Long-term Cognitive, Psychological, and Health Outcomes Associated With Child Abuse and Neglect Lane Strathearn, MBBS, FRACP, PhD,a,b Michele Giannotti, PhD,c Ryan Mills, MPH, PhD,d,e Steve Kisely, MD, PhD, DMedRes,f,g,h Jake Najman, PhD,d Amanuel Abajobir, MPH, PhDd,i

Potential long-lasting adverse effects of child maltreatment have been widely abstract reported, although little is known about the distinctive long-term impact of aDepartment of Pediatrics, Carver College of Medicine, The differing types of maltreatment. Our objective for this special article is to University of Iowa, Iowa City, Iowa; bCenter for Disabilities integrate findings from the Mater-University of Queensland Study of and Development, University of Iowa Stead Family Children’s Hospital, Iowa City, Iowa; cDepartment of Psychology and Pregnancy, a longitudinal prenatal cohort study spanning 2 decades. We Cognitive Science, University of Trento, Trento, Italy; dSchool compare and contrast the associations of specific types of maltreatment with of Public Health, The University of Queensland, Herston, Queensland, Australia; eDepartment of Paediatrics, Logan long-term cognitive, psychological, addiction, sexual health, and physical Hospital, Meadowbrook, Queensland, Australia; fSchool of health outcomes assessed in up to 5200 offspring at 14 and/or 21 years of Medicine, The University of Queensland and Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; age. Overall, psychological maltreatment (emotional abuse and/or neglect) gDepartments of Psychiatry and hCommunity Health and was associated with the greatest number of adverse outcomes in almost all Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada; and iMaternal and Child Wellbeing Unit, African areas of assessment. Sexual abuse was associated with early sexual debut and Population and Health Research Center, Nairobi, Kenya youth pregnancy, attention problems, posttraumatic stress disorder fi Dr Strathearn conceptualized and designed the symptoms, and depression, although associations were not speci c for sexual original study linking the Mater-University of abuse. Physical abuse was associated with externalizing behavior problems, Queensland Study of Pregnancy data set with delinquency, and drug abuse. Neglect, but not emotional abuse, was substantiated reports of child maltreatment, drafted associated with having multiple sexual partners, cannabis abuse and/or the special article, and reviewed and revised the manuscript; Dr Giannotti assisted in drafting the dependence, and experiencing visual hallucinations. Emotional abuse, but not manuscript and prepared all tables and figures; Drs neglect, revealed increased odds for psychosis, injecting-drug use, Mills, Kisely, and Abajobir conceptualized and wrote experiencing harassment later in life, pregnancy miscarriage, and reporting the original research articles summarized in this fi article; Dr Najman was the original principal asthma symptoms. Signi cant cognitive delays and educational failure were investigator of the Mater-University of Queensland seen for both abuse and neglect during adolescence and adulthood. In Study of Pregnancy; and all authors critically conclusion, child maltreatment, particularly emotional abuse and neglect, is reviewed the manuscript for important intellectual content and approved the final manuscript as associated with a wide range of long-term adverse health and developmental submitted and agree to be accountable for all outcomes. A renewed focus on prevention and early intervention strategies, aspects of the work. especially related to psychological maltreatment, will be required to address DOI: https://doi.org/10.1542/peds.2020-0438 these challenges in the future. Accepted for publication Jul 2, 2020 Address correspondence to Lane Strathearn, MBBS, FRACP, PhD, Stead Family Department of Pediatrics, Carver College of Medicine, The University of Iowa, Child maltreatment is a major public adverse outcomes associated with 100 Hawkins Dr, 213F CDD, Iowa City, IA 52242-1011. health issue worldwide, with serious maltreatment include cognitive E-mail: [email protected] and often debilitating long-term disability, anxiety and depression, PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, consequences for psychosocial psychosis, teen-aged pregnancy, 1098-4275). development as well as physical and addiction disorders, obesity, and Copyright © 2020 by the American Academy of mental health.1 In the United States cardiovascular disease.3 Pediatrics alone, 3.5 million children are reported Understanding the distinctive impact of for suspected maltreatment each year, differing types of maltreatment may To cite: Strathearn L, Giannotti M, Mills R, et al. with an annual substantiated help medical professionals provide Long-term Cognitive, Psychological, and Health maltreatment rate of 9.1 per 1000 more wholistic care and treatment Outcomes Associated With Child Abuse and Neglect. Pediatrics. 2020;146(4):e20200438 children.2 Some of the long-term recommendations as well as identify

