Brain Damage Evoked by Abuse of Children, Adolescents & Adults

Scores on Psychological Measures for Psychiatrically Hospitalized Adolescents Who Reported No Child Abuse or a High Level of Abuse (SD, standard deviation)

The timing of abuse is a critical feature of outcomes; i.e., the earlier the abuse the more damaging it is to children (up to age 7) and adolescents (ages 8-25). An important study by Keiley et al. (2001) reported the following. Younger children experienced harsh physical treatment by significant adults and were more likely to experience adjustment problems in early adolescence. Early physical maltreatment was related to more negative sequelae than the same type of maltreatment occurring at later periods. The early-harmed group of subjects exhibited higher initial levels of teacher-reported externalizing problems in kindergarten such as acting out and disrupting class activities and significantly different rates of change in these problem behaviors than other children. The early-harmed children were also seen by teachers in kindergarten as exhibiting higher levels of internalizing behaviors such as being withdrawn. The later-harmed children were seen by their teachers as increasing their externalizing problem behaviors more rapidly than did the early- or non-harmed children. These findings indicate that the timing of maltreatment is a salient factor in examining the developmental effects of physical harm as it occurs when brain circuits for emotion processing develop.

These are frequently reported consequences of abuse. Research has shown that adolescents and adults with a history of childhood maltreatment are more likely to develop depression and anxiety after being exposed to stress than those without this history. Here we select a few examples to substantiate these points. Mulder et al. (1998) examined the relationship between child sexual abuse, child physical abuse, current psychiatric illness, and measures of dissociation in a randomly-selected adult population. Each subject completed an interview including measures of childhood sexual and physical abuse, psychiatric diagnoses, and items from the Dissociative Experiences Scale. Many individuals experienced occasional dissociative symptoms as they attempted to remove themselves from memories of such experiences and 6% of the population suffered from three or more frequently occurring dissociative symptoms. Among these individuals, the rate of child sexual abuse was 2.5 times as high, the rate of physical abuse was 5 times as high, and the rate of current psychiatric disorder 4 times as high as the rates for other subjects. Physical abuse and current psychiatric illness were directly related to a high rate of dissociative symptoms but sexual abuse was not. The influence of sexual abuse was associated with current psychiatric illness and with childhood physical abuse. The latter was not directly related to current psychiatric illness and its association appeared to be mediated by its link to childhood sexual abuse. This confirms that a small proportion (~6%) of the general population suffer from high levels of dissociative symptoms and it questions the notion of a direct relationship between childhood sexual abuse and adult dissociative symptoms.

Li et al. (2021) explored the effects of emotional and behavioral problems on the child emotional abuse and depressive symptoms among college students. Information about childhood maltreatment, depressive symptoms, emotional and behavioral problems were gathered with a number of psychometric scales and questionnaires. Childhood emotional abuse was the strongest risk factor for depressive symptoms and the relationship between child emotional abuse and depressive symptoms was partially explained by emotional and behavioral problems with 69% total indirect effect. Among the 5 identified subtypes of emotional and behavioral problems, the effects of emotional problems (57%) and hyperactivity (29%) were higher than peer problems (8%) and prosocial behavior (4%). Conduct problems did not have a significant effect. Of the five identified subtypes of emotional and behavioral problems, four subtypes explained the relationship between childhood emotional abuse and depressive symptoms, including emotional problems, hyperactivity, peer problems and prosocial behavior.

Levin and Liu (2021) assessed processes underlying the risk for depression and anxiety in maltreated preadolescent children. This study analyzed data from the Longitudinal Studies of Child Abuse and Neglect and evaluated interpersonal and non-interpersonal life stress as predictors of depression and anxiety specifically, and internalizing symptoms more generally, in a sample of children vulnerable or exposed to maltreatment. Participants were assessed repeatedly over 6 years of early-to-mid childhood. Interpersonal life stress predicted greater depression and anxiety, but not general internalizing symptoms after emotional and behavioral problems and other factors such as sex were covaried. Non-interpersonal life stress was not predictive of depression and anxiety or general internalizing symptoms. These findings support the importance of interpersonal stress when considering the risk for depression and anxiety among preadolescent children vulnerable or exposed to maltreatment. Early intervention to decrease the occurrence and impact of these stressors could have long-lasting impacts on this vulnerable population.

