Impact of Childhood Maltreatment and Polyvictimization on Adult Revictimization
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Childhood maltreatment is the term used to capture physical, sexual, and emotional abuse, or neglect perpetrated against persons under the age of 18 years. Each type of abuse can have immediate and harmful physical and psychological consequences and is associated with increased vulnerability to revictimization during childhood and into adulthood. For many children, victimization experiences involve more than one type of maltreatment or traumatizing event. In fact, a significant number of children experience a variety of repeated abuses or traumatizing events that become part of a pattern of polyvictimization. These are also referred to as complex forms of trauma. Childhood maltreatment and polyvictimization also lead to poorer physical and psychological health throughout adulthood and increased the likelihood of adult revictimization. To accurately determine the magnitude of the negative physical and psychological consequences of childhood maltreatment and polyvictimization, victimizing events must be considered in relation to their impact on the following: (1) normal neurological, intellectual, and social development; (2) early childhood acquisition and use of coping strategies that are relevant to the management of normative challenges and traumatic experiences occurring in adolescence and adulthood; (3) participation in risk behaviors that heighten exposure to physical and psychological injury; and (4) the physical and psychological health outcomes that distinguish adults with histories of child abuse and neglect from adults with no history of childhood maltreatment and polyvictimization. This chapter addresses the scope and significance of childhood maltreatment and polyvictimization, the impact of childhood maltreatment and polyvictimization on adult revictimization, pathways from childhood maltreatment and polyvictimization to adult revictimization, and interventions to manage lifelong patterns of maltreatment and polyvictimization.
KeywordsChildhood maltreatment Polyvictimization Revictimization Retraumatization Physical health Psychological health Intervention
Childhood maltreatment captures a number of different types of harms that are intentionally perpetrated against children or reflect life circumstances that do not permit the appropriate prioritization of children and their welfare. Child physical abuse is defined by the use of physical force against a child with the intent to cause physical harm. Child sexual abuse is defined as any completed or attempted sexual act perpetrated against, any sexual contact with, or sexual exploitation of a child. Child emotional (or psychological) abuse captures those intentional, nonphysical behaviors by which a caregiver communicates to a child that they are not cared about, loved, or wanted. Child neglect is defined as the caregiver’s failure to provide for a child’s basic physical and emotional needs or the failure of the caregiver to protect the child from harm. These definitions of child abuse and neglect reflect the definitions crafted by Leeb and colleagues (2011) and used by the Centers for Disease Control and Prevention (CDC).
More recently, clinical practice and research has revealed that child maltreatment rarely occurs as an isolated event of abuse or neglect. Rather, maltreated children experience multiple forms of abuse and neglect and the experience of maltreatment can occur across multiple years and impact multiple stages of development. This pattern of victimization is best captured by the term polyvictimization, which was first forwarded by Finkelhor and colleagues (2007a). These experiences are also referred to as complex trauma (Courtois and Ford 2009; Ford and Courtois 2020). Polyvictimization can arise out of different environmental or contextual circumstances (Finkelhor et al. 2007b, 2009a) and can contribute to increased risk of revictimization (Finkelhor et al. 2007b).
There is growing concern over both the immediate and more obvious physical and psychological harms that are the results of child maltreatment and polyvictimization and the less immediately obvious impacts of these victimization experiences on the developmental processes that shape physiological, cognitive, behavioral, and affective responding across the lifespan. Childhood maltreatment and polyvictimization need to be considered in relation to: (1) normal neurological, intellectual, and social development; (2) early childhood acquisition and use of trauma-based coping strategies and adaptations that are relevant to the management of normative challenges and traumatic experiences occurring in adolescence and adulthood; (3) participation in risk behaviors that heighten exposure to physical and psychological injury; and (4) the physical and psychological health outcomes that distinguish adults with histories of child maltreatment and polyvictimization from adults with no such history. This chapter is designed to provide the scope and significance of childhood maltreatment and polyvictimization in general and in terms of their impact on adult revictimization. Potential pathways that explain the many negative physical and psychological consequences of child maltreatment to adult revictimization are reviewed, with an emphasis placed on the relation of childhood maltreatment to coping trajectories and to physical and psychological health outcomes experienced across the lifespan. This chapter ends with a brief discussion of interventions used to manage lifelong patterns of maltreatment and polyvictimization.
