 0.001), physical abuse ( p  < 0.05), emotional neglect p  < 0.01), and physical neglect ( p  < 0.05). However, no significant difference was observed for sexual abuse ( p  > 0.05). The effect sizes ( η2 ) for these differences were small, ranging from 0.004 to 0.015. The violent crime group had the highest mean scores for emotional abuse, physical abuse, emotional neglect, and physical neglect compared to the other crime type groups.

Chi-square analysis of self-esteem, shame, and crime types

Table  4 presents the results of the chi-square analysis of self-esteem, shame, and crime type among juvenile female offenders. The participants were categorized into four groups based on their crime types. Significant differences were found among the four groups in terms of self-esteem (t = 4.36, p  < 0.01) and shame (t = 3.59, p  < 0.01). The violent crime group had the highest mean scores for both self-esteem and shame compared to the other crime type groups. The property crime group had the lowest mean scores for self-esteem and shame. The results suggest that juvenile female offenders who committed violent crimes tend to have higher levels of self-esteem and shame compared to those who committed other types of crimes.

Correlation analysis of childhood maltreatment, self-esteem, and shame

Table  5 presents the results of the correlation analysis of childhood maltreatment, self-esteem, and shame among juvenile female offenders. The analysis revealed significant positive correlations among various types of childhood maltreatment. However, sexual abuse was negatively correlated with emotional neglect ( r = -0.185, p  < 0.001) and not significantly correlated with physical neglect ( r = -0.053, p  > 0.05). Childhood maltreatment was positively correlated with self-esteem ( r  = 0.351, p  < 0.001) and shame ( r  = 0.330, p  < 0.001). Self-esteem was also positively correlated with shame ( r  = 0.414, p  < 0.001). These findings suggest that juvenile female offenders who experienced higher levels of childhood maltreatment tend to have higher levels of self-esteem and shame. The results also indicate that different types of childhood maltreatment are interrelated, and they collectively contribute to the development of self-esteem and shame among juvenile female offenders. This result confirms Hypothesis 2.

Mediation analysis

The analysis of the mediation effects of exercise imagery showed that the mediation effect of shame was 0.042, and its bootstrap 95% confidence interval did not contain 0 (0.033, 0.052), which indicates that its mediation effect was significant (see Table  6 ; Fig.  1 ), This result confirms Hypothesis 3.

Diagram of structural equation model

Child abuse, encompassing neglect and harm to children under 18, includes emotional abuse, physical abuse, neglect, and sexual abuse. Emotional neglect occurs when a child’s emotional and relational needs are unmet due to a lack of attention. Emotional abuse involves inappropriate behaviors that disrespect a child’s relationships with others, potentially negatively impacting their psychological and emotional development. Additionally, physical neglect includes inadequate and unsafe supervision of minors, potentially placing them in danger and even predisposing some juveniles to criminal pathways [ 43 ]. This study conducted an explorative analysis of 1,227 female juveniles deprived of liberty for various offenses, aiming to explore the relationship between their experiences of childhood maltreatment and subsequent criminal behavior. The study found a close association between childhood experiences of maltreatment, particularly emotional abuse, physical abuse, and emotional neglect, and criminal behavior in juvenile females. Significant differences were observed in the levels of emotional abuse, physical abuse, and emotional neglect across different types of criminal activities, indicating that the severity of maltreatment may influence the inclination of young women to commit various types of crimes. Specifically, property crimes, violent crimes, and other types of offenses showed significant correlations with all forms of childhood maltreatment. These findings align with domestic and international research [ 44 , 45 , 46 ], further confirming the impact and formation process of childhood maltreatment on juvenile criminal behavior.

The results of this study indicate that different types of childhood maltreatment experiences are prevalent among juvenile female offenders. Emotional neglect had the highest mean score, suggesting that this type of maltreatment was the most common in the sample. The positive skewness of all maltreatment types indicates that most participants reported lower levels of maltreatment experiences, while a few individuals experienced more severe maltreatment. Sexual abuse had the highest skewness and kurtosis values, indicating that the distribution of sexual abuse experiences was more uneven compared to other types of maltreatment, with a few participants reporting extremely high levels of sexual abuse. These findings are consistent with previous research, demonstrating that childhood maltreatment is common among female offenders [ 47 ]. Studies have also shown that different types of maltreatment may have distinct impacts on an individual’s developmental trajectory [ 48 ]. For example, sexual abuse may be associated with more severe mental health problems and a higher risk of criminal behavior [ 49 ]. Therefore, it is crucial to consider the maltreatment experiences of female offenders and their potential differential effects when working with this population.

This study found significant differences in the types and severity of childhood maltreatment experienced by juvenile female offenders across different crime types. The violent crime group had the highest mean scores on most maltreatment types, suggesting that this group may have experienced more severe maltreatment. This finding is consistent with previous research indicating an association between childhood maltreatment experiences and violent offending [ 50 ]. Violent offenders may have internalized aggressive behavior through social learning processes, or maltreatment experiences may have led to difficulties in emotion regulation and impulse control, increasing the risk of violent behavior [ 51 ]. However, no significant differences were found in sexual abuse, which is inconsistent with some previous studies that have shown an association between sexual abuse and sexual offending [ 52 ]. This discrepancy may be due to differences in sample characteristics or measurement methods. Future research should further explore the relationship between sexual abuse and sexual offending and the potential moderating factors that may influence this relationship. Although there were significant differences between crime type groups, the effect sizes were small, suggesting that maltreatment experiences may be just one of many factors influencing criminal behavior. Other factors, such as individual characteristics, family dynamics, peer influences, and community contexts, may also play important roles in the development of female criminal behavior [ 53 ]. Therefore, prevention and intervention efforts should adopt a multifaceted approach that addresses not only maltreatment issues but also other relevant risk and protective factors.

