Impact of Opioid Dose Reductions on Patient-Reported Mental Health and Suicide-Related Behavior and Relationship to Patient Choice in Tapering Decisions

Mental health and suicide-related harms resulting from prescription opioid tapering are poorly documented and understood. Six health systems contributed opioid prescribing data from January 2016 to April 2020. Patients 18 to 70 years old with evidence of opioid tapering participated in semi-structured interviews. Individuals who experienced suicide attempts were oversampled. Family members of suicide decedents who had experienced opioid tapering were also interviewed. Interviews were analyzed using thematic analysis. The study participants included 176 patients and 16 family members. Patients were 68% female, 80% White, and 15% Hispanic, mean age 58. All family members were female spouses of White, non-Hispanic male decedents. Among the subgroup (n = 60) who experienced a documented suicide attempt, reported experiencing suicidal ideation during tapering, or were family members of suicide decedents, 40% reported that opioid tapering exacerbated previously recognized mental health issues, and 25% reported that tapering triggered new-onset mental health concerns. Among participants with suicide behavior, 47% directly attributed it to opioid tapering. Common precipitants included increased pain, reduced life engagement, sleep problems, withdrawal, relationship dissolution, and negative consequences of opioid substitution with other substances for pain relief. Most respondents reporting suicide behavior felt that the decision to taper was made by the health care system or a clinician (67%) whereas patients not reporting suicide behavior were more likely to report it was their own decision (42%). This study describes patient-reported mental health deterioration or suicide behavior while tapering prescription opioids. Clinicians should screen for, monitor, and treat suicide behavior while assisting patients in tapering opioids. PERSPECTIVE: This work describes changes in patient-reported mental health and suicide behavior while tapering prescription opioids. Recommendations for improving care include mental health and suicide risk screening during and following opioid tapering.

Implementation and Evaluation of Adverse Childhood Experiences Screening in Pediatrics and Obstetrics Settings

BACKGROUND

Screening for adverse childhood experiences (ACEs) in prenatal and pediatric populations is recommended by the California ACEs Aware initiative and is a promising practice to interrupt ACEs in children and mitigate ACEs-related health complications in children and families. Yet, integrating ACEs screening into clinical practice poses several challenges.

OBJECTIVE

The objective of this report was to evaluate the Kaiser Permanente Northern California and Kaiser Permanente Southern California pilots and implementation of ACEs screening into routine prenatal (Kaiser Permanente Northern California) and pediatric (Kaiser Permanente Southern California) care.

MATERIALS AND METHODS

These pilots were evaluated and compared to identify common challenges to implementation and offer promising practices for negotiating these challenges. Evaluation methods included feedback from staff, clinicians, and patients, as well as comparisons of methods to overcome various barriers to screening implementation.

RESULTS

Implementing ACEs screening, like implementation of any new component of clinical care, takes careful planning, education, creation of content and workflows, and continuous integration of feedback from both patients and staff.

CONCLUSION

This evaluation can serve as support for care teams who are considering implementing ACEs screening or who are already screening for ACEs. More research is needed regarding the relationship between ACEs and preventable and treatable health outcomes to improve health for patients and their families.

Adverse childhood experiences screening in healthcare settings: A focus on pediatric primary care

BACKGROUND

Adverse Childhood Experiences (ACEs) screening in healthcare settings is emerging as one of the tangible responses to address the consistent evidence linking ACEs with health. Kaiser Permanente Southern California (KPSC) began ACEs screening in pediatric primary care in 2018 and has developed screening and referral processes based on continued feedback from stakeholders as well as data driven assessment.

OBJECTIVE

We give an overview of the state of ACEs screening in pediatric healthcare settings, challenges facing pediatric providers, and suggestions to address them. We then describe the development of our ACEs screening and referral process within KPSC as an example of how a large healthcare system has implemented and adapted ACEs screening from pilot testing, to phased expansion, to complete implementation.

PARTICIPANTS AND SETTING

Children aged 2-18 years old who were members of KPSC 2018-2023.

RESULTS

We present data on the tailored screening and referral workflows we have developed, rates of positive screens and referrals, and how the initiation of ACEs screening may affect the rates of visit to behavioral health as a treatment option. We also integrate qualitative data to demonstrate the perspective of parents, with the goal of understanding what might help or hinder receipt of behavioral health treatment after ACEs screening.

CONCLUSIONS

We close with future directions for ACEs screening in healthcare settings and considerations for pediatric healthcare providers who may want to begin ACEs screening or adapt their screening and referral processes.

Patient perspectives on mental health and pain management support needed versus received during opioid deprescribing

Prescription opioid tapering has increased significantly over the last decade. Evidence suggests that tapering too quickly or without appropriate support may unintentionally harm patients. The aim of this analysis was to understand patients' experiences with opioid tapering, including support received or not received for pain control or mental health. Patients with evidence of opioid tapering from six health care systems participated in semi-structured, in-depth interviews; family members of suicide decedents with evidence of opioid tapering were also interviewed. Interviews were analyzed using thematic analysis. Participants included 176 patients and 16 family members. Results showed that 24% of participants felt their clinicians checked in with them about their taper experiences while 41% reported their clinicians did not. A majority (68%) of individuals who experienced suicide behavior during tapering reported that clinicians did check in about mood and mental health changes specifically; however, 27% of that group reported no such check in. More individuals reported negative experiences (than positive) with pain management clinics-where patients are often referred for tapering and pain management support. Patients reporting successful tapering experiences named shared decision-making and ability to adjust taper speed or pause tapering as helpful components of care. Fifty-six percent of patients reported needing more support during tapering, including more empathy and compassion (48%) and an individualized approach to tapering (41%). Patient-centered approaches to tapering include reaching out to monitor how patients are doing, involving patients in decision-making, supporting mental health changes, and allowing for flexibility in the tapering pace. PERSPECTIVE: Patients tapering prescription opioids desire more provider-initiated communication including checking in about pain, setting expectations for withdrawal and mental health related changes, and providing support for mental health. Patients preferred opportunities to share decisions about taper speed and to have flexibility with pausing the taper as needed.

Pre-surgical factors related to latent trajectories of 5-year weight loss for a diverse bariatric surgery population

BACKGROUND

Analyzing trajectories of weight loss may address how particular groups of patients respond to metabolic and bariatric surgery.

OBJECTIVES

The Bariatric Experience Long Term (BELONG) study was designed to use a theoretical model to examine determinants of weight loss and recurrence.

SETTING

Large integrated health system in Southern California with 11 surgical practices and 23 surgeons.

METHODS

A total of n = 1338 patients who had metabolic and bariatric surgery were surveyed before surgery to measure factors related to median percent total weight loss (%TWL) over 5 years. Longitudinal weight data were available for n = 1024 (76.5% of the sample). Data were analyzed using latent growth mixture models (GMM) to estimate trajectories of weight change separately for gastric sleeve and bypass operations. These trajectories were then described using relevant variables from the baseline survey.

RESULTS

For both gastric sleeve (n = 733) and bypass (n = 291) operations, 3 latent trajectories of median %TWL were found corresponding to most, moderate, and least %TWL. Sleeve trajectories were distinguished by body mass index at surgery and geocoded environmental factors. Bypass trajectories varied by self-reported and geocoded environmental factors, comorbidity burden, race, experiential avoidance, and weight control strategies.

CONCLUSIONS

Future research should examine the role of the built and perceived environment in surgical weight loss. Bariatric practices should focus less on the presurgical period for predictors of long-term weight loss and begin efforts to monitor real-time patient-reported outcomes to help tailor intervention strategies for patients who either do not lose an expected amount of weight or who begin to experience weight recurrence.

