Risk Factors Predict Repeat Abuse

By Nancy Walsh, Staff Writer, MedPage Today

Published: July 05, 2011

Reviewed by Zalman S. Agus, MD; Emeritus Professor

University of Pennsylvania School of Medicine and

Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

When child abuse has been substantiated, a number of risk factors can predict the likelihood that abuse will be repeated if the child is returned to the care of the abuser, according to a prospective cohort study. For instance, when the parents or caregivers were in their teens or twenties, were survivors of abuse, and had never taken parenting classes -- the child faced a 54% risk of being harmed again, wrote Suzanne R. Dakil, MD, and colleagues from the University of Texas Southwestern Medical Center in Dallas. But the risk was higher even higher -- 60% -- for children younger than 8.5 years who were returned to parents that had taken parenting class, the researchers reported online in the Archives of Pediatrics and Adolescent Medicine. Because both Federal and state laws encourage keeping children in the family home if possible after abuse, it's crucial that accurate ways of predicting future risk be identified, Dakil's group stated. Previous research into risk factors for repeated abuse has been limited in its focus primarily on individual factors, rather than the interaction of many factors. To look for patterns of characteristics associated with risk of repeated abuse, Dakil and colleagues used a statistical technique known as recursive partitioning analysis, which can identify multiple variables associated with a given outcome. They identified 2,578 children in the National Survey for Child and Adolescent Well-Being who remained in the home after a report of abuse, following them for five years. Child characteristics included in the analyses were age, sex, race, and health, while caregiver characteristics included age, marital and employment status, education, and physical and emotional health. Family and environmental characteristics included stress from unemployment, poverty, or drug use, social support, and domestic violence. A total of 44% of children in the sample were reported to child welfare authorities again after the index report. Bivariate analysis determined that these repeated reports were more likely when the child was between 3 years and 10 years of age and had behavior disturbances or developmental delays. A new report also was more likely if caregivers were younger, had themselves been abused, and were limited in their employment because of health or emotional problems. A family factor associated with repeated report was income below $20,000, while active domestic violence was less likely. The finding of lower risk in the presence of domestic violence may be explained by the possibility that children in such homes are more likely to be removed or to be provided with closer support and monitoring, according to the researchers. The recursive partitioning analysis identified risk clusters beginning with the determination of whether the index case had been substantiated, and found that in unsubstantiated cases, 56% were reported a second time. Among the 1,252 substantiated index cases, 38% involved a second report. However, this rose to 86% when the caregiver had a history of abuse and was younger than 33.5 years, the child was younger than 12.5 years but showed no behavioral difficulties, and when five or more children were present in the home. A cluster of characteristics associated with low incidence of repeated abuse -- 26% -- was a substantiated index report, older age of the caregiver, no parenting classes, and non-African-American race. "The findings, which go beyond prior research via a data-driven approach to identifying risk clusters, demonstrate that some risk factors, when combined, are powerful predictors of a child's future abuse risk," wrote Dakil and colleagues. The finding that risk was still high in cases where there had been parenting classes suggests that classes may not be adequate for high-risk families, and additional support or removal might be considered, they noted. And the increased risk seen with low income and behavior difficulties signals a need for assistance in basics such as housing, employment, medical care, and behavioral services. In contrast, lower-risk families might not need these intensive services. "These findings might be useful to [child protection services] in identifying at-risk children and making evidence-based decisions regarding child placement, families' service needs, and the duration and intensity of monitoring that families require," the researchers concluded. They acknowledged that their study was limited by reliance on caseworker reports, which can be influenced by high worker turnover, and families being lost to follow-up. The authors reported no financial disclosures.

Primary source: Archives of Pediatrics and Adolescent Medicine Source reference: Dakil S, et al "Recidivism in the child protection system: identifying children at greatest risk of reabuse among those remaining" Arch Pediatr Adolesc Med 2011; DOI:10.1001/archpediatrics.2011.129. Please go to MedPage Today for more information.

Effects of sexual abuse last for decades, study finds

Levels of so-called stress hormone are altered for years, sometimes causing physical and mental problems, researchers find 

By Joan Raymond, msnbc.com contributor

updated 6/30/2011 2:19:34 PM ET

Young girls who are the victims of sexual abuse experience physical, biological and behavioral problems that can persist for decades after, a new study shows.  


