© Janne Rueness, 2021
Series of dissertations submitted to the Faculty of Medicine, University of Oslo
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Tout ce qui est intéressant se passe dans l’ombre, décidément. On ne sait rien de la véritable histoire des hommes.
Louis-Ferdinand Céline (Voyage au bout de la nuit)
TABLE OF CONTENTS
Acknowledgments ... 7
Funding ... 9
List of tables, figures and text boxes ... 9
List of papers ... 10
Abbreviations ... 11
Summary ... 12
INTRODUCTION ... 14
The societal burden of child abuse ... 14
Prevalence of child abuse ... 14
Child abuse definitions ... 16
Nordic perspectives on child abuse ... 17
The Barnehus Model ... 19
Overlapping child abuse types and the number of child abuse types ... 20
Child abuse, posttraumatic stress reactions and other psychological trauma symptoms... 20
Physical health complaints ... 22
Child abuse and physical health ... 22
The role of child abuse types and poor physical health ... 24
Models and predictors for the development of physical health complaints ... 25
The relationship between psychological trauma symptoms and poor physical health ... 27
Knowledge gaps ... 28
Aims of the thesis ... 29
METHODS ... 30
The research projects ... 30
The Revictimization Study (papers 1 and 2) ... 30
Study design ... 30
Participants ... 30
Procedures ... 34
Exposures ... 35
The Barnehus Study (paper 3) ... 37
Study design ... 37
Participants ... 37
Procedures ... 38
Exposures ... 39
Measures ... 42
The other study variables in the thesis ... 42
Dependent variable ... 42
Mediator variable (paper 2) ... 43
Independent variables (paper 3) ... 43
Control variables ... 44
Missing values ... 45
Statistical analyses ... 45
Ethical considerations ... 48
RESULTS ... 52
The Revictimization Study ... 52
The Barnehus Study ... 53
DISCUSSION ... 55
Methodological considerations ... 59
Internal validity ... 59
Misclassification (information errors) ... 60
External validity ... 63
Implications ... 65
Conclusion ... 66
References ... 68
APPENDIX (papers 1, 2 and 3) ... 81
7 Acknowledgments
Several individuals have contributed to the work of this thesis. I owe my deepest gratitude to the adolescents at the Statens Barnehus who, in the midst of their own personal crises, participated in the study and shared their personal experiences of child abuse. I would also like to thank the adolescents who took their time to participate as study controls and the dedicated counselors at Statens Barnehus for collecting all the data. The Barnehus Study could not have been performed without their support and enthusiasm to complete the numerous, ambitious questionnaires.
Furthermore, I would like to thank all the adolescents and young adults who participated in the Revictimization Study for sharing their time and experiences.
The research work was conducted at the Norwegian Center for Violence and Traumatic Stress Studies (NKVTS) between 2016 and 2020. NKVTS has provided funding for this thesis for more than three years and has provided all of the structural facilities needed. I would like to thank all my former colleagues at NKVTS who have introduced me into the interdisciplinary field of violence research and have always made me feel welcome. Thank you for three years of appropriate and crazy fun, thank you for letting me be myself. Moreover, I appreciate and thank the leadership, administration and all the helping hands among the staff at NKVTS for their indirect contributions to my research work, including article promotion, assistance with reference searching, or fixing all kinds of annoying technical problems that accidently occurred en route. Thank you, Marianne, for our friendship, coffee breaks and lunch meal upgrades. Thank you, ToRe, for sharing my peculiar sense of details.
Thank you, Inger Elise, for your subtle reminders of where I belong.
Some researchers have made indispensable contributions to this Ph.D. project. I am most grateful to my main supervisor, Mia Cathrine Myhre, who gave me the opportunity to do research on the Barnehus Study. Thank you, Mia, for showing confidence in me. Thank you for all the fights and all the tears but mostly for the patient guidance, encouragement and advice you have provided me throughout this project, for always listening to my ideas and for mostly accepting them as well. I would also like to thank my cosupervisors Ida Frugård Strøm and Grete Dyb. Ida, thank you for our friendship, including your worldwide availability whenever I needed to ask for your advice. I hope you never regret suggesting yourself as a cosupervisor back in the jacuzzi days in Chicago, even though I know you have had a hard time in teaching me how to write clearly in a foreign, academic language.
Grete, thank you for your valuable contribution to the project as a coupervisor, coauthor and supporter throughout the years.
I would also like to thank Siri Thoresen. She included me in the Revictimization research group and generously shared the data from the epidemiological survey. She has also given indispensable contributions as a coauthor on papers 1 and 2. Else-Marie Augusti has been a collaborator in the Barnehus research group and has coauthored paper 3. I am thankful for her practical and academic contributions.
Tore Wentzel-Larsen deserves special thanks and has played a key role in all three papers. In addition to being a brilliant statistician and patient teacher in the field of statistics, he has also been an excellent coauthor and has improved all the papers in terms of content, language and grammar.
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I am also grateful to my colleagues at the Pediatric ward at Ullevål, Oslo University Hospital. Thank you, leader Cathrine, for your encouragement, enthusiasm and flexibility allowing me to combine research and clinic at the end of the research project. Thank you, dear inspiring colleagues at the Section of Social Pediatrics for making every day at work joyful. Thank you, brave young storytellers for sharing your experiences, thereby teaching me new perspectives of human evil. Altogether, I could not have had any better teachers in my lifelong fight against child abuse.
In regard to my private spheres, I would like to thank my fabulous friends for decades of contributing hilarious, nonscientific variations to my life. A special thanks to my family in law, who, in your own ways, have introduced me to the ups and downs of science and for your genuine practical and emotional support throughout my entire academic career.
Finally, my life is complete due to my beloved children and their perfect father. Thank you for your affection, your patience and your continuous support without complaint. Thank you for thinking clearly on my behalf whenever my own thoughts have locked. Thank you for always being there as my best friend. You are altogether the heart of my matter.
9 Funding
The Revictimization Study and the Barnehus Study were funded by the Program for Violence Studies at the NKVTS. The program was financed by governmental funding from the Norwegian Directorate of Health and the Ministry of Justice and Public Security. All data collected from study participants is the property of the NKVTS.
