PEDIATRICS Vol. 107 No. 4 April 2001, pp. 728-735

Type and Timing of Mothers' Victimization: Effects on Mothers and Children

Howard Dubowitz, MD, MS^*, Maureen M. Black, PhD^*, Mia A. Kerr, MS^*, Jon M. Hussey, PhD, Tanya M. Morrel, PhD^*, Mark D. Everson, PhD^§, and Raymond H. Starr Jr, PhD

From the ^* Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland; the  Department of Maternal and Child Health, University of North Carolina School of Public Health, Chapel Hill, North Carolina; the ^§ Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina; and the  Department of Psychology, University of Maryland, Catonsville, Maryland.

	ABSTRACT

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Objectives.  There is mounting concern about how mothers' own victimization experiences affect their children. This study examines the effects of mothers' victimization on their own mental health and parenting and on their children's behavior, development, and health. The effects of both timing and type of victimization are assessed. A related objective was to determine if there was a cumulative risk effect produced by victimization during both childhood and adulthood, or both physical and sexual.

Setting.  Urban families in an eastern state and urban and rural families in a southern state.

Participants.  A total of 419 mothers and their children 6 to 7 years old were identified from 2 sites. The eastern sample was recruited in the first 2 years of life from 3 pediatric clinics: 1 for children at high risk for human immunodeficiency virus disease, 1 for children with failure to thrive, and a third providing pediatric primary care. The southern sample was derived from a cohort of children at risk for adverse health or developmental outcomes, plus a systematic sampling of controls, recruited from area hospitals. At age 4, a random sample of children from the original cohort who had been maltreated along with a matched comparison group of nonmaltreated children were selected.

Results.  In general, mothers victimized during both childhood and adulthood had poorer outcomes than mothers victimized during either childhood/adolescence or adulthood who in turn had worse outcomes than mothers with no history of victimization. This manifested as more maternal depressive symptoms, harsher parenting, and more externalizing and internalizing behavior problems in their children. There were no significant differences in maternal functioning or child outcomes between those abused in childhood and those abused in adulthood. These findings were similar for type of victimization. Mothers' depression and harsh parenting were directly associated with their children's internalizing and externalizing behavior problems.

Conclusions.  Maternal victimization appears to be a highly prevalent problem in high-risk samples and is associated with harmful implications for mental health and parenting, as well as for the offspring. Pediatricians need to consider past and current victimization of mothers. Routine screening for these problems, followed by appropriate evaluation and intervention may reduce maternal depression, improve parenting, and reduce the incidence of behavior problems in children.  Key words:  maternal victimization, children, witness to violence, domestic violence.

Health care providers play a critical role in identifying abused and neglected children.¹ In recent years, the scope of child maltreatment has been broadened to consider the impact of maternal victimization on children.² Mothers may experience domestic violence, other forms of violence in adulthood, as well as victimization during childhood or adolescence. The victimization may be physical, sexual, or both. With the goal of ensuring children's physical and mental health, pediatric health care providers should have an interest in identifying current maternal victimization because it threatens children's health and well-being.^3-8 In addition, it may be important to ask mothers about victimization during their childhood and adolescent years because of its influence on their parenting ability and children's behavior.^9-12

Rates of physical and sexual abuse during childhood are high. The Third National Study of the Incidence and Prevalence of Child Abuse and Neglect¹³ estimated that almost 1% of children in the US (614 100) had been physically abused in 1993. Straus and Gelles¹⁴ found in their national survey that 11% of children 3 to 17 years old had been physically abused in the previous year. Several prevalence studies have indicated that between 20% and 40% of girls have been sexually abused.¹⁵ Although more recent estimates demonstrate steady increases in maltreatment rates over the past few decades, the increases may partly be the result of increased public and professional awareness. It is probable that child abuse and neglect were significant problems when today's parents were children.

