David M. Fergusson

Burden and consequences of child maltreatment in high-income countries.

Child maltreatment remains a major public-health and social-welfare problem in high-income countries. Every year, about 4-16% of children are physically abused and one in ten is neglected or psychologically abused. During childhood, between 5% and 10% of girls and up to 5% of boys are exposed to penetrative sexual abuse, and up to three times this number are exposed to any type of sexual abuse. However, official rates for substantiated child maltreatment indicate less than a tenth of this burden. Exposure to multiple types and repeated episodes of maltreatment is associated with increased risks of severe maltreatment and psychological consequences. Child maltreatment substantially contributes to child mortality and morbidity and has longlasting effects on mental health, drug and alcohol misuse (especially in girls), risky sexual behaviour, obesity, and criminal behaviour, which persist into adulthood. Neglect is at least as damaging as physical or sexual abuse in the long term but has received the least scientific and public attention. The high burden and serious and long-term consequences of child maltreatment warrant increased investment in preventive and therapeutic strategies from early childhood.

Developmental Trajectories of Childhood Disruptive Behaviors and Adolescent Delinquency: A Six-Site, Cross-National Study

This study used data from 6 sites and 3 countries to examine the developmental course of physical aggression in childhood and to analyze its linkage to violent and nonviolent offending outcomes in adolescence. The results indicate that among boys there is continuity in problem behavior from childhood to adolescence and that such continuity is especially acute when early problem behavior takes the form of physical aggression. Chronic physical aggression during the elementary school years specifically increases the risk for continued physical violence as well as other nonviolent forms of delinquency during adolescence. However, this conclusion is reserved primarily for boys, because the results indicate no clear linkage between childhood physical aggression and adolescent offending among female samples despite notable similarities across male and female samples in the developmental course of physical aggression in childhood.

Childhood sexual abuse and psychiatric disorder in young adulthood : II. Psychiatric outcomes of childhood sexual abuse

OBJECTIVE This is the second in a series of articles that describe the prevalence, correlates, and consequences of childhood sexual abuse (CSA) in a birth cohort of more than 1,000 New Zealand children studied to the age of 18 years. This article examines the associations between reports of CSA at age 18 and DSM-IV diagnostic classifications at age 18. METHOD A birth cohort of New Zealand children was studied at annual intervals from birth to age 16 years. At age 18 years retrospective reports of CSA prior to age 16 and concurrently measured psychiatric symptoms were obtained. RESULTS Those reporting CSA had higher rates of major depression, anxiety disorder, conduct disorder, substance use disorder, and suicidal behaviors than those not reporting CSA (p < .002). There were consistent relationships between the extent of CSA and risk of disorder, with those reporting CSA involving intercourse having the highest risk of disorder. These results persisted when findings were adjusted for prospectively measured childhood family and related factors. Similar but less marked relationships between CSA and nonconcurrently measured disorders were found. CONCLUSIONS The findings suggest that CSA, and particularly severe CSA, was associated with increased risk of psychiatric disorder in young adults even when due allowance was made for prospectively measured confounding factors.

Risk factors and life processes associated with the onset of suicidal behaviour during adolescence and early adulthood

BACKGROUND This study examined associations between childhood circumstances, adolescent mental health and life events, and the development of suicidal behaviour in young people aged between 15 and 21 years. METHOD Data were gathered over the course of a 21-year longitudinal study of a birth cohort of 1265 children born in New Zealand. The measures collected included: (1) patterns of suicidal behaviour (ideation, attempt) (15-21 years); (2) social background, family functioning, parental and individual adjustment during childhood (0-16 years); and (3) time dynamics of mental health and stressful life events during adolescence and early adulthood (15-21 years). RESULTS By the age of 21 years, 28.8% of the sample reported having thought about killing themselves and 7.5% reported having made a suicide attempt. The childhood profile of those at greatest risk of suicidal behaviour was that of a young person reared in a family environment characterized by socio-economic adversity, marital disruption, poor parent-child attachment and exposure to sexual abuse, and who as a young adolescent showed high rates of neuroticism and novelty seeking. With the exception of the socio-economic and personality measures, the effects of childhood factors were largely mediated by mental health problems and exposure to stressful life events during adolescence and early adulthood. Mental health problems including depression, anxiety disorders, substance use disorder, and to some extent conduct disorder, in addition to exposure to adverse life events, were significantly associated with the onset of suicidal behaviours. CONCLUSIONS Findings support a life course model of the aetiology of suicidal behaviour in which risk of developing suicidal behaviour depends on accumulative exposure to a series of social, family, personality and mental health factors.

