BROWN, JOCELYN M.D., M.P.H.; COHEN, PATRICIA Ph.D.; JOHNSON, JEFFREY G. Ph.D.; SMAILES, ELIZABETH M. M.phil.
Objective: To investigate the magnitude
and independence of the effects of childhood neglect, physical abuse, and
sexual abuse on adolescent and adult depression and suicidal behavior.
Method: A cohort of 776 randomly
selected children was studied from a mean age of 5 years to adulthood in
1975, 1983, 1986, and 1992 during a 17-year period. Assessments included
a range of child, family, and environmental risks and psychiatric disorders.
A history of abuse was determined by official abuse records and by retrospective
self-report in early adulthood on 639 youths. Attrition rate since 1983 has
been less than 5%.
Results: Adolescents and young adults
with a history of childhood maltreatment were 3 times more likely to become
depressed or suicidal compared with individuals without such a history (p
< .01). Adverse contextual factors, including family environment, parent
and child characteristics, accounted for much of the increased risk for depressive
disorders and suicide attempts in adolescence but not in adulthood (p
< .01). The effects of childhood sexual abuse were largest and most independent
of associated factors. Risk of repeated suicide attempts was 8 times greater
for youths with a sexual abuse history (odds ratio = 8.40, p < .01).
Conclusions: Individuals with a
history of sexual abuse are at greater risk of becoming depressed or suicidal
during adolescence and young adulthood. Adolescence is the most vulnerable
period for those youths who may attempt suicide repeatedly. Many of the apparent
effects of neglect, in contrast, may be attributable to a range of contextual
factors, suggesting broader focus for intervention in these cases.
Abundant research has shown that adults
who report having been abused as children are at increased risk for distress
and mental disorders (Bemporad and Romano, 1993; Famularo et al., 1992; Silverman et al., 1996).
However, it is not clear whether the risk is specifically attributable to
the abuse experience. The family circumstances in which abuse and neglect
take place are often extremely complex, involving a range of other potential
risks for subsequent disorders in the offspring. These risks include at least
4 major domains: risk factors in the child such as handicap, chronic illness,
or difficult temperament; dysfunctional child-rearing and family relationships;
parental substance abuse, poor health, or very young age; and poverty and
related stresses in the family and the community (Belsky, 1993; Brown et al., 1998).
Because these contextual factors are often and perhaps usually present, it
is unclear whether the negative outcomes in the child that are attributed
to abuse are actually specific effects of abuse. Alternatively, they may
be due to the environmental and familial context in which abuse and neglect
occur. If so, our attention to identified cases of abuse would need to focus
heavily on these associated risks, rather than on more limited efforts to
prevent further outright abuse or neglect.
To disentangle the specificity of these
effects, it is necessary to measure the context of abuse. However, most studies
have not assessed the effects of the abuse milieu independently from the
assessment of the abuse. Longitudinal research has shown that combinations
of these risks, assessed independently and prospectively, were powerful predictors
of abuse and neglect (Brown et al., 1998; Fergusson et al., 1996).
In the single report of which we are aware, adolescents who reported childhood
sexual abuse showed elevated rates of adolescent depression independently
of these associated childhood and family risk factors (Fergusson et al., 1996). However, maltreatment in this study was limited to self-reported sexual abuse.
Evidence about the type of child maltreatment
that constitutes the greatest risk for depressive disorder is relatively
sparse because most studies are limited to particular types or combinations
of maltreatment types. Thus, a number of studies have shown depression to
be related to childhood physical abuse (Duncan et al., 1996; Fergusson and Lynskey, 1997; Flisher et al., 1997; Kaplan et al., 1997) or to sexual abuse (Beitchman
et al., 1992; Boney-McCoy and Finkelhor, 1996; Dhaliwal et al., 1996; Fergusson
et al., 1996; Kendall-Tackett et al., 1993; Tebutt et al., 1997). Other studies have examined depression in those who have experienced 2 or more kinds of maltreatment (Cohen et al., 1996; Kaufman, 1991; Silverman et al., 1996; Toth et al., 1992; Toth and Cicchetti, 1996).