The prevalence of domestic violence in the United States ranges between 10% and 50% of families.^16,17 For example, population-based surveys have found annual rates of 116 per 1000 women for a violent act by an intimate partner and 34 per 1000 for severe violence by an intimate partner.¹⁴ Sternberg,¹⁶ summarizing the research on the co-occurrence of spousal and child abuse, found that between 40% and 60% of reported Child Protective Services (CPS) cases of child maltreatment included histories of domestic violence. The rate of victimization during adulthood, other than from domestic violence, is less certain, but still appears substantial, particularly in low-income areas where crime and substance abuse are prevalent.

	THE IMPACT OF VICTIMIZATION ON WOMEN'S MENTAL HEALTH

Long-term studies have found that child physical and sexual abuse are associated with adult mental health problems, particularly depression.^11,18,20-22 Much of this research, however, has been conducted on convenience samples, including college students and clinical patients. Domestic violence has also been linked to mental health problems, particularly depression and posttraumatic stress disorder (PTSD), in victimized women.²³

The longitudinal research of Widom and colleagues^24-26 has demonstrated a spectrum of adverse mental health outcomes related to earlier victimization, including PTSD, substance abuse disorders, and antisocial personality disorder. Another study of patients in a Southern California health maintenance organization found an array of physical and mental health problems in adults decades after traumatic experiences in childhood.²⁷

	THE IMPACT OF TYPE AND TIMING OF MATERNAL VICTIMIZATION ON ADULT MENTAL HEALTH

It is uncertain whether victimization at different times in a woman's life has a differential impact on her subsequent mental health. McCauley et al²⁰ found similarities in the mental health status of women in an adult primary care sample who reported physical or sexual abuse during childhood and women who reported current, but not childhood, abuse. They reported similar numbers of physical symptoms, emotional distress, substance abuse, and suicide attempts. They also found that patients who reported both childhood and adult abuse had higher levels of psychological problems and physical symptoms than those who reported childhood or adult abuse alone. This conclusion supports Rutter's²⁸ cumulative risk model; the likelihood of negative outcomes increases as risk factors accumulate. With regard to type of victimization, McCauley et al²⁰ did not find significant differences in adult mental health between women who had been sexually victimized and those who had been physically victimized.

	THE IMPACT OF TYPE AND TIMING OF MATERNAL VICTIMIZATION ON PARENTING

Few studies have examined the specific effects of physical and sexual abuse on parenting. A history of child sexual abuse has been associated with mothers' negative views of themselves as parents and an increased likelihood of using physical punishment to discipline their children.²⁹ Harsh physical punishment has been linked to physical abuse, and this too is thought to contribute to similar parenting behavior in adulthood.³⁰ Problems related to role differentiation between parents and children have also been associated with maternal histories of both sexual abuse³¹ and physical abuse.³² However, the specificity of sequelae of sexual abuse has been questioned by Zuravin and Fontanella³³ who found that sexual abuse did not have an independent effect on parenting beyond the negative impact of a general history of maltreatment (including neglect) and victimization. McCauley et al²⁰ also found that the impact of physical abuse on adult mental health was similar to that of sexual abuse. Thus, it is unclear whether histories of physical and sexual abuse have similar or different effects on adult mental health and parenting.

We are not aware of studies that have examined the influence of timing of victimization on parenting. Although current or recent victimization may appear more likely to impair women's parenting abilities, the long-term sequelae of childhood abuse may have a similar impact. Abused children may become depressed adults, impairing their parenting abilities.

The concern regarding the intergenerational transmission of abuse pertains to a particular effect of victimization on subsequent parenting. Few studies, however, have followed cohorts of maltreated children into parenthood.³⁴ For physical abuse, it is postulated that children who experience aggressive, harsh parenting are at risk to repeat this pattern with their own children. However, because sexual abuse is mostly perpetrated by males on females, any intergenerational transmission is likely to be through a different process. Zuravin et al,³⁴ in a study based on reports to CPS, found neither differences in transmission of abusive behavior according to the type of maltreatment, nor a cumulative risk. This may be the result of the multiple and common, family and environmental problems that often accompany different forms of abuse. Also, the general experience of trauma may be more important than the specific type and circumstances of the trauma.