Scope and Significance of Childhood Maltreatment and Polyvictimization
Childhood maltreatment occurs with alarming frequency and affects societies across the world. Research has been undertaken to document the prevalence of different types of child maltreatment across continents (Stoltenborgh et al. 2014). Large-scale investigations suggest the global rate of child sexual abuse to be 12% (Stoltenborgh et al. 2011). Rates of child sexual abuse vary by gender, with 18% of girls and 8% of boys having experiences of this form of abuse. These gender-specific rates of child sexual abuse hold true across time and populations examined (Finkelhor 1994; Pedera et al. 2009; Stoltenborgh et al. 2011). Global estimates of child physical abuse range from 14% to 55%, with 26% serving as the averaged rate across six continents (Stoltenborgh et al. 2014). Global estimates of child emotional abuse range from 11% to 47%, with 33% serving as the averaged rate across five continents. Global estimates of child physical neglect range from 7% to 19%, with 13% serving as the averaged rate across two continents. Global estimates of child emotional neglect range from 15% to 40%, with 28% serving as the averaged rate across three continents. It has to be recognized that estimates of child maltreatment vary dramatically when the source of the information is considered. On average, rates of self-reported child maltreatment are much greater than the rates reported by professional informants (i.e., child protection workers, medical professionals, police officers, and teachers) (Stoltenborgh et al. 2014). Because of reporting rate discrepancies across sources, reported rates of child maltreatment and polyvictimization should be estimated with recognition of the discrepancies in reports by source.
Within North America, the prevalence estimates for events of physical abuse, sexual abuse, emotional abuse, and neglect perpetrated against children are 24%, 14%, 29%, and 34%, respectively (Stoltenborgh et al. 2014). With the exception of child sexual abuse, rates of childhood maltreatment are similar across boys and girls. The rate of sexual abuse perpetrated against girls is more than twice the rate observed for boys. In addition to the physical and psychological harms suffered by victims, these forms of child maltreatment are associated with other ongoing costs to the individual and society. It has been estimated that the per victim lifetime cost of childhood abuse and neglect is $831,000 in nonfatal circumstances and $16 million when events of childhood abuse and neglect are fatal (Peterson et al. 2018). For the United States, the aggregate economic cost of childhood maltreatment ranges from 428 million to 2 trillion dollars. When the costs to society are calculated with respect to the personal and intergenerational impacts of child maltreatment, these costs are incalculable.
Finkelhor and colleagues have done much to highlight the occurrence of polyvictimization (defined as the experience of four or more different types of victimization in 1 year) and to document its relevance to the study of trauma symptoms in children. Using data from a nationally representative sample of 2,030 children ranging in age from 2 years to 17 years, these researchers examined rates of polyvictimization and tested the relation of polyvictimization to children’s reports of trauma symptoms (Finkelhor et al. 2007a). Twenty-two percent of the sample reported four or more different experiences of victimization; this rate of victimization was highly predictive of trauma symptoms, accounting for more of the variance in trauma symptoms than any single type of victimization and reducing or eliminating the influence of single types of victimization on trauma symptoms.
In a separate analysis of the data obtained from their nationally representative sample, Finkelhor and colleagues (2009a) identified four distinct pathways or environments that appear to be especially salient to the genesis of polyvictimization: (1) residing in a dangerous community; (2) living in a dangerous family; (3) living in a chaotic family with multiple problems; and (4) experiencing significant emotional problems that increase risk behavior, escalate animosity, and interfere with the ability to protect oneself. All four pathways were independently associated with the onset of polyvictimization, with onset determined to be particularly high at two ages: (1) in the year just prior to the seventh birthday, this period corresponding to children’s entry into the elementary school; and (2) in the year just prior to the 15th birthday, this period corresponding to the adolescents’ entry into high school. In a subsequent study, Finkelhor and colleagues (2009b) examined polyvictimization occurring over a 2-year assessment period. Eighty percent of the retained sample (1,467 children and youth) reported one lifetime victimization, with the median number of lifetime victimizations reported to be 2.6 victimizations. The 10% of children reporting the highest polyvictimization scores were more likely to experience emotional distress and report more non-victimization adversities and were less likely to be a member of an intact family.
