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A 12-Year Prospective Study of the Long-term Effects of Early Child Physical Maltreatment on Psychological, Behavioral, and Academic Problems in Adolescence
Jennifer E. Lansford, PhD;
Kenneth A. Dodge, PhD;
Gregory S. Pettit, PhD;
John E. Bates, PhD;
Joseph Crozier, MPM;
Julie Kaplow, PhD
Arch Pediatr Adolesc Med. 2002;156:824-830.
ABSTRACT
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Objective To determine whether child physical maltreatment early in life has long-term
effects on psychological, behavioral, and academic problems independent of
other characteristics associated with maltreatment.
Design Prospective longitudinal study with data collected annually from 1987
through 1999.
Setting and Participants Randomly selected, community-based samples of 585 children from the
ongoing Child Development Project were recruited the summer before children
entered kindergarten in 3 geographic sites. Seventy-nine percent continued
to participate in grade 11. The initial in-home interviews revealed that 69
children (11.8%) had experienced physical maltreatment prior to kindergarten
matriculation.
Main Outcome Measures Adolescent assessment of school grades, standardized test scores, absences,
suspensions, aggression, anxiety/depression, other psychological problems,
drug use, trouble with police, pregnancy, running away, gang membership, and
educational aspirations.
Results Adolescents maltreated early in life were absent from school more than
1.5 as many days, were less likely to anticipate attending college compared
with nonmaltreated adolescents, and had levels of aggression, anxiety/depression,
dissociation, posttraumatic stress disorder symptoms, social problems, thought
problems, and social withdrawal that were on average more than three quarters
of an SD higher than those of their nonmaltreated counterparts. The findings
held after controlling for family and child characteristics correlated with
maltreatment.
Conclusions Early physical maltreatment predicts adolescent psychological and behavioral
problems, beyond the effects of other factors associated with maltreatment.
Undetected early physical maltreatment in community populations represents
a major problem worthy of prevention.
INTRODUCTION
ANNUALLY, ACCORDING to the United States Department of Health and Human
Services (Washington, DC), approximately 3 million children are referred to
local child protective service agencies as possible victims of physical abuse,
emotional abuse, sexual abuse, or neglect.1
Of these, approximately 25% of cases involve physical abuse. The number of
reported cases is presumed to underestimate the actual prevalence and incidence
of child maltreatment.2 Despite the scope of
this problem, the long-term effects of early physical maltreatment remain
unclear.
Retrospective accounts of adolescents and adults who had been abused
when they were children suggest that physical maltreatment can have long-term
negative consequences.3-4 However,
because participants in retrospective studies generally are selected from
clinical samples in treatment, it is unclear whether they accurately represent
the population that had been maltreated as children.5-6
It is possible that relatively few adolescents and adults who had been maltreated
as children continue to experience problems and that it is only a small proportion
of those who do that end up in treatment and, consequently, retrospective
studies of abuse.
Cross-sectional and short-term longitudinal studies have demonstrated
that physical maltreatment is related to problems that arise in close temporal
proximity to the occurrence of the abuse, such as juvenile delinquency, psychopathology,
and disrupted social relationships.7-8
It is not clear from these studies, however, whether early physical maltreatment
plays an enduring role in the development of later adjustment problems in
adolescence or whether negative outcomes are the temporary result of trauma
that will diminish in importance over time. Some researchers have argued that
associations between abuse and adjustment problems can be explained by reporting
biases because many studies of the effects of physical maltreatment use samples
for which maltreatment is identified by referral to social service agencies.6 Of the community-wide population of maltreated children,
those who are referred may represent a biased, more problematic subgroup.