	THE IMPACT OF MATERNAL VICTIMIZATION ON CHILDREN

Research on the effects of different forms of maternal victimization on their children is limited to studies of domestic violence. Although longitudinal studies of child maltreatment have yet to examine the second generation of children, domestic violence may harm children in a number of ways. Children of mothers experiencing domestic violence are at increased risk of being abused by both their fathers and mothers.³⁵ In addition, witnessing violence has an adverse psychological impact on children and, thus, constitutes psychological abuse.^36,37 Children may also be harmed indirectly via the stress in the home and the mother's compromised ability to provide care. Most of the research has examined the impact of domestic violence on children's behavior; the impact on their social and cognitive functioning remains uncertain.³⁸

Research to date has not examined how a mother's victimization at different times in her life cycle may differentially affect her children. The few studies examining the impact of physical and sexual victimization have not found significant differences in mental health outcomes. As described earlier, the cumulative risk model has had limited support, and warrants additional evaluation. The following hypotheses were examined in this study:

1. Children's behavior, development and health are adversely affected by their mothers' victimization history.
2. There is a cumulative risk effect such that: a) victimization during both childhood/adolescence and adulthood is associated with worse child outcomes compared with victimization during any one period, and compared with no victimization, and b) children of mothers who experience both physical and sexual victimization have worse outcomes than those whose mothers have 1 form of victimization or no history of victimization.
3. A history of victimization is associated with maternal depressive symptoms and a harsh parenting style.

We were also interested in whether there were differences in child outcomes between children whose mothers had been sexually (but not physically) victimized and those whose mothers had been physically (but not sexually) abused. Similarly, the final objective was to examine whether the timing of mothers' victimization (during childhood/adolescence vs during adulthood) had differential effects on children.

	METHODS

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Participants

The sample consisted of 419 female primary caregivers, mostly mothers, and their children participating in a multisite longitudinal study of children's health and development and maltreatment among high-risk families.³⁹ The families were recruited from 2 sites: a southern state and an eastern city. The sampling criteria differed. The southern sample of families was identified from a statewide registry of high-risk newborns defined by medical and psychosocial risk factors. At age 4 to 5, a group of maltreated children and a comparison group of children not known to have been maltreated (ie, no CPS report) were identified from the high-risk cohort. The eastern sample of families was identified when the children were <2 years old from 3 pediatric clinics for: 1) children at risk of human immunodeficiency virus infection, 2) children with failure to thrive, and 3) pediatric primary care. Maltreatment was not a criterion.

Procedure

Mothers agreed to participate in a longitudinal study, following consent procedures approved by each site's institutional review board. Both sites used the same measures, data collection and handling procedures and data entry system. When the children were 4 to 5 years old, and again at 6 years, mothers completed study protocols including measures regarding their child, themselves, the family, the neighborhood, as well as stresses and supports. During the initial visit, mothers were asked about their possible victimization during childhood and adolescence as well as during adulthood. Two years later, they reported on their parenting practices, mental health status, and their children's behavior, development, and health.

Measures

Independent Variable Maternal history of victimization was measured when the children were 4 to 5 years old using a study-developed measure. The instrument was comprised of 11 dichotomous questions regarding physical and sexual abuse during the respondent's childhood, adolescence and adulthood. History of victimization was divided into 2 categories: timing and type. Timing was coded as 0 if mothers reported no history of victimization; 1 if mothers reported being victimized during adulthood only; 2 if mothers reported being victimized during childhood or adolescence only; and 3 if mothers reported being victimized during both adulthood and childhood/adolescence. Likewise, type of victimization was coded as 0 if mothers reported no victimization; 1 if mothers reported having been physically victimized; 2 if mothers reported having been sexually victimized; and 3 if mothers reported having been both physically and sexually victimized.