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 146, number 4, October 2020:e20200438 SPECIAL ARTICLE more specific public health targets for sociodemographic groups9 or to maltreatment, including deficits in primary prevention. specific types of child maltreatment, cognitive and educational 1,10 19–21 Unfortunately, however, little is such as sexual abuse. Other outcomes ; mental health known about the long-term effects of longitudinal studies have relied on problems, such as anxiety, differing types of child maltreatment, retrospective recall of maltreatment depression, posttraumatic stress rather than prospectively collected disorder (PTSD), psychosis, which include sexual abuse, physical 11–13 4 agency-reported data. In studies delinquency, and intimate abuse, emotional abuse, and neglect. 22–25 According to a meta-analysis review,5 in which prospective data have been partner violence (IPV) ; collected,7,13–17 only a few have substance abuse and addiction26–30; research on child maltreatment has 31 predominantly been focused on compared different types of child sexual health problems ; physical 7,16,17 fi 32–35 sexual abuse, with far less attention maltreatment. growth and health de cits ; and overall decreased quality of life.36 paid to psychological maltreatment In this special article, we review (emotional abuse and/or neglect) and findings from the Mater-University of Our purpose for this special article the co-occurrence of different types of Queensland Study of Pregnancy is to compare the effects of 4 maltreatment. In addition, most of the (MUSP), a now 40-year longitudinal differing types of maltreatment on current evidence is derived from prenatal cohort study from Brisbane, long-term cognitive, cross-sectional studies, which may be . 6–8 Australia, involving 7000 women psychological, addiction, and subject to recall bias, in which an and their children.18 Unique features health outcomes assessed in the outcome status (such as depression) of the MUSP include its use of offspring at ∼14 and/or 21 years fl may in uence recall of the exposure a population-based sample, its use of of age. Rather than providing (ie, previous maltreatment). Few prospectively substantiated child a systematic review or meta- previous studies have adequately maltreatment reports, and its analysis of the current controlled for confounding variables, consideration of different subtypes of literature, which would include such as perinatal risk, socioeconomic maltreatment. In addition, the study diverse study designs and adversity, parental psychopathology, design controlled for a wide range of purposes, we report and compare the and impaired early childhood confounders and covariates, including findings of individual articles that development, which may predispose both maternal and child used a common data set and to both child maltreatment and later sociodemographic and mental health standard methodology to study adverse health outcomes. variables. This combined body of a broad array of outcomes. We Longitudinal studies offer evidence work, which includes numerous particularly highlight the long-term that is more robust, but these studies publications over the past decade, has impact of emotional abuse and are relatively few in number and have documented a broad range of adverse neglect, which has received far generally been limited to certain outcomes associated with child less attention in the literature.

FIGURE 1 Overview of the MUSP enrollment and testing.

Downloaded from www.aappublications.org/news by guest on September 29, 2021 2 STRATHEARN et al FIGURE 2 Published studies from the Mater-University of Queensland Study of Pregnancy, linking long-term outcomes with specific maltreatment subtypes (adjusted coefficients or odds ratios 6 95% confidence intervals). CES-D, Center for Epidemiologic Studies–Depression Scale; CI, confidence interval; N,numberof a offspring in sample; N(Mal), number of offspring who experienced maltreatment. In different articles adjusting for co-occurrence of maltreatment subtypes was handled in different ways: (1) statistical adjustment: each maltreatment subtype predictor was statistically adjusted for the other maltreatment subtypes (eg, neglect was adjusted for the occurrence of physical, sexual, and emotional abuse) and is reflected in the table’s odds ratios and coefficients; (2) exclusive categories: different combinations of maltreatment types are included in mutually exclusive groups (eg, physical abuse only, physical abuse and emotional