Types of diabetes during pregnancy and risk of depression and anxiety in offspring from childhood to young adulthood

AIMS

To assess maternal pre-existing type 1 diabetes (T1D), type 2 diabetes (T2D), gestational diabetes mellitus (GDM) during pregnancy and risk of depression and anxiety from childhood to young adulthood in offspring.

MATERIALS AND METHODS

This birth cohort included singletons born during 1995-2015, followed using electronic medical records through 2020. Cox regression was used to estimate hazard ratio (HR) of depression or anxiety diagnosis during follow-up associated with in-utero exposure to maternal diabetes.

RESULTS

Among 439 590 offspring, 29 891 (6.8%) had depression and 51 918 (11.8%) had anxiety. T1D, followed by T2D and GDM requiring antidiabetes medication were associated with risk of depression and anxiety in offspring. Compared with no diabetes during pregnancy, the adjusted HRs (95% confidence interval) of depression in offspring associated with T1D, T2D or GDM requiring medications were 1.44 (1.09-1.91), 1.30 (1.15-1.47) and 1.18 (1.11-1.26) respectively; conversely, HRs were 0.97 (0.82-1.15) for T2D and 0.99 (0.94-1.04) for GDM without medications. The associations with anxiety followed similar patterns. The significant associations were observed for offspring ages 5-12 and >12-18 years and attenuated for 18-25 years.

CONCLUSION

These data suggest that the severity of diabetes (T1D vs. T2D requiring medications vs. GDM requiring medications) during pregnancy may increase the vulnerability of offspring for depression or anxiety.

Maltreatment type differences in cortisol stress response trajectories across adolescence

This study examined cortisol stress response trajectories across adolescence in 454 maltreated and comparison youth recruited from Los Angeles County between 2002 and 2005 (66.7% maltreated; 46.7% girls; 39.0% Latino; 37.7% Black; 12.3% Mixed or Biracial; 11.0% White; Mage  = 10.9 years, SD = 1.2). Adolescents' peak activation and cortisol reactivity and recovery slopes following the Trier Social Stress Test for Children were calculated at four waves, then used to model peak activation and cortisol reactivity and recovery trajectories arrayed by age. Maltreated youth had blunted cortisol reactivity at age 9 relative to comparison youth (b = -.19, p = .02). Sexually and physically abused youth showed blunted cortisol reactivity and recovery trajectories relative to emotionally abused and neglected youth.

Trends in firearm injury in a southern California health care system from 2010 to 2020

BACKGROUND

Firearm injury is a significant public health concern in the United States.

METHODS

Data on fatal and nonfatal firearm injuries were obtained from a cohort of N = 7,473,650 members of Kaiser Permanente Southern California, a large integrated healthcare system between 2010 and 2020. Age-adjusted rates of combined fatal and nonfatal firearm injury per 100,000 members were calculated by year, with the 2010 US census as the reference population. Trends were evaluated using Poisson or negative binomial regression.

RESULTS

There was an increasing trend in overall firearm injuries between 2010 and 2020 among adults in this large integrated healthcare system (p < .0001), primarily driven by non-self-inflicted firearm injuries (p < .0001). Self-inflicted injuries decreased during this time (p = .01). Injuries among youth showed no significant change.

CONCLUSION

There was an increasing trend in firearm injuries between 2010 and 2020 among adults in this large integrated healthcare system, primarily driven by non-self-inflicted firearm injuries; however, self-inflicted injuries decreased during this time. Injuries among youth showed no significant change.

Prenatal Exposure to Gestational Diabetes Mellitus is Associated with Mental Health Outcomes and Physical Activity has a Modifying Role

Background

Studies suggest a link between prenatal gestational diabetes mellitus (GDM) exposure and poor mental health outcomes. We examined associations between prenatal GDM exposure and depressive and anxiety symptoms in children and assessed physical activity as a potential modifier of these associations.

Method

Seventy children (AgeM(SD): 12(2.0), 56% GDM, 59% female) and their parents completed surveys: Center for Epidemiological Studies Depression Scale for Children (CES-DC), State-Trait Anxiety Inventory for Children (STAIC), Child Behavior Checklist (CBCL), and 3-day physical activity recall (3DPAR). Associations between mental health measures with GDM exposure and interactions between GDM exposure and child moderate-to-vigorous physical activity (MVPA) were assessed using regression.

Results

GDM-exposed children had higher anxiety (p = 0.03) and internalizing symptoms (CBCL) (p = 0.04) than unexposed children. There was an interaction between GDM exposure and child MVPA on anxiety (p = 0.02), internalizing (p = 0.04) and externalizing symptoms (p = 0.004). In the low MVPA group, GDM exposed children had more depressive (p = 0.03), anxiety (p = 0.003), and internalizing symptoms (p = 0.03) than unexposed children. In the high MVPA group, there were no group differences except with externalizing symptoms (p = 0.04).

Conclusion

Prenatal GDM is associated with higher anxiety and internalizing symptoms in children. Child MVPA modified the relationship between GDM exposure and mental health outcomes suggesting that physical activity during childhood could mitigate the negative mental health outcomes associated with prenatal GDM exposure.

Using natural language processing to identify child maltreatment in health systems

BACKGROUND

Rates of child maltreatment (CM) obtained from electronic health records are much lower than national child welfare prevalence rates indicate. There is a need to understand how CM is documented to improve reporting and surveillance.

OBJECTIVES

To examine whether using natural language processing (NLP) in outpatient chart notes can identify cases of CM not documented by ICD diagnosis code, the overlap between the coding of child maltreatment by ICD and NLP, and any differences by age, gender, or race/ethnicity.

METHODS

Outpatient chart notes of children age 0-18 years old within Kaiser Permanente Washington (KPWA) 2018-2020 were used to examine a selected set of maltreatment-related terms categorized into concept unique identifiers (CUI). Manual review of text snippets for each CUI was completed to flag for validated cases and retrain the NLP algorithm.

RESULTS

The NLP results indicated a crude rate of 1.55 % to 2.36 % (2018-2020) of notes with reference to CM. The rate of CM identified by ICD code was 3.32 per 1000 children, whereas the rate identified by NLP was 37.38 per 1000 children. The groups that increased the most in identification of maltreatment from ICD to NLP were adolescents (13-18 yrs. old), females, Native American children, and those on Medicaid. Of note, all subgroups had substantially higher rates of maltreatment when using NLP.

CONCLUSIONS

Use of NLP substantially increased the estimated number of children who have been impacted by CM. Accurately capturing this population will improve identification of vulnerable youth at high risk for mental health symptoms.

Assessment of Screening for Adverse Childhood Experiences and Receipt of Behavioral Health Services Among Children and Adolescents

IMPORTANCE

Screening for adverse childhood experiences (ACEs) in primary care settings has been increasing as a response to the overwhelming and consistent evidence of the deleterious associations between ACEs and later physical and mental health. However, there is little empirical guidance on the appropriate implementation of ACEs screening in pediatric primary care.

OBJECTIVE

To test the use of a pilot intervention for ACEs screening and referral on the receipt of behavioral health care for children and adolescents within a large integrated health care delivery system.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted in a large integrated health care system serving Southern California. Child and adolescent members of the target health care system younger than 18 years between July 1, 2018, and November 30, 2021, who received a positive screening for ACEs at the pilot clinic were included. This pilot clinic implemented an intervention that included additional screening questions and incorporated social workers into the process of evaluation and referral for behavioral health needs following ACEs screening.

EXPOSURES

ACEs screening.

MAIN OUTCOMES AND MEASURES

Visit to a behavioral health care service within 90 days of a positive ACEs screen determined as a score of 1 or higher and behavioral symptoms.

RESULTS

The cohort consisted of 4030 children (mean [SD] age, 9.94 [4.55] years) with positive ACEs screening, 48% adolescents (11-17.99 years), approximately equal gender (51% females), 73% Hispanic, and 33% with Medicaid insurance. After the intervention, children were more likely to have a behavioral health services visit within 90 days of the screening than before the intervention (from 4.33% to 32.48%; incidence rate ratio, 7.50; 95% CI, 1.55-36.2).