Control Variables Three control variables were included in data analyses: site, child's age, and maternal education. A dummy variable was created to control for the 2 sites where the data were collected: eastern and southern. Children's direct exposure to violence, both at home and in the community, was measured via Things I Have Seen and Heard: A Structured Interview for Assessing Young Children's Violence Exposure.⁴⁰ This was not related to the child outcomes, so we chose not to control for this variable in the statistical analyses.

Parenting Measures

Conflict Tactics Scale A 16-item adapted version of the Conflict Tactics Scale⁴¹ was used to measure verbal aggression and minor violence tactics used by mothers in disciplining their children. Mothers indicated how many times (1, 2, 3, 4, 5 or more) they used each tactic over the past year. The correlation between the verbal aggression and minor violence subscales was high (r = 0.60) and scores for both were averaged into 1 scale of harsh parenting.

Depression Maternal depression was measured by the Center for Epidemiologic Studies Depression Scale,⁴² a widely used 20-item measure with a dichotomous response set that has good internal consistency and demonstrated evidence of concurrent validity. Higher scores indicate more depressive symptoms.

Child Outcomes Child outcomes were measured via standardized measures and caregiver report during the 6-year-old visit. Outcomes included child's health status, cognitive development, and problem behaviors as reported by mothers.

Child's Health Status Mothers rated their child's health on a 4-point Likert scale (1 = excellent, 2 = good, 3 = fair, and 4 = poor) compared with other children of the same age.⁴³

Cognitive Development Children's cognitive performance was assessed using the Vocabulary and Block Design subscales of the Wechsler Preschool and Primary Scale of Intelligence-Revised Manual.⁴⁴ The scores were averaged and converted to a standard scale with a mean of 100 and a standard deviation of 15.

Behavioral Problems Mothers completed the Child Behavior Checklist,⁴⁵ a commonly used, 113-item measure of children's emotional and behavioral functioning. Mothers reported on the frequency of each behavior over the past 6 months (0 = never, 1 = occasionally, 2 = frequently). Scores were calculated for externalizing (eg, aggression and delinquency) and internalizing child problem behaviors (eg, withdrawal and depression), where higher scores indicated more problem behaviors. Raw scores were used in analyses to take advantage of the full range of scores as recommended by the authors.

	RESULTS

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Of the 419 mothers participating in this study, 48% were from the eastern city and 52% were from the southern state. Demographics for each site are shown in Table 1. Mothers from the southern sample were more likely to be married and not receiving Aid to Families With Dependent Children. Children from the eastern sample were younger, and there were more African Americans and boys.

A multiple analysis of variance was conducted to investigate differences in child outcomes, parenting practices, and maternal functioning by timing of victimization (see Table 2). The overall model was significant (P < .001) with significant univariate differences found for harsh parenting, maternal depression, and children's externalizing and internalizing problems. A posthoc analysis showed that mothers victimized both as an adult and as a child/teen were more depressed and reported more child externalizing behaviors than mothers who had not been victimized or had only been victimized during 1 period of their lives. Mothers victimized as a child/teen or both as a child/teen and adult reported more child internalizing behaviors than mothers with no victimization history. Mothers victimized both as a child/teen and an adult reported more child internalizing behavior problems than those victimized only as adults. Mothers victimized as both a child/teen and an adult reported greater use of harsh parenting practices than mothers who reported no history of victimization or who were victimized only as a child/teen. There were no differences in maternal mental health, parenting, or child outcomes between mothers victimized in childhood/adolescence versus adulthood.

This analysis was repeated to investigate the effects of type of victimization (see Table 3). Again, the overall model was significant (P < .001) allowing examination of the univariate F values. Results paralleled those for timing of victimization. Significant differences were found for harsh parenting, maternal depression, and children's externalizing and internalizing problem behaviors. A posthoc analysis showed that mothers with a history of victimization reported more child internalizing problems than mothers with no victimization history. Mothers with a history of either physical abuse only or both sexual and physical abuse reported more child externalizing behavior problems than mothers with no victimization history. Mothers who were both physically and sexually victimized reported harsher behavior toward their children than mothers with a history of only sexual victimization or mothers with no victimization history. Mothers who were both physically and sexually victimized reported higher levels of depression than all other mothers. There were no differences in maternal mental health, parenting, or child outcomes between mothers who were sexually versus physically victimized. Of note, children's physical health and cognitive development were not influenced by their mothers' history of victimization.