Researchers, who tracked a group of girls ranging in age from 6 to 16 at the start of the study in 1987 for the next 23 years, found that they had higher rates of depression and obesity, as well as problems with regulation of brain chemicals, among other issues, compared to a control group of girls who were not abused.


The racially-diverse group of 80 girls, who lived in the Washington, D.C., area, were victims of incest, broadly defined as suffering sexual abuse by a male living within the home. On average, the girls were abused for about two years prior to the abuse coming to the attention of child protective services. Some girls were abused when they were as young as age 2. 

Compared to a non-abused control group, the researchers found the study participants, all of whom were provided three therapy sessions on average in group and individual settings, suffered severe effects during different stages of their lives, which affected their sexual and cognitive development, mental and physical health, as well as their brain chemical profile. Study participants were more likely to be sexually active at younger ages, have lower educational status, and have more mental health problems. 

As children, they had higher levels of cortisol, the so-called "stress hormone," which is released in high levels during the body’s "fight or flight" response. But by about age 15, testing showed that cortisol levels were below normal, compared to the control group. Lower levels of cortisol have been linked to a decrease in the body’s ability to deal with stress, as well as problems with depression and obesity. Lower levels of the hormone have also been linked to post-traumatic stress disorder. 

“The cortisol levels (of some study participants) wound up looking like Vietnam vets,” says study co-author Dr. Frank Putnam, professor of pediatrics and psychiatry at Cincinnati Children's Hospital Medical Center. “That tells us they are in a chronic state of stress, and never feel safe.” 

During the last assessment, when study participants were in their 20s, their cortisol levels remained lower than the control group, on average. “That tells us their stress response system is burned out,” says Putman, which could explain why some are doing so poorly in life.”

The long-term effects of the abuse “were absolutely profound,” says lead author and child psychologist Penelope Trickett, USC professor of Social Work. “It’s just not mental health issues. Some of these women are suffering from a lot of problems today like sleep issues, poor health utilization, and have a lot of risky behaviors. It’s very disturbing.”

Trickett says some women who have been sexually abused themselves have told her the findings validated their realities. “A woman came up to me once at a talk and identified herself as a childhood victim of sexual abuse and thanked me for these findings and for trying to shed light on this issue.”

She also noted that not all of the 80 women in the study are extremely disabled from their experience. In the abused group, some 40 percent are obese as adults, compared to 20 percent in the control group. “But that still means that almost 60 percent of the abused group are not obese,” says Trickett. “The groups are statistically different, and that’s important. But both groups have variability. The abused group just has more variability within the group.”

Trickett also says the findings don’t mean that once someone is abused they are destined to a lifetime of struggle.

“These women are more likely to have problems in mental health and physical health than those who haven’t been abused,” she said. “But it really varies to what degree they are disabled by these challenges. Some are managing their lives pretty well, considering what they went through.”

Though the study participants received some psychological counseling there was no specific treatment for childhood trauma and sexual abuse in the late 1980s. “Three or four sessions isn’t a lot of treatment; it’s some, but it’s little compared to today,” says Trickett. According to Putnam, evidence-based treatments, such as trauma-focused cognitive-behavioral therapy, came about in the 1990s.

“But the big question is does treatment prevent these things from happening or reverse what has happened,” says Putnam. “And the answer is we don’t know.”

The researchers hope that study data are used to develop more comprehensive treatment programs. “What is clear here is that abuse is not something that’s a one-time fix,” says Trickett.

Prevention and getting kids into treatment early is “the first step,” says Carolyn Landis, a clinical psychologist with Rainbow Babies & Children’s Hospital in Cleveland, Ohio. “To see how these girls suffer into adulthood is extremely troubling,” she says.

“From my perspective, this data, especially regarding cortisol levels, can help professionals identify kids who may be at risk much earlier. We need to sensitize people and then find ways to help kids be safe.”

© 2011 msnbc.com.  Reprints 
http://www.msnbc.msn.com/id/43594639/ns/health-health_care/ 

CDC: Majority of U.S. adults had troubled childhoods

USA TODAY
Updated 12/17/2010 8:18 PM

By Steven Reinberg HealthDay

 

Almost 60% of American adults say they had difficult childhoods featuring abusive or troubled family members or parents who were absent due to separation or divorce, federal health officials report.