Also, because the effects of interventions provided by these agencies are
themselves unknown, studies using these types of samples confound the effects
of maltreatment and the effects of institutional interventions.9
Other researchers have contended that associations between physical abuse
and later adjustment problems can be accounted for by confounding factors,
such as poverty and family stress.5, 10
To address the question of whether physical maltreatment early in life
has long-term effects on psychological, behavioral, and academic outcomes
independent of other characteristics associated with maltreatment, prospective
longitudinal research with nonreferred community, rather than clinical, samples
is needed. Because a number of ecological risk factors (eg, poverty, family
stress) and child characteristics (eg, difficult temperament) are empirically
associated with physical maltreatment, it is important to control for these
correlates of maltreatment statistically to determine whether maltreatment
per se has effects on later outcomes above and beyond the effects of other
risk factors.10-11 In addition,
because gender and ethnicity affect individuals' risk for particular types
of problems, an important question is whether maltreatment affects long-term
outcomes in similar ways for boys and girls and for members of different ethnicities.
This study is a prospective investigation of a community sample first
identified when the participants were about 5 years old. Initial findings
revealed that the physically maltreated children in the sample were at risk
for aggressive behavior problems on school entry.12-13
To our knowledge, this article is the first report of adolescent outcomes
of early physical maltreatment in this sample.
PARTICIPANTS AND METHODS
PARTICIPANTS
During kindergarten preregistration for 2 cohorts of children in 1987
and 1988, parents at public schools in 3 geographic sites (Nashville and Knoxville,
Tenn, and Bloomington, Ind) were approached randomly and asked to participate
in a longitudinal study of child development.12, 14
The 15% of students who did not preregister at these schools were contacted
via telephone, letter, or on the first day of school and asked to participate.
Of those approached, 75% agreed to participate, resulting in a sample of 585
children who were first assessed during the summer before kindergarten matriculation
or within the first weeks of the school year. This sample did not differ in
any detectable way from the rest of the community populations.12, 14
The sample was 52% male (48% female) and 82% European American, 16% African
American, and 2% from other ethnic backgrounds. Children were reassessed annually,
with internal review board approval at each time point. Twelve years later
(when most of the sample had completed 11th grade), 79% of nonmaltreated and
77% of maltreated children continued to participate. The grade 11 maltreated
sample included 19 white girls, 19 white boys, 7 minority girls, and 8 minority
boys; the nonmaltreated sample included 172 white girls, 175 white boys, 33
minority girls, and 30 minority boys. Compared with the original sample of
585, the 463 continuing families were of slightly higher socioeconomic status
but participants and nonparticipants did not differ by race, single-parent
status, mothers' reports of children's internalizing or externalizing behaviors
in kindergarten, or abuse status.
MEASURES
During the summer before children entered kindergarten, detailed interviews
regarding children's developmental history were conducted with mothers in
their homes. Mothers responded to a variety of questions regarding the child's
misbehavior, discipline practices, and whether the child had ever been physically
harmed by an adult. Following this discussion, interviewers paused to rate
privately the probability that the child had been severely harmed, using a
criterion of intentional strikes to the child by an adult that left visible
marks for more than 24 hours or that required medical attention. A score of
0 was assigned if maltreatment had definitely not or probably not occurred,
and a score of 1 was assigned if maltreatment had probably occurred, definitely
occurred, or if authorities had been involved. Agreement between independent
raters for this classification was 90% ( = 0.56).13
Sixty-nine children (11.8% of the sample) were classified as having experienced
early physical maltreatment, a rate comparable with other reports using national
samples.15 All parents signed statements of
informed consent before participating in the study and were aware that cases
of maltreatment made known to the researchers would be reported as appropriate.
Discussion of each child classified as maltreated was held in close collaboration
with experts at relevant local agencies to determine which cases should be
reported to the Department of Health and Human Services.13
Authorities had been involved with 7 of the 69 children classified as physically
maltreated, and 6 new cases were reported to agencies; the other cases were
determined not to be cases of ongoing abuse and imminent danger (and thus
were not reportable in Tennessee and Indiana at that time).