List of tables, figures and text boxes
Table 1: Prevalence rates of lifetime, self-reported child abuse types in Norway ... 15
Table 2: Child abuse exposures in paper 1 and 2 ... 36
Table 3: Child abuse exposure variables in the Barnehus Study. ... 41
Table 4: The variables used in the papers ... 42
Table 5: Overview of the three papers ... 48
Figure 1: Flowchart for recruitment of wave 1 participants ... 32
Figure 2: Flowchart of the attrition from wave 1 to wave 2 ... 33
Figure 3: Flowchart for the recruitment of participants in the Barnehus Study ... 38
Figure 4: Mediation model of PTSR linking child abuse with physical health complaints ... 47
Text box 1: Definitions of child abuse types ... 17
Text box 2: Key legislation regulating child abuse in Norway ... 18
10 List of papers
Paper 1:
Rueness, J., Myhre MD, M. C., Strøm, I. F., Wentzel-Larsen, T., Dyb, G., & Thoresen, S. Child abuse and physical health: A population-based study on physical health complaints among adolescents and young adults. Scand J Public Health. 2020;48(5), 511–18.
https://doi.org/10.1177/1403494819848581
Paper 2:
Rueness J, Myhre MC, Strøm IF, Wentzel-Larsen T, Dyb G, Thoresen S: The mediating role of posttraumatic stress reactions in the relationship between child abuse and physical health complaints in adolescence and young adulthood. Eur J Psychotraumatol. 2019;10(1):1608719.
https://doi.org/10.1080/20008198.2019.1608719
Paper 3:
Rueness J, Augusti E-M, Strøm IF, Wentzel-Larsen T, Myhre MC. Adolescent abuse victims displayed physical health complaints and trauma symptoms during post disclosure interviews. Acta Paediatr.
2020;00:1-7.https://doi.org/10.1111/apa.15244
11 Abbreviations
ɲ Alpha
ACE Adverse childhood experiences ACME Average causal mediation effect ADE Average direct effect
BCa Bias corrected and accelerated CDC Centers for Disease Control CRP C-reactive protein
CSI Children’s Somatization Inventory CSSI Children’s Somatic Symptoms Inventory HPA Hypothalamic-pituitary-adrenal IPV Intimate partner violence
NKVTS Norwegian Center for Violence and Traumatic Stress Studies NPR Norwegian Population Registry
PCL Posttraumatic Checklist PTE Potential traumatic event PTSD Posttraumatic stress disorder PTSR Posttraumatic stress reactions REC Regional Committee of Health Ethics Rsep Rasch person separation reliability SES Socioeconomic status
TSCC Trauma Symptom Checklist for Children
UNCRC United Nations Convention of Rights of the Child
UEVO Youth Survey on Exposure to Violence and Abuse [Ungdomsundersøkelsen om erfaringer med vold og overgrep]
WHO World Health Organization
12 Summary
Background:
Child abuse is prevalent and constitutes a major public health problem worldwide. On the individual level, child abuse victims may struggle with psychological health problems and behavioral difficulties throughout their lifespan. Recently, child abuse has been associated with physical health problems in adolescence and adulthood, but the pathways involved are unclear.
Aims:
The overarching aim of the current thesis was to investigate physical health complaints in
adolescents and young adults who had experienced child abuse. The thesis also aimed to investigate whether psychological trauma symptoms contributed to the development of physical health
complaints in adolescence and young adulthood. More specifically, it investigated the following:
a) Whether child abuse types and the number of child abuse types experienced were associated with physical health complaints in adolescence and early adulthood (paper 1).
b) Whether posttraumatic stress reactions (PTSR) mediated the relationship between child abuse and physical health complaints in adolescence and early adulthood (paper 2).
c) Whether adolescents who had recently disclosed sexual abuse and family violence in forensic interviews had more psychological trauma symptoms than unaffected controls and to what degree psychological trauma symptoms such as anxiety, depression, PTSR, anger and dissociation were associated with physical health complaints (paper 3).
Methods:
Data from two different research studies was used: a community study of 1010 adolescents and young adults and a clinical study of child abuse victims that included 116 adolescents. Both studies applied a case-control design.
The community study was a longitudinal follow-up study (wave 2) of adolescents and young adults between 16 and 33 years from the general Norwegian population who had participated in a
previously conducted prevalence study on violence and abuse (wave 1). Participants in the follow-up study were drawn from wave 1 and comprised 506 cases and 504 controls. Wave 1 was conducted in 2013 and wave 2 was conducted in 2014. Cases included adolescents and young adults who had experienced physical or emotional abuse from parents, the witnessing of parental intimate partner violence (IPV), neglect, and/or sexual abuse during childhood. The youngest cases were first
contacted, and recruitment continued, increasing with age, until a quota of at least 500 respondents was reached. The controls had not experienced any of these abuse types, and matched the cases by age and gender. Wave 2-participants were interviewed by telephone about their current health and behavioral problems, including physical health complaints.
The clinical study was a cross-sectional study of adolescents between 10 and 18 years of age conducted at the Statens Barnehus (Children’s House) in Oslo, Norway, from 2016 to 2018. Data on psychological trauma symptoms and physical health complaints were assessed during face-to-face interviews with adolescents who had recently disclosed sexual abuse or family violence during
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forensic interviews at the Barnehus in Oslo, Norway. The Barnehus is a specialized Nordic police unit where evidence in violence-related police cases is gathered. A group of controls matched by age, sex and postal code from the Norwegian Population Registry (NPR) participated in the study by
completing an Internet questionnaire.
The statistical analyses used in this thesis included chi-square statistics, independent-sample t-tests, linear regression analyses, bootstrap analyses, and causal mediation analyses, including sensitivity analyses.
Results:
a) In the community study, adolescents and young adults who had experienced child abuse had higher levels of physical health complaints than the nonexposed individuals. Sexual and emotional abuse were unique predictors of physical health complaints. Physical health complaints increased with the higher number of child abuse types experienced (paper 1).
b) PTSR mediated the development of physical health complaints in adolescents and young adults who had experienced child abuse. The mediating effect of PTSR was larger for individuals who had experienced more than two child abuse types (paper 2).
c) In the clinical study, adolescents who had recently disclosed child abuse during forensic interviews had higher levels of PTSR than the nonexposed control group. In examinations of the health consequences for the different police-referred cases, sexual abuse victims also had higher levels of depression, dissociation and physical health complaints than the unexposed controls. Moreover, child abuse victims with the highest burden of trauma symptoms had the highest levels of physical health complaints (paper 3).
Conclusion:
These findings provide evidence of an early onset of physical health complaints in young child abuse victims and that psychological trauma symptoms such as PTSR may contribute to the development of physical health complaints in adolescence and early adulthood. Early identification of child abuse and trauma symptoms following abuse may be important to prevent the development of physical health complaints in adolescence and early adulthood. Early targeted treatment of trauma symptoms and physical health complaints may reduce the daily health burden of young child abuse victims and be beneficial for society by reducing the economic costs associated with child abuse.
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INTRODUCTION
The societal burden of child abuse
Child abuse is prevalent and is one of the major public health burdens worldwide. Studies confirm that child abuse accounts for substantial morbidity and mortality rates in Western societies (1, 2). On the individual level, child abuse has lifelong adverse social, health and economic consequences, including behavioral problems (i.e., binge drinking, tobacco use) (3, 4); psychological health problems (i.e., posttraumatic stress disorder, anxiety, depression, suicidality) (5-8); reduced health-related quality of life (9); and increased risk for delinquency, violent behavior and later victimization (10, 11).
