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/ 

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.

Chronically Ill Children Are 88% More Likely to Suffer Physical Abuse, Swedish Researchers Find

ScienceDaily (Feb. 18, 2011) — Children with chronic health conditions are 88% more likely to suffer physical abuse than healthy children, according to research in the March issue of Acta Paediatrica. They are also 154% more likely to suffer a combination of physical abuse and exposure to intimate partner violence than their healthy school friends.

Researchers from Karlstad University, Sweden, analysed 2,510 questionnaires completed anonymously by children aged ten, 12 and 15 from 44 schools. Nearly one in four had at least one chronic health condition, including visual, hearing or speech problems, diabetes, mental illness, physical disabilities, allergies, weight issues, epilepsy or Attention Deficit Hyperactivity Disorder.

"Twelve per cent of all the children who took part in the survey said they had been physically abused, 7% had witnessed intimate partner violence and 3% had experienced both" says lead author Birgitta Svensson from the Department of Health and Environmental Sciences at the University. "But when we looked at children with chronic illness, the figures were significantly higher for physical abuse and for physical abuse combined with intimate partner violence."

Child physical abuse ranged from severe shaking, ear boxing and hair pulling by an adult to being severely beaten with a hand or device. Intimate partner violence was defined as a child seeing adults in their family hit each other.

"It is clear from our study that children with chronic health conditions face an increased risk of child physical abuse and intimate partner violence and that certain factors may unite this group, regardless of the nature or severity of their health problem" says Svensson.

"Further analysis showed that children with chronic health conditions faced an even higher risk of physical abuse when they were also born outside Sweden or lived in a low income family. The most vulnerable children were those that fell into all three categories."

Key findings of the study include:

Chronic health problems:

• 39% of the children reported chronic health problems -- 25% reported one, 10% reported two and 4% reported three or more. Children aged 15 reported significantly more chronic health problems than younger children.

All child physical abuse (with or without intimate partner violence):

• Having a chronic health condition raised the risk of physical abuse by 88%, as did being 15-years-old (+77%), male (+30%), born outside Sweden (+113%) and not living with both biological parents (+90%).

Child physical abuse only:

• 7% of the healthy children and 12% of the children with chronic health problems had suffered physical abuse only.
• Chronic health raised the risk of physical abuse only (+ 67%) as did being 15 (+37%) male (+49%) and born outside Sweden (+89%).
• Abuse rates increased with the number of chronic health conditions, from 10% for children with one to 16% for children with three or more.

Child physical abuse plus intimate partner violence:

• 2% of the healthy children and 5% of the children with chronic heath had suffered physical abuse and witnessed intimate partner violence.
• Chronic health raised the risk of experiencing both (+154%) as did being 15 (+192%), born outside Sweden (+128%) and not living with both biological parents (+314%).
• The chance of experiencing both increased with the number of chronic conditions, from 3.5% for children with one to 12% for children with three or more.

"This information, and the other trends identified by this study, will be very useful to anyone who works with children" concludes Svensson. "We are now taking our research a stage further to look at how families handle this internal conflict and at the professional support they need and receive."