In the course of the developmental interview, mothers were also asked
questions about other risk factors that potentially act as confounds if not
considered in analyses of the effects of maltreatment. Socioeconomic status
was based on an index computed from parental education and occupation levels
(August B. Hollingshead, PhD, unpublished data, 1979, available from the Department
of Sociology, Yale University, New Haven, Conn). Families were coded as headed
by a single parent on the basis of mothers' reports of who lived in the household
at the time of the initial assessment. Family stress was assessed by averaging
responses to 10 questions regarding whether different types of major stressors
(eg, death of a family member, divorce) had occurred and how these changes
affected the child. Maternal social support was coded following questions
regarding mothers' social contact and who was available to help them in times
of need. Child exposure to violence was coded after mothers answered questions
about the kinds of conflicts, arguments, or violence the child was exposed
to between her or his parents, others in the home, and outside the home. Three
aspects of child temperament (ie, resistance to control, unadaptability, and
difficult temperament) were assessed using the 16-item Retrospective Infant
Characteristics Questionnaire.16-17
Finally, mothers were asked to describe the child's health during the prenatal
through early postnatal period. Interviewers then rated whether the child
was healthy at birth, had minor or brief problems, or had major health problems.
Children's official school records from 9th through 11th grades were
available. Children's official school records were available for each academic
year, when most of the sample was in the 9th through 11th grades; if a child
had been retained a grade, these records might have corresponded to a lower
grade. From these records, it was possible to determine adolescents' average
grades and standardized test percentiles in mathematics and language arts
across grades 9 through 11. The number of days absent and number of times
suspended during 9th through 11th grades also were documented in these records
and were averaged across years.
When their children had finished 11th grade, mothers completed the 113-item
Child Behavior Checklist.18 For each item,
the mother indicated whether the behavior was not true, somewhat or sometimes
true, or very or often true (scored as 0, 1, or 2, respectively) of her child.
Items were summed to create subscales of Aggression, Anxiety/Depression, Dissociation,
Delinquent Behavior, Post-Traumatic Stress Disorder (PTSD), Social Problems,
Thought Problems, and Social Withdrawal.18-20
Some items in the Dissociation and PTSD scales are also included in other
Achenbach subscales. Correlations between the Dissociation and PTSD scales
and the other subscales range from 0.53 to 0.82; correlations among the other
subscales range from 0.44 to 0.70. Because the constructs represented by the
different scales have been examined separately in the literature, we kept
these scales despite the redundancy in some of the items. Mothers also indicated
how often in the last year they pushed, grabbed, shoved, or hit the child.21 This rating was included as an additional control
variable to parse the effect of ongoing harsh maternal treatment.
In the summer after 11th grade, adolescents completed the Youth Self-Report
Form of the Child Behavior Checklist, with scales comparable with those completed
by their mothers.22 In addition, they completed
the Adolescent Behavior Questionnaire constructed for this study to indicate
the frequency with which they engaged in a series of problem behaviors. A
scale reflecting the number of drugs they had tried was the sum of whether
they had ever (1) smoked or chewed tobacco; (2) smoked marijuana; (3) "huffed"
or inhaled a substance; (4) tried crack or cocaine; (5) tried LSD (lysergic
acid diethylamide) or heroin; (6) used alcohol; or (7) tried any other method
to get high (possible range, 0-7 drugs tried). Dichotomous responses in 4
domains were summed to reflect whether the adolescent had (1) been in trouble
with the police; (2) gotten pregnant or impregnated someone; (3) run away
from home; and (4) whether they were currently in a gang (possible range,
0-4 behavior problems). Finally, adolescents indicated whether the chances
they would go to college were very low, low, about 50:50, high, or very high
(scored as 1-5, respectively).
RESULTS
Two (maltreated vs not maltreated) x 2 (gender) x 2 (white
vs minority) analyses of variance were conducted to examine adolescents' adjustment
as a function of early physical maltreatment, taking into account gender and
ethnicity. The main effects of maltreatment are presented in Table 1. The first 3 columns show the main effects of maltreatment
without controlling for other risk factors associated with maltreatment. The
second 3 columns depict the main effects of maltreatment, controlling for
ecological and child risk factors.