The Relation of Childhood Maltreatment and Polyvictimization to the Occurrence of Adult Revictimization
The determinantal impacts of child maltreatment increase markedly when the relation of child maltreatment to adolescent and adult experiences of victimization is considered. The occurrence and the severity of child sexual abuse are among the most reliable predictors of adult sexual victimization, with findings from empirical reviews suggesting that 50% to 67% of persons who report child sexual abuse experience sexual revictimization in adulthood (Classen et al. 2005; Walker et al. 2019). When calculating the risk of adult sexual victimization, the impacts of childhood maltreatment are cumulative, with 6% of sexually victimized adults reporting a single type of child abuse, 22% reporting the experience of two types of child abuse, and 33% reporting three types of child abuse (i.e., physical, sexual, and emotional abuse) (Classen et al. 2005). Women with a history of child sexual abuse as a single type of exposure are at least twice as likely to report experiences of sexual and physical revictimization in adulthood (Barnes et al. 2009). Relationship to the perpetrator is another parameter of child sexual abuse proposed to influence the likelihood of later revictimization. Although incestuous child sexual abuse has been suggested to translate to greater risk of adult revictimization (Kessler and Bieschke 1999), current findings regarding the impact of relationship to the perpetrator are equivocal. Incestuous child sexual abuse occurs in the context of multiple, co-occurring types of abuse and neglect and that it is the total experience of childhood maltreatment that predicts increased risk of adult physical and sexual revictimization (Aakvaag et al. 2017; Barnes et al. 2009; Li et al. 2019; Widom et al. 2008).
Research has been undertaken to determine whether experiences of child polyvictimization and adolescent/young adult revictimization conform to any temporal patterns that would then point to specific opportunities to intervene and potentially halt the progression to adult revictimization. To determine whether distinct temporal patterns of victimization and revictimization exist among persons with histories of interpersonal victimization, and to examine the outcomes associated with identified temporal patterns, Papalia and colleagues (2017) analyzed linked registry data from 401 persons with medically verified child sexual abuse histories and at least one documented experience of interpersonal revictimization and 109 persons with at least one documented experience of interpersonal victimization and no history of child sexual abuse. Comparisons made between these two groups revealed that persons with histories of child sexual abuse and interpersonal revictimization experienced significantly higher rates of victimization, were victimized over a significantly longer periods of time, were significantly more likely to involved in relationships that required the implementation of a personal safety intervention order for their protection, and were significantly more likely to have had contact with mental health services and to have received a mental health diagnosis. Attesting to the relation of child victimization and adult revictimization to behaviors that would be characterized as antisocial or criminal is the fact that the rate of violent offenses perpetrated by persons with histories of child sexual abuse and interpersonal revictimization was nearly three times that observed among persons with at least one documented experience of interpersonal victimization and no history of child sexual abuse.
Using longitudinal latent class analysis, Papalia et al. (2017) identified the following four distinct victimization trajectories among the 401 persons who experienced child sexual abuse and revictimization: (1) normative interpersonal revictimization trajectory (67%); (2) childhood-limited interpersonal revictimization trajectory (16%); (3) emerging-adulthood interpersonal revictimization trajectory (9%); and (4) chronic interpersonal revictimization trajectory (8%). Persons who experienced emerging-adulthood and chronic interpersonal revictimization trajectories were at greatest risk of revictimization, with peak rates of victimization occurring in early adulthood for those who evidenced the emerging-adulthood interpersonal revictimization trajectory and with elevated rates of victimization occurring throughout childhood and adolescence and into early adulthood for persons who evidenced the chronic interpersonal revictimization trajectory. Persons who experienced victimization consistent with these two trajectories were more likely to have experienced and perpetrated violence, to have had contact with mental health providers, and to be diagnosed with post-traumatic stress disorder than persons characterized by the normative and childhood-limited interpersonal revictimization trajectories. These findings demonstrate that, among persons with revictimization histories, those whose histories include child sexual abuse experience greater rates of victimization and more negative life outcomes. The findings also make clear that revictimization experiences can differ markedly across persons who share child sexual abuse histories and those different histories can translate to different health and functional outcomes.
The relation of repeated victimization to repeated traumatization and to compromised physical and psychological health and functioning is addressed comprehensively within Duckworth and Follette’s (2012) edited book detailing the assessment and treatment of retraumatization occurring consequent to different types of victimization experiences. The editors defined retraumatization as “traumatic stress reactions, responses, and symptoms that occur consequent to multiple exposures to traumatic events that are physical, psychological, or both” (p. 2). Contributors to the book were asked to address revictimization and retraumatization occurring within their context of expertise and to then expand out to address other clinically relevant historical traumas. In their chapter addressing sexual victimization, Ghimire and Follette (2012) describe retraumatization as it occurs consequent to cumulative experiences of child sexual abuse, adolescent sexual revictimization, and adult sexual revictimization. As researchers who examine physical and psychosocial outcomes experienced by survivors of serious, injury-causing motor vehicle collisions, Duckworth and Iezzi emphasize the importance of conceptualizing any single event of disabling physical injury and traumatization as potentially occurring in the presence of historic traumas (e.g., childhood physical abuse) and adult traumas (e.g., intimate partner violence) that are also likely to have resulted in physical injury and traumatization (Duckworth et al. 2008, 2012). These researchers note that initial attention paid by professionals to symptoms of retraumatization may be dramatically less in situations that emphasize physical harms and that initial attention paid by professionals to symptoms of physical injury may be dramatically less in situations that emphasize psychological harms. It can be concluded from the book that victimization experiences often involve polyvictimization, with events occurring repeatedly within and across contexts, and that revictimization contributes to repeated experiences of traumatization.
