CHILD AND ADOLESCENT DISORDERS (TD BENTON, SECTION EDITOR)

Longitudinal Outcomes for Victims of Child Abuse

E. Taylor Buckingham & Peter Daniolos

Published online: 10 January 2013# Springer Science+Business Media New York 2013

Abstract Childhood abuse and neglect (child maltreat-ment) represent a common and significant public healthburden. The consequences of maltreatment can be seenimmediately, in the short term and in the long term. Deter-mination of the exact prevalence of childhood maltreatmentis difficult, as many cases go unreported; however inreported cases there is an estimated $124 billion annualburden on the US health-care system. The evaluation ofpotential maltreatment is difficult as many of the initialsymptoms are subtle and can be explained with alternativeillnesses or injuries. Potential immediate and short-termeffects include brain injury, shaken baby syndrome andbehavioral regression. The potential long-term sequelae ofchild maltreatment are explored in detail here and includeincreased risks of the development of mental health disorders,substance use disorders and chronic physical complaints dur-ing development and adulthood. Lastly, the review providesan overview of current treatment approaches for victims ofchildhood maltreatment.

Keywords Childhood maltreatment . Child abuse . Childneglect . Depression . Posttraumatic stress disorder .

Anxiety . Substance abuse . Chronic physical complaints .

High-risk behaviors . Evaluation . Treatment . Child andadolescent disorders . Psychiatry

Introduction

Childhood abuse and child maltreatment is a common andsignificant burden on the healthcare system that can produceimmediate, short term and long term sequelae [1]. The totalimpact of child maltreatment is difficult to determine be-cause of underreporting of cases or cases being diagnosed asanother type of illness or injury [2]. However, utilizing onlyconfirmed cases of maltreatment, there is an estimated an-nual cost of $124 billion dollars to the US health-caresystem alone [3]. Additionally, there is increasing evidencethat exposure to maltreatment during childhood and/or ado-lescence can produce long-term consequences for the victimmany years later, including being 25 % more likely to have ateen pregnancy [4]. Furthermore, 30 % of maltreatmentvictims will abuse their own children [4] and 80 % of 21-year-old victims develop at least one psychological disorder[4]. Other possible long-term consequences of early mal-treatment include increased risk of specific mental healthdisorders (particularly depression, anxiety disorders andPTSD) [5•, 6], substance abuse [4], legal difficulties [4, 7],chronic physical complaints [8, 9•] and reduced academic andemployment achievement [7]. The goal of this review is tooutline the current epidemiology of child maltreatment, ex-amine the evaluation of a patient with possible maltreatment,discuss the short- and long-term effects of maltreatment andfinally to provide a brief treatment overview for victims ofmaltreatment. This review is generated by key word searchesin PubMed, MEDLINE and PSYCHINFO utilizing the keywords of child abuse, child maltreatment, posttraumatic stressdisorder, neglect and reactive attachment disorder.

Epidemiology and Prevalence

Child maltreatment is a common event; however, develop-ment of definitive prevalence data has been very difficult

This article is part of the Topical Collection on Child and AdolescentDisorders

E. T. Buckingham : P. Daniolos (*)Child and Adolescent Psychiatry, Department of Psychiatry,University of Iowa Hospitals and Clinics,200 Hawkins Drive, 1882 JPP,Iowa City, IA 52242, USAe-mail: peter-daniolos@uiowa.edu

E. T. Buckinghame-mail: edward-buckingham@uiowa.edu

Curr Psychiatry Rep (2013) 15:342DOI 10.1007/s11920-012-0342-3

because of numerous obstacles [10]. Many cases of childmaltreatment go unreported or underreported [11]. Alterna-tively, maltreatment cases may be classified as another type ofillness or injury [12]. The primary source of maltreatment datacomes from formal abuse claims made to the local authoritiesor the Department of Human Services [4]. While the numberof child maltreatment claims is likely an underestimate of thetrue prevalence, there are still 3.3 million claims of abuse peryear in the US, with approximately 30 % being confirmedafter investigation [13, 14]. Child maltreatment data fromunderdeveloped countries have been difficult to obtain.

