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Effect of Abuse on Health
Results of a National Survey
Angela Diaz, MD;
Elisabeth Simantov, PhD;
Vaughn I. Rickert, PsyD
Arch Pediatr Adolesc Med. 2002;156:811-817.
ABSTRACT
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Hypothesis The magnitude of risk would be highest for those reporting both types
of abuse compared with those reporting 1 type or none.
Objective To examine the independent associations between physical or sexual abuse
or both and self-reported health status, mental health, and health-risk behaviors
among a national school-based sample of adolescent girls.
Design A secondary data analysis of a cross-sectional survey.
Setting A nationally representative sample of 3015 girls in grades 5 through
12 from 265 public, private, and parochial schools (with an oversampling of
urban schools) completed an anonymous survey conducted by the Commonwealth
Fund Adolescent Health Survey.
Patients or Other Participants Girls were eligible for this study if they responded to 2 questions
assessing past physical and sexual abuse.
Results Among the respondents, 246 (8%) reported a history of physical abuse;
140 (5%), sexual abuse; and 160 (5%), both. Logistic regression controlling
for grade, ethnicity, family structure, and socioeconomic status found that
those who reported both types of abuse compared with those who did not report
any were significantly more likely to experience moderate to severe depressive
symptoms (adjusted odds ratio [AOR], 5.10), moderate to high levels of life
stress (AOR, 3.28), regular smoking (AOR, 5.90), regular alcohol consumption
(AOR, 3.76), use of other illicit drugs in the past 30 days (AOR, 3.44), and
fair to poor health status (AOR, 1.74). Finally, girls who reported both types
of abuse were 2.07 times more likely to report moderate to high depressive
symptoms compared with those reporting only sexual abuse (95% confidence interval,
1.14-3.74).
Conclusions The magnitude of risk for adolescents reporting both types of abuse
compared with no abuse is much greater than that for either abuse type alone.
However, compared with both types, no significant increase in risk was detected
in those reporting physical abuse only, and only depressive symptoms increased
in those reporting sexual abuse only.
INTRODUCTION
THE PREVALENCE and incidence of child maltreatment vary widely in the
general population.1-2 Various
methodological factors contribute to the wide range of prevalence estimates,
including definition variability, sampling differences, methods of data collection,
and the number and types of questions used to assess childhood maltreatment.3 To acquire estimates, retrospective studies have used
adults, because physical and sexual abuse that occurs during childhood often
goes unreported.3 Sampling adolescents as opposed
to adults is a practical solution to obtain prevalence estimates, especially
when anonymous survey methods are used. Most studies that examine prevalence
of child abuse experiences among adolescents use clinic-based samples. Few
large-scale studies of adolescents exist. In a study that considered a large
school-based sample, Neumark-Sztainer et al4
found that 12.2% of girls reported experiencing sexual abuse and 15.5% reported
physical abuse. Another study that examined substance abuse patterns among
a large cohort of Minnesota public school students in grades 6, 9, and 12
found rates of self-reported sexual abuse among girls to vary from 4.9% in
grade 6 to 11.7% in grade 12.5 Rates of self-reported
physical abuse ranged from 7.4% in grades 6 and 12 to 11.2% in grade 9. Thus,
from a representative US sample of adolescent participants, we might arrive
at a reliable estimate of the prevalence of childhood maltreatment.
Although we may be unsure of the actual estimates, childhood physical
and/or sexual abuse has been shown to be significantly associated with many
physical and psychological sequelae, including depression, anxiety, substance
abuse, and disordered eating.1-2,6-9
The relationship between child abuse and later sequelae vary widely across
samples and types of abuse.6 Although Perkins
and Luster10 did not find a significant relationship
between sexual abuse and purging among midwestern adolescent girls, Rorty
and colleagues11 found that multiple forms
of abuse (combinations of physical, psychological, and sexual abuse) predicted
bulimia. Unfortunately, few studies that examined the long-term effects of
childhood abuse have paid sufficient attention to the independent and combined
effects of childhood sexual and physical abuse.12
Wind and Silvern13 conducted one of the
first studies of the relationship between the type and extent of childhood
abuse and adult functioning. As might be expected, these researchers found
that adults who reported both physical and sexual abuse reported more symptoms
on measures of posttraumatic symptoms, depression, and low self-esteem compared
with a nonabused control group. In addition, the group who reported combined
abuse reported significantly more symptoms on these measures compared with
those who reported 1 type of abuse as children. No difference on indices of
depression or low self-esteem were detected between the physically and sexually
abused groups. More recently, Schaaf and McCanne12
found that college-aged women who reported experiencing a combination of types
of abuse displayed much greater rates of revictimization and posttraumatic
stress disorder than the nonabused group. However, they did not find differences
in rates of revictimization or posttraumatic stress disorder diagnosis between
the groups reporting physical or sexual abuse only. Unfortunately, the impact
of various types of child maltreatment has exclusively focused on adult survivors,
and the associated health risks among adolescents remain infrequently examined.