The global scope and significance of childhood maltreatment and polyvictimization and the impact of these traumatizing experiences on the likelihood of adult revictimization and retraumatization are undeniable. Victims of childhood maltreatment experience repeated exposure to multiple types of maltreatment; these experiences of polyvictimization often translate to compromised health and functioning throughout the lifespan. Child maltreatment and polyvictimization impact physical and psychological health directly in the form of physical injuries and psychological injuries that take the form of somatic symptoms, depressive symptoms, anxiety symptoms, traumatic stress symptoms, and acting out behaviors of all kinds. Child maltreatment and polyvictimization increase the likelihood of adult revictimization and retraumatization and decrease the likelihood that a life of purpose, achievement, prosocial engagement, and overall well-being will be attained. Together, these findings point to the need to examine those personal, interpersonal, and socioenvironmental factors that influence the likelihood of repeated exposure to traumatizing events, the level of psychological health and well-being that can be achieved and sustained in the face of traumatic events, and the availability of interpersonal and structural resources that might serve to protect the individual from (further) harm or mitigate the harms that occur consequent to traumatic event exposure.
Pathways from Child Maltreatment to Adult Revictimization
At the level of the individual and at the level of society, the deleterious impacts of childhood maltreatment and polyvictimization are persistent and pervasive and require a lifespan approach to appreciating the developmental factors that are most relevant to the short- and long-term outcomes experienced by victims. Experiences of childhood maltreatment and polyvictimization also predict the extent to which other harms will be suffered during adolescence and adulthood. The cumulative burden of childhood victimization and the associated experience of adult revictimization can be tied to the impacts on neurobiological and social development, the acquisition and use of coping behaviors, engagement in risky lifestyle behaviors, and the physical, psychological, and quality of life outcomes experienced by persons who suffer victimization and revictimization across the lifespan.
Impact of Childhood Maltreatment and Polyvictimization on Neurobiological Development
The neurobiological impacts of childhood maltreatment are influenced by the type of maltreatment experienced, the age of the child and the developing brain, the chronicity of the maltreatment, and the number of different types of maltreatment to which the child experiences (Bick and Nelson 2016; De Bellis and Zisk 2014; Teicher and Samson 2016). Physical abuse, through direct injury of the brain, and physical and sexual abuse, through chronic activation of the stress response, can result in reduced brain volume, changes in specific brain structures, and changes in the neurochemistry of the brain that can be observed at the level of overt behavior (Bick and Nelson 2016; Leeb et al. 2011; Teicher and Samson 2016). Neglect, which accounts for the majority of reported child maltreatment, can impact brain development in a myriad of ways, including through improper nutrition and/or medical care (failure to provide) and through ingestion of toxins and unintentional injury occurring as a consequence of inadequate supervision (failure to supervise) (Leeb et al. 2011). Emotional abuse, examples of which include verbal attacks, insecure or disorganized forms of attachment as a result of inadequate attention to the child, threats of other types of maltreatment, and the willful withholding of those things that are considered necessary for life (e.g., food, shelter, and environmental and interpersonal stimulation), can also result in direct and indirect impacts on brain development (Leeb et al. 2011).
As would be predicted, these types of maltreatment are associated with the greatest neurodevelopmental harms when they are perpetrated against children under the age of 5 years, a period characterized by particularly rapid brain development and a period during which disruptions can result in persisting changes to brain structure and function (Kavanaugh et al. 2017; Maguire et al. 2009). Of course, the impacts of these neurodevelopmental harms can be inferred most directly from the neurocognitive functioning of abused and neglected children. A comprehensive review by Kavanaugh et al. (2017) revealed that the neurocognitive impacts experienced by maltreated children and adolescents are many and include compromised language acquisition, visuospatial skills, memory, and intellectual performance. Critical to judgment and decision-making are the impacts of maltreatment on executive functioning, both in general and in relation to identifying and managing interpersonal and social threats. The developmental timing and the severity of childhood maltreatment, whether defined by the chronicity of maltreatment or by the varied types of abuse and neglect that comprise the maltreatment, interactively contribute to the magnitude of the associated neurobiological and neurodevelopmental consequences. Consistent with these conclusions are Ford’s (2009) characterizations of childhood retraumatization experiences as (a) contributing to the development of a “survival brain” rather than a “learning brain” and (b) occasioning post-traumatic reactivity in the face of both developmentally appropriate challenges and traumatic events and circumstances.