While precise prevalence numbers are difficult to obtain,it does appear that child maltreatment chronicity as mea-sured by official maltreatment claims provides a strongindicator of negative outcomes for maltreatment victims[15]. A large study completed by Jonson-Reid and colleaguesin the US [16••] examined nearly 6,000 low-income childrenin an urban Midwestern city. The participants were followedfor several years comparing maltreatment record reports tonegative future outcomes including substance abuse, mentalhealth treatment, brain injury, sexually transmitted disease,suicide attempts and violent delinquency before the age of18. There was a noticeable relationship between the number ofmaltreatment reports and likelihood of future negative out-comes (such as mental health disorders, substance use), butthe study also found that tertiary prevention and treatmentimproved future outcomes.

There are many different types of maltreatment that achild may experience. It is also common for a child toexperience more than one type of maltreatment. The mostcommon type of maltreatment is neglect and represents78.3 % of maltreatment claims. Physical abuse (17.6 %),sexual abuse (9.2 %), psychological abuse (8.1 %) andmedical neglect (2.4 %) represent additional types of abuse.As of 2010, there were 5 deaths secondary to child maltreat-ment in the US per day, a rate that has climbed steadily from3.13 deaths per day in 1998 [17].

Laslett et al. [18] found that alcohol was a major riskfactor for possible childhood maltreatment. A review of29,455 children identified between 2001 and 2005 foundthat almost one quarter of children had experienced morethan one incident of maltreatment in the 5-year period andthat caregiver alcohol abuse was significantly linked torecurrent maltreatment (p<0.001). Additional risk factorsincluded caregiver drug abuse, low socioeconomic status,and caregiver mental health history. The following caseillustrates some of the diagnostic challenges.

Case Example

Beth is a 13-year-old female who had a history of multiplepast psychiatric diagnoses including attention deficit

hyperactivity disorder; mood disorder, not otherwise speci-fied; oppositional defiant disorder; bipolar disorder andpossible reactive attachment disorder. She has a long-standing history of disruptive behavior, chronic irritabilityand rapid mood swings. She has been hospitalized for acutepsychiatric issues at least ten times and has a history of oneresidential placement for chronic disruptive behaviors. Shehas a history of multiple past psychiatric medication trialsincluding mood stabilizers, antipsychotics, alpha agonists,low dose SSRIs and low-dose beta blockers all with poorresponses.

She presented to an academic medical center for a secondopinion regarding diagnosis and treatment options. Wheninterviewed she quickly denied any traumatic life experien-ces and changed the subject whenever attempts were madeto explore her childhood. Eventually, while playing with adollhouse, she enacted a scene where the parent dolls werephysically fighting, and she laughed as she did this.When the interviewer commented that it is hard to seeone’s parents fighting, Beth’s affect shifted, and she be-came quiet. Later in the interview she reluctantly dis-closed that she had seen her parents fight to the point thatone or the other would bleed. However, she insisted thatthis did not bother her. Through later guardian inter-views it was confirmed that she had a significant traumahistory, including witnessing domestic violence during herearly childhood to the degree that she feared for her ownsafety and experiencing significant neglect from her sub-stance addicted parents. Prior providers had not furtherexplored this or connected these traumatic experienceswith her current symptoms, instead attributing her symptomsto other diagnoses such as oppositional defiant disorder(ODD).

