Key Words: children, abuse, trauma, psychiatric disorders, Attachment Disorder
Abstract
It is important to understand the relationships among family violence, child maltreatment, and psychiatric and behavioral disorders in order to prevent, assess, and treat these very serious social problems. This study demonstrates a strong level of comorbidity among these problems. All subgroups (Psychiatric, Violent, Sexual Offending, Delinquent, Attachment Disordered, and Substance Abusers) had a high percentage of childhood trauma, family violence, and psychiatric problems. The psychiatric population had substantial aggression, but were less aggressive (57%) than other groups. Seventy-three to 92% of all groups had psychiatric disorders. Over 75% of all groups had histories of childhood trauma with the Attachment Disordered group having the highest percentage (98%). The study points to the need for professionals to assess a broad range of individual and family problems when persons are referred for services, regardless of the presenting problem. However, more study is needed.
Introduction
Family violence, childhood maltreatment, school shootings, rampant substance abuse, increasing prison populations, and insufficient support for human services are significant social issues in the United States . Until we study and understand the factors that support or decrease the likelihood for these problems, we cannot effectively prevent or treat them. We hypothesize that these are not independent issues, but rather interrelated. Kleinman (1997) found that epidemiological studies have shown the various social problems (substance abuse, violence, family breakdown) to be strongly linked to mental health issues. The present study looks at the correlations among individual violence, psychiatric disorders, substance abuse, attachment disorders, sexual offending, childhood trauma, and a history of family violence. Violent youth and adults have problems in multiple domains, such as school, family, community, work, and among peers (Seifert, 2000). In order to examine the issue of comorbidity of family violence, child maltreatment, and psychiatric and behavioral disorders, we administered the youth and adult versions of the Child and Adolescent Risk Evaluation and Comprehensive Adult Risk Evaluation (CARE). We also administered the youth version of the CARE (Seifert, 2003a), formerly the CARV (Seifert, Phillips & Parker, 2001), to a sample of 415 youth, as well as the adult version of the CARE (Seifert, 2003b) to 64 adults. The youth and adult samples were combined for this comorbidity study. Additionally, a comparison of subgroups by age did not yield significant differences between the analysis of the youth and adult samples. In the present study, significant correlations were found among behavior problems, psychiatric symptoms, attachment disorders, individual violence, and histories of abuse, neglect, and family violence. While many mental health and behavioral disorders have a biological basis, they also may be a result of, exacerbated by, or have associations with exposure to violence or child maltreatment. While this study could not determine if these are merely co-existing problems or if there are causal links, it was an attempt to examine this issue. It is important to understand the nature and extent of these relationships among disorders in order to prevent and treat them.
The various disorders described in this study, except Reactive Attachment Disorder (RAD), are well researched as independent entities. However, the comorbidity literature is less extensive. DeFrancesco (2001) documents the high level of co-morbidity of ADHD and disorders of conduct among youth. A large percentage of youth with histories of abuse and neglect are found among youth or adults with both ADHD and behavioral disorders (Rulo-Pierson, 2001; Seifert, 2000). It is hypothesized that some percentage of children with ADHD and conduct disorders may have RAD as well. Attachment disordered youth or adults, by definition, have been severely neglected, abused, or exposed to domestic violence. This results in behaviors that are often violent, oppositional, and antisocial. Research, such as this study, provides statistical descriptions of the sub-populations and estimates of comorbidity, which will help de
Unlike other disorders, Reactive Attachment Disorder, which is caused primarily by pathological care giving, has not been extensively researched. Consequently, its association with psychiatric and behavioral disorders and violence has not been well documented. This study provides a beginning look at the role of early bonding in the development of behavioral and mental health problems.
Post Traumatic Stress Disorder (PTSD) can be an outcome of childhood trauma. It is characterized by continued heightened arousal and difficulties with mood and concentration long after the trauma has passed. Those who have been traumatized can, therefore, develop symptoms of anxiety, attention, and mood disorders. If maltreatment, neglect, or exposure to violence occurs before the age of 4, the ability to bond with others can also be affected.
