Facts of Life:
Issue Briefings for Health Reporters

Vol. 4, No. 2 March 1999

Child Abuse Can Last a Lifetime

The Issue
The Facts
Interview: Adversity Breeds Disease
Interview: Abused Stress Response
The Long-Lasting Effects
Altered Stress Response May Make You Sick
Abusing the Brain
The Research

The Issue:

Adult survivors of childhood physical, emotional, or sexual abuse are not only at increased risk for depression and other mental health disorders, but new evidence suggests they are increasingly more likely to suffer from heart disease, obesity, and other potentially fatal physical conditions. Although it appears that trauma survivors frequently smoke, drink, and overeat as a way to cope with their emotional turmoil, other evidence suggests that the trauma itself may have profound effects on the body that leave it increasingly vulnerable to disease. Researchers, for example, have found that childhood abuse survivors show changes in brain structure and in their physiological responses to stress.

The Facts:

• Almost one million American children were victims of abuse or neglect in 1996. Of these, more than half (52 percent) were victims of neglect, 24 percent suffered physical abuse, and 12 percent were sexually abused. A parent was the abuser in 77 percent of cases; in 11 percent the abuser was another relative.[12]
• A study of nearly 600 women found that those who had been sexually abused as children were significantly more likely than the control group to report eating disorders, depression, phobias and other anxiety disorders, substance abuse, and suicide attempts.[9]
• A survey of nearly 2,000 women showed that those who had been physically or sexually abused as children were significantly more likely than non-abused women to report physical symptoms such as back pain, stomach pain, headaches, genital pain, shortness of breath, diarrhea, and vomiting during the previous six months.[6]
• The cost of child abuse is $56 billion annually, including $3.6 billion in medical and mental health care costs, according to the National Institute of Justice, U.S. Department of Justice.[7]
• Childhood abuse appears to affect the developing brain. Among 104 children admitted to a psychiatric hospital, 54.4 percent of those with a history of early physical, sexual, or psychological abuse had abnormal results on an electroencephalogram, compared with 26.9 percent of children who weren't abused. In another group of 51 children, victims of abuse or neglect showed physical alterations in the bundle of nerve fibers that connects the hemispheres of the brain.[11]

Vol. 4, No. 2 March 1999

Child Abuse Can Last a Lifetime

The Issue
The Facts
Interview: Adversity Breeds Disease
Interview: Abused Stress Response
The Long-Lasting Effects
Altered Stress Response May Make You Sick
Abusing the Brain
The Research

The Issue:

Adult survivors of childhood physical, emotional, or sexual abuse are not only at increased risk for depression and other mental health disorders, but new evidence suggests they are increasingly more likely to suffer from heart disease, obesity, and other potentially fatal physical conditions. Although it appears that trauma survivors frequently smoke, drink, and overeat as a way to cope with their emotional turmoil, other evidence suggests that the trauma itself may have profound effects on the body that leave it increasingly vulnerable to disease. Researchers, for example, have found that childhood abuse survivors show changes in brain structure and in their physiological responses to stress.

The Facts:

• Almost one million American children were victims of abuse or neglect in 1996. Of these, more than half (52 percent) were victims of neglect, 24 percent suffered physical abuse, and 12 percent were sexually abused. A parent was the abuser in 77 percent of cases; in 11 percent the abuser was another relative.[12]
• A study of nearly 600 women found that those who had been sexually abused as children were significantly more likely than the control group to report eating disorders, depression, phobias and other anxiety disorders, substance abuse, and suicide attempts.[9]
• A survey of nearly 2,000 women showed that those who had been physically or sexually abused as children were significantly more likely than non-abused women to report physical symptoms such as back pain, stomach pain, headaches, genital pain, shortness of breath, diarrhea, and vomiting during the previous six months.[6]
• The cost of child abuse is $56 billion annually, including $3.6 billion in medical and mental health care costs, according to the National Institute of Justice, U.S. Department of Justice.[7]
• Childhood abuse appears to affect the developing brain. Among 104 children admitted to a psychiatric hospital, 54.4 percent of those with a history of early physical, sexual, or psychological abuse had abnormal results on an electroencephalogram, compared with 26.9 percent of children who weren't abused. In another group of 51 children, victims of abuse or neglect showed physical alterations in the bundle of nerve fibers that connects the hemispheres of the brain.[11]

Adversity Breeds Disease

Vincent J. Felitti, MD, FACP, is head of preventive medicine at Kaiser Permanente in San Diego, CA. He has been following 20,000 patients for the managed care organization. He tracks the effects of "adverse childhood experiences" including physical or sexual abuse and living with a violent, alcoholic, or mentally ill parent.[3]

Q: You've been following a large group of patients. How did your study come about?