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 146, number 4, October 2020 3 METHODS healthy physical and emotional and size, comparability between development of a child,” which respondents and nonrespondents, Description of the MUSP Cohort encompassed physical, emotional and ascertainment of outcomes, and medical neglect.37 statistical quality.42 On the basis of Between 1981 and 1983, 8556 this assessment, all of the MUSP consecutive pregnant women who Inclusion Criteria for Original studies were determined to be of low attended their first prenatal clinic Research Publications risk of bias, with a score of 4 out of 5 visit at the Mater Mothers’ Hospital in points (Supplemental Information). Brisbane, Australia, agreed to We searched PubMed from inception participate (Fig 1). After excluding to April 2020 for published MUSP mothers who did not deliver articles in which agency-reported Predictors: Maltreatment Types a singleton infant at the Mater child maltreatment was evaluated as In all but 2 studies (which used Mothers’ Hospital or withdrew the predictor of a range of outcomes. notified maltreatment21,26) events consent, the MUSP birth cohort Studies needed to meet the following were dichotomized and coded as consisted of 7223 mother-infant criteria for inclusion in the review: fi substantiated maltreatment versus no dyads, who were followed over 2 (1) noti ed or substantiated abuse substantiated maltreatment. decades: at 3 to 5 days, 6 months, and neglect was listed as a main According to a validated classification 5 years, 14 years and 21 years. predictor variable and (2) outcomes of maltreatment types,43 specific Midway through the study, this rich included standardized measurements categories and co-occurring forms of data set was anonymously linked to of cognitive, psychological, childhood maltreatment44 were used state reports of child abuse and behavioral, or health functioning. ∼ to predict outcomes. In 2 studies,19,20 neglect, which identified some form From 340 published MUSP studies, fi of suspected maltreatment in .10% we identi ed 24 articles dealing with all types of abuse were combined into of cases.37 Notified cases, which had child maltreatment, of which 21 1 category and compared to neglect, been referred from the community or included state-reported maltreatment whereas in another study, sexual by general medical practitioners, versus self-reported maltreatment abuse was compared to any were investigated by the Queensland data (n = 3). Nineteen of the 21 combination of nonsexual 21 government child protection agency. articles met all inclusion criteria and maltreatment. In 2 other 26,40 Substantiated maltreatment was were evaluated in this review (Fig 2). studies, emotional abuse and determined after a formal One study was excluded because it neglect (examples of psychological investigation when there was only examined outcomes associated maltreatment) were combined, partly 8 fi “reasonable cause to believe that the with sexual abuse. Another article because of overlapping de nitional child had been, was being, or was was excluded because its outcome constructs from the government child ”38 measures were similar to another protection agency (emotional abuse likely to be abused or neglected. 29 Substantiated maltreatment occurred included study. included “emotional deprivation,” and when a notified case was confirmed neglect included the failure to provide for (1) sexual abuse, “exposing a child Quality of Supporting Literature for “healthy…emotional to or involving a child in Each of the reviewed articles followed development”). In all but 2 of the 25,33 inappropriate sexual activities”; (2) Strengthening the Reporting of included articles, co-occurrence physical abuse, “any non-accidental Observational Studies in of different types of maltreatment physical injury inflicted by a person Epidemiology (STROBE) guidelines was considered, either by examining who had care of the child”; (3) for the conduct of cohort studies.41 specific combinations of emotional abuse, “any act resulting in The quality of the studies was also maltreatment types (in exclusive or a child suffering any kind of evaluated by using a modified version nonexclusive overlapping categories) emotional deprivation or trauma”;or of the Newcastle-Ottawa Scale, which or by statistically adjusting for all (4) neglect, “failure to provide is used to assess the following remaining types of maltreatment conditions that were essential for the domains: sample representativeness (Fig 2).

FIGURE 2 Continued abuse only, physical and emotional abuse and neglect [without sexual abuse], etc; see Table 1); (3) nonexclusive categories: maltreatment categories may overlap with other categories (eg, any substantiated abuse [sexual, physical, or emotional] versus any substantiated neglect); and (4) none: no statistical adjustments or combined categories were presented for co-occurring maltreatment subtypes. bAdjusted coefficients (95% CI) were reported as statistical association measures rather than adjusted odds ratios. cCases of notified (rather than substantiated) maltreatment. In the study by Mills et al,26 a sensitivity analysis was performed after exclusion of unsubstantiated cases of maltreatment. The associations between any maltreatment and substance use were similar to those seen in the original analysis after full adjustment. dMedium effect size, based on magnitude of the adjusted odds ratio (2 # odds ratio # 4). eLarge effect size, based on magnitude of the adjusted odds ratio (odds ratio . 4).

