23 Mar 2015: The PLOS ONE Staff (2015) Correction: Association of Childhood Physical and Sexual Abuse with Intimate Partner Violence, Poor General Health and Depressive Symptoms among Pregnant Women. PLoS ONE 10(3): e0122573. doi: 10.1371/journal.pone.0122573 View correction
We examined associations of childhood physical and sexual abuse with risk of intimate partner violence (IPV). We also evaluated the extent to which childhood abuse was associated with self-reported general health status and symptoms of antepartum depression in a cohort of pregnant Peruvian women.
In-person interviews were conducted to collect information regarding history of childhood abuse and IPV from 1,521 women during early pregnancy. Antepartum depressive symptomatology was evaluated using the Patient Health Questionnaire-9. Multivariable logistic regression procedures were used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (95%CI).
Any childhood abuse was associated with 2.2-fold increased odds of lifetime IPV (95%CI: 1.72–2.83). Compared with women who reported no childhood abuse, those who reported both, childhood physical and sexual abuse had a 7.14-fold lifetime risk of physical and sexual IPV (95%CI: 4.15–12.26). The odds of experiencing physical and sexual abuse by an intimate partner in the past year was 3.33-fold higher among women with a history of childhood physical and sexual abuse as compared to women who were not abused as children (95%CI 1.60–6.89). Childhood abuse was associated with higher odds of self-reported poor health status during early pregnancy (aOR = 1.32, 95%CI: 1.04–1.68) and with symptoms of antepartum depression (aOR = 2.07, 95%CI: 1.58–2.71).
These data indicate that childhood sexual and physical abuse is associated with IPV, poor general health and depressive symptoms in early pregnancy. The high prevalence of childhood trauma and its enduring effects of on women’s health warrant concerted global health efforts in preventing violence.
Citation: Barrios YV, Gelaye B, Zhong Q, Nicolaidis C, Rondon MB, Garcia PJ, et al. (2015) Association of Childhood Physical and Sexual Abuse with Intimate Partner Violence, Poor General Health and Depressive Symptoms among Pregnant Women. PLoS ONE 10(1): e0116609. doi:10.1371/journal.pone.0116609
Academic Editor: Jon D. Elhai, Univ of Toledo, UNITED STATES
Received: September 20, 2014; Accepted: December 10, 2014; Published: January 30, 2015
Copyright: © 2015 Barrios et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Data Availability: All relevant data are within the paper and its Supporting Information files. The participant level data are from the Pregnancy Outcomes, Maternal and Infant Study whose authors may be contacted at email@example.com. The local ethical committee does not allow public deposition of the data.
Funding: This research was supported by an award from the National Institutes of Health (NIH), the Eunice Kennedy Shriver Institute of Child Health and Human Development (R01-HD-059835). The NIH had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Competing interests: The authors have declared that no competing interests exist.
Childhood abuse has been shown to be associated with serious adverse health consequences across the life course [1–4]. Notably, childhood trauma and adverse experiences have been linked with increased risks of developmental difficulties, sensation seeking behaviors, as well as somatic and mental health outcomes including increased risks of asthma , early age at menarche [6,7] chronic systemic inflammation , substance abuse , mood and anxiety disorders , suicidal behaviors  and premature mortality . Some investigative teams have reported that women with a history of childhood abuse, particularly childhood sexual abuse, may be at exceptionally high risk of revictimization in adulthood [12,13]. For example, Russell et al  reported that childhood incest victims were almost twice as likely to experience rape or attempted rape after age 14 years, as compared with a group of women with no history of incest. Similar associations of childhood abuse with increased risks of both physical and sexual abuse have been documented in population-based surveys, clinical samples and cohorts of college women [14,15]. Additionally, a history of childhood abuse has been linked to an increased risk of exposure to intimate partner violence (IPV) in adulthood by most [16–20], though not all  previous investigators.
Despite inconsistent findings across studies, available evidence suggests that women with a history of childhood abuse have an increased risk of IPV in adulthood. Many of the earlier studies, however, have been conducted in North American and European populations. Hence, relatively little is known about the epidemiology and association of childhood abuse and IPV among women in low- and middle-income countries such as Peru. In the recent World Health Organization  multi-country study on domestic violence, the lifetime prevalence of any physical or sexual partner violence varied from 15% to 71% [23–25]. Moreover, studies have also shown that victims of IPV are more likely to experience depression [26–28], anxiety , suicide ideation [30–33], and post-traumatic stress disorder [34–36] than those without such history. However, many studies have not quantified risk by type of abuse experienced at the hands of an intimate partner in relation to type of childhood abuse. In a large sample of low-income pregnant Peruvian women receiving routine prenatal care, we examined the associations of women’s childhood experiences of physical and sexual abuse with risk of physical and sexual abuse by an intimate partner. We also evaluated the extent to which, if at all, childhood physical and sexual abuse was associated with women’s self-reported general health status and symptoms of antepartum depression.
The PrOMIS Study
The population for the present study was drawn from participants of the ongoing Pregnancy Outcomes, Maternal and Infant Study (PrOMIS) Cohort, designed to examine maternal social and behavioral risk factors of preterm birth and other adverse pregnancy outcomes among Peruvian women. The study population consists of women attending prenatal care clinics at the Instituto Nacional Materno Perinatal (INMP) in Lima, Peru. The INMP is the primary reference establishment for maternal and perinatal care operated by the Ministry of Health of the Peruvian government. Recruitment began in February 2012. Women eligible for inclusion were those who initiated prenatal care prior to 16 weeks gestation since, on average, less than 10% of women initiate prenatal care after 16 weeks of gestation at INMP. Women were ineligible if they were younger than 18 years of age, did not speak and read Spanish, or had completed more than 16 weeks gestation.The eligibility criteria threshold of initiating prenatal care prior to the completion of 16 weeks gestation was set so as to mitigate concerns about reverse causality and recall bias while enrolling a study population that is sufficiently generalizable to the source population of women seeking care at the study site. Before setting this threshold, we determined that over 90% of women delivering at INMP initiate prenatal care prior to 16 weeks gestation.
Enrolled participants were invited to take part in an interview where trained research personnel used a structured questionnaire to elicit information regarding maternal socio-demographic, lifestyle characteristics, medical and reproductive histories, and early life experiences of abuse and with symptoms of mood and anxiety disorders. All participants provided written informed consent. The institutional review boards of the INMP, Lima, Peru and the Harvard School of Public Health Office of Human Research Administration, Boston, MA approved all procedures used in this study.
