Mothers with a history of childhood sexual abuse
What are the indirect effects of childhood sexual abuse on maternal parenting?
Understanding the experiences and behaviours of survivors of childhood sexual abuse in the parenting role is important, as parental wellbeing is central to children's social, physical and mental health (FaHCSIA, 2011). Theoretical frameworks and empirical evidence suggest that an individual's developmental history, especially if it includes childhood sexual abuse, plays a significant role in the development of one's parenting skills (Belsky & Vondra, 1989; Berlin et al., 2011; Bromfield et al., 2010; Chiang, 2009; Cross, 2001; DiLillo & Damashek, 2003; Ehrensaft et al., 2003; Kim, Trickett, & Putnam, 2010). Women in these circumstances are at greater risk of perpetrating neglect or abuse toward their own children if adequate intervening protections - such as community or family support and financial resources - are not made available (Levendosky & Graham-Bermann, 2001).
By expanding our understanding of the indirect effects of childhood sexual abuse in areas such as substance abuse, mental health, homelessness and domestic violence, we can become more informed of the stressors that affect some women's parenting capacities. Knowledge about childhood sexual abuse survivors' parenting styles and relationships with their children can also illuminate avenues for intervention to help mothers cope with parenting difficulties. Service responses to current behaviours, such as substance misuse, and its impacts on parenting can also be placed in a broader historical context, potentially disrupting the intergenerational ripple effects that may emanate from maternal experiences of childhood sexual abuse.
The following subsections examine some of the significant domains in which the negative outcomes of childhood sexual abuse are understood in research. By providing a background to the complex issues faced by some survivors of childhood sexual abuse, a broader context can then be employed in understanding the effects of such abuse on parenting abilities.
Poor mental health
A large body of literature has linked survivors of childhood sexual abuse with poor long-term mental health outcomes (AIHW, 2007; Banyard et al., 2003; Berlin et al., 2011; Bromfield et al., 2010; Cannon et al., 2010; Chiang, 2009; ChildSafety, 2008; Classen et al., 2002; Covington, 2008; DiLillo & Damashek, 2003; Ehrensaft et al., 2003; Haskell & Randall, 2009; Higgins & McCabe, 2000; Humphreys, 2007; Keel, 2005; Kim, Trickett, & Putnam, 2010; KPMG, 2009; Lamont, 2010; Macy et al., 2010). For example, adult women with childhood sexual abuse histories have been found to have a higher risk of mental health problems such as depression, anxiety, substance abuse and self-harm when compared to community populations, a point discussed further in this paper (Cutajar et al., 2010; Henderson & Bateman, 2010; Horvarth, 2010; Mullen & Fleming, 1998). Many women who seek mental health treatment report histories of long-term emotional, physical and sexual abuse (Australian Social Inclusion Board [ASIB], 2011; Haskell & Randall, 2009).
In Australia, childhood sexual abuse is responsible for nearly 1% of the total burden of disease3 and injury among women (AIHW, 2007). Of the 14 major risk factors examined by the AIHW researchers, childhood sexual abuse was found to be the second leading cause of disease in females under the age of 45; that is, within the age parameters of childbearing. Anxiety, depression, suicide, self-harm and substance abuse accounted for 94% of this burden (AIHW, 2007). In a study of Australian mothers that examined the intergenerational transmission of childhood sexual abuse and the effects on parenting abilities, Oates et al. (1998) found a higher incidence of mental health problems among mothers with histories of childhood sexual abuse, compared to those in the control group.
Impacts on parenting
Evidence suggests that maternal experiences of childhood sexual abuse and mental health issues are indirectly linked to parenting outcomes. For example, Schuetze and Das Eiden (2005) and Banyard et al. (2003) found that women with a history of childhood sexual abuse are more likely to experience depression, which in turn affects parenting, including maternal attitudes toward their parenting ability and the use of punitive discipline strategies (AIHW, 2009a; Banyard et al., 2003; DiLillo & Damashek, 2003; Goodman, Fels, & Glenn, 2006; Kim et al., 2010). Based on a qualitative analysis of mothers with identified histories of childhood sexual abuse, Cross (2001) found that these mothers had the parenting deficits of having inappropriate developmental expectations for their children, role-reversal relationships (i.e., with the child assuming the parenting role) and difficulty balancing discipline and affection (see also Banyard et al., 2003; DiLillo & Damashek, 2003; Kim et al., 2010). However, these authors also found that mothers with mental health issues and a history of childhood sexual abuse did not have more significant parenting deficits than mothers with mental health issues and no history of childhood sexual abuse. This suggests that women with poor mental health may experience parenting problems, and childhood sexual abuse can be understood as an additional significant contributor to mental health issues that, in turn, lead to poor parenting outcomes.