The results of this study indicate that juvenile female offenders of different crime types differ significantly in self-esteem and shame. The violent crime group had the highest mean scores on self-esteem and shame, while the property crime group had the lowest scores. This finding is partially consistent with previous research suggesting that violent offenders may have higher self-esteem [ 54 ]. The high self-esteem of violent offenders may serve as a defensive mechanism to cope with feelings of shame and guilt or may reflect positive attitudes toward aggressive behavior [ 55 ]. However, the violent crime group also reported higher levels of shame, which is inconsistent with some previous studies that have shown a negative association between shame and aggressive behavior [ 56 ]. This discrepancy may reflect the multifaceted nature of shame, which can either promote or inhibit aggressive behavior, depending on how individuals cope with shame [ 57 ]. For some violent offenders, high shame may lead to aggressive behavior as a way to externalize their shame. Future research should further explore the complex relationship between shame and violent offending and the potential moderating factors that may influence this relationship. The property crime group had the lowest scores on self-esteem and shame, suggesting that this group may have unique difficulties in emotional regulation. Low self-esteem and low shame may reflect negative evaluations of self-worth and a lack of concern for the consequences of criminal behavior. Prevention and intervention efforts should focus on enhancing self-esteem among property offenders while fostering healthy shame and empathy.

This study explored the relationships between childhood abuse, self-esteem, and shame, and the results revealed significant positive correlations among these variables. This finding is partially consistent with previous research, which has shown a positive correlation between childhood abuse and shame [ 58 ]. Abusive experiences may lead individuals to form negative self-evaluations and internalize shame [ 59 ]. However, the positive correlation between childhood abuse and self-esteem is inconsistent with most prior studies, which have found associations between childhood abuse and low self-esteem [ 60 ]. The positive correlation in the current study may reflect a defensive form of high self-esteem, a fragile and unstable form of self-esteem that appears as narcissism on the surface but hides deeper insecurities and self-doubts [ 61 ]. This defensive high self-esteem may serve as a coping mechanism to deal with the emotional pain and shame resulting from abusive experiences. The positive correlation between self-esteem and shame further supports the concept of defensive high self-esteem. Individuals with defensive high self-esteem may be more prone to experiencing shame because their self-esteem is built on an unstable foundation, making it vulnerable to threats and challenges [ 55 ]. When faced with difficulties or failures, they may be more likely to interpret these as reflections of their own deficiencies or inadequacies, triggering feelings of shame. These findings highlight the complex impact of childhood abuse on the emotional well-being of juvenile female offenders. While abusive experiences may lead to a superficially high self-esteem, this self-esteem may be fragile and defensive, associated with greater shame. Prevention and intervention efforts should focus on fostering genuine self-esteem, one that is based on self-acceptance and a sense of self-worth, rather than reliance on external validation [ 62 ].

The results of the mediation analysis indicate that childhood abuse affects self-esteem through two pathways: The direct effect suggests that experiences of childhood abuse may lead to increased self-esteem. The mediation effect suggests that childhood abuse also indirectly influences self-esteem by increasing feelings of shame. This finding supports the theoretical perspective that shame plays a crucial role in the impact of childhood abuse on self-esteem [ 59 ]. Childhood abuse may first evoke intense feelings of shame, which in turn may lead to changes in self-esteem. Shame may prompt individuals to adopt defensive strategies, such as displaying an inflated sense of self-esteem, to cope with painful emotions and self-doubt [ 55 ]. The study results provide valuable information for formulating prevention and intervention measures targeting female juvenile offenders. Particularly in family and educational environments, more attention and resources are needed to mitigate these environmental factors’ negative impacts on young women and to provide necessary support and treatment for those who have already suffered abuse.

Practical implications

The findings of this study have important practical implications for the prevention and treatment of criminal behavior in juvenile female offenders with a history of childhood maltreatment. The results emphasize the necessity of early identification and intervention for abused children, the importance of incorporating shame-reduction and self-esteem building strategies into treatment programs, and the need for a comprehensive treatment approach. Furthermore, the study highlights the need for further research to develop and evaluate targeted interventions for this population, which may help reduce recidivism rates and improve long-term outcomes.

Limitations and future directions

The study’s limitations include reliance on self-report measures, potential recall or reporting bias, and a cross-sectional design that precludes causal inferences. Future research should incorporate diverse data sources, employ longitudinal designs, and investigate additional correlates of criminal behavior to gain a more comprehensive understanding of female offending. The role of defensive high self-esteem in the relationship between childhood maltreatment and maladaptive outcomes, as well as potential moderating factors, warrant further exploration. Despite these limitations, the findings emphasize the importance of addressing childhood maltreatment in prevention and intervention efforts for female offenders. Trauma-informed care approaches may promote rehabilitation and reduce recidivism risk. Further research is needed to develop effective strategies fostering the healthy development of childhood maltreatment survivors.

Conclusions

This study investigated the relationships between childhood maltreatment, shame, and self-esteem among juvenile female offenders and explored the potential influencing factors on their criminal behavior. Notably, the study found that childhood maltreatment was positively associated with both shame and self-esteem, suggesting that abusive experiences may lead to a defensive form of high self-esteem that masks underlying insecurities and self-doubt. Mediation analysis further indicated that childhood maltreatment affects self-esteem through direct and indirect pathways. The direct effect suggests that childhood abuse may lead to increased self-esteem, possibly reflecting a defensive coping mechanism. The indirect effect, mediated by shame, suggests that childhood maltreatment may first evoke intense feelings of shame, which in turn influence self-esteem. Shame may prompt individuals to adopt defensive strategies, such as displaying an inflated sense of self-esteem, to cope with painful emotions and self-doubt.

Data availability

No datasets were generated or analysed during the current study.

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Author Xiaomei Chen wrote the main manuscript text. Author Bo Dai handled data collection and prepared figures. Author Shuang Li contributed to literature collection and review. Author Lili Liu contributed to data collection. All authors reviewed the manuscript.