Impact of Child Maltreatment and Polyvictimization on Psychosocial Development
Experiences of childhood maltreatment sometimes result in psychosocial impacts that further compromise health and functioning. Childcare circumstances that involve parents and/or close relatives would be presumed to be among those in which child safety would be high and risk of harm to the child would be low. The data pertaining to cases of child abuse and neglect substantiated by child protection services fly in the face of such presumptions of child safety (U.S. Department of Health and Human Services 2012). Approximately 80% of perpetrators of child abuse and neglect are parents, with an additional 10% of perpetrators identified as non-parental relatives and unmarried partners of parents. Children who experience such harms at the hands of trusted caregivers experience difficulties with attachment and interpersonal relating that have impacts throughout their lives (Cameranesi et al. 2019; Cheung et al. 2018; Courtois 2012). In an effort to limit risk of detection and/or disclosure of abuse and neglect, maltreated children are often refused the opportunity to interact socially with peers and adults outside of the home context and deprived the opportunity to develop those skills that are important to the development of healthy and supportive relationships. Experiences of abuse and neglect can also negatively impact school attendance and performance and limit participation in social activities that are known to be associated with more positive outcomes across a host of life domains (Bick and Nelson 2016; Khambati et al. 2018; Leeb et al. 2011).
Experiences of child maltreatment and polyvictimization are associated with psychological distress and functional impairment. Clinically significant post-traumatic stress reactions have been observed in children who have had direct exposure to maltreatment and in those who have matured in the context of domestic, school, and community violence (Rosen et al. 2018; Duckworth et al. 2000; Kendall-Tackettet et al. 1993; Layne et al. 2014; Pynoos et al. 1987; Widom 1999). Although post-traumatic stress responses are among the most frequently studied responses to childhood maltreatment, other internalizing (e.g., depressive reactions) and externalizing (e.g., aggressive or violent engagement with others) behaviors evidenced in childhood and adolescence are known to contribute to both physical and psychological morbidity and mortality (Child Welfare Information Gateway 2019). Findings from a large-scale, national cohort study of former child welfare clients who received out-of-home care due to need for protection suggest that such individuals are far more likely to be hospitalized for suicide attempts and to be diagnosed with severe psychiatric disorders during adolescence and young adulthood (Vinnerljung et al. 2006). Child maltreatment and polyvictimization are associated with poorer functioning across a variety of performance domains. Children who experience maltreatment and violent victimization experience deficits in cognitive and intellectual functioning, lower levels of educational attainment, higher rates of teen pregnancy, lower levels of employment, and increased engagement in criminal and violent behavior (Currie and Widom 2010; Fang et al. 2012; Putnam 2006).
Impact of Child Maltreatment and Polyvictimization on the Acquisition and Use of Personal and Interpersonal Coping Resources
There are certain biological and situational realities that limit the coping options available to maltreated children. Due to differences in physical size and strength, children rarely have the option to engage in physical defense or effective avoidance of older and often adult perpetrators. Due to differences in cognitive development, children can rarely craft and deliver a sufficiently convincing argument around the inappropriateness of the maltreatment and immediate and future harms that are likely to result from such maltreatment. As a function of these coping limitations, child maltreatment and polyvictimization contribute to the adoption of coping behaviors that may serve to increase risk of revictimization and associated harms.
Dissociation has long been theorized to be an emotion-focused coping strategy that permits children to distance themselves from the distress generated by acts of maltreatment and polyvictimization (Putnam 1996, 2006). Dissociation and other forms of avoidant coping have been determined to contribute to the level of trauma-related psychological dysfunction experienced consequent to childhood victimization (Dalenberg et al. 2012; Fortier et al. 2009) and to predict a poorer response to treatment (Vonderlin et al. 2018). As a cognitive strategy, it is likely that avoidant coping interferes with those cognitive processes (e.g., meaning making) that are associated with more optimal post-trauma outcomes (Walsh et al. 2010). It can also be supposed that cognitive avoidance interferes with attentional processes that are relevant to threat perception (Lacelle et al. 2012), thereby increasing the likelihood of child and adult revictimization and further impairing functioning across a host of life domains.
In the context of child maltreatment and polyvictimization, avoidant coping strategies sometimes serve to deescalate threat and better ensure survival. Avoidant coping strategies that are learned, practiced, and reinforced under such traumatic circumstances are likely to be regarded by the maltreated child as particularly effective and will be employed repeatedly, even in life contexts that render avoidant coping ineffective or even dangerous. This overgeneralized use of avoidant coping to manage the emotional distress is something that is addressed as a primary component of trauma-focused treatments (Courtois 2012; Dalenberg et al. 2012). Child maltreatment and polyvictimization also serve to limit children’s acquisition of the full range of coping strategies that are so key to effective coping (Modecki et al. 2017).