On further interview, she disclosed more information asshe gained comfort with the clinician. She reported chronicirritability and low mood that worsened when she spent timewith her biologic mother. When not upset, she was able toidentify activities that she enjoyed and engaged in numeroussocial activities with same age peers. She reported frequentnightmares of her parents attacking each other, flashbacksrelated to the past trauma, reliving of the past trauma when-ever exposed to reminders such as witnessing two adultsshouting at each other, multiple triggers towards increasingirritability, easy startling, avoidance of environmental stim-uli such as violent films that reminded her of her pasttrauma, feelings of detachment, behavioral outbursts andhypervigilance. She also admitted to periods of intense ragewhere she felt as if she “might just kill” the person withwhom she was arguing, which would often lead to herphysically striking out at them. She described a foreshort-ened sense of the future and a sense of helplessness, with thelatter worsening in the presence of any interpersonal con-flict. She did not have a history of sustained elevated mood,

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decreased need for sleep, racing thoughts or other signs ofmania.

A diagnosis of posttraumatic stress disorder was made,and the patient was referred for trauma-focused cognitivebehavioral therapy. SSRI medications were recommended totarget PTSD symptoms. She was also referred for a prazosinstudy for individuals with PTSD and nightmares.

Evaluation of Possible Maltreatment

The assessment of potential child maltreatment (see Table 1)can be very difficult because of the absence of clear physicalsigns and variability in the child’s ability to describe poten-tial maltreatment based on their developmental stage [19]. Inaddition, children and adolescents with developmental dis-abilities are more likely to be victims of maltreatment andmay have a reduced ability to describe their maltreatment. Itis not uncommon for disclosure of abuse to be a gradualprocess, which can particularly be seen with sexual abuse[20]. Given that maltreatment can produce acute physicaland psychological findings, short-term physical and psycho-logical findings and long-term physical and psychologicalfindings, this often creates a very large differential diagnosisfor other possible causes, such as an alternative primarymental health problem (depression, anxiety or disruptivebehavior), acute injuries (such as unintentional fractures orbruising) or chronic illness (metabolic disease, coagulationdisorders, etc.) [21]. Many cases of maltreatment (includingearly deaths) are often misclassified as being accidentalinjuries or other causes of significant injury or mortality[21].

Complicating the evaluation of child maltreatment is thatthe patients may present in a variety of different settings.Ideally, a child suspected of experiencing maltreatmentshould be evaluated in a center with specific experienceand expertise [22]. However, it is common for patients topresent to emergency departments or their primary careprovider for maltreatment evaluations. The diagnosis ofPTSD can be particularly difficult in the primary care setting,as the initial complaints are often vague and could potentiallybe explained by alternative illness or injury [23].

If maltreatment is suspected, documentation of a physicalexam, including photographic evidence if indicated andlaboratory studies, such as a sexually transmitted infectionpanel, should be considered [24]. Both the physical examand the interview process should be done in such a manneras to minimize additional trauma. Children may experiencesignificant trauma from this evaluation and other types ofmedical procedures without proper precautions. Therefore,the evaluation should be completed by a clinician withexpertise in such evaluations.

Acute and Short-Term Consequences of Maltreatment

While a complete discussion of potential acute and short-term consequences of maltreatment is beyond the scope ofthis article, a brief overview will be provided because of thepotential these consequences present for setting up long-term difficulty or immediate risk to the individual. As dis-cussed in the evaluation section, maltreatment may initiallypresent with vague symptoms or symptoms that can beexplained by another process, such as accidental injury.Therefore, special awareness is needed when evaluating apatient for possible maltreatment.

Several possible findings of maltreatment are presentacutely following maltreatment. These can include fractures,particularly in a pattern that does not appear to match thereported injury, or shaken baby syndrome, particularly if thevictims are under 3 years of age [25]. It is also possible tosee bruising patterns that do not fit the reported injury, orevidence of intracranial hemorrhage or eye injury. Someinjuries may present immediate risk of mortality, such asshaken baby syndrome or intracranial hemorrhage, and im-mediate medical evaluation and treatment may be warranted.