On the societal level, exposure to child abuse may adversely impact work productivity, income revenue and taxes, and added societal expenses related to welfare benefits and health care usage (12, 13). Moreover, the socioeconomic costs following child abuse are vast. A cost-analysis from Norway estimated the lifetime socioeconomic costs related to child abuse to be 3.3-7.5 billion euro, which was four times the societal costs used to prevent child abuse in Norway (14). Hence, the prevention of child abuse and its negative health trajectory will be beneficial on an individual and a societal level. To achieve this aim, a better understanding of the consequences of child abuse on health outcomes at an early age is warranted.
Prevalence of child abuse
The prevalence of child abuse varies highly across studies and between countries, from nearly zero to above 90.0% (15, 16). In a recent review of a series of meta-analyses, the overall prevalence of self- reported exposure to child abuse before 18 years of age was 12.7% for sexual abuse, 22.6% for physical abuse, 36.3% for emotional abuse, 18.4% for emotional neglect and 16.3% for physical neglect (17). The great majority of prevalence studies on child abuse are from the USA and Europe.
Some recent national surveys in low- and middle-income countries have been conducted, but data from many countries are still lacking (17). Prevalence estimates of child abuse are difficult to compare across countries and studies because estimates vary according to the methods of research used. Definitions of child abuse differ across cultures, and factors such as the lack of standardized child abuse measures and the quality of official statistics may explain some of the variation in the results (18). However, a meta-analysis of prevalence studies of worldwide child abuse concluded that the overall prevalence of child abuse seems to be fairly similar, although studies from low- and middle-income countries were severely underrepresented (17).
In regard to prevalence studies on child abuse types, research is dominated by publications on physical and sexual abuse. In particular, the number of publications on sexual abuse is greater than the total number of publications on all other types of child abuse (19). The fewest studies have been conducted on emotional abuse and neglect, which may be due to difficulties in measuring neglect and emotional abuse in the community (17, 19). Moreover, research has also demonstrated gender differences in prevalence rates for specific types of child abuse. It has been established that the majority of sexual abuse and emotional abuse sufferers are girls (19-23). In contrast, males are at higher risk of witnessing violence and of exposure to severe forms of physical violence (24, 25).
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Table 1: Prevalence rates of lifetime, self-reported child abuse types in Norway.
With some exceptions, the Prevalence, the Revictimization and the Barnehus Study used similar definitions of physical, sexual and emotional abuse, neglect and the witnessing of parental IPV.
1The UEVO Study included a broader assessment of “non-contact” sexual abuse than the Prevalence Study. In the Prevalence Study, experience of “non-contact” sexual abuse was only covered by the question: Have you ever experienced other types of sexual assault? In the UEVO Study, sexual abuse was defined as being shown private part or forced to show one’s private parts. Moreover, sexual abuse included being forced to touch another person’s private parts; or forceful touching of private parts; or having sex, such as intercourse, licking, sucking or fondling (20).
2 The UEVO Study applied a broader assessment of emotional abuse than the Prevalence Study and included the following additional items: been locked out from your home, been locked into a room, threatened to be left by a parent and threatened to hurt the family’s pet (20).
Prevalence studies estimating child abuse have displayed somewhat lower estimates of child abuse in Nordic countries (Norway, Sweden, Denmark, Iceland and Finland) than in other countries (26). In a review consisting of 24 Nordic studies, the authors found a prevalence of child sexual abuse by a parent in the range of 0.2–1.2%, of severe physical abuse in the range of 3.0-9.0% and of witnessing family violence between 7.0% and 12.5% (26). The authors suggest that possible explanations for this difference in prevalence estimates include factors such as socioeconomic welfare, free access to
Age span Adulthood
18-75 years
Adolescence 16-17 years
Adolescence 12-16 years Data source The Prevalence
Study
The Prevalence Study
The UEVO Study
Total sample size 4527 2062 9240
Participants (%, n) n % n % n %
Child abuse type Physical abuse
Less severe physical violence 1356 30.2 194 9.4 1337 14.5
Severe physical violence 220 5.0 36 1.8 375 4.0
Any of the above forms of physical violence from parents
1408 31.1 198 9.6 1742 19.4 Sexual abuse1
Rape 139 2.9 37 1.8 96 1.0
Any type of sexual abuse 681 15.0 174 8.4 543 6.0 Emotional abuse2 607 13.4 136 6.6 1600 18.0 Witnessing parental IPV
Towards mother or father 448 9.4 68 3.3
Towards the mother 1583 17.1
Towards the father 1214 13.1
Neglect
Physical or emotional neglect 8.5 175 1263 14
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public health and social services in Nordic countries, which, in turn, facilitate the likelihood of the identification of families at risk (26). Moreover, a low cultural acceptance of physical discipline in Nordic countries over time, including offensive legislation towards child abuse, may have contributed to a reduced prevalence of child abuse in Norway over time. Factors such as economic growth and cultural perceptions may also have changed over time, with corresponding changes in child abuse prevalence. For instance, sexual abuse within the family and physical abuse in Sweden and Finland have declined since the 1990s (26, 27).
Consistent with the findings from the Nordic review, authors of the Norwegian Prevalence Study on Violence in Norway from 2013 found that adults more frequently reported exposure to sexual abuse before 13 years of age and less severe physical abuse in their childhood than adolescents (28, 29).
Findings from the Prevalence Study are displayed in Table 1, and two of the papers in the current thesis have used follow-up data from this survey. In addition, Table 1 includes recent prevalence rates of child abuse in Norway from the Youth Survey on Exposure to Violence and Abuse (the UEVO Study) (20).
Child abuse definitions
Conceptual understandings of child abuse vary across cultures and among professions. Moreover, definitions of child abuse have changed over time. In an effort to reach a uniform definition of child abuse across cultures, the World Health Organization (WHO), in collaboration with the International Society for the Prevention of Child Abuse and Neglect, compared 58 definitions of child abuse and agreed upon a conceptual definition of child abuse in 1999. This definition, as follows, is applied throughout the current thesis:
Child abuse or child maltreatment is the abuse and neglect that occurs to children under 18 years of age. Child abuse includes all forms of physical or emotional ill- treatment, sexual abuse, neglect or negligent treatment, or commercial or other exploitation of children that causes actual or potential harm to a child’s health, survival, development, or dignity in the context of a relationship of responsibility, trust or power (30, p.15)
The WHO further distinguishes four child abuse types: physical abuse, sexual abuse, emotional abuse and neglect (31, 32). In addition, the witnessing of family violence is increasingly recognized as an independent child abuse type (19). Since 2008, the Centers for Disease Control (CDC) and Prevention has acknowledged the witnessing of family violence as an independent child abuse type (31). In the current thesis, the witnessing of family violence is regarded as an independent child abuse type.
The WHO defines adolescents as people between 10 and 19 years of age (33). However, the United Nations Convention on the Rights of the Child (UNCRC) and Norwegian legislation apply the term child to any individual less than 18 years of age (34). By this definition, the great majority of adolescents in this thesis are acknowledged as children in a juridical context.
