Violence and Victims, Volume 25, Number 3, 2010

Adult Health and Relationship

Outcomes Among Women With
Abuse Experiences During Childhood
Elizabeth A. Cannon, MS
Amy E. Bonomi, PhD, MPH
The Ohio State University

Melissa L. Anderson, MS
Group Health Cooperative

Frederick P. Rivara, MD, MPH

Harborview Injury Prevention and Research Center and
the University of Washington

Robert S. Thompson, MD
Group Health Cooperative
Associations between child abuse and/or witnessing intimate partner violence (IPV) during
childhood and womens health, adult IPV exposure, and health care use were examined.
Randomly sampled insured women ages 1864 (N = 3,568) completed a phone interview
assessing childhood exposure to abuse and witnessing IPV, current health, and adult IPV
exposure. Womens health care use was collected from automated health plan databases.
Poor health status, higher prevalence of depression and IPV, and greater use of health care
and mental health services were observed in women who had exposure to child abuse and
witnessing IPV during childhood or child abuse alone, compared with women with no
exposures. Women who had witnessed IPV without child abuse also had worse health and
greater use of health services. Findings reveal adverse long-term and incremental effects of
differing child abuse experiences on womens health and relationships.

Keywords: adult health; health care utilization; intimate partner violence; child abuse;
witnessing intimate partner violence

hild abuse history is prevalent among women (Arnow, 2004; Chartier, Walker, &
Naimark, 2007; Newman et al., 2000; Tang et al., 2006; Thompson et al., 2006)
and is associated with poor health across the lifespan (Batten, Aslan, Maciejewski,
& Mazure, 2004; Bensley, Van Eenwyk, & Wynkoop Simmons, 2003; Carlson, McNutt,
& Choi, 2003; McCauley et al., 1997; Moeller, Bachmann, & Moeller, 1993; Nicolaidis,
Curry, McFarland, & Gerrity, 2004; Thurston et al., 2008; Walker et al., 1999). As well,
witnessing intimate partner violence (IPV) in childhooda stressful, adverse experience (Felitti et al., 1998)is associated with poor health well into adulthood (Dube,

2010 Springer Publishing Company

291

DOI: 10.1891/0886-6708.25.3.291

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Cannon et al.

Anda, Felitti, Edwards, & Williamson, 2002). Studies suggest a doseresponse relationship between adverse childhood exposures (such as child abuse and witnessing IPV) and
poor self-rated health in adulthoodthe more traumatic exposures in childhood, the poorer
ones self-rated health in adulthood (Bensley et al., 2003; Dube, Felitti, Dong, Giles, &
Anda, 2003; Edwards, Holden, Felitti, & Anda, 2003; Felitti et al., 1998).
Studies have also shown an association between childhood abuse and adverse relationship outcomes in adulthood, including IPV victimization (Bensley et al., 2003; Coid et al.,
2001; Nicolaidis et al., 2004; Thompson et al., 2006; Whitfield, Anda, Dube, & Felitti,
2003). This relationship has also been shown for witnessing IPV during childhood and
IPV exposure in adulthood (Bensley et al., 2003; Thompson et al., 2006; Whitfield et al.,
2003). Moreover, a graded relationship has been found between the number of child abuse
exposures and IPV (Bensley et al., 2003; Whitfield et al., 2003).
In addition, the extant literature points to higher health care use for women with exposure to childhood physical and sexual abuse (Anda, Brown, Felitti, Dube, & Giles, 2008;
Arnow, 2004; Arnow et al., 2000; Bonomi, Anderson, et al., 2008; Chartier et al., 2007;
Finestone et al., 2000; Newman et al., 2000; Tang et al., 2006). For example, one recent
study found that adverse childhood experiences (such as physical abuse, sexual abuse, and
witnessing IPV) were associated with increased prescription drug use (Anda et al., 2008).
In addition, the same study found a graded relationship between number of adverse childhood experiences and risk for number of classes of drugs used.
Although some studies have examined the individual and combined effects of child abuse
and witnessing IPV on adult health status, IPV exposure (i.e., Bensley et al., 2003) and adult
health care utilization, they have examined only a couple of outcomes, such as IPV victimization and self-reported overall health, and none to our knowledge have examined more than one
objective indicator of health care use by these exposures. In addition, prior studies did not conceptualize IPV as including physical, sexual, and nonphysical types of abuse (Bensley et al.,
2003)covering the range of abuse experiences acknowledged by key violence prevention
organizations such as the Centers for Disease Control and Prevention (Saltzman, 2004). The
present investigation examines a wide range of self-reported health and relationship outcomes
(i.e., IPV victimization in adulthood) and health care use (derived from automated health plan
data) associated with exposure to child abuse (physical and/or sexual) only, witnessing IPV
during childhood, or exposure to both child abuse and witnessing IPV during childhood using
data from women enrolled in a large health care delivery system.
Based on prior research that points to a doseresponse relationship between adverse
childhood experiences and self-rated health (e.g., Dube et al., 2003), IPV victimization
(e.g., Bensley et al., 2003), and health care utilization (Anda et al., 2008), we hypothesized that the most pronounced adverse health indicators (e.g., poor self-rated health, IPV
occurrence, and health care use) would be observed in women who had been exposed to
both child abuse and witnessing IPV during childhood compared with nonabused women.
However, we also expected increased rates of adverse health outcomes in women who had
one exposure only (e.g., witnessing IPV, child abuse) compared with nonabused women.