Few studies have either examined the comparative effects of physical abuse,
sexual abuse, and neglect or investigated simultaneously the effects of physical
abuse, sexual abuse, and neglect. Focusing on one type of abuse may be misleading
not only because different types of abuse often coexist (Cicchetti and Rizley, 1981; McGee et al., 1995), but also because some long-term psychological sequelae may be specifically associated with certain types of abuse (Briere and Runtz, 1990).
Research on depression among victims of childhood maltreatment either has focused on its short-term impact during childhood (Swanston et al., 1997; Wozencraft et al., 1991)
or has been based on the retrospective self-reports of adults who were abused
as children. Few studies have examined both adolescent and adult outcomes
(Stevenson, 1999). Thus, it is of particular
interest to investigate whether the effects of childhood maltreatment persist
during adolescence and early adulthood.
Several retrospective studies have shown that a history of abuse is associated with increased risk for suicide attempts (Brent
et al., 1993b; Davidson et al., 1996; Deykin et al., 1985; Deykin and Buka,
1994; Shaunesey et al., 1993; Silverman et al., 1996), but other studies have not (Brent et al., 1993a; Flisher et al., 1997; Spirito et al., 1987).
These differences may stem in part from design differences in the studies
and differential definition of abuse. In addition, these studies have not
been able to consider the potentially confounding effects of other childhood
factors that predispose both to maltreatment and to later suicidal behavior.
Suicidal behavior has been associated with poor parent-child relationships
(Fergusson and Lynskey, 1995), family stress (Brent et al., 1993a), and parental psychopathology (Garfinkel et al., 1982; Shaffer et al., 1988), factors also implicated in child maltreatment (Wagner, 1997). Thus, the meaning of the association with suicidal behavior remains unclear.
The study reported here has several
characteristics that made it possible to address these questions. First,
the sample consists of a large random sample of persons studied from childhood
to adulthood. Thus a range of factors related to the incidence of child maltreatment
were assessed prospectively by parental and child interview and interviewer
observation. Second, reports of child maltreatment were obtained both by
report of study members when they became adults and from official records.
Third, all 3 types of childhood maltreatment-neglect, physical abuse, and
sexual abuse-were assessed.
The participants in this study were
members of a random sample of families with one or more children between
the ages of 1 and 10 years drawn in 1975 on the basis of residence in either
of 2 upstate New York counties (Kogan et al., 1977).
This sample was seen for follow-up interviews in 1983, 1986, and 1992. The
1983 sample of 776 families, including a subsample drawn to replace excess
loss from areas of urban poverty, was a close match to the area population
of children in this age range, according to U.S. Census data on family income
and structure (Cohen and Cohen, 1996). Approximately
20% of the sample had an income below the poverty level at some time since
the child's birth. Attrition since 1983 has been less than 5%. At each follow-up,
mothers and one child, who had been selected randomly from among age-eligible
offspring at intake, were interviewed separately in their homes. Interviews
included psychiatric assessments of the child as well as assessment of a
broad array of potential risks for substance use or psychiatric disorder.
At each assessment, written informed consent was obtained from all youths
and their parents after the study procedures had been fully explained (Bird et al., 1992).
The 639 youths in this study (334 males
and 305 females) consisted of those who were older than 18 at the time of
the fourth assessment for whom we were able to obtain information regarding
childhood maltreatment from New York State records. Participants for whom
childhood maltreatment data were not available did not differ from the rest
of the sample with regard to family income, welfare support, urbanicity,
or race, but they were more likely to be male (60% compared with 48% of the
sample with maltreatment data) and their mothers had fewer years of education
(mean = 12.26 years compared with 12.64 years in the families with maltreatment
Assessment of Adolescent and Young Adult Depression and Suicidal Behavior.
