Childhood Physical Abuse and Adult Health Outcomes Esme
Childhood Physical Abuse and Adult Health Outcomes Esme Fuller-Thomson, Ph. D Professor & Sandra Rotman Chair Factor-Inwentash Faculty of Social Work & Faculty of Medicine
Influential Papers n Adverse Childhood Experiences (ACE) Study (Felitti, Anda et al. 1998) n Questions on 7 categories of ACE: psychological, physical or sexual abuse; violence against mother; or living with household members who were substance users, mentally ill, suicidal or ever imprisoned n Measured association between number of ACE categories (0– 7) and adult health outcomes including: heart disease, cancer, stroke, bronchitis or emphysema, diabetes, hepatitis, skeletal fractures n Controlled for socio-demographic variables n A graded relationship between the number of ACE categories and each of the health outcomes was found
Influential Papers n National Comorbidity Study (Goodwin & Stein, 2004) n n n American population-based study of noninstitutionalized adults (n=5877) Measured effects of self-reported childhood physical abuse (CPA), sexual abuse and neglect separately Assessed relationship between abuse and over 15 physical disorders Controlled for demographics, lifetime depression & anxiety disorders, lifetime alcohol & substance dependence CPA associated with lung disease, peptic ulcer, and arthritic disorders
Influential Papers n Wisconsin Longitudinal Study (Springer et al. 2007) n n n Population-based survey of >2000 middle-aged men and women Measured exposure to childhood physical abuse (CPA) using Conflicts Tactics Scale 17 physical health outcomes measured Controlled for age, sex, family background and childhood adversities CPA associated with allergy, arthritis, asthma, bronchitis/emphysema, circulation problems, high blood pressure, heart troubles, liver troubles, and ulcer
What Might Explain the Link Between Physical Abuse & Health? http: //www. youtube. com/watch? v=Nw. Ufyt 6 Qbz. A
Potential Pathways It is possible that the abuse-health outcome relation can be explained by other factors n At least five pathways have been discussed in the literature: n Other childhood stressors n Health behaviors n Socioeconomic factors n Marital Dissolution n Mental health n
Other Childhood Stressors n Childhood physical abuse (CPA) often occurs concurrently with other adverse childhood experiences including: n n Parental addictions (e. g. , Springer et al. 2007) Parental conflict/divorce (e. g. , Brown et al. 2000; Springer et al. 2007) Household poverty and parental unemployment (e. g. , Gillham et al. 1998) It may be the convergence of several early stressors that result in negative health outcomes
Health behaviors Many survivors of CPA adopt unhealthy behaviors to cope with adverse experiences n This is consistent with evidence that CPA is associated with: n n Smoking (i. e. , Felitti et al. 1998; Anda et al. 2006; Dube et al. 2003) Obesity (e. g. , Felitti et al. 1998) Alcohol use (e. g. , Felitti et al. 1998; Anda et al. 2006; Dube et al. 2003)
Physical Inactivity awenetwork. eu/. . . /03/walking_dog_with_car 11. jpg
Socioeconomic Factors n n Those experiencing childhood abuse often go on to have greater disadvantage in adulthood CPA associated with: n n n Greater educational difficulties and poorer outcomes (e. g. , Mullen et al. 1996; Rowe et al. 1999) Decline in SES since childhood (e. g. , Mullen et al. 1996) Socioeconomic disadvantage predisposes individuals to increased health problems
The Whitehall Study http: //photos. igougo. com/images/p 338013 -London- Whitehall_Place. html
Marital Dissolution n Abuse survivors have higher rates of marital dissolution. Unmarried respondents have higher rates of many chronic conditions. http: //www. youtube. com/watch? v=Nw. Ufyt 6 Qbz. A
Mental Health n It’s been well established that CPA is associated with mental health outcomes including: n n n depression (e. g. , Dube et al. , 2003; Felitti et al. , 1998; Mc. Cauley et al. , 1997; Springer et al. , 2007) anxiety (e. g. , Mc. Cauley et al. , 1997; Springer et al. , 2007) Mental health outcomes (especially depression) have been associated with a number of physical health conditions
Long-term Influences http: //www. youtube. com/watch? v=kbw. Nl. XCo-x. Q
Canadian Community Health Survey (CCHS) n Conducted by Statistics Canada in 2005 n n n Cross-sectional representative survey provides estimates of health determinants, risk factors and health status. Used data from provinces of Saskatchewan and Manitoba Response rates were 84. 1% and 83. 3%, respectively Sample included 13, 093 males and females Universal free health care system
Measure of Childhood Physical Abuse n Respondents were asked n n “While you were a child or teenager living at home, were you ever physically abused by someone close to you? ” 6. 9% reported they had been physically abused.