We hypothesized that there would be a cumulative effect of increased victimization on the child outcomes. Because there were few differences between experiencing only physical or sexual victimization, these 2 categories were combined into 1 category of history of victimization resulting in 3 levels of victimization (ie, none, 1 type, both types). Similarly, with timing, the 2 categories of having been victimized as an adult or as a child/teen were collapsed. Bivariate correlations among these variables and all outcome measures are shown in Table 4. Next, we used a series of multiple regressions to examine the cumulative effect of type of victimization (Table 5) and of timing of victimization (Table 6) on children's behavior problems, maternal functioning and parenting, after controlling for study site, maternal education, and child's age. With regard to type of victimization, having experienced both types of abuse predicted increased externalizing and internalizing problems for children, increased maternal depressive symptoms, and increased use of harsh parenting. Similar results were found for victimization during different times in the women's lives.

	DISCUSSION

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Our findings support the negative impact of maternal victimization on children described by other researchers.^16,36,38 One or more of a variety of mechanisms may operate to explain these findings. For example, because of their own psychological issues, victimized mothers may use less optimal parenting strategies (eg, harsh parenting) or be less attentive and emotionally available to their children. Such mothers may also have less tolerance for the normative stresses of parenting and consequently be more inclined to view their children's behavior as problematic.

Our findings also support the hypothesis that there would be a cumulative effect of being victimized during both childhood/adolescence and adulthood. This group of mothers reported more depression, more frequent use of harsh parenting practices, and more child internalizing and externalizing behavior problems than those who were not victimized. Having been victimized during 1 period resulted in intermediate findings (ie, better than having both forms but worse than no victimization) in some areas. Roberts et al⁴⁶ also found that women who had experienced both child and adult abuse suffered more mental health ill-effects than women abused as a child or as an adult. Similarly, McCauley et al²⁰ found that women in primary care practices who reported both childhood and adult abuse had higher levels of psychological problems and physical symptoms than those who reported childhood or adult abuse alone. These findings support Rutter's²⁸ cumulative risk model, suggesting that each traumatic experience adds to the burden, thereby compromising functioning and leading to negative implications for the offspring. Among mothers who were victimized either during childhood/adolescence or during adulthood (but not both), there were no differences in their depressive symptoms, parenting, or children's behavior. McCauley et al²⁰ also found that women who were abused only as children did not differ from women who reported current, but not childhood, abuse in number of physical symptoms, emotional distress, substance abuse, or suicide attempts. The lack of differences may be attributable to victimization at any time being associated with a range of negative outcomes that are more similar than different. Among women who reported a history of victimization, almost half had been abused during both childhood and adulthood. Thus, chronic victimization is more common than being victimized during either one of these periods.

The findings pertaining to the type of victimization similarly support the hypothesis of a cumulative risk effect in that mothers who experienced both physical and sexual victimization had the worst outcomes, compared with those who had 1 form of victimization and those who had not been victimized. Among women who were either physically or sexually abused (but not both), there were no differences in their depressive symptoms, use of harsh parenting, or in their children's behavior. McCauley et al²⁰ also found that it made little difference whether the abuse was sexual or physical. Cumulative risk again appears to be operating, and the harmful impact of physical and sexual victimization may be more similar than different. For example, Hall et al¹⁹ found that physical and sexual child abuse are similarly associated with adult depressive symptoms. What appears important is the fact that trauma has a negative effect on women, and multiple types of trauma are still more damaging.

