Do race, neglect, and childhood poverty predict physical health in adulthood? A multilevel prospective analysis☆
Introduction
In the United States, childhood neglect is the most common form of maltreatment and accounts for over 60% of cases reported to child protective services. In 2011, 541,000 children in the United States were estimated to be victims of neglect (U.S. Department of Health and Human Services, 2012). Studies have also reported associations between childhood neglect and childhood poverty (Berger, 2005, Drake and Pandey, 1996, Theodore et al., 2007) with estimated rates of neglect of 2.2 children per 1,000 in middle- and upper-socioeconomic status (SES) families compared to 16.1 per 1,000 children in low-SES families (Sedlak et al., 2010). Furthermore, both neglect and poverty in childhood are associated with a range of negative sequelae, including poor physical health in adulthood (Conroy et al., 2010, Danese et al., 2009, Lanier et al., 2009). However, few studies have examined physical health consequences of neglect (Wegman & Stetler, 2009). In this study, we focus on cases of childhood neglect that represent judgments that caregivers failed to provide food, shelter, clothing, and/or attend to the medical needs of the child beyond acceptable community standards at the time.
When examining the link between childhood neglect and poverty and adult outcomes, we have based our work on an ecological model that stresses the importance of social context and the need to consider the individual in the framework of the broader environment in which he or she functions (Belsky, 1980, Garbarino, 1977, Widom, 2000). This work is based on the premise that children exist within the context of families and that families are embedded in neighborhoods or, in some cases, isolated from neighborhoods. Thus, in order to understand adult outcomes, we believe it is important to take into account characteristics of the individual (race, gender, childhood neglect), the family (family poverty), and the neighborhood (neighborhood poverty) and the ways in which these factors work together or interact.
To date, much of the research on childhood neglect has focused on mental health, rather than physical health, outcomes. However, theoretical models of the impact of early stressful experiences (Repetti, Taylor, & Seeman, 2002) suggest that neglect may lead to poorer physical health by disrupting stress–response pathways and psychosocial functioning and contributing to risky behaviors. Several papers report a connection between physical and sexual abuse and adult physical health outcomes (Arnow et al., 1999, Drossman et al., 1995, Fuller-Thomson et al., 2011, Newman et al., 2000, Rapkin et al., 1990, Sachs-Ericsson et al., 2011, Walker et al., 1988). Studies of the relation between neglect and health outcomes are rare (Goodwin and Stein, 2004, Widom et al., 2012b).
At the same time, research has shown that impoverished environments in childhood have long-term physical health effects (Case, Lubotsky, & Paxson, 2002). Studies examining family poverty with cross-sectional and longitudinal designs consistently find that children growing up in poorer families are at increased risk for health problems that may persist into adulthood (Adler and Rehkopf, 2008, Case et al., 2002, Cohen et al., 2010, Conroy et al., 2010, Galobardes et al., 2004). Neighborhood level studies also link poverty to poor physical health in adulthood (Franzini et al., 2005, Moore et al., 2010, Wilkinson and Pickett, 2007). The few studies that have examined the role of individual level poverty within the context of the community have found that both family and neighborhood factors were important for physical health (Case et al., 2005, Franzini et al., 2005, Moore et al., 2010).
Because childhood risk factors of neglect and poverty tend to co-occur, and many believe that poverty accounts for the negative consequences associated with neglect, it is important to understand if and how they each impact functioning and whether they interact. Lacking such knowledge, policy makers and interventionists may misappropriate efforts and miss important opportunities to create meaningful change.
To our knowledge, few studies have simultaneously examined the roles of neglect and poverty in relation to physical health. Goodwin and Stein (2004) found that when adult poverty and race were controlled, the association between childhood neglect and self-reported diseases in adulthood became stronger. However, independent effects of poverty and race were not reported and childhood poverty was not assessed. In another study using hospital record data and a longitudinal design, Lanier et al. (2009) found that neglect, welfare receipt, and average neighborhood income in childhood were all independently related to risk for hospital care and cardiovascular and respiratory disease in children and adolescents. Danese et al. (2009) found that maltreatment in childhood was related to C-Reactive Protein (CRP) levels after controlling for adult SES. Finally, one recent study (Widom, Czaja, Bentley, et al., 2012) followed a sample of court-substantiated cases of childhood maltreatment and matched controls into adulthood and found that neglect predicted several health outcomes, despite controlling for poverty. In that study the contributions of race, childhood family and neighborhood poverty, and their interactions were not addressed.
The burden of poverty and poor health is not distributed equally in the United States, with approximately 35% of Black children living in poverty during 2009 compared to 17% of White children (Macartney, 2011). Blacks also tend to exhibit poorer physical health, relative to Whites (Adler & Rehkopf, 2008).