The fight, flight, or freeze response results in the felt need to engage in extensive movement. This is seen in various settings. In an effort to self-soothe and discharge stress chemicals in the body, many traumatized people often feel the need to pace, run, walk, or rock. Practitioners who are treating Attachment Disordered children have observed the frequent co-occurring attention and hyperactivity problems. Their effect is often flat or out of control. The majority of attachment disordered youth have experienced childhood trauma (Levy & Orlans, 1998). It appears that the assessment and treatment of behavioral, sexual, and psychiatric disorders among young people and adults should include assessment and treatment, when indicated, of the entire family for problems of abuse and neglect, mental health issues, attachment problems, and family violence.
Method
The Sample
The youth (Seifert, 2003a) and adult (Seifert, 2003b) versions of the CARE were administered to 479 participants. The sample included clients in East Coast and Mid-Western U.S. residential and outpatient treatment settings, as well as a detention center and a prison for young, violent offenders. Also incorporated into the study are a group of youth and adults who do not have any problems or have only mild problems. Ages in the sample ranged from 2 to 74. Twenty-three percent (112) of the sample were diagnosed with attachment disorder, 36% (171) were substance abusers, 23% percent (112) had committed sexual offenses, 79% (378) had a psychiatric disorder, 57% (272) had been assaultive, and 76% (366) had experienced childhood trauma.
Ethnicity was varied. Sixty percent (285) of the sample were Caucasian, 31% (148) were African American, 4% (17) were Hispanic, 1% (5) were Asian, 0.2% (1) were American Indian, and 4% (18) were of another ethnicity. Five were missing this data. Gender distribution of the sample was 69% (329) male and 31% (147) female. Three were missing this data. The sample included persons with a wide range of intellectual capacity. Twenty-four percent (114) had below-average intelligence, 61% (293) had average intelligence, and 12% (56) had above-average intelligence. Intelligence was unknown for 16 persons. Slightly more than half (57%, 274) of the sample had histories of assaultive behavior, while 43% (205) had no history of assaults. There were a variety of placements in the sample. Sixty percent (285 youth) lived at home, 8% (38 youth) were in a foster of group home, 4% (18) were in detention, 4% (18) were in prison, 14% (67) were in a residential treatment center, 1% (5) were in a hospital, and 9% (45 adults) were living independently.
Procedures
The youth and adult versions of the CARE were administered to persons in various settings. Many were administered as part of an intake process or a psychological testing battery. Data was collected through a combination of interview and record review. Data was subjected to statistical analysis. Descriptive statistics were used for the seven subpopulations: psychiatric, substance abuse, attachment disordered, sex offenders, assaultive, delinquent, and those with childhood trauma. Multiple regression analyses were used to identify the strongest statistical predictors of each subgroup. Correlations among variables were examined.
The Measures
The youth version of the CARE is a screening tool that assesses behavioral problems in children and teens (Seifert, 2003a). The adult version of the CARE, Comprehensive Adult Risk Evaluation (Seifert, 2003b), uses the same items and scoring as the youth version. Divided into two segments, 49 items are divided into five categories. The test measures both risk and protective factors for behavioral disorders. The risk categories are individual characteristics and history (e.g., history of violence, enuresis, poor anger management, and psychosis), peer interactions (e.g., bullying behaviors and deviant peer group), educational, school, and work problems (such as learning problems, lack of work success, and school failure), and family characteristics and dynamics (such as a history of harsh caregiver disciplinary practices and family violence). There is one resiliency category (e.g., supportive adult and school or work success). Both static and dynamic factors are used. Static factors are historical events and characteristics that are not subject to change, such as history of abuse and neglect. Dynamic factors are those that can be changed with treatment, such as social skill and problem solving ability.
The CARE includes risk and resiliency factors that are associated with severe behavior problems and aggression (Seifert, 2000; Quinsey, Harris, Rice, & Cormier, 1998). The CARE is based on the idea that the more risk factors and the fewer resiliency factors that an offender has, the greater his or her risk for violent recidivism or other offending behaviors.
The CARE sample size was 550 persons. The validity and reliability of the CARE was assessed for the youth and adult participants, and for the total sample. The youth CARE score is significantly correlated with past assaults (r = .62, p = .00) and severity of behavior problems (r = .78, p = .00). The youth CARE score is also significantly associated with assaults at six months (r = .60, p = .00) and one year (r = .54, p = .00) after administration of the CARE. The adult CARE score is significantly correlated with past assaults (r = .66, p = .00) and severity of behavior problems (r = .68, p = .00). For the total sample, the CARE score was significantly associated with severity of behavior problems (area under the ROC curve = .91, r = .79, p = .00) and with past assaultiveness (area under the ROC curve = .91, r = .64, p = .00). The scale reliability was also measured. The Alpha was .78 and the test-retest correlation was .83 (p = .00).
