Walker, Edward A. MD; Gelfand, Ann RN, MA; Katon, Wayne J. MD; Koss, Mary P. PhD; Von Korff, Michael SciD; Bernstein, David PhD; Russo, Joan PhD
PURPOSE: Several recent studies have found associations between childhood maltreatment and adverse adult health outcomes. However, methodologic problems with accurate case determination, appropriate sample selection, and predominant focus on sexual abuse have limited the generalizability of these findings.
SUBJECTS AND METHODS: We administered a survey to 1,225 women who were randomly selected from the membership of a large, staff model health maintenance organization in Seattle, Washington. We compared women with and without histories of childhood maltreatment experiences with respect to differences in physical health status, functional disability, numbers and types of self-reported health risk behaviors, common physical symptoms, and physician-coded ICD-9 diagnoses.
RESULTS: A history of childhood maltreatment was significantly associated with several adverse physical health outcomes. Maltreatment status was associated with perceived poorer overall health (ES = 0.31), greater physical (ES = 0.23) and emotional (ES = 0.37) functional disability, increased numbers of distressing physical symptoms (ES = 0.52), and a greater number of health risk behaviors (ES = 0.34). Women with multiple types of maltreatment showed the greatest health decrements for both self-reported symptoms (r = 0.31) and physician coded diagnoses (r = 0.12).
CONCLUSIONS: Women with childhood maltreatment have a wide range of adverse physical health outcomes.
Each year nearly 3 million children in the United States are reported to child protective services as alleged victims of maltreatment (1). Although early childhood maltreatment has been associated with many psychological sequelae (2), only recently have studies also found adverse effects on adult physical health (3-43). Most of these studies have been done in specialty medical clinics that tend to accumulate patients with more severe emotional and physical problems, potentially distorting the magnitude of the association (5, 6, 11, 12, 15, 17-21, 23, 30-34, 38, 41, 43). Some have been conducted in specialized settings (eg, college campuses) with limited generalizability (3, 10, 16, 24, 25, 29). Although some studies have been done in primary care settings (13, 14, 22, 26, 40) and in the general population (9, 27, 35-37, 42), they examined a relatively narrow range of health outcomes. Finally, most studies have used nonstandardized health assessment instruments and did not validate patient health reports with physician-coded diagnoses.
Few such studies have been conducted in health maintenance organizations (HMO) (7, 13, 14), which offer several advantages for investigating this relation. Health care utilization is nearly completely captured, and detailed automated records of visits, diagnoses, and pharmacy use are often available. Both clinic attenders and nonattenders can be surveyed, and the characteristics of nonresponders to surveys can be compared with those who participated. Finally, studying HMO enrollees provides an opportunity to estimate the magnitude of the association in a general population sample.
Prior studies have used a wide variety of methods to determine childhood maltreatment status. Most used maltreatment assessment instruments of unknown reliability and validity or focused narrowly on sexual abuse, ignoring important associations between other forms of maltreatment (eg, physical and emotional abuse, physical and emotional neglect) and health status.
We used validated instruments to measure childhood maltreatment in a cohort of female enrollees in an HMO. We hypothesized that (1) sexual abuse, as well as other forms of childhood maltreatment, would be associated with decrements in adult health status; (2) compared with women without a history of childhood maltreatment, those with maltreatment histories would have higher levels of functional disability, more physical symptoms, increased numbers of health risk behaviors (eg, smoking, alcoholism, obesity, unsafe sex practices), and a greater number of diagnoses; and (3) women with histories of childhood sexual maltreatment would have even worse health status than women with other forms of maltreatment.
We drew a random sample of 1,963 English-speaking women, aged 18 to 65 years, from the enrolled membership of Group Health Cooperative of Puget Sound, a large staff model HMO in Washington State. Using the total design method of Dillman (44), we mailed an introductory letter to each of the women announcing the study, followed by a 22-page questionnaire and consent form. The questionnaire had been reviewed and approved by the Human Subjects Committees of both Group Health and the University of Washington. To maximize participation rates, women who did not respond within 2 weeks received reminder letters and follow-up telephone calls. Of the 1,963 women, 51 were ineligible or had undeliverable surveys, for a total sample of 1,912 eligible women.
Functional disability. Functional disability was measured using the SF-36. Low scores are indicative of self-perceived disability in physical, social, occupational, and emotional role functioning. The SF-36 results can be compared with those in the general population and in medical clinic patients (45).
We computed the two-factor physical and mental health component scores according to the method of Ware et al (46) To do so, the SF-36 subscale scores are transformed into Z scores using general population parameters, changed into factor coefficients, and further transformed into T scores (mean = 50, SD = 10). The physical component score includes physical function, role function, health perception, and freedom from pain. The mental health component score contains information on emotional role, social role, mental health, and vitality. Overall health was reported on a 1 (excellent) to 5 (poor) scale, using the first question of the SF-36.