It is also possible to see effects within a few days toweeks of maltreatment. Changes in the daily functioningof a child or adolescent should be noted, such as changesin sleep pattern, increase in frequency or severity of night-mares, reduction in appetite, increased irritability, socialisolation or behavioral regression, as all are potential warn-ing signs of possible maltreatment and may indicate theneed for further evaluation. An increase in sexual behaviorincluding masturbation may also be observed [19].

Table 1 Considerations when evaluating a patient for potential child-hood maltreatment

Component of assessment Possibly suggestive maltreatment

Physical exam •Mechanism of injury is inconsistentwith physical exam findings (long bonefracture following minimal trauma)

•Multiple areas of bruising of varyingages

Suggested laboratorystudies

•Urine drug screen

• Sexually transmitted infection studies(gonorrhea, chlamydia, HPV, HIV)

•Bone scan to examinefor healed fractures

Patient interview/mentalhealth presentation

•lnconsistent history of injury(i.e., cause of injury changes basedon multiple interviews)

•Lack of collateral information thatis consistent with an injury

•Parent refusal to allow the childto be interviewed alone

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Long-Term Consequences of Maltreatment

Experiencing maltreatment during childhood or adolescencecan increase the likelihood for many negative outcomes inthe future [26]. Individuals who experience maltreatment aremore likely to develop mental health disorders and sub-stance abuse disorders, and they are at increased risk ofchronic physical complaints. Sadly, there is also good evi-dence that those who are victims of maltreatment are morelikely to become abusers themselves in the future, althoughit is also true that most individuals who are abused do not goon to abuse others, in some cases becoming hypervigilantfor any potential abuse of their children, which can cause itsown set of difficulties for the child. The types of potentialconsequences of maltreatment will be examined further.

The increased risk for the development of mental healthdisorders has been widely studied, but recent data continueto demonstrate the dramatic impact that maltreatment canhave on future development. Cloitre et al. [5•] found thatvictims of maltreatment are likely to have experienced morethan one trauma (both in type and frequency) and that theywill endorse a wide range of symptoms, which can includedysphoria, anger and dissociation. There was a linear rela-tionship between the number of trauma types experiencedbefore age 18 and symptom complexity. In this large, retro-spective study (total of 582 participants), it was noted thatthose who had experienced multiple types of abuse duringchildhood were more likely to develop complex illness moreresistant to treatment. The mean number of types of traumawas 3.1, most commonly emotional, sexual and physicalabuse. When evaluating younger patients (children and ado-lescents) who presented to a child trauma clinic (n0152),who had experienced at least one PTSD criterion A stressor[in which a person experiences, witnesses or is confrontedwith an event(s) that involve actual or threatened death orserious injury and has a response of fear, helplessness orhorror], the study found that the vast majority (80 %) hadexperienced more than one type of trauma at a very youngage [6]. There was a correlation between the number of traumatypes (regardless of age) and the complexity of illness thatdeveloped both during a young age and adulthood.

Nanni and colleagues [27] demonstrated additional evi-dence of the effects of child maltreatment on the illnesscourse of depression. A review of 16 epidemiologic studies(n023,544 patients) found that childhood maltreatment wasassociated with an elevated risk of developing recurrent andpersistent depressive episodes (odds ratio02.27, 95 % con-fidence interval01.8–2.87). Therefore, an individual with ahistory of maltreatment had 2.27 greater odds of developingrecurrent depression compared to someone without a historyof maltreatment. Additionally, if an individual had experi-enced maltreatment during childhood, there was increasedrisk of treatment resistance for depression (odds ratio01.43;

