Treating child abuse-related posttraumatic stress and comorbid substance abuse in adolescents

OBJECTIVE: Child abuse is a risk factor for developing Posttraumatic Stress Disorder (PTSD) and subsequent Substance Use Disorder (SUD). The purpose of this review is to summarize current knowledge about effective treatments for adolescent abuse-related PTSD, SUD, and the co-occurrence of these conditions.METHOD: The literature on empirical treatment studies for these conditions in adolescence was reviewed, summarized, and synthesized.RESULTS: Randomized controlled studies of abuse-related PTSD and SUD in adolescents have supported the efficacy of cognitive behaviorally-based individual and family treatment components. Components overlap considerably in empirically supported treatments for each disorder. An integrated treatment approach is described for use in adolescents with abuse-related PTSD and SUD, with recommendations for optimizing services for this population and for future research.CONCLUSIONS: The available evidence on effective treatments suggests that integrated PTSD- and SUD-focused cognitive-behavioral and family treatment for adolescents with comorbid abuse-related PTSD and SUD may optimize outcomes for this population.     

Borderline personality features and emotion regulation deficits are associated with child physical abuse potential

The present study extends prior research examining the association between borderline personality disorder (BPD) features and child physical abuse (CPA) risk. We hypothesized that: (1) high CPA risk parents (compared to low CPA risk parents) would more often report clinically elevated levels of BPD features; (2) high CPA risk parents with elevated BPD features would represent a particularly high-risk subgroup; and (3) the association between elevated BPD features and CPA risk would be partially explained by emotion regulation difficulties. General population parents (N = 106; 41.5% fathers) completed self-report measures of BPD features, CPA risk, and emotion regulation difficulties. Results support the prediction that BPD features are more prevalent among high (compared to low) CPA risk parents. Among the parents classified as high CPA risk (n = 45), one out of three (33.3%) had elevated BPD features. In contrast, none of the 61 low CPA risk parents reported elevated BPD symptoms. Moreover, 100% of the parents with elevated BPD features (n = 15) were classified as high-risk for CPA. As expected, high CPA risk parents with elevated BPD features (compared to high CPA risk parents with low BPD features) obtained significantly higher scores on several Child Abuse Potential Inventory scales, including the overall abuse scale (d = 1.03). As predicted, emotion regulation difficulties partially explained the association between BPD features and CPA risk. Findings from the present study suggest that a subset of high CPA risk parents in the general population possess clinically significant levels of BPD symptoms and these parents represent an especially high-risk subgroup. Interventions designed to address BPD symptoms, including emotion regulation difficulties, appear to be warranted in these cases.     

Understanding child protection decisions involving parents with mental illness and substance abuse

Among children investigated for maltreatment, those with parents experiencing mental illness or substance abuse are more likely to be placed out-of-home; however, little is known about why these children are at greater risk. Using a sample of 2488 Structured Decision Making^® assessments administered in San Francisco county from 2011 to 2015, we identified a profile of safety threats that accounts for why workers are more likely to determine children of parents with mental illness and/or substance abuse unsafe in the home. Eight percent of assessments in our sample involved parents with current mental illness only and 10% had comorbid substance abuse. The odds of an unsafe determination more than doubled among parents with mental illness (OR = 2.52, p < 0.001) and were nearly tenfold higher among parents with comorbid substance abuse (OR = 9.62, p < 0.001). Three safety threats accounted for all of the effect of parental mental illness on safety determination: caretaking impairment due to emotional stability/developmental status/cognitive deficiency (57%), failure to meet a child’s immediate needs (30%), and threats of harm (14%). Three safety threats accounted for 55% of the effect of comorbid mental illness and substance abuse on safety determination: failure to meet a child’s immediate needs (21%), presence of a drug-exposed infant (21%), and caretaking impairment due to emotional stability/developmental status/cognitive deficiency (14%). Results suggest that sustained linkage to effective mental health services and material resources at the outset of a child welfare case may help to promote faster and more likely reunification, and prevent future maltreatment.     

