The Association Between Childhood Physical and Sexual Abuse and Functioning and Psychiatric Symptoms in a Sample of U.S.

Transcription

1 MILITARY MEDICINE, 176, 2:176, 2011 The Association Between Childhood Physical and Sexual Abuse and Functioning and Psychiatric Symptoms in a Sample of U.S. Army Soldiers Abby E. Seifert, MA * ; Melissa A. Polusny, PhD ; Maureen Murdoch, MPH, MD ABSTRACT Objective: We examined associations between abusive childhood experiences and functioning and psychiatric symptoms in an active duty sample of U.S. Army soldiers. Methods: Cross-sectional survey of 204 soldiers stationed at a southern U.S. Army facility. Results: Forty-six percent of individuals reported childhood physical abuse alone, whereas 25% reported both childhood physical and sexual abuse. Soldiers work, role, and social functioning; physical functioning; depression severity; and severity of alcohol misuse did not differ significantly with childhood abuse status ( p > 0.22 for all). However, individuals who reported both childhood physical and sexual abuse reported severer posttraumatic stress disorder symptoms than did soldiers who reported no childhood abuse or childhood physical abuse only ( p = 0.007). Conclusions: Although abusive childhood experiences were common, soldiers with such experiences reported functioning as well as those soldiers without such experiences. Posttraumatic stress disorder symptoms were significantly elevated only in those who reported both childhood physical and sexual abuse. INTRODUCTION In the general population, childhood physical and sexual abuse is common. 1 Such experiences are also believed to be common among military personnel, although prevalence estimates vary widely. 2 6 The long-term adverse consequences of abusive childhood experiences, specifically childhood sexual abuse, on later mental health sequelae have been well-documented in civilian populations. These include anxiety disorders, such as posttraumatic stress disorder (PTSD), depression, somatization, substance abuse, binge eating, dissociation and memory impairment, suicidal and parasuicidal behavior, sexual dysfunction and dissatisfaction, poor self-esteem, and personality disorders, such as borderline personality disorder. 7 9 Not surprisingly, adverse consequences of childhood abuse have also been documented in veteran and active duty samples. For example, in one small sample of male veterans who were admitted into an inpatient treatment program, childhood physical abuse was significantly correlated with severity of combat-related PTSD. 10 In another sample, veterans with bipolar disorder who reported any type of childhood abuse * Department of Psychology, 3700 Wood Hall, Western Michigan University, Kalamazoo MI Center for Chronic Disease Outcomes Research, 1 Veterans Drive, Minneapolis, MN Minneapolis Veterans Affairs Medical Center, 1 Veterans Drive, Minneapolis, MN Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN Department of Medicine, University of Minnesota Medical School, Minneapolis, MN Dr. Murdoch and Dr. Polusny are core investigators in the Center for Chronic Disease Outcomes Research (CCDOR). CCDOR is a Veterans Affairs (VA) Health Services Research and Development (HSR&D) Service Center of Excellence. The views presented in this paper are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the Department of Defense. were more likely to have comorbid PTSD, panic, and substance use disorders and to be involuntarily hospitalized in comparison to nonabused veterans. In the same sample, veterans who reported both childhood physical and sexual abuse had more major depressive episodes and a higher percentage of reported suicide attempts in comparison to those who reported childhood physical abuse or childhood sexual abuse alone. 11 In addition, in a sample of active duty soldiers seeking mental health treatment, abusive childhood experiences predicted PTSD and depression. 12 And finally, U.S. Navy recruits with a history of childhood abuse were more likely to use alcohol and to have alcohol-related problems than those without a history of childhood abuse. 13 In addition to adverse psychological sequelae, childhood abuse histories have been associated with attrition from basic military training. 3,6 Attrition from basic military training is particularly troubling for the military because basic training represents a significant investment in terms of cost and time for the Department of Defense. For example, in 2000, the U.S. General Accounting Office cited that early separation from the military costs, on average, $38,000 per enlistee. 14 Unfortunately, today, the cost of attrition is likely to be more. Health surveillance, or the process of systematically evaluating threats to workers health, well-being, and performance, has been ongoing in the military since the Persian Gulf War. The purpose of collecting health surveillance data is to identify unmet needs and intervene. Overall, the objective is to protect the health of our troops and increase deployment readiness. Recently, some have argued that health surveillance questionnaires should assess for childhood abuse experiences. 15 Collection of such data could inform prevention or intervention programs for individuals suffering from adverse psychological sequelae related to childhood abuse experiences. However, there is concern that health surveillance data could be improperly used. In particular, some military personnel 176 MILITARY MEDICINE, Vol. 176, February 2011