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Chen, X., Dai, B., Li, S. et al. Childhood maltreatment, shame, and self-esteem: an exploratory analysis of influencing factors on criminal behavior in juvenile female offenders. BMC Psychol 12 , 257 (2024). https://doi.org/10.1186/s40359-024-01758-x

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Childhood maltreatment responsible for up to 40% of mental health conditions among Australians, finds research

by University of Sydney

A study examining childhood maltreatment in Australia has revealed the shocking burden for Australians, estimating it causes up to 40% of common, life-long mental health conditions.

The mental health conditions examined were anxiety, depression, harmful alcohol and drug use, self-harm and suicide attempts . Childhood maltreatment is classified as physical, sexual and emotional abuse , and emotional or physical neglect before the age of 18.

Childhood maltreatment was found to account for 41% of suicide attempts in Australia, 35% for cases of self-harm and 21% for depression.

The analysis, published in JAMA Psychiatry , is the first study to provide estimates of the proportion of mental health conditions in Australia that arise from childhood maltreatment . The researchers said the results are a wakeup call for childhood abuse and neglect to be treated as a national public health priority.

"The results are devasting and are an urgent call to invest in prevention—not just giving individual support to children and families, but wider policies to reduce stress experienced by families," said Dr. Lucinda Grummitt, from the University of Sydney's Matilda Centre, who led the study. "Investments to address childhood maltreatment have the potential to avert millions of cases of mental disorders in Australia."

The analysis also found that if childhood maltreatment were eradicated in Australia, more than 1.8 million cases of depression, anxiety and substance use disorders could be prevented.

The study also found that elimination of childhood maltreatment in Australia would have prevented 66,143 years of life lost (death) and 118,493 years lived with disability in 2023, totaling 184,636 years of healthy life lost through mental health conditions.

Researchers examined data that included national surveys provided by the Australian Child Maltreatment Study in 2023 (8,500 participants), the Australian National Study of Mental Health and Wellbeing 2020-2022 (15,893 participants) and the Australian Burden of Disease study 2023.

The study made use of analytical methods to investigate the link between child maltreatment and mental health, which isolated other influential factors such as genetics or social environments. This provides stronger evidence that childhood maltreatment causes some mental health conditions .

Mental health conditions are currently the leading cause of disease burden globally and affect 13% of the global population. In Australia, suicide is the leading cause of death for young people.

Previous research (independent of the University of Sydney study) had found that over half (53.8%) of Australians experienced maltreatment during their childhood.

Dr. Grummitt said there are effective interventions, such as programs to support children experiencing maltreatment or parent education programs, but the most sustainable solution to prevent child maltreatment is policy-driven prevention.

"Policies to alleviate stress experienced by families, such as paid parental leave , affordable childcare, income support like Jobseeker, and making sure parents have access to treatment and support for their own mental health could make a world of difference for Australian children. Addressing the societal and economic conditions that give rise to child maltreatment can play a large part in preventing mental disorders at a national level," Dr. Grummitt said.

The researchers cite an example in the United States where the introduction of state paid parental leave policies and timely access to subsidized childcare were strongly linked to reduced rates of child maltreatment.

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Childhood maltreatment responsible for up to 40 percent of mental health conditions

A study examining childhood maltreatment in Australia has revealed the shocking burden for Australians, estimating it causes up to 40 percent of common, life-long mental health conditions.

The mental health conditions examined were anxiety, depression, harmful alcohol and drug use, self-harm and suicide attempts. Childhood maltreatment is classified as physical, sexual and emotional abuse, and emotional or physical neglect before the age of 18.

Childhood maltreatment was found to account for 41 percent of suicide attempts in Australia, 35 percent for cases of self-harm and 21 percent for depression.

The analysis, published in JAMA Psychiatry is the first study to provide estimates of the proportion of mental health conditions in Australia that arise from childhood maltreatment.  

The researchers said the results are a wakeup call for childhood abuse and neglect to be treated as a national public health priority.

“The results are devasting and are an urgent call to invest in prevention – not just giving individual support to children and families, but wider policies to reduce stress experienced by families,” said Dr Lucinda Grummitt , from the University of Sydney’s Matilda Centre , who led the study.

The analysis also found that if childhood maltreatment was eradicated in Australia, more than 1.8 million cases of depression, anxiety and substance use disorders could be prevented.

“Investments to address childhood maltreatment have the potential to avert millions of cases of mental disorders in Australia.”

The study also found elimination of childhood maltreatment in Australia would, in 2023, have prevented 66,143 years of life lost (death) and 118,493 years lived with disability, totaling 184,636 years of healthy life lost through mental health conditions.

Researchers examined data that included national surveys provided by the Australian Child Maltreatment Study in 2023 (8500 participants), the Australian National Study of Mental Health and Wellbeing 2020-2022 (15,893 participants) and the Australian Burden of Disease study 2023.

The study made use of analytical methods to investigate the link between child maltreatment and mental health, which isolated other influential factors such as genetics or social environments. This provides stronger evidence that childhood maltreatment causes some mental health conditions.

Mental health conditions are currently the leading cause of disease burden globally and affect 13 percent of the global population. In Australia, suicide is the leading cause of death for young people.

Previous research  (independent to the University of Sydney study) found over half (53.8 percent) of Australians experienced maltreatment during their childhood.

Dr Grummitt said there are effective interventions, such as programs to support children experiencing maltreatment or parent education programs, but the most sustainable solution to prevent child maltreatment is policy-driven prevention.

“Policies to alleviate stress experienced by families, such as paid parental leave, affordable childcare, income support like Jobseeker, and making sure parents have access to treatment and support for their own mental health could make a world of difference for Australian children.

“Addressing the societal and economic conditions that give rise to child maltreatment can play a large part in preventing mental disorders at a national level,” Dr Grummitt said.

The researchers cite an  example  in the United States where the introduction of state paid parental leave policies and timely access to subsidised childcare were strongly linked to reduced rates of child maltreatment.

If you or anyone needs help:

• Lifeline  on 13 11 14
• Kids Helpline  on 1800 551 800
• MensLine Australia  on 1300 789 978
• Suicide Call Back Service  on 1300 659 467
• Beyond Blue  on 1300 22 46 36
• Headspace  on 1800 650 890
• QLife  on 1800 184 527
• ReachOut  at  au.reachout.com

Declaration:  The authors have no conflicts of interest to declare.