In cross-sectional studies examining poverty and race together, Black–White differences in health status (diabetes, blood pressure and obesity) were considerably minimized when poverty was taken into account (Bleich et al., 2010, LaVeist et al., 2009, Thorpe et al., 2008), which suggests that poverty may account for the negative health outcomes associated with minority status. However, other research has reported that large race differences in physical health persist despite controlling for poverty (Adler and Rehkopf, 2008, Williams et al., 2009). There is also evidence that the effects of poverty on health vary by race, which suggests that race may moderate the impact of poverty on health (Reagan et al., 2012, Wickrama et al., 2006). In these studies, although Blacks were at risk for worse outcomes overall, Whites showed stronger associations between poverty and negative outcomes. Finally, recent research has shown that Black and White children manifest mental health consequences of childhood neglect differently (Widom, Czaja, Wilson, Allwood, & Chauhan, 2012). In sum, we argue that to understand the consequences of neglect on adult physical health, it is necessary to also consider the role of race and its interactions with childhood neglect and poverty.
Men and women have also been found to be at risk for different physical health outcomes (Leuzzi, Sangiorgi, & Modena, 2010). Men are more likely to manifest traditional signs of heart disease, including hypertension, whereas women are more likely to develop inflammation (Ridker, 2003), that is reflected in higher than normal levels of CRP. Because gender differences in physical health outcomes may be partially explained by the different responses of men and women to adverse/stressful experiences, such as poverty, childhood neglect, and racism (Taylor et al., 2000), we include gender as a factor that may explain or modify the outcomes of childhood neglect and poverty.
We use data from a prospective study with clear temporal relationships and documented cases of child neglect. The design also includes a matched control group of children that establishes the base rates of health outcomes expected in a sample of adults from comparable backgrounds who did not come to court attention in childhood as victims of neglect. Physical health assessments are based on blood tests and physical measurements made by a licensed registered nurse. We focus on three health indicators (CRP, hypertension, and pulmonary functioning) that represent vital cardiac and pulmonary systems. The deficits in the functioning of these symptoms are associated with high rates of morbidity and mortality in the United States (Kochanek et al., 2011, U.S. Department of Health and Human Services, 2010) and with race and childhood adversity (Repetti et al., 2002, Thorpe et al., 2008, Williams et al., 2009). CRP measures inflammation in the body and has been identified as one of the strongest markers and predictors of cardiac disease, the leading cause of death in the United States (Ridker, 2003, Ridker et al., 2000). Over 30% of Americans aged 20 and older have a diagnosis of hypertension (high blood pressure), and a primary diagnosis of hypertension accounts for 39 million yearly patient visits to physicians (Centers for Disease Control and Prevention, 2013). According to the same report, pulmonary dysfunction and respiratory disease is the fourth leading cause of death in the United States.
We address two basic questions: (a) Do childhood neglect, race, and childhood family and neighborhood poverty each predict physical health indicators in adulthood? and (b) Do childhood neglect, race, gender, and childhood family and neighborhood poverty interact to predict health indicators in adulthood and, if so, how? Our fundamental hypothesis is that childhood neglect leads to physical health outcomes, independent of poverty, race, and gender, although we also expect interactions illustrating the important role of these contextual factors.
Section snippets
Design and participants
Data were collected as part of a large prospective cohort design study (Leventhal, 1982, Schulsinger et al., 1981) in which abused and/or neglected children were matched with non-abused and non-neglected children and followed into adulthood. Because of the matching procedure, the participants were assumed to differ only in the risk factor; that is, having experienced childhood abuse or neglect. Because it is not possible to assign participants randomly to groups, the assumption of equivalency
Data analyses
We first assessed preliminary relations among predictors and covariates using correlations and Chi-squares. Then, in order to assess whether each predictor is related to each outcome independently, bivariate relationships were examined between the independent variables (childhood neglect, race, gender, family and neighborhood poverty), covariates, and outcomes (indicators of adult health) through the use of correlations and odds ratios with SPSS version 20 (IBM, 2011). Because our goal is to
Results
Preliminary analyses in Table 1 show the bivariate associations between predictors and covariates. Table 2 presents the results of bivariate analyses of the relations between the predictors (childhood neglect, race, gender, and childhood family and neighborhood poverty) and covariates with each of the indicators of physical health (CRP, pulmonary functioning, and hypertension). Multivariate results are presented in Table 3. We report the results of each outcome separately.
Discussion
Using data from a prospective cohort design study, we examined whether race, childhood neglect, and childhood family and neighborhood poverty predicted physical health in middle adulthood. These findings are the first from a prospective study that focuses on childhood neglect and adult physical health indicators and illustrate the challenges of disentangling the contributions of different childhood experiences to adult health outcomes.
Our bivariate results showed that childhood neglect
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This research was supported in part by grants from NICHD (HD40774), NIMH (MH49467 and MH58386), NIJ (86-IJ-CX-0033 and 89-IJ-CX-0007), NIDA (DA17842 and DA10060), NIAAA (AA09238 and AA11108) and the Doris Duke Charitable Foundation (Widom, PI). Points of view are those of the authors and do not necessarily represent the position of the United States Department of Justice.