Wednesday, July 21, 2010

Abused Children at Risk of Developing Psychiatric Disorders as Young Adults

From Medscape Medical News
Abused Children at Risk of Developing Psychiatric Disorders as Young Adults

Deborah Brauser

July 16, 2010 — Childhood abuse and neglect are significantly associated with increased rates of anxiety, mood, and substance use disorders in young adulthood, according to a new cohort study of more than 2000 participants from New Zealand.

Past research showing this association has relied heavily on retrospective reports of child maltreatment, whereas "the few" using prospective ascertainment have shown a weaker association, giving weight to the possibility that it is "the memory of maltreatment that raises the risk of later mental disorders," report the researchers.

However, this study showed that "maltreatment, not just memory of maltreatment, [was] associated with subsequent psychopathology," write lead author Kate Scott, PhD, senior lecturer and senior clinical psychologist in the Department of Psychological Medicine at the University of Otago-Wellington, New Zealand, and colleagues.

Therefore, "there is a need for both targeted mental health interventions with the present and past clients of child welfare agencies and for concerted population-level strategies to meet the needs of the many other children who experience maltreatment," add the study authors.

"Most clinicians are well aware of the effects of child abuse," Dr. Scott told Medscape Medical News. "The key message is for the research community...and for agencies with responsibility for the welfare of children — that they need to intervene to deal with the mental health effects of adverse environments in order to help prevent later disorders."

The study appears in the July issue of the Archives of General Psychiatry.

Reporting Retrospectively and Prospectively

The investigators examined data from 2144 respondents (between the ages of 16 and 27 years) to the Te Rau Hinengaro: New Zealand Mental Health Survey between the years 2003 and 2004. This survey used face-to-face interviews and included questions about sociodemographic information and some forms of child maltreatment (representing retrospective reporting).

It also included the World Mental Health–World Health Organization Composite International Diagnostic Interview to assess lifetime and 12-month prevalence of disorders based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria.

"Most [past] studies rely on adults to provide information on whether they were maltreated as children," said Dr. Scott. "Those retrospective reports are problematic because recall is not perfect and is affected by current mood, among other things, [which] might lead to a bias."

So 221 of the survey participants were also identified as having records on a New Zealand national child protection agency electronic database (representing prospectively ascertained child maltreatment).

In addition, "the odds ratios (ORs) were estimated first with the comparison group [those without a child protection agency record] inclusive of people retrospectively reporting child maltreatment and second, with the comparison group exclusive of people who retrospectively reported child maltreatment," explain the study authors.

Significant Risks for Disorders

Results showed that "after adjusting for demographic and socioeconomic correlates, child protection agency history was associated with several individual mental disorders, mental disorder comorbidity, and all mental disorder groups [at] both12-months and lifetime," report the authors.

The ORs were 5.12 for 12-month posttraumatic stress disorder (PTSD; 95% confidence interval [CI], 2.42 - 10.83), 2.41 for any anxiety disorder (95% CI, 1.47 - 3.97), 1.86 for any mood disorder (95% CI, 1.12 - 3.08), and 1.71 for any substance use disorder (95% CI, 1.01 - 2.88).

"These associations increased in magnitude when those who retrospectively reported child maltreatment were removed from the comparison group," write the study authors. This included an elevated OR of 10.92 for PTSD (95% CI, 4.38 - 27.22).

Finally, "the associations with 12-month mental disorder groups indicate that those in the child protection agency group still, after an average of 10 years since intervention to reduce maltreatment, have higher rates of mental disorder, with an approximately 3-fold increase in the odds of having multiple (≥3) disorders," the study authors report.

Important for the Field

"I think this study is tremendously important for the field," Katie McLaughlin, PhD, from the Harvard School of Public Health and the Department of Health Care Policy at Harvard Medical School in Boston, Massachusetts, told Medscape Medical News.

Dr. McLaughlin, who was not involved with this study but has recently written about the topic, noted that there has been increasing interest during the years in the role of adverse childhood experiences on health across the life course. "The majority of the research has been retrospective, which has raised some concerns. So I think this is really a critical paper in building the case for the importance of actual experiences as important determinants of a population's health."

When asked whether she had any concerns with the study, Dr. McLaughlin said that she sees it "as sort of a first paper, looking at the basic associations between maltreatment experiences and adult psychiatric disorders. I think there are a lot of questions that remain, and there's a lot I'd love to see [the investigators] do with this data. However, there's nothing that raises serious concerns for me about their general conclusions."

Overall, she noted that the study has "important implications" for both research and practice. "For the research community, I think it demonstrates that this association we see time and again in retrospective studies is most likely real and not a result of biases associated with distortions of memories or distorted reporting among people with mental disorders."

"For clinicians, I think the take-home message is that childhood maltreatment is something we need to be paying attention to very closely," added Dr. McLaughlin. "I don't think this is a surprise for people who work with kids. But the interesting point for clinicians who work with adults with mental disorders is that this is something important that we should be thinking about — that events that happen in childhood seem to have lasting effects in adulthood and may very well be relevant for addressing in therapy."

The New Zealand Mental Health Survey was supported by the Ministry of Health, the Alcohol Advisory Council of New Zealand, and the Health Research Council of New Zealand. The study authors have disclosed no relevant financial relationships..

Arch Gen Psychiatry. 2010;67:712-719. Abstract

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