Science Daily Link

MEDICAL NEWS: No Benefit Seen in Routine Screening for Domestic Abuse

MedPage Today
No Benefit Seen in Routine Screening for Domestic Abuse

By John Gever, Senior Editor, MedPage Today
Published: August 04, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Screening all women in medical clinics for intimate partner violence in a randomized trial did not reduce rates of abuse or improve their quality of life, researchers said. Among those for whom the screening revealed a history of abuse, recurrence of partner violence during 18 months of follow-up was reduced by a nonsignificant 18% (odds ratio 0.82, 95% CI 0.32 to 2.12) compared with control participants, according to Harriet L. MacMillan, MD, of McMaster University in Hamilton, Ontario, and colleagues. The study randomized more than 6,700 eligible and consenting women at 26 Ontario medical clinics to either screening before their medical evaluation, so that interventions could be recommended to women exposed to partner violence, or to completing the screening questionnaires after the clinic visit. Writing in the Aug. 5 Journal of the American Medical Association, the researchers found that quality of life scores improved somewhat more at the 18-month follow-up in the screened group -- from 52.1 to 58.5, compared with an increase from 50.6 to 52.7 in the control group (P<0.05). Depression scores were also modestly reduced. But when MacMillan and colleagues imputted outcomes for the more than 40% of participants in both groups who dropped out of the study during follow-up, these differences shrank to insignificance. The screened women also showed no reduction in after-effects of domestic violence, such as post-traumatic stress disorder and drug and alcohol problems, compared with the unscreened group. "These results do not provide sufficient evidence to support universal IPV screening in healthcare settings in the absence of an effective intervention to prevent or reduce intimate partner violence," the researchers concluded. The trial did not employ a specific intervention for those with positive screening results. Clinicians were informed of available local services for victimized women, but they provided referrals at their own discretion. In fact, the researchers said, "fewer than half [44%] of the screened-positive women reported having a discussion about violence with their clinician during their visit." MacMillan and colleagues said it may be argued that even small improvements in outcomes justify screening, particularly as the trial did not identify any specific harms to participants from the screening. For example, other researchers suggested last year that performing such screens on mothers bringing their children to pediatric clinics would be beneficial. (See Pediatricians Should Screen Moms for Domestic Violence) But the researchers pointed out that 87% of participants were not exposed to partner violence, suggesting a significant amount of wasted effort in the screening. They also noted that the screening had a false-positive rate of 11%, requiring additional clinical effort and opportunity costs to identify those with positive results who actually needed no intervention. In an accompanying editorial, Kathryn E. Moracco, PhD, MPH, of the University of North Carolina in Chapel Hill, N.C., and Thomas B. Cole, MD, MPH, a contributing editor at JAMA, suggested that the effectiveness of medical screening for partner violence can't be properly evaluated until there are clinic-based interventions with proven efficacy. "Specific interventions to prevent the recurrence of abuse for women at risk of violence should be implemented and rigorously tested, preferably in randomized trials, without further delay," they wrote. "The results of the [current study] should dispel any illusions that universal screening with passive referrals to community services is an adequate response to violence in intimate relationships," they contended. In the study, women presenting at 11 emergency departments, 12 family practice centers, and three ob/gyn clinics during an 18-month period beginning in July 2005 were nominally eligible to participate. Those younger than 18 or older than 64 were excluded, as were women who did not make their own appointments or who did not have a male partner in the past year. Participation was also limited to those who spoke English, were able to be alone, and were not seriously ill. These exclusions meant that, of more than 120,000 women presenting at these clinics, about 87,000 were ineligible. Another 13,000 either refused to provide information to determine eligibility or were missed by the investigators. About 1,500 more who were eligible declined to participate. That left about 6,700 to be randomized. The investigators designated certain days as "screening days" during which all eligible and consenting female patients were asked to complete the screening questionnaire before they saw clinicians. An equal number of days provided the nonscreened control, with participants completing the questionnaire after the clinic visit. The screening instrument was the Woman Abuse Screening Tool, with the Composite Abuse Scale used to determine exposure to violence during follow-up. Other outcomes such as PTSD, depression, and substance abuse were measured with standard instruments such as the Short Form-12 and Short Form-36. Quality of life was evaluated with the World Health Organization Quality of Life (WHOQOL)–Bref questionnaire. Of 2,733 screened patients, 347 had positive results. A similar proportion of the 2,948 patients in the control group who completed the questionnaires also had positive results. Those in the unscreened group could also be asked about domestic violence if the clinician chose. Participants were interviewed every six months afterward through the 18-month follow-up period. Attrition was steady, reaching 43% in the screened group and 41% in the control patients at the end of follow-up. Growth trajectories were calculated with a logistic model for abuse recurrence and with a linear model for quality of life. A secondary analysis used imputed observations based on partial follow-up data to compensate for the high attrition. The researchers found that, among the screened-positive women still in the study at 18 months, 8% had called a crisis hotline, while 9% had contacted a counseling or advocacy center for abused women, and 4% had sought refuge at a shelter during the follow-up period. Some 26% had talked with a psychologist or social worker. These figures were very similar to those in the control group whose screening results were positive. MacMillan and colleagues said it was notable that absolute improvements in most outcomes were seen in both groups relative to baseline. They speculated that participation in the study -- being asked about intimate partner violence and its effects -- may have been beneficial in itself. Every participant was given an information card with details on services for abused women in their communities. The authors also noted that the study began during a period when crime statistics indicated violence was at a high point, and "was likely to decrease over time regardless of any intervention." Besides the high loss to follow-up, limitations to the study included the reliance on participant self-report for baseline and follow-up data, as well as the carefully controlled trial conditions that would probably not occur in ordinary medical practice. They also noted that significant costs were involved to support the highly trained research assistants who ensured that women filled out the written screen and that positive results were delivered immediately to the clinicians. In addition, each clinician received specific training. Also, the study was conducted in Canada where women have universal access to most healthcare services. The study was funded by a grant from the former Ontario Women's Health Council (Ontario Ministry of Health and Long-Term Care).  MacMillan reported holding a Canadian Institutes of Health Research (CIHR) New Emerging Team grant from the Institutes of Gender and Health.

Primary source: Journal of the American Medical Association Source reference: MacMillan H, et al "Screening for intimate partner violence in health care settings: a randomized trial" JAMA 2009; 302: 493-501. Additional source: Journal of the American Medical Association Source reference: Moracco K, et al., "Preventing intimate partner violence: screening is not enough" JAMA 2009; 302: 568-69.