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Study shows generational decline in australia's mental health, screen time, alcohol & poor sleep for girls: how the pandemic impacts teens, moving on from covid means facing its impact on mental health, say experts.

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Maltreatment, Violence, and Self-Injury

At a glance.

Although children with disabilities are no more aggressive than other children, they may have an increased chance of being victims of bullying, abuse, and neglect.

Childhood maltreatment

• Parents can more easily become stressed with the demands placed on them by parenting a child with a disability.
• Kids with behavior problems, such as attention-deficit / hyperactivity disorder (ADHD) or other conduct problems, may be more likely to experience physical abuse because parents can become frustrated by the child's difficult behavior and respond harshly.
• Kids who are less able to do things independently rely more on adults for their care. These children may be more likely to be sexually abused or neglected by adults.
• Abusers may take advantage of kids who have problems speaking, hearing or who don't understand social situations very well. These children may be more likely to experience sexual abuse.

Youth violence and aggression

Most children with developmental disabilities are not any more violent or aggressive than other children. However, some children may feel a lot of frustration related to their developmental disability.

• This frustration is sometimes shown through aggression or even self-harming behaviors, such as banging their head or cutting their skin.
• Other children have conditions that are more directly connected to aggressive behavior. For example, children with oppositional defiant disorder are often annoyed and angry, and they argue with adults in order to gain control.

There are many reasons children with developmental disabilities may have aggression problems. It is important to remember that everyone has times when they get frustrated or angry, and children should be taught that frustration is normal. It is best to try to understand the reasons behind the aggression and violence. Knowing this will help parents and health professionals work toward reducing the problems; teaching the child ways to cope with frustration should be part of this plan.

Children with disabilities may have low self-esteem or feel depressed, lonely or anxious because of their disability, and bullying may make this even worse. Bullying can cause serious, lasting problems not only for children who are bullied but also for children who bully and those who witness bullying.

Children do not always know when they are bullied. They might feel bad but don't know how to talk about it. Children with disabilities that affect how they think, learn, or interact with others might need a very detailed explanation about how to recognize bullying when it happens to themselves or others.

Self-injury

Children and youth with developmental disabilities, such as autism and intellectual disability, are more likely to engage in other forms of self-injury than children without these disabilities. 1 2 3 Youth with depression, anxiety disorder, and conduct disorder have a higher chance of self-violence, including suicide, than children without these disorders. 4

It is important to understand the reasons for self-directed violence and other forms of self-injury among children with disabilities in order to find the best treatment. It is also important to coordinate care given by family, school, and healthcare providers.

Find help: SAMHSA's 988 Suicide and Crisis Helpline ‎

• Schroeder, S.R., Oster-Granite, M.L., and Thompson, T. (Eds.) (2002). Self-injurious behavior: Gene-brain-behavior relationships. Washington, D.C.: American Psychological Association.
• Richards, C., Oliver, C., Nelson, L., & Moss, J. (2012). Self-injurious behaviour in individuals with autism spectrum disorder and intellectual disability . Journal of Intellectual Disabilities Research, 56, 476-489.
• Soke GN, Rosenberg SA, Hamman RF, et.al. Prevalence of Self-injurious Behaviors among Children with Autism Spectrum Disorder—A Population-Based Study . Journal of Autism and Developmental Disorders. 2016.
• Meltzer, H., Harrington, R., Goodman, R., Jenkins, R. (2001) Children and adolescents who try to harm, hurt or kill, themselves. National Statistics: London.

Child Development

The early years of a child’s life are very important for their health and development. Parents, health professionals, educators, and others can work together as partners to help children grow up to reach their full potential.

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Committee on Child Maltreatment Research, Policy, and Practice for the Next Decade: Phase II; Board on Children, Youth, and Families; Committee on Law and Justice; Institute of Medicine; National Research Council; Petersen AC, Joseph J, Feit M, editors. New Directions in Child Abuse and Neglect Research. Washington (DC): National Academies Press (US); 2014 Mar 25.

New Directions in Child Abuse and Neglect Research.

• Hardcopy Version at National Academies Press

1 Introduction

The 1993 National Research Council (NRC) report Understanding Child Abuse and Neglect notes that “Child maltreatment is a devastating social problem in American society” ( NRC, 1993 , p. 1). The committee responsible for the present report, armed with research findings gleaned during the past 20 years, regards child abuse and neglect not just as a social problem but as a serious public health issue. Researchers have found that child abuse and neglect affects not only children but also the adults they become. Its effects cascade throughout the life course, with costly consequences for individuals, families, and society. These effects are seen in all aspects of human functioning, including physical and mental health, as well as important areas such as education, work, and social relationships. Furthermore, rigorous examinations of risk and protective factors for child abuse and neglect at the individual, contextual, and macrosystem levels have led to more effective strategies for prevention and treatment.

This public health problem requires swift and effective action. The committee's deliberations led to recommendations for responding to the problem of child abuse and neglect while remaining realistic about the nature of feasible actions in these challenging political and economic times. The intent is to capitalize on existing opportunities whenever possible while advocating for new actions when they are needed.

The committee also believes that the existing body of research creates enormous opportunities for research going forward; the nation is poised to take full advantage of a developing science of child abuse and neglect. In particular, the results of studies of the consequences of child abuse and neglect, integrating biological with behavioral and social context research, as well as studies and controlled prevention trials that integrate basic findings with services research, now provide a solid base for moving forward with more sophisticated and systematic research designs to address important unanswered questions. New knowledge and better research tools can yield a better understanding of the causes of child abuse and neglect, as well as the most effective ways to prevent and treat it.

At the same time, however, the existing research and service system infrastructures are inadequate for taking full advantage of this new knowledge. The committee hopes that this gap will narrow as researchers in diverse domains collaborate to elucidate the underlying causes and consequences of child abuse and neglect, as those implementing promising interventions learn how best to take evidence-based models to scale with fidelity, and as policies are examined more rigorously for their ability to improve outcomes and create a coordinated and efficient system of care.