Children's psychiatric disorders were assessed with the National Institute
of Mental Health Diagnostic Interview Schedule for Children (DISC) (Costello et al., 1984), using algorithms for DSM-III-R
diagnoses which combine information from parent and child and require associated
impairment. Previous research has supported the reliability and validity
of the DISC-I and of the DSM-III Axis I diagnostic
algorithms that were used in the present study. Suicide attempts were reported
and described by children with regard to method, frequency, and associated
treatment (Lewis et al., 1988; Velez and Cohen, 1988). Suicide attempts in adolescents are not uncommon and often are impulsive (Shaffer, 1974). Therefore, we also examined those who reported repeated attempts, which are likely to have a higher risk of lethality.
Assessment of Childhood Maltreatment.
Data regarding child maltreatment were obtained from the New York State Central
Registry for Child Abuse and Neglect (NYSCR). In accordance with state guidelines
at the time this study was conducted, only those cases reported to official
agencies and determined to be valid cases of abuse are retained in the NYSCR.
Information regarding whether records pertaining to the families participating
in the present study were included in the NYSCR files was determined by NYSCR
trained staff. Information including the source of the report, type of abuse,
and the perpetrator's relationship to the child was abstracted by one of
the authors under the supervision of the NYSCR staff. The names identified
were matched to identification number and kept in separate locked files,
to maintain participants' confidentiality. Abuse history data were then added
to the data files without identifying information, resulting in a "blind
deck" that was used for all of the statistical analyses that were conducted
for this report. Self-reports of child abuse were also obtained in the young
adult follow-up in 1992. Young adults were asked during childhood whether
(1) someone with whom they lived hurt them physically so that they were still
injured or bruised the next day, could not go to school, or needed medical
attention, and if so, how often (physical abuse); (2) they had been left
overnight or longer without an adult caretaker before age 10 (neglect); and
(3) any older person (not a boy/girlfriend) ever touched them or played with
them sexually or forced them to touch the older person before age 18. Sexual
abuse was considered to have been experienced when 2 or more such experiences
For the current report we combined official
and self-reported abuse and neglect, for a total of 81 identified cases.
Because of the limitations in the self-report questions, and in the frequency
with which sexual abuse can be officially documented, most cases of neglect
(n = 39) were identified by official record and most cases of sexual abuse (n
= 22) were identified by self-report. For 24 of the 81 children with either
neglect or abuse, more than one type was present (see Brown et al., 1998, for a more complete presentation and discussion of source differences in reports).
Assessment of Risks for Abuse or Neglect. As detailed in our earlier report (Brown et al., 1998),
the following prospectively assessed risks were significantly associated
with childhood neglect, physical abuse, or sexual abuse: the youth's sex,
ethnicity, IQ, difficult childhood temperament, low maternal education, low
maternal self-esteem, maternal alienation, anger, dissatisfaction, external
locus of control, sociopathy, serious maternal illness, low maternal and
paternal involvement, low paternal warmth, low religious participation, teenage
mother when the youth was born, single parenthood, welfare support, low family
income, large family size, and poor marital quality.
Data analyses began with examination
of bivariate associations between childhood maltreatment and risk for depressive
disorders and suicidal behavior during adolescence and young adulthood, including
statistical control for effects of age and sex. Logistic regression analyses
determined whether these associations were potentially attributable to the
effects of the previously identified contextual risk factors for maltreatment.
These analyses were repeated for separate consideration of adolescent and
young adult outcomes. In addition, analyses determined whether the effects
were limited to specific kinds of child maltreatment.
The first question addressed was whether
a history of child abuse or neglect predicted depressive disorders in adolescence
or young adulthood. Both dysthymia and major depressive disorder were elevated
in those with a history of abuse or neglect, and these disorders were elevated
in both adolescence and young adulthood (Table 1).
The odds of a depressive disorder was 3.4 to 4.5 times greater in those for
whom child maltreatment was identified. In adolescents, at least some fraction
of this elevated risk appears to have been attributable to the other contextual
factors that were associated with childhood abuse or neglect; in fact, the
odds ratio (OR) decreases from 3.28 to 2.63 after controlling for these factors.
In young adulthood, in contrast, the estimated risk after controlling statistically
for these associated factors remained high (OR = 3.95, p < .01).