Self-reported history of physical symptoms. We included 15 common physical symptoms derived from the somatization section of the Diagnostic Interview Schedule used in the National Institutes of Mental Health Epidemiologic Catchment Area Study (47); they account for a significant number of complaints to primary care physicians. Participants were asked to rate the degree of bother from these symptoms during the previous 6 months on a 5-point Likert scale from "none of the time" (1) to "all of the time" (5). Those who rated the degree of bother as at least some of the time (3 or more) were considered to have the symptom in subsequent analyses.
Health risk behaviors. We also inquired about repetitive adult behaviors that have the potential for creating or worsening health problems, including smoking, use of alcohol, driving while intoxicated, avoiding regular gynecological examinations, not wearing seat belts, sedentary lifestyle, and high-risk sexual encounters. Participants were asked to rate the behaviors on a 5-point Likert-type scale ranging from "never" to "often," except that use of alcohol was measured using the CAGE questions. Women were asked to report their current height, and their current and average lifetime weight.
Measures of childhood maltreatment. Maltreatment severity was assessed using the 28-item short form of the Childhood Trauma Questionnaire (48, 49). This self-administered questionnaire inquires about childhood maltreatment in five areas: emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect. Respondents are presented with a series of statements about childhood experiences and are asked to choose responses on a 5-point Likert-type scale that ranges from "never true" to "very often true." Most items are phrased in objective, nonevaluative terms (eg, "When I was growing up someone touched me in a sexual way or made me touch them"), whereas others call for more subjective evaluation (eg, "When I was growing up I believe I was sexually abused"). These questions were preceded by the instruction, "In this section we would like to know about experiences you may have had before you were 18 years of age."
Validation studies of the Childhood Trauma Questionnaire have been conducted in seven different clinical and nonreferral samples with >2,200 respondents (48). These studies have supported the reliability and validity of trauma reports obtained with this instrument, including their stability over time, convergent and discriminant validity with structured trauma interviews, and corroboration using independent data. For this study, a short form of the questionnaire was used that showed good reliability and validity in previous studies, including the invariance of its factor structure across clinical and nonclinical samples and external validation against independent evidence.
The items used to construct the five maltreatment scales were derived from the following definitions of abuse and neglect. Sexual abuse was defined as "sexual contact or conduct between a child younger than 17 years of age and an adult or older person (at least 5 years older than the child)." Physical abuse was defined as "bodily assaults on a child by an adult or older person that posed a risk of, or resulted in, injury." Emotional abuse was defined as "verbal assaults on a child's sense of worth or well-being or any humiliating or demeaning behavior directed toward a child by an adult or older person." Physical neglect was defined as "the failure of caretakers to provide for a child's basic physical needs, including food, shelter, clothing, safety, and health care" (poor parental supervision was also included if it placed a child's safety in jeopardy). Emotional neglect was defined as "the failure of caretakers to meet children's basic emotional and psychological needs, including love, belonging, nurturance, and support."
We also recorded the diagnoses that were reported during clinical care by the participants' physicians (including nonresponders) during a 1-year period. For each woman, each diagnosis (as International Classification of Diseases [ICD]-9 code) was counted only once. We selected the 25 most commonly used diagnostic codes for further examination. These codes were divided into four groups: infectious diseases (vaginitis, urinary tract infection, upper respiratory infection, sinusitis, rhinitis, pharyngitis, bronchitis, cellulitis), pain disorders (neck pain, migraine, dysmenorrhea, headache, back pain, abdominal pain), mental health diagnoses (stress, depression, adjustment problems, marital discord), and other diseases (hypertension, diabetes, dermatitis, asthma, allergy, acne, abnormal menstrual bleeding).
In another part of the study, an experienced clinical interviewer, blind to the Childhood Trauma Questionnaire scores and using the definitions of the five types of maltreatment described above, administered 2- to 3-hour structured interviews to 250 of the women to determine whether they had a history of clinically significant abuse or neglect. We then employed receiver operating characteristic (ROC) methods to determine threshold scores for each of the five subscales, using these independent clinician assessments as the gold standard criteria. These threshold scores provided very good to excellent sensitivity and specificity (>=0.85) for each of the five subscales. Using these scores, we constructed three mutually exclusive groups. All women who scored at or above a score of 8 on the sexual abuse scale were placed in the "sexual maltreatment" group (including women who also had scores exceeding other maltreatment scale thresholds). Next, women who scored at or above the threshold scores for one or more of the nonsexual scales (physical abuse (8), physical neglect (8), emotional neglect (15), or emotional abuse (10) were classified as a "nonsexual maltreatment." The remaining women, with scores below the thresholds for all five maltreatment groups, were considered to be a "neither form of maltreatment" group. This last group contains women with a range of maltreatment experiences from none to just below the thresholds, and thus does not represent a "no maltreatment" group.