Prevalence and risk factors of child maltreatment among migrant families in China

Although cases of child abuse among migrant families are often reported by social media, the issue of child maltreatment among migrant families in China has received little empirical attention. This study investigated both the prevalence of child maltreatment by parents among migrant families, and the individual, family and community-level risk factors associated with child abuse in this context. A survey was conducted with 667 migrant and 496 local adolescents in Shenzhen, South China, with a stratified two-stage cluster sampling design. Logistic regression analysis was conducted to compare the prevalence of maltreatment between migrant and local adolescents, and also to explore risk factors associated with the psychological and physical maltreatment in both groups. The results showed that parent-to-child abuse was more prevalent among migrant than local adolescents, with migrant adolescents 1.490 and 1.425 times more likely to be psychologically and physically abused by their parents than their local counterparts. Low academic performance, delinquent behavior, family economic adversity and low parent attachment put migrant adolescents at increased risk of both psychological and physical maltreatment, and neighborhood disorganization was significantly related to psychological aggression among migrant adolescents. The findings confirm that child abuse perpetuated by parents is a serious problem in Mainland China, especially among migrant families, and implications for policy and practice are discussed.     

Analog of parental empathy: Association with physical child abuse risk and punishment intentions

Objectives

Current research has been inconsistent in corroborating that parents’ compromised empathy is associated with elevated physical child abuse risk, perhaps in part because of an emphasis on dispositional empathy rather than empathy directed at their own children. Research has also relied on self-reports of empathy that are susceptible to participant misrepresentation. The present study utilized an analog task of parental empathy to investigate the association of parental empathy toward one's own child with physical child abuse potential and with their tendency to punish perceived child misbehavior.

Methods

A sample of 135 mothers and their 4–9 year old children were recruited, with mothers estimating their children's emotional reactions using a behavioral simulation of parental empathy. Mothers also provided self-reports on two measures of child abuse potential, a measure of negative attributions and expected punishment of children using vignettes, as well as a traditional measure of dispositional empathic concern and perspective-taking.

Results

Findings suggest that parental demonstration of poorer empathic ability on the analog task was significantly related to increased physical abuse potential, likelihood to punish, and negative child attributions. However, self-reported dispositional empathy exhibited the pattern of inconsistent associations previously observed in the literature.

Conclusions

Parental empathy appears to be a relevant target for prevention and intervention programs. Future research should also consider similar analog approaches to investigate such constructs to better uncover the factors that elevate abuse risk.     

Children with burns referred for child abuse evaluation: Burn characteristics and co-existent injuries

Intentional burns represent a serious form of physical abuse that must be identified to protect children from further harm. This study is a retrospectively planned secondary analysis of the Examining Siblings To Recognize Abuse (ExSTRA) network data. Our objective was to describe the characteristics of burns injuries in children referred to Child Abuse Pediatricians (CAPs) in relation to the perceived likelihood of abuse. We furthermore compare the extent of diagnostic investigations undertaken in children referred to CAPs for burn injuries with those referred for other reasons. Within this dataset, 7% (215/2890) of children had burns. Children with burns were older than children with other injuries (median age 20 months vs. 10 months). Physical abuse was perceived as likely in 40.9% (88) and unlikely in 59.1% (127). Scalds accounted for 52.6% (113) and contact burns for 27.6% (60). Several characteristics of the history and burn injury were associated with a significantly higher perceived likelihood of abuse, including children with reported inflicted injury, absent or inadequate explanation, hot water as agent, immersion scald, a bilateral/symmetric burn pattern, total body surface area ≥10%, full thickness burns, and co-existent injuries. The rates of diagnostic testing were significantly lower in children with burns than other injuries, yet the yield of skeletal survey and hepatic transaminases testing were comparable between the two groups. This would imply that children referred to CAPs for burns warrant the same level of comprehensive investigations as those referred for other reasons.     

Analog assessment of frustration tolerance: Association with self-reported child abuse risk and physiological reactivity

Although frustration has long been implicated in promoting aggression, the potential for poor frustration tolerance to function as a risk factor for physical child abuse risk has received minimal attention. Instead, much of the extant literature has examined the role of anger in physical abuse risk, relying on self-reports of the experience or expression of anger, despite the fact that this methodology is often acknowledged as vulnerable to bias. Therefore, the present investigation examined whether a more implicit, analog assessment of frustration tolerance specifically relevant to parenting would reveal an association with various markers of elevated physical child abuse risk in a series of samples that varied with regard to age, parenting status, and abuse risk. An analog task was designed to evoke parenting-relevant frustration: the task involved completing an unsolvable task while listening to a crying baby or a toddler's temper tantrum; time scores were generated to gauge participants’ persistence in the task when encountering such frustration. Across these studies, low frustration tolerance was associated with increased physical child abuse potential, greater use of parent–child aggression in discipline encounters, dysfunctional disciplinary style, support for physical discipline use and physical discipline escalation, and increased heart rate. Future research directions that could better inform intervention and prevention programs are discussed, including working to clarify the processes underlying frustration intolerance and potential interactive influences that may exacerbate physical child abuse.     

