Child abuse has been found to predict mental disorders, substance-related problems, and health risk behaviors (Gilbert et al., 2009
). Retrospective studies with adults have suggested that child abuse leads to major physical health problems (Brown, Young, Anda, Felitti, & Giles, 2006
). Child abuse has been systematically related to diminished subjective health quality and obesity (Thomas, Hypponen, & Power, 2008
). With some specific conditions excepted (e.g., sexually transmitted diseases: Wilson & Widom, 2009
); however, few prospective studies have examined whether child abuse leads to physical health problems. In addition, consideration of the relationship between child abuse and later substance use disorders is important for understanding health outcomes.
A few studies have examined the relationship between child maltreatment and global health status. Hussey and colleagues (Hussey, Chang, & Kotch, 2006
) studied a large sample of adolescents who, when follow-up in young adulthood, completed a retrospective child abuse questionnaire. Child abuse reports were associated with poorer subjective health quality in adolescence. Among 378 adolescent enrolled in addictions treatment (Stevens, Murphy, & McKnight, 2003
), PTSD-like symptoms were positively associated with subjective health symptoms. Among 1041 children at high risk for child abuse and neglect (Flaherty et al., 2006
), child maltreatment at age 4 years predicted poorer overall child health at age 6 as well as an increased incidence of illnesses requiring medical attention.
Child abuse has been associated with overweight status in some studies. In the Hussey study (2006
), physical abuse, but not sexual abuse, was found to be associated with overweight status by BMI in late adolescence. Among 782 community subjects (Johnson, Cohen, Kasen, & Brook, 2002
), childhood sexual abuse (n
= 22) was not associated with adolescent or young adulthood obesity. In a prospective study of female children with sexual abuse (n
= 84) and a comparison sample (n
= 102), those with a sexual abuse history showed a more rapid increase in BMI during adolescence and a higher obesity rate in young adulthood (Noll, Zeller, Tricket, & Putnam, 2007
). Among over 9,000 children followed to middle adulthood (Thomas et al., 2008
), physical abuse, but not sexual abuse, predicted increased BMI and higher rates of obesity in middle adulthood. In the latter study, child abuse did not predict type 2 diabetes in middle adulthood. Comorbid obesity, high blood pressure, lipid abnormalities, increased blood glucose, and diabetes mellitus have been termed “metabolic syndrome” (Steinberger et al., 2009
). Given a relationship between child abuse and obesity, one might expect that child abuse would predict elevations in other metabolic syndrome indicators. This possibility has not been studied.
Stressors have been found to induce changes in immune functioning, and immune system indicators may be relevant to understanding child abuse and health. In the laboratory, immunoglobulin increases have been demonstrated in response to acute stressors (Endresen et al., 1991
). Immunoglobulin increases have also been observed in response to natural stressors. In young adults, school exams predicted increases in plasma immunoglobulins IgM, IgG, and IgA (Glaser, Mehl, Penn, & Speicher, 1986
). A study comparing 14 girls with sexual abuse and 13 control girls (De Bellis, Burke, Trickett, & Putnam, 1996
) did not observe significant group differences on plasma antinuclear antibody titers. Immunoglobulin levels have not been previously studied in association with child abuse.
While individuals with child abuse have not been reported to have diagnosed medical diseases in adolescence and young adulthood, studies in later adulthood have noted an association between child abuse and some specific medical disease outcomes. Adults with child maltreatment histories have been reported to show elevated rates of liver disease, lung cancer and heart disease (Dong, Dube, Felitti, Giles, & Anda, 2003
; Dong et al., 2004
; Brown et al., 2006
). These medical diseases may be an indirect result of risky health behaviors, particularly substance use disorders.