Definitions of the distinct child abuse types used in this thesis are presented in Text box 1.
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Text box 1: Definitions of child abuse typesaccording to the WHO and CDC (31, 35).
Nordic perspectives on child abuse
Different cultures have different rules about what are considered acceptable behaviors towards children and acceptable parental caretaking. Since the 1980s, there has been an increasing societal recognition to consider the child as an independent individual with similar rights as adults. As of August 2020, child corporal punishment is illegal in 60 countries and 132 countries now have laws protecting children from violence at school (36). The Nordic countries were among the first countries in the world to ratify the UNCRC, which Norway signed in 1991 (37). Specifically, article 19 of the UNCRC incorporates the full range of human rights for children, emphasizing the state’s responsibility of “protecting children from sexual, physical and mental abuse, neglect or exploitation” (34).
According to the UNCRC, the witnessing of family violence by a child is also regarded as abuse (34).
Since 2003, this convention has been validated as a Norwegian law (38). Should there appear a contradiction between the UNCRC and Norwegian legislation the convention will prevail.
Compared to other European countries, Nordic countries have a more offensive approach regarding what is considered illegal in terms of acceptable parenting, reflecting a strong perception of children and children’s independent rights. According to civilian legislation (The Children Act), all types of
Physical abuse: The intentional use of physical force against a child by a parent or caregiver that results in- or has a likelihood of resulting in- harm for the child’s health, survival, development or dignity. This includes hitting, beating, kicking, shaking, biting, strangling, scalding, burning, poisoning or suffocating.
Sexual abuse: is the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not
developmentally prepared, or else that violates the laws or social taboos of society. Children can be sexually abused by both adults and other children who are – by virtue of their age or stage of development – in a position of responsibility, trust or power over the victim.
Emotional abuse: Failure on the part of a parent or caregiver to provide a developmentally appropriate and supportive environment. Acts in this category may have a high probability of damaging the child’s physical and mental health, or its physical, mental, spiritual, moral or social development.
Neglect: Failure on the part of a parent or caregiver to provide for the development and well- being of the child where the parent is in a position to do so, in one or more of the following areas: health, education, emotional development, nutrition, shelter and safe living conditions.
Witnessing family violence: child’s observing the abuse or violence towards other family members.
Witnessing parental IPV: child’s observing the physical violence, sexual violence, stalking, or psychological harm by a current or former partner or spouse.
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abuse or violence against children have been prohibited since 1987 in Norway, including less severe corporal punishment (Text box 2) (39). Due to some inconsistencies in the interpretation of the Children Act, a specification was added in 2010 clarifying that all forms of violence towards a child, regardless of context, severity or number of events, are illegal, including hitting as part of corporal punishment (40).
Text box 2:Key legislation regulating child abuse in Norway
In addition to the civilian legislative regulation of child abuse in the Children Act, child abuse is also regulated by criminal legislation. The Penal Code specifies the distinct types of offenses towards children that are subject to a penalty or fine. The major focus in this act, however, is on sexual and physically violent offenses (41). Other child abuse types, such as emotional abuse, neglect or the witnessing of family violence, are not explicitly specified. Nevertheless, they are indirectly regulated throughout the Penal Code, such as in the section concerning violence in close relationships (Text box 2). An important consequence of the Penal Code focusing on sexual and violent offenses is that the
Child abuse in Norwegian legislation Civil law
The Children Act: §30.
The child must not be subjected to violence or in any other way be treated so as to harm or endanger his or her mental or physical health.
Criminal law
The Penal Code: Chapter 26. The sexual offences.
This chapter concerns the punishment or fine of any type of sexual activity towards children younger than 16 years, including sexually offensive conduct, sexual acts and intercourse.
The chapter also regulates the punishment to any person who obtains sexual activity through violence or threatening conduct or engages in sexual activity with a person (regardless of age) who is unconscious or in other ways incapable of resisting the act.
The Penal Code: Chapter 25. The violent offences.
This chapter specifies the types of violent offences leading to a punishment or a fine, such as physical assaults containing characteristics of abuse or leading to severe pain or injury or causing serious bodily harm.
Violence in close relationships, §.282: Punishment to any person who by threats, force, deprivation of liberty, violence or other degrading treatment seriously or repeatedly abuses/a spouse or cohabitant/a spouse or cohabitant’s relative in direct line of ascent/a member of the person’s household/anyone in the person’s care.
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majority of police investigations on child abuse towards minors are on sexual abuse or severe physical abuse (42).
The description of the sexual offenses in the Penal Code is consistent with the WHO definition of child sexual abuse, specifying that the abuse may be performed by any individual in a position of responsibility, trust or power over the child, such as, but not necessarily, a parent or caregiver.
Violence in close relationships is the juridical term for abuse conducted by someone close to the child, such as a parent or caregiver. The current thesis uses the phrase “violence in close
relationships” as the juridical term for family violence. Family violence includes the WHO/CDC child abuse types: physical abuse, emotional abuse, neglect, and the witnessing of violence.
The Barnehus Model
The Barnehus is perhaps one of the main policy ventures related to children as crime victims in Nordic countries. Similar to the Children’s Advocacy Centers in the USA since the 1980s, the Barnehus model was introduced in Nordic countries as a result of concern due to the lack of competence within the juridical system to meet the needs of children and adolescents who were crime victims (43). Moreover, there was a need for a more integrated health and social care service for children who had experienced abuse. A central concept within the Barnehus model is that different governmental agencies, such as social services, law enforcement and health care, should collaborate under one roof regarding investigations of suspected abuse against children (43).
Moreover, the model builds upon the principle that the children should have to go to only one single place for forensic interviews, health examinations and counseling instead of being referred to several places. A voluntary psychological follow-up consultation is one of the services proposed by the Barnehus in Norway. All children participating in forensic interviews are offered voluntary follow-up consultations some weeks after the child forensic interviews (42). The purpose of this consultation is to ensure that the offended children are adequately cared for throughout the police investigations;
to disclose any unmet social, psychological or medical needs; and to refer the children to health services when necessary. To summarize, the two most important aims of the Barnehus model are to improve the quality of the police investigations and to protect the offended child or adolescent (43, 44). This model implicates a close collaboration among the local police, child protection services and the health care system. The first Barnehus, or “Barnahúsið”, was established in Iceland in 1998, and in 2007, Norway followed. By the end of 2017, there were 17 Barnehus in Norway (42).
The organization of the Barnehus differs somewhat within Nordic countries. In Norway, the Barnehus is organized under the National Police Directorate, which implies that the Barnehus offers services only to minors who are part of police investigations, and mostly children or adolescents who have experienced sexual or severe physical abuse. Additionally, the Barnehus model comprises only minors who are entitled to undergo child forensic interviews, excluding the youngest children below 4 years of age and children or adolescents with severe mental retardation.
