The hallmarks of childhood abuse and neglect: A systematic review

Abuse, neglect and neurodevelopment across the life course: what can paediatricians and child psychiatrists do about this together? The Illingworth-Rees keynote lecture 2023

Paediatricians and child psychiatrists share complex cases, often associated with abuse, neglect and other 'Adverse Childhood Experiences (ACEs)'. ACEs are associated in a dose-response relationship with both mental and physical health problems across the life span. We found that 9-year-old children who had been abused and neglected were much more likely to also have symptoms of heritable neurodevelopmental conditions (NDCs) such as ADHD, autism and intellectual disabilities. To our surprise, these were not caused by the abuse and neglect. Instead, both the NDCs and the abuse and neglect were being caused by additional genetic factors. We also found that children who have experienced abuse and neglect, and who also have NDCs, are at twice the risk of developing symptoms of severe mental illness in adolescence. This has caused us to develop our 'Double Jeopardy' hypothesis-that experiencing both abuse and neglect and NDCs in childhood might double the risk of a range of physical and mental health problems across the life span.Both paediatricians and child psychiatrists will be faced with children who have complex problems, and they will sometimes need to work together to solve these-whether or not abuse or neglect is in the mix.Dr Corinne Rees's words were prescient: 'The truth that psychological issues and behaviour are integral to all illness indicates the necessity for every doctor to feel competent in considering their relevance'. As paediatricians and child psychiatrists, let's move forward together to overcome the mind-body dichotomy for the benefit of our patients.

Correction: The hallmarks of childhood abuse and neglect: A systematic review

[This corrects the article DOI: 10.1371/journal.pone.0243639.].

The Awareness of Child Abuse and Neglect Among the Saudi Population: A Narrative Review

Child abuse and neglect (CAN) is a pressing global issue with profound implications for the well-being of children. The aim of this review is to examine the existing literature and synthesize evidence on the awareness, knowledge, and attitudes toward child abuse and neglect within the Saudi population. This review synthesizes the existing literature to illuminate the awareness, knowledge, and attitudes surrounding CAN within the Saudi population. Ten studies spanning the years 2019-2023 were meticulously analyzed, offering a comprehensive snapshot of CAN perceptions across various segments of society. The studies, encompassing diverse methodologies and populations, collectively underscore the commendable levels of awareness and knowledge demonstrated by healthcare professionals, including primary healthcare (PHC) physicians, nurses, and medical practitioners. Notably, several studies reveal that these professionals exhibit robust recognition of different forms of child abuse, a vital aspect in the identification and prevention of abuse cases. While positive attitudes toward CAN were prevalent among healthcare providers, barriers to reporting were highlighted. The fear of consequences and uncertainty emerged as key deterrents to reporting among medical and dental students and nurses, respectively. These findings emphasize the necessity for creating supportive environments that empower professionals to report suspected cases of abuse while addressing apprehensions. The parental perception of CAN also came into focus, revealing a disparity between the recognition of CAN as a common problem and the adequate knowledge of emotional abuse and neglect. These findings point toward a need for targeted public awareness campaigns that differentiate between disciplinary practices and abusive behaviors. In conclusion, this review offers a nuanced understanding of the Saudi population's awareness, knowledge, and attitudes toward child abuse and neglect. The synthesis of findings across diverse studies informs future interventions, advocating for enhanced awareness, reporting, and prevention strategies. By empowering individuals and professionals alike, a safer environment for Saudi children can be nurtured, fostering a future free from the shadows of abuse and neglect.

Is there evidence of a causal link between childhood maltreatment and attention deficit/hyperactivity disorder? A systematic review of prospective longitudinal studies using the Bradford-Hill criteria

Background

Studies report an elevated risk of maltreatment in children with attention deficit/hyperactivity disorder (ADHD), and elevated levels of ADHD in people who suffered childhood maltreatment (CM). However, the direction(s) of causality between CM and ADHD remain unclear-does ADHD create a context for CM, does CM cause ADHD, or both?

Objective

This study systematically reviews and qualitatively synthesizes the research evidence relating to this question using Bradford-Hill criteria for establishing causality-strength, temporality, dose-response and plausibility.

Methods

We conducted a systematic review, following PRISMA guidelines, of prospective longitudinal studies examining both CM and ADHD. We then used Bradford-Hill criteria to assess the quality of evidence for a causal link between CM and ADHD.

Results

All 11 included studies demonstrated an association between CM and ADHD. Seven included evidence for temporality: five suggesting that CM precedes ADHD in the lifespan; two suggesting ADHD precedes CM. Four studies demonstrated a dose response relationship in which greater CM exposure was associated with elevated risk of ADHD. Studies presented a range of plausible mechanisms, including CM causing ADHD through biological programming, versus ADHD causing CM through parental stress.