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Differences Between Maltreated and Nonmaltreated Children in Academic,
Psychological, and Behavioral Problems in Adolescence*
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As shown, adolescents who had been maltreated early in life had lower
grades and standardized test scores in language arts, were absent from school
almost twice as many days, and were suspended from school more than twice
as many times as adolescents who had not been maltreated. However, with the
exception of school absences, all of these effects could be accounted for
by risk factors associated with maltreatment rather than maltreatment per
se.
In grade 11, mothers reported that adolescents who had experienced early
maltreatment had levels of aggression, anxiety/depression, dissociation, delinquent
behaviors, PTSD, social problems, thought problems, and social withdrawal
that were on average twice as high as those of their nonmaltreated counterparts.
The effects of maltreatment on all of these psychological and behavioral problems
as reported by adolescents' mothers could not be explained away by other risk
factors (with the lone exception of delinquent behavior). However, adolescents
who had been maltreated did not differ from those who had not been maltreated
on these dimensions based on their own reports; these variables are not shown
in Table 1 and were excluded from
further analyses. On the Adolescent Behavior Questionnaire, adolescents who
had been maltreated reported more behavior problems than did their nonmaltreated
counterparts (although this effect was accounted for by other risk factors
rather than abuse per se) and were less likely to anticipate attending college
(a little better than a 50% chance vs a high or very high chance) even after
controlling for other risk factors.
The magnitude of the effects of early maltreatment on several adolescent
problems depended on the adolescent's gender and ethnicity. Maltreatment x
gender and maltreatment x ethnicity interactions were tested for all
dependent variables; only interactions significant after controlling for ecological
and child covariates are shown in the figures. As shown in Figure 1, boys and girls who had been maltreated were more likely
to experience adjustment problems compared with nonmaltreated adolescents,
but the effects of early maltreatment were stronger for girls than for boys.
Although not shown in Figure 1,
significant maltreatment x gender interactions for dissociation (F1,377 = 5.40, P<.05), PTSD (F1,377 = 14.39, P<.001), social problems (F1,377 = 5.99, P<.05), thought problems (F1,377 = 7.82, P<.01), and social withdrawal
(F1,377 = 5.48, P<.05) replicated the
pattern of findings depicted for aggression and anxiety/depression. Figure 2 illustrates all significant maltreatment
x ethnicity interactions, controlling for ecological and child covariates.
This figure indicates that for school absences, the negative effect of maltreatment
was stronger for minority than white children. In addition, minority adolescents
who were maltreated were suspended more often and had more behavior problems
than did minority adolescents who were not maltreated; the effect was in the
opposite direction but not significant for white adolescents.
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Figure 1. Representative significant maltreatment
x gender interactions from analyses of covariance. School absences were
obtained from official school records. Aggression and Anxiety/Depression subscale
scores are from the mothers' reports. Note: Although not shown here, interactions
were significant for subscales of Dissociation, PTSD, Social Problems, Thought
Problems, and Social Withdrawal. These effects replicated those shown for
Aggression and Anxiety/Depression. The bar represents the group mean with
SE.
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Figure 2. Significant maltreatment x
ethnicity interactions from analyses of covariance. School absences and suspensions
were obtained from official school records. Behavior problems were determined
from adolescent reports. The bar represents the group mean with SE.
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These findings indicate that physical maltreatment in the first 5 years
of life places a child at risk for a variety of psychological and behavioral
problems during adolescence. Although on average, adolescents who had been
maltreated experienced more problems than did their nonmaltreated counterparts,
one may wonder whether the same group of children who had been maltreated
displayed a pervasive set of maladaptive outcomes or whether different maltreated
children display different maladaptive outcomes. To examine this question,
we created a variable reflecting the number of problems adolescents experienced,
including (1) aggression at clinically deviant levels and (2) anxiety/depression
at clinically deviant levels (each 1 SD or more above the nationally normed
mean as recommended by Achenbach18); (3) school
suspension; (4) trouble with the police; (5) pregnancy or impregnating someone;
(6) running away from home; and (7) gang membership. Thus, adolescents could
experience as few as 0 or as many as 7 problems.