Pediatricians and other primary care providers need to screen vigorously
for adverse childhood events among their patients and to treat affected children
and adolescents for the consequences of child maltreatment.14
However, the relationship between the various types of abuse and adolescent
health, including behaviors that put health at risk (health-risk behaviors),
mental health problems, and health status, remains unclear. The purpose of
this study was 2-fold. First, we reported the prevalence of physical and/or
sexual abuse among a nationally representative sample of adolescent girls.
Second, we examined the independent associations between abuse (physical,
sexual, or both) and self-reported health status, mental health, and health-risk
behaviors. We hypothesized that the magnitude of risk would be highest for
those reporting both types of abuse compared with those reporting 1 type or
none.
SUBJECTS AND METHODS
The study population included a nationally representative sample of
3575 girls in grades 5 through 12 who participated in the 1997 Commonwealth
Fund Adolescent Health Survey. We purposely described female respondents only,
because recent data confirm that although the substantiated rates for many
types of maltreatment are similar for boys and girls, the rates of sexual
abuse differ significantly by sex, with the highest rates found among girls.15 This cross-sectional survey was conducted by Louis
Harris and Associates, Inc, The Commonwealth Fund, New York, NY, from December
1996 through June 1997.16-17 Briefly,
the nationwide survey used a 2-stage sampling strategy and a cluster design
with oversampling of some units to ensure a representative sample. Respondents
were selected from a nationally representative cross-section of 265 public,
private, and parochial schools, with an oversampling of 32 urban schools.
For a school to participate, permission was required from the lead administrators
and school principal. Any school declining to participate was replaced by
randomly choosing 1 of 5 schools with matching demographics and geography.
The school selection procedure and survey method are discussed in more detail
in a previously published study.18 Within each
participating school, students in a randomly selected grade in an English
classroom were surveyed anonymously in class. Louis Harris and Associates
obtained approval for the study from the appropriate officials in accordance
with the policies governing each school and collected data from students in
compliance with the participating schools' internal review processes regarding
informed consent. Some items of a sensitive nature were omitted from the questionnaire
administered to students in grades 5 through 8, and similarly, versions of
the questionnaires differed slightly between the sexes. The sensitive items
in the questionnaire that were omitted from grades 5 through 8 were about
sexual activity, pregnancy, and birth control. We believe that omission of
these questions from the younger group's questionnaire had no impact on our
study, because these questions did not apply directly to sexual abuse or any
type of abuse. Moreover, the students were provided with an explicit invitation
to skip any questions they did not feel comfortable answering. Of the girls
who completed the survey, 50% were white (non-Hispanic); 15%, black (non-Hispanic);
9%, Hispanic; 3%, Asian; 2%, other; and 21%, unknown ethnicity.
Our secondary data analysis used only the girls who responded to both
questions assessing a history of sexual and physical abuse. Five hundred sixty
girls (16%) did not respond to both questions, leaving a total of 3015 respondents
to be included in the present analyses.
MEASURE AND DATA DEFINITIONS
The anonymously completed measure collected information across a number
of domains, including demographic characteristics, physical or sexual violence,
substance use (ie, cigarettes, alcohol, and other illicit drugs), and perceived
health status. In addition, standardized measures of depressive symptoms and
self-esteem and an index of life stress were included. For this study, 2 questions
assessed abuse and were used to create the following 3 mutually exclusive
categories: physical abuse only, sexual abuse only, and both. If a subject
provided a positive response to the question, "Have you ever been sexually
abused?" and a negative response to the question "Have you ever been physically
abused?" the response was coded as sexual abuse only. No definitions for physical
or sexual abuse were provided in the survey.
Demographic information collected included current grade, race/ethnicity,
family structure, and parental education. Subjects were dichotomized into
the younger group in grades 5 through 8 and the older group in grades 9 through
12. Race/ethnicity was categorized into non-Hispanic white, non-Hispanic black,
Hispanic, other, and unknown. The latter category was used in all cases where
this question was not answered. Family structure was assessed with the question
"What adults do you live with?" We grouped adolescents as living with both
parents, 1 parent, or some other adult or family structure unknown. We used
the last grade completed by either parent as an index of socioeconomic status.