Conclusions

The high quality prospective longitudinal studies reviewed confirm the association between ADHD and CM, but present conflicting evidence about the direction of causality and mechanisms underpinning this association. To better understand the complex interplay between CM and ADHD, more studies using new research designs will be required that can partition effects by type of CM and account for bidirectional effects and other complexities.

Current Weight Status of Sexually Assaulted Pediatric Female Patients in an Emergency Department Setting

Background: The relationship between childhood sexual abuse (CSA) and childhood obesity (CO) is unclear with studies reporting conflicting results in female populations. This study aims to assess the association between suspected CSA and current emergency department (ED) weight status when compared with trauma patients. Methods: This is a single-center retrospective case-control study that utilized pediatric ED data (2016-2018) from identified female patients (6-17 years old) with a chief complaint of sexual assault and trauma registry patients. Focus was on female patients for literary comparisons. Two weight measurements were calculated based on available height data: BMI-for-age and weight-for-age. Nonparametric testing and binary logistic regression were utilized. Results: There were 2044 study participants: 1454 (71.1%) cases and 590 (28.9%) controls. Cases were older, underrepresented minorities (URMs), and carried public insurance (all p-values <0.001). Using BMI-for-age, patients with a sexual assault complaint had a 67% increased odds for CO after adjusting for age, URM status, and insurance type [adjusted odds ratio (aOR) = 1.67 (95% confidence intervals [CIs] 1.07-2.62); p-value = 0.03], whereas the weight-for-age metric increased the aOR odds by 58% [aOR = 1.58 (95% CI 1.14-2.17); p-value = 0.01] when compared with pediatric trauma patients. Similar results were found in a sensitivity analysis using patients matched on age and URM. Conclusion: Our data demonstrated an association between suspected CSA and CO. More research is needed to identify the biopsychosocial implications for this relationship and the potential to augment clinical care.

Investigating effect modification between childhood maltreatment and genetic risk for cardiovascular disease in the UK Biobank

Cardiovascular disease (CVD) is influenced by genetic and environmental factors. Childhood maltreatment is associated with CVD and may modify genetic susceptibility to cardiovascular risk factors. We used genetic and phenotypic data from 100,833 White British UK Biobank participants (57% female; mean age = 55.9 years). We regressed nine cardiovascular risk factors/diseases (alcohol consumption, body mass index [BMI], low-density lipoprotein cholesterol, lifetime smoking behaviour, systolic blood pressure, atrial fibrillation, coronary heart disease, type 2 diabetes, and stroke) on their respective polygenic scores (PGS) and self-reported exposure to childhood maltreatment. Effect modification was tested on the additive and multiplicative scales by including a product term (PGS*maltreatment) in regression models. On the additive scale, childhood maltreatment accentuated the effect of genetic susceptibility to higher BMI (Peffect modification: 0.003). Individuals not exposed to childhood maltreatment had an increase in BMI of 0.12 SD (95% CI: 0.11, 0.13) per SD increase in BMI PGS, compared to 0.17 SD (95% CI: 0.14, 0.19) in those exposed to all types of childhood maltreatment. On the multiplicative scale, similar results were obtained for BMI though these did not withstand to Bonferroni correction. There was little evidence of effect modification by childhood maltreatment in relation to other outcomes, or of sex-specific effect modification. Our study suggests the effects of genetic susceptibility to a higher BMI may be moderately accentuated in individuals exposed to childhood maltreatment. However, gene*environment interactions are likely not a major contributor to the excess CVD burden experienced by childhood maltreatment victims.

An investigation of the utility of the Australian Guide to the diagnosis of fetal alcohol spectrum disorder in young children

BACKGROUND

Early diagnosis of children with fetal alcohol spectrum disorder (FASD) assists in implementing critical early support. The challenge lies in having a diagnostic process that enables valid and reliable assessment of domains of functioning in young children, with the added complexity that many children will also have co-occurring exposure to childhood adversity that is likely to impact these domains.

METHODS

The aim of this study was to test a diagnostic assessment of FASD in young children using the Australian Guide to the Diagnosis of FASD. Ninety-four children (aged 3 to 7 years) with confirmed or suspected prenatal alcohol exposure were referred to two specialist FASD clinics for assessment in Queensland, Australia.

RESULTS

There was a significant risk profile with 68.1% (n = 64) children having had contact with child protection services, and most children living in kinship (n = 22, 27.7%) or foster (n = 36, 40.4%) care. Forty-one percent of the children were Indigenous Australians. The majority (64.9%, n = 61) of children met criteria for FASD, 30.9% were classified as "At Risk" for FASD (n = 29), and 4.3% received no FASD diagnosis (n = 4). Only 4 (4%) children were rated as severe for the brain domain. Over 60% of children (n = 58) had two or more comorbid diagnoses. Sensitivity analyses indicated that the removal of comorbid diagnoses in the Attention, Affect Regulation, or Adaptive Functioning domains resulted in a change in 7 of 47 cases (15%) to an "At Risk" designation.