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Overlapping child abuse types and the number of child abuse types
There is increasing recognition that child abuse victims frequently suffer from several child abuse types, simultaneously as part of the same abusive event, subsequently or in different arenas (45-48).
In the Norwegian Prevalence Study from 2013, 42.1% and 64.4% of adolescents and adults,
respectively, who had experienced child abuse answered that they had experienced more than one child abuse type (28, 29). In high-risk samples, such as clinical samples from psychiatric practices, the figures of overlapping abuse are typically higher (46).
However, it may sometimes be difficult to differentiate the distinct abuse types because every abuse type contains some components of other abuse. An example of this is that sexual abuse frequently involves some sort of physical abuse in terms of forceful holding or some sort of emotional abuse such as verbal humiliation. Some researchers even argue that single child abuse types do not exist (49). Further, there is some evidence that certain abuse types are more likely to occur in
combinations with other abuse types than in isolation. In particular, physical and emotional abuse, and neglect, commonly cluster. In a systematic review on the prevalence of overlapping child abuse, authors found that emotional abuse and neglect typically cooccurred with physical abuse (46). In a recent German general population study, the most common abuse combinations were physical and emotional neglect combined and physical abuse in combination with physical and emotional neglect (21). Because exposure to more than one abuse type is frequent and the rule rather than the
exception, one could also question whether it is of clinical relevance to study the distinct child abuse types in isolation. Nevertheless, research on the “pure” effects of the distinct child abuse types is limited, as such research requires specific data on several abuse types within the same dataset to adjust for exposure to other abuse types. Additionally, such research requires that each abuse type can be easily distinguished from other abuse types (45).
In the existing literature, individual experiences of multiple child abuse types is commonly referred to as polyvictimization, multitype maltreatment, multiple child abuse or the number of child abuse types (45, 47, 50). Sometimes authors do not specifically clarify whether these terms refer to exposure to different child abuse types, other forms of victimization or repeated events of the same abuse type. To address such overlaps in child abuse types, this thesis uses the expression “the number of child abuse types”, which is the total number of different child abuse types experienced by a single individual, both simultaneously and over time.
Child abuse, posttraumatic stress reactions and other psychological trauma symptoms
In this thesis, posttraumatic stress reactions or PTSR refers to reactions included in the diagnosis of posttraumatic stress disorder (PTSD) in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (51). Such reactions include self-perceived psychological reactions following a traumatic event, including persistent re-experiencing of the event, the avoidance of stimuli associated with the event and hyperarousal symptoms, such as impaired sleep, negative thoughts or irritability (51). A potential traumatic event (PTE) is defined as “an experience involving threat to one’s physical integrity, witnessing such a threat occur to someone else, or learning of threat or actual harms to
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someone beloved or closely related“(52). Opposite to PTSR, PTSD is trauma-specific and can be diagnosed only following exposure to a PTE (51).
PTSR and PTSD are common in the general population. In community study from the USA, 7.8% of adults reported having a PTSD diagnosis in their lifetime (53). However, the prevalence of a confirmed PTSD diagnosis in preadolescents and adolescents is likely much lower and was only approximately 0.5% in a general adolescent population sample from the USA (54). Reports of a single symptom (i.e., painful recall) or subclinical PTSD were much more common, with cumulative rates of 9.1% and 2.2%, respectively (54). While adolescents with PTSD may have clinical psychological symptoms resembling those of adults, children often show fewer signs of avoidance (6). As a consequence, scholars globally have raised concerns that these symptoms in children and adolescents are overlooked and underdiagnosed (55).
PTSR develop frequently following a traumatic event or stressor. Individuals who have experienced child abuse are at high risk for developing PTSR or PTSD (6). Certain abuse characteristics may be specifically traumatic for the child, such as abuse involving physical injury or the use of physical force, penetration or torture, resulting in PTSR or PTSD (6). Violent and sexual abuse have been identified as some of the trauma types with the highest likelihood of PTSR development (54). Approximately half of women endorsing a history of rape have also been diagnosed with PTSD at some time in their life (56). However, other features of child abuse that are not solely restricted to sexual abuse or severe physical abuse may also contribute to the development of PTSR. Such features include the duration or chronicity of the abuse, the involvement of threats and force, abuse severity, residence in an unsafe household and the absence of parents being able to protect the child (6, 57). Thus, it is likely that PTSR could develop in all kinds of child abuse victims, including those experiencing emotional abuse or neglect or witnessing violence (58-62).
Child abuse has also been associated with trauma symptoms such as depression, anxiety and dissociation (5, 8, 63). Second to PTSD or PTSR, depression is a well-recognized trauma symptom following child abuse, especially in female victims. Women with a history of physical abuse have higher lifetime rates of major depression (64). Sexual abuse and physical abuse have both been associated with higher levels of PTSD and depression in national samples of US women (25, 65).
However, depression is also comorbid with PTSD, as nearly half of women diagnosed with lifetime PTSD also reported a lifetime diagnosis of depression (53). Findings from the National Survey of Adolescents in the USA found that 30.0% of women with a history of rape had also experienced a depressive episode during their life. In comparison, only 10.0% of nonabused women had a lifetime history of depression (56). Higher risks for most anxiety disorders have also been identified in sexual abuse victims in a systematic review (5). Dissociation includes “disruption in emotion, body
representation, motor control and behavior” (66). A couple of studies have found that female sexual abuse victims may have dissociation symptoms and that dissociation and PTSD typically co-occur in women (63, 67). However, research on males investigating other trauma symptoms than PTSR or PTSD are lacking.
Most of our current knowledge on how child abuse relates to psychological trauma symptoms, such as depression, anxiety, depression, dissociation and anger is based on findings from studies on sexual abuse, and the literature lacks research on victims of other child abuse types (8). However, studies of childhood victims of physical and emotional abuse report higher levels of depression and anxiety in
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sufferers as well, indicating a possible overarching relationship between child abuse and the development of psychological trauma symptoms (64, 65).
Physical health complaints
Physical health complaints are patterns of persistent bodily symptoms that may cause considerable bodily distress, which may be burdensome for the sufferer and typically lead to frequent health care visits (68). Such complaints overlap with but may also be distinguished from somatization, which is the conversion of mental experiences or states into bodily symptoms (69). However, the
differentiation of somatization symptoms from symptoms of a biomedical disease is problematic both in clinical practice and in research. The term “physical health complaints” in the current thesis does not differentiate between the two. While burdensome for the individual, persistent physical health complaints are typically difficult for clinicians to treat. Moreover, they are costly for society because of referrals to specialized health care centers or supplementary investigations (70).
Adult patients frequently present to their medical doctors with single or multiple physical health complaints, such as stomach pain, heart beats, dizziness, diarrhea, weakness, nausea and fatigue. In many of these patients, structural pathology correlating with the symptoms cannot be identified (68). In adults, idiopathic bowel disease and chronic fatigue are more frequent than other symptoms, while in pediatric populations, the most common symptoms are pain (i.e., musculoskeletal pain, headache), psychogenic nonepileptic seizures and abdominal pain (71, 72).