Reported contact with child protection services among those reporting child physical and sexual abuse: results from a community survey

OBJECTIVE: This study uses results from a large community survey to examine the relationship between a history of child maltreatment and self-reports of contact with Child Protection Services (CPS). METHODS: The Ontario Health Supplement was a province-wide, probability-based survey of household dwellings in the province of Ontario, Canada. A random sample of residents aged 15 and older participated in the Ontario Health Supplement (N=9953). A face-to-face interview included a question about contact with Child Protection Services (CPS), and the Child Maltreatment History Self-Report, a self-administered questionnaire, was used to assess history of child physical and sexual abuse. RESULTS: Only a very small percentage of respondents with a history of child abuse reported contact with CPS; 5.1% of those with a history of physical abuse, and 8.7% of those with a history of sexual abuse. Contact with CPS was associated with younger age of respondent for both types of abuse and female gender for physical abuse. In the case of sexual abuse, younger respondents whose parental employment classification was in the lower socioeconomic group were more likely to have contact with CPS. CONCLUSIONS: Interventions that target only those who come in contact with CPS will not reach most persons exposed to child abuse.     

Randomized controlled trial of a parenting program to reduce the risk of child maltreatment in South Africa

Parenting programs in high-income countries have been shown to reduce the risk of child maltreatment. However, there is limited evidence of their effectiveness in low- and middle-income countries. The objective of this study was to examine the initial effects of a parenting program in reducing the risk of child maltreatment in highly-deprived and vulnerable communities in Cape Town, South Africa. Low-income parents (N = 68) with children aged three to eight years were randomly assigned to either a group-based parenting program or a wait-list control group. Observational and parent-report assessments were taken at baseline and at immediate post-test after the intervention was delivered. Primary outcomes were parent-report and observational assessments of harsh parenting, positive parenting, and child behavior problems. Secondary outcomes were parent-report assessments of parental depression, parenting stress, and social support. Results indicated moderate treatment effects for increased frequency of parent-report of positive parenting (d = 0.63) and observational assessments of parent-child play (d = 0.57). Observational assessments also found moderate negative treatment effects for less frequent positive child behavior (d = −0.56). This study is the first randomized controlled trial design to rigorously test the effectiveness of a parenting program on reducing the risk of child maltreatment in sub-Saharan Africa using both observational and self-report assessments. Results provide preliminary evidence of effectiveness of reducing the risk of child maltreatment by improving positive parenting behavior. Further development is required to strengthen program components regarding child behavior management and nonviolent discipline strategies. Future research would benefit from a larger trial with sufficient power to determine program effectiveness.     

Adolescent risk factors for child maltreatment

We investigate adolescent risk factors, measured at both early and late adolescence, for involvement in child maltreatment during adulthood. Comprehensive assessments of risk factors for maltreatment that use representative samples with longitudinal data are scarce and can inform multilevel prevention. We use data from the Rochester Youth Development Study, a longitudinal study begun in 1988 with a sample of 1,000 seventh and eighth graders. Participants have been interviewed 14 times and, at the last assessment (age 31), 80% were retained. Risk factors represent 10 developmental domains: area characteristics, family background/structure, parent stressors, exposure to family violence, parent–child relationships, education, peer relationships, adolescent stressors, antisocial behaviors, and precocious transitions to adulthood. Maltreatment is measured by substantiated reports from Child Protective Services records. Many individual risk factors (20 at early adolescence and 14 at later adolescence) are significantly, albeit moderately, predictive of maltreatment. Several developmental domains stand out, including family background/structure, education, antisocial behaviors, and precocious transitions. In addition, there is a pronounced impact of cumulative risk on the likelihood of maltreatment. For example, only 3% of the youth with no risk domains in their background at early adolescence were involved in later maltreatment, but for those with risk in 9 developmental domains the rate was 45%. Prevention programs targeting youth at high risk for engaging in maltreatment should begin during early adolescence when risk factors are already at play. These programs need to be comprehensive, capable of addressing the multiple and interwoven nature of risk that is associated with maltreatment.     

