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Questions Does a history of childhood abuse and neglect increase risk of depressive disorders and suicidal behaviour in adolescents or young adults? Does this risk differ by type of maltreatment (ie, physical abuse, sexual abuse, or neglect)?
Population based cohort study beginning in 1975, with follow up in 1992.
2 counties in upstate New York, USA.
639 youths (52% men) who were >18 years of age for whom information about child maltreatment was available from state records.
Assessment of risk factors
Data on child maltreatment were obtained from the New York State Central Registry for Child Abuse and Neglect and from retrospective self reports during the 1992 follow up. Data were also collected on the following contextual factors: sex, ethnicity, IQ, difficult childhood temperament, low maternal education, low maternal self esteem, maternal alienation, anger, dissatisfaction, external locus of control, sociopathy, serious maternal illness, low maternal and paternal involvement, low parental warmth, low religious participation, teenage mother when youth was born, single parenthood, welfare support, low family income, large family size, and poor marital quality.
Main outcome measures
Depressive disorders, assessed using the National Institute of Mental Health Diagnostic Interview Schedule for Children with algorithms for DSM-III-R diagnoses, and self reported suicide attempts.
81 cases of child abuse and neglect were identified; 24 children (30%) had >1 type of maltreatment. After adjustment for contextual factors, participants who had a history of maltreatment had an increased risk of major depressive disorder (OR 3.00, CI 1.43 to 6.33), dysthymia (OR 4.83, CI 1.89 to 12.44), and suicide attempts (OR 3.29, CI 1.94 to 16.74) compared with participants who had no history of maltreatment. Adolescents had an increased risk of repeated suicide attempts (OR 30.29, CI 1.70 to 539.80). Participants who were sexually abused had the highest risk of major depressive disorder (OR 3.17, CI 1.04 to 9.56), dysthymia (OR 9.74, CI 2.79 to 34.27), suicide attempts (OR 5.71, CI 1.94 to 16.74), and repeated suicide attempts (OR 8.40, CI 1.86 to 38.06). Participants who were physically abused had an increased risk of depression during adulthood (OR 3.83, CI 1.38 to 10.58) and repeated suicide attempts during adolescence (OR 10.74, CI 1.06 to 108.72). Childhood neglect alone was not associated with depressive disorders or suicidal behaviour.
History of childhood maltreatment increased the risk of depressive disorders and suicidal behaviour in adolescents and young adults, independent of contextual factors associated with maltreatment. Children who were sexually abused had higher risks of depressive disorders than those who were physically abused or neglected.
A variety of adolescent and adult outcomes have been linked to childhood physical or sexual abuse or neglect. This study is unique in that it investigates the effects of childhood maltreatment beyond the contextual factors that often accompany abuse, neglect, and depression and suicidality. Other work has concentrated on only one type of abuse. In this study, the authors examined all 3 types of childhood maltreatment: neglect, physical abuse, and sexual abuse.
The participants were from 2 New York counties, so the extent of generalisability of the results to other populations is unknown. The authors stated that some participants (n=24) reported both physical abuse and neglect. They did not indicate the criteria used to classify them into types of abuse. This could have influenced the results, in that increased numbers of neglected children classified as abused might have reduced the independent effects of abuse. Conversely, if increased numbers of abused children were classified as neglected, this could have increased the independent effect of neglect. These authors have done a much better job than most in separating out abuse types. As the authors point out, there are limitations to self reported data because depressed participants may recall abuse and neglect more readily. The use of official records where possible is a strength of this study.
This study contributes 4 important findings: adolescents or adults who were abused as children were 3–4 times more likely to become depressed or suicidal; some relations between childhood maltreatment and depression and suicidal behaviour may be explained by adverse contextual factors related to family environment and parent and child characteristics; sexual abuse was associated with the greatest risk of depression and suicide; and sexually abused adolescents were prone to repeated suicide attempts. This work is relevant to nurses working in a variety of settings, including public health, mental health, and primary care. Because the effects of neglect could not be separated from those of contextual factors, it is possible that changing contextual factors could alter negative outcomes resulting from neglect. This study also clarifies the importance of dealing with both the abuse and the contextual factors to enhance positive outcomes. This is an important consideration for practitioners in that it means that assessment of depressed adolescents and adults should include a history of all types of childhood abuse. Because adolescents seem most vulnerable to repeated suicide attempts, providing ongoing support and monitoring their status over time is important.
Source of funding: National Institute of Mental Health.
For correspondence: Dr J Brown, Department of Pediatrics, Child Advocacy Center, Vanderbilt Clinic VC4-402, 622 West 168th Street, New York, NY 10032, USA. Fax +1 212 305 9742.
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