Physical health complaints are common in the general population. In a Norwegian general population sample, 75% of respondents reported having at least one physical health complaint during the past 30 days (73). Three main categories of symptoms were commonly reported: pain in different
locations (i.e., back, head, muscles, abdomen); functional disturbance in different organ systems (i.e., palpitations, dizziness, nausea); and complaints of fatigue or exhaustion (71).
Physical health symptoms or complaints highly overlap with PTSR, anxiety and depression in adolescents and adults (71, 74). The overall number of physical health symptoms or complaints seems to be a strong predictor of poor health status and frequent health care use and appears to be a better measure of the overall severity of physical health status than the severity of a single physical symptom (75). Moreover, the long-term outcome for patients with multiple complaints is poor, with high rates of disability and sick leave, thus constituting a substantial component of the global burden of disease (75).
Child abuse and physical health
Groundbreaking evidence of a possible relationship between child abuse and poor physical health in adulthood was presented in the Adverse Childhood Experiences (ACE) Study in 1998 (50). ACEs include harms that affect children directly (i.e., sexual, emotional or physical abuse and neglect) and indirectly through their living environments (i.e., parental conflict, imprisonment, substance use, or
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the mental illness of a parent) (50). This first large-scale study in the USA quantified the impacts of ACEs on health throughout the lifespan. A key finding from the study was that the effects of ACEs on physical health appeared to be cumulative, with risks of poor physical health outcomes increasing with the number of ACEs suffered (50). Following this study, which gained enormous scientific attention, several researchers have tried to investigate this link more in-depth using various physical health outcomes. Studies using objective measures of physical health have showed higher levels of cardiovascular, respiratory and inflammatory disease (49, 76, 77). Also, studies using subjective measures of physical health have displayed higher levels of headache, generalized pain and poor self- perceived health, in child abuse victims (8, 9, 78-80). Today, researchers have acknowledged that the magnitude of the effect of child abuse on physical health may be comparable to that of child abuse on mental health (49).
Studies on adolescents investigating the relationship between child abuse and physical health are limited, as most of our current knowledge relies on findings from retrospective studies on adults (19).
However, a series of prospective studies provide evidence of associations between child abuse and poor physical health outcomes in children and adolescents (81-83). Moreover, some cross-sectional studies have also investigated how child abuse relates to physical health in childhood or adolescence.
In a community study from Taiwan, 10- to 12-year-old adolescents had more physical health outcomes than unexposed adolescents, such as higher risks for having a medical condition requiring hospitalization, more frequent use of daily medication, and higher prevalence of heart murmurs and asthma (84). Authors of a community study in the USA found some evidence of higher levels of obesity and poor self-reported health in adolescents who had been exposed to abuse (85). In contrast, a large community study investigating medical health records in youth with an ICD-9 diagnosis of child abuse found fewer medical diagnoses across all major physical diseases than in youth without a diagnosis of abuse (86).
A dose-response relationship
Many studies have confirmed the same cumulative patterns between ACEs and physical health as documented in the ACE Study. In adult samples, a dose-response relationship between numbers of ACEs experienced and later health or behavioral outcomes is more or less established (45, 76). For children and adolescents, the existing evidence of a similar pattern is weaker. A series of prospective clinical studies conducted on one clinical sample of high-risk children into adulthood found that children with reports of more than 4 childhood adversities at age 4 had a tripled risk of having an illness requiring medical attention at age 6 compared to those who had experienced 0 or 1-3 ACEs (81). The follow-up study at age 12 presented some evidence of a cumulative relationship between the number of ACEs and poor physical health similar to that of adults, suggesting that such dose effects may emerge over time (83). In a general population study of 10- to 12-year-old adolescents, allergic inflammation and asthma were more common in those who had experienced multiple types of victimization (84). In summary, there is some evidence that a dose-response relationship between child abuse and poor physical health may occur as early as adolescence or even in childhood. The conflicting results among studies may be due to the characteristics of the different study samples, methodological differences in data collection by self-report studies versus register data sampling,
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and the lack of adjustment for possible confounders, which illustrates the need for more studies on young samples.
The role of child abuse types and poor physical health
There is evidence that all the distinct child abuse types relate to poor physical health (49). However, sexual abuse studied in isolation is the only type with a sufficient number of publications to be subject to large systematic reviews. Findings from a systematic review on sexual abuse from 2009 showed increased risks for lifetime diagnoses of nonspecific chronic pain, functional gastrointestinal disorders, psychogenic seizures and chronic pelvic pain in adults (87). This systematic review
assessed sexual abuse in relation to a broad spectrum of physical health outcomes, but the authors did not differentiate between those who had experienced only sexual abuse in childhood and those who had experienced both child abuse and sexual victimization in adulthood (87). A possibly causal relationship between sexual abuse and poor physical health has also been investigated in a recent, larger umbrella review. In this review, the authors suggested that sexual abuse exposure in childhood had a more adverse impact on physical health outcomes in domains of pain, somatization and
somatoform disorders than sexual violence exposure in adulthood (88). In studies on young populations, sexual abuse has been associated with functional somatic health symptoms in adolescents and self-reported poor general health in young adults (9, 78).
Following publications on child sexual abuse, physical abuse is the second most studied child abuse type in relation to physical health (49). Cross-sectional studies on physical abuse victims have shown associations between physical abuse and self-reported physical health complaints in adolescence (89, 90). In a prospective study of young adults, child physical abuse predicted malnutrition and higher levels of the biochemical markers albumin and blood urea nitrogen, indicating effects on numerous organs (91). However, physical abuse is frequently studied in combinations with other child abuse types, and the literature lacks studies on adolescents. The first systematic review summarizing previous evidence of associations between various combinations of physical- and emotional abuse and neglect and health outcomes was published in 2012 (8). This review provided weak or
inconsistent evidence of associations between those abuse types with arthritis, ulcers, headache, cardiovascular disease and cancer in adulthood.
With some notable exceptions, emotional abuse or neglect is mostly studied in combination with other child abuse types. Findings from this research suggest that child emotional abuse victims may have increased risks of headache and obesity in adulthood (79, 92). Correspondingly, a study of survivors of child neglect reported more diabetes, poorer lung functioning, vision and oral health problems in adulthood (91). Finally, there is increasing recognition that children who have witnessed parental IPV also have more physical health complaints in adolescence and adulthood (93, 94).
In research comparing the effects of distinct child abuse types on physical health, there is mixed evidence that certain abuse types may have more adverse effects on physical health than other abuse types, especially sexual abuse. In a study comparing clusters of ACEs, the authors found that child sexual abuse victims had poorer general physical health and more mental distress than child physical and emotional abuse victims (95). This finding was supported by Chartier et al., who found that obesity was much more common in sexual abuse victims than in physical abuse victims (96). In
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contrast, authors from another study found that physical abuse victims had significantly higher average levels of biochemical markers such as C-reactive protein (CRP) and Hemoglobin A1c than sexual abuse victims. Moreover, physical abuse victims had higher levels of CRP than child neglect victims (91). Studies comparing the effects of emotional abuse with those of other child abuse types are lacking, but there is some evidence that emotional abuse is related to migraine in adulthood to a greater extent than other child abuse types (79).