CONCLUSIONS AND RELEVANCE

In this cohort study, the implementation of a new ACEs screening and referral process was associated with increased receipt of behavioral health services among children with a positive ACEs screening. This could be useful strategy for other health care systems responding to state and local mandates to screen and provide care for children with ACEs.

The impact of stay-at-home orders on the rate of emergency department child maltreatment diagnoses

BACKGROUND

There is limited data regarding the rates and severity of child maltreatment in medical settings during the COVID-19 pandemic, and the reports are somewhat contradictory.

OBJECTIVE

To examine the rates of emergency department (ED) child maltreatment (CM) diagnosis before and after the California statewide stay-at-home order, as well as potential disparities by age, gender, race/ethnicity, and Medicaid status.

METHODS

A retrospective pre-post interrupted time series was conducted using data from the electronic health records of children (<18 years) with at least one emergency department visit between January 1, 2019 and September 30, 2021. Enactment of the stay-at-home order in California, March 2020 was used to determine a change in trend of rates of diagnosis of CM in the ED.

RESULTS

Overall the study included 407,228 pediatric ED visits. There was a significant change in the percentage of CM visits immediately after the stay-at-home order, followed by small month to month decreases returning to near pre-stay-at-home order levels. This significant increase was driven by higher risk for children <4 years old. The increased rate of CM in the first month after the stay-at-home order was also elevated for female, Black, and Hispanic children.

CONCLUSIONS

Our results indicated the rates of CM diagnoses in the ED doubled after the March 2020 stay-at-home order in California. Additionally, our findings suggest that some children may be at higher risk than others, which supports the importance of social safety nets for children in times of national emergency.

Using machine learning to determine the shared and unique risk factors for marijuana use among child-welfare versus community adolescents

Objective

This study used machine learning (ML) to test an empirically derived set of risk factors for marijuana use. Models were built separately for child welfare (CW) and non-CW adolescents in order to compare the variables selected as important features/risk factors.

Method

Data were from a Time 4 (M_age = 18.22) of longitudinal study of the effects of maltreatment on adolescent development (n = 350; CW = 222; non-CW = 128; 56%male). Marijuana use in the past 12 months (none versus any) was obtained from a single item self-report. Risk factors entered into the model included mental health, parent/family social support, peer risk behavior, self-reported risk behavior, self-esteem, and self-reported adversities (e.g., abuse, neglect, witnessing family violence or community violence).

Results

The ML approaches indicated 80% accuracy in predicting marijuana use in the CW group and 85% accuracy in the non-CW group. In addition, the top features differed for the CW and non-CW groups with peer marijuana use emerging as the most important risk factor for CW youth, whereas externalizing behavior was the most important for the non-CW group. The most important common risk factor between group was gender, with males having higher risk.

Conclusions

This is the first study to examine the shared and unique risk factors for marijuana use for CW and non-CW youth using a machine learning approach. The results support our assertion that there may be similar risk factors for both groups, but there are also risks unique to each population. Therefore, risk factors derived from normative populations may not have the same importance when used for CW youth. These differences should be considered in clinical practice when assessing risk for substance use among adolescents.

Factors Associated With Firearm Injury Among Pediatric Members of a Large Integrated Healthcare System

BACKGROUND AND OBJECTIVES

Few studies have tested multiple socio-ecological risk factors assocated with firearm injury among pediatric populations and distinguished self-inflicted from non-self-inflicted injury. To address this gap, the current study examined demographic, individual psychosocial, and neighborhood variables as risk factors for firearm injury among a large cohort of children and adolescents.

METHODS

Retrospective cohort study. Data were obtained from the electronic health records of a large integrated healthcare system. The cohort included children <18 years with at least one clinical encounter between January 1, 2010 and December 31, 2018. Poisson regression was used to examine demographic (age, gender, race and ethnicity, Medicaid status), psychosocial (depression, substance use disorder, medical comorbidities), and neighborhood education variables as potential risk factors for non-self-inflicted and self-inflicted firearm injuries.

RESULTS

For non-self-inflicted injury, the highest relative risk was found for children age 12-17 years old compared to 0-5 year olds (RR = 37.57); other risk factors included male gender, Black and Hispanic race and ethnicity (compared to White race), being a Medicaid recipient, lower neighborhood education, and substance use disorder diagnosis. For self-inflicted injury, only age 12-17 years old and male gender were associated with increased risk.

CONCLUSIONS

These results reinforce the established higher risk for firearm injury among adolescent males, highlight differences between self-inflicted and non-self-inflicted injuries, and the need to consider demographic, psychosocial, and neighborhood variables as risk factors to inform interventions aimed to reduce firearm injuries among children and adolescents.

Incidence of child maltreatment diagnosis in electronic health records of a large integrated healthcare system: 2001-2018

The purpose of this study was to identify the number of children (<18years old) with an International Classification of Disease (ICD) diagnosis code for child maltreatment each year from 2001-2018 and examine differences by age, gender, and race/ethnicity. Data were drawn from the electronic health records of children (birth to <18years old) who were members of a large integrated healthcare system in California. We calculated the incidence rate (1 per 1000 children) for each year from 2001-2018 separately by age groups, gender, and race/ethnicity. Adolescents (11-15years old) had the overall highest incidence of all ages groups. Females had nearly twice the rate of males for the past 5years. Lastly, for race/ethnicity Black children had the highest incidence and Asian children the lowest. The findings demonstrate that maltreatment diagnosis in medical settings may be underused. Understanding the trends of these ICD codes by demographic characteristics yields information that health care providers may use to both increase the identification and documentation of child maltreatment.

Injuries Associated With Subsequent Child Maltreatment Diagnosis: By Age, Race, Gender, and Medicaid Status

This study examined injuries that may precede a child maltreatment (CM) diagnosis, by age, race/ethnicity, gender, and Medicaid status using a retrospective case-control design among child members of a large integrated healthcare system (N = 9152 participants, n = 4576 case). Injury categories based on diagnosis codes from medical visits were bruising, fractures, lacerations, head injury, burns, falls, and unspecified injury. Results showed that all injury categories were significant predictors of a subsequent CM diagnosis, but only for children < 3 years old. Specifically, fracture and head injury were the highest risk for a subsequent CM diagnosis. All injury types were significant predictors of maltreatment diagnosis for Hispanic children < 3 years, which was not the case for the other race/ethnicities. Overall, these findings suggest that all types of injury within these specific categories should have a more thorough assessment for possible abuse for children under 3 years. This work can inform the development of clinical decision support tools to aid healthcare providers in detecting abusive injuries.

Opioid-related variables did not improve suicide risk prediction models in samples with mental health diagnoses

Background

Suicide risk prediction models derived from machine learning of electronic health records and insurance claims are an innovation in suicide prevention. Some models do not include opioid-related variables despite the relationship between opioids and suicide. This study evaluated whether inclusion of opioid-related variables improved suicide risk prediction models developed by the Mental Health Research Network.

Methods

Approximately 630 opioid-related variables and interactions terms were introduced into existing suicide prediction models run in datasets of patient visits in mental health care (n = 27,755,401 visits) or primary care when a mental health diagnosis was given (n = 19,340,461 visits). Training and validation datasets were created. LASSO regression with 10-fold validation identified variables to be added to the models.

Results

The new models predicting suicide attempts and suicide deaths in the mental health specialty visit sample performed as well as the existing models (new C-statistic for attempts model = 0.855, CI: 0.853-0.857 versus original C-statistic = 0.851, CI 0.848-0.853; death model = 0.868, CI: 0.856-0.879 versus 0.861, CI 0.848-0.875). The new model for suicide death in the primary care sample improved (0.855, CI: 0.837-0.874 versus 0.833, CI 0.813-0.853) while performance of the new model for suicide attempt in that sample degraded (0.843, CI: 0.839-0.847 versus 0.853, CI 0.849-0.857).