 

In fact, nearly 9% said that while growing up they underwent five or more "adverse childhood experiences" ranging from verbal, physical or sexual abuse to family dysfunction such as domestic violence, drug or alcohol abuse, or the absence of a parent, according to the U.S. Centers for Disease Control and Prevention (CDC).

"Adverse childhood experiences are common," said study coauthor Valerie J. Edwards, team lead for the Adverse Childhood Experiences Team at CDC's National Center for Chronic Disease Prevention and Health Promotion. "We need to do a lot more to protect children and help families," she said.

About a quarter of the more than 26,000 adults surveyed reported experiencing verbal abuse as children, nearly 15% had been physical abused, and more than 12% — more than one in 10 — had been sexually abused as a child.

Since the data are self-reported, Edwards believes that the real extent of child abuse may be still greater. "There is a tendency to under-report rather than over-report," she said.

The findings are published in the Dec. 17 issue of the CDC's journal Morbidity and Mortality Weekly Report.

For the report, researchers used data from the Behavioral Risk Factor Surveillance System, which surveyed 26,229 adults in Arkansas, Louisiana, New Mexico, Tennessee and Washington. Edwards is cautious about extrapolating these results, but based on other data they probably are about the same in other states, she said.

While there were few racial or ethnic differences in reports of abuse, the report confirmed that women were more likely than men to have been sexually abused as children. In addition, people 55 and older were less likely to report being abused as a child compared to younger adults.

One theory why older people did not report as much childhood abuse is that since these takes a toll on health in adulthood, many of these older abuse victims may have died early, Edwards said. The CDC report, for example, notes that adverse childhood experiences are associated with a higher risk of depression, heart disease, diabetes, cancer, substance abuse and premature death. "So (childhood abuse) may be associated with years of life lost," she said.

There was no difference in the number of people reporting childhood abuse in any other age group, Edwards added.

Adverse childhood experiences included in the report included verbal abuse, physical abuse, sexual abuse, incarceration of a family member, family mental illness, family substance abuse, domestic violence and divorce.

According to the report, about 7.2% had had a family member in prison during their childhood and 16.3% had witnessed domestic violence in the family home. In addition, about 29% grew up in a home where someone abused alcohol or drugs. "These cases occur across all racial groups and ethnicities," Edwards noted.

Almost one in five respondents (19.4 percent) had lived as a child with someone who was depressed, mentally ill or suicidal, the report noted.

Although the volume of abuse and dysfunction is significant, such traumatic experiences cannot be used to describe a person or determine what that person will be, the researchers cautioned. Instead, they said, keeping track of these abusive experiences is important to gain a better understanding of them and their effect on society.

In addition, it's crucial to work harder to prevent abuse and household stress as well as finding better ways to identify and treat children at risk, they said.

"For adults who have had these experiences and feel they are still causing them problems, they are not alone and there is help available," Edwards said.

Dr. Lee M. Sanders, an associate professor of pediatrics at the University of Miami Miller School of Medicine said that "one of the things we don't realize when we look around at our neighborhoods and communities is that these problems are so common."

"That's something to be concerned about. That's something to take communal action on," he added.

Identifying and treating abuse early can prevent many serious health consequences later in life. Programs that provide quality care for children, as well as home visitation programs in early infancy and parenting programs, are part of the solution to this problem, Sanders said.

"These interventions are important not just because abuse is so common, but because of the lifelong health implications," Sanders said. "There is a connection of these events to lifelong implications, not just for mental health for adults, but also for physical health."

For example, a person who has several of these events is more likely to get cancer and heart disease, Edwards said. "This is serious and it's not just a quirk of statistics. It's a real relationship."

Domestic Abuse Often Escapes Notice of ER Staff: Study

Most not identified as victims when treated in emergency department
By Robert Preidt (* link will not be available after 06/16/2011)
Friday, March 18, 2011

Related MedlinePlus Pages

• Domestic Violence
• Emergency Medical Services

FRIDAY, March 18 (HealthDay News) -- Three of four domestic violence victims treated in hospital emergency departments are not identified as victims of abuse, a new study reveals.