Exposure to childhood sexual and physical abuse and adjustment in early adulthood

OBJECTIVE This research examined linkages between exposure to childhood sexual abuse (CSA) and childhood physical punishment/abuse (CPA) and mental health issues in early adulthood. METHOD The investigation analyzed data from a birth cohort of over 1,000 New Zealand young adults studied to the age of 25. RESULTS Exposure to CSA and CPA was associated with increased risks of later mental disorders including depression, anxiety disorder, conduct/anti-social personality disorder, substance dependence, suicidal ideation, and suicide attempts at ages 16-25. Control for social, family, and individual factors reduced the associations between CPA and mental health outcomes to the point of statistical non-significance. However, there was a consistent finding for CSA to remain associated with increased risks of later mental health problems. After adjustment, those exposed to CSA including attempted or completed sexual penetration had rates of disorder that were 2.4 times higher than those not exposed to CSA. Those exposed to harsh or abusive physical punishment had rates of disorder that were 1.5 times higher than those exposed to no or occasional physical punishment. It was estimated that exposure to CSA accounted for approximately 13% of the mental health problems experienced by the cohort. Findings showed that exposure to CPA had only weak effects on later mental health. It was estimated that exposure to CPA accounted for approximately 5% of the mental health problems experienced by the cohort. CONCLUSIONS Exposure to CSA was associated with consistent increases in risks of later mental health problems. Exposure to CPA had weaker and less consistent effects on later mental health. These findings suggest that much of the association between CPA and later mental health reflects the general family context in which CPA occurs, whereas this is less the case for CSA.

Life course outcomes of young people with anxiety disorders in adolescence

OBJECTIVE This study examined associations between the extent of anxiety disorder in adolescence (14-16 years) and young peoples later risks of a range of mental health, educational, and social role outcomes (16-21 years). METHOD Data were gathered over the course of a 21-year longitudinal study of a birth cohort of 1,265 New Zealand children. Measures collected included (1) an assessment of DSM-III-R anxiety disorders between the ages of 14 and 16 years; (2) assessments of mental health, educational achievement, and social functioning between the ages of 16 and 21 years; and (3) measures of potentially confounding social, family, and individual factors. RESULTS Significant linear associations were found between the number of anxiety disorders reported in adolescence and later risks of anxiety disorder; major depression; nicotine, alcohol, and illicit drug dependence; suicidal behavior; educational underachievement; and early parenthood. Associations between the extent of adolescent anxiety disorder and later risks of anxiety disorder, depression, illicit drug dependence, and failure to attend university were shown to persist after statistical control for the confounding effects of sociofamilial and individual factors. CONCLUSIONS Findings suggest that adolescents with anxiety disorders are at an increased risk of subsequent anxiety, depression, illicit drug dependence, and educational underachievement as young adults. Clinical and research implications are considered.

The stability of child abuse reports: a longitudinal study of the reporting behaviour of young adults

BACKGROUND The aims of this study were to use longitudinal report data on physical and sexual abuse to examine the stability and consistency of abuse reports. METHODS The study was based on the birth cohort of young people studied in the Christchurch Health and Development Study. At ages 18 and 21 years, these young people were questioned about their childhood exposure to physical punishment and sexual abuse. Concurrent with these assessments, sample members were also assessed on measures of psychiatric disorder and suicidal behaviour. RESULTS Reports of childhood sexual abuse and physical punishment were relatively unstable and the values of kappa for test-retests of abuse reporting were in the region of 0.45. Inconsistencies in reporting were unrelated to the subjects psychiatric state. Latent class analyses suggested that: (a) those not abused did not falsely report being abused; and (b) those who were abused provided unreliable reports in which the probability of a false negative response was in the region of 50%. Different approaches to classifying subjects as abused led to wide variations in the estimated prevalence of abuse but estimates of the relative risk of psychiatric adjustment problems conditional on abuse exposure remained relatively stable. CONCLUSIONS There was substantial unreliability in the reporting of child abuse. This unreliability arose because those who were subject to abuse often provided false negative reports. The consequences of errors in reports appear to be: (a) that estimates of abuse prevalence based on a single report are likely to seriously underestimate the true prevalence of abuse; while (b) estimates of the relative risk of psychiatric adjustment problems conditional on abuse appear to be robust to the effects of reporting errors.