Variables
Variables that were measured included a history of behavior problems, impulsivity, attachment disorder, family violence, psychosis, enuresis, and aggression. Individual characteristics included social skill problems, dif
Results
Populations can be statistically assessed in a variety of ways. Some are of more practical utility and others may lead to a theoretical model of the disorder or behavior. While it may appear repetitive, a variety of descriptions are used for the various sub-populations for comparison purposes.
Regression Analysis
A regression analysis was applied to six subgroups: those with psychiatric diagnoses, substance abuse, childhood trauma, assaultive behaviors, sexual offenses, and RAD. The items of the CARE were used to determine the strongest statistical predictors. Correlations less than .2 were not reported. Psychosis, impulsivity, and parental discipline that was harsh, lax, or inconsistent were statistical predictors of Psychiatric Problems (see figure 1). Severity of behavior problems, delinquency or crime, and favorable attitudes toward antisocial behavior were significantly associated with substance abuse (see figure 2). Attachment disorder and family violence predicted childhood trauma (see figure 3).
Attachment Disorder, severity of behavior problems, and enuresis predicted assaultiveness (see
Comorbidity of Populations
Characteristics of the subgroups were assessed. All subgroups had a high percentage (greater than 73%) of persons with psychiatric problems (see see figures 7 & 8). More than 75% of all groups had histories of childhood trauma with the Attachment Disordered group having the highest percentage. Greater than 70% of those in all groups reported histories of family violence. The psychiatric group had the lowest percentage (74%) of those with histories of family violence, while attachment disordered persons had the highest percentage (91%). It appears that one-fourth of the psychiatric group did not have a history of trauma or family violence factors. These persons may have had a mental illness that was primarily biological in nature. All groups had high percentages of those with psychiatric disorders. Sex offenders, substance abusers, and the criminal/delinquent group had the lowest percentages of psychiatric disorder (73%, 75%, 75%), while the attachment disordered and violent group had the highest percentages (92%, 80%; see Figures 7 & 8). Greater than 70% of all groups had histories of assaultiveness, except for the psychiatric group, which was slightly more than half. Sex offenders were more likely to have committed other delinquencies, and the psychiatric group was the least likely to have criminal histories. Comorbidity among these populations demonstrates the need to assess clients and their families for multiple issues, regardless of the presenting problem.
A Comparison of the Characteristics of Subsets
The following section describes the characteristics or traits of subsets. Greater than 70% of all groups had anger management problems, impulsivity, and poor social skills. At least 80% of all groups had poor problem-solving skills. Substance abusers (53%) and those with criminal or delinquent histories (50%) were more likely to be absent from work or school than persons in other subgroups. More than 65% of all groups had moderate to severe behavior problems before the age of 12. The psychiatric group had the lowest percentage of those with learning problems (56%) and school behavior problems (54%). Those in the psychiatric group were also less likely to be bullies (26%). Seventeen to 20 percent of all groups had neurological problems. Twenty-one to 33% had run away from home. Approximately one-third of all groups had some level of paranoia. More than half of all groups had emotional displays that were either flat or out of control, and there were large numbers of family problems in each group. The value of describing these populations, and the commonalities and distinctions between them, is in fashioning treatment modalities that can be tailored to their needs, as well as those of their families.
Correlations
Many of the variables in this study were correlated. A correlation matrix of a large number of variables is large and complex. It is presented in two parts (see Tables 1 and 2). An assaultive history is significantly correlated (correlation greater than .3) with severity of behavior problems, sexual assault, impulsivity, delinquent/criminal behavior, anger problems, attachment disorder, poor social skills, and school behavior problems. Delinquent and criminal behavior is correlated with severity of behavior problems, sexual assault, assaultiveness, impulsivity, substance abuse, and school behavior problems. Attachment Disorder is associated with severity of behavior problems, assaultiveness, and childhood trauma. Sexual Assaultiveness is correlated with severity of behavior problems, physical assaults, and delinquency/criminality. Psychiatric disorders show no associations above .3 in table 1. Substance abuse is correlated with severity of behavior problems and delinquency/criminality.