2 have expressed concern that asking questions about childhood abuse experiences could stigmatize some individuals or impair career advancement. 15 Moreover, there is some concern that a history of childhood abuse could be used to disqualify some recruits in hopes of reducing basic training, attrition-related costs. Furthermore, even in a study where childhood abuse history predicted early attrition from basic training, Smikle et al., 5 found that later job performance was not impeded by such experiences for those individuals who successfully completed basic training. The current study expands upon the findings of Smikle et al 5 by examining not only work functioning but also social, role, and physical functioning and psychiatric symptoms in a sample of U.S. Army soldiers. We also examine the impact of childhood physical abuse with and without childhood sexual abuse on these outcomes. The hypotheses for the current study were twofold. On the basis of civilian and military literature, we anticipated that individuals with a history of childhood abuse would have poorer functioning and more severe psychiatric symptoms (PTSD, depression, and alcohol misuse) than those without such histories. Furthermore, we hypothesized that individuals who experienced both childhood physical and sexual abuse would describe poorer functioning and more psychiatric symptoms than individuals who experienced childhood physical abuse alone or childhood sexual abuse alone. METHOD The Minneapolis Veterans Affairs Medical Center s Human Studies Subcommittee, the Army post s Commanding Officer, and the Division Equal Opportunity office reviewed and approved the study s protocol. Participants All data were collected from a single Southern Army installation. In October 1999, a convenience sample of 108 active duty enlisted men and 96 enlisted women in their first duty tour (mean service length, 3.1 years; standard deviation (SD) = 2.7) completed a consent document and 21-page questionnaire in an on-site classroom. Participants were offered food while completing the survey and a $10 gift certificate. The mean age of the participants was 24 years (SD = 5). All participants were selected because they had completed their basic military training and were in their first tour of duty. Ranks ranged from E-1 (private [1%]) to E-5 (sergeant [8%]), with the exception of 1 individual who had a rank of W-1 (warrant officer). Most individuals had a rank of E-4 (corporal [52%]), with fewer individuals with a rank of E-3 (33%) and E-2 (5%). Fifty percent of participants were Caucasian, 30.6% were African American, 4.6% were Native American, and 8.7% were Hispanic. Materials Independent Variables Childhood physical abuse was assessed using 2 items from Bernstein et al s 16 Childhood Trauma Questionnaire s physical and emotional abuse subscale: (1) I was punished with a belt, a board, a cord, or some hard object and (2) Adults in my family hit me so hard that it left me with bruises or marks. Participants were determined to have a history of childhood physical abuse if they endorsed 1 of these 2 items. Childhood sexual abuse was assessed using 4 items from the Childhood Trauma Questionnaire s sexual abuse subscale: (1) Someone tried to touch me in a sexual way or tried to make me do sexual things or watch sexual things, (2) Someone threatened to hurt me or tell lies about me unless I did something sexual with them, (3) Someone molested me, and (4) I believe that I was sexually abused. Participants were determined to have a history of childhood sexual abuse if they endorsed any of these 4 items. Childhood physical abuse and childhood sexual abuse were modeled dichotomously as yes/no variables. Dependent Variables Work, role, and social functioning were assessed using the modified self-reported Social Adjustment Scale (SAS-SR). 17 The SAS-SR measures adjustment in work roles, social and community activities, economic self-sufficiency, and marriage, extended family, family unit, and parental relationships. We used the SAS-SR composite score, which averages adjustment/functioning across all domains, with higher scores indicating poorer functioning. The SAS-SR has an internal consistency of PTSD symptom severity was assessed using the Penn Inventory for Post-Traumatic Stress Disorder. 