The study population for this report is derived from information collected from those participants who enrolled in the PrOMIS Cohort Study between February 2012 and March 2013. During this period 1,810 eligible women were approached, and 1,556 (86%) agreed to participate. Thirty-five participants were excluded from the present analysis because of missing information concerning experience with abuse in childhood and/or missing information for IPV in adulthood. Women excluded from this analysis did not differ in regards to sociodemographic and lifestyle characteristics as compared with those included. A total of 1,521 women remained for analysis.
Childhood Abuse Assessment
We used the Childhood Physical and Sexual Abuse Questionnaire to elicit information concerning participants’ experiences with physical and sexual abuse in childhood . The instrument consists of eight questions concerning abuse taken from the Centers for Disease Control and Prevention (CDC) Adverse Childhood Experiences Study. Participants were rated as having experienced childhood abuse if, before the age of 18 years, they reported that an older person touched them, they were made to touch someone else in a sexual way, or intercourse was attempted or completed (sexual abuse); or that they were hit, kicked, or beaten often and/or their life was seriously threatened (physical abuse). Participants who responded ‘no’ to all questions regarding sexual and physical abuse were categorized as ‘no abuse’. Those responding ‘yes’ to only physical abuse questions were categorized as ‘physical abuse only’ and those responding ‘yes’ to only sexual abuse questions were categorized as ‘sexual abuse only’. Those responding ‘yes’ to any physical abuse questions and ‘yes’ to any sexual abuse questions were categorized as having experienced ‘both physical and sexual abuse’. Participants who responded ‘yes’ to any questions of physical abuse or ‘yes’ to any questions of sexual abuse or yes to both abuse types were categorized as having experienced ‘any abuse’.
Questions on IPV were adapted from the protocol of Demographic Health Survey Questionnaires and Modules: Domestic Violence Module  and the WHO Multi-Country Study on Violence Against Women . Women were assessed for a range of physical and/or sexual coercive acts used against them by a current or former husband or intimate partner without their consent. Women were classified as having experienced moderately severe physical violence if they endorsed any of the following acts: being slapped, having her arms twisted or something thrown at her, being pushed or shoved. Participants were classified as having experienced severe physical violence if they reported experiencing any of the following acts: being hit, kicked, dragged or beaten up, being choked or burnt on purpose, or being threatened or hurt with a weapon (such as, gun, knife, or other object). Participants were classified as having experienced sexual violence if they endorsed any of the following: being physically forced to have sexual intercourse, having had unwanted sexual intercourse because of fear of what the partner might do, and being forced to perform other sexual acts that the respondent found degrading or humiliating. In this study, women were categorized as having experienced one or more acts of physical or sexual violence, physical violence only, sexual violence only, or both physical and sexual violence at any time from a current or former male partner. All study personnel were trained on interviewing skills, contents of the questionnaire, and ethical conduct of violence research (including issues of safety and confidentiality). Interviewers were trained to refer participants found to be in physically dangerous situations and/or in immediate need for counseling to psychologists at local women’s organizations, hospital psychiatrists, and battered women’s shelters.
Depressive symptomatology during pregnancy was evaluated using the Patient Health Questionnaire-9 (PHQ-9) . The PHQ-9 has been demonstrated to be a reliable tool for assessing depressive disorders among a diverse group of obstetrics-gynecology patients [40,41] and in Spanish-speaking women . The 9-item instrument asks respondents to rate the relevancy of each statement comprising emotional, cognitive, and functional somatic symptoms over the past two weeks on a four-point scale a) never; b) several days; c) more than half the days; or d) nearly everyday. The PHQ-9 total score is the sum of scores for the nine items for each participant, and ranged from 0–27. Participants were assigned to one of five depressive symptom categories based on total PHQ-9 score, (a) no depressive symptoms (0–4), (b) mild (5–9), (b) moderate (10–14), (c) moderately severe (15–19) and (d) severe (20–27) depressive symptoms. For the purpose of this study, we assigned participants to one of two categories of depressive symptoms based on total PHQ-9 score, (a) no depressive symptoms (0–9) and (b) moderate to severe depressive symptoms (10–27) [39,43,44]. A meta-analysis of 14 studies support the use of a PHQ-9 score of ≥10 to classify subjects with major depressive disorder . Briefly, the authors reported that a cut-off of ≥10 had a sensitivity and specificity of 0.80 and 0.92, respectively .
Participants’ age was categorized as follows: 18–20, 20–29, 30–34, and ≥35 years. Other sociodemographic variables were categorized as follows: maternal ethnicity (Hispanic vs. others); educational attainment (≤6, 7–12, and >12 completed years of schooling); marital status (married and living with partner vs. others); employment status (employed vs. not employed); access to basic foods (very hard/hard, somewhat hard, not very hard); parity (nulliparous vs. multiparous); planned pregnancy (yes vs. no); self-reported health in the last year (good vs. poor) and gestational age at interview.
Frequency distributions of maternal sociodemographic and reproductive characteristics were examined. Chi-square tests for categorical variables and Student’s t tests for continuous variables were conducted to determine whether there were statistically significant differences in the association between socio demographic and reproductive characteristics and history of any childhood abuse. Multivariate adjusted logistic regression procedures were used to calculate maximum likelihood estimates of odds ratios (ORs) and 95% confidence intervals (CIs) of history of lifetime IPV (any lifetime physical or sexual violence, physical violence only, sexual violence only, and both physical and sexual violence) in relation to history of childhood abuse. We included covariates of a priori interest (i.e., maternal age, education, employment status, parity and difficulty paying for the very basics) in the final multivariate adjusted logistic regression models. Multinomial logistic regression procedures were used to estimate odds of lifetime IPV in relation to types of history of childhood abuse (e.g., physical abuse only, sexual abuse only, and both physical and sexual abuse). These analyses were important for identifying heterogeneity in risk of IPV in relation to prior history of abuse. For these analyses, women who had no history of childhood abuse (either physical or sexual) and no history of IPV constituted the reference group. All statistical analyses were performed using SAS 9.3 (SAS Institute, Cary, NC, USA). All reported P-values are 2-tailed with statistical significance set at 0.05.
In this cohort, the vast majority of participants reported exposure to physical or sexual abuse as a child. As shown in Fig. 1, 61.1% of exposed women reported experience of physical abuse; and 32.2% reported experience with sexual abuse. Overall, 37.3% of the cohort reported childhood physical abuse only, 24.3% of the cohort reported experience with both physical and sexual abuse; and 7.8% experienced sexual abuse only in childhood. Of the 489 women who experienced sexual abuse in childhood, 24% were victims of rape. Additionally, of the 489 women who were sexually abused in childhood, 93.3% reported that an adult sexually abused them.