Researchers at the University of Pennsylvania School of Medicine analyzed court, police and emergency department (ED) records from a semi-rural county in Michigan between 1999 and 2002, and found that 80 percent of women who reported domestic assaults to police came to an emergency department at least once during the four years after the reported assault.

Most of the women sought ED care frequently, an average of seven times each during the study period.
However, only 28 percent of the women were ever identified in EDs as victims of domestic violence. The study authors speculated that the reason for this is likely because most of their ED visits were for medical complaints, not injuries associated with abuse. Among these patients, only 3.8 percent of emergency visits were reported to be mainly due to an assault.

Victims of domestic violence were four times more likely to be identified if they went to the ED on the day of the assault. They were also more likely to be identified if they were transported to the hospital by police or if their chief complaints involved mental health issues such as suicidal behavior or substance abuse issues such as overdoses.

The study is to be published online this week in the Journal of General Internal Medicine.
 
The findings highlight the need for emergency department staff to screen women who don't appear to be at risk for domestic violence, said the study authors.

"Emergency departments are a safety net for women with health issues of all kinds, but our study shows we're not doing a good enough job of assessing our patients' entire situation," Dr. Karin V. Rhodes, director of the division of emergency care policy research in the emergency medicine department, said in a university news release.

"There is no reason in the age of information technology that we should not provide routine screening and referrals to the social services patients can use to protect themselves from future violence," she added.

SOURCE: University of Pennsylvania, news release, March 16, 2011

HealthDay

Copyright (c) 2011 HealthDay. All rights reserved.

More Health News on:

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Moms With Tough Childhoods More Likely to Have Smaller Babies: Study

Abuse, poverty during a mother's youth is associated with heightened health risks for the next generation

By Robert Preidt  (*this news item will not be available after 06/29/2011)

Thursday, March 31, 2011 

THURSDAY, March 31 (HealthDay News) -- Women who suffered abuse in childhood are at increased risk of having low birth weight babies, a new study indicates.

It also found that poverty during childhood and substance use during adolescence and pregnancy boosts the chances of having low birth weight babies, who are at increased risk for death before their first birthday and chronic health problems.

About 8 percent of babies born in the United States each year have a low birth weight -- less than 5 pounds, 8 ounces (2,500 grams).

Researchers at the University of Washington in Seattle examined data from 136 mothers who had been part of a study since childhood. They found that women who suffered emotional, physical or sexual abuse or poverty in childhood were more likely to smoke, drink or use drugs during pregnancy, which increases the risk of having a low birth weight baby.

"Our findings suggest that a mother's economic position in childhood and her experience of maltreatment during childhood have implications for her children born years later," study author Amelia Gavin, an assistant professor in the School of Social Work, said in a university news release.

"What is important about this study is that it was the mother's experience of poverty and maltreatment in childhood, not her poverty or depression or obesity in adulthood, that contributed to her infant's low birth weight," she added.

Doctors should ask prospective mothers about any childhood maltreatment and offer help to those at risk for substance abuse during pregnancy, Gavin suggested.

The study was published online recently in the Journal of Adolescent Health.

SOURCE: University of Washington, news release, March 29, 2011

HealthDay Copyright (c) 2011   HealthDay.   All rights reserved.

PTSD Risk in Women Tied to Genetics

By John Gever, Senior Editor, MedPage Today
Published: February 23, 2011
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

A common gene variant was associated with a nearly doubled likelihood of posttraumatic stress disorder (PTSD) in at-risk urban women -- but not in otherwise similar men, researchers said. 

The affected gene encodes a receptor protein believed to mediate stress responses, and is also modulated by estrogen signaling, according to Kerry Ressler, MD, PhD, of Emory University in Atlanta, reporting in the Feb. 24 issue of Nature.

Heavily traumatized civilian women with two copies of a specific single nucleotide polymorphism (SNP) in the ADCYAP1R1 gene were more likely to show PTSD with an odds ratio of 1.66 (95% CI 1.32 to 2.09) relative to similar women without the condition, Kessler and colleagues found.