• THE 1993 REPORT

Two decades ago, the Administration on Children, Youth and Families (ACYF) within the U.S. Department of Health and Human Services asked the National Academy of Sciences to conduct a study of research needs in the area of child abuse and neglect. That study resulted in the 1993 NRC report, which synthesizes the research on child abuse and neglect and, adopting a child-oriented developmental and ecological perspective, outlines 17 research priorities in an agenda that addresses 4 objectives:

clarify the nature and scope of child maltreatment;

provide an understanding of the origins and consequences of child maltreatment to improve the quality of future policy and program efforts;

provide empirical information about the strengths and limitations of existing interventions while guiding the development of more effective interventions; and

develop a science policy for child maltreatment research that recognizes the importance of national leadership, human and financial resources, instrumentation, and appropriate institutional arrangements.

• TRENDS SINCE 1993

Since the 1993 report, research on child abuse and neglect has expanded, and understanding of the consequences and other aspects of child abuse and neglect for the children involved, their families, and society has advanced significantly. During that same period, rates of reported physical and sexual abuse (but not neglect) have declined substantially, for reasons not fully understood. On the other hand, reports of psychological and emotional abuse have risen.

Child abuse and neglect nonetheless remains a pervasive, persistent, and pernicious problem in the United States. Each year more than 3 million referrals for child abuse and neglect are received that involve around 6 million children, although most of these reports are not substantiated. In fiscal year 2011, the latest year for which data are available, state child protective services agencies encountered 676,569 children, or about 9.1 of every 1,000 children, who were found to be victims of child abuse and neglect, including physical abuse, sexual abuse, psychological abuse, and medical and other types of neglect. More than one-quarter had been victimized previously. Of these 676,569 children, 1,545 died as a result of the abuse or neglect they suffered—most younger than 4 years old ( ACF, 2012 ). Yet these figures are underestimates because of underreporting ( GAO, 2011 ). For example, the estimate of the rate of child abuse and neglect by caretakers in 2005-2006 derived from the most recent National Incidence Study of Child Abuse and Neglect, a sample survey, was 17.1 of every 1,000 children (totaling more than 1.25 million children), and many more were determined to be at risk ( Sedlak et al., 2010 ). This uncertainty as to the extent of child abuse and neglect hampers understanding of its causes and consequences, as well as effective prevention and treatment interventions.

Research conducted since 1993 has made clear that child abuse and neglect has much broader and longer-lasting effects than bruises and broken bones or other acute physical and psychological trauma. As noted above, child abuse and neglect can have long-term impacts on its victims, their families, and society. Children's experiences of these long-term consequences vary significantly, depending on the severity, chronicity, and timing of abuse or neglect, as well as the protective factors present in their lives. Nevertheless, abused and neglected children are more prone to experience mental health conditions such as posttraumatic stress disorder and depression, alcoholism and drug abuse, behavioral problems, criminal behavior and violence, certain chronic diseases, and diminished economic well-being.

Society is also affected. Each year, cases of abuse or neglect may impose a cumulative cost to society of $80.3 billion—$33.3 billion in direct costs (e.g., hospitalization, childhood mental health care costs, child welfare system costs, law enforcement costs) and $46.9 billion in indirect costs (e.g., special education, early intervention, adult homelessness, adult mental and physical health care, juvenile and adult criminal justice costs, lost work productivity) ( Gelles and Perlman, 2012 ). An analysis by the Centers for Disease Control and Prevention found that the average lifetime cost of a case of nonfatal child abuse and neglect is $210,012 in 2010 dollars, most of this total ($144,360) due to loss of productivity but also encompassing the costs of child and adult health care, child welfare, criminal justice, and special education ( Fang et al., 2012 ). The average lifetime cost of a case of fatal child abuse and neglect is $1.27 million, due mainly to loss of productivity. These costs are comparable to those of other major health problems, such as stroke and type 2 diabetes, issues that garner far more research funding and public attention.

• THE CURRENT STUDY

In 2012, ACYF requested that the National Academies update the 1993 NRC report. ACYF asked that the updated report “provide recommendations for allocating existing research funds and also suggest funding mechanisms and topic areas to which new resources could be allocated or enhanced resources could be redirected.” Box 1-1 contains the complete statement of task for this study.

Statement of Task. Building on Phase 1, an ad hoc committee will conduct a full study that will culminate in an updated version of the 1993 NRC publication entitled Understanding Child Abuse and Neglect . Similar to the 1993 report, the updated report (more...)

• STUDY APPROACH

The Institute of Medicine of the National Academies appointed a committee with expertise in relevant areas—child development and pediatrics, psychology and psychiatry, social work and implementation science, sociology, and policy and legal studies—to conduct this study. The chair and one committee member had been the chair and a member, respectively, of the 1993 study committee, which provided for continuity. The committee commissioned a number of background papers that reviewed research results and research infrastructure needs in key areas of child abuse and neglect research. It held four face-to-face meetings, including two public sessions, as well as many whole-committee and subcommittee conference calls, to review the literature; discuss current understanding of the extent, causes, and consequences of child abuse and neglect, the effectiveness of intervention programs, and the impact of public policies; and discuss the draft report chapters and reach consensus on findings, conclusions, and recommendations.

In constructing the evidence base for this report, the committee looked back nearly 20 years to assess the state of research on child abuse and neglect. Doing so involved a conscious decision to privilege the peer-reviewed literature across a variety of disciplines (e.g., social-cultural science, developmental science, neuroscience, prevention and intervention science, epidemiology) and multiple dimensions of child abuse and neglect, including etiology, consequences, prevention, and intervention, as well as ethics, service delivery, and policy. The committee considered the most rigorous evidence drawn from a variety of study designs and methods, including mixed-methods, experimental, observational, prospective, retrospective, descriptive, longitudinal, epidemiological, meta-analysis, and cost-effectiveness studies.