Sociodemographic and reproductive characteristics of the study population are summarized in Table 1. Approximately 70.0% of study participants reported a history of physical or sexual abuse in childhood (<18 years of age). Individuals who were exposed to physical or sexual abuse as a child were older, more likely to have difficulty paying for basic needs, and to report poor health status as compared with those who were not abused as a child. Participants who were abused as children were less likely to be nulliparous as compared to those not abused as a child. The two study groups were similar with regards to educational attainment, gestational age at interview, race/ethnicity and employment status. Of note, individuals abused in childhood were more likely to have a positive lifetime history of physical or sexual abuse by an intimate partner in adulthood (44.9% vs. 25.8%, p-value <0.01).
Table 2, shows adjusted odds ratio (aOR) and 95% confidence interval (95% CI) of experiencing lifetime IPV in relation to childhood abuse history. Women with a history of experiencing any childhood abuse had 2.2-fold increased odds of suffering from any lifetime IPV (aOR = 2.20; 95%CI: 1.72–2.83). Compared to women who reported no history of childhood abuse those who experienced any childhood abuse also had increased odds of experiencing lifetime physical IPV only (aOR = 1.94; 95%CI: 1.45–2.58), lifetime sexual IPV only (aOR = 2.27; 95%CI: 1.30–3.95) and lifetime physical and sexual IPV (aOR = 3.29; 95%CI: 2.01–5.38). The association of experiencing IPV during lifetime was particularly strong among women with a history of both physical and sexual abuse during childhood (aOR = 7.14; 95%CI: 4.15–12.26) lifetime IPV. Associations of childhood abuse with IPV during the past year were similar in direction as lifetime IPV, but lower in magnitude (Table 3). Compared to women who had no childhood abuse history, those women who suffered from both physical and sexual childhood abuse had the highest odds of experiencing any IPV (aOR = 3.00; 95%CI: 2.07–4.35), physical IPV only (aOR = 2.73; 95%CI: 1.77–4.20), sexual IPV only (aOR = 4.24; 95%CI: 1.77–10.17) and both physical and sexual IPV (aOR = 3.33; 95%CI: 1.60–6.89) in the past year.
Table 4, shows the association of childhood abuse with self-reported health status in the past year and during the current pregnancy. Compared to women with no childhood abuse history, those women who experienced any childhood abuse had increased odds of reporting their health as poor in the past year (aOR = 1.63; 95%CI: 1.26–2.11) and during the current pregnancy (aOR = 1.32; 95%CI: 1.04–1.68). We found elevated odds of poor self-reported health in the past year among abused women, specifically for women with a history of both physical and sexual childhood abuse (aOR = 2.12; 95%CI: 1.56–2.89). Of note, the association remained virtually unchanged when we included women’s experience with IPV in the current pregnancy into the model (aOR = 2.02; 95% CI: 1.42–2.87). A similar association, but lower in magnitude, was found for self-reported poor health status during the current pregnancy.
We also evaluated the prevalence of antepartum depression, measured using the PHQ-9 instrument, according to childhood abuse. As shown in Table 5, compared to women who had no childhood experience with physical or sexual abuse, those who experienced any childhood abuse had 2.1-fold increased odds of experiencing antepartum depression (aOR = 2.07; 95%CI: 1.58–2.71). We observed elevated odds of antepartum depression among women with a history of both physical and sexual childhood abuse (aOR = 2.47; 95%CI: 1.79–3.40); and this association remained even when exposure to IPV during the index pregnancy was accounted for in multivariable models (aOR = 2.14; 95%CI: 1.47–3.11). Of note, the odds of antepartum depression were not elevated in women with a history of only sexual childhood abuse.
Finally, we wanted to evaluate the phenomenon of re-victimization, and therefore repeated multinomial logistic regression to identify whether women who reported childhood physical only, sexual abuse only or both physical and sexual abuse had distinctly different odds of experiencing subsequent intimate partner violence in adulthood. In Fig. 2 we can see that the odds of revictimization by an intimate partner increased for all women who experienced any childhood abuse. The association was particularly strong for those who experienced both physical and sexual abuse. For example, compared to women never abused, those women who experience childhood sexual abuse only had a 3.4-fold increased odds of suffering physical and sexual abuse IPV during lifetime (OR = 3.44; 95%CI: 1.64–7.22). Notably, those who experienced both types of childhood abuse, physical and sexual, had a 6.9-fold increased odds of subsequently also experiencing both types of adulthood IPV (aOR = 6.88; 95%CI: 4.03–11.76). These results indicate that women with a history of childhood abuse, particularly those physically and sexually abused, are at increased risk for revictimization by an intimate partner during their lifetime.
Our study extends the literature by adding evidence of increased odds of adult physical and sexual abuse among pregnant Peruvian women with a history of childhood physical and sexual abuse. Strengths of our study include having a large sample size, the relatively high participation rate (86%), and the use of structured questionnaires including a validated instrument for assessing maternal antepartum depression. Furthermore, multivariable regression analyses are conducted to evaluate the type/types of childhood abuse that are associated with IPV, health status and antepartum depression. Because exposure to physical and sexual abuse is highly interrelated, we conducted statistical analyses to simultaneously consider the impact of independent and joint experiences on each outcome.