These thresholds generally identified women who had moderate to severe levels of abuse or neglect. For example, women in the sexual abuse group were likely to have experienced one or more rape experiences as children or prolonged periods of fondling by a family member that left them unable to achieve normal adult sexual function. Women in the nonsexual group were characterized by one or more experiences of maltreatment including significant, ongoing humiliation or cruelty by parents, repeated physical abuse leading to physical injury requiring medical attention, consistent parental inattention to physical needs of food clothing or shelter, or persistent emotional withdrawal and abandonment by caregivers due to drugs, personality factors, or psychiatric illness.
After determining the prevalence rates of the various forms of maltreatment, we compared the demographic characteristics and health outcomes of the maltreatment groups with the "neither form of maltreatment" group. Univariate and multivariate analysis of covariance with post hoc tests were used for normally distributed data. For categorical variables, we used logistic regression to calculate odds ratios (OR) with 95% confidence intervals (CI), adjusting for demographic differences between the groups.
Several variables, such as marital status and education, have been shown to have independent effects on health outcomes and could, therefore, be potential confounders of the association between maltreatment and health status. Alternatively, they may also be long-term effects of maltreatment, and thus could be considered mediators. Because both of these roles (confounder and mediator) are possible, we took a conservative approach and adjusted analyses for these covariates, thereby diminishing the differences between the groups.
Because the outcomes we were examining might be due to the cumulative effects of multiple forms of maltreatment, we also counted the number of maltreatment types that exceeded threshold levels for each patient. This generated a maltreatment summary score from 0 (no thresholds exceeded) to 5 (thresholds exceeded for all forms of abuse and neglect). We used Pearson correlations to examine the association between this summary score and physical symptoms, functional disability and number of ICD-9 codes. Statistical significance was set at P <0.05, two-sided. Continuous variables are reported as means ± SD.
Of the 1912 surveys initially mailed to eligible participants, 1,225 (62%) were completed. There were no significant differences between women who did and did not complete the survey with respect to age, mean number of primary care or specialty clinic visits, emergency room visits, outpatient mental health days, pharmacy visits, filled prescriptions, or physician-coded diagnoses. Participants had a mean age of 42 ± 12 years. Fifty-one percent were married and 57% had completed college. The median income was approximately $40,000. The participants were 79% white, 6% black, 8% Asian, 2% Hispanic, and 1% Native American. These demographic characteristics closely mirror those of the HMO population from which the sample was drawn, and are also typical of the Puget Sound region of Washington State.
Childhood abuse and neglect histories were reported by 43% of the women (sexual abuse, 18%; physical abuse, 14%; emotional abuse, 24%; emotional neglect, 21%; physical neglect, 12%). Twenty percent of the women met threshold criteria for one form of maltreatment, 10% met two, 7% met three, 4% met four, and 2% met all five criteria. Maltreatment was associated with lower rates of marriage and fewer years of education, but not with race, age, or household income (Table 1).
Women with a history of maltreatment were more likely to report fair or poor overall health (OR = 1.5, 95% CI: 1.3 to 1.7), as well as greater physical and mental functional disability as indicated by lower scores on the SF-36 scales (Table 2). The mean physical component score was 49 ± 8 in those with sexual maltreatment, 51 ± 8 in those with nonsexual maltreatment, and 52 ± 8 in those with neither (P <0.001). Similarly, the mean mental health component scores were 44 ± 12, 46 ± 12, and 48 ± 10 in the same groups (P <0.001). For both measures, higher scores indicate better function.
Women with maltreatment had greater mean numbers of distressing physical symptoms (neither form of maltreatment: 1.9 ± 2.0, nonsexual maltreatment: 2.7 ± 2.3, sexual maltreatment: 3.4 ± 2.7, P <0.001) in analyses that adjusted for marital status and education. The presence of any maltreatment was associated with a greater level of many different physical symptoms (Table 3).
Women with maltreatment histories were significantly more likely to engage in health risk behaviors such as driving while intoxicated, having sexual experience without knowing their partner's history, having probable alcoholism, and being obese (Table 4). The mean number of health risk behaviors was significantly different between the groups after adjusting for marital status and education (neither form of maltreatment: 1.5 ± 1.4; nonsexual maltreatment: 1.9 ± 1.5; sexual maltreatment: 2.2 ± 1.4, P <0.001).
Maltreatment was also significantly associated with an increased number of physician-coded diagnoses (excluding health maintenance codes such as routine gynecologic examinations) for the 18-month period before the study (Table 5). This increase was not only due to mental health diagnoses and medically unexplained pain complaints, but also to medical diagnoses.