Downloaded from www.aappublications.org/news by guest on September 29, 2021 4 STRATHEARN et al FIGURE 3 Covariates used in published articles from the MUSP to adjust for possible confounding. a Race: child’s race, parental race, and maternal or paternal racial origin at pregnancy. b Child age: child age and gestational age. c Maternal age: maternal age at the first visit clinic or at pregnancy. d Maternal education: maternal education (prenatal or at birth). e Family income: annual family income, familial income over the first 5 years or family poverty before birth or over the first 5 years of life, family income before birth, and annual family income. f Maternal marital status and social support: same partner at birth and 14 years and social support at 5 years. g Maternal depression: maternal depression during pregnancy, 3- to 6-month follow-up, or 21- year follow-up; chronic maternal depression. h Maternal alcohol use: maternal alcohol use at 3- to 6-month or 14-year follow-up and binge drinking. i Maternal cigarette use: cigarette use during pregnancy, 6 months postpartum, or at 14-year follow-up. ADHD, attention-deficit/hyperactivity disorder; CES- D, Center for Epidemiologic Studies–Depression Scale; IPV, intimate partner violence.

Covariates health outcome studies adjusted for 2. Psychological and mental health All of the odds ratios, mean relevant covariates (such as BMI in outcomes at 21 years included differences, or coefficients were a study of dietary fat intake and internalizing and externalizing adjusted for potential confounding parental height when studying behavior problems (which were variables (Fig 3). All articles adjusted offspring height). In selected articles, also assessed at 14 years), lifetime for a variety of sociodemographic maltreatment subtypes were also anxiety disorder, depressive statistically adjusted for the other disorder and symptoms, PTSD, variables, such as age, race, education, types of maltreatment to determine lifetime psychosis diagnosis, income, and marital status. Perinatal independent effects. psychotic symptoms (such as and/or childhood factors, such as delusional experience or visual birth weight, gestational age, and Outcomes and/or auditory hallucinations), breastfeeding status, were used as delinquency, experience of IPV or covariates, particularly in articles in A total of 46 outcomes were assessed harassment, and overall quality which cognitive and educational at 14 years (n = 5200) and/or of life. outcomes were examined. 21 years (n = 3778) (Fig 1) and were Psychological and mental health grouped into 5 domains (Fig 2): 3. Addiction and substance use, variables (such as internalizing and 1. Cognition and education outcomes measured at both time points, externalizing behavior problems, included reading ability and included alcohol and cigarette use maternal depression, chronic stress, perceptual reasoning measured in at 14 and 21 years, and cannabis or exposure to violence) were adolescence, and, at age 21, abuse and/or dependence primarily included as covariates in receptive verbal intelligence and (including early onset) and mental health outcome studies, failure to complete high school or injecting-drug use at the 21-year especially for psychosis. Addiction be either enrolled in school or follow-up. studies adjusted for youth and employed; attention problems 4. Sexual health was investigated at maternal alcohol or tobacco use, were measured at both time age 21 in terms of early initiation among other covariates, and physical points. of sexual experience, having

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 146, number 4, October 2020 5 FIGURE 3 Continued Covariates used in published articles from the MUSP to adjust for possible confounding.