Limitations

Analyses did not include patients without recent care, data did not include illicit opioid use or unrecognized opioid use disorder.

Conclusions

Among patients with mental health diagnoses, inclusion of opioid-related variables did not improve prediction of suicide risk beyond mental health predictors.

Effect of Caregiver Depressive Symptoms on the Concordance Between Caregiver and Youth Assessment of Youth Physical Health

OBJECTIVES

To explore how caregivers' (birth parents, adoptive parents, relative caregivers, and unrelated caregivers) depressive symptoms moderate the concordance between their and their youth's assessment of the youth's physical health symptoms, diseases, and physical health status.

METHODS

Participants included 224 youth with mean age of 18.0 years (SD = 1.3) and their caregivers. Multiple-group models were run to test whether caregiver depression status moderated the concordance between youth and caregiver report of physical health outcomes. Models compared caregivers above the mean for depression in the sample (n = 62) with caregivers below the mean for depression in this sample (n = 128).

RESULTS

There was a strong correlation between youth and caregiver report of pain in the last 30 days and physical health status in the caregiver group with no/fewer depressive symptoms [r (128) = 0.29, p = 0.04; r (128) = 0.59, p < 0.01], but no significant correlation between the two in the caregiver group with higher depressive symptoms [r (62) =  - 0.27, p = 0.27; r (62) =  - 0.14, p = 0.57].

CONCLUSIONS FOR PRACTICE

Higher caregiver depressive symptoms was associated with worse concordance between caregiver and youth assessment of the youth's pain and physical health status. These two health issues are less visible and more subjective and communication between caregiver and youth may be affected by the caregiver's depressive symptoms. Since both caregiver and youth assessments of a youth's physical health provide the best clinical data, it may be helpful for health providers to assess caregiver's mental health status to provide a more complete picture.

Associations Between Psychosocial Functioning and Physical Health in Youth with Maltreatment Experiences

Childhood maltreatment often results in long-term untoward outcomes, although some individuals demonstrate better psychosocial functioning. Maltreatment is linked with poor physical health outcomes but little is known about how psychosocial functioning is related to physical health. The aims of this study were to: 1) Identify heterogeneity of psychosocial functioning using a latent profile analysis. Positive functioning was measured by both fewer problematic symptoms (depressive, PTSD, anxiety, externalizing behavior, and substance abuse disorder) and the presence of the protective factor of social support; and 2) Explore the relationship between emergent classes of psychosocial functioning and physical health (self-reported illnesses, symptoms, and health status as well as measured overweight/obesity). Participants included a sample of youth with child welfare-documented maltreatment (n=219; mean age 18.3 years; range 15-23 years) at Time 4 (T4) of a longitudinal study. Mean differences or odds ratios were assessed across the health variables between classes. The three resulting classes were labeled: 1) higher support/lower symptoms (60.7%); 2) lower support/higher internalizing symptoms (29.2%); and 3) lower support/higher externalizing/substance abuse symptoms (10%). Youth in the lower/support/higher externalizing/substance abuse symptoms class had a similar high level of internalizing symptoms as the lower support/higher internalizing symptoms class. Youth in the lower support/high externalizing/substance abuse symptoms class had more colds and pain symptoms in the past month and gastrointestinal illnesses in the past year than the higher support/lower symptoms class, and more illnesses, respiratory problems, and gastrointestinal illnesses the last year than the lower support/higher internalizing symptoms class. Overall, functioning class was related to certain health problems which often have a stress component and were more prevalent for youth with more externalizing and substance abuse symptoms.

Implications of adverse childhood experiences screening on behavioral health services: A scoping review and systems modeling analysis

Widespread implementation of adverse childhood experiences (ACEs) screening is occurring in the United States in response to policies and practice recommendations. However, limited research has established how these screening efforts impact the health care system and ultimately health outcomes. This article examines the current knowledge base on screening in medical settings. A scoping review of articles reporting on ACEs screening and prevalence in the United States was conducted. Of the 1,643 unique studies across two decades, 12 articles meeting criteria included nine on routine screening in medical settings and three on population-based surveys. A Monte Carlo simulation model was designed to synthesize evidence, identify key areas of uncertainty, and explore service system implications. Results indicated significant heterogeneity in the proportion of respondents who reported ACEs, with 6% to 64% of patients reporting 1+ ACEs and .01% to 40.7% reporting 4+ ACEs. Gaps in the literature were identified regarding cut-scores for referrals and referral completion rates. Three scenarios, modeled based on these data and past research on behavioral health screenings in pediatric primary care, demonstrated how ACEs screening may differentially impact behavioral health care systems. Priorities for future research were highlighted to refine estimates of the likely impact of ACEs screening on health care delivery. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Medical Visits From Birth to 6 Months Predict Child Maltreatment Diagnoses Up to Age 5

Electronic health record data for pediatric members of Kaiser Permanente Southern California were used to identify key variables (ie, the number of emergency department visits and the number of providers) available in early infancy (0-6 months) placing children at higher risk of a maltreatment diagnosis in the first 5 years of life. The analytic sample included 96 462 children age 0 to 5 years born from January 1, 2009, to June 30, 2018. Poisson regression showed that children with ≥2 emergency department visits from birth to 6 months were at twice the risk of a maltreatment diagnosis before age 2 and 5 years compared with those children with no emergency department visits. Children with more continuity of primary care providers (0-5 providers) in the first 6 months of life were at lower risk of a maltreatment diagnosis at 2 years and 5 years than those children who saw multiple providers (6+). Information about medical utilization in early infancy may help physicians and other medical providers identify children at higher risk of maltreatment and prevent future incidents.

Child maltreatment and romantic relationships in adolescence and young adulthood: The mediating role of self-perception

BACKGROUND

Child maltreatment (CM) can disrupt the development of self, influencing the ability to form positive relationships, including romantic attachment. While mental health is a known mediator of maltreatment history and romantic relationships, less is known about the role of self-perception.

OBJECTIVE

The goal of this work is to understand the role self-perception plays in the association between CM history and romantic relationships during adolescence and young adulthood.

PARTICIPANTS

Longitudinal data from child welfare involved and comparison youth were gathered to examine whether self-perception mediated the association between CM history and the proportion of positive romantic relationships. Mean age at T1 was 11.03 years and 18.24 years at T4.

METHODS

Participants in the CM group were recruited from active Child Protective Services cases in a large west coast city. The comparison group was recruited using names from school lists of children residing in the same 10 zip codes. Assessments were conducted at an urban research university. After assent/consent were obtained, the adolescent was administered questionnaires. For the current analyses, only those who indicated they had ever had a romantic relationship were included (n = 306). Hypotheses were tested used path modeling in Mplus 7.0.

RESULTS

CM history was associated with lower self-perceptions in all domains. Only behavioral (β = 0.15, p= 0.02) and scholastic (β= -0.14, p= 0.04) self- perceptions predicted proportion of later positive romantic relationships. A significant mediation effect was found only for behavioral self- perceptions.

CONCLUSIONS

Interventions aimed at bolstering self- perceptions and engagement in positive behaviors could strengthen positive relationships for youth with CM and child welfare experiences.