CONCLUSIONS

These results highlight the complexity of presentation and the extent of impairment in the sample. The use of comorbid diagnoses to substantiate a "severe" designation in specific neurodevelopmental domains raises the question of whether there were false-positive diagnoses. The complexity of determining causal relationships between exposure to PAE and early life adversity on developmental outcomes continues to be a challenge in this young population.

"I will commit to this child as much as I can for the time that they are with me:" A qualitative examination of how foster carer commitment relates to short-term foster care for young children following abuse and neglect

BACKGROUND

Foster carer commitment to the child has been shown to be of paramount importance in young children's recovery and development following abuse and neglect. In Dozier's definition of commitment in the US, there is a focus on both emotional investment in the child and committing to an enduring relationship with the child. How this relates to the routine practice of short-term, temporary, foster care has not been studied.

OBJECTIVE

This is the first qualitative study to explore the drivers of, and barriers to, commitment in short-term foster care within the broader aim of examining whether short-term care is meeting the needs of maltreated young children.

PARTICIPANTS & SETTING

Fourteen foster carers took part in research interviews and five focus groups were conducted with infant mental health professionals.

METHODS

Interviews and focus group data were subject to qualitative thematic analysis in order to identify patterns of commonality in relation to our research questions.

RESULTS

Three broad themes pertain to commitment and the meeting of young children's needs in short-term foster care: Influence, Timescales and Choice in the fostering role. These themes were found to house both drivers of, and barriers to, commitment in short-term care, which are influenced by systemic normalisations of fostering practices.

CONCLUSIONS

The emotional investment facet of commitment is more alive in the 'psyche' of short-term foster care than commitment to an enduring relationship. A long-term outlook for the child may be an undefined facet of commitment that is more akin with short-term placements.

Personality functioning and the pathogenic effect of childhood maltreatment in a high-risk sample

BACKGROUND

While the psychopathological sequalae of childhood maltreatment are widely acknowledged, less is known about the underlying pathways by which childhood maltreatment might lead to an increased risk for mental health problems. Recent studies indicated that impaired personality functioning might mediate this relationship. The aim of the present paper was to extend the current literature by investigating the mediating effect of impaired personality functioning between different types of childhood maltreatment and self-reported mental health problems in a high-risk sample.

METHODS

Overall, 173 young adults (mean age = of 26.61 years; SD = 3.27) with a history of residential child welfare and juvenile justice placements in Switzerland were included in the current study. The Childhood Trauma Questionnaire (CTQ-SF), Semi-structured Interview for Personality Functioning DSM-5 (STiP-5.1) and the self-report questionnaires of the Achenbach System of Empirically Based Assessment scales (ASEBA) were used. Mediation analyses were conducted through structural equation modeling.

RESULTS

Overall, 76.3% (N = 132) participants indicated at least one type of childhood maltreatment, with emotional neglect being most commonly reported (60.7%). A total of 30.6% (N = 53) participants self-reported mental health problems. Emotional abuse (r = 0.34; p < .001) and neglect (r = 0.28; p < .001) were found to be most strongly associated with mental health problems. In addition, impaired personality functioning was fond to be a significant mediator for overall childhood maltreatment (β = 0.089; p = 0.008) and emotional neglect (β = 0.077; p = 0.016). Finally, impaired self-functioning was found to be a significant mediator when both self-functioning and interpersonal functioning were included as potential mediators in the relationship between overall childhood maltreatment (β1 = 0.177, p1 = 0.007) and emotional neglect (β1 = 0.173, p1 = 0.003).

CONCLUSION

Emotional neglect may be particularly important in the context of childhood maltreatment, personality functioning, and mental health problems and, therefore, should not be overlooked next to the more "obvious" forms of childhood maltreatment. Combining interventions designed for personality functioning with trauma-informed practices in standard mental health services might counteract the psychopathological outcomes of maltreated children and adolescents.

Indigenous Service Provider Perspectives of an Online Education Module to Support Safe Clinical Encounters about Family Violence in Canada