The committee built on a literature review conducted as part of a workshop exploring major research advances since publication of the 1993 report ( IOM and NRC, 2012 ). That initial literature review yielded a brief updated summary of selected research literature, reports, and grey literature on the topics covered in the original report ( NRC, 1993 ). Relevant studies were selected through a search of several scientific databases and were augmented by additional research conducted by other agencies and organizations (see IOM and NRC, 2012 , for more detailed information).

The committee expanded on the 2012 literature review and critically examined publications derived from a literature database search, supplemented by the committee's knowledge of relevant work in the field. The review strategy began with a keyword search of electronic citation databases, followed by a review of the literature gleaned from published research syntheses, academic books, and peer-reviewed journals (i.e., Child Abuse and Neglect, Child Maltreatment, Children and Youth Services Review, Child Welfare, Protecting Children ); websites of research, nonprofit, and policy organizations (including evidence-based clearinghouses); professional conference proceedings; and other grey literature. Literature on child abuse and neglect in the United States was the primary focus; however, the committee also considered key studies from other countries. While the committee's approach did not represent a systematic review of the evidence, it did provide a body of research well suited to guide an understanding of critical issues and formulation of the recommendations presented in this report.

Definitions

As described in Chapter 2 , definitions of child abuse and neglect can vary considerably as legal definitions differ across states, and researchers apply diverse standards in determining whether abuse or neglect has occurred. A basic yet important definition of child abuse and neglect is contained in Section 3 of the Child Abuse Prevention and Treatment Act (CAPTA) 1 :

At a minimum, any recent act or set of acts or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act, which presents an imminent risk of serious harm.

While this federal definition sets a minimum standard for legal definitions, each state has developed its own definitions of child abuse and neglect. Child abuse and neglect are usually represented by four major categories: physical abuse, neglect, sexual abuse, and emotional (or psychological) abuse. Table 1-1 presents examples of acts that are considered to represent each of these four types of abuse and neglect, as compiled by the Child Welfare Information Gateway.

Examples of Acts of Child Abuse and Neglect.

The examples listed in Table 1-1 are drawn from state definitions of child abuse and neglect; however, they are not representative of any specific state. There is considerable variation across jurisdictions with regard to statutory descriptions of which acts constitute abuse or neglect. In addition, child abuse and neglect are defined in many contexts outside of legal and child protection system venues, research being the most notably germane to this report. Many studies identify cases of abuse and neglect through the use of survey instruments. Across these studies is found much variation in the types of questions asked of respondents and the types of responses that indicate instances of abuse or neglect. While some standards have been developed, definitions of child abuse and neglect in this context are often tailored to the needs of specific studies.

Given this definitional landscape, which is discussed further in Chapter 2 , the committee made two significant determinations with regard to definitions of child abuse and neglect for the purposes of this report. First, the scope of the discussion in this report is limited to actions (or inaction) of parents or caretakers, to the exclusion of extrafamilial abuse. This scope is reflective of the minimum definitional standard prescribed by CAPTA. Although individual jurisdictions may expand their definitions of abuse to include actions by extrafamilial parties, the CAPTA minimum standard is the most universally relevant to legal and child protection systems across the United States, as well as the data drawn from such sources for research purposes. Restricting the scope of this report to parent or caregiver actors also allowed the committee to conduct a more focused evaluation of the causes and consequences of abuse and neglect, as well as the delivery of prevention and treatment services, within the context of family and home. It is important to note that while this scope applies to the organization and content of the report, some of the studies discussed in the following chapters draw samples from jurisdictions that include instances of extrafamilial abuse in their definitions.

Second, the report does not specify a particular set of circumstances that would define whether or not an instance of child abuse or neglect has occurred. In addition to the need to review many studies that incorporate samples based on differing characterizations of acts of child abuse and neglect, there is insufficient evidence with which to determine the single most reliable, effective, and appropriate definitional approach. As studies are presented throughout the report, methodological limitations identified by the committee are described where applicable.

• RESEARCH ADVANCES IN CHILD ABUSE AND NEGLECT

As noted above, research conducted in the past 20 years has revealed child abuse and neglect to be a serious public health problem, but it has also revealed that rates of physical and sexual abuse of children (although not neglect) appear to have declined. Credited with the possible declines are some policy and practice reforms that include more aggressive prosecution of offenders, especially in the area of child sexual abuse; more effective treatment programs for victims of child abuse and neglect; and increased investments in prevention programs, especially for new parents. Yet contradictions and inconsistencies in the data demand more analysis.

Publications on child abuse and neglect increased more than threefold over the past two decades. Among the key areas seeing significant advances are (1) research on the consequences of child abuse and neglect, demonstrating that its effects are severe, long-lasting, and cumulative over adulthood; (2) research demonstrating effects on the brain and other biological systems, as well as on behavior and psychosocial outcomes; and (3) rigorous treatment and prevention research demonstrating the effectiveness of interventions.

Despite these advances, however, the research evidence also underscores how much remains unknown. More specific research designs and incorporation of core questions into studies examining factors that impact parental capacity and child development are needed to enable greater understanding and more effective prevention of child abuse and neglect. Also needed is a better understanding of the remarkable declines in reported child abuse, why children have differential sensitivity to abuse of similar severity, and how different types of abuse impact a child's developmental trajectory.

Needed as well are improved theories and research that can make it possible to disentangle the multiple causes and consequences of child abuse and neglect. The complexity of child abuse and neglect requires a systems approach, employing integrated, cross-disciplinary thinking, and research methods that can support better-specified model testing. Among specific improvements needed are refined theoretical models and research designs representing the relevant disciplines and ecological levels with appropriate specification of effects; multiple measures and methods for tracking core constructs, including neurological and other biological measures such as genetic and epigenetic factors; longitudinal research designs with which to assess the sequences of events that lead to abusive and neglectful behaviors and to identify treatment and prevention interventions that can protect against the intergenerational transfer of abuse and neglect; appropriate statistical analyses that differentiate effects at various ecological levels; appropriate statistical control to create more rigorous experimental opportunities when randomized controlled trials are infeasible for evaluating interventions; and designs that account for overlapping variance due to children's being nested within multiple layers of systems. Simpler designs and analyses can still play a role, especially when descriptive studies are needed to generate hypotheses. And essential for any study is clarity of the question being examined, preferably with a hypothesis that can be tested; the appropriate research design and statistical analysis can then be identified.