multiple sexual partners, youth differences and coefficients, along experienced at least 1 episode of pregnancy, and miscarriage or with the corresponding 95% substantiated maltreatment. termination. confidence intervals, and were Substantiated sexual abuse was 5. Physical health outcomes plotted to visualize and compare the reported in 2.0% (n = 147), physical fi measured at 21 years included statistical signi cance of each abuse in 4.0% (n = 287), emotional fi symptoms of asthma, high dietary association across speci c outcome abuse in 3.7% (n = 267), and neglect fat intake, poor sleep quality, and categories and types of maltreatment in 3.7% of cases (n = 269) (Table 1). – height deficits. (Figs 4 8). Almost 60% of the children with substantiated maltreatment had The 14-year assessments included Ethical Approval multiple substantiated episodes (293 a youth questionnaire (n = 5172) and The MUSP was approved by the children; range: 2–14 episodes per in-person cognitive testing (n = 3796). Human Ethics Review Committee of child; median: 3 episodes per child37). The 21-year visit included an in- The University of Queensland and the Of the 3778 young adults included in person assessment of mental health Mater Misericordiae Children’s the 21-year follow-up, 4.5% (n = 171) diagnoses in a subset of the cohort Hospital. Ethical approval was had a history of substantiated (n = 2531) with the World Health obtained separately from the Human maltreatment,39 including sexual Organization Composite International Ethics Review Committee of The abuse (n = 53), physical abuse (n = Diagnostic Interview (CIDI), which is University of Queensland for linking 60), emotional abuse (n = 71), and based on Diagnostic and Statistical substantiated child maltreatment neglect (n = 89). Manual of Mental Disorders, Fourth data to the 21-year follow-up data. Edition criteria45 (Fig 1). All of the More than half of the children who questionnaire and interview measures experienced substantiated were validated, except for reported RESULTS maltreatment were reported for fi $2 co-occurring maltreatment types frequencies of speci cevents(ie, Prevalence and Co-occurrence of pregnancy, number of cigarettes, etc). (Table 1). Of the substantiated sexual Maltreatment Subtypes abuse cases, 57.1% of the children Associations were described by using In this cohort of 7214 children experienced $1 additional either adjusted odds ratios or mean (Fig 1), 7.1% (n = 511 children) maltreatment types (84 of 147); for

Downloaded from www.aappublications.org/news by guest on September 29, 2021 6 STRATHEARN et al FIGURE 3 Continued Covariates used in published articles from the MUSP to adjust for possible confounding. physical abuse, this proportion was education and alcohol and/or tobacco increase in the likelihood of being 79.1% (227 of 287); for emotional use (Fig 3). Specifically, proxy unemployed at age 21 years20 (Figs 2 abuse, 83.5% (223 of 267); and for measures of IQ, such as reading and 4). neglect, 73.6% (198 of 269). In ability and perceptual reasoning, at particular, emotional abuse and age 14 years were adversely neglect co-occurred, with or without associated with both substantiated Psychological and Mental Health Outcomes other types of maltreatment, in ∼59% abuse and neglect.19 Sexual abuse of cases.46 was associated with attention During adolescence, physical abuse, problems in adolescence, whereas emotional abuse, and neglect were all Cognition and Education Outcomes nonsexual maltreatment was significantly associated with both Abuse (a combined category) and associated with attention problems at internalizing and externalizing neglect were both associated with both time points.21 Young adults who behavior problems, although this was significantly lower cognitive scores at experienced substantiated child not the case for physical abuse both 14 and 21 years, as well as with maltreatment had reduced scores on notifications without co-occurring negative long-term educational and the Peabody Vocabulary Test at emotional abuse or neglect.22 After employment outcomes in young 21 years. In terms of educational adjustment for relevant adulthood.19,20 This was after outcomes in young adulthood, both sociodemographic variables, the adjusting for factors such as the abuse and neglect manifested associations with emotional abuse child’s race, sex, birth weight, a threefold to fourfold increase in and neglect remained significant at breastfeeding exposure, and age; odds of failing to complete high 21 years.39 No statistically significant family income; and maternal school and a twofold to threefold association was found between sexual

