انعطاف پذیری برای آسیب شناسی روانی بزرگسالان بدنبال بدرفتاری در دوران کودکی: شواهدی از یک جامعه نمونه

Abstract Objective Child abuse is an important risk for adult psychiatric morbidity. However, not all maltreated children experience mental health problems as adults. The aims of the present study were to address the extent of resilience to adult psychopathology in a representative community sample, and to explore predictors of a good prognosis. Methods Data are drawn from a follow-up of the Isle of Wight study, an epidemiological sample assessed in adolescence and at midlife. Ratings of psychiatric disorder, peer relationships and family functioning were made in adolescence; adult assessments included a lifetime psychiatric history, personality and social functioning assessments, and retrospective reports of childhood sexual and physical abuse. Results Ten percent of individuals reported repeated or severe physical or sexual abuse in childhood. Prospective measures revealed increased rates of adolescent psychiatric disorders in this group. Rates of adult psychopathology were also high. A substantial minority of abused individuals reported no mental health problems in adult life. Resilience of this kind was related to perceived parental care, adolescent peer relationships, the quality of adult love relationships, and personality style. Conclusion Good quality relationships across childhood, adolescence and adulthood appear especially important for adult psychological well being in the context of childhood abuse.

Child abuse is a serious and common risk that affects the long-term mental health of individuals in profound ways. However, a growing body of evidence indicates that the mental health of a substantial minority of abused individuals appears relatively unaffected (McGloin & Widom, 2001). Gaining a fuller understanding of the factors and processes involved in positive adaptation is important for several reasons. Theoretically, models of resilience have the potential to enhance the understanding of the mechanisms by which abuse affects psychosocial development. Clinically, some protective factors may be amenable to external manipulation and could thus present a potential focus for future treatments and interventions. The present study uses longitudinal data from a general population sample studied first in adolescence and again at mid-life to examine correlates and outcomes of childhood abuse, the extent of resilience for adult psychopathology, and the factors that best predict such resilience. In the UK approximately one or two children die each week at the hands of an adult. Over 30,000 children's names in England were on the child protection register in the year up to 31 March 2002, a rate of approximately 2.5 per 1,000 (NSPCC, 2003). However, estimates of the cumulative incidence of abuse from general population surveys suggest that most children's experiences of abuse are not officially recorded. Such studies point to rates of approximately 8% for serious forms of sexual abuse (see Fergusson & Mullen, 1999 for a review) and approximately 7% for serious forms of physical abuse (Cawson, Wattam, Brooker, & Kelly, 2000), with many children experiencing both. The implications for children's psychological development and long-term mental health have been well documented. Consequences include cognitive delays and lowered IQ (e.g., Koenen, Moffitt, Caspi, Taylor, & Purcell, 2003), neurobiological abnormalities (see Glaser, 2000 for a review), dysfunctional behaviors such as conduct problems, aggression and substance abuse (e.g., Fergusson, Horwood, & Lynskey, 1996; Schuck & Widom, 2001), and an increased risk of adolescent and adult psychiatric disorders including depression, suicide, anxiety disorder, PTSD, and somatization disorders (e.g., Brown, Cohen, Johnson, & Smailes, 1999; Fergusson et al., 1996; Fergusson & Lynskey, 1997; Lansford et al., 2002). Associations with adult psychopathology are independent of other associated environmental adversities (e.g., Brown et al., 1999 and Fergusson et al., 1996), and environmentally mediated effects of abuse have been documented in genetically informative designs (Kendler et al., 2000). Current evidence also makes clear, however, that not all abused children go on to experience mental health problems later in life. A number of reviews have estimated that around a third of individuals who have experienced sexual abuse will not exhibit adult psychiatric problems (e.g., Fergusson & Mullen, 1999; Stevenson, 1999). McGloin and Widom (2001) found that 48% of children with documented histories of abuse or neglect did not meet criteria for adult psychiatric disorders including depression, anxiety, PTSD and ASPD, while 38% had not had a diagnosis for substance abuse. Examining successful functioning over a broad range of domains of adult psychosocial functioning, 22% were classified as “resilient.” Researchers have long realized that understanding positive adaptation in the face of adversity is important, but there has been considerable debate on how best to define and study the concept of resilience (Kaufman, Cook, Arny, Jones, & Pittinsky, 1994; Luthar, 2003; Luthar, Cicchetti, & Becker, 2000; Masten, 2001, Rutter, 1985 and Rutter, 2006). It is generally agreed that a working definition should consider two points. First, the experience to which individuals have been exposed should present a sufficient “risk” to which individuals can be considered to have shown “resilience.” Second, markers of resilience should encompass