It has been posited that childhood maltreatment, particularly maltreatment perpetrated by persons who serve as caregivers, acts to breech the trust that typically characterizes the child-caregiver relationship (Janoff-Bulman 1992; Freyd 1994) and creates attachment trauma. As a behavioral strategy, avoidance appears to exert its effect on post-trauma psychological outcomes through its effect on attachment processes (Alexander 2012) and support-seeking behavior (Cameranesi et al. 2019; Cheung et al. 2018). The impacts of child maltreatment on access to social support appear to be persistent, with individuals who report child maltreatment experiencing unstable social support across the lifespan (Horan and Widom 2015).
In the context of both child and adult victimization, certain behavioral responses can be characterized as reactions to victimization experiences and as attempts to cope with the distress generated by these experiences. Child sexual abuse and other forms of child victimization are associated with greater engagement in risky sexual behavior, substance use and abuse, antisocial behavior, and criminal behavior (Horan and Widom 2015). The early onset of and persistent use of these risky behaviors have been determined to predict revictimization as well as a host of other physical and psychological consequences (Widom et al. 2008). Research findings suggest that, among adolescents with history of child maltreatment, better mental health outcomes are associated with the educational attainment of the caregiver, the use of positive coping strategies (i.e., problem analysis, advice seeking, response planning, and use of humor), and levels of esteem and efficacy that support the adoption and testing of such positive coping strategies (Cheung et al. 2018; Hardner et al. 2018).
Childhood Maltreatment and Polyvictimization as Predictors of Psychological and Physical Health in Adulthood
Among the more costly consequences of childhood maltreatment and polyvictimization are the long-lasting, negative physical and psychological health outcomes that result from such experiences. The health consequences of childhood maltreatment have received considerable empirical attention (Afifi et al. 2016; Cameranesi et al. 2019; Irish et al. 2010; Monnat and Chandler 2015; Norman et al. 2012). Irish et al. (2010) conducted a meta-analytic review of 31 studies that evaluated the physical health outcomes experienced by survivors of childhood sexual abuse. Across all six health outcomes assessed by the reviewed studies (i.e., general health, gastrointestinal health, gynecologic health, cardiopulmonary symptoms, pain, and obesity), individuals with a history of child sexual abuse reported more physical complaints than individuals with no history of child sexual abuse. These findings are supported by findings from a large-scale Canadian study that revealed all types of child abuse to be associated with having a physical disease or chronic health condition in adulthood (Afifi et al. 2016).
Norman and and colleagues (2012) conducted a systematic review and meta-analysis of 124 studies examining the long-term health consequences associated with nonsexual child maltreatment. A dose-response relation was observed between child physical and emotional abuse and neglect and long-term psychological health outcomes, with children who experienced more severe abuse and neglect being at greater risk for clinically significant psychological dysfunction in the form of major depressive disorders, anxiety disorders, eating disorders, childhood conduct and behavioral disorders, substance use and dependence disorders, suicide behaviors, and risky sexual behaviors.
Using data from more than 25,000 persons who responded to the 2012 Canadian Community Health Survey-Mental Health, Cameranesi et al. (2019) examined the direct and mediated effects of child abuse on adult physical and psychological health. The researchers defined child abuse to include exposure to intimate partner violence, child physical abuse, and child emotional abuse. Findings revealed child abuse to have direct effects on adult physical and psychological health and indirect effects on adult health through its relation to social support and life stressors. These findings point to the need to evaluate the developmental challenges and harms that occur as direct consequences of child maltreatment and the general life stressors and support resources, both social and economic, that serve as a backdrop to events of child maltreatment.
The rapidly growing literature addressing adverse childhood events (ACEs) attempts to document events of child maltreatment as well as the familial and household circumstances that can be considered to compound the effects of child maltreatment (Crandall et al. 2019; Felitti et al. 2019; Hughes et al. 2017; Monnat and Chandler 2015). The ACEs that are under study include all types of child maltreatment as well as household dysfunction in the form of domestic violence perpetrated against the mother, parental separation or divorce, substance abuse and other forms of mental illness suffered by any member of the household, and imprisonment of any member of the household (Felitti et al. 2019). Among the more recent, large-scale examinations of ACEs and their impacts is a study of more than 50,000 US adults who participated in the Behavioral Risk Factor Surveillance System (BRFSS) survey for the years 2009 to 2012 (Monnat and Chandler 2015). Findings indicated that ACEs negatively impact self-rated general health and functioning and increase the risk of diabetes and heart attack, with the link between ACE exposure and adult health being influenced by stress-related coping and economic status attained in adulthood.