Expanding our Understanding of Intergenerational Exposure to Adversity

The present study examined the intergenerational continuity of adverse childhood experiences (ACEs) for parents and their adolescent offspring. Data were from a longitudinal study of the effects of maltreatment on adolescent development. Only biological parents (n=185) and one adolescent per parent (n=164) were included in the analytic sample. Self-reported retrospective data on childhood adversities was obtained at the 3^rd wave for parents and the 4^th wave for adolescents (M _age=18.16). For siblings in the study, one was randomly chosen to be included. Latent class analysis was used to examine 1-4 class solutions for parents and adolescents separately and crosstabs were used to show the concordance between assignment to similar classes for the parent and child. Results indicated 2 class solutions for both the parent and child: a high ACEs class characterized by witnessing intimate partner violence and all maltreatment types and a low ACES class characterized by no adversities. Concordance was highest for both parent and child being assigned to the low ACEs class (52% of the dyads). There were 9% of the dyads who were concordant for being assigned to the high ACEs class, indicating less continuity of adversity than expected. Overall the findings show some intergenerational continuity of adversity, but further work should be done to characterize the different patterns of concordance/discordance between parent and child ACEs.

Parental Exposure to Childhood Maltreatment and Offspring's Mental Health: Investigating Pathways Through Parental Adversity and Offspring Exposure to Maltreatment

Parental exposure to child maltreatment (CM) is an important predictor of their offspring's CM experiences and mental health. However, less attention has been paid to examine possible mechanisms of transmission, which is critical to inform prevention and intervention efforts. The current study tested (1) whether the association between parental CM exposure and offspring CM exposure was mediated by (a) parental exposure to violence in adulthood or (b) other emotional stressors/adversities in adulthood and (2) the indirect effects from parental CM exposure to offspring mental health outcomes through parental adversity and offspring CM exposure. Data came from a longitudinal study of maltreatment on adolescent development, and analyses focused on adolescents living with a biological parent (N = 185, 51% female). Biological parents (95% mothers) reported on their history of CM and exposure to other adversities across their lifetime. Adolescents self-reported lifetime CM experiences and current depression, anxiety, posttraumatic stress disorder, and externalizing behaviors in late adolescence (M_age = 18.49). Results showed a significant indirect effect of parent CM exposure on offspring's CM exposure and mental health through parental emotional stressors/adversities, but not physical violence. These findings highlight different types of stressors that may impact the risk for intergenerational transmission of CM and subsequent offspring mental health.

The Implementation of Screening for Adverse Childhood Experiences in Pediatric Primary Care

OBJECTIVE

To assess the implementation of screening, screening rates, and prevalence of adverse childhood experiences (ACEs) in a large integrated healthcare system.

STUDY DESIGN

Kaiser Permanente Southern California is a large integrated healthcare system with 15 medical centers/hospitals and 233 medical office buildings that serve approximately 1.5 million children. Screening for ACEs began in July 2018 at 1 medical center (Downey, Bellflower medical office) for 3- and 5-year-old well-child visits (yearly physical examination). It quickly expanded to 3 other medical centers (6 clinics in total) and now also includes the 10- and 13-year-old well-child visits.

RESULTS

Since July 2018 we have screened 3241 3-year-olds (53% of the target population), 2761 5-year-olds (53%), 545 10-year-olds (37%), and 509 13-year-olds (13%). Of the 3-year-olds who were screened, 15% had an ACEs score of 1 or higher. Of the 5-year-olds that were screened, 17.5% had an ACEs score of 1 or higher. Of the 10-year-olds, 30.5% had an ACEs score of 1 or higher and of the 13-year-olds, 33.8% had an ACEs score of 1 or higher.

CONCLUSIONS

Although we have encountered some challenges, particularly with follow-up for those screening positive for ACEs, screening was feasible. The data show an increasing trend of ACEs in 3- to 13-year-old children, highlighting the need for early education about ACEs to mitigate the effects of toxic stress.

How the Structure of Egocentric Facebook Networks is Associated With Exposure to Risky Content for Maltreated versus Comparison Youth

The current study examined the size and connectedness of egocentric Facebook networks as predictors of exposure to risky content among a sample of maltreated and comparison youth (n=118). Social network measures (i.e., size, density, average degree, percent of isolates) were computed from the mutual friend list. A content analysis of posts by friends captured references to alcohol use, marijuana use, partying, and sexual content. Multiple-group path models showed that the larger size of the Facebook network and higher average degree predicted references to marijuana use only for comparison youth, whereas for maltreated youth a higher percent of isolates predicted more references to sexual content by Facebook friends. Structural measures of online networks may have potential utility for identifying those at risk.

Does the source matter? Social support and suicide attempts among homeless youth

The impact of social support on suicide is understudied among youth experiencing homelessness (YEH). This is problematic because assumptions about the protectiveness of relationships may not generalize to conflictive YEH environments. This study, which included 1047 YEH, used path modeling with a logistic regression estimator to examine associations between social support from family, home-based friends, and street-based friends and past-year suicide attempt. Social support from home-based friends but not family or street-based friends decreased suicide attempt risk. Moreover, social support from home-based friends moderated the association between depression and attempt risk. Targeted programming strengthening home-based-friend relationships represents a valuable endeavor.

ACEs are not equal: Examining the relative impact of household dysfunction versus childhood maltreatment on mental health in adolescence

RATIONALE

Adverse Childhood Experiences (ACEs) have shown substantial effects on health across the lifespan. However, many studies on this topic discount the individual items as well as the distinction between household dysfunction and maltreatment experiences.

OBJECTIVE

The current study examined individual ACEs items as well as the relative contribution of the household dysfunction scale versus the childhood maltreatment scale for predicting mental health outcomes in adolescence. Lastly, we examined the utility of a cut-off score for ACEs in predicting mental health.

METHODS

Data were from Time 4 of a longitudinal study of the effects of maltreatment on adolescent development (n = 352; Mean age = 18). Self reported ACEs were assessed via structured interview and mapped onto the original ACEs questionnaire (Kaiser-CDC). Mental health outcomes were symptoms of depression, anxiety, trauma, and externalizing behavior.

RESULTS

MANCOVA showed few mean differences between those endorsing 'yes' versus 'no' for the household dysfunction items, with the exception of witnessing parental Intimate Partner Violence (IPV). Those who endorsed witnessign IPV reported more symptoms of depression, anxiety, and trauma. On the other hand, all of the maltreatment items were asscociated with significantly higher scores on at least three of the four outcomes for those endorsing versus not. Sexual abuse and physical abuse were associated with symptoms of depression, trauma, and externalizing behavior. Neglect was associated with depressive, trauma, and anxiety symptoms. Emotional abuse and emotional neglect were both associated with all four mental health outcomes. When household dysfunction and maltreatment sum scores were entered into the model together, maltreatment primarily accounted for mental health symptoms. Finally, our results did not indicate a meaningful cutoff for the number of ACEs needed to predict mental health outcomes.

CONCLUSIONS

Our findings support the assessment of maltreatment events as more salient than household dysfunction in mental health treatment and caution health providers against only using the total ACEs score in clinical decision-making.

A pilot study examining risk behavior in facebook posts for maltreated versus comparison youth using content analysis

BACKGROUND

Social Media use is highly prevalent among contemporary adolescents yet, no studies have examined the similarity in risk content (e.g., substance use, sexual behaviors) between the online posts of maltreated youth and their friends.

OBJECTIVE

The current study examined the risk content of Facebook posts among a sample maltreated and comparison youth and compared the rates of risk content produced by the participants versus their Facebook friends.

PARTICIPANTS AND SETTING

Data were from a sample of maltreated (n = 56) and comparison (n = 62) youth. At the time of data collection participants were in young adulthood (M = 21.78 years; SD = 1.45), but the timeframe of their Facebook profiles captured mid adolescence to young adulthood.

METHODS

Data were downloaded from the Facebook profiles of all participants and the posts and comments were coded for references to alcohol, marijuana, hard drugs, partying, and sexual content.

RESULTS

The results showed that maltreated and comparison youth were similar in the amount of risky content they posted on Facebook as well as in the amount posted by their Facebook friends. Correlations between participant's and friends' posts showed stronger associations for posts about alcohol use for the maltreated group but stronger associations in the comparison group for posts about marijuana, hard drug, and sexual references. Gender differences were also examined, with males producing more online risky content than females.