18 The Penn Inventory has an internal consistency of Higher scores indicate severer symptoms and scores of 35 or higher have identified PTSD in veterans with 93% to 97% accuracy. 19 Depression was assessed using the 5-item RAND Mental Health Battery (MHI-5). 20 MHI-5 scores of 17 or more have sensitivity of 0.48 and a specificity of 0.95 for major depression. The MHI-5 has an internal consistency of Alcohol misuse was assessed using the TWEAK, 21 a CAGE 22 variant with improved sensitivity for alcohol-related problems in reproductive-aged women. 21 Using a cutoff score of 3 or more, TWEAK sensitivities range from 0.83 to and specificities range from 0.68 to 0.96 for alcohol abuse problems. 23 Analyses Categorization of Participants We created 3 ordered child abuse categories as follows: no childhood physical abuse or childhood sexual abuse, childhood physical abuse only, and childhood physical abuse and childhood sexual abuse. The category of childhood sexual abuse only was not included because only 1 participant reported childhood sexual abuse independent of childhood physical abuse; that individual was excluded from analyses. Seven participants who did not answer the childhood abuse questions were also excluded. Of the remaining participants, 29% reported no childhood physical abuse or childhood sexual MILITARY MEDICINE, Vol. 176, February

3 abuse, 46% reported childhood physical abuse, and 25% reported childhood physical and sexual abuse. We tested for monotonic associations between functioning and mental health symptoms and the ordinal categories of childhood abuse using one-way analyses of variance. 24 There were no significant deviations from linearity. For context, we also report the percentage of participants who met survey criterion for PTSD, depression, and problem drinking according to childhood abuse category, using Mantel Haenszel s χ 2 test for monotonic trend. Diagnostic cutoff scores were determined from each measure s published criteria. 18,20,23 We also used Mantel Haenszel s χ 2 test for monotonic trend to examine associations between troops reports of military sexual stressors (modeled as yes/no variables) and the ordinal categories of childhood abuse. Because there have been conflicting data as to whether childhood abuse affects girls and boys development differently, 25,26 we formally tested for moderating effects of gender by adding a childhood abuse categoryby-gender interaction term to each model described earlier. There were no significant interactions by gender in any of the analyses. We used a p value of less than 0.05 to denote statistical significance. RESULTS Table I shows participants demographic characteristics according to their childhood abuse category. Compared to women, more men reported a history of childhood physical abuse only and fewer men reported a history of both childhood physical and sexual abuse. African American participants were more likely than other participants to report a history of both childhood physical and sexual abuse and were least likely to report experiencing no childhood physical or sexual abuse. Table II shows participants endorsement of specific childhood abuse experiences based on participants assignment to childhood abuse categories, childhood physical abuse only, and childhood physical and sexual abuse. Virtually all participants in these 2 categories reported being punished with a belt, board, cord, or other hard object. Even compared to participants who reported childhood physical abuse only, those TABLE I. Demographic Characteristics who reported childhood physical and sexual abuse more frequently reported being hit hard enough that bruises or marks were left. Women who reported a history of childhood physical and sexual abuse endorsed more sexual abuse items than did the men in this category. Table III describes the functioning and psychiatric symptoms reported by participants according to childhood-abuse category. In terms of functioning and psychiatric symptoms, only the severity of PTSD symptom was significantly associated with childhood abuse category. Prevalence of PTSD survey diagnosis was at least 5% points higher among soldiers who reported childhood physical and sexual abuse compared with participants who reported no abuse or childhood physical abuse only. In addition, the prevalence of problem drinking was at least 10% higher for participants who reported childhood physical and sexual abuse compared with participants who reported no abuse or childhood physical abuse only; however, the differences in prevalence were not statistically significant. DISCUSSION In the present sample, almost half of the participants reported a history of childhood physical abuse and an additional onefourth reported a history of both childhood sexual and physical abuses. Our findings are consistent with previous studies, documenting that trauma exposure, including childhood abuse experiences, is relatively common among U.S. Army soldiers. 