As shown in Figure 3, cross-tabulations
of this problem count by early maltreatment revealed that 74% of adolescents
who had been maltreated experienced at least 1 adjustment problem compared
with only 43% of nonmaltreated adolescents. Twenty-one percent of maltreated
adolescents experienced 3 or more problems compared with 7% of nonmaltreated
adolescents. Thus, maltreatment in the first 5 years of life almost doubles
the risk of any problem and triples the risk of experiencing problems in multiple
domains during adolescence ( 23= 26.11, P<.001).
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Figure 3. Number of psychological and behavioral
problems experienced by maltreated and nonmaltreated adolescents.
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COMMENT
This prospective study of a community-based sample provides support
for the role of physical maltreatment in the first 5 years of life in the
development of psychological and behavioral problems during adolescence, above
and beyond other risk factors related to maltreatment. It does not seem to
be the case that the effects of early physical maltreatment on psychological
and behavioral problems are short-lived. Rather, the effects persist over
at least a 12-year period. The effects range from externalizing to internalizing
outcomes and touch 3 of 4 children who had been maltreated. The long-term
effects of early physical maltreatment seem to be worse for girls than for
boys and for minority than white adolescents, although the latter finding
should be interpreted with caution because the sample of maltreated minority
children was small. If replicated, this finding regarding ethnic differences
in the effects of physical maltreatment will contribute to a growing body
of literature on culture-specific ways in which parenting behaviors may affect
child outcomes. There is evidence that parents' use of physical discipline
is related to problem behaviors for European American children but that there
is no relation between physical discipline and problem behaviors for African
American children.23-24 Our findings
suggest that this link is limited to physical discipline and does not apply to physical maltreatment.
Because these effects were found in a community rather than clinical
sample, it cannot be argued that differences between maltreated and nonmaltreated
children were distorted by including only cases of maltreatment serious enough
to have required intervention. Furthermore, although 13 of the 69 maltreated
children did have experiences with social service agencies, most of the sample
did not; we have minimized the confounding of experiences with social service
agencies and the experience of maltreatment by not drawing the sample from
cases involved with child protective services. Finally, because this is a
prospective study, our findings are not inflated by retrospective biases.
All of these methodological advances address limitations in previous research
on the effects of child physical maltreatment.5-6,9
An inherent limitation of correlational studies is that without random
assignment, which obviously cannot be implemented in comparisons of children
who have and have not been maltreated, the possibility that omitted variables
are responsible for the observed associations can never be eliminated entirely.
For example, physical maltreatment is sometimes comorbid with emotional abuse,
sexual abuse, or neglect. We did not assess, and therefore cannot control
for, these other types of maltreatment. Particularly in the case of academic
achievement and problems, many of the effects of maltreatment were accounted
for by risk factors that we did assess and that are correlated with the experience
of maltreatment. Physical maltreatment per se seemed less important in the
prediction of academic outcomes than the constellation of other risk factors
associated with maltreatment. However, because these other risk factors reflect
real circumstances of maltreated children's lives, maltreatment should not
be assumed to be unimportant in the development of academic achievement or
conduct at school.
An additional limitation of this study is that the distinction between
children who had been maltreated and those who had not was made without knowledge
of the chronicity, severity, or timing of the maltreatment. One would expect
more psychological, behavioral, and academic problems for children whose history
was characterized by maltreatment that was chronic, severe, or both. Furthermore,
maltreatment classification was made on the basis of maltreatment within the
first 5 years of life. There is evidence that maltreatment in early childhood
is more strongly related to subsequent adjustment problems than is later maltreatment25; thus, focusing on the effects of maltreatment during
this period is of particular interest. Nevertheless, in our analyses, children
who were not maltreated in their first 5 years but were subsequently maltreated
would have been classified with the nonmaltreated participants. Including
these children in the nonmaltreated group would likely have the effect of
attenuating differences between the nonmaltreated and maltreated groups. Our
findings of differences between them are, therefore, especially impressive.