For each woman, the number of maltreatment categories that exceeded clinical thresholds was associated with the number of physical symptoms (r = 0.31, P <0.001), physical disability (r = 0.15, P <0.001), mental disability (r = 0.21, P <0.001), health risks (r = 0.21, P <0.001), and the number of physician-recorded diagnoses (r = 0.12, P <0.001).
Compared with women who did not meet the threshold criteria for childhood maltreatment, those with childhood abuse or neglect had significantly greater levels of functional disability, more physical symptoms, more health risk behaviors, and a greater number of physician-coded diagnoses. The number of maltreatment categories was significantly correlated with the number of physical symptoms and physician-coded diagnoses as well as increased functional disability and health risks.
This study has several limitations. More than one third of the women who were contacted did not participate. It is unknown whether this created a response bias. More severely traumatized women may have elected not to participate to avoid recreating painful memories, which might cause an underestimation of the actual effects. On the other hand, less severely traumatized women may have chosen not to participate because the subject was not important to them, which might have caused us to over-estimate the associations. It is reassuring that the maltreatment rates found in this study are comparable with those obtained in previous national samples (50), and that there were no significant differences between responders and nonresponders in use of HMO resources.
The cross-sectional design of this study cannot demonstrate a causal connection between childhood maltreatment and adult health status. Other factors, such as adult rape, domestic violence, family disorganization, parental absence or incarceration, parental drug use or mental illness, or unemployment, could account for some of the effects that we observed. We are currently completing in-depth interviews on more than 250 of the women from this study to measure these other variables. Finally, we did not include men in our study, thus limiting the generalizability of our findings to women.
Although the group of women who reported threshold levels of sexual maltreatment had the poorest health outcomes, it is unlikely that sexual abuse, per se, is the sole explanation. For many women in this group, sexual abuse was only one of several forms of maltreatment they experienced as children. Many women also had later episodes of adult physical and sexual violence. Since the number of abuse categories was correlated with an increased risk of adverse health outcomes, we believe that the adverse health effects in women with a history of sexual maltreatment are largely due to multiple forms of maltreatment in girls who were not properly protected in their early families.
Despite these limitations, this study made several methodological improvements over previous investigations. The survey was composed largely of instruments with known validity and reliability, and examined a wide range of health outcomes. Conducting the investigation in an HMO allowed linkage of the survey to utilization records for primary care visits, inpatient stays, specialty care visits, costs, and physician-coded diagnoses. This also allowed comparison with women who did not return the survey. We used a well-validated instrument that has excellent psychometric properties. We examined not only sexual abuse, but also four additional types of childhood maltreatment, and also assessed the severity and overall impact of maltreatment.
The effect sizes in this study were moderate (averaging between 0.15 and 0.3), which is consistent with the role of maltreatment, or any other single variable, in predicting adverse health outcomes. Previous studies of selected patients have demonstrated larger associations between maltreatment and health status, but the magnitude of these effects may be a result of the greater prevalence of illness in patients chosen from clinical settings.
The long-term effects of childhood maltreatment are important concerns for society and health policy planners. The women in this study who experienced maltreatment had higher rates of physical diseases and unexplained physical symptoms, as well as a greater number of health risk behaviors. In some women, maladaptive coping behaviors such as somatization, smoking, alcohol abuse, unsafe sex practices, and obesity are effects of the maltreatment experiences that lead to further long-term health consequences, increasing costs to health care plans and to society (51).
More importantly, these effects of early maltreatment remain a principal concern for primary care providers. The primary care setting affords an opportunity to recognize and manage many of the emotional and physical sequelae of this early maltreatment. Because of the sensitive nature of this experience, it may not be beneficial to screen for past histories of maltreatment. The disclosure of this information might be used to deny health insurance due to a "preexisting condition." Previous ethical dilemmas over the confidentiality of human immunodeficiency virus (HIV) status should serve as an example of how necessary it is to handle potentially sensitive information carefully. Nevertheless, awareness of the link between maltreatment and adverse health outcomes may sensitize the physician to inquire selectively when it appears that such a discussion may be useful. For example, women who have difficulty with gynecological examinations or other procedures may respond to gentle inquiry about past traumatic experiences. Often, the building of a trusting relationship with the physician over time will allow such care to take place.
Primary care physicians may not feel adequately trained nor have sufficient time to deal with the complex needs of more severely maltreated patients. Yet, the majority of childhood abuse and neglect survivors are likely to benefit from long-term, stable relationships with reliable and supportive medical caregivers who listen compassionately to their symptomatic distress and encourage lifestyle choices that promote physical and mental health. While many physicians do not discuss these issues for fear of opening Pandora's box, the majority of women report feeling comfortable discussing these issues when they are appropriate for medical care (52). The judicious use of antidepressant medications, when appropriate, and timely referrals to mental health providers and support groups may also assist these patients in their continuing adaptation to the emotional and physical wounds they received as children.
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