A: About 12 years ago, we were running a large weight-loss program, treating about 1,500 patients a year. The biggest problem we had was patient dropout, particularly among people who were otherwise successfully losing weight. In interviews, it quickly became evident that many of these people had been raped, molested, or otherwise abused as children. While many very much wanted to lose weight, they were terrified of the possibility of being attractive to others if they lost a lot of weight.

Q: Could you explain that?

A: One woman, for example, told me how happy she was to be losing weight. As we went through her life year by year, she told me at 23 she had been raped and gained 105 pounds. Then she looked down and muttered, "Overweight is overlooked, and that's the way I need to be." Several weeks later, she fled the program.

In 1993, we did an analysis of the life experiences of 131 obese patients in the weight program, comparing them with an equal number of always slender, middle-aged adults. The obese patients were more likely to have been physically or sexually abused and to have grown up in badly dysfunctional households than were the normal weight adults.[4]

Q: What factors are you examining in your patients?

A: We are studying seven adverse childhood experiences (ACE): three categories of abuse (verbal, physical, or sexual) and four categories of household dysfunction (living with an alcoholic or an addict, with a criminal who had been imprisoned, with a mentally ill family member, or with a mother who was treated violently).

Among more than 9,500 patients who participated in the first wave of the study, 52 percent had at least one adverse childhood experience; 6.2 percent had four or more. People with four or more adverse childhood experiences were four to 12 times more likely to display a range of health risk factors, including alcoholism, drug abuse, depression and a suicide attempt.

They were two to four times more likely to smoke, rate their health as poor, and to have had a sexually transmitted disease. They were also two to four times more likely to have illnesses that are among the leading causes of death, such as heart disease, emphysema, diabetes, and stroke. As the number of adverse childhood experiences increased so did the number of health problems.

We also saw clear evidence that people with greater adverse childhood experiences were dying at accelerated rates. The 50- and 60-year-olds in our study showed a progressively lower prevalence of adverse childhood experiences than did the 20- and 30-year-olds. You would expect the prevalence to be the same no matter what the age group. So we saw that people with higher exposures were dying earlier.

Q: You also found that people who had one risk factor were more likely to display another.

A: There's a very important message there. The standard public health approach has always been to look upon these risk factors as discreet and independent of each other. But, take something like smoking. When you look carefully into the lives of people who are smoking now, it's a meaningful marker for other coincident health stressors, whether it's food, alcohol, promiscuity, whatever.

The basic message that is now clear is that much of what comes into medical offices today was actually predetermined decades ago by what happened to people as children. So primary prevention of abuse and some of these adverse events is important.

Q: What will it take to turn it around?

A: We are currently studying a large cohort of children in three cities. We are sending specially trained visitors into each home during the first three years of life to see if these children are better off, in some measurable way, than children who receive standard pediatric care. I think it's still too early to tell, but just listening to anecdotal experiences of the home visitors, it seems pretty much a no-brainer that this is going to work. The real question is whether the major impact will be immediate or 15, 25, or 30 years from now. I'd put my money on the long term.

Q: More than half of your adult sample has already been exposed to one or more adverse events during childhood. What do you do for them?

A: That's the right question, and I don't think anyone has a dazzlingly bright answer. Attempting to treat people for risk factors is quite difficult. There's been an enormous reduction in smoking, but some people still smoke despite huge social pressures against it. It's clear they have to be getting something quite important out of it.

Q: So people are smoking, drinking, or becoming obese as a way of dealing with the trauma?

A: Absolutely. The conventional idea is that people do these things because they are self-destructive. They actually do these because they are self-caring. As long as these things are viewed as public health problems, rather than personal solutions, then we will be limited to sloganeering: "Don't smoke. It's bad for you."

Q: Rather than asking, "Why are you smoking?"

A: Yes. I have one patient, a 47-year-old woman, who would like to stop smoking because four years ago she was operated on for lung cancer. She had been a five-pack-a-day smoker. Three packs a day is as low as she can get. But the history underneath this is quite interesting. She's a long-term incest case, and this is really the only way that she has that works to hold herself together emotionally.

Q: So primary care doctors should suspect childhood trauma when you see intractable problems?

A: They certainly should. The real problem is that very few health care providers are comfortable discussing these issues with patients. So, simply knowing about the prior abuse isn't going to have much benefit unless medical schools or residency programs build in training that enables physicians to speak comfortably with patients about these topics.

Using obesity as a handy example, probably the single, most useful question that we found is, "How old were you when you first began putting on weight?" And whatever the answer is, the follow-up question is, "Why do you think it was then and not two years earlier or five years later?" Most people can't answer that question, and so the question isn't really asked seeking an answer. It's posed to plant a seed.