The same SNP -- called rs2267735, substituting a cytosine base for a guanine -- in men exposed to fearful situations showed no association with PTSD, the researchers also found (OR 0.95, 95% CI 0.71 to 1.27).
The authors did point out, however, that women are more likely to develop PTSD than men, and this discrepancy may relate to the modulation of the receptor pathway by estrogen.

Nearly 40% of women in the study had the CC genotype, carrying two copies of the risk-associated SNP.
In that group, an average of 15 PTSD symptoms were identified clinically, compared with 11 in individuals with the CG or GG genotypes (P<0.05).

About one-third of the 763 women in the study were diagnosed with PTSD.

Other researchers contacted by MedPage Today and ABC News said the results were promising but needed replication in larger and different samples.

"This study was done on chronically ill patients, those with both chronic medical and chronic psychological comorbidities, so it's difficult to know if the signaling is from PTSD or from their comorbidities," said Charles Marmar, MD, of NYU Langone Medical Center in New York City, in an e-mail. "There's a need for replication in a younger, healthier population with more recent trauma exposure."

Judith A. Myers-Walls, PhD, of Purdue University in West Lafayette, Ind., also noted that the methodology left some questions unanswered.

"The data were collected after the PTSD symptoms were identified, so it is not clear whether the stress reaction itself created the changes in physiology or they existed before the exposure to the stressful situation," she said in an e-mail.

Among the individual PTSD symptoms, hyperarousal was the one most strongly associated with the CC genotype. After controlling for trauma history, age, and race, women with the CC genotype had mean hyperarousal scores of about 5.2, compared with 3.9 among women with at least one G allele (P=0.0008).
Women with the CC genotype also showed exaggerated startle responses.

All these effects were completely confined to women in the study. For the genetic research, Ressler and colleagues initially analyzed a group of 503 women and 295 men. They then confirmed the findings in a replication set of 260 women and 179 men -- also drawn from the same population of trauma-exposed city dwellers but enrolled later and interviewed by different staff.

Most of the associations reported in the Nature paper were calculated from both samples combined.
Ressler and colleagues actually started out investigating the role of a protein called PACAP, the pituitary adenylate cyclase-activating polypeptide, which earlier studies had linked to cellular stress responses. PACAP is the natural ligand for the receptor encoded by ADCYAP1R1.

Blood levels of the peptide were significantly associated with PTSD symptom counts, startle reflexes, and other measures of fear physiology, the researchers found -- but again only in women.

Ressler and colleagues also found that expression of an ADCYAP1R1 homologue in rodents was increased with estrogen replacement and with fear conditioning -- supporting a role for the gene and its protein product, the PAC1 receptor, in handling stress.

The researchers suggested that PACAP had potential clinical application as a biomarker of active PTSD, whereas ADCYAP1R1 genotype might be used to identify individuals most at risk for PTSD following trauma.
More study of the pathway may also reveal therapeutic targets for PTSD treatments, Ressler and colleagues indicated.

In an accompanying commentary published in Nature, Murray B. Stein, MD, of the University of California San Diego, suggested it would be premature to put the study's findings into clinical use immediately.
In addition to replicating the findings, he wrote, "more must be learned about the relationship between PACAP levels in peripheral blood and cerebrospinal fluid, and, particularly, in the regions of the brain that modulate the fear response."

Stein also called for studies of other genetic factors previously linked to PTSD and how they may be related to ADCYAP1R1.

Steven P. Hamilton, MD, PhD, of the University of California San Francisco, told MedPage Today and ABC News in an e-mail that the study's genetic findings were clearly important, at least as a starting point.
"So far, we have only a minimal understanding of the genetic factors influencing PTSD, so this finding is a promising advance, and suggests that more genetic research into anxiety disorders is warranted," said Hamilton.

The study was funded primarily by the National Institutes of Health. Some authors also received salary support from other government and foundation sources.
Study authors and Stein declared they had no relevant financial interests.

This article was developed in collaboration with ABC News.

Primary source: Nature
Source reference:
Ressler K, et al "Post-traumatic stress disorder is associated with PACAP and the PAC1 receptor" Nature 2011; 470: 492-497.


Additional source: Nature
Source reference:
Stein M, "A molecular shield from trauma" Nature 2011; 470: 468-469.