CONCLUSIONS

Next steps should incorporate a more nuanced analysis to determine which online friends are the sources of risky content.

The Moderating Role of Cortisol Reactivity on the Link Between Maltreatment and Body Mass Index Trajectory Across Adolescence

PURPOSE

Child maltreatment increases risk for obesity, yet differential effects of maltreatment type remain unclear. Cortisol reactivity may help clarify these effects, given links among cortisol reactivity, maltreatment, and obesity. We examined these associations in boys and girls across adolescence.

METHODS

We collected data from 454 adolescents (212 girls) across four waves (aged 8-13 years at Time 1), including 303 maltreated youth. We modeled body mass index (BMI) percentile trajectories arrayed by age separately for boys and girls and tested whether cortisol reactivity at Time 1 moderated the association between maltreatment type and BMI growth.

RESULTS

In girls, cortisol reactivity moderated the association between maltreatment type and quadratic change in BMI. At low levels of cortisol, sexually abused girls had a steeper quadratic increase in BMI compared with comparison (-.65, 95% confidence interval [CI] -1.09 to -.22) and physically abused (-.76, 95% CI -1.29, -.24) girls. At high levels of cortisol, sexually abused girls did not differ from comparison (.15, 95% CI -.40 to .70) or physically abused (.21, 95% CI -.38 to .80) girls in quadratic change in BMI. In boys, cortisol reactivity did not moderate the association between maltreatment type and BMI growth.

CONCLUSIONS

The combination of lower cortisol reactivity and sexual abuse may put girls at risk for BMI increase during later adolescence. Given the negative consequences of high BMI, identifying and intervening with these girls could lead to better health and well-being among this group. Cortisol reactivity may not play the same role among boys.

Depressive Symptoms Predict Characteristics of Online Social Networks

PURPOSE

There is a substantial body of literature that examines depression or well-being as outcomes of social media use, but there are fewer studies that seek to understand how mental health may lead to different patterns of online interactions. The purpose of the present study was to examine how depressive symptoms may predict subsequent structural characteristics of the online social network.

METHODS

Data came from Time 3 and Time 5 of a longitudinal study on the effects of maltreatment on adolescent development. At Time 3, adolescents reported on their depressive symptoms (n = 319), and at Time 5, a subsample was enrolled in the Facebook data collection (n = 133). An application downloaded the friend list, and network metrics were computed. Path models examined the main effect of depressive symptoms at Time 3 on Facebook social network measures.

RESULTS

The coefficients indicated that higher levels of depressive symptoms at Time 3 predicted fewer Facebook friends (smaller size), fewer ties between friends (lower average degree), more components, and fewer friends in the main component of the network.

CONCLUSIONS

Depression may alter how youth form and maintain online friendships. Using social network characteristics may help identify youth at risk for serious mental illness.

Does Social Support Mediate the Association Between Maltreatment Experiences and Depressive Symptoms in Adolescence

The current study examined social support as a mediator between maltreatment experiences (number of victimizations, maltreatment types) and depressive symptoms in adolescence. The data came from the first two time points of a longitudinal study of the effects of maltreatment on adolescent development. The enrolled sample were 454 male and females ( n = 303 maltreated, n = 151 comparison) between 9 and 13 years ( M _age = 10.82); Time 2 (T2) occurred approximately 1 year after baseline. Maltreatment data came from case records; participants reported on perceived social support and depressive symptoms. Results from path models indicated that depressive symptoms mediated the association between maltreatment experiences (i.e., physical abuse, neglect, and number of maltreatment victimizations) and family social support. There was no evidence that social support functioned as a mediator. This is the first study to find support for depressive symptoms as a mechanism linking maltreatment with decreased perceived family support. These findings point to the importance of assessing mental health and social support simultaneously to understand the functioning of youth with maltreatment histories.

Predictors and correlates of unstable housing experiences among a child welfare-involved sample

The study examined whether youth demographics, family factors, and maltreatment type were related to unstable housing and whether unstable housing predicted delinquency and marijuana use. Participants included 216 child welfare-affiliated adolescents (mean age = 18.2 years). Youth with more lifetime residences were more likely to experience unstable housing although Latino youth (compared to White, Black, or multiethnic/biracial) were less likely to experience unstable housing. Unstable housing was associated with subsequent delinquency. Caregiver type (parent vs. relative/unrelated caregiver) was not related to unstable housing, thus homelessness prevention programs should include youth who remain with their parents and those with non-parent caregivers.

The Influence of Online-Only Friends on the Substance Use of Young Adults with a History of Childhood Maltreatment

BACKGROUND

Existing research shows that having offline friends that use substances increases risk for individual substance use in adolescence. However, there is little research examining the influence of online social networks on substance use in young adulthood.

OBJECTIVES

This study examined the number of online-only Facebook friends (i.e. those with no in-person contact) that were substance users in relation to the participants' alcohol and marijuana use in the past year.

METHODS

The sample (n = 114) were selected from participants enrolled in a longitudinal study on childhood maltreatment in an urban city within the United States. The mean age of the sample was 21.84 (SD = 1.43), 61% female. With participant permission, data were downloaded from Facebook to obtain the list of online friends. A self-report questionnaire recorded the substance use of each participant. Path analysis and logistic regression were used to examine (a) the number of online-only friends who drink as a predictor of participants' problem drinking, (b) the number of online-only friends who smoke marijuana as a predictor of participants' marijuana use, and (c) moderation by maltreatment status.

RESULTS

The results showed a significant effect of the number of online-only friends who smoke marijuana on the participant's marijuana use. However, after including offline friends this significant effect was no longer present, but offline friends predicted individual marijuana use. Conclusions/Importance: These findings demonstrate that substance use in online social networks may be associated with individual use in young adulthood, but that offline influence is stronger.

Suicidal because I don't feel connected or vice versa? A longitudinal study of suicidal ideation and connectedness among child welfare youth

Suicide is a major public health problem among youth involved with the child welfare system. Although social connectedness rests at the core of many prevention approaches, we know little about this relationship over time in this vulnerable population. This study tested the hypotheses that inverse relationships would exist between connectedness in three social domains (i.e., caregiver, peers, and school) and suicidal ideation over time. The current study used baseline and 18-month follow-up data from 995 youth who participated in the National Survey of Child and Adolescent Well-Being (NSCAW II)-a nationally representative study of children and families investigated by a child welfare agency conducted from 2008 to 2011. A cross-lagged path model was used for the analysis. There were significant main effects of suicidal ideation at Time 1 on peer connectedness (β= -.17, p < .01) and caregiver connectedness (β= -.12, p < .05) at Time 2, but not on school connectedness (β= -.05, ns). There was no main effect of any of the connectedness variables at Time 1 on suicidal ideation at Time 2. Screening for suicidal ideation is important for managing immediate risk but our findings suggest that such ideation also foreshadows disconnectedness from their primary caregiver and peers in the future. These findings demonstrate that there is clinical value in engaging child-welfare-involved youth and their social systems about how their suicide-related experiences may affect vital social ties. Therefore, there may be merit to designing and exploring the effects of pilot programming focused on mitigating social distancing that suicide-related experiences engender.

