Effects of child abuse and neglect for adult survivors
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Experiencing abuse and neglect in childhood can lead to adverse outcomes in adulthood. The purpose of this resource is to indicate the potential long-term effects of child abuse and neglect that may extend into adulthood.
Types of abuse and neglect
Child abuse and neglect refers to any behaviour by parents, caregivers, other adults or older adolescents that is outside the norms of conduct and entails a substantial risk of causing physical or emotional harm to a child or young person. Such behaviours may be intentional or unintentional and can include acts of omission (i.e., neglect) and commission (i.e., abuse) (Bromfield, 2005; Christoffel et al., 1992; Gilbert et al., 2009). The five main subtypes of child abuse and neglect are physical abuse, emotional maltreatment, neglect, sexual abuse and witnessing family violence.
For more information on the definitions of child abuse and neglect see What is Child Abuse and Neglect?
Factors affecting the consequences of abuse and neglect
The consequences of experiencing child abuse and neglect will vary considerably. For some adults, the effects of child abuse and neglect are chronic and debilitating, other adults have less adverse outcomes, despite their histories (Miller-Perrin & Perrin, 2007). Critical factors that may influence the way child abuse and neglect affects adults include the frequency and duration of maltreatment and if more than one type of maltreatment has occurred.
Chronic maltreatment defined as "recurrent incidents of maltreatment over a prolonged period of time" (Bromfield & Higgins, 2005, p. 39) has been linked to worse outcomes than transitory or isolated incidents of maltreatment (e.g., Ethier, Lemelin, & Lacharite, 2004; Graham et al., 2010; Johnson-Reid, Kohl, & Drake, 2012).
Research suggests that maltreatment types are interrelated, that is, a large proportion of adults who experience childhood abuse or neglect are exposed to more than one type of abuse (known as multi-type maltreatment). Further to this, other forms of victimisation (known as poly-victimisation) such as bullying or assault by a peer have often been found to co-occur with child maltreatment (Finkelhor, Ormrod, & Turner, 2007). Research indicates that those who experience multi-type maltreatment and/or poly-victimisation are more likely to experience high levels of trauma symptoms and worse outcomes as adults than those who are exposed to no maltreatment or only one type (Finkelhor et al., 2007; Higgins & McCabe, 2001; Richmond, Elliot, Pierce, Aspelmeier, & Alexander, 2009).
In attempting to explain some of the adverse outcomes associated with chronic and multi-type maltreatment a concept that is often employed is complex trauma. Complex trauma reflects the multiple and interacting symptoms, disorders and multiple adverse experiences and the broad range of cognitive, affective and behavioural outcomes associated with prolonged trauma, particularly if occurring early in life and involving an interpersonal element (e.g., sexual abuse; Price-Robertson, Rush, Wall, & Higgins, 2013).
For further details on the chronic maltreatment, the interrelatedness of sub-types child abuse and neglect, and complex trauma, see Rarely an Isolated Incident: Acknowledging the Interrelatedness of Child Maltreatment, Victimisation and Trauma (Price-Robertson et al., 2013).
Other factors that may affect the consequences of child abuse and neglect on adult survivors include:
- the age and developmental stage at which maltreatment occurred: some evidence suggests that the younger the child was at the time of the onset of the maltreatment, the more likely they are to experience problems later in life;
- the severity of maltreatment: the greater the severity of abuse or neglect, the higher the likelihood of negative outcomes;
- the type/s of abuse and/or neglect: different sub-types of maltreatment may be related to different negative outcomes;
- the victim/survivor's perceptions of the abuse: worse outcomes are likely if there is the victim/survivor experiences feelings of self-blame, shame or stigmatisation;
- the relationship the victim/survivor had (or has) with the perpetrator: for example, in child sexual abuse increased negative affects tend to be associated with the perpetrator being a father, father-figure or someone with whom the child has an intense, emotional relationship;
- whether the abuse or neglect was detected and action taken to assure the safety of the child (e.g., child protection intervention);
- positive or protective factors that may have mitigated the effects of maltreatment (e.g., family support, perpetrator readiness for change); and
- whether victims/survivors received therapeutic services to assist them in recovery (Bromfield & Higgins, 2005; Miller-Perrin & Perrin, 2007; Price-Robertson et al., 2013).