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 146, number 4, October 2020 7 FIGURE 4 Child maltreatment and cognition and educational outcomes at 14 and 21 years. A, Adjusted coefficients 6 95% confidence intervals. B, Odds ratios 6 95% confidence intervals. * P , .05. abuse and these behavior problems at Physical abuse was associated with Additionally, physical abuse, emotional either time point. externalizing behavior problems and abuse, and neglect all revealed delinquency (in men), internalizing increased odds of cannabis Psychological maltreatment in behavior problems and depressive dependence at age 21, with early onset childhood was associated with all of symptoms, experience of IPV, and associated with physical abuse and the other 15 psychological and PTSD22,24,25,39 (Figs 2 and 5). neglect.28 In contrast, only emotional mental health outcomes in young abuse significantly predicted injecting- adulthood, except for delinquency in Addiction and Substance Use drug use in young adult men, after women. This was true after Outcomes adjustment for maternal alcohol use adjustment for sociodemographic Overall, emotional abuse and/or and depression, whereas all types of variables and psychological and neglect were associated with all substantiated childhood maltreatment mental health problems (such as categories of substance use and were associated with injecting-drug attention-deficit/hyperactivity addiction at both 14 and 21 years, use in women.27 Sexual abuse was not disorder, aggressive behavior whereas physical and sexual abuse associated with any addiction or problems, and maternal depression were associated with surprisingly few substance use outcome except for or adverse life events, in the case of substance abuse outcomes. cigarette use at 21 years (Figs 2 and psychosis and/or IPV exposure Specifically, childhood emotional 6). outcomes) (Fig 3). Specifically, both abuse and neglect were associated emotional abuse and neglect were with adolescent substance use at age Sexual Health Outcomes significantly associated at 21 years 14, including alcohol use and All forms of maltreatment were with all of the following outcomes: smoking.26 This was after adjustment significantly associated, at 21 years, anxiety, depression, PTSD, psychosis for sociodemographic factors and with early onset of sexual activity and (with some exceptions), delinquency youth and maternal drug use. The subsequent youth pregnancy. This in men, and experiencing IPV and association with cigarette and alcohol was after adjustment for factors such harassment (except for – use persisted from adolescence to as gestational age, youth neglect).22 25,39 Emotional abuse and adulthood. The category of "any psychopathology, and drug use. neglect were the only maltreatment cigarette use" was the only addiction Neglect was the only type of subtypes associated with a significant outcome associated with all 4 types of maltreatment associated with having decrease in quality-of-life scores.36 maltreatment.40 At 21 years, multiple sexual partners and was the The only mental health outcomes emotional abuse and neglect were maltreatment type most strongly associated with sexual abuse were both associated with the early onset associated with most other sexual clinical depression, lifetime PTSD, and of cannabis abuse after adjustment health outcomes, especially youth experiencing physical IPV.8,25,39 for maternal stress and cigarette use. pregnancy. Pregnancy miscarriage

Downloaded from www.aappublications.org/news by guest on September 29, 2021 8 STRATHEARN et al FIGURE 5 Child maltreatment and psychological and mental health outcomes at 14 and 21 years. A, Adjusted coefficients 6 95% confidence intervals. B, Odds ratios 6 95% confidence intervals. * P , .05. was modestly associated with Physical Health subtypes except sexual abuse (which emotional abuse, whereas was not associated with any of the termination of pregnancy was not Reduced adult height at 21 years, physical health outcomes). At associated with any maltreatment adjusted for parental height, was 21 years, physical abuse was also subtype31 (Figs 2 and 7). associated with all maltreatment associated with high dietary fat

FIGURE 6 Child maltreatment and addiction and substance use outcomes at 14 and 21 years (adjusted odds ratio 6 95% confidence interval). * P , .05.

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 146, number 4, October 2020 9 FIGURE 7 Child maltreatment and sexual health outcomes at 21 years (adjusted odds ratio 6 95% confidence interval). * P , .05. intake, a risk factor for obesity the MUSP study on cognitive and 1. deficits in cognitive development, (adjusted for BMI), and poor sleep educational outcomes of maltreated attention, educational attainment, quality in men (adjusted for youth, the population attributable and employment; psychopathology and drug use). risk of child maltreatment leading to 2. serious mental health problems, “ ” Asthma at 21 years revealed a modest failure to complete high school was including anxiety, depression, “ association with emotional abuse. The 13%, and 14% for failure to be in PTSD, and psychosis, as well as combined category of any either education or employment at delinquency and the experience ”20 maltreatment was also associated 21 years. of IPV; with high dietary fat intake (Figs 2 Based on one published metric of 3. substance use and addiction and 8). effect size using the magnitude of the problems; 47 Magnitude of Effects adjusted odds ratio, 77% of the 4. sexual health problems; and statistically significant associations in To estimate the magnitude of this review were considered to have 5. physical health limitations potential effects of child a medium to large effect size (odds and risk. maltreatment on long-term outcomes, ratio $2), including 10% with a large These results were seen after other studies have used a number of effect size (odds ratio .4) (Fig 2). statistical techniques. In one adjustment for a broad range of Australian study that used the MUSP relevant sociodemographic, perinatal, and other data sets, the population DISCUSSION psychological, and other risk factors attributable risk of child In summary, over the past decade, the (Fig 3). Many of the studies also maltreatment causing anxiety MUSP has revealed that child adjusted for the other subtypes of disorders in men and women, was maltreatment is associated with child maltreatment and demonstrated estimated to be 21% and 31%, a broad array of adverse outcomes that specific maltreatment types were respectively, and 16% and 23% for during adolescence and young closely associated with particular depressive disorders.46 Similarly, in adulthood, including the following: outcomes.