Based on their examination of 37 studies, with study samples totaling more than 250,000 participants, Hughes and colleagues (2017) provided additional empirical confirmation of the relation of ACE exposure to adult physical and psychological health. Specifically, these researchers examined the impact of the frequency of ACE exposures on the risk of 23 health outcomes in adulthood. It was determined that exposure to a minimum of four ACEs increased risk for all health outcomes, with ACE-related risk being greatest for the following diseases, conditions, and health risk behaviors: problematic drug use; interpersonal and self-directed violence; sexual risk-taking; mental illness; smoking; heavy alcohol use; poor self-rated health; cancer; heart disease; respiratory disease; physical inactivity; overweight or obesity; and diabetes. In a related study, Felitti et al. (2019) determined that persons who report exposure to four or more ACEs are at 4- to 12-fold increased risk of alcoholism, drug abuse, depression, and suicidal behavior; 2- to 4-fold increased risk of smoking, poor self-rated health, sexual intercourse with 50 or more partners, and sexually transmitted infections; and an approximate 1.5-fold increased risk of physical inactivity and severe obesity.
As a logical outgrowth of clinical and research interest in ACEs and their impacts, research is being undertaken to examine the impact of advantageous childhood experiences or “counter-ACEs” on adult health and general well-being. Crandall et al. (2019) examined the influence of advantageous childhood experiences on the relation of childhood adversity to adult health. With counter-ACEs defined as higher perceived socioeconomic status, higher parental education, and more positive childhood experiences and relationships, the investigators determined that, in the presence of moderate experiences of childhood adversity, higher numbers of counter-ACEs serve to protect against poor health and increase general well-being. These findings suggest the importance of acting to both reduce the frequency of ACEs and promote positive childhood experiences at a frequency sufficient to mitigate the impact of adverse experiences when they do occur.
In the context of treating individuals with histories of child maltreatment and polyvictimization and adult revictimization, the primary challenge is to comprehensively evaluate all current and historic experiences and learned responses that are relevant to the client’s clinical presentation and to identify modifiable targets for intervention based on that evaluation data. For any given client, the presenting problem (e.g., traumatic brain injury), the immediate circumstances that contribute to the presenting problem (e.g., military combat), and the treatment setting that is deemed appropriate to manage the presenting problem (e.g., brain rehabilitation clinic) may not be sufficient to capture the all historic and current variables that are relevant to the initiation and maintenance of the presenting problem. When patients with complex histories of revictimization and retraumatization present for treatment, the presenting problem is not necessarily the problem that accounts most for the functional impairments and/or distress that patients report. For example, for the patient who experiences a range of problems consequent to an injury-causing MVC, treatment in the rehabilitative care setting would reasonably target the patient’s experience of pain, functional impairment, and emotional distress specific to the index MVC. Despite the presumed advantages of conducting a comprehensive evaluation of all current and historic factors that influence post-MVC outcomes, it cannot be assumed that all evaluators and treaters of MVC patients directly question the patient experiences of ACEs and/or adult challenges and traumas that would be predicted to influence the patient’s clinical presentation and response to treatment.
Despite the complex nature of children’s reactions to experiences of maltreatment and polyvictimization, and despite the fact these adverse experiences increase the likelihood of a variety of adult traumas, most interventions are conceived and implemented to address specific problematic responses occurring in specific adult populations consequent to specific traumatizing events. There are a number of evidenced-based treatments that can be used to effectively manage trauma-related symptoms in adults (American Psychological Association 2019). The past two decades have witnessed efforts to expand the application of these empirically supported treatments. In the context of treating trauma, prolonged exposure (Foa et al. 2007) and cognitive processing therapy (Resick and Schnicke 1993) are interventions that were employed and empirically validated with victims of sexual assault and are now considered treatments of choice for managing psychological distress related to a host of traumatizing circumstances, including military combat, intentional and unintentional injury, and natural disaster. Interventions are now being developed to address the injuries, functional impairments, and distress reactions that occur as a function of repeated exposure to a diverse array of traumatizing events (e.g., narrative exposure therapy as developed by Schauer et al. (2011) and treatment of complex trauma as described by Courtois and Ford (2009)); these treatments largely rely on evidenced-based strategies that emphasize exposure and emotional processing of cognitive and contextual reminders of traumatic events, applied in a sequence starting with a focus on personal safety and life stabilization. Considerable clinical research needs to be performed to document the effectiveness of treatments that address adult revictimization and retraumatization.