Measures of Chronic Health Conditions n Have you been “diagnosed by a health professional” with any of the following “long-term conditions” that have “lasted six months or more”?
Chronic Fatigue Syndrome Figure 1 a: Odds Ratio and 95% Confidence Interval of Chronic Fatigue Syndrome for Women Reporting Childhood Physical Abuse* 7 6 5 Odds Ratio 4 3 4, 17 4, 14 3, 24 2 2, 85 3, 28 2, 11 1 0 Adjusted for age Adjusted for and race only childhood stressors Adjusted for Full adjustment adult health adult socio- mental health Health behaviours economic status behaviors & stressors *All data are adjusted for age and race. Sample sizes vary from n=7, 276 in the first model to n=7, 072 in the fully adjusted model Fuller-Thomson, Sulman, Brennenstuhl & Merchant (in press). Journal of Aggression, Maltreatment & Trauma
Fibromyalgia Figure 1 b: Odds Ratio and 95% Confidence Interval of Fibromyalgia for Women Reporting Childhood Physical Abuse* 4 3, 5 3 2, 5 Odds 2 Ratio 1, 5 1 0, 5 0 2, 44 Adjusted for age and race only 2, 08 Adjusted for childhood stressors 2, 29 Adjusted for adult health behaviours behaviors 2, 18 Adjusted for adult socioeconomic status & stressors 2, 04 1, 65 Adjusted for Full adjustmental health *All data are adjusted for age and race. Sample sizes vary from n=7, 276 in the first model to n=7, 070 in the fully adjusted model. Fuller-Thomson, Sulman, Brennenstuhl & Merchant (in press). Journal of Aggression, Maltreatment & Trauma
Multiple Chemical Sensitivities Figure 1 c: Odds Ratio and 95% Confidence Interval of Multiple Chemical Sensitivities for Women Reporting Childhood Physical Abuse* 6 5 4 Odds 3 Ratio 3, 15 3, 21 3, 32 2, 85 2, 66 2, 82 2 1 0 Adjusted for age Adjusted for and race only childhood stressors Adjusted for Full adjustment adult health adult sociomental health behaviours economic status behaviors & stressors *All data are adjusted for age and race. Sample sizes vary from n=7, 272 in the first model to n=7, 068 in the fully adjusted model. Fuller-Thomson, Sulman, Brennenstuhl & Merchant (in press). Journal of Aggression, Maltreatment & Trauma
Irritable Bowel Syndrome Figure 1 d: Odds Ratio and 95% Confidence Interval of IBS for Women Reporting Childhood Physical Abuse* 2, 5 2 Odds 1, 5 Ratio 1 1, 52 1, 49 1, 47 1, 34 1, 22 1, 14 0, 5 0 Adjusted for age and race only Adjusted for childhood stressors Adjusted for adult health behaviours behaviors Adjusted for adult socioeconomic stauts & status stressors Adjusted for Full adjustmental health *All data are adjusted for age and race. Sample sizes vary from n=7, 274 in the first model to n=7, 067 in the fully adjusted model. Fuller-Thomson, Sulman, Brennenstuhl & Merchant (in press). Journal of Aggression, Maltreatment & Trauma
Results - Migraine Figure 2: Odds Ratio and 99% Confidence Interval of Migraines among Individuals Reporting Childhood Physical Abuse vs. Those not Reporting Abuse* 2, 5 2 Odds Ratio 1, 5 1, 77 1, 82 1, 68 1, 77 1, 57 1, 68 1, 47 1, 36 1 0, 5 0 Adjusted for Adjusted for a age, gender adverse adult current health current history of and race only childhood socioeconomic behaviors stressors physical health mood/anxiety conditions indicators conditions disorder Full adjustment *All data are adjusted for age, gender and race. Sample sizes vary from n=12944 in the first model to n=12362 in the fully adjusted model. Fuller-Thomson, Baker & Brennenstuhl (2010). Headache, 50: 749 -760
Results - Peptic Ulcer Figure 3: Odds Ratios and 95% Confidence Intervals of a Diagnosis of Peptic Ulcers among those Reporting Childhood Physical Abuse* 4, 00 3, 50 Odds Ratio 3, 00 2, 50 2, 00 2, 87 2, 44 2, 68 2, 66 2, 49 2, 29 1, 68 1, 50 1, 00 0, 50 0, 00 Adjusted for Adjusted for Full age, race and adverse adult SES current health adult stress mood and adjustment sex only childhood behaviors and martial anxiety conditions status disorders *All data are adjusted for age, race and sex. Sample sizes vary from n=12, 924 in the first model to n=12, 372 in the fully adjusted model. Fuller-Thomson, Bottoms, Hurd, & Brennenstuhl (In Press). Journal of Interpersonal Violence