Less appreciated are more subtle personality internalizing consequences of abuse related suicidal ideations in survivors. An early study by Bolger et al. (1998) performed a longitudinal study to assess risks associated with maltreatment in a community sample of maltreated children and an equal number of non-maltreated children. Heightened difficulties in peer relationships and self-esteem were associated with greater severity and chronicity of maltreatment. For example, children who experienced chronic maltreatment were less well-liked by peers and type of maltreatment was related to specific aspects of children’s adjustment. For instance, sexual abuse predicted low self-esteem, but not problems in peer relationships. Emotional maltreatment, on the other hand, was related to difficulties in peer relationships, but not low self-esteem. Thus, the best predictions of specific aspects of children’s adjustment were provided by considering timing, type, and severity of maltreatment. For some groups of maltreated children, having a good friend was associated with improvement over time in self-esteem.
Sekowski et al. (2020) proposed that childhood maltreatment led to high levels of generalized guilt and shame resulting in an increase of depressive symptoms and suicidal thoughts in adolescents. Inpatient adolescents aged 12-17 years completed the Childhood Trauma Questionnaire to measure various types of maltreatment, the Personal Feelings Questionnaire to evaluate generalized guilt and shame, the Beck Depression Inventory-II to assess depressive symptoms, and the Columbia-Suicide Severity Rating Scale to assess suicidal ideation. Findings partly confirmed the indirect positive effects of sexual and emotional abuse and emotional and physical neglect on suicidal ideation via generalized self-conscious emotion and/or depression. Indirect negative effects of physical abuse on suicidal thoughts via generalized guilt and shame and depression were also found. Thus, this study provides information on the potential mechanisms underlying the association between childhood maltreatment and suicidal ideation in adolescents. Generalized guilt and/or shame could be possible targets for interventions for victims of some forms of maltreatment.

Aggression and substance use disorder are common expressions of anger in survivors of abuse with the latter being an attempt to self-medicate associated suffering. General aggression may be more severe due to early experiences to trauma (physical, emotional, sexual abuse and/or neglect) and may place one at risk for adult psychopathology through heightened trait anger expression-internal (Anger-In) and external (Anger-Out). Win et al. (2021) considered if childhood maltreatment severity predicted elevated adult major depressive disorder (MDD), generalized anxiety disorder (GAD), panic disorder (PD), and alcohol use disorder (AUD) including trait anger expression - internal and external - 9 years apart. Time 1 childhood trauma severity (retrospectively-reported, Time 2 Anger-In and Anger-Out and Time 3 adult MDD, GAD, PD and AUD were measured. This study showed that Anger-Out and Anger-In partially explained the relations between child trauma severity and adult psychopathology diagnoses. Higher Time 1 childhood trauma severity was related to greater Time 2 Anger-Out and Anger-In, and increased Time 2 Anger-Out and Anger-In were thereby related to elevated Time 3 adult MDD, PD and AUD, but not GAD severity. Trait anger accounted for 14-50% of the variance of child trauma–adult MDD, PD and AUD. It also suggests that these symptoms evolve over time.
Aggression in maltreated individuals can frequently escalate into violent crime. The Justice Department’s Bureau of Justice Statistics reports that women in U.S. prisons reported higher levels of child abuse than women in general. More than 33% of female state prison and jail inmates said they had been abused as children, as did 14% of males. In the general population, estimates of child physical abuse were 12-17% for females and 5-8% for males. For prisoners who had spent part of their childhoods in foster care, the abuse rate was higher; 44% of the male and 87% of female prisoners who had spent the majority of their childhood in foster care or institutions reported abuse. This study drew a strong link between prior abuse and violent crime. Among male inmates in state prisons, 76% who were abused and 61% not abused had a current or past sentence for a violent offense. Among female offenders, 45% of the abused and 29% not abused had served a sentence for a violent crime. Due to the high level of adolescent abuse histories in prison inmates, child abusers do not fare well in the penal system.