a variety of domains and be evident across an extended time period (Luthar et al., 2000 and Rutter, 2006). This is particularly important in discussions of resilience in the face of abuse, given the negative implications over a broad range of functioning. In line with these considerations, we defined resilience in the present study by identifying individuals who (1) had experienced repeated, ongoing or severe sexual and/or physical abuse, and (2) who reported no psychiatric disorders or suicidality over a 30-year adult follow-up period. This definition stringently defined the risk to which individuals were said to be resilient and covered a broad spectrum of psychiatric outcomes over a long time span. Research has highlighted a variety of mechanisms that may explain positive life trajectories in the face of childhood adversity. Resilient functioning appears to arise from the interaction between heritable factors, individual characteristics and experiential factors over time. Genetic factors (e.g., polymorphism in monoamine oxidase A genotype), biological factors (e.g., stress-reactivity), cognitive factors (e.g., intelligence, locus of control, self-esteem, planning, self-regulation), and inter-personal factors (e.g., emotionally-responsive parenting, peer affiliations and friendships, supportive and affectionate marital relationships) are all related to individual variability in responses to adversity (e.g., Caspi et al., 2002 and Masten et al., 1999; Quinton, Rutter, & Liddle, 1984; Rutter, 2006; Werner & Smith, 2001). In relation to child abuse, previous research has highlighted several important factors that consistently appear to be related to better or worse adaptation. First, cognitive ability, cognitive styles and personality factors may be important. Studies of selected samples suggest that high self-esteem, internal locus of control, external attributions of blame, and individuals’ coping strategies all predict more positive outcomes both cross-sectionally and prospectively across childhood (e.g., Cicchetti, Rogosch, Lynch, & Holt, 1993; McGee, Wolfe, & Olson, 2001). The family background and parenting of abused and neglected children are also likely to be important. Most studies suggest that the more sensitive, caring and safe the home environment, the more adaptive the outcome will be (Egeland, Carlson, & Sroufe, 1993; Romans, Martin, Anderson, O'Shea, & Mullen, 1995; Spaccarelli & Kim, 1995). In addition, Heller, Larrieu, D’Imperio and Boris (1999) suggest that the availability of emotional support at the time of the abuse will strengthen the ability of an individual to draw support from others in adulthood, thereby engendering resilient functioning. The ability to form, maintain and benefit from good inter-personal relationships appears to be another important factor in predicting positive adaptation in the context of childhood abuse (Bolger & Patterson, 2003; Lynskey & Fergusson, 1997). Lynskey and Fergusson (1997) studied resilience following childhood sexual abuse in a community sample that combined retrospective reports of abuse with prospective and contemporaneous reports of potential protective factors. The strongest predictors of resilience were the extent of recalled parental care and support, and the quality of adolescent peer relationships. Adults with a history of child abuse are more likely to have difficulties over a broad range of inter-personal functioning, including adult love relationships, friendships, criminality and employment (e.g., Hill et al., 2001 and Widom, 1989). In addition, they also appear at increased risk of serious negative life events such as revictimization (Coid et al., 2001). Both prospective and retrospective evidence suggests that adult experiences may mediate the relationships between childhood abuse and adult psychopathology (Coid et al., 2003; Horwitz, Widom, McLaughlin, & White, 2001). At the same time, research also highlights the potential for adult experiences as providing important turning points for individuals from at-risk backgrounds (Rutter, 2006). Taken together, these findings suggest that mechanisms of resilience need to take account of the pathways linking childhood experience to adult psychopathology (Hill, 2003). Finally, when testing predictors of resilience it is also necessary to consider variability in the severity of the initial risk exposure. Characteristics of the abuse experience, such as timing, duration, frequency, severity, degree of threat and relationship to the perpetrator are all associated with better or worse outcomes (e.g., Bulik, Prescott, & Kendler, 2001; Keiley, Howe, Dodge, Bates, & Pettit, 2001; Manly, Kim, Rogosch, & Cicchetti, 2001). Given these consistent findings, it is clearly important to test whether specific risk and protective factors predict resilience over and above the severity of the abuse experience. To summarize, research to date has highlighted a range of possible mechanisms that may account for resilience following child abuse. However, important gaps in understanding remain. Many previous studies have only tested resilience in the short term or for particular outcomes. Second, few studies have examined resilience to the effects of child abuse in representative epidemiological surveys. Finally, many hypothesized resilience factors may be as important to positive adaptation in non-abused as in abused samples. Non-abused comparison groups are required to identify factors that are of particular importance for understanding resilience in the context of abuse.