Adolescents provided 1 of the following 6 possible responses to the
question about cigarette use: never, tried 1 or 2 cigarettes, sometimes, smoked
several cigarettes in the past week, smoked a pack or more in the past week,
and used to smoke but quit. For these analyses, we categorizied respondents
as nonsmokers (never smoked or tried it once) or as former (smoked but quit),
occasional (smoke sometimes), or regular (smoke several cigarettes or more
per week) smokers. With regard to alcohol use, subjects selected 1 of the
following 5 responses: never, once or twice in a lifetime, once in a while,
at least once a month, and at least once a week. To gauge the intensity of
drinking, those who said they drink at all were also asked how many alcoholic
drinks they typically consume in a night when they drink, with responses ranging
from 1 to more than 6. A follow-up question asked how often they drank "enough
to feel buzzed, tipsy, or drunk." We classified respondents as nondrinkers
(never drink or tried it once or twice) or as occasional (drink once in a
while or at most once a month and consume fewer than 3 drinks when drinking)
or regular (drink at least once a month or more frequently and consume at
least 3 drinks when drinking) drinkers. Finally, we assessed illicit drug
use with the general question "Have you used any illegal drugs in the past
month or not?" Girls who responded yes to this question were coded as illicit
drug users in the past month.
An index of depressive symptoms was developed using a modified version
of the Children's Depression Inventory.19 This
scale consisted of 14 items, each with the following 3 response options: none/mild,
moderate, or severe. Each subject was asked to rate the degree to which each
statement described her for the past 2 weeks, and a total score was computed.
Consistent with previous work, total scores of at least 9 were used to define
moderate to high levels of depressive symptoms.18
To measure self-esteem, we used the 10-item Rosenberg Self-Esteem Scale20; scored on a 4-dimension scale, it has been used
extensively with adolescents.21-23
We dichotomized the results between a total score of no greater than 20 and
at least 21 (range, 10-40) to indicate low levels and adequate to high levels
of self-esteem, respectively.18 Subjects were
also asked whether disruptive or stressful life events had occurred in the
past year, such as the death of a close friend, divorce or separation of parents,
or parental loss of a job or trouble with the law. Based on their responses
to 14 items using a scale from 0 to 4, a total score was obtained. Subjects
with a score of at least 17 were defined as having moderate to high levels
of life stress.18 Finally, to measure the constructs
of perceived health status, subjects were asked to rate their current health
on a 4-point scale from poor to excellent.
STATISTICAL ANALYSIS
The statistical consequences of the sampling plan were incorporated
into the analysis through the following 3 different means: (1) responses were
weighted to reflect grade enrollment, region, and ethnicity; (2) age groups
were included in the analysis to allow for correlation of students' responses
within classes; and (3) to stratify the sample by type of school and region,
we included 4 variables (urban private/parochial, urban public, suburban private/parochial,
and suburban public).
Bivariate relationships were examined using cross-tabulations and  2 statistics. In addition, associations were considered using binomial
and multinomial logistic regressions. We examined the relative significance
of each type of abuse compared with nonabuse for self-rated health, psychosocial/behavioral
variables (eg, self-esteem and depression), and health-risk behaviors (regular
smoking, alcohol consumption, and illicit drug use) after adjusting for grade
level, race/ethnicity, parental education, and family structure. Finally,
to detect whether the magnitude of risk for those reporting both types of
abuse was greater, additional logistic regression and multinomial analyses
were conducted in which those who reported physical or sexual abuse only were
used as a reference group. Adjusted odd ratios were used to express the magnitude
of outcomes when variables were dichotomized; among variables that were expressed
in 3 or more levels (eg, smoking), adjusted odds ratios from the multinomial
logistic regression that controlled for appropriate demographic characteristics
as already described were used to demonstrate the magnitude of the independent
relationship. All analyses were performed using Software for Statistical Analysis
of Survey Data, version 7.0 (STATA, College Station, Tex)
RESULTS
Of the 3015 girls in this sample, 546 (18%) reported a history of physical
and/or sexual abuse. Two hundred forty-six (8%) reported experiencing physical
abuse only; 140 (5%), sexual abuse only; and 160 (5%) both types of abuse.
Table 1 presents selected
demographic characteristics among this school-aged sample stratified by abuse
status. All analyses used no abuse as a reference category. Adolescent girls
who reported abuse were notably more likely than those who did not to be in
grades 9 through 12, to live in a single-parent household or with an adult
other than a parent, and to have parents with less than a high school education.