By this it is meant that while abuse evokes immediate brain damage, it can evolve into further difficulties with time. Most important among these is PTSD which can be an initial (presenting) symptom of abuse or it can emerge years later. PTSD and maltreatment share many epidemiological (population demographics), symptoms, causes and predictive outcomes. There are four primary symptoms of PTSD including; 1) re-experiencing the event(s) via nightmares, flashbacks and/or intrusive recollections, 2) avoiding reminders associated with the event(s), 3) negative mood and thinking, and 4) excess arousal of heart rate and breathing particularly under stress conditions. The following views are from Kearney et al. (2010) and supporting references in this article.
Children faced with abusive parents are at risk for poor regulation of the pituitary gland and its chemical secretions. Secure attachment status, appropriate social/parental feedback, and responsible and sensitive parental care are especially important influences on development of what is called the hypothalamic-pituitary-adrenal axis. Alterations in this developmental trajectory produce impairments that continue among adults with a history of childhood maltreatment. Children with pituitary dysregulation act aggressively and otherwise inappropriately, leading to maladaptive disciplinary practices.
In contrast, some children and adolescents may be buffered from the major biological effects following maltreatment by certain genetic characteristics, good affect regulation and cognitive functioning, positive self-concept, social support, proximity to a non-offending and caring parent, cultural factors, key learning experiences, or even extended dissociation from such events. In other words, resilient individuals may have factors that help them to avoid the worst outcomes experienced by vulnerable patients.
Chronically maltreated youths have great difficulty understanding their environment and may not develop or execute appropriate methods for coping with stress or solving problems. Problems in emotional and behavioral self-regulation can then lead to excessive anxiety, depression, cognitive distortions, somatization, dissociation from such experiences, aggression, impulsivity, suspiciousness, and other systemic maladaptive responses. Common long-term effects of maltreatment include school failure and absenteeism, less anticipation of attending college, social and thought problems, physical and sexual revictimization, violence perpetration, and various psychopathologies such as depression, substance abuse, personality disorders, PTSD, anxiety and other disorders in adulthood.
PTSD is especially likely in maltreatment cases involving physical abuse with longer duration of maltreatment, threat or force, feelings of guilt, exaggerated startle responses, and a perception that one has been victimized. PTSD in maltreated youths is associated with many types of behavior problems. Prominent examples include somatic complaints, social withdrawal, fear, depression, social and cognitive problems, poor school performance and social competence, and delinquent and aggressive behaviors. Maltreated boys with symptoms of PTSD are at risk of using threatening behaviors or physical abuse against dating partners. Youths with PTSD demonstrate a stronger relationship between exposure to parental violence and interpersonal aggression toward friends or romantic partners than youths without PTSD.
The severity, duration, frequency, unpredictability, and proximity of threatening, harmful, and uncontrollable stressors are important risk factors for the eventual development of PTSD. Trauma may involve a single event or, in many maltreatment cases, repeated events that may become predictable over time due to continued activation of the stress response.
Cognitive vulnerabilities are also expressed for patients with PTSD. Their inability to sufficiently process traumatic events leads to impaired emotionality, disruptions of previously held and potentially rigid views about safety of self and the world, perpetuated beliefs about ongoing threat, impaired habituation of symptoms from ongoing avoidance of trauma-based thoughts, negative self-evaluation regarding competence, and self-blame regarding traumatic events. These problems are maintained by poor verbal processing of the events, intense emotions such as anger, maladaptive appraisals of life events and future harm, negative appraisals about one’s vulnerability and recovery immediately after trauma. Internal causal attributions of negative events, attentional bias toward threat, thought suppression and avoidance, rumination, excessive worry, and distraction are also problematic. Thus, brain events triggered by abuse can often evolve into PTSD and possibly other symptoms such as those associated with panic and anxiety.