Discussion
Implications for Intervention
The implications for intervention are that regardless of the reason that a person comes to the attention of a criminal justice, social service, or mental health agency, there is a high likelihood that other problems exist within the individual and the family. All problem areas should be assessed and either treated or referred for treatment. This study also makes a case for providing early mental health services for the children who have been abused, neglected, or exposed to domestic violence. There appears to be a relationship between childhood trauma and later youth violence or other behavior problems. To end youth and adult violence, we must look at the violent family roots and intervene as early as possible. It also supports the idea that the separation between mental health, criminal justice, and social service agencies is artificial for the majority of the population that each agency serves. In an age when we are looking for ways to effectively and ef
Limitations of the Study
There were several problems with this study. The sample size was still quite small for the number of variables being examined. A larger sample is needed and is being collected. Abuse and neglect before the age of 4 is not often in the record, and youth or adults either do not remember, are in denial, or do not want to say that they were abused or neglected at an early age. Therefore, this data is sometimes difficult to collect. The definition and study of attachment disorders is still quite new, so those rating children may not have the knowledge base to recognize it. While youth or adults in the study came from many different agencies, a more diverse sample is needed. Several items on the CARE, such as problem-solving ability and social skills, depend on the judgment of the person doing the rating and can differ from person to person. This needs further evaluation. More research is needed on the issues of violence and attachment problems.
Conclusions
There was considerable comorbidity among the seven groups studied. All groups had a high percentage of youth or adults who had experienced childhood trauma or were from families with histories of violence. All groups had a high level of individuals with psychiatric problems. The majority of substance abusers, sexual offenders, and those with attachment disorders were also physically assaultive. A large percentage of substance abusers and sexual offenders also had criminal or delinquent histories. Specifically, 92% of attachment disordered youth or adults had psychiatric problems. Eighty-seven percent of sexual offenders had committed a violent offense. Eighty-three percent of attachment disordered persons had been violent. Seventy-two percent of substance abusers had also committed an assault.
Violent offenders had attachment disorders, severe behavior problems, enuresis, impulsivity, anger problems, poor social skills, and school behavior problems. Those with attachment disorders had experienced childhood trauma, beliefs in the legitimacy of aggression as a means to an end, emotional displays that were flat or out of control, severe behavior problems, and physical assaultiveness. Substance abusers had severe behavior problems and were delinquent or criminal. The psychiatric group had psychosis and parental discipline that was lax, inconsistent, or harsh, as well as childhood trauma and family violence. The sexual offenders were primarily male and had a low IQ, a history of physical assaults, deviant peers, and exhibited severe behavioral problems and other delinquencies.
The treatment of comorbid conditions needs further study and development. The relationship of attachment and bonding to later violence issues needs to be studied. Effective interventions for attachment disorders need more research. The many aspects of violence within the family need to be treated effectively. The various public agencies need to look at how their populations and missions overlap. If we are ever to stem the tide of violence, we must look at its family, community, physiological, and psychological/developmental roots and the interaction of these domains. We must look at epidemiological clusters of social and mental health issues (Kleinman, 1997).
The study of violence also needs the development of a theoretical model to explain the phenomenon. This study implicates the interaction of personal and environmental factors in explaining the occurrence of violence. Within the personal and environment categories are the physical, social, and psychological/ developmental domains. At the next level are the factors that make a person vulnerable or resilient to developing the behavior. The role of environmental violence and attachment disorders in the development of psychiatric and behavioral disorders needs further investigation.
References
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About the Author
Kathryn Seifert received her Ph.D. from the University of Maryland, Baltimore Campus in 1995. She is a Diplomate (DABPS) in forensic psychology and a Fellow in the American College of Advanced Practice Psychologists and the Maryland Psychological Association. Dr. Seifert has over 30 years of experience in mental health, addictions, and criminal justice work. In addition to creating the CARE, Dr. Seifert has authored articles and lectured nationally and internationally on youth or adult violence. She founded Eastern Shore Psychological Services, a multi-disciplinary private practice that specializes in working with high-risk youth or adults and their families.