Results - Osteoarthritis Figure 4: Odds Ratio and 95% Confidence Interval for Osteoarthritis Among Individuals Reporting Childhood Physical Abuse vs. Individuals not Reporting Abuse* 3 2, 5 2 Odds Ratio 1, 5 1, 99 1, 73 1, 84 1, 89 1, 56 1 0, 5 0 Adjusted for age, gender, race, & SES only Childhood stressors Adult health behaviors Mood Disorder Full adjustment *All data are adjusted for age, gender, race & SES. Sample sizes vary from n=10, 965 in the first model to n=10, 629 in the fully adjusted model. Fuller-Thomson, Stefanyk & Brennenstuhl (2009). Arthritis Care & Research, 61: 1554 -1562.
Results - Heart Disease Figure 5: Odds Ratio and 95% Confidence Interval for Heart Disease Among Individuals Reporting Childhood Physical Abuse vs. Individuals not Reporting Abuse* 2, 5 2 Odds 1, 5 Ratio 1, 57 1, 55 1, 47 1, 53 1, 57 1, 45 1 0, 5 0 Adjusted for Childhood age, gender stressors and race only Adult health behaviors Adult stressors Depression High blood pressure Full adjustment *All models controlled for age, gender and race. Sample sizes vary from n=12, 929 in the first model to n=12, 388 in the fully adjusted model. Fuller-Thomson, Brennenstuhl & Frank (2010). Child Abuse & Neglect, 34: 689 -98.
Results - Cancer Figure 6: Odds Ratio and 95% Confidence Interval for Cancer Among Individuals Reporting Childhood Physical Abuse vs. Individuals not Reporting Abuse* 2, 5 2 Odds 1, 5 Ratio 1 1, 49 1, 52 1, 41 1, 47 1. 45 0, 5 0 Adjusted for age, gender and race only Childhood stressors Adult health behaviours Adult stressors Full adjustment *All data are adjusted for age, gender and race. Sample sizes vary from n=12, 947 in the first model to n=12, 485 in the fully adjusted model. Fuller-Thomson & Brennenstuhl (2009). Cancer, 115: 3341 -50.
When controlling for potentially confounding factors, childhood physical abuse was significantly associated with: TWICE THE ODDS OF n n Multiple Chemical Sensitivities (OR=2. 82; 95%= CI 1. 90, 4. 17) Chronic Fatigue Syndrome (OR=2. 11; 95% CI= 1. 22, 3. 65); BETWEEN 36% AND 68% HIGHER ODDS OF n n n Ulcers OR=1. 68 (95% CI 1. 22, 2. 32); Fibromyalgia OR=1. 65 (95% CI =1. 08, 2. 52); Osteoarthritis OR=1. 56 (95% CI =1. 21, 2. 00); Heart disease OR = 1. 45 (95% CI = 1. 01, 2. 08), Cancer OR =1. 45 (95% CI = 1. 05, 1. 99) Migraine OR=1. 36 (99% C. I. = 1. 04, 1. 79); NO ASSOCIATION WITH IRRITABLE BOWEL SYNDROME
What about ADHD-ADD & Dyslexia? n n n n ADHD/ADD OR=7. 64 (95% CI = 4. 38, 13. 33) DYSLEXIA OR=6. 09 (95% CI = 3. 58, 10. 34) Adjusted for age, gender, race, parental divorce, parental addictions, parental unemployment Do disorders promote abuse or abuse ‘cause’ the disorders? What about potential impulse control issues in parents? Michael de Bellis showed brain changes linked to reading & attention deficit problems. Other 3 childhood stressors not associated with ADHD/ADD or dyslexia. (Not all ACES are equally salient for each outcome. ) (Unpublished data)
Limitations Self-report of a medical diagnosis rather than chart reviews n Retrospective self-report of childhood physical abuse (potential recall bias due to illness) n Cross-sectional data precludes causal inferences n Missing some risk factors (e. g. genetic factors) n
Important Questions Remaining: n n n n What promotes resiliency in many abuse survivors? How do gender differences play out? What do prospective studies tell us? What role does PTSD play in the abuse-health relationship? What about psycho-social characteristics (sense of coherence, mastery, self-esteem, social support? ) Do sleep disorders attenuate the relationship? What role is played by biological embedding, epigenetics (Michael Meaney), alleles (Caspi),