Several limitations, however, should be considered when interpreting the results from our study. First, experience of childhood abuse, IPV, and maternal antepartum depressive symptoms were assessed based on self-report in this cross-sectional study. Therefore, these measures may be subjected to non-systematic errors in recall, as well as systematic non-disclosure leading to misclassification. Investigators have noted that individuals are likely to minimize experiences of past violence rather than suggest that they had experienced violence in their lifetime . Errors in recall may have led to an underestimation of reported associations. Indeed, investigators who have conducted longitudinal studies of adults whose childhood abuse was documented have reported that participants’ retrospective reports of childhood abuses are likely to underestimate actual experiences [47,48]. In addition, since the exact age of onset for childhood abuse was not collected in our study, it is possible that younger study participants whose onset was closer to the interview period might have recalled their experiences more accurately than older participants. To help mitigate the likelihood of systematic reporting errors, well-trained interviewers used a standard questionnaire to collect information from all study participants. Additionally, our investigative team worked to make sure that neither the interviewers nor study participants were aware of specific study hypotheses. Furthermore, instruments used in this study to characterize participants’ violence exposure histories [i.e., The Childhood Physical and Sexual Abuse Questionnaire , the Demographic Health Survey Questionnaires and Modules: Domestic Violence Module  and the WHO Multi-Country Study on Violence Against Women  have been shown to be broadly applicable in ascertaining violence exposures in multicultural settings. Additionally, maternal antepartum depression was determined using an instrument that has well-established psychometric properties in diverse Spanish-speaking study populations [42,45,49,50]. Second, we did not have information on the temporal relationship between the onset and end of the reported violence, which precludes the determination of causality in this relationship. In addition, we did not have data on onset of depression or lifetime history of depression. Prospective studies that include clinical evaluation of participants’ mental health status are needed to confirm causal inferences. Third, although 81% of women reporting IPV in the index pregnancy are married and/or lived with their partner, we cannot with certainty claim the perpetrator of IPV was the father of the child. Finally, despite controlling for potential confounders, residual confounding by factors not measured in our study (e.g., witnessing of parental violence, family conflict and social networks) may have influenced reported estimation of associations. Lastly, results from our hospital-based study may not be applicable to the general population of women because women seeking care at INMP are primarily from a low socioeconomic background and may have high-risk pregnancies. However, our study provides data on an important population in Peru, a population of pregnant women that has been documented to have a high burden of social, medical and mental health problems [24,51–54].
The prevalence of childhood physical and sexual abuse and lifetime exposure to physical and sexual abuse by an intimate partner in our study sample is largely consistent with estimates previously reported in the literature [23,24,55–59]. Our finding of increased odds of IPV among women with a history of childhood sexual abuse is consistent with several studies that have documented high risks of violence re-victimization among individuals with a history of childhood sexual abuse [18,60–62]. For example, in their study of pregnant women receiving prenatal care in Soweto, South Africa, Dunkle and colleagues  reported that women who were sexually abused as children had an increased risk of being sexually abused by an intimate partner. In their study of urban pregnant women in the US, Nelson et al, reported that women reporting any type of childhood violence were 2.5-fold as likely to be experiencing violence in their study pregnancy (OR = 2.5, 95%CI: 1.8–2.7) . Our findings are also consistent with reports from Arata et al  and Trickett et al  who reported elevated risks of re-victimization among women who were sexually abused in childhood. Our study extends the existing literature by documenting particularly elevated odds of lifetime risk of physical and sexual abuse by an intimate partner among low-income pregnant women with a history of childhood physical and sexual abuse.
In the present study we found that childhood abuse was associated with 30% higher odds of self-reported poor health status. These findings are consistent with earlier reports. For example, other investigators have reported that survivors of childhood sexual abuse tend to have more negative perceptions of their general health [63,64] and mental health status . In a study of 179 Brazilian women, investigators reported that women who were sexually abused children had poorer perception of health status, including mental health status as compared with non-abused women .
In addition to self-reported health, childhood physical and sexual abuse has been shown to be associated with a number of adverse health outcomes in adulthood. For example, childhood sexual abuse has been associated with increased risks of depression [66–68] and suicidal behavior [69–71]. Of note among pregnant women, a history of childhood sexual abuse has been associated with antepartum depression [72,73]. Our finding showing increased odds of antepartum depression among women with a history of childhood physical or sexual abuse (OR = 2.1; 95%CI: 1.6–2.7) is generally consistent with the existing literature. For example, in their study of Israeli pregnant women, Yampolsky et al , women with a history of childhood sexual abuse had a 1.5-fold increased risk of depression as compared with women who reported no abuse as a child. In a sample of 357 pregnant US women, Benedict et al. found that history of childhood sexual abuse was associated with more than two-fold increased odds of antepartum depression (OR = 2.4; 95%CI: 1.1–5.3) . Bonomi et al, in a Seattle-based health maintenance organization, found that women with history of psychical and sexual childhood abuse had significantly lower functional health and well-being scores (as measured using the 36-Item Short Form Survey Instrument) (2.32–4.52 points lower), increased odds of fair/poor health (prevalence odds ratio = 1.84; 95%CI: 1.3−2.6) and increased odds of depressive symptoms (prevalence odds ratio = 2.2; 95% CI: 1.8–2.6) (assessed using Center for Epidemiological Studies-Depression Scale) . In sum, our findings and those of others [72,73,76] indicate that childhood abuse has long lasting implications for general and mental health.
Child abuse, a severe early life stressor, is thought to disrupt neurodevelopmental processes that contribute to physical, behavioral and mental health problems later in life. The influences of early life abuse are thought to be modulated, in part, via three neurobiological stress response systems: (1) the serotonin system; (2) the sympathetic nervous system; and (3) the hypothalamic-pituitary-adrenal axis [77–79]. Disruptions to any or all of these systems are known to promote a cascade of physiological, neurochemical, and hormonal changes, which can lead to alterations in brain structure and function and contribute to a myriad of enduring behavioral and cognitive problems[77,78]. For instance, childhood abuse has been linked to behavioral outcomes including internalizing behavioral problems such as limited stress tolerance, anxiety, affective instability, dissociative disturbances, depression and suicidality; as well as externalizing behavioral symptoms including poor impulse control, episodic aggression, substance abuse, attention deficit hyperactivity disorder and conduct disorder [78,80–84]. Childhood abuse has also been associated with a number of cognitive problems including low academic performance and IQ, as well as language, memory, and attention deficits . Taken together, evidence of neuropsychological impairments associated with childhood abuse are consistent with the thesis that early childhood stressors and trauma predispose individuals to subconscious beliefs of unworthiness which may lead to the avoidance of those who truly care and instead a tendency to gravitate towards chaotic relationships [86,87]. In addition findings from structural neuroimaging studies provide evidence of deficits in brain volume, gray and white matter of several regions, most prominently the dorsolateral and ventromedial prefrontal cortex but also hippocampus, amygdala, and corpus callosum among victims of childhood abuse . These data also add biological plausibility to our findings and those of others [2,16,19].