Long-term consequences of child abuse and neglect
The remainder of this paper explores the major negative physical, cognitive, psychological, behavioural and social consequences of child abuse and neglect that extend into adulthood. The research reviewed included high quality literature reviews/meta-analyses and primary research in English speaking countries. The negative consequences associated with past histories of abuse and neglect are often interrelated, as one adverse outcome may lead to another (e.g., substance abuse problems or engaging in risky sexual behaviour may lead to physical health problems). Adverse consequences are broadly linked to all abuse types, however, where appropriate, associations are made between specific types of abuse and neglect and specific negative outcomes.
Adverse outcomes of abuse and neglect often emerge in childhood and adolescence and may continue in adults with histories of abuse and neglect (Miller-Perrin & Perrin, 2007). For a more detailed discussion of the impact of child abuse and neglect on children see, The Effects of Child Abuse and Neglect for Children and Adolescents.
Intergenerational transmission of abuse and neglect
Although most survivors of child maltreatment do not go on to maltreat their own children, some evidence suggests that adults who were abused or neglected as children are at increased risk of intergenerational abuse or neglect compared to those who were not maltreated as children (Kwong, Bartholomew, Henderson, & Trinke, 2003; Mouzos & Makkai, 2004; Pears & Capaldi, 2001). In a study by Pears and Capaldi (2001), parents who had experienced physical abuse in childhood were significantly more likely to engage in abusive behaviours toward their own children or children in their care. Oliver (1993), in a review of the research literature, concluded that an estimated one-third of children who are subjected to child abuse and neglect go on to repeat patterns of abusive parenting towards their own children. Although this is a significant number, it is also important to note that Oliver's estimations indicate that a majority of maltreated children do not go on to maltreat their own children. Kwong and colleagues (2003) determined that growing up in abusive family environments can teach children that the use of violence and aggression is a viable means for dealing with interpersonal conflict, which can increase the likelihood that the cycle of violence will continue when they reach adulthood.
Research suggests that adults, particularly women, who were victimised as children are at risk of re-victimisation in later life (Cannon, Bonomi, Anderson, Rivara, & Thompson 2010; Mouzos & Makkai, 2004; Whiting, Simmons, Havens, Smith, & Oka, 2009; Widom, Czaja, & Dutton, 2008). Findings from the Australian component of the International Violence Against Women Survey (IVAWS) indicated that 72% of women who experienced either physical or sexual abuse as a child also experienced violence in adulthood, compared to 43% of women who did not experience childhood abuse (Mouzos & Makkai, 2004). Further to this, a review of approximately 90 sexual victimisation studies found that over 30 studies had reported a link between child sexual assault and sexual re-victimisation in adulthood (Classen, Gronskaya Palesh, & Aggarwal, 2005). In a prospective study by Widom and colleagues (2008), all types of childhood victimisation (physical abuse, sexual abuse and neglect) measured were associated with increased risk of lifetime re-victimisation. Findings indicated that childhood victimisation increased the risk for physical and sexual assault/abuse, kidnapping/stalking, and having a family friend murdered or commit suicide (Widom et al., 2008). Women who experience childhood violence or who have witnessed parental violence could be at risk of being victimised as adults as they are more likely to have low self-esteem and they may have learnt that violent behaviour is a normal response to dealing with conflict (Mouzos & Makkai, 2004).
Physical health problems
Adults with a history of child abuse and neglect are more likely than the general population to experience physical health problems including diabetes, gastrointestinal problems, arthritis, headaches, gynaecological problems, stroke, hepatitis and heart disease (Felitti et al., 1998; Sachs-Ericsson, Cromer, Hernandez, & Kendall-Tackett, 2009; Springer, Sheridan, Kuo, & Carnes, 2007). In a review of recent literature, Sachs-Ericsson et al. (2009) found that a majority of studies showed that adult survivors of childhood abuse had more medical problems than non-abused counterparts. Further to this, a US meta-analysis of 78 total effect sizes from 24 studies found that child maltreatment was related to an increased risk of neurological, musculoskeletal, respiratory, cardiovascular and gastrointestinal problems but contrary to some other studies, not gynaecological problems (Wegman & Stetler, 2009). Using survey data from over 2,000 middle-aged adults in a longitudinal study in the United States, Springer et al. (2007) found that child physical abuse predicted severe ill health and several medical diagnoses, including heart and liver troubles and high blood pressure. Finally, in a study of the adult health and relationship outcomes of child abuse and witnessing intimate partner violence that utilised a large random sample of women, researchers reported that those who had experienced child abuse only, intimate partner violence only, and the group exposed to both forms of maltreatment were all more likely to report a range of negative physical and mental health outcomes as well as a higher utilisation of health care services in adulthood than those who were not exposed to either type of abuse (Cannon, Bonomi, Anderson, Rivara, & Thompson, 2010).