Cost of Injury and Violence in the United States

from CDC's National Center for Injury Prevention and Control. 

 CDC's Injury Center is pleased to announce the release of the new WISQARS^TM (Web-based Injury Statistics Query and Reporting System) Cost of Injury Reports.* 
 

WISQARS™ data can be used to learn more about the public health and economic burden associated with unintentional injury and violence-related injury in the United States.
 
The Cost of Injury Reports module provides cost estimates for injury deaths, hospitalizations, and emergency department visits where the patient was treated and released. 
 
The new module allows users to create reports of: medical costs (e.g., treatment and rehabilitation), work loss costs (e.g., lost wages, fringe benefits, and self-reported household services), and combined costs (medical plus work loss) based on a number of variables including: intent and mechanism (cause) of injury, body region and diagnosis of injury, geographic location (for deaths only), sex, and age.

 
Learn More

• Cost of Injury Reports Module
• About Cost of Injury Reports
• WISQARS^TM

* WISQARS^TM Cost of Injury Reports are based on lifetime medical and lifetime work loss costs in 2005. This was the most recent year of unit cost data available at the time the module was developed. NCIPC plans to update these estimates to more recent years in the future.

---

Video Series on: The A.C.E. Study - Adverse Childhood Experiences

ACE Study - 

Vincent Felitti, MD 

 

"We saw that things like intractable smoking, things like promiscuity, use of street drugs, heavy alcohol consumption, etc., these were fairly common in the backgrounds of many of the patients...These were merely techniques they were using, these were merely coping mechanisms that had gone into place."– Vincent Felitti, MD

When Dr. Vincent Felitti, head of the Department of Preventive Medicine at Kaiser Permanente in San Diego, began to delve into the reasons for the high dropout rate of patients who'd been successfully losing weight in Kaiser’s obesity program, he found to his surprise that a high proportion of those dropping out had histories of childhood abuse or neglect. Dr. Robert Anda, who had been doing research with the Centers for Disease Control and Prevention on the psychosocial origins of health-risk behaviors in patients at VA hospitals, heard Felitti speak about his findings, and in 1992 the two began to collaborate on the largest-scale study to date of the incidence and effects of childhood trauma, known as the Adverse Childhood Experiences (ACE) Study.

According to data collected from the over 17,000 Kaiser patients in this ongoing retrospective and prospective study, adverse childhood experiences, though well concealed, are unexpectedly common, have a profound negative effect on adult health and well-being a half century later, and are a prime determinant of adult health status in the United States.


The Origins of Addiction: Evidence from the Adverse Childhood Experiences Study  

Vincent J. Felitti, MD - Department of Preventive Medicine - Kaiser Permanente Medical Care Program

ABSTRACT:
A population-based analysis of over 17,000 middle-class American adults undergoing comprehensive, biopsychosocial medical evaluation indicates that three common categories of addiction are strongly related in a proportionate manner to several specific categories of adverse experiences during childhood. This, coupled with related information, suggests that the basic cause of addiction is predominantly experience-dependent during childhood and not substance-dependent. This challenge to the usual concept of the cause of addictions has significant implications for medical practice and for treatment programs....

Our overall findings, presented extensively in the American literature, demonstrate that:
• Adverse childhood experiences are surprisingly common, although typically concealed and unrecognized.
• ACEs still have a profound effect 50 years later, although now transformed from psychosocial experience into organic disease, social malfunction, and mental illness.
• Adverse childhood experiences are the main determinant of the health and social well-being of the nation....

Conclusion:
The current concept of addiction is ill founded. Our study of the relationship of adverse childhood experiences to adult health status in over 17,000 persons shows addiction to be a readily understandable although largely unconscious attempt to gain relief from well-concealed prior life traumas by using psychoactive materials 


The Relation Between Adverse Childhood Experiences and Adult Health: Turning Gold into Lead 

By Vincent J Felitti, MD  

The ACE Study reveals a powerful relation between our emotional experiences as children and our adult emotional health, physical health, and major causes of mortality in the United States. Moreover, the time factors in the study make it clear that time does not heal some of the adverse experiences we found so common in the childhoods of a large population of middle-aged, middle-class Americans. One doesn't "just get over" some things.