Would trauma-focused Cognitive Behavioral Therapy (CBT) buffer the impact of abuse on health? CBT is very effective for children & adolescents with -PTSD -Anxiety -Depression, • (NNT of 3 -7; medium to large effect sizes vs controls) n Would it work for prevention in
Thank you to my co-authors: Tobi Baker Jennifer Bottoms Sarah Brennenstuhl John Frank Marion Hurd Moeza Merchant Deborah Sinclair Maria Stefanyk Joanne Sulman
References Anda RF, Felitti VJ, Bremner JD, Walker JD, Whitfield C, Perry BD et al. (2006). The enduring effects of abuse and related adverse experiences in childhood. European Archives of Psychiatry Clinical Neuroscience, 256: 174 -186. Brown T, Frederico M, Hewitt L, Sheehan R. (2000). Revealing the existence of child abuse in the context of marital breakdown and custody and access disputes. Child Abuse & Neglect, 24: 849 -59. Dube SR, Felitti VJ, Dong M, Giles WH, Anda RF. (2003). The impact of adverse childhood experiences on health problems: Evidence from four birth cohorts dating back to 1900. Preventive Medicine, 37: 268 -277. Felitti V, Anda R, Nordenberg D, Williamson D, Spitz A, Edwards V et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14: 245 -258. Fuller-Thomson E, Bottoms J, Brennenstuhl S, Hurd M. (2011). Association between childhood physical abuse and ulcers: Findings from a population-based study. Journal of Interpersonal Violence, in press. Fuller-Thomson E, Sulman J, Brennenstuhl S, Merchant M. (2011). Functional Somatic Syndromes and Childhood Physical Abuse in Women: Data from a Population-Based Study. Journal of Aggression, Maltreatment and Trauma, in press. Fuller-Thomson E, Brennenstuhl S, Frank, J. (2010). The Association between Childhood Physical Abuse and Heart Disease in Adulthood: Findings from a Representative Community Sample. Child Abuse & Neglect, 34: 689 -98. Fuller-Thomson E, Baker TM, Brennenstuhl S. (2010). Investigating the Associated between Childhood Physical Abuse and Migraine. Headache, 50: 749 -760.
References continued Fuller-Thomson E, Stefanyk, M, Brennenstuhl S. (2009). The robust association between physical childhood abuse and osteoarthritis and rheumatoid arthritis in adulthood: Findings from a representative community sample. Arthritis Care & Research, 61: 1554 -1562. Fuller-Thomson E, Brennenstuhl S. (2009). Making a Link Between Childhood Abuse and Cancer: Results from a Regionally Representative Survey. Cancer, 115: 3341 -50. Gillham B, Tanner G, Cheyne B, Freeman I, Rooney M, Lambie A. (1998). Unemployment rates, single parent density, and indices of child poverty: Their relationship to different categories of child abuse and neglect. Child Abuse & Neglect, 22: 79 -90. Goodwin RD, Stein MB. (2004). Association between childhood trauma and physical disorders among adults in the United States. Psychological Medicine, 34: 509 -520. Mc. Cauley J, Kern DE, Kolodner K, Dill L, Schroeder AF, De. Chant HK, et al. (1997). Clinical characteristics of women with a history of childhood abuse: Unhealed wounds. JAMA, 277: 1362 -8. Mullen PE, Martin JL, Anderson JC, Romans SE, Herbison GP. (1996). The long-term impact of the physical, emotional, and sexual abuse of children: A community study. Child Abuse& Neglect, 20: 7 -21 Springer KW, Sheridan J, Kuo D, Carnes M. (2007). Long-term physical and mental health consequences of childhood physical abuse: Results from a large population-based sample of men and women. Child Abuse & Neglect, 31: 517 -530 Rowe E, Eckenrode J. (1999). The timing of academic difficulties among maltreated and nonmaltreated children. Child
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