Although maltreated adolescents and nonmaltreated adolescents did not
differ in their self-reported psychological and behavioral problems on the
Youth Self-Report Form of the Child Behavior Checklist, they did differ in
their self-reported likelihood of attending college and, before controlling
for the covariates, in the number of behavior problems they experienced. However,
mothers reported more differences between the maltreated and nonmaltreated
adolescents in grade 11 than did the adolescents themselves. Because mothers
were also the source of information about the children's abuse status before
kindergarten, one must consider the possible effects of method variance on
these findings. Nevertheless, it is impressive that early physical maltreatment
remained a significant predictor of a range of psychological and behavioral
problems after controlling for other important child and family risk factors.
Further research will be needed to determine whether early emotional abuse,
sexual abuse, and neglect similarly affect long-term adjustment and whether
these findings generalize to reports of adjustment made by other individuals.
A task facing researchers is to elucidate psychological, social, and
biological mechanisms through which the adverse effects of physical maltreatment
occur. Because the adverse effects are wide-ranging, it is likely that characteristics
of children will moderate outcomes. We doubt that the risks associated with
physical maltreatment are engendered through a single instance of trauma.
Rather, we believe that the mechanisms through which risk operates are likely
to include (1) impaired relationships with adults and peers that preclude
maltreated children from developing social competencies; (2) acquired social-cognitive
problems, such as hostile attributional biases and problem-solving deficits;
and (3) acquired physiological emotion dysregulation, which impairs intrapersonal
as well as interpersonal functioning. Future studies are needed to support
or refute these hypotheses.
A task facing practitioners and social service system managers is to
design treatments for physically maltreated young children that will be effective
in preventing the maladaptive outcomes for which they are at risk. No such
treatment has yet been documented through rigorous tests. Public health practitioners
should also try to discover noniatrogenic ways of screening and detecting
young children who have been physically maltreated so that effective treatments
can reach this at-risk population. Finally, the task facing policy makers
is to create conditions across society that reduce the likelihood of physical
maltreatment occurring in the first place. The findings reported here suggest
that this need is urgent and will affect the next generation of adolescents.
| What This Study Adds
Despite the scope of the problem of child maltreatment, the long-term
effects of early physical maltreatment remain unclear. This study was conducted
to determine whether child physical maltreatment early in life has long-term
effects on psychological, behavioral, and academic problems in a community
sample, independent of other characteristics associated with maltreatment.
We found that physical maltreatment within the first 5 years of life predicts
psychological and behavioral problems at least 12 years later, controlling
for other risk factors associated with maltreatment. These findings have not
confounded the experience of maltreatment with social service agency involvement
and are not marred by retrospective biases. Thus, they represent a methodological
advance that highlights the need for practitioners and social service system
managers to design treatments for physically maltreated young children that
will be effective in preventing the maladaptive outcomes for which they are
at risk.
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AUTHOR INFORMATION
Accepted for publication April 18, 2002.
The Child Development Project has been funded by grants MH42498 and
MH56961 from the National Institute of Mental Health, Bethesda, Md, and HD30572
from the National Institute of Child Health and Human Development, Bethesda.
Portions of this research were presented at the biennial meeting of
the Society for Research in Child Development, Minneapolis, Minn, April 20,
2001.
We are grateful for the ongoing dedication of the Child Development
Project participants and research staff.
Corresponding author and reprints: Jennifer E. Lansford, PhD, Center
for Child and Family Policy, Box 90545, Durham, NC 27708-0545 (e-mail: lansford{at}pps.duke.edu).
From the Center for Child and Family Policy (Drs Lansford and Dodge)
and the Department of Psychology (Mr Crozier and Dr Kaplow), Duke University,
Durham, NC; the Department of Human Development and Family Studies, Auburn
University, Auburn, Ala (Dr Pettit); and the Department of Psychology, Indiana
University, Bloomington, (Dr Bates).
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