While some longitudinal studies on child abuse and neglect do exist, including the Longitudinal Studies in Child Abuse (LONGSCAN) and National Survey of Child and Adolescent Well-Being (NSCAW), additional longitudinal, prospective studies are needed. An example of the kind of study required is the Fragile Families and Child Wellbeing Study, which is following a cohort of nearly 5,000 children born in large U.S. cities between 1998 and 2000, with an oversample of 75 percent children born to unmarried parents (for further information, see www.fragilefamilies.princeton.edu ). This longitudinal study (now producing the sixth wave of data on children and their families 15 years after the original data collection) has examined many questions related to the nature of the sample, including child abuse and neglect (e.g., Guterman et al., 2009 ; Lee et al., 2008 ; Whitaker et al., 2007 ). The study employs embedded variables, such as children and parents within families, including all the variations that currently occur in families, and many types of data, from neighborhood characteristics to biological measures.

Importantly, this study serves as an example for the rigor of data analysis. A recent working paper by McLanahan and colleagues (2012) carefully reviews the literature on the causal effects of father absence to examine how study design impacts findings. The authors conclude that studies with more rigorous designs have found negative effects of father absence on child well-being, but with smaller effect sizes than have been found with standard cross-sectional designs. These conclusions demonstrate the importance of designing rigorous studies to examine complex questions such as those relating to child abuse and neglect. The Fragile Families study can provide a great deal of information on child abuse and neglect, and a similarly rigorous study designed to examine the many important questions concerning child abuse and neglect could do much more.

Both practice and policy research require similar improvements. Future research efforts need to address the impacts of service integration and the additive effects of conducting multiple interventions that simultaneously address the problem at the individual and community levels. While strengthening the response to child abuse and neglect will require continued rigorous prevention and treatment research on the efficacy of promising interventions, equally important is examining how such efforts can be replicated with quality and consistency. Finally, research is needed to understand the role and impacts of a more integrated, systemic response to child abuse and neglect with respect to participant outcomes and system performance. A better understanding also is needed of the utility and potential limitations of employing a singular focus on evidence-based decision making to guide policy and practice.

• A SYSTEMS FRAMEWORK FOR CHILD ABUSE AND NEGLECT

Research advances in child abuse and neglect make clear that attaining a better understanding of the problem and mounting an effective response will require a systems perspective (e.g., Senge and Sterman, 1992 ). The public health problem of child abuse and neglect encompasses many embedded systems that are engaged both positively and negatively in creating, sustaining, and responding to the problem. Such systems include individual development, family systems, social relationship systems, and service systems from the local to the national level, among others. All of these systems and factors within them involve complex interdependencies, such that efforts to solve one aspect of the problem may reveal or even create problems at other levels.

Systems thinking has been adopted in the child protection field both in the United States and globally (e.g., Wulczyn et al., 2010 ). As Wulczyn and colleagues note, the systems approach fits well with the major theoretical model in the field of child development—that of Bronfenbrenner (1979) . From any perspective, children can be considered in terms of the nested or embedded and interacting structures (e.g., families, communities) that affect them. Conversely, considering any child-related issue without taking such a perspective will be an incomplete exercise. From the perspective of the child protection system, all of the systems that work with children are highly entangled and must work in concert to achieve effective results ( Wulczyn et al., 2010 ). Figure 1-1 depicts the interplay among the actors, contexts, and components of child protection systems.

Child protection systems: actors, contexts, and components. SOURCE: Wulczyn et al., 2010 (reprinted with the permission of the paper authors).

Policy and program failures typically are considered to be system failures ( Petersen, 2006 ). They often involve a given system's establishing unsustainable ends or goals, or the use of approaches that fail to achieve the intended results and may have unintended consequences that may be worse than the initial problem. The common system failures (e.g., Senge and Sterman, 1992 ; Sterman, 2002 ) include misspecified ends, unintended consequences, drifting goals, underinvestment in capacity, and delays in delivering results.

An underlying problem that can contribute to all of these types of system failure is incomplete analysis of opportunities and challenges at the initial stage. To be effective, change efforts and the policies designed to sustain them must include a rigorous analysis of system dynamics. For example, the usefulness of systems analysis has been demonstrated in multiple successful applications to business challenges (e.g., Ford, 1990 ; Harris, 1999 ; Jones and Cooper, 1980 ), as well as in current efforts to apply systems analysis to the child protection system (e.g., Wulczyn et al., 2010 ). Systems analysis helps reveal mental models held by participants, including beliefs, assumptions, and presumed knowledge. This allows all participants in a change effort to recognize and take responsibility for their mental models and to account for them in the design of the change effort. In addition, systems analysis includes identification of potential barriers or challenges to implementation so that approaches to overcome them can be anticipated. Finally, the systems analysis approach views all solutions identified by the process as interim, systematically building feedback into the implementation of a change effort. By intentionally seeking, generating, and learning from feedback over time, participants in change efforts will improve their understanding of the system and efforts to improve it, and will see concomitant improvements in the efforts' results.

The complexity of child abuse and neglect makes the problem difficult to address in the absence of a full understanding of the diverse and multilevel systems that impact its incidence, consequences, and social response. By contrast, sustained and thoughtful systems thinking can lead to rigorous research designs that can advance knowledge and program or service implementation in meaningful ways. Such research can progress from addressing symptoms to focusing increasingly on core causes and solutions that draw more effectively on the strengths of multiple actors and domains.

Prevention of child abuse and neglect is a complex problem that can be solved only if many societal systems and the people within them cooperate to play positive roles ( Wulczyn et al., 2010 ). As with all complex societal problems, child abuse and neglect has no single cause; therefore, tackling the problem strategically at multiple levels is the only way to make a substantial impact on the problem.