Delinquency,depression, and substance use disorder among child welfare-involved adolescent females

Although adolescents with delinquency are known to have higher-than-average rates of depression or substance use disorder (SUD), research on the topic is inconsistent. It remains unclear weather depression or SUD leads to delinquency, whether delinquency leads to depression or SUD, or whether there is bi-directionality. Utilizing the National Survey of Child and Adolescent Well-Being (Wave I: 2008–2009; Wave II: 18 months later: N = 5872), we used logistic regression to predict depression from delinquency (and vice versa), and SUD from delinquency (and vice versa). After inclusion of control variables, we found that females with minor theft in Wave I were more than 4 times as likely (adjusted odds ratio [aOR] = 4.34; 95% CI: 1.10–17.16) as females without minor theft to be depressed in Wave II, and those with public disorder in Wave I were almost 3 times as likely (aOR = 2.74; 95% CI: 1.03–7.30) as those without public disorder to have SUD in Wave II. Overall delinquency also predicted depression or SUD, and SUD predicted delinquency. Practitioners could address risk for depression or SUD among child welfare-involved adolescent females by focusing on overall delinquency or on specific types of delinquency (minor theft for depression and public disorder for SUD) and by offering interventions (e.g., cognitive-behavioral psychotherapy) that have been shown to be effective in preventing depression or SUD. In addition, with respect to our finding that SUD predicts delinquency among adolescent females, practitioners can help prevent delinquency by offering interventions (e.g., intensive outpatient treatments) that have well documented effectiveness in addressing SUD.     

Perinatal mental health and risk of child maltreatment: A systematic review and meta-analysis

BackgroundMental health problems in parents have been identified as a risk factor for child maltreatment. The perinatal period (from conception to 1 year) is a critical period but it is unclear whether perinatal mental health problems are also associated with increased risk.ObjectiveTo review evidence on perinatal mental health and risk of child maltreatment.MethodsSearches were conducted on six databases and 24 studies reported in 30 papers identified. Studies were conducted in seven countries, mainly the USA (n = 14). Sample sizes ranged from 48-14,893 and most examined mothers (n = 17). Studies were conducted in community (n = 17) or high-risk (n = 7) samples.ResultsThe majority of studies found a relationship between parental perinatal mental health problems and risk of child maltreatment, but inconsistent findings were observed between and within studies. The few studies that examined fathers (n = 6) all found a relationship between fathers’ mental health and risk of child maltreatment. Meta-analysis of 17 studies (n = 22,042) showed perinatal mental health problems increased risk of child maltreatment by OR 3.04 (95% CI 2.29–4.03). This relationship was moderated by type of sample, with larger effects for risk of child maltreatment in high-risk samples. The relationship was not moderated by type of mental illness, child maltreatment; methodological or measurement factors.ConclusionThe association between perinatal mental health and risk of child maltreatment is similar to that observed at other times during childhood. Methodological heterogeneity and inconsistent findings mean conclusions are tentative and need to be considered alongside other individual, family and social/cultural risk factors.     

Maternal history of child maltreatment and maternal depression risk in the perinatal period: A longitudinal study

Existing research is limited, with only a few studies considering each single type and multiple types of child maltreatment (CM) as well as multiple assessments of maternal depression throughout the perinatal period. The purpose of the study was to assess each type and accumulative types of CM in relation to the risk of maternal depression throughout the perinatal period. In total, 276 pregnant women were recruited from the prenatal clinic at a general hospital in China. Maternal CM history and depression risk were assessed at late pregnancy, postpartum week 1, and postpartum week 4 using the Childhood Trauma Questionnaire (CTQ) and Edinburgh Postnatal Depression Scale (EPDS). The GEE showed that physical and emotional neglect and multiple types of CM were associated with higher overall depression risk across the perinatal period. The multinomial regression models showed physical neglect and multiple types of CM predicted higher risk of both antepartum and postpartum depression. Emotional and sexual abuse and emotional neglect predicted antepartum depression risk, while none of the three types of CM predicted postpartum depression risk. Physical abuse did not predict antepartum and postpartum depression risk. The findings suggest that maternal history of child physical and emotional neglect play significant roles in perinatal depression risk with physical neglect as the most important predictor. Routine screening for maternal CM history and depression risk in prenatal clinics is needed to aid in the early detection and treatment of depression.     

The linkages among childhood maltreatment, adolescent mental health, and self-compassion in child welfare adolescents

Objectives

Childhood maltreatment is a robust risk factor for poor physical and mental health. Child welfare youths represent a high-risk group, given the greater likelihood of severe or multiple types of maltreatment. This study examined the relationship between childhood maltreatment and self-compassion – a concept of positive acceptance of self. While not applied previously to a child welfare sample, self-compassion may be of value in understanding impairment among maltreatment victims. This may be most pertinent in adolescence and young adulthood, when self-identity is a focal developmental process.