It is unclear exactly how maltreatment experiences are related to physical health problems, although it seems likely there are a number of different causal mechanisms and mediating factors. For instance, some researchers suggest that poor health outcomes in adult survivors of child abuse and neglect could be due to the direct effects of physical abuse in childhood, the impact early life stress has on the immune system or to the greater propensity for adult survivors to engage in high-risk behaviours (e.g., smoking, alcohol abuse and risky sexual behaviour) (Sachs-Ericsson et al., 2009; Watts-English, Fortson, Gilber, Hooper, & De Bellis, 2006; Wegman & Stetler, 2009).
Mental health problems
Persisting mental health problems are a common consequence of child abuse and neglect in adults. Mental health problems associated with past histories of child abuse and neglect include personality disorders, post-traumatic stress disorder, dissociative disorders, depression, anxiety disorders and psychosis (Afifi, Boman, Fleisher, & Sareen, 2009; Cannon et al., 2010; Chapman et al., 2004; Clark, Caldwell, Power, & Stansfeld, 2010; Maniglio; 2012; McQueen, Itzin, Kennedy, Sinason, & Maxted, 2009; Norman et al., 2012; Springer et al., 2007). Depression is one of the most commonly occurring consequences of past abuse or neglect (Kendall-Tackett, 2002). In an American representative study based on the National Co-morbidity Survey, adults who had experienced child abuse were two and a half times more likely to have major depression and six times more likely to have post-traumatic stress disorder compared to adults who had not experienced abuse (Afifi et al., 2009). The likelihood of such consequences increased substantially if adults had experienced child abuse along with parental divorce (Afifi et al., 2009).
In a prospective longitudinal study in the United States, Widom, DuMont, and Czaja (2007) found that children who were physically abused or experienced multiple types of abuse were at increased risk of lifetime major depressive disorder in early adulthood. Further to this, a large, nationally representative study in the US reported that those who had experienced child physical abuse were at a higher risk for a range of psychiatric disorders in adulthood than those not reporting such abuse (Sugaya et al., 2012). Disorders included (in descending order of strength of association) attention-deficit hyperactivity disorder, post-traumatic stress disorder, bipolar disorder, panic disorder, drug abuse, nicotine dependence, generalised anxiety disorder, and major depressive disorder. The same study reported that many adults reporting child physical abuse also reported child sexual abuse and neglect and, importantly, the study found a dose-response relationship with those experiencing a higher frequency of abuse at higher risk of psychiatric disorder than those reporting lower frequency of abuse.
Consistent evidence shows associations between child abuse and neglect and risks of attempted suicide in young people and adults (Felitti et al., 1998; Gilbert et al., 2009; Norman et al., 2012). In the Adverse Childhood Experiences (ACE) study in the United states, Felitti et al. (1998) indicated that adults exposed to four or more adverse experiences in childhood were 12 times more likely to have attempted suicide than those who had no adverse experiences in childhood. In a meta-analysis by Gilbert et al. (2009), retrospective studies (which record participants recollections of past traumatic events) showed a strong association between child abuse and neglect and attempted suicide in adults. Prospective studies (which trace participant's experiences of traumatic events over several years) indicated a more moderate relationship (Gilbert et al., 2009). The higher rates of suicidal behaviour in adult survivors of child abuse and neglect has been attributed to the greater likelihood of adult survivors suffering from mental health problems.
