Self-reported and agency-notified child sexual abuse in a population-based birth cohort
Introduction
Child sexual abuse (CSA) has been associated with many adverse outcomes in adulthood such as depression, posttraumatic stress disorder (PTSD), physical health problems, drug use, risky sexual behaviour, and suicidality (Cutajar et al., 2010, Gilbert et al., 2009, Tebbutt et al., 1997). However, there are a number of important methodological variations behind these findings. Among the most crucial is the distinction between cross-sectional self-report studies, in which respondents recall sexual abuse that may have occurred years or even decades prior, and prospective studies that utilise contemporaneous government agency records to define the exposure to abuse. Another important distinction is between studies using a clinical population (e.g. patients attending a mental health clinic) and those addressing a representative population-based sample (Widom et al., 2004).
Retrospective self-report has the advantage of being inexpensive and convenient. The confidentiality and anonymity of recall-based questionnaires also helps address concerns that child sexual abuse is a largely hidden phenomenon (Hardt and Rutter, 2004). However, there is a small but important literature on the accuracy of retrospective recall of childhood abuse that demands attention. Hardt and Rutter (2004) systematically reviewed the literature about self-report of childhood maltreatment. They found that approximately one third of adults who experience significant, agency-substantiated abuse as children do not appear to remember it in adulthood (Widom et al., 1999, Williams, 1994). Furthermore, subjects' self-report of the occurrence of childhood abuse does not remain stable throughout their adulthood (Della Femina et al., 1990, Dube et al., 2004), or can change from childhood to adulthood (Banyard et al., 2001). There can be surprising discrepancies between the recall of siblings who were exposed to the same maltreatment (Bifulco et al., 1997). Reasons for inaccurate disclosure in self-report interviews can include embarrassment, defence against negative emotions, and protection of the abuser (Della Femina et al., 1990). Adults with no or minimal mental health issues tend to under-report agency-documented adverse childhood experiences, while those with psychological problems are more likely to retrospectively report them (Cohen and Cohen, 1984).
Findings such as these call into question the validity of apparent associations between child maltreatment and later psychosocial problems that have been derived from retrospective self-report studies, even where a number of such studies have concurred (Widom et al., 2004). The use of child maltreatment data obtained from statutory child protection authorities confers the potential benefit of a contemporaneous, impartial, third party assessment of maltreatment including sexual abuse. However, there are also questions about the accuracy of this method (McGee et al., 1995). The major disadvantage of reliance on agency data is that this data may be relatively insensitive, as only a proportion of all cases of child maltreatment are reported to child protection authorities. This may be particularly relevant in the case of child sexual abuse: an Australian cross sectional self-report study of child sexual abuse suggested a lifetime incidence of approximately 15% in boys and 30% in girls (Dunne et al., 2003), whereas in a prospective birth cohort just over 2% of subjects had been reported to the authorities as suspected cases of sexual abuse (Mills et al., 2014).
Therefore, one expects that reliance on agency data will tend to result in the misclassification of a proportion of sexually abused children into the non-maltreated group (Widom et al., 2004). Additionally, government agency outcome data tends to lack the precision that can be obtained from cross sectional questionnaires, unless researchers engage in detailed coding from the original case notes. For example, the subjects notified to, or substantiated by, a government agency as cases of sexual abuse could cover a very diverse range of inappropriate sexual exposures, from risk alone (e.g. living in a home with a known child sexual offender), to violent sexual assault. Another issue to consider when using prospective agency reports of child sexual abuse is that identified cases may subsequently receive intervention that could alter the longer term psychological outcome, while cases that do not come to the attention of authorities may have more severe consequences due to the secrecy and potential chronicity (Kendall-Tackett and Becker-Blease, 2004).
Very few studies have had the ability to compare the long-term outcome of retrospectively self-reported child sexual abuse with that following prospectively documented notifications of sexual abuse. One such study was by Raphael et al. (2001), who followed 676 subjects with court-documented child maltreatment (including sexual abuse) histories and 520 matched controls. The study found that retrospectively reported child maltreatment, including sexual abuse, was associated with unexplained pain symptoms in adulthood. However, prospectively documented maltreatment was not. While this study raised important questions about the validity of studies using retrospective self-report of maltreatment, it was in the context of a deliberately selected high-risk population. Other major birth cohorts that have addressed outcomes following CSA have either relied on adult self-report (Boden et al., 2007, van Roode et al., 2009), or agency records of general maltreatment without specifically defining CSA exposure (Sidebotham and Heron, 2006).
Thus, there remain many uncertainties about the validity of, and factors influencing, adult recollection of childhood sexual abuse that have yet to be explored outside of socially and clinically high-risk groups. This present study is the first to our knowledge that has sought to use data linkage between a large prospective birth cohort and a state child protection agency to address two major questions about child sexual abuse. First, what is the relationship between adult self-report of CSA and contemporaneous government agency notification? Second, what are the psychological outcomes in adulthood following CSA as defined by self-report, when compared with agency-notified CSA?
Section snippets
Data sources
The Mater-University of Queensland Study of Pregnancy (MUSP) is a longitudinal birth cohort study. Between 1981 and 1983, 8556 consecutive pregnant women attending the Mater Misericordiae Mothers' Hospital for their first prenatal visit were invited to participate (Keeping et al., 1989). The final cohort numbered 7223 mother and infant pairs, which included only consenting participants who delivered live, singleton infants at the study hospital. At the first prenatal visit, the women completed
Results
Of the 7223 mother and child dyads in the original cohort, the statutory agency child protection history was available for 7214. For eight pairs, there was insufficient demographic data to positively identify the child protection record. One subject was inadvertently omitted from the child protection search. The proportion of children completing the main questionnaire at the 21-year follow-up was 52.4% (3778 of 7214), of whom 3739 (51.8% of cohort) answered the sexual abuse self-report
Discussion
This study is the first to compare retrospective self-reports of child sexual abuse with prospectively recorded government agency notifications in a population-based sample. There are several important findings. First, it confirmed the widely held assumption that the vast majority of cases of child sexual abuse go unreported to the authorities – in this study 25.2% of a large birth cohort reported in adulthood that they had experienced child sexual abuse, but only 5.7% of these cases – and 2.5%
Conclusions
This large birth cohort study has demonstrated the disparity in the incidence of CSA when measured by retrospective self-report, when compared with prospective government agency documentation. Both retrospectively recalled CSA and agency-recorded notification of CSA are associated with adverse psychiatric outcomes in adulthood, with high odds ratios of PTSD being a particularly notable finding. The findings support the allocation of resources to prevention and contemporaneous identification of
Contributors
Ryan Mills (corresponding author) planned the research questions and analyses, and was primary author of the manuscript. Steve Kisely performed the analyses and assisted with writing. Rosa Alati assisted with planning the study and writing the paper. Lane Strathearn performed the original child protection data collection and linkage, and reviewed the manuscript. Jake M. Najman directed all phases of MUSP data collection, provided guidance in formulation of the research question, and assisted
Role of funding source
The study was primarily funded by the National Health and Medical Research Council (NHMRC), Australia.
Rosa Alati is funded by a National Health & Medical Research Council Career Development Awards (CDA) Level 2 (ID Number: APP1012485).
Lane Strathearn was supported by Award Number R01DA026437 from the National Institute on Drug Abuse, and Award Number R01HD065819 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
The content is solely the responsibility of
Conflicts of interest
None.
Acknowledgement
The authors thank the MUSP Team, MUSP participants, the Mater Misericordiae Hospital and the Schools of Social Science, Public Health, and Medicine (University of Queensland) for their support.
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