Childhood sexual abuse and psychiatric disorder in young adulthood: I. Prevalence of sexual abuse and factors associated with sexual abuse

OBJECTIVE To present accounts of the prevalence of childhood sexual abuse (CSA) and social, family, and related factors that are associated with increased risk of CSA, using data gathered during an 18-year longitudinal study of a New Zealand birth cohort. METHOD A birth cohort of more than 1,000 children born in Christchurch (New Zealand) was studied prospectively to the age of 16 years. At age 18, retrospective reports of CSA were obtained. RESULTS Of the cohort, 10.4% (17.3% of females and 3.4% of males) reported having experienced CSA before the age of 16 years. Rates of severe abusive experiences involving intercourse were lower: 5.6% of females and 1.4% of males reported abuse involving attempted or completed intercouse. Multivariate analyses that the risk of CSA was elevated among females (p < .0001), those exposed to high levels of marital conflict (p < .005), those reporting low parental attachment (p < .001), those reporting high levels of paternal overprotection (p < .005), and those with parents who reported alcoholism/alcohol problems (p < .05). The level of prediction of CSA from childhood and family factors was not sufficient to identify individuals at risk of CSA with any degree of accuracy. CONCLUSIONS CSA was not an uncommon experience in this cohort. Those most likely to be exposed to CSA were girls reared in families in families characterized by high levels of marital conflict and impaired parenting and in families having parents with adjustment problems.

Does father absence place daughters at special risk for early sexual activity and teenage pregnancy

The impact of father absence on early sexual activity and teenage pregnancy was investigated in longitudinal studies in the United States (N = 242) and New Zealand (N = 520), in which community samples of girls were followed prospectively from early in life (5 years) to approximately age 18. Greater exposure to father absence was strongly associated with elevated risk for early sexual activity and adolescent pregnancy. This elevated risk was either not explained (in the US. study) or only partly explained (in the New Zealand study) by familial, ecological, and personal disadvantages associated with father absence. After controlling for covariates, there was stronger and more consistent evidence of effects of father absence on early sexual activity and teenage pregnancy than on other behavioral or mental health problems or academic achievement. Effects of father absence are discussed in terms of life-course adversity, evolutionary psychology, social learning, and behavior genetic models.

Interventions to prevent child maltreatment and associated impairment

Although a broad range of programmes for prevention of child maltreatment exist, the effectiveness of most of the programmes is unknown. Two specific home-visiting programmes-the Nurse-Family Partnership (best evidence) and Early Start-have been shown to prevent child maltreatment and associated outcomes such as injuries. One population-level parenting programme has shown benefits, but requires further assessment and replication. Additional in-hospital and clinic strategies show promise in preventing physical abuse and neglect. However, whether school-based educational programmes prevent child sexual abuse is unknown, and there are currently no known approaches to prevent emotional abuse or exposure to intimate-partner violence. A specific parent-training programme has shown benefits in preventing recurrence of physical abuse; no intervention has yet been shown to be effective in preventing recurrence of neglect. A few interventions for neglected children and mother-child therapy for families with intimate-partner violence show promise in improving behavioural outcomes. Cognitive-behavioural therapy for sexually abused children with symptoms of post-traumatic stress shows the best evidence for reduction in mental-health conditions. For maltreated children, foster care placement can lead to benefits compared with young people who remain at home or those who reunify from foster care; enhanced foster care shows benefits for children. Future research should ensure that interventions are assessed in controlled trials, using actual outcomes of maltreatment and associated health measures.