Over half the mothers in this high-risk sample reported having been physically or sexually victimized at some time. In contrast, McCauley et al²⁰ found that 22% of women in a primary care setting reported having been physically or sexually abused during childhood. Our elevated rate may be attributable to the different context of the study and differences in the measure of victimization. Approximately half of the mothers in our study who had been victimized during childhood or adolescence were later revictimized as adults, indicating a strong association between these experiences. Similarly, McCauley et al²⁰ found that 50% of women abused as children were subsequently abused as adults. We are not aware of prospective, longitudinal research of sexually abused girls that has examined their subsequent victimization in adulthood. We can only speculate as to why a substantial association exists between early and later victimization. Possibly, the effects of early abuse, including mental health problems such as depression and PTSD, are risk factors for dysfunctional and violent relationships in adulthood.⁴⁷ It is also possible that some of the same risk factors that contribute to early victimization are influential in later years.⁴⁸ Although the association between child and adult victimization may lead some to inappropriately conclude that there are personality characteristics that predispose these girls and women to being victims, we are unaware of evidence supporting this notion. In addition, approximately one-third of the women who had been abused in childhood, did not report victimization as adults. Thus, the path of repeated victimization is present but not inevitable.^9,10,12,49

Study Limitations

There are several limitations in this study. Recall bias is a concern; women who may have been experiencing difficulties as adults or with their children could have been more likely to recall or perceive previous victimization. Another limitation is that of shared method variance given that most of the data were based on maternal reports. In addition, 2 studies have found evidence suggesting that a mother's own psychological issues may significantly influence her ratings of her child on measures like the Child Behavior Checklist.⁵⁰ For example, one study found that mothers' own psychiatric symptoms were significantly associated with their reports of child behavior problems.

The measure of maternal victimization did not probe the nature of these experiences. However, the findings are consistent with theory and findings of others. In addition, mothers' mental health status and their parenting were each assessed using only 1 measure. Additional and more comprehensive measurement of these areas appears important for future research. Regarding the associations between harsh parenting, mothers' depressive symptoms and children's behavior problems, we cannot disentangle cause or effect.

Caution is warranted in generalizing these findings to other populations. This study is based on identified high-risk families, but included those living in an inner-city as well as those in a variety of settings in a rural state (50% in 1990). Another limitation is possible confounding by risk factors not examined. We did control partly for social class (ie, maternal education), and children's general exposure to violence was not related to our measures of their functioning. Despite these shortcomings, the findings of the impact of mothers' victimization on themselves and their children appear to be valid.

	CONCLUSIONS

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Maternal victimization during both childhood and adulthood is a highly prevalent problem among low-income, high-risk groups of mothers that is associated with harmful implications for mental health and parenting, and for their offspring. In general, more victimization (ie, both as a child and as an adult; both physical and sexual) was associated with worse outcomes in the mothers and in their children, supporting the model of cumulative risk. There were no significant differences in the outcomes of abuse during either period, or between physical and sexual victimization. Pediatricians need to be aware of possible past and current maternal victimization and the potential sequelae for all involved. The problem is sufficiently prevalent making it very important for health care professionals to routinely screen for maternal victimization, followed by efforts to facilitate appropriate evaluation and intervention.^5,7

	ACKNOWLEDGMENTS

This research was supported by Grants 90CA1568, 90CA1569, and 90CA1572 from the Children's Bureau, Office on Child Abuse and Neglect, Administration for Children, Youth, and Families; Grants 90CA1401, 90CA1433, and 9-CA1467 from the National Center on Child Abuse and Neglect; and Grants MCJ-240568 and MCJ-240621 from the Maternal and Child Health Research Program, US Department of Health and Human Services.

	FOOTNOTES

Received for publication May 23, 2000; accepted Nov 14, 2000.

Address correspondence to Howard Dubowitz, MD, MS, Department of Pediatrics, University of Maryland School of Medicine, 520 W Lombard St-Rear, First Floor, Gray Lab Bldg, Baltimore, MD 21201. E-mail: hdubowitz{at}peds.umaryland.edu

	ABBREVIATIONS

CPS, Child Protective Services; PTSD, posttraumatic stress disorder.

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