Suicidal behavior was also strongly associated with a history of childhood maltreatment. As Table 1 shows for the combined period, both any suicide attempts (OR = 4.06, p < .01) and repeated attempts (OR = 3.34, p
< .05) were elevated in those with such a history. When these are broken
down by age, we see that suicide attempts were more common among maltreated
youths in both adolescence (OR = 2.67, p < .05) and young adulthood (OR = 4.05, p
< .01). However, in adolescence the data are consistent with the interpretation
that other factors that are associated with elevated risk for maltreatment
may account for the elevation in adolescent suicide attempt (OR = 1.48, p > .05).
Despite the small numbers, the data
appear to be quite different when we examine repeated suicide attempts. In
adolescence more than half (5/9) of all those who reported repeated suicide
attempts were among the one eighth of the sample with reported childhood
maltreatment. This elevation in risk persisted when other childhood negative
prognostic factors were added to the equation (OR = 30.29, but note the very
large confidence limits on this estimate). Youths with and without abuse
history had an equal risk of repeated suicide attempt in young adulthood
(OR < 1). We also calculated the population attributable risk of suicide
attempt due to sexual abuse, which was 16.4%.
We next examined the specific types
of child maltreatment to determine whether they were differentially related
to depression and suicidal behavior.
The associations of depressive disorder and suicidal behavior with each of the specific types of maltreatment are shown in Table 2. These rates may be contrasted with the rates for the youths for whom no maltreatment was identified, as shown in Table 1.
In almost all cases the raw rates of disorder or suicidal behavior were elevated.
An examination of the raw rates also shows that without exception the rates
were highest for those youths who had experienced sexual abuse. More than
one third of these persons (8/22) met criteria for a depressive disorder
in either adolescence or adulthood or both, and an equal number reported
having attempted suicide.
The next columns in Table 2
examine the odds of each disorder associated with each type of maltreatment
in comparison with the group without reported maltreatment. These equations
included the potentially confounding contextual factors that, as noted above,
have been shown to be related to the incidence of maltreatment. Examination
of the column of ORs associated with neglect shows that with only 2 exceptions
the estimates exceeded 1.4, and in 6 of 11 cases they exceeded 2.0. However,
as indicated by the magnitude of the confidence intervals (CIs), in no case
was depression or suicidal behavior unambiguously attributable to childhood
neglect. These findings are consistent with the relatively large magnitude
of the contextual influence on childhood neglect.
The findings with regard to physical
abuse are somewhat more mixed. Not only are the point estimates a little
larger, but in addition 2 ORs are greater than 1.0, namely that for adult
depressive disorder (OR = 3.83, CI = 1.38-10.58, p < .01) and that for repeated suicide attempts by adolescents (OR = 10.74, CI = 1.06-108.72, p
< .05). Note that overall the impact of neglect, physical abuse, and sexual
abuse appears to be comparable with regard to adult depression, with respective
ORs of 3.45, 3.83, and 3.22.
As was true for the unadjusted rates,
the ORs associated with sexual abuse are generally both larger and more independent
of other risks, despite the very small sample size. Risk for dysthymia and
major depression was greatly elevated among the sexually abused, with ORs
of 9.74 and 3.17, respectively. The rate of suicide attempt was elevated
in the combined youth and adult time period (OR = 5.71, CI = 1.94-16.74,
p < .01). The largest elevation of risk was found
for repeated suicide attempts, in which the overall risk was elevated more
than 8 times (OR = 8.40, CI = 1.86-38.06, p < .01), and the risk among adolescents was even more elevated (OR = 15.78, p
< .01), although the small sample makes these estimates very unstable.
One third of the 9 adolescents who had made repeated suicide attempts were
in this small group of persons who had experienced childhood sexual abuse.
This study addressed 3 questions regarding
the magnitude of risk of depression and suicidality associated with child
maltreatment, the independence of these effects from effects of contextual
factors known to be associated with risk for maltreatment, and differential
risk associated with type of maltreatment.
Regarding the first question, our findings
indicate that being abused as a child makes an adolescent or an adult 3 to
4 times more likely to become depressed or suicidal. This is in accordance
with the findings of previously published studies (Beitchman et al., 1992; Fergusson et al., 1996; Kendall-Tackett et al., 1993; McCord, 1983; Silverman et al., 1996).