27 In fact, the prevalence of childhood physical abuse in our sample was considerably higher than what has been found in the general population, where estimates range from 14% to 32%. 1 However, contrary to our hypothesis, we found few differences between participants with and without childhood abuse histories in terms of psychiatric symptoms and functioning. Although prevalence of problem drinking appeared clinically elevated in soldiers reporting both childhood physical and sexual abuse, only severity of PTSD symptom was statistically associated with childhood abuse experiences. Specifically, we found that soldiers reporting a history of both childhood physical and sexual abuse reported greater PTSD symptoms than soldiers with no childhood abuse or with a history of childhood physical abuse only. Active Duty Troops Demographic Characteristics by Childhood Abuse Category Overall ( N = 204) No Childhood Abuse ( N = 57) Childhood Abuse Category Childhood Physical Abuse Only ( N = 90) Childhood Physical and Sexual Abuse ( N = 49) χ 2 (Degree of Freedom) p Value Sex (% male) (1) 0.06 Race/ethnicity (% reporting) White (1) 0.22 African American (1) 0.02 American Indian (1) 0.04 Hispanic (1) 0.07 Married (%) (1) 0.11 At Least Some College Education (%) (1) MILITARY MEDICINE, Vol. 176, February 2011

4 TABLE II. Abuse Items Reported by Respondents in CPA Only and CPA and CSA Groups, Overall and by Gender Childhood Abuse Category Childhood Physical Abuse Only ( N = 90) Childhood Physical and Sexual Abuse ( N = 49) Abusive Items Reported % of Respondent Reporting I was punished with a belt, a board, a cord or some other hard object. Overall Male Female Adults in my family hit me so hard that it left me with bruises or marks. Overall Male Female Someone tried to touch me in a sexual way or tried to make me do sexual things or watch sexual things. Overall Male Female Someone threatened to hurt me or tell lies about me unless I did something sexual to them. Overall Male Female Someone molested me. Overall Male Female I believed that I was sexually abused. Overall Male Female TABLE III. Variables Functioning and Mental Health Symptoms According to Childhood Abuse Category Overall ( N = 204) No Childhood Abuse ( N = 57) Childhood Abuse Category Childhood Physical Abuse Only ( N = 90) Childhood Physical and Sexual Abuse ( N = 49) Test Statistic (Degree of Freedom) p Value Functioning Social Functioning, Mean (SD) 1.9 (0.7) 1.9 (0.7) 1.9 (0.7) 2.0 (0.7) 1.5 (1,193) a 0.23 Physical Functioning, Mean (SD) 0.8 (1.1) 0.8 (1.0) 0.9 (1.1) 0.8 (1.1) 0.02 (1,144) a 0.88 Psychiatric Symptoms PTSD Symptom Severity, Mean (SD) 19.7 (10.6) 18.2 (11.4) 18.4 (9.6) 23.9 (10.4) 5.4 (1,191) a Percentage Meeting Survey Criterion for (1) b 0.35 Depression Symptom Severity, Mean (SD) 11.7 (3.8) 11.7 (3.8) 11.3 (3.7) 12.4 (3.8) 0.8 (1,193) a 0.36 Percentage Meeting Survey Criterion for (1) b 0.37 Alcohol Abuse Symptom Severity, Mean (SD) 1.6 (1.7) 1.6 (1.8) 1.4 (1.4) 1.8 (1.9) 0.2 (1,173) a 0.65 Percentage Meeting Survey Criterion for (1) b 0.34 a F-test for linearity. b Mantel-Haenzel χ2 for trend. Despite reporting severer PTSD symptoms and heavier drinking, the combination of childhood physical and sexual abuse was not associated with impaired functioning in this sample of Army soldiers. If our findings generalize, collecting health surveillance data on adverse childhood experiences may have limited utility in improving successful personal and military functioning. Policymakers may find these data helpful while considering the pros and cons of asking military personnel about childhood abuse experiences. On the one hand, asking questions about adverse childhood experiences could identify a subgroup of individuals who may be suffering from adverse mental health sequelae. Our data suggest that individuals who experienced both childhood physical and sexual abuse report severer PTSD symptoms in comparison with those who experienced no childhood abuse or childhood physical abuse alone. In this way, health surveillance combined with empirically supported treatments for trauma survivors might benefit these individuals, particularly before deploy- MILITARY MEDICINE, Vol. 176, February