95 % CI01.11–1.83). A twin study examined the heritablecontributions, types of trauma, and risks for PTSD andmajor depression [28]. Phone interviews conducted with2,591 participants found that genetic factors, such as familyhistory of mental health illness, were associated in 47 % ofvariance in low-risk (minor accident, non-life threateningevents, etc.) trauma exposure and 60 % in high-risk trauma(life threatening event, witnessed death of parent, etc.) ex-posure towards the development of PTSD and major depres-sion. These data suggest a genetic predisposition andvulnerability to the development of PTSD symptoms; how-ever, no specific genes have been confirmed to produce thispredisposition. This study also found that individuals with afamily history of PTSD or MDD were more at risk todevelop one illness (r00.89, 95 % CI00.77–0.98 forMDD and r00.89, 95 % CI 0.78-.099 for PTSD) and thatMDD and PTSD occur together frequently following ahistory of maltreatment. These findings suggest that certainindividuals are predisposed to the development of mentalhealth symptoms following maltreatment and that both ge-netics and environment (i.e., exposure to trauma) contributeto illness development.

While depression and PTSD are the most common men-tal health sequelae following maltreatment, many othertypes of mental health illness have been linked to a historyof maltreatment. Reactive attachment disorder (RAD), inwhich the individual may have significant difficulty informing future relationships following maltreatment, hasreceived increasing attention in the past several years [29].Individuals with RAD may display difficulty in affect reg-ulation, engage in aggressive or disruptive behavior andhave a poor response to traditional treatment [29]. Attachmentfoundations are formed from a very young age (between 0 and3 years), but a safe secure environment is needed to encouragetypical development throughout childhood and adolescence.Therefore, maltreatment at any age in development may leadto the development of RAD, but maltreatment at a young ageproduces a larger risk. However, mental illness is not the onlypotential long-term consequence of childhood maltreatment.

Experiencing maltreatment increases the risk for chronicphysical conditions in adulthood [9•] and high-risk behav-iors [30]. In a multi-country survey, Scott and colleaguesfound that individuals who suffered three or more childhoodtraumas were more likely to development adult-onset heartdisease, asthma, diabetes mellitus, arthritis, chronic spinalpain and chronic headaches (hazard ratios 1.44–2.19). Inaddition, maltreated individuals were more likely to developchildhood-onset mental health disorders (PTSD and depres-sion) [9•]. An analysis of 637 participants with a history ofmaltreatment found that these individuals were more likelyto engage in sexual intercourse by the age of 14, but thiseffect was somewhat reduced when there was an increase inparental monitoring. This latter finding is evidence of the

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hyper-sexualization, which can occur in a child who expe-riences sexual abuse, where a child resorts to sexual activitypossibly as a way of dulling thoughts and feelings linked tothe abuse [30]. Chronic fatigue syndrome is also associatedwith a history of maltreatment [8]. In this study 216 indi-viduals with a history of maltreatment and chronic fatiguesyndrome demonstrated significantly higher levels of psy-chological distress and limitations in daily activities, butwere not more severely fatigued compared to control sub-jects who had chronic fatigue syndrome but no history ofabuse. An intervention of cognitive behavioral therapy wasfound to be effective for chronic fatigue syndrome symp-toms in both subject groups, and a history of maltreatmentwas not found to limit the effectiveness of CBT [8].

There is growing evidence that experiencing maltreatmentduring development leads to physiological changes in brainstructure and function during childhood, adolescence andadulthood [31–34].While some, but not all studies have foundconsistent changes, there have been several studies in differentpopulations that have found clear changes. Edmiston et al.[35] conducted an MRI study of 42 adolescents with a self-reported history of maltreatment that did not have psychiatricdiagnoses. Exposure to trauma correlated negatively with graymatter volume in the prefrontal cortex, striatum, amygdala,sensory association cortices and cerebellum. Decreases in thedorsolateral and orbitofrontal cortices, insula and ventral stria-tum were associated with physical abuse. Shea et al. [36]found that females with a history of PTSD and/or majordepressive disorder were more likely to have a history ofchildhood maltreatment and hypothalamic-pituitary-adrenal(HPA) axis dysregulation.