The application of evidence-based treatments for trauma to child populations is a more recent development and the effectiveness of these interventions with child populations is less well established. In a systematic review of the research literature, McTavish and colleagues (2019) examined 14 databases to identify 15 randomized controlled trials of psychosocial interventions aimed at managing the impacts of the child sexual abuse. These researchers determined that trauma-focused cognitive behavioral therapy, provided to children and their caregivers, consistently yielded mental health benefits. Other promising interventions were identified, including prolonged exposure, individual psychotherapy, and risk reduction through family therapy.
Based on their review and synthesis of findings from seven meta-analyses (capturing a total of 77 separate studies) that evaluated the treatment of child sexual abuse, Benuto and O’Donohue (2015) forwarded five major conclusions: (1) interventions administered in agency settings tended to garner more positive results than those administered in research settings; (2) interventions that involve longer duration of treatment tend to result in more positive outcomes; (3) eclectic or play therapy approaches are more effective for children who evidence poorer social functioning; (4) for interventions that target behavior problems, self-concept, post-traumatic stress, and/or caregiving behaviors, interventions that derive from the cognitive-behavioral orientation are moderately effective at best but these interventions are superior to interventions that derive from other theoretical orientations; and (5) there is no clear evidence that would support one therapy format (individual, family, or group) over another.
Of course, for those who are committed to the safety and well-being of children, the prevention of all types of child maltreatment is the ultimate aim. Efforts to prevent child maltreatment have traditionally taken the form of social services, school-based programs, parenting programs, and primary care interventions. Given the often extreme and enduring consequences of child maltreatment, it is critical that the effectiveness of all types of prevention efforts be evaluated. Research has recently been undertaken to determine the effectiveness of primary care interventions. The US Preventive Services Task Force (2018) reviewed 22 randomized clinical trials that identified high-risk families with no existing signs of child or adolescent maltreatment and employed a variety of interventions aimed at prevention of maltreatment. Interventions employed across the clinical trials included patient referrals to resources within their community, parent training, and psychotherapy aimed at improving the effectiveness of parents’ coping behaviors and strengthening the parent-child relationship. The effectiveness of interventions was evaluated using direct evidence of abuse or neglect and direct evidence of need for protection as well as evidence that can be considered to point to abuse and neglect, including injuries, emergency department and hospital visits, and inadequate provision of medical care. The Task Force concluded that the evidence for the effectiveness of these primary care interventions is not sufficient to deem them more beneficial than harmful. Despite these conclusions, the American Academy of Pediatrics “strongly recommends clinician involvement in preventing child maltreatment and provides guidance and information on risk factors, protective factors, and clinical management” (U.S. Preventive Services Task Force 2018, p. 2127).
Child maltreatment is a common phenomenon across the world.
Child maltreatment is associated with increased vulnerability to revictimization from childhood to adulthood.
Polyvictimization is defined by repeated abuses of various types.
Polyvictimization is associated with a greater physical and psychological burden than victimization that is of one type.
Child polyvictimization serves to precipitate adult revictimization.
Child maltreatment is associated with an impact on neurological and social development.
Child maltreatment leads to the development of maladaptive coping strategies that have consequences into adulthood.
Child maltreatment and polyvictimization predict psychological and physical health in adulthood.
Although there is no gold standard for preventing and managing the full array of consequences the result from child maltreatment and polyvictimization, there are a number of interventions (e.g., trauma-focused cognitive behavioral therapy and risk-reduction strategies) that can be used to effectively address certain aspects of child maltreatment and polyvictimization and adult revictimization.
Summary and Conclusion
Childhood maltreatment is a significant personal experience and a major public health problem that is associated with a number of adverse physical and psychological outcomes across the lifespan. All forms of childhood maltreatment affect children and tend to co-occur in various combinations in childhood and adulthood. For a smaller but significant subgroup of maltreated children, the experience of different types of victimizing events is identified as polyvictimization and is associated with an increased physical and psychological burden. Childhood experiences are then carried into adulthood and add to an already overwhelming physical and psychological burden, which ultimately leads to a poorer quality of life, lower sense of well-being, and more compromised social and interpersonal relations. The identification of possible childhood trajectories continues to receive empirical attention and hopefully will lead to interventions that will ultimately identify childhood maltreatment and polyvictimization and reduce their consequences. At this time, successful interventions likely require matching innovative, empirically based and empirically supported approaches to primary clinical presentations (e.g., complex post-traumatic stress, domestic violence, or physical injury).
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