Interview:

Abused Stress Response

Frank W. Putnam, MD, is chief of developmental traumatology at the National Institute of Mental Health. With Penelope K. Trickett, PhD, of the University of California at Los Angeles, Putnam has been studying 77 sexually abused girls for more than a decade, comparing their social, psychological, and biological development with a matched group of girls who were not abused.[10]

Q: You've examined the stress response in sexually abused girls. What have you found? A: We examined the girls fairly recently after the abuse

occurred - within six months of when it had been disclosed to legal authorities. Abused girls show an elevated stress reaction in response to having their blood drawn. We drew morning blood samples from the girls when they arrived at our office and 20 and 40 minutes later. Compared with the non-abused girls, the abused girls released higher levels of the stress hormone cortisol throughout the 40-minute period. The abused girls started out higher, and the stress of inserting the IV led to a greater peak response during the first 20 minutes. Then at 40 minutes the control girls dropped below the baseline, while the abused girls remained above the baseline value.

Q: In some girls, you studied their stress response by actually injecting them with stress hormones.[2]

A: With George P. Chrousos, MD, of the National Institute of Child Health and Human Development, we gave some girls an infusion of corticotrophin-releasing factor (CRF). Under stress, the hypothalamus releases CRF in the brain, which signals the pituitary to release adrenocorticotrophic hormone (ACTH), which in turn stimulates the adrenal gland to release cortisol, a major stress hormone. What we saw was that for the same amount of CRF, the abused girls produced less ACTH than did the controls. So they had what's known as ACTH blunting. But for the lower level of ACTH produced, they actually produced the same amounts of cortisol or more.

As we followed all of the abused girls over time, they went from being hypercortisolemic - putting out too much cortisol - to hypocortisolemic - putting out too little cortisol. There have been similar findings among Vietnam veterans with post-traumatic stress disorder studied 20 or more years after the war.

Q: What are the implications for the girls' physical and mental health?

A: It remains quite speculative at this point. One finding that has attracted a fair amount of attention is that cortisol can be neurotoxic. In animal studies, high levels of cortisol, either induced by stressing the animal or by artificially injecting it with high levels of the hormone, have produced damage to an area of the brain called the hippocampus.

Q: Has there been evidence of brain changes in child survivors of trauma?

A: Michael De Bellis, MD, at the University of Pittsburgh recently presented data that show decreases in some areas like the corpus callosum, which connects the two brain hemispheres, and larger brain volumes in other areas. Overall he finds smaller brain sizes. Although the data from our own imaging studies are preliminary, they appear similar to his.

Q: What other long-term effects does abuse have?

A: We had reports of more illness by the mothers of abused children. The children were also significantly more likely to report physical complaints, such as headaches, joint pains, and stomach pains. That fits with much of the profile we know about the effects of maltreatment on physical health. Women with histories of maltreatment and sexual abuse utilize health care services at two to three times the rate of non-abused individuals.

We did a simple measure of immune competence called the antinuclear antibody (ANA). It measures the levels of antibodies that one makes against one's own body and is elevated in auto-immune diseases like lupus. The abused girls had ANA levels several times higher than those of the control kids. So we have a very simple marker suggesting immune stress in the maltreated kids.

Q: Might this explain why there are more physical health complaints among abuse survivors over time?

A: It certainly is compatible with studies suggesting that the immune surveillance mechanism may be impaired or there may be more auto-immune problems. And it is also compatible with a whole literature of stress responses in animals suggesting significant immune compromise as a result of chronic stress.

The Long-Lasting Effects

Women who were physically, sexually, or emotionally abused as children are significantly more likely to be hospitalized and to have a host of physical and mental health problems.

James R. Moeller, PhD, and colleagues at Columbia University's College of Physicians and Surgeons surveyed more than 660 predominately white, middle class women recruited from a gynecologic practice.[8] More than half (53 percent) of them reported that they had been abused as children.

Those who had been abused were significantly less likely to rate their health as excellent than were non-abused women. They were more likely to report a range of physical health complaints including fatigue, obesity, gynecologic problems, headaches, insomnia, and alcohol and drug abuse. They were also more likely to report mental health symptoms such as depression, anxiety, tension, emotional outbursts, nightmares, suicide attempts, and thoughts about hurting themselves.

"It appears that abusive acts perpetrated towards children continue to carry detrimental psychological and physical consequences into the adult years for many women," Moeller and colleagues say.

Altered Stress Response May Make You Sick

Could an altered stress response help explain the increased prevalence of some physical illnesses seen among survivors of abuse? That is the intriguing implication of recent research.

Christine Heim, PhD, of the Center for Psychobiological and Psychosomatic Research at the University of Trier in Trier, Germany, studied 16 women with unexplained chronic pelvic pain.[5] Two-thirds of the women had been abused during childhood, adulthood, or both, compared with 21.4 percent of a comparison group who did not have chronic pelvic pain. Forty percent of those with chronic pelvic pain met criteria for post-traumatic stress disorder; none in the comparison group did.