Structural characteristics of the online social networks of maltreated youth and offline sexual risk behavior

Maltreated youth are at risk for exposure to online sexual content and high-risk sexual behavior, yet characteristics of their online social networks have not been examined as a potential source of vulnerability. The aims of the current study were: 1) to test indicators of size (number of friends) and fragmentation (number of connections between friends) of maltreated young adults' online networks as predictors of intentional and unintentional exposure to sexual content and offline high-risk sexual behavior and 2) to test maltreatment as a moderator of these associations. Participants were selected from a longitudinal study on the effects of child maltreatment (n = 152; Mean age 21.84 years). Data downloaded from Facebook were used to calculate network variables of size (number of friends), density (connections between friends), average degree (average number of connections for each friend), and percent isolates (those not connected to others in the network). Self-reports of intentional and unintentional exposure to online sexual content and offline high-risk sexual behavior were the outcome variables. Multiple-group path modeling showed that only for the maltreated group having a higher percent of isolates in the network predicted intentional exposure to online sexual content and offline high-risk sexual behavior. An implication of this finding is that the composition of the Facebook network may be used as a risk indicator for individuals with child-welfare documented maltreatment experiences.

Longitudinal Relationship Between Mental Health Symptoms and Sleep Disturbances and Duration in Maltreated and Comparison Adolescents

PURPOSE

To examine the longitudinal relationships between mental health symptoms and sleep for male and female maltreated and comparison adolescents.

METHODS

Participants were from a longitudinal study of child maltreatment (maltreated n = 247; comparison n = 138). The current analyses used data from Time 3 (T3; average age 13.7 years) and Time 4 (T4; average age 18.2 years). Path models tested cross-lagged effects between mental health symptoms (depression and Post Traumatic Stress Disorder [PTSD]) and sleep (disturbances and duration) and main effects of maltreatment on Time 4 variables, stratified by sex.

RESULTS

Reciprocal relationships between depressive and PTSD symptoms and sleep disturbances were found only for females. Specifically, depressive and PTSD symptoms at T3 predicted sleep disturbances at T4 and sleep disturbances at T3 also predicted depressive and PTSD symptoms at T4. Regarding sleep duration, PTSD symptoms at T3 predicted shorter sleep duration at T4 among females but not for males. There was no effect of maltreatment status on mental health symptoms or sleep disturbance, but maltreated adolescents reported longer sleep duration at T4 than comparison adolescents.

CONCLUSIONS

The reciprocal nature of the relationship between mental health symptoms and sleep disturbances in females highlights the need to treat both mental health symptoms as well as sleep problems in female adolescents to improve mental and physical health. The absence of a negative effect of maltreatment on sleep may be due to the fact that the maltreated youth and comparison youth lived in the same low-income urban communities and were exposed to the same nocturnal environmental irritants.

Longitudinal associations of maternal depression and adolescents' depression and behaviors: Moderation by maltreatment and sex

This study explored the longitudinal relationships among maternal depressive symptoms, children's depressive symptoms, aggression, and rule breaking and tested the moderating effects of maltreatment and child sex. A sample of 175 biological mother-child dyads (86 maltreated and 89 comparison) were seen at three time points, beginning at an average child age of 10.87 years. Results from cross-lagged models showed maternal depressive symptoms were related to higher levels of children's depressive symptoms but not children's aggression or rule breaking. Rule breaking predicted maternal depressive symptoms only in the comparison group. Child sex moderated some relationships. Boys' depression predicted maternal depressive symptoms, whereas maternal depressive symptoms predicted aggression among girls. There was no evidence in this sample that child maltreatment increased the effects of maternal depressive symptoms on child outcomes. These results suggest that attention in clinical practice to the importance of addressing maternal depression as well as addressing children's functioning should continue into adolescence. (PsycINFO Database Record

Concordance Between Self-Reported Childhood Maltreatment Versus Case Record Reviews for Child Welfare-Affiliated Adolescents

The present study used data from an ongoing longitudinal study of the effects of maltreatment on adolescent development to (1) describe rates of maltreatment experiences obtained from retrospective self-report versus case record review for adolescents with child welfare-documented maltreatment histories, (2) examine self-reported versus child welfare-identified maltreatment in relation to mental health and risk behavior outcomes by maltreatment type, and (3) examine the association between the number of different types of maltreatment and mental health and risk behavior outcomes. Maltreatment was coded from case records using the Maltreatment Case Record Abstraction Instrument (MCRAI) and participants were asked at mean age = 18.49 about childhood maltreatment experiences using the Comprehensive Trauma Interview (CTI). Results showed that an average of 48% of maltreatment found by the MCRAI for each type of maltreatment were unique cases not captured by the CTI, whereas an average of 40% self-reported maltreatment (CTI) was not indicated by the MCRAI. Analyses with outcomes showed generally, self-reported maltreatment, regardless of concordance with MCRAI, was related to the poorest outcomes. The difference in associations with the outcomes indicates both self-report and case record review data may have utility depending on the outcomes being assessed.

Childhood Sexual Abuse and Early Timing of Puberty

PURPOSE

The purpose was to examine whether the timing of puberty, indexed by breast development and pubic hair development, was earlier for sexually abused females compared with a matched comparison group of nonabused females, controlling for key alternative confounds.

METHODS

A cohort of sexually abused females and matched comparisons was followed longitudinally at mean ages 11 through 20 years. Sexually abused participants (N = 84) were referred by protective services. Comparison participants (N = 89) were recruited to be comparable in terms of age, ethnicity, income level, family constellation, zip codes, and nonsexual trauma histories. Stage of puberty was indexed at each assessment by nurse and participant ratings of breast and pubic hair development using Tanner staging-the gold standard for assessing pubertal onset and development. Cumulative logit mixed models were used to estimate the association between sexual abuse status and the likelihood of transitioning from earlier to later Tanner stage categories controlling for covariates and potential confounds.

RESULTS

Sexual abuse was associated with earlier pubertal onset: 8 months earlier for breasts (odds ratio: 3.06, 95% CI: 1.11-8.49) and 12 months earlier for pubic hair (odds ratio: 3.49, 95% CI: 1.34-9.12). Alternative explanations including ethnicity, obesity, and biological father absence did not eradicate these findings.

CONCLUSIONS

This study confirms an association between exposure to childhood sexual abuse and earlier pubertal onset. Results highlight the possibility that, due to this early onset, sexual abuse survivors may be at increased risk for psychosocial difficulties, menstrual and fertility problems, and even reproductive cancers due to prolonged exposure to sex hormones.

Maltreated and comparison adolescents' recollections of lifetime residences: Relationship to delinquency and marijuana use

Both childhood maltreatment and frequent childhood residence changes are associated with poor behavioral outcomes including drug use and delinquency. It is not clear whether a higher number of residences results in poorer outcomes for maltreated adolescents compared to adolescents living in the same community but without child welfare-documented maltreatment. Our study of child welfare-affiliated maltreated youth (n=216) and comparison youth (n=128) from the same community (age M = 18.21, SD = 1.42) examined: 1. whether child/caregiver characteristics and maltreatment status were associated with lifetime number of residences and 2. whether child/caregiver characteristics, residences, and maltreatment status were associated with delinquency and marijuana use. The outcomes of this study, number of residences, delinquency, and marijuana use, were all skewed, and consequently negative binomial regressions were used. Maltreatment status, ever living with a non-parent caregiver, and being older are associated with more residence changes during childhood. More residences and male sex are associated with person offense delinquency and marijuana use. In lower income neighborhoods, such as where the adolescents in this study lived, residence changes are not unusual, but in this study maltreated youth moved more often than youth from the same community. It is important to help caregivers who live in disadvantaged neighborhoods, especially families with child welfare involvement, understand the behavioral consequences of residence changes and provide support for stable long-term housing.

Self-Report of Health Problems and Health Care Use among Maltreated and Comparison Adolescents

The study aims were to compare maltreated and comparison adolescents' health problems and to identify how individual, family and home characteristics and maltreatment status affect adolescents' self-report of health status and health care use. The sample was 224 maltreated adolescents (mean age = 18.3 years) and 128 comparison adolescents (mean age = 18.15 years). Comparison adolescents reported more cold and pain symptoms during the previous 30 days but no differences in other physical health problems, self-assessment of their physical and mental health or health care use compared to maltreated adolescents. Girls were more likely to have had a dental checkup, to have seen a psychological counselor, and to self-identify their physical health as poor compared to boys. Older adolescents were less likely to have had a medical checkup or seen a psychological counselor than younger adolescents. A history of maltreatment was not related to health or health care disparities for adolescents growing up in the same low-income environment as adolescents without a maltreatment report. The environmental context and geographical location in which these adolescents grew up may be the primary driver in their health behaviors and health problems and not the experience of maltreatment.