• THE UNIQUE ROLE OF SOCIAL AND ECONOMIC STRATIFICATION

In the 1993 NRC report, issues concerning the influence of sociocultural factors on child abuse and neglect are addressed only marginally and, in truth, somewhat superficially. What is more, that report often implies that the racial and socioeconomic dimensions of abuse and neglect represent “cultural” effects. This misnomer distorts understanding of those social, economic, and cultural factors that influence the prevalence, mechanisms, processes, and outcomes of child abuse and neglect. The present report proposes several new conceptual and empirical directions for addressing these themes in future research on child abuse and neglect. Unfortunately, they are not well covered in existing research in the field, so the review of the literature presented herein generally is missing these perspectives.

The committee emphasizes the importance of adopting a critical stratification lens in considering and writing about the impact of social and economic factors on child abuse and neglect. Stratification involves the rank ordering of people based on their social and economic traits ( Keister and Southgate, 2012 ). Based on this rank ordering, people have unequal access to resources and are differentially exposed to certain behaviors, processes, and circumstances (e.g., discrimination) that influence the nature, power, vulnerability, privilege, and protection of children who are abused, those who abuse them, and those who are charged with preventing and intervening in abuse situations. This lens therefore makes it possible to consider the various domains of stratification—race, skin color, ethnicity, class (social and economic), gender, sexual orientation, immigration status—and how the inequalities that ensue because of rank ordering in these domains impact child abuse and neglect. In addition, this lens enables intersectionality to be infused into the discourse; thus, how the multiple strata occupied by an individual (e.g., a poor dark-skinned Latino female) collectively influence the lived experiences of child abuse and child neglect for all involved can be discussed and differentiated ( Burton et al., 2010 ; Dill and Zambrana, 2009 ). Finally, attention to stratification issues points to the need to consider how place matters relative to child abuse and neglect. Stratification processes create inequalities in physical and environmental locations that differentially shape certain behaviors and outcomes. Researchers in the field need to consider whether differences in the prevalence and nature of child abuse and neglect are observed in certain urban, suburban, rural, and regional areas of the United States and how those differences are related to population, institutional, and political inequalities.

Also important is avoiding the error of equating domains of stratification with the attributes and practices of culture. Culture is distinct from stratification. It is not necessarily circumscribed by the same mechanisms and processes as, for example, racial stratification; it encompasses but is larger than stratification issues. In Geertz's classic work The Interpretation of Culture , culture is defined as “an historically transmitted pattern of meanings embodied in symbols, a system of inherited conceptions expressed in symbolic forms by means of which men communicate, perpetuate, and develop their knowledge about and attitudes toward life” ( Geertz, 1973 , p. 89). And as Swidler notes, “seeing culture as meaning embodied in symbols focuses attention on such phenomena as beliefs, ritual practices, art forms, and ceremonies, and on informal cultural practices such as language gossip, stories, and rituals of daily life” ( Swidler, 2001 , p. 12). Thus, a fundamental component of culture is the social processes by which these symbols, attitudes, and modes of behavior are shared, reified, and sanctioned within families and communities. A focus on culture then directs attention to different types of questions, such as how certain religions and other collectives (not necessarily defined by race) value children, adopt harsh parenting styles, or execute certain moral codes/beliefs in the contexts in which they reside.

Attention to these issues will contribute to achieving the goal for research on child abuse and neglect of having sufficient specificity so that understanding of the problem's causes and consequences, as well as programs or services to address it, will be focused rather than overly general. Research conducted to date is informative about risk factors but not about how or why more risk factors lead to worse results, or which risk factors are more important than others and for which types of abuse or neglect. For example, poverty is a risk factor, yet many poor children are not abused or neglected. Which poor children are abused and why? The committee believes attention to these issues of social and economic stratification will yield increased understanding and more effective responses to the problem.

Significant progress has been made in efforts to understand child abuse and neglect; to document its devastating and lifelong impacts on both its victims and society; and to develop, test, and replicate evidence-based treatment and prevention strategies. Today, strong evidence demonstrates that child abuse and neglect is a public health issue in terms of both its immediate impact on child development and well-being and its impact on long-term productivity.

Research advances in child abuse and neglect underscore the importance of viewing the problem as a systemic challenge. The interdependency of myriad factors operating at multiple levels and in multiple domains complicates understanding of the causes and consequences of child abuse and neglect and challenges the ability to design, implement, and sustain effective responses. Building on the gains realized in the past 20 years will require a research paradigm and infrastructure capable of capturing this complexity.

• ORGANIZATION OF THE REPORT

This report is organized into nine chapters. Between this introductory chapter and the final chapter, which contains the committee's recommendations, are seven chapters that review the state of knowledge and contain the committee's findings and conclusions related to important aspects of child abuse and neglect research. In these chapters, major research findings are summarized at the end of major sections, and each chapter ends with overall conclusions. The aspects of child abuse and neglect addressed are the extent of the problem ( Chapter 2 ); research on its causes ( Chapter 3 ); research on its consequences ( Chapter 4 ); an overview of the child welfare system, which constitutes society's primary vehicle for identifying and responding to formal reports of child abuse and neglect ( Chapter 5 ); research on the implementation and impacts of prevention and treatment programs ( Chapter 6 ); an overview of the infrastructure for child abuse and neglect research ( Chapter 7 ); and research on relevant public policies ( Chapter 8 ). The recommendations presented in Chapter 9 are based on the findings and conclusions in these chapters, as well as the supporting discussion.

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42 U.S.C. § 5101 note.

• Cite this Page Committee on Child Maltreatment Research, Policy, and Practice for the Next Decade: Phase II; Board on Children, Youth, and Families; Committee on Law and Justice; Institute of Medicine; National Research Council; Petersen AC, Joseph J, Feit M, editors. New Directions in Child Abuse and Neglect Research. Washington (DC): National Academies Press (US); 2014 Mar 25. 1, Introduction.
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