Methods

The present sample was drawn from the Maltreatment and Adolescent Pathways (MAP) Longitudinal Study, which followed randomly selected adolescents receiving child protection services across two years within an urban catchment area. Child maltreatment was assessed at baseline using the Childhood Trauma Questionnaire ( [Bernstein et al., 1994] and [Bernstein et al., 2003]). Mental health, substance and alcohol use problems, suicide attempt, and self-compassion were assessed at the two-year follow-up point. There were 117 youths, aged 16–20 years (45.3% males) who completed the self-compassion scale (Neff, 2003). Bivariate correlations were computed between adolescent self-compassion and each form of self-reported maltreatment (physical abuse, sexual abuse, emotional abuse, emotional neglect, and physical neglect). Finally, hierarchical, stepwise regression was used to examine unique contributions of child maltreatment subtypes in predicting adolescent self-compassion, as well as maltreatment-related impairment.

Results

Higher childhood emotional abuse, emotional neglect, and physical abuse were associated with lower self-compassion. Controlling for age and gender, emotional abuse was significantly associated with reduced self-compassion, even when the effects of emotional neglect and physical abuse were taken into account. Youths with low self-compassion were more likely to have psychological distress, problem alcohol use, and report a serious suicide attempt, as compared with those with high self-compassion. A number of maltreatment-related areas of impairment, identified by screening instruments, were significantly associated with lower self-compassion.

Conclusion

Self-compassion may be a fruitful aspect of research to pursue in an effort to better understand the impact of childhood emotional abuse on adolescent functioning, particularly considering the under-researched group of those receiving child protective services.     

From mother to child: Maternal betrayal trauma and risk for maltreatment and psychopathology in the next generation

The objective of this study was to investigate whether experiences of high betrayal trauma (BT; maltreatment by a parent/caregiver) during mothers' own childhoods may influence the intergenerational transmission of maltreatment and its associated psychopathology from mothers to their children. A prospective, longitudinal design was utilized to assess maternal physical and sexual betrayal trauma in relation to children’s own maltreatment experiences, and child mood and behavioral symptoms during pre-adolescence. Data from 706 mothers and children who participated in the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) was analyzed, including: mothers’ physical and sexual maltreatment histories, child protective services’ documented physical and sexual maltreatment during children’s first twelve years of life, and mother- and child-reports of child internalizing and externalizing symptoms at age 12. Children of mothers who survived high BT (maltreatment by a caregiver) were 4.52 times more likely to experience maltreatment than children of no BT mothers (mothers whom were not maltreated), and 1.58 times more likely than children whose mothers survived low BT (maltreatment by a non-caregiver). Higher levels of maternal physical BT significantly predicted more internalizing and externalizing symptoms in children at age 12, according to both mother (CBCL) and child (YSR) reports. More incidents of child physical maltreatment partially mediated associations between maternal physical BT and child symptoms. Incidents of sexual maltreatment also partially mediated associations between maternal sexual BT and child internalizing and externalizing symptoms (CBCL only). These findings have implications for understanding the role of betrayal trauma in perpetuating the cycle of maltreatment across generations.     

Vulnerability or resilience to early substance use among adolescents at risk: The roles of maltreatment and father involvement

Although research has indicated that maltreated children are at higher risk of adolescent substance use, it remains unclear whether the type and timing of maltreatment affect the likelihood of adolescent substance use. Research has also found father involvement to be a potential protective factor against adolescent substance use, but the role of quality vs. quantity of father involvement as well as gender differences in the effects of father involvement on substance use among at-risk adolescents have not been studied. The current study adds value to the existing literature by filling these gaps in knowledge. We conducted a secondary data analysis with a sample of 685 at-risk adolescents drawn from the Longitudinal Studies of Child Abuse and Neglect. The study found a connection between early childhood (birth to 5) physical abuse and adolescent substance use, but not for later childhood physical abuse or other forms of child maltreatment. The quality of father involvement was found to be a protective factor, regardless of child gender; quantity of father involvement was not significant. Based on these findings, development of intervention strategies focusing on prevention of early childhood physical abuse and promoting positive father-child relationships are important prevention strategies for adolescent substance use. Additionally, professionals working with at-risk adolescents need to be cognizant of the implications of early childhood physical abuse and act accordingly to mitigate the increased potential for adolescent substance use.