The symptoms of abuse are not limited to brain damage. Somatic disorders resulting from abuse include obesity, which can be categorized as a psychiatric condition, and numerous additional disorders. These include chronic pain conditions that last for more than 3 months and are often reported by police officers and military service members with a history of maltreatment as well as women that have been raped.
Rueness et al. (2020) identified general health problems in addition to psychopathologies in sexually abused adolescents. They displayed higher levels of PTSD, depression, dissociation and physical health complaints than unaffected controls. Family violence victims had higher levels of PTSD as well. Trauma symptoms were associated with physical health complaints, and these were most prominent in adolescents with the highest burden (frequency and amplitude) of symptoms. These included stomach ache, headache, lower back pain, pain in their arms or legs, dizziness, tachycardia (elevated heart rate), nausea and weakness. The most frequently reported combination of abuse types was physical abuse and emotional abuse (51%), followed by physical abuse combined with witnessing family violence (34%) or neglect (14%). The abuse cases had higher levels of PTSD than controls. In addition, sexual abuse victims had higher mean scores for depression, dissociation and physical health complaints. When trauma symptoms studied in relation to physical health complaints, there was evidence for associations between anxiety, PTSD, dissociation symptoms and physical health complaints among the sexually abused adolescents. There were notable associations between the family violence victims and different trauma symptoms and physical health complaints. Most of the associations between trauma symptoms and physical health complaints were more pronounced in family violence victims compared to sexual abuse victims. Thus, abuse victimization is not limited to psychopathologies but encompasses a range of physical health symptoms as well.

Chronic pain can cause significant problems for many adolescents; considerably affecting their physical, psychological and social functioning. Further, it is a frequent outcome of child and adolescent abuse. A pain syndrome is said to be chronic if it lasts more than three months, can engage any part of the body, and can be localized or widespread. They can have clear peripheral tissue damage such as nerve damage via pressure (e.g., in the spinal cord) or not; the latter of which are termed functional pain disorders. Non-specific chronic low back pain occurs when nerve or inflammatory responses cannot be identified. Abuse survivors can suffer with these syndromes for a lifetime and are very difficult to treat. Here we consider a few examples of abuse-evoked chronic pain.
A review of the literature showed an extreme range of pain reports (King et al., 2011) as follows: headache: 8-83%; abdominal pain: 4-53%; back pain: 14-24%; musculoskeletal pain: 4-40%; multiple pains: 4-49%; other pains: 5-88%. Pain prevalence rates were generally higher in girls and increased with age for most pain types. Lower socioeconomic status was associated with higher pain prevalence especially for headache. Needless to say, such wide discrepancies reflect the fact that causal relations need to be identified as there are many causes of pain including child and adolescent abuse.
In another review of the literature, Davis et al. (2005) evaluated the strength of existing evidence of the association between self-reports of childhood abuse and chronic pain in adults. They showed the following: 1) individuals who reported child abuse or neglect reported more pain symptoms and related conditions than those not abused or neglected in childhood; 2) patients with chronic pain were more likely to report child abuse or neglect than healthy controls; 3) patients with chronic pain were more likely to report child abuse or neglect than non-patients with chronic pain identified from the community; 4) individuals from the community reporting pain were more likely to report having been abused or neglected than community residents not reporting pain.
Along with many other studies, these observations provide evidence that individuals who report abusive or neglectful childhood experiences are at increased risk for chronic pain in adulthood relative to individuals not reporting abuse or neglect in childhood.
Hammond et al. (2019) evaluated a cohort of subjects over time; 0-1 years until age 14-15 years and measured relationships between early-life family stressors, and health professional-diagnosed migraine and self-reported, unclassified frequent headache (>1 per week) including the relevance of depression and anxiety in late adolescence. The proportion of respondents with migraine and frequent headache was 3% and 11%, respectively. There were no direct associations between distal early life family factors and adolescent headache. Symptoms of depression- and anxiety-mediated relationships between family dysfunction, punitive parenting, and parental depressive symptomatology were common for current migraine but not frequent headache. Thus, the presence of family dysfunction, punitive parenting, and higher parental depressive symptomatology in early life are associated with a greater likelihood of migraine in adolescence through greater symptoms of depression and anxiety
Trivedi et al. (2021) explored the relationship between self-reported abuse history with migraine-related sensory hypersensitivity. Patients with migraine completed questionnaires for depression, photosensitivity which is common in migraine and other questionnaires and asked if they believed they had suffered emotional, physical, or sexual abuse in their life. The 38% that reported a history of abuse reported significantly greater headache frequency and higher average or median anxiety, depression, photophobia, and enhanced pain during migraine. Headache frequency was significantly related to a history of abuse with increased sensory pain during an attack. Anxiety and depression were significantly related to abuse with photophobia, and enhanced pain. Thus, a history of abuse is associated with greater migraine-related sensory hypersensitivity symptoms.
Individuals with functional gastrointestinal disorders (FGIDs; no apparent site of symptom origin) report experiencing trauma more often than healthy controls. Sherman et al. (2015) explored the possibility that adolescents with FGIDs since childhood and a trauma history would exhibit heightened sensitivity to heat pain stimuli and more frequent clinical symptoms compared to patients with FGIDs but no trauma history and healthy controls using self-report measures, an experimental pain protocol, and a psychiatric diagnostic interview. FGID+Trauma patients exhibited more pain sensitivity than FGID+No Trauma patients and controls. Also, FGID+Trauma patients had greater gastrointestinal and non-gastrointestinal symptom severity, number of chronic pain sites, and disability. Thus, assessing trauma history in patients with FGIDs could identify a subset at risk for greater pain-related symptoms.
Irritable bowel syndrome (IBS) is a stress-sensitive gastrointestinal disorder of brain-gut interactions characterized by abdominal pain with changes in stool form and/or frequency. White et al. (2010) evaluated the association between major traumas and IBS among women veterans including trauma history, PTSD and depression. IBS prevalence was 34%. The most frequently reported trauma was sexual assault (39%) that increased IBS risk. Depression and PTSD were significantly more common in IBS cases than controls, but neither substantially explained the association between trauma and increased IBS risk. Thus, women veterans report high frequency of physical and sexual traumas and a lifetime history of a broad range of traumas is independently associated with an elevated risk of IBS.
Davila et al. (2003) evaluated the incidence of genitourinary impairments including urinary incontinence in self-identified sexual abuse survivors in comparison to controls. Of abuse survivors, 72% and of controls 22% reported experiencing urinary incontinence. Many symptoms of stress incontinence, urge incontinence and voiding dysfunction were also reported by a greater percent of abuse survivors. These findings further support the role of abuse in significantly higher incidence of genitourinary dysfunction, including stress and urge incontinence, and voluntary urinary retention.
Surprisingly, there are even more somatic complaints in adults who experienced childhood maltreatment. These include arthritis (Von Korff et al., 2009), fibromyalgia (Imbierowicz and Egle, 2003), temporomandibular disorder (Campell et al., 2000) and vulvodynia (Harlow and Stewart, 2005). Thus, a full accounting of adult onset pain syndromes potentially linked to child and adolescent maltreatment likely involves a dozen or more chronic pain impairments.