Our study reinforces numerous previous studies confirming high prevalence of childhood abuse [57,88] and high prevalence of lifetime IPV [23,24]. The high frequencies of exposure coupled with the complexity and interrelationships among the types of exposure support arguments for much more systematic, frequent, and intensive efforts to monitor the epidemiology of violence across the life course. Considering that victimization experiences accumulate across the life course, intervention should also target child victims and aim to prevent their future re-victimization. Policies and programs for preventing childhood abuse and its underlying causes are needed. There is a limited but promising body of evidence for preventative intervention programs for childhood abuse such as training in parenting and home visitations [22,89–91]. Careful cross-cultural adaptation of these programs and rigorous evaluation to monitor their impact is warranted. Our findings also suggest that childhood abuse and abuse by an intimate partner in adulthood are factors associated with maternal self-reported health status and antepartum depression. Asking pregnant women during early prenatal care visits about their experience with current and childhood violence may open a discussion about the potential risk of coping with these traumatic events through substance use during the pregnancy. Providing treatment for depression early in pregnancy may significantly improve pregnancy and early child developmental outcomes. The high prevalence of childhood abuse and the enduring effects of early trauma on women’s health warrant concerted global health efforts in preventing violence. Women abused as children are set on a trajectory for subsequent abuse and are a particularly vulnerable population. Public health efforts should be made to prevent childhood abuse, identify women with a history of childhood abuse and provide these women assistance with management of risky health behaviors, mental health issues and ongoing IPV.
This research was supported by an award from the National Institutes of Health (NIH), the Eunice Kennedy Shriver Institute of Child Health and Human Development (R01-HD-059835). The NIH had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. The authors wish to thank the dedicated staff members of Asociacion Civil Proyectos en Salud (PROESA), Peru and Instituto Materno Perinatal, Peru for their expert technical assistance with this research.
Conceived and designed the experiments: MAW. Performed the experiments: MAW SES. Analyzed the data: MAW QZ YVB BG. Contributed reagents/materials/analysis tools: MAW PJG PAMS SES. Wrote the paper: MAW YVB BG QZ CN MBR PJG PAMS SES.
- 1. Danese A, Moffitt TE, Harrington H, Milne BJ, Polanczyk G, et al. (2009) Adverse childhood experiences and adult risk factors for age-related disease: depression, inflammation, and clustering of metabolic risk markers. Arch Pediatr Adolesc Med 163: 1135–1143. doi: 10.1001/archpediatrics.2009.214. pmid:19996051
- 2. Dube SR, Anda RF, Felitti VJ, Chapman DP, Williamson DF, et al. (2001) Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. JAMA 286: 3089–3096. doi: 10.1001/jama.286.24.3089. pmid:11754674
- 3. Fang X, Brown DS, Florence CS, Mercy JA (2012) The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse Negl 36: 156–165. doi: 10.1016/j.chiabu.2011.10.006. pmid:22300910
- 4. Sachs-Ericsson N, Blazer D, Plant EA, Arnow B (2005) Childhood sexual and physical abuse and the 1-year prevalence of medical problems in the National Comorbidity Survey. Health Psychol 24: 32–40. doi: 10.1037/0278-6184.108.40.206. pmid:15631560
- 5. Coogan PF, Wise LA, O’Connor GT, Brown TA, Palmer JR, et al. (2013) Abuse during childhood and adolescence and risk of adult-onset asthma in African American women. J Allergy Clin Immunol 131: 1058–1063. doi: 10.1016/j.jaci.2012.10.023. pmid:23219171
- 6. Kendall-Tackett KA, Simon AF (1988) Molestation and the onset of puberty: data from 365 adults molested as children. Child Abuse Negl 12: 73–81. doi: 10.1016/0145-2134(88)90009-9. pmid:3365584
- 7. Wise LA, Palmer JR, Rothman EF, Rosenberg L (2009) Childhood abuse and early menarche: findings from the black women’s health study. Am J Public Health 99 Suppl 2: S460–466. doi: 10.2105/AJPH.2008.149005. pmid:19443822
- 8. Bertone-Johnson ER, Whitcomb BW, Missmer SA, Karlson EW, Rich-Edwards JW (2012) Inflammation and early-life abuse in women. Am J Prev Med 43: 611–620. doi: 10.1016/j.amepre.2012.08.014. pmid:23159256
- 9. Banducci AN, Hoffman EM, Lejuez CW, Koenen KC (2014) The impact of childhood abuse on inpatient substance users: specific links with risky sex, aggression, and emotion dysregulation. Child Abuse Negl 38: 928–938. doi: 10.1016/j.chiabu.2013.12.007. pmid:24521524
- 10. Hornor G (2010) Child sexual abuse: consequences and implications. J Pediatr Health Care 24: 358–364. doi: 10.1016/j.pedhc.2009.07.003. pmid:20971410
- 11. Brown DW, Anda RF, Tiemeier H, Felitti VJ, Edwards VJ, et al. (2009) Adverse childhood experiences and the risk of premature mortality. Am J Prev Med 37: 389–396. doi: 10.1016/j.amepre.2009.06.021. pmid:19840693
- 12. Russell DE (1983) The incidence and prevalence of intrafamilial and extrafamilial sexual abuse of female children. Child Abuse Negl 7: 133–146. doi: 10.1016/0145-2134(83)90065-0. pmid:6605793
- 13. Schaaf KK, McCanne TR (1998) Relationship of childhood sexual, physical, and combined sexual and physical abuse to adult victimization and posttraumatic stress disorder. Child Abuse Negl 22: 1119–1133. doi: 10.1016/S0145-2134(98)00090-8. pmid:9827317
- 14. Siegel JM, Sorenson SB, Golding JM, Burnam MA, Stein JA (1987) The prevalence of childhood sexual assault. The Los Angeles Epidemiologic Catchment Area Project. Am J Epidemiol 126: 1141–1153. pmid:3500638
- 15. Runtz MG, Schallow JR (1997) Social support and coping strategies as mediators of adult adjustment following childhood maltreatment. Child Abuse Negl 21: 211–226. doi: 10.1016/S0145-2134(96)00147-0. pmid:9056101
- 16. Coid J, Petruckevitch A, Feder G, Chung W, Richardson J, et al. (2001) Relation between childhood sexual and physical abuse and risk of revictimisation in women: a cross-sectional survey. Lancet 358: 450–454. doi: 10.1016/S0140-6736(01)05622-7. pmid:11513908
- 17. Bensley L, Van Eenwyk J, Wynkoop Simmons K (2003) Childhood family violence history and women’s risk for intimate partner violence and poor health. Am J Prev Med 25: 38–44. doi: 10.1016/S0749-3797(03)00094-1. pmid:12818308
- 18. Trickett PK, Noll JG, Putnam FW (2011) The impact of sexual abuse on female development: lessons from a multigenerational, longitudinal research study. Dev Psychopathol 23: 453–476. doi: 10.1017/S0954579411000174. pmid:23786689
- 19. Zhang TH, Chow A, Wang LL, Yu JH, Dai YF, et al. (2013) Childhood maltreatment profile in a clinical population in China: a further analysis with existing data of an epidemiologic survey. Compr Psychiatry 54: 856–864. doi: 10.1016/j.comppsych.2013.03.014. pmid:23597603
- 20. Barnes JE, Noll JG, Putnam FW, Trickett PK (2009) Sexual and physical revictimization among victims of severe childhood sexual abuse. Child Abuse Negl 33: 412–420. doi: 10.1016/j.chiabu.2008.09.013. pmid:19596434
- 21. Hotaling G, Sugarman D (1990) A risk marker analysis of assaulted wives. Journal of Family Violence 5: 1–13. doi: 10.1007/bf00979135
- 22. WHO (2005) Promoting mental health: concepts, emerging evidence, practice: report of the World Health Organization, Department of Mental Health and Substance Abuse [Accessed on September 19, 2014.]. Available: http://www.who.int/mental_health/evidence/MH_Promotion_Book.pdf.
- 23. Garcia-Moreno C, Jansen HA, Ellsberg M, Heise L, Watts CH (2006) Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence. Lancet 368: 1260–1269. doi: 10.1016/S0140-6736(06)69523-8. pmid:17027732
- 24. Perales MT, Cripe SM, Lam N, Sanchez SE, Sanchez E, et al. (2009) Prevalence, types, and pattern of intimate partner violence among pregnant women in Lima, Peru. Violence Against Women 15: 224–250. doi: 10.1177/1077801208329387. pmid:19126836
- 25. Sarkar NN (2008) The impact of intimate partner violence on women’s reproductive health and pregnancy outcome. J Obstet Gynaecol 28: 266–271. doi: 10.1080/01443610802042415. pmid:18569465
- 26. Campbell J (2002) Health consequences of intimate partner violence. Lancet 359: 1331–1336. doi: 10.1016/S0140-6736(02)08336-8. pmid:11965295
- 27. Nicolaidis C, Curry M, McFarland B, Gerrity M (2004) Violence, mental health, and physical symptoms in an academic internal medicine practice. J Gen Intern Med 19: 819–827. doi: 10.1111/j.1525-1497.2004.30382.x. pmid:15242466
- 28. Pico-Alfonso MA, Garcia-Linares MI, Celda-Navarro N, Blasco-Ros C, Echeburua E, et al. (2006) The impact of physical, psychological, and sexual intimate male partner violence on women’s mental health: depressive symptoms, posttraumatic stress disorder, state anxiety, and suicide. J Womens Health (Larchmt) 15: 599–611. doi: 10.1089/jwh.2006.15.599. pmid:16796487
- 29. Hedin LW, Grimstad H, Moller A, Schei B, Janson PO (1999) Prevalence of physical and sexual abuse before and during pregnancy among Swedish couples. Acta Obstet Gynecol Scand 78: 310–315. doi: 10.1080/j.1600-0412.1999.780407.x. pmid:10203298
- 30. Kernic MA, Wolf ME, Holt VL (2000) Rates and relative risk of hospital admission among women in violent intimate partner relationships. Am J Public Health 90: 1416–1420. doi: 10.2105/AJPH.90.9.1416. pmid:10983199
- 31. Roberts GL, Lawrence JM, O’Toole BI, Raphael B (1997) Domestic violence in the Emergency Department: I. Two case-control studies of victims. Gen Hosp Psychiatry 19: 5–11. doi: 10.1016/S0163-8343(96)00119-3. pmid:9034805
- 32. Bergman B, Brismar B (1991) Suicide attempts by battered wives. Acta Psychiatr Scand 83: 380–384. doi: 10.1111/j.1600-0447.1991.tb05560.x. pmid:1853731
- 33. Thompson MP, Kaslow NJ, Kingree JB (2002) Risk factors for suicide attempts among African American women experiencing recent intimate partner violence. Violence Vict 17: 283–295. doi: 10.1891/vivi.17.3.283.33658. pmid:12102054
- 34. Frank JB, Rodowski MF (1999) Review of psychological issues in victims of domestic violence seen in emergency settings. Emerg Med Clin North Am 17: 657–677, vii. doi: 10.1016/S0733-8627(05)70089-4. pmid:10516845
- 35. Golding J (1999) Intimate partner violence as a risk factor for mental disorders: A meta-analysis. Journal of Family Violence 14: 99–132.
- 36. Woods SJ (2000) Prevalence and patterns of posttraumatic stress disorder in abused and postabused women. Issues Ment Health Nurs 21: 309–324. doi: 10.1080/016128400248112. pmid:11075070
- 37. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, et al. (1998) Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 14: 245–258. doi: 10.1016/S0749-3797(98)00017-8. pmid:9635069
- 38. DHS (2005) Demographic Health Survey questionnaires and modules: Domestic violence module. [Accessed on September 19, 2014.]. Available: http://www.measuredhs.com/aboutsurveys/dhs/modules_archive.cfm.
- 39. Kroenke K, Spitzer RL, Williams JB (2001) The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 16: 606–613. doi: 10.1046/j.1525-1497.2001.016009606.x. pmid:11556941
- 40. Harrison PA, Sidebottom AC (2008) Systematic prenatal screening for psychosocial risks. J Health Care Poor Underserved 19: 258–276. doi: 10.1353/hpu.2008.0003. pmid:18264001
- 41. Spitzer RL, Williams JB, Kroenke K, Hornyak R, McMurray J (2000) Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic patients: the PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study. Am J Obstet Gynecol 183: 759–769. doi: 10.1067/mob.2000.106580. pmid:10992206
- 42. Wulsin L, Somoza E, Heck J (2002) The Feasibility of Using the Spanish PHQ-9 to Screen for Depression in Primary Care in Honduras. Prim Care Companion J Clin Psychiatry 4: 191–195. pmid:15014707 doi: 10.4088/pcc.v04n0504
- 43. Cripe SM, Sanchez SE, Sanchez E, Ayala Quintanilla B, Hernandez Alarcon C, et al. (2010) Intimate partner violence during pregnancy: a pilot intervention program in Lima, Peru. J Interpers Violence 25: 2054–2076. doi: 10.1177/0886260509354517. pmid:20145196
- 44. Gomez-Beloz A, Williams MA, Sanchez SE, Lam N (2009) Intimate partner violence and risk for depression among postpartum women in Lima, Peru. Violence Vict 24: 380–398. doi: 10.1891/0886-6708.24.3.380. pmid:19634363
- 45. Gilbody S, Richards D, Brealey S, Hewitt C (2007) Screening for depression in medical settings with the Patient Health Questionnaire (PHQ): a diagnostic meta-analysis. J Gen Intern Med 22: 1596–1602. doi: 10.1007/s11606-007-0333-y. pmid:17874169
- 46. Ellsberg MC, Winkvist A, Pena R, Stenlund H (2001) Women’s strategic responses to violence in Nicaragua. J Epidemiol Community Health 55: 547–555. doi: 10.1136/jech.55.8.547. pmid:11449011
- 47. Della Femina D, Yeager CA, Lewis DO (1990) Child abuse: adolescent records vs. adult recall. Child Abuse Negl 14: 227–231. doi: 10.1016/0145-2134(90)90033-P. pmid:2340430
- 48. Williams LM (1995) Recovered memories of abuse in women with documented child sexual victimization histories. J Trauma Stress 8: 649–673. doi: 10.1002/jts.2490080408. pmid:8564277
- 49. Zhong Q, Gelaye B, Fann JR, Sanchez SE, Williams MA (2014) Cross-cultural validity of the Spanish version of PHQ-9 among pregnant Peruvian women: a Rasch item response theory analysis. J Affect Disord 158: 148–153. doi: 10.1016/j.jad.2014.02.012. pmid:24655779
- 50. Zhong Q, Gelaye B, Rondon M, Sanchez SE, Garcia PJ, et al. (2014) Comparative performance of Patient Health Questionnaire-9 and Edinburgh Postnatal Depression Scale for screening antepartum depression. J Affect Disord 162: 1–7. doi: 10.1016/j.jad.2014.03.028. pmid:24766996
- 51. Cripe SM, Sanchez SE, Gelaye B, Sanchez E, Williams MA (2011) Association between intimate partner violence, migraine and probable migraine. Headache 51: 208–219. doi: 10.1111/j.1526-4610.2010.01777.x. pmid:20946432
- 52. de Paz NC, Sanchez SE, Huaman LE, Chang GD, Pacora PN, et al. (2011) Risk of placental abruption in relation to maternal depressive, anxiety and stress symptoms. J Affect Disord 130: 280–284. doi: 10.1016/j.jad.2010.07.024. pmid:20692040
- 53. Gelaye B, Lam N, Cripe SM, Sanchez SE, Williams MA (2010) Correlates of violent response among Peruvian women abused by an intimate partner. J Interpers Violence 25: 136–151. doi: 10.1177/0886260508329127. pmid:19252073
- 54. Miranda JJ, Lopez-Rivera LA, Quistberg DA, Rosales-Mayor E, Gianella C, et al. (2014) Epidemiology of road traffic incidents in Peru 1973–2008: incidence, mortality, and fatality. PLoS One 9: e99662. doi: 10.1371/journal.pone.0099662. pmid:24927195
- 55. Barth J, Bermetz L, Heim E, Trelle S, Tonia T (2013) The current prevalence of child sexual abuse worldwide: a systematic review and meta-analysis. Int J Public Health 58: 469–483. doi: 10.1007/s00038-012-0426-1. pmid:23178922
- 56. Cyr K, Clement ME, Chamberland C (2014) Lifetime prevalence of multiple victimizations and its impact on children’s mental health. J Interpers Violence 29: 616–634. doi: 10.1177/0886260513505220. pmid:24158747
- 57. Finkelhor D, Turner HA, Shattuck A, Hamby SL (2013) Violence, crime, and abuse exposure in a national sample of children and youth: an update. JAMA Pediatr 167: 614–621. doi: 10.1001/jamapediatrics.2013.42. pmid:23700186
- 58. Stoltenborgh M, van Ijzendoorn MH, Euser EM, Bakermans-Kranenburg MJ (2011) A global perspective on child sexual abuse: meta-analysis of prevalence around the world. Child Maltreat 16: 79–101. doi: 10.1177/1077559511403920. pmid:21511741
- 59. Pereda N, Guilera G, Forns M, Gomez-Benito J (2009) The prevalence of child sexual abuse in community and student samples: a meta-analysis. Clin Psychol Rev 29: 328–338. doi: 10.1016/j.cpr.2009.02.007. pmid:19371992
- 60. Arata CM (2000) From child victim to adult victim: a model for predicting sexual revictimization. Child Maltreat 5: 28–38. doi: 10.1177/1077559500005001004. pmid:11232060
- 61. Dunkle KL, Jewkes RK, Brown HC, Yoshihama M, Gray GE, et al. (2004) Prevalence and patterns of gender-based violence and revictimization among women attending antenatal clinics in Soweto, South Africa. Am J Epidemiol 160: 230–239. doi: 10.1093/aje/kwh194. pmid:15257996
- 62. Nelson DB, Uscher-Pines L, Staples SR, Grisso JA (2010) Childhood violence and behavioral effects among urban pregnant women. J Womens Health (Larchmt) 19: 1177–1183. doi: 10.1089/jwh.2009.1539. pmid:20392141
- 63. Gonzalez A, Boyle MH, Kyu HH, Georgiades K, Duncan L, et al. (2012) Childhood and family influences on depression, chronic physical conditions, and their comorbidity: findings from the Ontario Child Health Study. J Psychiatr Res 46: 1475–1482. doi: 10.1016/j.jpsychires.2012.08.004. pmid:22959202
- 64. Irish L, Kobayashi I, Delahanty DL (2010) Long-term physical health consequences of childhood sexual abuse: a meta-analytic review. J Pediatr Psychol 35: 450–461. doi: 10.1093/jpepsy/jsp118. pmid:20022919
- 65. Aquino NM, Sun SY, Oliveira EM, Martins Mda G, Silva Jde F, et al. (2009) Sexual violence and its association with health self-perception among pregnant women. Rev Saude Publica 43: 954–960. doi: 10.1590/S0034-89102009005000068. pmid:19967257
- 66. Kendler KS, Bulik CM, Silberg J, Hettema JM, Myers J, et al. (2000) Childhood sexual abuse and adult psychiatric and substance use disorders in women: an epidemiological and cotwin control analysis. Arch Gen Psychiatry 57: 953–959. doi: 10.1001/archpsyc.57.10.953. pmid:11015813
- 67. Lindert J, von Ehrenstein OS, Grashow R, Gal G, Braehler E, et al. (2014) Sexual and physical abuse in childhood is associated with depression and anxiety over the life course: systematic review and meta-analysis. Int J Public Health 59: 359–372. pmid:24122075 doi: 10.1007/s00038-013-0519-5
- 68. Dinwiddie S, Heath AC, Dunne MP, Bucholz KK, Madden PA, et al. (2000) Early sexual abuse and lifetime psychopathology: a co-twin-control study. Psychol Med 30: 41–52. doi: 10.1017/S0033291799001373. pmid:10722174
- 69. Devries KM, Mak JY, Child JC, Falder G, Bacchus LJ, et al. (2014) Childhood Sexual Abuse and Suicidal Behavior: A Meta-analysis. Pediatrics.
- 70. Molnar BE, Berkman LF, Buka SL (2001) Psychopathology, childhood sexual abuse and other childhood adversities: relative links to subsequent suicidal behaviour in the US. Psychol Med 31: 965–977. doi: 10.1017/S0033291701004329. pmid:11513382
- 71. Easton SD, Renner LM, O’Leary P (2013) Suicide attempts among men with histories of child sexual abuse: examining abuse severity, mental health, and masculine norms. Child Abuse Negl 37: 380–387. doi: 10.1016/j.chiabu.2012.11.007. pmid:23313078
- 72. Seng JS, Sperlich M, Low LK (2008) Mental health, demographic, and risk behavior profiles of pregnant survivors of childhood and adult abuse. J Midwifery Womens Health 53: 511–521. doi: 10.1016/j.jmwh.2008.04.013. pmid:18984507
- 73. Leeners B, Rath W, Block E, Gorres G, Tschudin S (2014) Risk factors for unfavorable pregnancy outcome in women with adverse childhood experiences. J Perinat Med 42: 171–178. doi: 10.1515/jpm-2013-0003. pmid:24334452
- 74. Yampolsky L, Lev-Wiesel R, Ben-Zion IZ (2010) Child sexual abuse: is it a risk factor for pregnancy? J Adv Nurs 66: 2025–2037. doi: 10.1111/j.1365-2648.2010.05387.x. pmid:20636469
- 75. Benedict MI, Paine LL, Paine LA, Brandt D, Stallings R (1999) The association of childhood sexual abuse with depressive symptoms during pregnancy, and selected pregnancy outcomes. Child Abuse Negl 23: 659–670. doi: 10.1016/S0145-2134(99)00040-X. pmid:10442831
- 76. Bonomi AE, Cannon EA, Anderson ML, Rivara FP, Thompson RS (2008) Association between self-reported health and physical and/or sexual abuse experienced before age 18. Child Abuse Negl 32: 693–701. doi: 10.1016/j.chiabu.2007.10.004. pmid:18602692
- 77. Teicher MH, Samson JA, Polcari A, McGreenery CE (2006) Sticks, stones, and hurtful words: relative effects of various forms of childhood maltreatment. Am J Psychiatry 163: 993–1000. doi: 10.1176/appi.ajp.163.6.993. pmid:16741199
- 78. Hart C, de Vet R, Moran P, Hatch SL, Dean K (2012) A UK population-based study of the relationship between mental disorder and victimisation. Soc Psychiatry Psychiatr Epidemiol 47: 1581–1590. doi: 10.1007/s00127-011-0464-7. pmid:22202973
- 79. Watts-English T, Fortson BL, Gibler N, Hooper SR, De Bellis MD (2006) The Psychobiology of Maltreatment in Childhood. Journal of Social Issues 62: 717–736. doi: 10.1111/j.1540-4560.2006.00484.x
- 80. Brodsky BS, Mann JJ, Stanley B, Tin A, Oquendo M, et al. (2008) Familial transmission of suicidal behavior: factors mediating the relationship between childhood abuse and offspring suicide attempts. J Clin Psychiatry 69: 584–596. doi: 10.4088/JCP.v69n0410. pmid:18373384
- 81. Clark DB, De Bellis MD, Lynch KG, Cornelius JR, Martin CS (2003) Physical and sexual abuse, depression and alcohol use disorders in adolescents: onsets and outcomes. Drug Alcohol Depend 69: 51–60. doi: 10.1016/S0376-8716(02)00254-5. pmid:12536066
- 82. Heffernan K, Cloitre M (2000) A comparison of posttraumatic stress disorder with and without borderline personality disorder among women with a history of childhood sexual abuse: etiological and clinical characteristics. J Nerv Ment Dis 188: 589–595. doi: 10.1097/00005053-200009000-00005. pmid:11009332
- 83. Kendall-Tackett KA, Williams LM, Finkelhor D (1993) Impact of sexual abuse on children: a review and synthesis of recent empirical studies. Psychol Bull 113: 164–180. doi: 10.1037/0033-2909.113.1.164. pmid:8426874
- 84. Kessler RC, Berglund PA, Foster CL, Saunders WB, Stang PE, et al. (1997) Social consequences of psychiatric disorders, II: Teenage parenthood. Am J Psychiatry 154: 1405–1411. pmid:9326823 doi: 10.1176/ajp.154.10.1405
- 85. Pechtel P, Pizzagalli DA (2011) Effects of early life stress on cognitive and affective function: an integrated review of human literature. Psychopharmacology (Berl) 214: 55–70. doi: 10.1007/s00213-010-2009-2. pmid:20865251
- 86. Briere J, Runtz M (1990) Differential adult symptomatology associated with three types of child abuse histories. Child Abuse Negl 14: 357–364. doi: 10.1016/0145-2134(90)90007-G. pmid:2207804
- 87. Stern AE, Lynch DL, Oates RK, O’Toole BI, Cooney G (1995) Self esteem, depression, behaviour and family functioning in sexually abused children. J Child Psychol Psychiatry 36: 1077–1089. doi: 10.1111/j.1469-7610.1995.tb01352.x. pmid:7593400
- 88. Pineda-Lucatero AG, Trujillo-Hernandez B, Millan-Guerrero RO, Vasquez C (2009) Prevalence of childhood sexual abuse among Mexican adolescents. Child Care Health Dev 35: 184–189. doi: 10.1111/j.1365-2214.2008.00888.x. pmid:18991975
- 89. Fraser JA, Armstrong KL, Morris JP, Dadds MR (2000) Home visiting intervention for vulnerable families with newborns: follow-up results of a randomized controlled trial. Child Abuse Negl 24: 1399–1429. doi: 10.1016/S0145-2134(00)00193-9. pmid:11128173
- 90. Knox M, Burkhart K, Cromly A (2013) Supporting positive parenting in community health centers: The Act Raising Safe Kids Program. Journal of Community Psychology 41: 395–407. doi: 10.1002/jcop.21543
- 91. Sanders MR, Montgomery DT, Brechman-Toussaint ML (2000) The mass media and the prevention of child behavior problems: the evaluation of a television series to promote positive outcomes for parents and their children. J Child Psychol Psychiatry 41: 939–948. doi: 10.1111/1469-7610.00681. pmid:11079436