FIGURE 8 Child maltreatment and physical health outcomes at 21 years. A, Adjusted odds ratio 6 95% confidence interval. B, Adjusted coefficients 6 95% confidence interval. * P , .05.

Downloaded from www.aappublications.org/news by guest on September 29, 2021 10 STRATHEARN et al TABLE 1 Nonexclusive and Exclusive Categorization of Child Maltreatment Subtypes (Single and in neglect, in particular, may lead to Combination) Within the MUSP Cohort deficits in emotion recognition and Combinations of Substantiated Maltreatment n % of Cohort regulation, as well as insensitivity to (N = 7214) reward,3 potentially influencing social Nonexclusive categories of maltreatment and emotional development. Any sexual abuse 147 2.0 Neglected children are less able to Any physical abuse 287 4.0 discriminate facial expressions and Any emotional abuse 267 3.7 emotions,58 whereas youth who have Any neglect 269 3.7 Exclusive categories of maltreatment been emotionally neglected show None 6703 92.9 blunted development of the brain’s Sexual abuse only 63 0.87 reward area, the ventral striatum.59 Physical abuse only 60 0.83 Reduced reward activation may Emotional abuse only 24 0.33 predict risk for depression,59 Neglect only 71 0.98 60 Sexual and physical abuse only 10 0.14 addiction, and other 61 Sexual and emotional abuse only 6 0.08 psychopathologies. Sexual abuse and neglect only 12 0.17 Physical and emotional abuse only 74 1.03 Neglect was also associated with the Physical abuse and neglect only 23 0.32 early onset of sexual activity, multiple Emotional abuse and neglect only 37 0.51 Sexual, physical, and emotional abuse only 5 0.07 sexual partners, and youth pregnancy, Sexual and physical abuse and neglect only 5 0.07 even after adjustment for other Sexual and emotional abuse and neglect only 11 0.15 maltreatment subtypes. This suggests Physical and emotional abuse and neglect only 75 1.04 that neglect may result in Sexual, physical, and emotional abuse and neglect 35 0.49 compensatory efforts to obtain sexual Total with any substantiated maltreatment 511 7.1 intimacy, consistent with other studies revealing higher rates of Abuse, Neglect, and Cognitive Psychological Maltreatment: unprotected sex62 and adolescent Development Emotional Abuse and/or Neglect pregnancy in neglected children.63 In the animal literature, female rodents One of the most striking conclusions fi that experience maternal deprivation Signi cant cognitive delays and from this review was the broad educational failure were seen for both association between emotional abuse tend to have an earlier onset of abuse and neglect across adolescence and/or neglect and adverse outcomes puberty and increased sexual and adulthood. In another study, the in almost all areas of assessment receptivity, leading to elevated authors concluded that preexisting (Fig 2). In stark contrast, physical reproductive activity to help offset an cognitive impairments at 3 or 5 years abuse and sexual abuse were environment of higher offspring may explain this association, rather risk.64,65 16 associated with far fewer adverse than maltreatment per se. outcomes. Overall, quality of life was However, other research has lower for those who had experienced Sexual Abuse revealed that children neglected over emotional abuse and neglect but not fi 66 the rst 4 years of life show for those who had experienced As observed elsewhere, sexual a progressive decline in physical or sexual abuse. Although abuse was associated with early cognitive functioning, which is emotional abuse and neglect often co- sexual experimentation and youth fi associated with a signi cantly occur with other types of pregnancy as well as symptoms of reduced head circumference at 2 and maltreatment,46 the associated PTSD and depression. Risky sexual 48 4 years of age. In rodent models, outcomes were generally robust even behaviors were independent of other contingent maternal behavior is after statistical adjustment or types of maltreatment but were not fi linked with infant cognitive separation into differing speci c for sexual abuse. An development, and possible maltreatment categories (Fig 2). additional MUSP study comparing mechanisms include increases in self-reported and agency-notified synaptic connections within the Emotional abuse and neglect in early child sexual abuse revealed hippocampus49 and reduced childhood may lead to consistent associations with major apoptotic cell loss.50 psychopathology via insecure depressive disorder, anxiety Prolonged maternal separation, in attachment,53,54 which has been disorders, and PTSD.8 The absence of contrast, is associated with associated with externalizing associations with other adverse impaired cognitive development behavior problems55 and impaired outcomes, however, may be, in part, in rodent and primate models.51,52 social competence.56,57 Emotional due to the lower prevalence of