Child Maltreatment and Sexual Risk Behavior: Maltreatment Types and Gender Differences

OBJECTIVE

To compare sexual risk behaviors in maltreated male and female sexually active adolescents with a comparison population and examine whether specific maltreatment experiences were associated with sexual risk behaviors and teen pregnancy.

METHOD

Data came from the fourth assessment (M = 7.2 years after baseline) of an ongoing longitudinal study with case-control design. The sample was restricted to only the sexually active adolescents, leaving a sample of 251 (n = 82 comparison, n = 169 maltreated, mean age = 18.49 years, SD = 1.46). Maltreatment type was coded from case records, and sexual behaviors were assessed via computerized questionnaire.

RESULTS

Maltreated youth were significantly younger at first consensual intercourse than comparison youth, and males were younger than females. Maltreated males reported significantly higher number of lifetime sexual partners than maltreated females. Neglected, sexually abused, and physically abused youth were more likely to have had a one-night stand than comparison youth. Sexually abused females were at higher risk of having sex under the influence than other maltreated females. Neglected females were more likely to have ever been pregnant than females with other maltreatment types or comparison females. A higher number of maltreatment victimizations predicted a younger age at first pregnancy involvement for both sexes.

CONCLUSION

Many maltreated youth continue to be at high risk for engaging in behaviors that may initiate a trajectory of problematic sexual behaviors. The findings highlight maltreated males and neglected females as vulnerable groups that should be targeted in prevention efforts to curtail sexual risk behaviors and prevent teenage pregnancy.

Child Maltreatment and Sexual Risk Behavior: Maltreatment Types and Gender Differences

OBJECTIVE

To compare sexual risk behaviors in maltreated male and female sexually active adolescents with a comparison population and examine whether specific maltreatment experiences were associated with sexual risk behaviors and teen pregnancy.

METHOD

Data came from the fourth assessment (M = 7.2 years after baseline) of an ongoing longitudinal study with case-control design. The sample was restricted to only the sexually active adolescents, leaving a sample of 251 (n = 82 comparison, n = 169 maltreated, mean age = 18.49 years, SD = 1.46). Maltreatment type was coded from case records, and sexual behaviors were assessed via computerized questionnaire.

RESULTS

Maltreated youth were significantly younger at first consensual intercourse than comparison youth, and males were younger than females. Maltreated males reported significantly higher number of lifetime sexual partners than maltreated females. Neglected, sexually abused, and physically abused youth were more likely to have had a one-night stand than comparison youth. Sexually abused females were at higher risk of having sex under the influence than other maltreated females. Neglected females were more likely to have ever been pregnant than females with other maltreatment types or comparison females. A higher number of maltreatment victimizations predicted a younger age at first pregnancy involvement for both sexes.

CONCLUSION

Many maltreated youth continue to be at high risk for engaging in behaviors that may initiate a trajectory of problematic sexual behaviors. The findings highlight maltreated males and neglected females as vulnerable groups that should be targeted in prevention efforts to curtail sexual risk behaviors and prevent teenage pregnancy.

Childhood maltreatment, pubertal development, HPA axis functioning, and psychosocial outcomes: An integrative biopsychosocial model

The timing and pace of pubertal development has been associated with psychosocial functioning, with pubertal variables represented both as predictors (e.g., earlier puberty linked with poor outcomes) and as sequelae (e.g., early stress linked with earlier puberty). However, the literature has largely not tested mediational models or prospective mechanisms of associations between puberty and psychosocial variables. In a longitudinal study including 454 youth followed over four timepoints (mean ages 10-18), structural equation modeling tested a hypothesized path from childhood maltreatment to cortisol (Time 1) to pubertal stage (Time 2), and psychosocial outcomes (Times 3 and 4). There was not support for the full hypothesized pathway in either gender. However, for boys, maltreatment was associated with attenuated cortisol, and more pubertal change predicted subsequent delinquency. For girls, cortisol predicted more pubertal change which then predicted substance use. This study demonstrates links between HPA axis function, pubertal development, and risky outcomes.

Body mass index trajectory throughout adolescence: a comparison of maltreated adolescents by maltreatment type to a community sample

BACKGROUND

Childhood maltreatment is associated with adult obesity, but there is conflicting evidence regarding the relationship between childhood maltreatment and obesity during adolescence.

OBJECTIVES

To compare the body mass index (BMI) trajectory of adolescents with a specific type of maltreatment (sexual abuse, physical abuse, emotional abuse or neglect) to adolescents with another type of maltreatment (maltreated sample n = 303) and to a comparison group (n = 151).

METHODS

Individual growth models were used to estimate average growth trajectories of BMI percentile separately by sex (ages 9 to 22 years). Unconditional and conditional linear and quadratic growth models were estimated and maltreatment types were added before including covariates (ethnicity, anxiety, depression and pubertal stage).

RESULTS

BMI growth trajectories of sexually abused girls and neglected girls were significantly different from comparison girls. Comparison girls had a growth trajectory that reached its apex at 15 years and then began to decline, whereas sexually abused girls and neglected girls had lower BMI than comparison girls until age 16-17 years when their BMI was higher than comparison girls.

CONCLUSIONS

Late adolescence appears to be the developmental period during which differences in BMI percentiles become pronounced between girls with sexual abuse or with neglect vs. comparison girls.

Elucidating the mechanisms linking early pubertal timing, sexual activity, and substance use for maltreated versus nonmaltreated adolescents

PURPOSE

To test models linking pubertal timing, peer substance use, sexual behavior, and substance use for maltreated versus comparison adolescents. Three theoretical mechanisms were tested: (1) peer influence links early pubertal timing to later sexual behavior and substance use; (2) early maturers engage in substance use on their own and then select substance-using friends; or (3) early maturers initiate sexual behaviors which lead them to substance-using peers.

METHODS

The data came from a longitudinal study of the effects of child maltreatment on adolescent development (303 maltreated and 151 comparison adolescents; age, 9-13 years at initial wave). Multiple-group structural equation models tested the hypotheses across three time points including variables of pubertal timing, perception of peer substance use, sexual behavior, and self-reported substance use.

RESULTS

Early pubertal timing was associated with substance-using peers only for maltreated adolescents, indicating the mediation path from early pubertal timing through substance-using peers to subsequent adolescent substance use and sexual behavior only holds for maltreated adolescents. Mediation via sexual behavior was significant for both maltreated and comparison adolescents. This indicates that sexual behavior may be a more universal mechanism linking early maturation with risky friends regardless of adverse life experiences.

CONCLUSIONS

The findings are a step toward elucidating the developmental pathways from early puberty to risk behavior and identifying early experiences that may alter mediation effects.

Pubertal Timing and Tempo: Associations With Childhood Maltreatment

The present study examined pubertal timing and tempo in a sample of 445 adolescents (53% male), using both variable-centered (latent growth curve) and person-centered (latent class) approaches, to discern the pubertal development trajectories associated with the experience of maltreatment. Results from the variable-centered analyses indicated a slower initial tempo that increased later for boys who had experienced neglect. The person-centered results indicated three classes for boys that mainly differentiated tempo effects and two classes for girls primarily distinguishing timing differences. For girls, sexual abuse predicted membership in an earlier pubertal timing class. These findings enhance our knowledge of the variability in pubertal development as well as gender differences in maltreatment types that may alter pubertal timing and tempo.