Given this brief review, it is clear that survivors of all forms of abuse can suffer pervasive mental and peripheral physical health problems. The psychopathologies are based on organic brain damage that have yet to be understood and treated effectively. As noted earlier, different groups are vulnerable to some but of course, not all health symptoms. Moreover, there is a group of resilient individuals that are able to evade many of the worst outcomes and the reasons for this are mainly speculative. One likely possibility is based on genetics, others are environmental or cognitive coping abilities. Also relevant are the number of comorbid impairments such as attention deficit/hyperactivity, anxiety or panic disorders that would further impair the survivor’s brain functions.
Symptom severity is related to the age of abuse onset with young children and adolescents suffering the most symptoms. These are not limited to the proximal timing of abuse but can last long into adulthood. Over time symptoms can also evolve into PTSD and other psychopathologies suggesting that treatment efforts must also evolve with such changes. The solutions to many survivor issues may be resolved to some extent by rhythmic breathing exercises, other mentally focused approaches and DBT. As we do not know exactly what is impaired in survivor brain chemistry, it is not possible to develop rational therapies including drug treatments. At present approaches are tried and, if they do not succeed, others are employed.
In the long-run, the only solutions to these extremely complex problems are to analyze the brains of experimental animals who have undergone systematic forms of abuse to show what has gone wrong in the brain and suggest how to fix such impairments. This is one of the key missions of Cingulum Neurosciences Institute.