Second, some relationships of childhood
maltreatment with depression and suicidal behavior may be explained by adverse
contextual factors in the areas of family environment and parent and child
characteristics. These findings were both developmentally and abuse-specific.
The child abuse milieu accounts for a significant increase in the risk of
depressive disorders and suicide attempts in adolescence and adulthood; however,
the former effect was greater.
Our finding that physical abuse is associated
with suicidal behavior and depression is consistent with previous findings
on the effects of physical abuse (Malinosky-Rummell and Hansen, 1993; Silverman et al., 1996).
Our findings also suggest that childhood neglect alone is not likely to be
responsible for depressive disorders and suicidal behavior as its effects
cannot be separated from those of other risk factors.
Third, this study adds new information
on the differential risks that are associated with different types of childhood
maltreatment. Sexual abuse carries the greatest risk of depression and suicide,
independently of the contextual risks under which the abuse occurs. This
is in accordance with other longitudinal studies (Fergusson et al., 1996). Furthermore, the estimate from this study of the population attributional risk is comparable with Fergusson and colleagues' data (1996)
suggesting that between 16.5% and 19.5% of suicide attempts in young adults
may be due to exposure to child sexual abuse. Our findings suggest that adolescence
is the most vulnerable time for sexually abused youths, who are more prone
to make repeated suicide attempts. Physical abuse alone also contributes
to repeated suicide attempts during adolescence and to adult depression.
Because most cases of sexual abuse in
this study were self-reported, it is possible that depressed individuals
were particularly prone to recall sexual abuse. In addition, we have undoubtedly
missed a good many of the cases of neglect because the question on self-reported
neglect was so limited. On the other hand, while the sensitivity of our question
was inadequate, the specificity should have been good, and specificity is
a more critical issue for accurate estimation of risk (Cohen, 1988). Unfortunately, the timing and chronicity of abuse could not be evaluated. Unlike Fergusson and colleagues (1996),
we did not have a measure of severity of sexual abuse. It is likely that,
apart from the contextual factors under which child abuse occurs, individuals
most at risk for suicidal ideation and repeated attempts tend to have experienced
the most severe forms of sexual abuse. In future studies, characteristics
of the abuse, such as relationship of the perpetrator, duration, frequency,
and severity, should be defined and taken into account.
These data have several implications
for the field. First, it seems clear from this study that clinicians evaluating
depressed and suicidal youths should screen specifically for the presence
of different types of abuse, alone or in combination. Second, the milieu
under which the abuse occurs should be assessed carefully; possible contributors
to depression are familial risks such as maternal sociopathy, early separation
from mother, and poor marital quality; parental risks such as low paternal
involvement; and environmental risks such as welfare dependence and maternal
young age. These data suggest that contextual factors such as family conflict,
parental substance abuse, and illegal activities should be addressed and
dealt with in the treatment of depressed and suicidal adolescents who have
been neglected in childhood. Third, clinicians evaluating depressed and suicidal
youths should screen for prior history of sexual abuse; when appropriate,
a forensic team with expertise in interviewing, colposcopic examinations,
and reporting laws should be consulted; and monitoring of the sexually abused
adolescent with previous suicide attempt is imperative (Green, 1993).
Furthermore, a base-line assessment for depressive disorder and suicide should
be part of every program diagnosing and reporting child sexual abuse. Strategies
to follow these victims into adolescence should be developed, ensuring monitoring
through community prevention programs, primary care providers, or foster
From a public health point of view,
our findings are encouraging: they suggest that interventions such as the
nurse home visitation programs, developed by Olds and colleagues (1997),
may reduce not only the rate of child abuse and neglect but also its mental
health consequences. Such programs that have shown effectiveness in keeping
adolescent offspring off welfare, deter from criminal activities, and delay
age of first pregnancy may also reduce adolescent and adult depression (Olds et al., 1998).
Our study suggests that children who have been neglected are less likely
to become depressed or suicidal if the contextual risks that comprise their
lives could be changed.
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Key Words: depression; suicidality; child abuse and neglect