5 ment, as pre-existing PTSD symptoms may be a risk factor for the later development of combat-related PTSD 28 (Polusny, Erbes, Murdoch, Arbisi, Rath, unpublished data). On the other hand, PTSD symptomatology can result from a range of potentially traumatic experiences, and thus, it may be more useful to screen military personnel for PTSD symptoms in general, rather than simply screening for adverse childhood experiences or other stressful life events in particular. Moreover, research has found that individuals who are hospitalized 29 or receive an International Classification of Diseases, Ninth Revision psychiatric diagnosis as their primary diagnosis 30 are at an increased risk for military attrition in comparison to individuals who receive a nonpsychiatric diagnosis. This has also been found for hospitalized individuals who received a secondary psychiatric diagnosis. 29 As such, general mental health screening may be more beneficial than screening for aversive childhood experiences when considering how to improve personal and military functioning and to decrease attrition. Although not statistically significant, problem drinking prevalence appeared to be clinically higher in those who experienced both childhood physical and sexual abuse compared to other soldiers. Trent et al 13 also found that adverse childhood experiences were associated with increased alcohol use in a sample of Navy recruits. In addition, they found that Navy recruits with a history of childhood abuse were more likely to exhibit alcohol problems than recruits who did drink, but did not have a history of childhood abuse. One potential explanation of our findings is that baseline alcohol consumption may be higher for those individuals who choose to enter the military. For example, one study found that high school students who enter the military tend to be heavier drinkers compared to those who do not enter the military. 31 Furthermore, once entering the military, heavy drinking may be promoted as part of the work place culture or because of easy alcohol availability. Some have suggested that military personnel may engage in binge drinking to cope with boredom and with the absence of other reinforcing or pleasurable activities. 32 Although substantial prior research has associated aversive childhood histories with subsequent psychiatric sequelae, 4,7 9,12 longitudinal research 33,34 also suggests that psychological resilience is more often the rule than the exception for individuals who experience traumatic life events. Therefore, it is not surprising that we found childhood abuse experiences were not associated with most indices of psychiatric symptoms and functioning. Overall, our findings suggest that military personnel in our sample were quite resilient. On average, individuals in our study had comparable prevalence rates of PTSD (7.2% vs. 7.8% 35 ), as individuals in the national population. Although we cannot speak of the exact mechanisms contributing to resilience in our sample, it is possible that resilient individuals are more likely to enlist in the Armed Services, and thus, such individuals may be healthier and more competent than individuals who are less resilient to traumatic life events. On the other hand, if some individuals entered the Armed Forces to escape abusive home situations, as others have suggested, 36,37 then the military could serve as a supportive environment for them. Further research is needed to determine under what circumstances military troops are resilient. The current study has several important limitations. First, participants were selected because of their availability on the day of data collection and may not be representative of other Army soldiers or troops from other services. Other studies have used similar enrollment methods, without finding evidence of biased selection, 38,39 but we still recommend replication in other samples. In addition, the sample size was small and our statistical power may have been limited, particularly in terms of problem drinking, where there appeared to be a clinically large, but not a statistically significant association. Causality cannot be determined from this study, and mono-method variance bias could also have influenced study conclusions. In this study, childhood abuse histories were common. However, in contrast to our initial hypotheses, we found few differences between individuals with and without such histories in terms of functioning. Although there is an ongoing debate about whether or not to include questions about childhood abuse experiences on health surveillance questionnaires, the value of this approach is currently unknown. Future research should explore whether screening for childhood abuse experiences improves clinical outcomes and whether active treatment of individuals with PTSD or sub-threshold PTSD before deployment enhances health, well-being, or performance in military personnel. ACKNOWLEDGMENTS Funding for this study was provided by the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Service (IIR no ). REFERENCES 1. Briere J, Elliott DM : Prevalence and psychological sequelae of selfreported childhood physical and sexual abuse in a general population sample of men and women. Child Abuse Negl 2003 ; 27: Crawford SL, Fiedler ER : Childhood physical and sexual abuse and failure to complete military basic training. 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