Childhood abuse has been found to be associated with or to predict adolescent substance use disorders. Among 3,559 students in grades 7 through 12, Hamburger, Leeb, and Swahn (2008
) found that sexual abuse, physical abuse, and witnessing violence were associated with increased preteen alcohol use. Using data from the National Longitudinal Study of Adolescent Health (n
= 12,748), Shin, Edwards, and Heeren (2009
) found physical abuse and sexual abuse were associated with binge drinking. In a subset of the subjects described here, sexual abuse, physical abuse, and other stressors were more common among adolescents with AUD than among control adolescents (Clark, Lesnick, & Hegedus, 1997a
). Physical or sexual abuse accelerated the onset of AUD and accounted for the relationship between AUD and major depressive disorder (Clark, De Bellis, Lynch, Cornelius, & Martin, 2003
The adverse health consequences associated with AUD, reflected by organ pathology and disease history, have been more systematically studied in adults than in adolescents. In adults, abnormalities found to be caused by chronic alcohol dependence include elevated liver injury indices (Allen, Fertig, Litten, Sillanaukee, & Anton, 1997
), elevated immunoglobulins (Mili, Flanders, Boring, Annest, & DeStefano, 1992
), elevated erythrocyte mean cell volume (MCV) (Seppa, Sillanaukee & Koivula, 1992
), and decreased electrolytes, such as calcium, magnesium, phosphate, and potassium (Elisaf, Bairaktari, Kalaizidia, & Siamopoulos, 1998
). The medical records of 417 adolescents with substance use disorders and 2082 demographically matched subjects, those with substance use disorders had more abdominal pain, sleep disorders, and asthma (Mertens, Fisher, Fleming, & Weisner, 2007
). In some of the subjects described here (Clark, Lynch, Donovan, & Block, 2001
), 128 adolescents with AUD (compared with 131 controls) showed more health-related symptoms (HS), laboratory tests indicating liver injury, and some physical exam abnormalities. Thus, some health problems reported by adolescents with AUD have been verified by objective findings and may be attributable to toxic alcohol effects on the liver and other organs.
While adolescents with AUD evidence objective indicators of some health problems, their subjective HS seem disproportionately elevated. These HS may, to some extent, reflect somatic anxiety symptoms (Ginsburg, Riddle, & Davies, 2006
). In prior reports on the present sample (Clark et al., 1997b
), adolescents with AUD were observed to have elevated rates of anxiety disorders, including PTSD. In our study of health problems among adolescents with AUD (Clark et al., 2001
), we found that an index of negative emotionality was highly correlated with HS, mediated the relationship between AUD and HS, and was not correlated with serum liver enzyme levels or physical exam abnormalities. Among adult women (Lang et al., 2008
), child abuse was observed to lead to mental and physical health difficulties through anxiety disorder symptoms. Child abuse may induce HS, at least in part, through anxiety.
Prior research has had several shortcomings. In most studies, the relationship between child abuse and health outcomes has been determined exclusively with cross-sectional or retrospective methods. In some studies, decades have passed between recalled childhood events and the adulthood assessment, amplifying the potential for recall bias. The available studies on adolescents have typically assessed health status with only a few global and subjective questions. Some studies with large community samples have included few subjects with child abuse histories. Studies on child abuse have rarely examined the effects of other traumatic experiences. Substance use that may adversely influence health outcomes has typically not been concurrently examined. The extent to which HS may be attributable to anxiety has also been neglected in child abuse studies.
The present study addresses several of these shortcomings. We examined relationships among child abuse, AUD, and physical health problems in adolescence, and prospectively assessed later adolescent and young adult health outcomes. This is the first study to examine these relationships with a comprehensive physical health assessment. The evaluation included questions on 136 health symptoms, laboratory studies of blood including liver injury and other objective indicators, and physical examinations including blood pressure and body mass index (BMI) measurements. Child abuse was considered in the context of other traumatic experiences. We concurrently measured AUD and cigarette smoking. The study conducted 1-year follow-up and young adult outcome evaluations. We hypothesized that child abuse and other traumatic experiences would be associated with HS, being overweight, and stress-related laboratory findings, while AUD would be associated with liver injury. We expected the relationship between child abuse and HS to be mediated by anxiety.