Taken together, each of the different child abuse types shows associations with a variety of physical health outcomes in the existing literature, especially sexual abuse. However, interpretations are limited since evidence is sparce on emotional abuse, the witnessing of family violence and neglect.
Moreover, because studies rarely assess all abuse types simultaneously, it is difficult to assess the unique contribution of the distinct abuse types on health outcomes. Because there is some evidence in the literature that pathways leading to poor physical health in child abuse victims may differ according to the abuse type experienced, it is important to continue research on the distinct child abuse types and physical health.
Models and predictors for the development of physical health complaints
Theoretical framework for the investigation of the relationship between child abuse and physical health complaints
Several researchers have tried to understand how childhood adversities transform into medical, organic disease. A unique direct effect between child abuse and poor physical health is unlikely, and several indirect pathways may be involved. Biological models have been proposed, as well as models investigating how psychosocial or behavioral factors relate to physical health.
The biological model proposes that poor physical health develops as a result of a prolonged
physiological response to a chronic stressor in the human body, such as child abuse. The hypothesis is that the body’s physiological response to stress leads to a cascade of pathophysiological processes, including neuroendocrine responses, regulation of the immune system and inflammation, which in turn results in poor physical health (97). The role of the hypothalamic-pituitary-adrenal (HPA) axis has gained particular attention in research. Higher physiological activity in the HPA axis has been found in child abuse victims, as well as in nonabused patients suffering from cardiovascular, gastrointestinal and pain disorders, suggesting that the HPA axis represents a possible common pathway in the development of such physical health outcomes (98, 99). Moreover, epigenetic pathways have also been suggested to mediate the relationship between child abuse and physical health, such as abuse-induced changes in DNA methylation of the human genome (100).
Other researchers have focused on psychosocial models to investigate how exposure to child abuse develops into poor physical health, including indirect behavioral, social, cognitive and psychological pathways. Behavioral pathways, such as risky health behavior, including early initiation of smoking and alcohol consumption, binge drinking, illicit drug use, overeating and obesity, were suggested as a possible explanatory mechanism by the authors of the ACE Study (4, 50, 101). Risky health behavior, in turn, have obvious adverse effects on later physical health outcomes (92, 102-104). Moreover,
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social pathways, such as poverty, marginalization, a reduced ability to form social relationships, loneliness, social isolation, poor interpersonal relationships and a lack of social support, may interfere negatively with an individual’s capacity to seek medical care and to comply with medical advice, thus leading to poor health (78, 105, 106). Of note, child abuse victims are at particular risk for exposure to new violence in adolescence and adulthood. Such revictimization in adulthood has been shown to amplify negative psychological and cardiovascular health in a dose-response pattern (107-109). Cognitive pathways, such as impaired perception of other people’s motives, including chronically negative, fearful or mistrusting thoughts, have also been proposed in understanding how poor physical health develops following abuse (105). Further, a child abuse victim may have an impaired health perception, which may predict illness and mortality (110). Psychological pathways have been investigated in the general trauma literature, including models investigating whether depression and PTSR following a traumatic event lead to poor physical health outcomes (111-113).
Research specifically investigating the psychological pathway in child abuse victims is limited.
Constituting the theoretical background for two of the papers in the current thesis, this pathway will be more profoundly described in the following sections. Taken together, it is likely that child abuse may be linked to poor physical health via a complex multitude of biological and psychosocial
mechanisms. However, research on a more specific understanding of the relationship between them is limited.
Predictors of poor physical health in child abuse research
Sociodemographic factors, including gender, age, socioeconomic status (SES) and national background, may influence the development of physical health complaints in child abuse victims.
Specifically, female gender is associated with self-reported physical health problems, both in studies investigating child abuse in relation to self-perceived physical health and in prevalence studies of physical health symptoms in the general population (20, 21, 114). Larger effect sizes regarding physical health outcomes have been found in studies consisting of exclusively female abuse victims than in studies consisting of both genders (49). Although, in general, morbidity increases with increasing age, a systematic review examining the effects of age on physical health outcomes in adults found no evidence that increasing age would moderate the relationship between child abuse exposure and physical health (49).
SES encompasses not only income but also quality of life, educational attainment, occupational prestige, and subjective perceptions of social status. Researchers have long recognized that children living in families with limited economic resources are at higher risk for abuse than children from higher socioeconomic strata (115-117).Moreover, low SES has been linked toDvariety of negative health outcomesthroughout the lifespan, such as higher rates of cardiovascular disease for adults and obesity, more self-rated health complaints and higher levels of physiological markers (118-121).
Additionally, in child abuse research, low SES have been found to predict more functional somatic symptoms in adolescent sexual abuse victims (78).
Subjective perceptions of physical health complaints may also vary across cultures. Child abuse, race and poverty are often interrelated and associated with social determinants of health, which may in turn influence physical health (118, 122). Factors, such as food insecurity, social cohesion, and perceived discrimination has also been associated with poor physical health, self-care, and quality of
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life (123)Although structural differences between cultures are small within the Nordic countries, they should be nevertheless be accounted for in research regarding child abuse and health.
The relationship between psychological trauma symptoms and poor physical health
Trauma researchers have increasingly tried to investigate how or whether psychological trauma symptoms, mostly PTSR, relate to physical health. In the trauma literature, both PTSR and PTSD have been frequently studied in relation to physical health outcomes, mostly in adult samples (124).
Findings from adult samples of war veterans, survivors of natural disasters or other types of trauma have repeatedly demonstrated associations between PTSR and poor physical health in domains of cardiovascular, respiratory, gastrointestinal disease, cancer and chronic pain conditions (124-127). A meta-analysis on self-perceived physical health found that adults with a high burden of PTSR had more general health symptoms, greater frequency of symptoms, greater severity of pain and poorer self-reported quality of life (124).
Several mechanisms may link PTSR with poor physical health. The dysregulation of the HPA axis and the activation of neuroendocrine responses have been independently linked to PTSR, suggesting that PTSR represent an independent risk factor for chronic stress (128). Moreover, each of the key features of PTSR, including hyperarousal, avoidance and re-experiencing, may have a role in this development. Each of these key features has shown independent adverse effects on physical health (129, 130). Hyperarousal symptoms such as impaired sleep, fear, negative thoughts and irritability are associated with inflammatory disease and autoimmune disease (131, 132). Re-experiencing may manifest as physical symptoms, such as palpitations and dizziness, pain, and nausea, contributing to an individual’s perception of poor physical health. Sleep disturbances following PTSR are extensively studied and are associated with poorer self-perceived health, quality of life and daily functioning (133-135). Moreover, PTSR sufferers may have higher risks of engaging in risky health behaviors, which, in turn, may lead to poor physical health (136). Finally, PTSR-related avoidance symptoms, such as social withdrawal and loneliness, leading to isolation and inactivity, may, in turn, lead to poor self-reported health status in adolescents and young adults (106, 137).