Treatment Overview

Given that child maltreatment can produce such a wide rangeof immediate, short-term and long-term consequences, indi-vidual treatment must be tailored to each patient, includingadjustment based on the individual’s developmental level[37]. However, there are several overall treatment strategiesthat should be considered [38]. A mainstay of treatment forsequelae of maltreatment is psychotherapy [39]. Many differ-ent medications have also been studied to address the widevariety of symptoms following maltreatment [40]. Combina-tion psychotherapy and psycho-pharmacotherapy appears tobe the most effective treatment strategy overall. Even withtreatment, symptoms often remain [41, 42].

Psychotherapy remains critical for the treatment of thevictims of child maltreatment [43]. The most common formof psychotherapy for traumatized youth is cognitive behav-ioral therapy (CBT) or modified trauma-focused CBT [44].However, psychotherapy may need to be adjusted if thepatient is too young for CBT techniques. The use of play

therapy, in which the play objects allow the child to displacedifficult feelings, which can then be indirectly addressed bythe therapist in order to allow the child to process herthoughts and feelings, can be utilized in younger patients[45]. The use of crisis management immediate de-briefing-type interventions has produced conflicting data, in which itappears that some children benefit from intervention, whileothers may have worsening symptoms due to forced pro-cessing of trauma in a premature timeframe [45]. Ideally,therapy should be provided by an experienced provider andinclude family education and therapy if needed.

Nearly every type of psychotropic medication has beenused to address the wide variety of symptoms followingmaltreatment. The selective serotonin reuptake inhibitors(SSRIs), which have been most commonly used to treatanxiety disorders, are typically well tolerated with relativelylimited side effects [46]. However, SSRIs may not produceresolution of symptoms, and hypervigilance and nightmarestend to be unaffected by SSRIs; in fact, nightmares may beworsened secondary to an increased amount of REM sleep.The use of antipsychotics such as quetiapine has also beenevaluated [40], but has been associated with metabolic sideeffects such as weight gain, increased blood glucose goalsand hypercholesterolemia. The use of benzodiazepines forinsomnia [47] has also been reviewed, but treatment effec-tiveness is limited by both a treatment-induced increasedamount of REM sleep leading to a higher frequency ofnightmares and sleep disturbances and also physiologic/psychologic tolerance in a short period of time. Prazosinand other medications have also been used to addresstrauma-related insomnia and nightmares with varyingdegrees of success [40, 41, 43, 46, 48]. Therefore, medica-tions should be considered as a treatment augmentationstrategy for victims of maltreatment rather than the primarysource of treatment.

Conclusions

Childhood maltreatment can produce significant long-termconsequences for affected individuals. Experiencing child-hood maltreatment increases the likelihood for mental healthdisorders, both during development and into adulthood. Themost common types of mental health disorders associatedwith maltreatment are posttraumatic stress disorder and ma-jor depressive disorder, but affected individuals are alsomore likely to develop anxiety disorders and substanceabuse disorders. In addition, experiencing maltreatment dur-ing development increases the likelihood of chronic physicalcomplaints and disorders during adulthood, including chronicfatigue syndrome, asthma, heart disease and diabetes.

While it is difficult to determine the exact prevalence ofchild maltreatment in the US or worldwide, it is well known

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thatmaltreatment affects many individuals in a variety of formsand that the presentation can be subtle and misdiagnosed ormisunderstood as originating from an alternative cause. Also,as illustrated in the case of Beth, the very nature of the condi-tion is such that a child who has experienced trauma will tendto cope by avoidance and denial, and therefore do all that theycan to NOT talk or think about it, especially when beinginterviewed by a clinician. Thus, a structured interview formatmay not reveal much information at all, highlighting the needfor a gentle approach when interacting with such youth. Treat-ment for affected individuals should be tailored based on theirparticular symptoms, developmental age and history. Psycho-therapy remains a mainstay in the treatment of past abuse, andthe use of psycho- pharmacotherapy should be considered foraugmentation if needed.

Disclosure No potential conflicts of interest relevant to this articlewere reported.

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