Given colonial genocide, Indigenous peoples are rightfully reticent to disclose their experiences of family violence to practitioners working within mainstream health care and social services. Health care and social service providers (HSSPs) have varied formal education on providing trauma-and-violence informed care to Indigenous and non-Indigenous families affected by family violence, including intimate partner violence and child maltreatment. The purpose of this study is to understand and describe the perspectives of Six Nations of the Grand River community members on the relevance of an education module to support HSSPs to provide physically and emotionally safe care to Indigenous families affected by family violence. Two-Eyed Seeing and Two Row Wampum approaches guided our qualitative study. Twenty-one (66.7% women) Indigenous HSSPs completed a semi-structured interview; 15 identified as a regulated HSSP, nine as a Knowledge Keeper/Cultural Holder, and three as a HSSP trainees. Conventional content analysis guided the development of codes and categories. The Violence, Evidence, Guidance, Action (VEGA)-Creating Safety education module was described as having elements consistent with Indigenous experiences and values, and supportive of Indigenous peoples seeking care from HSSPs for family violence related concerns. Participants described several suggestions to better adapt and align the module content with the diversity of values and beliefs of different Indigenous Nations. Collectively, the Creating Safety module may be used as an educational adjunct to Indigenous-focused, cultural safety training that can support HSSPs to provide physically, emotionally, and psychologically safe care to Indigenous peoples who have experienced family violence. Future work needs to consider the perspectives of other Indigenous communities and Nations.

A meta-analysis of childhood maltreatment in relation to psychopathic traits

Psychopathy is a personality disorder characterized by a mix of traits belonging to four facets: affective (e.g., callous/lack of empathy), interpersonal (e.g., grandiosity), behavioral instability (e.g., impulsivity, poor behavioral controls), and social deviance (e.g., juvenile delinquency, criminal versatility). Several scholars have argued that early childhood maltreatment impacts the development of psychopathy, although views regarding its role in the four facets differ. We conducted a meta-analysis including 47 studies comprising a total of 389 effect sizes and 12,737 participants, to investigate the association between psychopathy and four types of child maltreatment: physical abuse, emotional abuse, neglect, and sexual abuse. We found support for a moderate link between overall psychopathy and childhood physical abuse, emotional abuse, and neglect, as well as overall childhood maltreatment. The link between psychopathy and childhood sexual abuse was small, but still statistically significant. These associations were stronger for the behavioral and antisocial facets than for the affective and interpersonal facets of psychopathy, but nearly all associations were statistically significant. Our findings are consistent with recently developed theories on the role of complex trauma in the development of severe personality disorders. Trauma-focused preventive and therapeutic interventions can provide further tests of the trauma-psychopathy hypothesis.

The expected and the unexpected in recovery and development after abuse and neglect: The role of early foster carer commitment on young children's symptoms of attachment disorders and mental health problems over time

BACKGROUND

Whilst we know that foster care is better than institutional care for abused and neglected children, we know less about the specific qualities of foster care that are important for their development and recovery from maltreatment effects.

OBJECTIVE

This is the first study to investigate the effects of foster carer commitment on symptoms of Attachment Disorders (AD) and mental health problems in young children post-maltreatment.

PARTICIPANTS & SETTING

144 children, age 0-5, recently accommodated into foster care as part of an ongoing Randomised Controlled Trial.

METHODS

Children were assessed using the Disturbances of Attachment Interview and the Strengths and Difficulties Questionnaire, then followed up 15 months and 2.5 years thereafter. Commitment of the foster carer was measured by 'This Is My Baby' interview. Multiple regression was used to analyse the data.

RESULTS

Higher initial foster carer commitment, measured shortly after entry to care, was associated with a reduction in Reactive Attachment Disorder symptoms 15 months after placement, with a modest (non-significant) association persisting 2.5 years later. Initial commitment was not associated with symptoms of Disinhibited Social Engagement Disorder at any follow-up time point, nor with symptoms of mental health problems at 15 months. However, higher initial commitment was unexpectedly associated with higher mental health symptom scores at 2.5 years post-accommodation.

CONCLUSIONS

This study highlights the complex and non-linear development of children in committed foster care, underscoring the need to examine multiple time-points and to consider symptoms of Attachment Disorders separately from those of other mental health problems.

Effects of early life adversity on immediate early gene expression: Systematic review and 3-level meta-analysis of rodent studies

Early-life adversity (ELA) causes long-lasting structural and functional changes to the brain, rendering affected individuals vulnerable to the development of psychopathologies later in life. Immediate-early genes (IEGs) provide a potential marker for the observed alterations, bridging the gap between activity-regulated transcription and long-lasting effects on brain structure and function. Several heterogeneous studies have used IEGs to identify differences in cellular activity after ELA; systematically investigating the literature is therefore crucial for comprehensive conclusions. Here, we performed a systematic review on 39 pre-clinical studies in rodents to study the effects of ELA (alteration of maternal care) on IEG expression. Females and IEGs other than cFos were investigated in only a handful of publications. We meta-analyzed publications investigating specifically cFos expression. ELA increased cFos expression after an acute stressor only if the animals (control and ELA) had experienced additional hits. At rest, ELA increased cFos expression irrespective of other life events, suggesting that ELA creates a phenotype similar to naïve, acutely stressed animals. We present a conceptual theoretical framework to interpret the unexpected results. Overall, ELA likely alters IEG expression across the brain, especially in interaction with other negative life events. The present review highlights current knowledge gaps and provides guidance to aid the design of future studies.