Heim infused both groups of women with corticotropin-releasing factor (CRF) to artificially stimulate their bodies' stress response. Under stress, CRF signals the pituitary to release adrenocorticotrophic hormone (ACTH), which stimulates the adrenal gland to release cortisol, a major stress hormone.

When their bodies were challenged with CRF, women with chronic pelvic pain displayed normal levels of ACTH, but low to normal levels of cortisol in their saliva. This pattern is consistent with findings in patients with chronic fatigue, fibromyalgia, arthritis, and asthma, Heim says.

When cortisol is released during stress, it suppresses substances that modulate immune function, inflammation, and pain. Heim points out: "A persistent lack of cortisol in traumatized or chronically stressed individuals might promote an increased vulnerability for auto-immune disorders, inflammation, chronic pain syndromes, allergies and asthma."

Abusing the Brain

Scientists are finding clear and convincing evidence that severe abuse in childhood can have profound effects on the body that can be detected many years after the abuse has ended.

J. Douglas Bremner, MD, of the Yale University School of Medicine and colleagues have used magnetic resonance imaging (MRI) to explore the effects of abuse on the brain.[1] In one study, they examined the MRIs of 17 adult survivors of severe childhood physical or sexual abuse and compared them with scans from a matched group of adults who had not been abused. All of the abuse survivors met criteria for post-traumatic stress disorder (PTSD), an extreme response to trauma that can leave patients hyper-aroused, emotionally numb, and prone to re-experiencing the trauma through flashbacks.

Bremner found that the adult abuse survivors showed a 12 percent reduction in the size of their left hippocampus, a region of the brain known to be involved in memory. The longer the duration of childhood abuse, the greater the reduction in the size of the hippocampus. They found similar reductions in the size of the right hippocampus in veterans with combat-related PTSD. Both the survivors of childhood abuse and the veterans displayed significant memory deficits.

"The brain apparently pays a very important price as a result of that trauma," says Bruce McEwen, PhD, a Rockefeller University researcher who has studied the effects of extreme stress on the brains of laboratory animals. "Believe me, there are other things going on in the brain besides damage to the hippocampus. This is just what we can put our finger on at this time."

The Research

1. Bremner JD, et al. (1997) "Magnetic Resonance Imaging-Based Measurement of Hippocampal Volume in Posttraumatic Stress Disorder Related to Childhood Physical and Sexual Abuse - A Preliminary Report." Biological Psychiatry. 41:23-32.
2. De Bellis MD, et al. (1994) "Hypothalamic-Pituitary-Adrenal Axis Dysregulation in Sexually Abused Girls." Journal of Clinical Endocrinology and Metabolism. 78:249-255.
3. Felitti VJ, et al. (1998) "Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study." American Journal of Preventive Medicine. 14(4):245-258.
4. Felitti VJ. (1993) "Childhood Sexual Abuse, Depression and Family Dysfunction in Adult Obese Patients: A Case-Control Study." Southern Medical Journal. 86:732-736.
5. Heim C, et al. (1998) "Abuse Related Posttraumatic Stress Disorder and Alterations of the Hypothalamic-Pituitary-Adrenal Axis in Women with Chronic Pelvic Pain." Psychosomatic Medicine. 60:309-318.
6. McCauley J, et al. (1997) "Clinical Characteristics of Women with a History of Childhood Abuse: Unhealed Wounds." Journal of the American Medical Association. 277:1362-1368.
7. Miller, TR. (1996) "Victim Costs and Consequences: A New Look." Washington, DC: National Institute of Justice.
8. Moeller TP, et al. (1993) "The Combined Effects of Physical, Sexual, and Emotional Abuse During Childhood: Long-Term Health Consequences for Women." Child Abuse and Neglect. 17:623-640.
9. Mullen PE, et al. (1993) "Childhood Sexual Abuse and Mental Health in Adult Life." British Journal of Psychiatry. 163:721-732.
10. Putnam FW and Trickett PK. (1997) "Psychobiological Effects of Sexual Abuse: A Longitudinal Study." Annals of the New York Academy of Science. 821:150-159.
11. Teicher MH. (1997) "Preliminary Evidence for Abnormal Cortical Development in Physically and Sexually Abused Children Using EEG Coherence and MRI." Annals of the New York Academy of Sciences. 821:160-175.
12. U.S. Department of Health and Human Services. (1998) "Child Maltreatment 1996: Reports from the States to the National Child Abuse and Neglect Data System." Washington, DC: U.S. Government Printing Office.

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The Center for the Advancement of Health, a nonprofit institute, promotes the science that explores health as a complex and dynamic system of relationships among biology, behavior, psychology, and social context and works to integrate this knowledge into public awareness, health care policy, and health care practice. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding.

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