Intimate partner violence
Studies show an association between childhood abuse and adverse relationship outcomes in adulthood for women, including intimate partner violence (Banyard & Williams, 1996; Berlin et al., 2011; Cannon et al., 2010; Coid et al., 2001; DiLillo & Damashek, 2003; DiLillo et al., 2001; Ehrensaft et al., 2003; Higgins & McCabe, 2000; Johnson, 2004). Experiences of childhood sexual abuse in particular, are found to substantially increase the risk of re-victimisation in adulthood, with women who have experienced multiple forms of childhood abuse being most at risk (Banyard & Williams, 1996; Browne & Bassuk, 1997; Cannon et al., 2010; Classen et al., 2002; Coid et al., 2001; DiLillo & Damashek, 2003; DiLillo et al., 2001). Studies have consistently showed that, compared to participants who have not experienced abuse as children, women with histories of childhood sexual abuse are three times more likely to experience incidents of intimate partner violence, including physical assault and rape (Cannon et al., 2010; Coid et al., 2001; DiLillo et al., 2001; McCloskey & Bailey, 2000; Trask, Walsh, & DiLillo, 2011).
Some studies indicate that exposure to multiple incidents of child abuse and intimate partner violence as a child are factors that account for the use of physical discipline and neglect in parenting in adulthood (Banyard et al., 2003; Cross, 2001; DiLillo & Damashek, 2003; Kim et al., 2010). While studies have shown that, on its own, a history of childhood sexual abuse does not relate directly to negative parenting outcomes, it is understood to be a factor that compounds re-victimisation, which can effect parenting styles and use of discipline (Banyard et al., 2003; Carolan et al., 2010; Levendosky & Graham-Bermann, 2001).
Impacts on parenting
Understanding a woman's history of childhood sexual abuse and her adult experience of intimate partner violence can provide some insight into how her parenting style may emerge. Traumatic experiences in both childhood and adulthood are related to having difficulties in parenting (Banyard et al., 2003; FaHCSIA, 2008; Radford & Hester, 2006; Renner & Shook Slack, 2006). Renner and Slack's study of 1,005 women found that exposure to childhood sexual abuse is one form of childhood violence that is highly predictive of women experiencing intimate partner violence in adulthood.
The continuing impact of violence may undermine the attachment between a mother and her child (FaHCSIA, 2008; Perry, 2001). Excessive physical discipline of children may also be a reflection of a mother's diminished capacity and ability to cope with parenting stressors due to her own compounding trauma (Banyard & Williams, 1996; Banyard et al., 2003; Bromfield et al., 2010; DiLillo & Damashek, 2003; DiLillo et al., 2001).
It is often at this intersection that child protection authorities, police and the courts intervene in the mother-child relationship. Maternal capacities are examined, judgements made and parenting rights removed. Little attention is given to the seemingly insurmountable challenge required by these women to not only change who they are under a blanket of complex trauma, but to do this while meeting the expectations of systems that create formidable institutional barriers (Carolan et al., 2010).
Studies focusing on women's pathways to substance abuse, find that many of them have histories of childhood sexual, physical and emotional abuse (Covington, 2008; Messman-Moore & Long, 2002; Ouimette, Kimerling, Shaw, & Moos, 2000; Simpson & Miller, 2002; Ullman, Najdowski, & Filipas, 2009). Furthermore, women with childhood sexual abuse histories are more likely to be diagnosed with substance abuse issues than their non-abused counterparts, which has in turn been found to lead to an increased risk of re-victimisation (Covington, 2008; Johnson, 2004; Ouimette et al., 2000; Simpson & Miller, 2002). These studies indicate historically that substance-addicted women report a greater incidence of sexual, physical and emotional abuse by more perpetrators, more frequently and for longer periods of time than their non-addicted counterparts. For example, Polusny and Follette (1995) found that in community samples, lifetime diagnoses of substance use disorders ranged from 14% to 31% for women with childhood sexual abuse histories, compared with 3% to 12% for women who had no reported experience of childhood sexual abuse. In clinical samples, the rates of lifetime substance use diagnoses among sexual abuse survivors ranged from 21% to 57%, compared with a range of 2% to 27% for women without such histories.