No significant differences were found in the race/ethnicity distribution among
abuse categories.
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Table 1. Demographic Characteristics Stratified by Abuse Status*
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The prevalence of regular cigarette smoking, regular alcohol consumption,
and use of other drugs in the past 30 days were significantly higher among
girls who reported abuse compared with those who did not report abuse
(Table 2). Among girls who reported only
sexual abuse, a lower proportion reported regular cigarette and alcohol use.
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Table 2. Prevalence of Health-Risk Behaviors Stratified by Abuse Status*
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As might be expected, adolescent girls who reported some history of
abuse were significantly more likely to report fair or poor health status,
moderate to high levels of depressive symptoms, low self-esteem, and moderate
to high levels of life stress compared with those who did not report abuse
(reference group) (Table 3). Girls
who reported experiencing both types of abuse reported the highest rates of
depressive symptoms, life stress, and low self-esteem. With the exception
of depressive symptoms, few differences were noted between those girls who
reported only physical compared with only sexual abuse.
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Table 3. Health Status and Mental Health Characteristics Stratified
by Abuse Status*
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Table 4 presents the independent
associations between abuse status and various outcome measures. As can be
seen, girls who reported experiencing both types of abuse were significantly
more likely to experience negative outcomes compared with nonabused girls.
In some instances, the adjusted odds ratios and adjusted odds ratios from
the multinomial logistic regression were twice as high among those who experienced
both types of abuse compared with those who reported only 1 type. Specifically,
girls who reported both types of abuse were 5.10 times more likely to report
moderate to high levels of depressive symptoms and 5.90 times more likely
to report regular smoking. In contrast, those girls who reported only sexual
abuse were 2.47 times more likely compared with their nonabused peers to experience
moderate to high levels of depressive symptoms and 2.67 times more likely
to report regular smoking.
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Table 4. Independent Associations Between Abuse Status and Health Status,
Mental Health, and Health-Risk Behaviors*
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To evaluate the relative likelihood for each health outcome according
to abuse status, we compared those who reported experiencing both types of
abuse with those reporting sexual or physical abuse only. When those reporting
both types of abuse were contrasted with those reporting sexual abuse only,
a significant finding emerged (data not shown). Adolescent girls who reported
both types of abuse were 2.07 times more likely (95% confidence interval [CI],
1.14-3.74) to report moderate to high levels of depressive symptoms compared
with those who reported sexual abuse only. When those reporting physical abuse
only were used as the reference group, the adjusted odds ratios for moderate
to high levels of depressive symptoms (1.51 [95% CI, 0.97-2.35]; P = .07) and self-esteem (1.53 [95% CI, 0.96-2.45]; P = .08) approached significance when controlling for demographic characteristics
and nonabuse status.
COMMENT
Our data found that almost 20% of adolescent girls in this nationally
representative sample reported experiencing physical or sexual abuse or both.
Although these rates are somewhat lower than those of studies using clinical
samples, these data are consistent with those of samples drawn from statewide
school-based research.4-5 These
alarming percentages underscore the importance of the position of the American
Academy of Pediatrics, which advocated that pediatricians assume an important
role in the identification and prevention of violence against children.24
Consistent with our hypothesis, adolescent girls who reported experiencing
both physical and sexual abuse compared with those who did not report child
maltreatment demonstrated higher levels of risk for common health-risk behaviors
that occur in adolescence. Finkelhor25 postulates
that early age, frequent and/or severe abuse, and abuse by a biological parent
have been consistently linked to a greater likelihood of problems in adulthood
such as substance abuse and depression. Thus, adolescent girls who report
experiencing both types of abuse would seem to be at greatest risk for development
of future psychopathology and to require early identification and treatment
when contrasted with their nonabused peers.
We found that the risk for moderate to high levels of depressive symptoms
was 5 times higher for those who reported both types of abuse compared with
those who reported no abuse and twice as high among those who reported only
sexual abuse, when controlling for important demographic characteristics.
Moreover, independent of child maltreatment, adolescent girls and young women
are at higher risk for mental health difficulties, relative to their male
counterparts.26 In addition, Harkness and Monroe27 found severe abuse, sexual abuse, antipathy, and
neglect to be significantly associated with endogenous depression among adult
women. Unfortunately, although some data suggest that the psychological health
of abused children improves over time, many children remain at a level of
clinical concern.1 Therefore, when screening
for abuse, and when this history is affirmed, the pediatrician should also
evaluate for depressive symptoms, especially among young girls who report
a history of both types of abuse.
