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Abuse in childhood can set up a row of falling dominoes that increases the risks of mental and physical health issues, legal troubles, and even early death, according to two large longitudinal studies.

A study on found that children abused before age 5 are two to three times more likely to experience negative health outcomes as young adults, particularly when the abuser is a loved and trusted person, said Jennifer Lansford, PhD, of Duke University in Durham, North Carolina, and colleagues.

The found that adults maltreated as children were up to five times more likely to die by age 33. These deaths were largely due to self-harming behaviors such as poisonings, alcohol and/or other substances, and suicide, said Leonie Segal, PhD, of the University of South Australia in Adelaide, and colleagues.

The studies were simultaneously published in Pediatrics.

"These results demand our attention," Segal said. "We must ask, what are we doing or failing to do in supporting children exposed to child abuse or profound neglect and their distressed families? How can we do better, from early childhood, to stop this progression to an untimely death?"

"This speaks to the importance of early intervention by pediatricians, teachers, adults, and society in general, talking about nonviolent forms of discipline and providing support for parents," especially during the COVID-19 pandemic, when families are under enormous logistical and financial stress, noted Lansford in an interview with MedPage Today.

"This is one reason why calls to Child Protective Services [CPS] and domestic violence hotlines have increased so much," she added. "Family violence is also associated with more stressful life experiences. The need for social safety nets to both prevent and treat violence against children is crucial."

Lansford and co-authors examined early adulthood outcomes of 1,048 participants followed from kindergarten to adulthood in two multisite studies. In an interview during kindergarten, the children's caretakers were asked about responses to the child's problem behaviors. The participants were interviewed annually until age 20, and sporadically thereafter.

Of the combined cohort, the mean age was about 6 years at study entry; 33% were Black and 66% were white. About a third lived in single-parent homes; 18% of the mothers hadn't completed high school at the time of enrollment. Participants were about 25 years old at their last assessment.

Outcome measures included any physical signs of abuse, as well as family financial issues, legal issues, or conflict within the family; a move or major home remodeling; separation or divorce; and parent-child separation.

Of the cohort, 93 had been abused or suffered a major stressor from ages 1 to 5 years. However, Lansford noted that abusive caretakers don't always admit the problem, so these numbers are probably an underestimation.

The researchers found that more young adults with early abuse or severe stressors had received special education services (RR 3.2) and repeated a grade (RR 2.14). Just 13.6% had a 4-year college degree compared with about 30% of those who did not experience abuse, but this was not a statistically significant difference after controlling for numerous confounding factors.

Additionally, they had double the odds of receiving any kind of public assistance (19.5% vs 9.8%) and significantly worse physical health (self-report index 0.74 vs 0.81). Risky sexual behavior wasn't significantly different.

They also had numerically more convictions for drug use (19.6% vs 10.3%), public or private order offenses (33.3% vs 23%), and violent crime (26.7% vs 16%), and more than twice the chance of being convicted in the last 12 months (18% vs 7%).

The mechanisms behind these increased risks aren't entirely clear, Lansford said. "There is evidence that physical abuse changes brain structure at this critical time of maturation. It surely causes relationship issues and disrupts a child's ability to trust and feel secure. Children become hypersensitive to hostile cues and more likely to interpret ambiguous information as hostile. In the long term, this change can make them hypervigilant and more aggressive."

Other researchers have been looking at markers of cellular aging in abused children. Among the findings: maltreatment and other adverse childhood experiences sufficiently predicted shortened telomere length and DNA methylation.

The study by Segal and team comprised all people born in South Australia from 1986-2003 and included in linked databases (N=331,254). Contact with CPS was considered a proxy for childhood exposure to violence. The number of deaths by age 33 was the main outcome measure. The study adjusted for child and maternal characteristics.

In all, 20% of the cohort had some CPS contact by age 16; only 2% had been placed in out-of-home care (OOHC).

Those with CPS contact were more than twice as likely to die by age 33 (HR 2.09). Those placed in OOHC were 4.67 times more likely to die, although placement before age 3 somewhat mitigated this risk (HR 1.75).

Several causes of death were significantly higher in the CPS-exposed group compared with the control group. These included deaths from poisonings, alcohol and/or other substances, and mental health problems (RR 4.8), as well as suicide (RR 2.8). Natural deaths were also significantly higher (RR 1.99).

By age 33, overall mortality in the CPS-exposed group was 30.9 per 1,000 compared with 5.1 per 1,000 in in the non-exposed group. Individuals with confirmed maltreatment exposure in childhood had considerably higher mortality (13.7 per 1,000).

"The strength of association was highest in categories indicating more serious maltreatment exposure, supporting the relationship as causal, when taken together with well-described mechanisms linking [child maltreatment] to disturbed emotional and behavioral responses, a high sense of shame and low impulse control, risk factors for substance use, and suicide," the authors wrote.

"Child maltreatment exerts a devastating impact in terms of increased risk of death. I think these findings are especially pertinent now, given the considerable increased stresses on families associated with the COVID-19 pandemic, which will undoubtedly increase the exposure of children to serious child abuse and neglect. We need to act now to avoid these potential disastrous consequences in adolescence and adulthood," said Segal.

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