In Australia, Cutajar et al. (2010) investigated the rate and risk of suicide and accidental fatal drug overdose in more than 2,000 individuals - up to 44 years after experiencing childhood sexual abuse. They found females with a history of childhood sexual abuse were shown to have 88 times higher risk of accidental fatal overdose and 40 times higher risk of suicide.4
Simpson and Miller (2002) conducted a systematic review of studies that examined rates of childhood sexual abuse or childhood physical abuse among females with substance abuse problems. Across the studies they found women and girls with substance abuse issues were nearly two times more likely to have a history of childhood sexual abuse relative to the general population.
Women and girls with childhood sexual abuse histories are typically found to have elevated rates of substance use problems, regardless of whether they are sampled from populations of mental health treatment seekers, medical clinic attendees, or general community members.5
Impacts on parenting
Substance abuse by parents has been identified as one of the key risk factors for child abuse and neglect. As mothers are most commonly the primary caregiver of their children, intoxication and withdrawal may diminish their capacity to respond to a child's emotional, physical and social needs, leading to abuse and neglect. Mood swings and inconsistent parenting styles may emerge for mothers with substance abuse issues, which may result in controlling and punitive parenting, or permissive and neglectful parenting (Bromfield et al., 2010). Substance abuse can also lead to role-reversal in the mother-child relationship, with children taking on duties such as caring for siblings and meal preparation (Bromfield et al., 2010; Jeffreys, Hirte, Rogers, & Wilson, 2009).
Homeless women often report multiple experiences of violent victimisation at the hands of multiple perpetrators, beginning in childhood and extending into adulthood (Morrison, 2009). Domestic and family violence has been identified as being the largest single cause of homelessness in Australia (FaHCSIA, 2008), placing women and their children at significant risk of housing instability. Two in every three women accessing homelessness services across Australia are accompanied by children and cite breakdowns in interpersonal relationships as the primary reason for seeking support (AIHW, 2009a).
US and Canadian research has shown that 43% of homeless women reported a history of childhood sexual abuse (Browne & Bassuk, 1997; Dunlap, Brazeau, Stermac, & Addison, 2004). The Australian study, The Secret Life of Us (Graham, 2005), examined the reasons for homelessness among 156 girls aged 13-18 years, and found that for 18% of this cohort, childhood sexual abuse was one of the underlying reasons why these girls left home.
Impacts on parenting
Research indicates that when a history of childhood sexual abuse co-occurs with mental health issues, intimate partner violence, substance abuse and homelessness, the costs to individuals and the community are multiplied (ASIB, 2011; Hayes, Gray, & Edwards, 2008; KPMG, 2009). Among the homeless population, complex issues - such as those associated with mental health, intimate partner violence and substance abuse - are commonly found to occur (AIHW, 2009a).
When the issue of homelessness compounds with the other potential harms associated with a maternal history of childhood sexual abuse, a mother's ability to protect her children can be undermined. The volatility and chaos of homelessness means that it is virtually impossible to maintain consistently effective parenting practices (Paquette & Bassuk, 2009). Exposure to homelessness can lead to the removal of children through statutory intervention, largely due to the issues of neglect, which are often associated with poor mental health or substance abuse. The removal of children, while often cited as being in the best interest of the child, often further compounds the trauma, loss and distress of these mothers.
Once a woman enters supported accommodation, there is a tacit acknowledgement that all other avenues for support have been exhausted. In their struggle to exit homelessness, these women must navigate complex service systems. Mothers who parent in this environment are often stigmatised and heavily scrutinised, especially if child statutory agencies are involved, adding to the weight of stressors affecting their families (Paquette & Bassuk, 2009).
3 The burden of disease is the impact of a health problem on a society beyond the immediate cost of treatment - measured by financial cost, mortality, morbidity or other indicators.
4 In terms of mechanism or manner of suicide in the childhood sexual abuse cohort, women died as a result of carbon monoxide poisoning (3), hanging (1), decapitation (1) and drug overdose (1) (Cutajar et al., 2010)
5 This holds true despite the studies reviewed varying widely in methodology and sophistication; that is, the findings across studies appear to be generally robust, despite methodological differences.