Other psychological trauma symptoms, such as depression and anxiety, have been linked to chronic pain and physical health complaints in the general population (138, 139). Additionally, in studies of child abuse victims, trauma symptoms, including depression, generalized anxiety disorder and posttraumatic stress disorder, have been found to cooccur with poor self-reported physical health outcomes (140). Moreover, dissociation symptoms have been associated with chronic physical symptoms in sexually abused females (67).
Among the psychological trauma symptoms, PTSR seem to be most strongly associated with poor physical health. Compared to other trauma symptoms, PTSR and PTSD studies are overrepresented.
Few studies in child abuse research compare the effects of distinct psychological trauma symptoms on physical health. In a study of undergraduate students who had been sexually abused, PTSR, but not depression, predicted physical health (141). Moreover, depression and dissociation have been found to be related to physical health complaints in female sexual and physical abuse victims who were already diagnosed with PTSD (63). In fact, some researchers argue that symptoms such as
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depression, anxiety and dissociation following a traumatic event only occur within the context of PTSR (142). This argument is supported by findings from other researchers, such as in a study comparing anxiety symptoms in youth with and without high levels of PTSR (143). In that study, the authors found that youth with a high burden of PTSR had also high levels of anxiety, depression and somatic complaints (143).
Limited evidence is found in the literature on the associations between psychological trauma
symptoms, such as PTSR, and physical health complaints in adolescent or younger samples who have experienced child abuse. The few studies that have investigated this topic have shown that such symptoms may cooccur as early as adolescence and young adulthood (95, 144). One study examined the physical health complaints in sexually abused children who were diagnosed with PTSD; the study reported more sleep problems, changes in appetite, headaches and stomach pain in these children (145). Another study of Romanian orphans who were physically abused and neglected in early childhood showed that they displayed trauma symptoms, but not physical health complaints, in late childhood (146). Additionally, in a community study from the USA of female children and
adolescents, PTSR predicted physical health complaints in adolescence (147). Moreover, the extent to which PTSR were linked to physical health outcomes was similar for objectively measured physical disease and subjectively reported somatic experiences. Findings from these studies suggest that there may be an association between psychological trauma symptoms, such as PTSR, and physical health complaints. However, future studies are needed to confirm these findings in young study samples.
Knowledge gaps
Most studies investigating the relationship between child abuse and physical health have been conducted on adult populations, and the findings are not necessarily generalizable to younger samples. Moreover, findings from other countries, such as the comprehensive literature from the USA, may not be representative of Scandinavian countries due to the differences between cultures and in accessibility to health care systems and living conditions.
Research that has investigated the relationship between child abuse and physical health in young samples has shown conflicting results. Moreover, most research has focused on sexual and physical abuse in childhood, and there is a knowledge gap in research investigating emotional abuse, neglect, and the witnessing of family violence in relation to physical health. Finally, possible pathways
involved in this relationship, such as the psychological pathway, examining trauma symptoms and PTSR, are not fully investigated. As a result, we have little knowledge on whether psychological trauma symptoms relate to physical health outcomes in adolescents and young adults who have experienced child abuse.
Reducing the public health burden associated with child abuse requires a better understanding of its causes and consequences. On the societal level, early identification of physical health complaints following child abuse may be important to reduce the long-term economic and societal costs associated with child abuse, such as lost work productivity and increased welfare or health care
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usage. From the long-term perspective, targeted interventions towards such symptoms may also prevent chronic conditions.
On an individual level, a high burden of physical health complaints throughout adolescence and continuing into adulthood may be limiting for the child abuse victim. Poor daily functioning due to a high burden of symptoms, as well as problems with interpersonal relations and general wellbeing, may be restrictive in several domains, such as education and employment. Early identification of trauma symptoms and physical health complaints is necessary to improve the daily health burden of child abuse victims.
Aims of the thesis
The overall aim of the current thesis was to investigate physical health complaints in adolescents and young adults who had experienced child abuse and how psychological trauma symptoms contributed to the development of physical health complaints in child abuse victims. Specifically, the research aims for each of the papers were the following:
Study aims
Paper 1:
The primary aim of the study was to investigate whether adolescents and young adults with a history of child abuse had more physical health complaints than individuals without a history of child abuse.
Five different child abuse types were studied (physical, sexual, emotional abuse, neglect, the witnessing of parental IPV). The second aim was to estimate associations between different child abuse types and physical health complaints and associations between the number of child abuse types and physical health complaints.
Paper 2:
The aim of the study was to investigate PTSR as a possible mediator in the relationship between child abuse and physical health complaints in adolescence and young adulthood. Five different child abuse types (physical, sexual, emotional abuse, neglect, the witnessing of parental IPV) were explored in isolation and in combination.
Paper 3:
The primary aim of the study was to investigate whether adolescents who had recently disclosed sexual abuse or family violence during forensic interviews had more psychological trauma symptoms and physical health complaints than their unexposed peers. The second aim was to investigate to what degree physical health complaints were associated with psychological trauma symptoms in adolescents who had recently disclosed sexual abuse or family violence.
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METHODS
The research projects
The current thesis used data from two different research studies: an epidemiological survey and a clinical study. Both studies are described in more detail below.
The epidemiological survey was a longitudinal two-wave study. The Prevalence Study (wave 1) was conducted in April-September 2013 and investigated the prevalence of abuse and violence in
childhood and adulthood in the general Norwegian population. Wave 1 included two subsamples: an adolescent sample (aged 16-17 years) and an adult sample (aged 18-33 years). The Revictimization Study (wave 2) was a follow-up study of a subset of wave 1 participants and was conducted in October-December 2014This study investigated possible consequences of violence, such as
revictimization, psychological health symptoms, behavioral factors and physical health complaints, in adolescence and young adulthood.
The clinical study (The Barnehus Study) was conducted at the Statens Barnehus in Oslo, Norway, in October 2016-November 2018. This study aimed to explore current health and behavioral problems in adolescents (aged 10-18 years) who had recently disclosed exposure to child abuse during forensic interviews.
The Revictimization Study (papers 1 and 2)
The current thesis used the study sample from the Revictimization Study in papers 1 and 2.
Study design
The Revictimization Study (wave 2) was a longitudinal study of 1010 adolescents and young adults who had participated in wave 1. Wave 2 had a case-control design.
Participants
The study sample included 506 cases who had reported an experience of child abuse in wave 1.
Moreover, it included 504 unexposed controls from wave 1, matching the cases by age and gender.
Participants were between 16 and 33 years of age.