Eating disorders and obesity
Eating disorders and obesity are common among adult survivors of child abuse and neglect (Johnson, Cohen, Kasen, & Brook, 2002; Kendall-Tackett, 2002; Rodriguez-Srednicki & Twaite, 2006; Rohde et al., 2008; Thomas, Hypponen, & Power, 2008). Prospective research studies have consistently shown links between child abuse and neglect and obesity in adulthood (Gilbert et al., 2009). Using a large population-based survey, Rohde and colleagues (2008) found that both child sexual abuse and physical abuse were associated with a doubling of the odds of obesity in middle-aged women. In a prospective longitudinal study in the United Kingdom, results indicated that severe forms of childhood adversity, such as physical abuse, witnessing domestic violence and neglect were associated with increased risk of obesity in middle adulthood by 20 to 40% (Thomas et al., 2008). In a community based study, Johnson and colleagues found (2002) that adolescents and young adults with a history of child sexual abuse or neglect were five times more likely to have an eating disorder compared to individuals who did not have a history of abuse. Stress and mental health problems such as depression may increase the likelihood of adults with a history of abuse and neglect becoming obese or having an eating disorder (Rodriguez-Srednicki & Twaite, 2006).
Alcohol and substance abuse
Associations have often been made between childhood abuse and neglect and later substance abuse in adulthood (Gilbert et al., 2009; Simpson & Miller, 2002; Widom, White, Czaja, & Marmorstein, 2007). In a systematic review of 224 studies, a strong relationship was found between child physical and sexual abuse and substance abuse problems in women (Simpson & Miller, 2002). Less of an association was found among men, although men with child sexual abuse histories were found to be at greater risk of substance abuse problems. The authors suggested that it is possible that men are less likely to disclose childhood abuse due to social values and expectations (Simpson & Miller, 2002). A recent meta-analysis of 124 studies of non-sexual child abuse and neglect reported that there was robust evidence of an association between these types of maltreatment and an increased risk of drug use (Norman et al., 2012). In the Adverse Childhood Experiences Study in the United States, adults with four or more adverse experiences in childhood were seven times more likely to consider themselves an alcoholic, five times more likely to have used illicit drugs and ten times more likely to have injected drugs compared to adults with no adverse experiences (Felitti et al., 1998). The higher rates of substance abuse problems among adult survivors of child abuse and neglect may, in part, be due to victims using substances to self-medicate from trauma symptoms such as anxiety, depression and intrusive memories caused by an abusive history (Whiting et al., 2009).
Aggression, violence and criminal behaviour
Violence and criminal behaviour is another frequently identified long-term consequence of child abuse and neglect for adult survivors, particularly for those who have experienced physical abuse or witnessed domestic violence (Gilbert et al., 2009; Kwong et al., 2003; Miller-Perrin & Perrin, 2007). Widom (1989) compared a sample of adults with a history of substantiated cases of child abuse and neglect in the United States with a sample of matched comparisons and found that adults with a history of abuse and neglect had a higher likelihood of arrests, adult criminality, and violent criminal behaviour. In a study of 36 men with a history of perpetrating domestic violence, Bevan and Higgins (2002) found that child maltreatment (particularly child neglect) and low family cohesion were associated with the frequency of physical spouse abuse. Witnessing domestic violence (but not physical abuse) as a child had a unique association with psychological spouse abuse and trauma symptomology. Adults with a history of child physical abuse or witnessing domestic violence may be more likely to be violent and involved in criminal activity as they have learned that such behaviour is an appropriate method for responding to stress or conflict resolution (Chapple, 2003). Substance abuse problems are also associated with higher rates of criminal behaviour (e.g., theft, prostitution) to support addiction (Dawe, Harnett, & Frye 2008).
High-risk sexual behaviour
Adults who have experienced childhood abuse and neglect, particularly child sexual abuse, are more likely to engage in high-risk sexual behaviour. This can lead to a wide range of sexually transmitted diseases or early pregnancy (Cohen et al., 2000; Hillis, Anda, Felitti, Nordenberg, & Marchbanks, 2000; Norman et al., 2012; Steel & Herlitz, 2005; Young, Deardorff, Ozer, & Lahiff, 2011). Using a random population sample in Sweden, Steel and Herlitz (2005) found that a history of child sexual abuse was associated with a greater frequency of unintended pregnancy, younger age at first diagnosis of a sexually transmitted disease, greater likelihood of participation in group sex and a greater likelihood of engaging in prostitution. In a large retrospective study in the United States, the prevalence of sexually transmitted diseases was three and a half times higher for men and women who were exposed to three to five adverse childhood experiences compared to adults who had no adverse childhood experiences (Hillis et al., 2000). Steel and Herlitz (2005) determined that factors that may increase the likelihood of engaging in risky sexual behaviours include: the inability to be assertive and prevent unwanted sexual advances, feeling unworthy, and having competing needs for affection and acceptance. These are all feelings that may occur as a consequence of child abuse and neglect.