METHODS
Participants
The sample comprised 3,568 randomly sampled, English-speaking women aged 1864
enrolled for 3 years or longer at Group Health Cooperative between 1991 and 2001, who

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293

participated in a telephone survey between December 2003 and August 2005 to assess
abuse exposure and health outcomes. Group Health provides health services to more than
550,000 mostly urban residents of Washington State and northern Idaho. Of 6,666 women
selected, 345 were excluded because they were found to be ineligible once they were contacted (209; e.g., they no longer belonged to Group Health Cooperative), deceased (3), too
ill (15), or had a language barrier or hearing impairment (118). Of the 6,321 remaining
women, 1,829 (28.9%) refused participation, 539 (8.5%) were located but did not complete
the interview, 385 (6.1%) could not be located, and 3,568 (56.4%) completed the survey.
The study was approved by Group Healths Institutional Review Board.

Outcome Measures
The primary outcomes were self-reported general health, physical, social, and mental functioning; depression and physical symptoms; and IPV experienced since age 18, as well as
health care utilization determined from automated databases to corroborate womens selfreports of health indicators. Health indicators were probed before abuse exposures in order
to reduce response bias due to the order of the questions.
General Health, Physical, Social, and Mental Functioning. Twenty questions from
the Short Form-36 (SF-36) Health Survey, version 2 were used to assess womens general
health, vitality, mental health, emotional functioning, and social functioning in the past 4
weeks (Ware, Kosinski, & Dewey, 2000). The Physical Component Summary (PCS) and
Mental Component Summary (MCS) scoresaggregate measures of physical and mental
functioningwere also determined using a subset of the 20 questions from each SF-36 area.
The SF-36 subscale scores and the PCS and MCS scores were standardized to have a mean
of 50 and standard deviation of 10, with higher scores indicating better functioning. These
standardized scores allowed for easy comparisons across subscales and clinical populations
(Ware et al., 2000). The general health item from the SF-36 was dichotomized (fair/poor
vs. good/very good/excellent health; Diehr & Patrick, 2003; Diehr, Patrick, McDonell, &
Fihn, 2003).
Depression. Women rated the frequency of depressive symptoms (0 = less than 1 day
per week to 3 = five or more days per week) using five questions from the Center for
Epidemiological Studies-Depression (CES-D) scale (Shrout & Yager, 1989). Scores for
each of the five items are summed; a score of four or greater (range: 015) indicates minor
depressive symptoms (Shrout & Yager, 1989), and a score of six or greater, severe depressive symptoms (Bonomi, Kernic, Anderson, Cannon, & Slesnick, 2008).
Physical Symptoms. Women indicated how bothered they were by 14 common physical
symptoms in the past 6 months (range: 1 = none of the time to 5 = all of the time; Robins,
Helzer, Croughan, & Ratcliff, 1981). The symptoms included joint pain, back pain, insomnia, fatigue, abdominal pain, severe headache, numb hands or feet, diarrhea, constipation,
shortness of breath, pain in jaw or ears, dizziness, nausea or vomiting, and chest pain. The
number of symptoms bothering respondents at least some of the time (a 3 on the 15
scale) was counted (Robins et al., 1981).
Health Care Utilization. We collected data on womens health care utilizationincluding any mental health, inpatient, outpatient, and emergency department visits; number of
visits to primary and specialty health care; and number of prescription fillsfrom January
1, 1992, to December 31, 2002, using Group Healths automated databases (Bonomi,
Anderson, et al., 2008; Rivara et al., 2007). Group Health databases precisely capture
health services provided by Group Health and other health care providers with whom
Group Health contracts (Boudreau, