Elsevier

Child Abuse & Neglect

Volume 32, Issue 6, June 2008, Pages 637-647
Child Abuse & Neglect

Effects of multiple maltreatment experiences among psychiatrically hospitalized youth

https://doi.org/10.1016/j.chiabu.2008.02.003Get rights and content

Abstract

Objective

Relying on indicators coded from information collected routinely during intake assessments at a secure inpatient psychiatric facility, this study examined the extent to which different forms of maltreatment accounted for variations in youths’ emotional and behavioral problems.

Methods

Clinical information was reviewed for a large (N = 401) and diverse sample (mean age = 13.9 years; 53% male; 54.6% racial/ethnic minority) of youth admitted to a publicly funded psychiatric hospital. Data were drawn from intake narratives, standardized psychopathology rating scales, and psychiatric diagnostic ratings.

Results

Findings provide some support for a hierarchical classification of multiple maltreatment experiences with sexual abuse identified as the specific form of maltreatment most reliably associated with poor adjustment. Support also was obtained for a cumulative classification approach, as the number of different types of maltreatment experiences was linked positively to elevated psychopathology ratings.

Conclusions

Even in this high-risk, atypical sample, maltreatment experiences account for variation in levels of psychopathology. These results have implications for classifying multiple maltreatment and enhancing clinical care for atypical youth who have been maltreated.

Practice implications

Clinicians working in youth psychiatric populations should implement maltreatment-specific psychotherapy approaches for maltreated youth, even as adjunctive treatments in a therapeutic milieu.

Introduction

Child maltreatment predicts negative outcomes such as low intellectual functioning (Kaufman, Jones, Stieglitz, Vitulano, & Mannarino, 1994), aggression (Kaufman & Cicchetti, 1989), substance use (Harrison, Fulkerson, & Beebe, 1997), internalizing disorders (depression, anxiety; Toth, Cicchetti, & Kim, 2002), risky sexual behaviors (Fergusson, Horwood, & Lynsky, 1997), and suicidal tendencies (Brown, Cohen, Johnson, & Smailes, 1999). The vast majority of research on the effects of maltreatment has been conducted in community samples or with youth involved with protective service agencies. However, the problems resulting from maltreatment (particularly assaultive and suicidal behaviors) are often those that can result in psychiatric hospitalization. In fact, many psychiatrically hospitalized youth have been maltreated (Day, Franklin, & Marshall, 1998; Fehon, Grilo, & Lipschitz, 2001). However, there is relatively less research available on the sequelae of maltreatment among youth admitted for inpatient psychiatric treatment, and especially those who exhibit very high levels of psychopathology.

Research on high-risk populations is essential to broadening our understanding of child psychopathology and enhancing treatments for youth affected by maltreatment. The deleterious effects of maltreatment in normative and even modestly at-risk populations are well established, and some research in inpatient psychiatric populations has replicated these effects. Among youth showing very high levels of psychopathology and thus expected to possess elevated organic, dispositional risk, it might be difficult to observe the additive harmful effects of maltreatment. Research with a high-risk population thus can yield important information on how maltreatment accounts for variation in symptom levels. Such research also can aid in the development of better-elaborated targeted treatments for youth already receiving mental health services. The aim of this study was to examine the extent to which different forms of maltreatment account for variations in emotional and behavioral problems in a large sample (N = 401) of psychiatrically hospitalized youth, about half of whom had experienced at least one form of maltreatment.

Empirical evidence indicates clearly that child maltreatment is associated with a host of negative outcomes. Maltreatment can include a wide range of experiences ranging from sexual or physical abuse to neglect to experiences with domestic violence and emotional abuse. The most extensively researched forms of maltreatment, however, are sexual abuse, physical abuse, and neglect. Although each of those forms of maltreatment has been shown independently to correlate or lead to maladjustment, empirical findings have been less clear with respect to determining which type of maltreatment is associated with the worst outcomes, whether multiple maltreatment reliably is more detrimental than is single-form maltreatment, and whether different configurations of maltreatment experiences (e.g., physical plus sexual abuse) have different patterns of effects (see, e.g., analysis and discussion by Ney, Fung, & Wickett, 1994).

One common method of assessing the impact of the different forms of maltreatment has been to classify them hierarchically. Hierarchical classification operates according to the theory that some forms of maltreatment are inherently more detrimental than others because these types of maltreatment are active (rather than passive) and violate more strongly held social norms (Kinard, 1994, Lau et al., 2005; Manly, Cicchetti, & Barnett, 1994; Toth & Cicchetti, 1996). Here, abuse is worse than neglect because abuse is an act of commission and neglect is an act of omission. Sexual abuse is considered the worst form of maltreatment because it violates more strongly held social norms, and sexual abuse is followed in the hierarchy by physical abuse and then neglect. Although it is an act of commission, emotional abuse is considered least harmful in the hierarchical approach (Manly et al., 1994). Thus, a youth who was sexually abused, regardless of whether other forms of maltreatment have been experienced, is classified as “sexually abused.” A youth who was abused physically, but not sexually, is considered “physically abused,” a youth who was neglected but neither physically nor sexually abused is classified as “neglected,” and a youth who was emotionally abused but experienced none of the other forms of maltreatment is considered “emotionally abused” (Manly et al., 1994). Hierarchical classification thus relies on dichotomized indicators of maltreatment (i.e., 1 = maltreated, 0 = not maltreated) to derive the various subgroups of maltreated youth.

Generally, findings from studies using hierarchical classification systems support that each category is associated with maladjustment, but findings are mixed regarding whether certain types of maltreatment lead to specific negative outcomes. For instance, some researchers report sexual abuse to be more strongly associated with risky sexual behaviors than other forms of maltreatment (Cavailoa & Schiff, 1988; Fergusson et al., 1997; Krahé, Scheingerger-Olwig, Waizenhofer, & Kolpin, 1999). However, Arata and colleagues found that sexually and physically abused youth did not differ in their number of sexual partners (Arata, Langinrichsen-Rohling, Bowers, & Farrill-Swails, 2005). Similarly, findings are mixed regarding whether forms of maltreatment higher on the hierarchy are associated with worse adjustment (Engels, Moisan, & Harris, 1994; Gauthier, Stollack, Messe, & Aronoff, 1996; Lau et al., 2005; Roesler & McKenzie, 1994; Teicher, Samson, Polcari, & McGreenery, 2006). A limitation to hierarchical classification, which may account for some inconsistent findings, is that the severity of maltreatment is easily confounded with exposure to multiple types of maltreatment. This is particularly problematic for understanding emotional abuse, given that it frequently co-occurs with the other forms of maltreatment; in fact Manly et al. (1994) could not evaluate its impact via hierarchical classification because the “emotionally abused” group was too small.

An alternative to hierarchical classification is cumulative classification (also considered “multiple maltreatment,” e.g., Trickett, 1998; or “polyvictimization,” e.g., Finkelhor, Ormrod, & Turner, 2007). This sort of classification runs parallel to a cumulative risk view in developmental psychopathology more generally. Broadly, the cumulative risk scheme does not assign any single risk factor a higher status or greater weight than any other. Instead, the cumulative risk model asserts that it is the number of risk factors that is most important when predicting negative outcomes, not the presence of specific types of risks (Rutter, 1979, Sameroff, 2000). Thus, when applying a cumulative risk model to maltreatment, youth are grouped by how many types of maltreatment they have experienced without ordering the types into any hierarchy. Generally, research indicates that experiencing more types of maltreatment is associated with worse adjustment (Appleyard, Egeland, van Dulmen, & Sroufe, 2005; Arata et al., 2005; Turner, Finkelhor, & Ormrod, 2006). In comparing the cumulative and hierarchical classification schemes, however, Lau and colleagues (Lau et al., 2005) reported that hierarchical classification added to the prediction of adjustment beyond information provided by cumulative classification.

Although much maltreatment research has focused on community samples or on youth identified by child protection agencies, some has examined whether the relations between maltreatment and negative adjustment indices generalize to other high-risk, atypical populations such as youth in psychiatric hospitals. Indeed, a substantial proportion of youth who are involved in psychiatric inpatient programs have a history of childhood maltreatment (Fehon et al., 2001). Thus, maltreatment appears to be a key risk factor for hospitalization. Still, not all youth referred to inpatient psychiatric treatment have been maltreated. Thus there also is reason to consider how well the typically observed relations between maltreatment and maladjustment in community-based normative or child protective samples will generalize to youth in psychiatric inpatient treatment. For example, research relying on hierarchical or cumulative classifications of maltreatment experiences suggests a generally linear relation between maltreatment severity (in a hierarchy) or amount (cumulatively) and greater maladjustment. However, on average youth in psychiatric hospitals exhibit more severe difficulties than do youth in the larger community, imposing a degree of range restriction on measures of maladjustment.

Extant literature on the effects of maltreatment in youth psychiatric populations shows some consistency with research in more normative youth populations in terms of the generally harmful impact of maltreatment. For example, Grilo, Sanislow, Fehon, Lipschitz, et al. (1999) have shown that greater abuse during childhood is linked to elevated psychiatric symptoms in adolescence including depression, suicide risk, violent behavior, and substance abuse. In a separate study, however, Grilo, Sanislow, Fehon, Martino, and McGlashan (1999) found that abused and non-abused adolescent inpatients significantly differed only in their mean levels of self-criticism (as an index of depression) and alcohol abuse; however, these groups did differ meaningfully in the extent to which their psychiatric symptoms accounted for suicide risk. Specifically, externalizing and internalizing problems predicted suicide risk in abused adolescents but only internalizing problems predicted risk in non-abused adolescents.

Other studies of youth psychiatric samples have shown, for example, that sexual and emotional abuse might be more psychologically damaging than physical abuse or neglect (Sullivan, Fehon, Andres-Hyman, Lipschitz, & Grilo, 2006), that sexual and physical abuse are linked independently to elevated post-traumatic stress symptoms but jointly to greater internalizing problems (Naar-King, Silvern, Ryan, & Sebring, 2002), and that sexual and physical victimization by family members is associated with elevations in both externalizing and internalizing psychopathology (Muller, Goebel-Fabbri, Diamond, & Dinklage, 2000). Still, although findings across studies have been revealing with regard to the generally deleterious effect of maltreatment, limitations across studies on sample size and maltreatment measurement have prevented firm conclusions about the differential impact of various forms and combinations of maltreatment experiences among youth inpatients. This issue is complicated too by reports from research teams such as Cohen et al. (1996), who observed no substantial variation in symptoms among adolescent inpatients as a function of maltreatment type.

Discerning the impact of various combinations of maltreatment on psychiatrically hospitalized youth can have important implications for clinical practice with those youth. For instance, maltreated and hospitalized youth might benefit from specialized treatment services adjunctive to standard hospital milieu therapies (e.g., trauma-focused cognitive-behavioral therapy for sexual abuse victims; Deblinger, Steer, & Lippman, 1999). Examining maltreatment in the hospitalized population also affords information critical to refining models of child psychopathology. Psychopathology in childhood can emerge via additive and interactive effects of organic, individually based risk factors (such as impulsivity and emotional liability) and contextually based risk factors (such as maltreatment and stressful life events). Youth admitted for inpatient treatment exhibit historical risk profiles high in both individual and contextual risk (Boxer, 2007). Thus it is of interest to ascertain whether different configurations of maltreatment experiences still contribute to variation in functioning in this population.

This study examined the psychopathology symptoms of different approaches to classifying maltreatment in a large (N = 401) sample of youth psychiatric inpatients. The sample for this study was comprised of youth receiving inpatient psychiatric treatment in a state-funded secure hospital. Data on histories of maltreatment and current psychopathology obtained at hospital intake were analyzed to examine three different classification schemes: hierarchical classification (e.g., Manly et al., 1994), cumulative classification (e.g., Finkelhor et al., 2007), and an independent effects model (forms of maltreatment considered separately, and not aggregated). We hypothesized generally that maltreatment experiences would account for variation in psychopathology measured at intake. We conducted exploratory analyses to determine which model of maltreatment effects provided the most explanatory power for understanding differences as a function of youths’ configurations of maltreatment experiences.

Section snippets

Participants

Participants were drawn from the database of a larger project examining the characteristics, management, and outcomes of youth receiving inpatient treatment (Boxer, 2007). Analyses in this investigation are based on a sample of 401 youths (mean age at admission = 13.9 years, SD = 2.1, range 10–17 years; 53% male) admitted consecutively to a secure, publicly funded inpatient psychiatric hospital in the Midwest. Inpatients younger than 10 years at admission were excluded from this study. As noted

Preliminary analyses of maltreatment classifications and criterion variables

Table 1 presents descriptive diagnostic and psychopathology information for maltreated and non-maltreated groups. These data indicate that the study sample generally is comparable to those described in other studies of maltreatment in youth psychiatric populations with regard to psychiatric diagnostics, but perhaps somewhat more severe in terms of psychopathology rating scale data. Significance testing (t tests and χ2 analyses) yielded statistically (mean differences in continuous ratings) as

Discussion

We analyzed data from a large sample of psychiatrically hospitalized youth to evaluate three different conceptions of how multiple maltreatment experiences account for variation in psychopathology symptoms. Via combinations of dichotomized indicators of four different types of maltreatment (sexual abuse, physical abuse, emotional abuse, neglect), we examined a hierarchically ordered model of maltreatment effects (i.e., sexual abuse produces the worst symptoms), a cumulative model of effects

Acknowledgements

The author acknowledges and appreciates support from several individuals. Substantial logistical support for this investigation was provided by Robert Bailey. Assistance in the data coding process was provided by James Bow, Joy Ensor, Rashmi Bhandari, Ruth Robinson, Esther Petrovich, Elizabeth Rakstis, Vicki Alley, Dianne Tomaine, Judy Valentine, Sara Chase, Jessica Luitjohan, Rebecca Gerhardstein, and Sarah Savoy. Consultation on the initial design of the project was provided by Rowell

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    This project was supported by a grant from the National Institute of Mental Health (MH72980, Paul Boxer, PI).

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