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 146, number 4, October 2020 11 substantiated sexual abuse, especially findings were mostly unchanged negative long-term health and at the 21-year follow-up. when using propensity analysis, developmental outcomes extending which is used to assess the effects of into adolescence and young Physical Abuse nonrandom sampling variation by adulthood. Although these data do Outcomes associated with physical analyzing the probability of not establish causality, abuse differed from those associated assignment to a particular category neurodevelopmental pathways are with sexual abuse, with increased within an observational study given likely influenced by stress and early odds of externalizing behavior the observed covariates.72 social experience through epigenetic problems, and delinquency in men. Specifically, the sample was weighted mechanisms, which may affect gene Jaffee3 suggests that physical abuse, so that it better resembled expression and regulation and, in particular, may lead to sociodemographic characteristics at ultimately, behavior and a hypervigilance response to threat, baseline to minimize bias from development.3,74 including negative attentional bias, differential attrition in those with Understanding the developmental disproportionate to relatively mild greater socioeconomic disadvantage. roots of these adverse outcomes may threat cues. Studies have revealed motivate physicians to more that physically abused children show Secondly, differences in the fi systematically inquire about early-life selective attention to anger cues,67 prevalence of speci c maltreatment fl trauma and refer patients to more have difficulty disengaging from subtypes might have in uenced the appropriate treatment services.75,76 them,58,68 and are more likely to statistical power to detect true Even more importantly, early misinterpret facial cues as being effects, particularly regarding sexual intervention and prevention angry or fearful.69 abuse (Table 1). programs, such as prenatal and 77 Limitations Finally, the co-occurrence of different infancy nurse home visiting, have types of maltreatment may have demonstrated, in randomized clinical Although these studies demonstrated impacted the ability to accurately trials, diminished rates of child abuse significant associations between predict the associations between and neglect.78,79 Long-term benefits maltreatment and a range of long- specific types of maltreatment and to the offspring include decreased term outcomes, association does not outcomes. Other studies have childhood internalizing problems,80 equal causality. The causal revealed that emotional abuse and reduced antisocial behavior and mechanisms proposed above are neglect, in particular, are more likely substance abuse in adolescence,81 tentative and may relate to multiple to co-occur with each other and with and improved cognitive skills types of maltreatment. 73 other types of maltreatment. extending into young adulthood.80,82 Other limitations should also be However, even in those articles that Supporting at-risk parents and young considered. Firstly, selective attrition statistically adjusted for other co- children should thus be an urgent of socioeconomically disadvantaged occurring maltreatment subtypes, the priority. and maltreated young people was associated outcomes linked with evident in the MUSP cohort emotional abuse and/or neglect were (Supplemental Information). generally robust. In articles that did ABBREVIATIONS However, based on multiple not adjust for these co-occurrences, CIDI: Composite International Di- imputation calculations and inverse some of the strongest associations agnostic Interview probability weighting of MUSP were still observed for emotional IPV: intimate partner violence data,18,70 differences in the rate of abuse and/or neglect. MUSP: Mater-University of loss to follow-up, for both dependent Queensland Study of and independent variables, made Pregnancy little difference to either the CONCLUSIONS PTSD: posttraumatic stress estimates or their precision, Child maltreatment, particularly disorder mirroring findings from other psychological maltreatment, is longitudinal studies.71 In addition, the associated with a broad range of

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: Partially supported by the US National Institute on Drug Abuse (R01DA026437). The content is solely the responsibility of the authors and does not necessarily represent the official views of this institute or the National Institutes of Health. Funded by the National Institutes of Health (NIH). POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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