Strong associations have been made between histories of child abuse and neglect and experiences of homelessness in adulthood. A study by Herman, Susser, Struening, and Link (1997) found that the combination of lack of care and either physical or sexual abuse during childhood was strongly associated with an elevated risk of adult homelessness. Adults who experienced a combination of a lack of care and either child physical or sexual abuse were 26 times more likely to have been homeless than those with no experiences of abuse. In a study examining whether adverse childhood events were related to negative adult behaviours among homeless adults in the United States, 72% of the sample had experienced one or more adverse childhood events (Tam, Zlotnick, & Robertson, 2003). Higher rates of homelessness among adult survivors of abuse and neglect could be due to difficulties securing employment or experiences of domestic violence. Although evidence associating past histories of child abuse and neglect and unemployment is limited, a small body of research suggests that children and adolescents affected by abuse and neglect risk poor academic achievement at school, which may lead to difficulties finding employment in adulthood (Gilbert et al., 2009). The relationship between homelessness and adult survivors of abuse and neglect may also be connected to other adverse outcomes linked to child abuse and neglect such as substance abuse problems, mental health problems and aggressive and violent behaviour. These consequences may make it difficult to achieve stable housing.
Research investigating the effects of child abuse and neglect in adulthood is extensive. However, in most research studies it is difficult to make casual links between abuse and neglect and adverse consequences due to several limitations. Many research studies are unable to control for other environmental and social factors. This makes it difficult to rule out influences such as socio-economic disadvantage, disability and social isolation when associating abuse and neglect with negative consequences.
Most research studies on adult survivors are based on retrospective reporting of events and are therefore reliant on participants' recollection of events over long periods. This can limit the data in that participants' recollections may have changed over time. Prospective longitudinal studies have the advantage of tracing participants with reported experiences of child abuse or neglect over several years. However prospective studies alone are not completely representative of the population, as a high proportion of child abuse and neglect goes undetected and those experiencing abuse and neglect are less likely to participate or remain in a longitudinal study (Kendall-Tackett & Becker-Blease, 2004). Kendall-Tackett and Becker-Blease (2004) argued that there should be a mix of prospective and retrospective studies as both types of research can provide insight into the long-term consequences of child abuse and neglect.
Other limitations in the research included:
- Studies focused solely on one type of abuse (particularly sexual abuse). Focusing research on only one type of abuse or neglect overlooks the effects of children experiencing chronic and multiple types of abuse and neglect. Without assessing chronicity and the effects of other forms of child abuse and neglect, bias and misleading conclusions are often made on the specific impact of that form of maltreatment (Bromfield, Gillingham, & Higgins, 2007; Higgins & McCabe, 2001).
- Reliance on recruiting participants already involved in clinical services. Only including participants involved in clinical services excludes adult survivors who have not sought clinical services. This can make negative outcomes appear worse than in reality as participants are only those who have presented with a problem.
- Far more studies focused on the effects of child abuse and neglect in women compared to men. Having more research on the effects of child abuse and neglect in women makes it difficult to compare differences between men and women as less is known on the effects of child abuse and neglect on men (Springer et al., 2007; Widom, DuMont et al., 2007).
In spite of the various limitations, research consistently indicates that adults with a history of child abuse and neglect are more likely to experience adverse outcomes.
The effects of child abuse and neglect can lead to a wide range of adverse outcomes in adulthood. Adverse outcomes associated with past histories of child abuse and neglect are often inter-related. Experiencing chronic and multiple forms of maltreatment or victimisation can increase the risk of more severe and damaging adverse consequences in adulthood.
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This paper was prepared by Cathryn Hunter, Senior Research Officer with the Child Family Community Australia information exchange at the Australian Institute of Family Studies.
Previous editions have been compiled by Alister Lamont.