Another important finding in our data was that adolescent girls who
reported experiencing both types of abuse were almost 6 times more likely
to report regular smoking compared with their nonabused peers. Moreover, among
those who reported sexual or physical abuse only compared with those who reported
no abuse, we found approximately 2.5 and 3.5 increases, respectively, in the
risk for reported regular smoking. These relationships are not surprising,
as a link between smoking and depressive symptoms has been demonstrated.18 Adolescent girls offer insight on this association
when they say that they smoke to reduce or alleviate stress.28
In contrast to our second hypothesis, we did not detect significant
increases in risk when girls reporting both types of abuse were compared with
those reporting physical abuse only. In addition, we observed only negligible
differences in the magnitudes of risk for health-risk behaviors, poor health
status, and poor mental health between those reporting sexual or physical
abuse only compared with those reporting no abuse. With the exception of depressive
symptoms, the experience of only 1 type of abuse places young girls at risk
for substance abuse, low self-esteem, and higher levels of life stress, compared
with young girls without a history of victimization. These data are consistent
with other research investigating substance abuse,5
anxiety,1 depression,1
and disordered eating4 and their relationship
to self-reported physical or sexual abuse. For example, Neumark-Sztainer et
al4 found similar risk magnitudes for disordered
eating among adolescent girls who reported experiencing physical or sexual
abuse after controlling for sociodemographic and psychosocial factors.
Several limitations of our study deserve mention. First, the 2 single
questions used to identify a history of physical and/or sexual abuse may have
underestimated the prevalence in this sample. Typically, the self-reported
rates of victimization increase when specific behaviors are assessed instead
of labels, because an adolescent may not believe she experienced abuse. Second,
we cannot establish causality for the observed relationships between abuse
type and health-risk behaviors, health status, or mental health. Although
cross-sectional data can rule out potential causes when associations are not
present, they cannot determine the temporal order of events. Furthermore,
our use of adjusted odds ratios from the logistic and the multinomial logistic
regressions throughout the analysis rather than relative risk may overstate
the size of the effects for some outcomes. Third, our conclusions cannot be
generalized to adolescents who are not attending or enrolled in school. Adolescents
who have dropped out of high school may be at increased risk for psychological
and behavioral sequelae of abuse, thus potentially decreasing our prevalence
estimate of child maltreatment. Finally, we cannot ensure that each student
who experienced abuse disclosed this information on the survey. However, efforts
were taken to ensure that each participant understood their responses to be
anonymous, and the collected data are consistent with those of other reports
describing the prevalence of child maltreatment.
In 1999, an estimated 826 000 children and adolescents were victims
of substantiated abuse and neglect, and slightly more than half (52%) of these
were girls.15 Secondary analysis of a nationally
representative sample underscores the need for pediatricians and other primary
care providers to offer universal screening to patients, including adolescents.
Moreover, pediatricians who provide care to adolescent girls must be mindful
of depressive symptoms, their association with any childhood maltreatment,
and the demonstrated relationship with other health-compromising behaviors
common to this population.
| What This Study Adds
Many studies examining the long-term effects of childhood abuse have
paid insufficient attention to the independent and combined effects of childhood
sexual and physical abuse, especially among adolescents. In addition, prevalence
estimates of the occurrence of physical and sexual abuse of children have
been conducted primarily among clinic-based samples. This study used a nationally
representative sample to provide prevalence estimates for childhood abuse
and to examine the independent associations between physical or sexual abuse
or both and self-reported health status, mental health, and health-risk behaviors.
We hypothesized that adolescent girls who reported both forms of abuse would
be at the greatest risk for adverse health outcomes.
We found that the magnitude for increased health risk is greater for
those young women who reported experiencing both types of abuse compared with
those who did not report abuse. However, the increase in health risk is not
significantly different when the comparison group is that reporting physical
or sexual abuse only.
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AUTHOR INFORMATION
Accepted for publication April 25, 2002.
Corresponding author and reprints: Angela Diaz, MD, Mount Sinai Adolescent
Health Center, 320 E 94th St, New York, NY 10128 (e-mail: angela.diaz{at}msnyuhealth.org).
From the Department of Pediatrics, Mount Sinai School of Medicine (Dr
Diaz), the Center for Home Care Policy and Research, Visiting Nurse Service
of New York (Dr Simantov), and the Center for Community Health and Education,
Mailman School of Public Health (Dr Rickert), New York, NY.
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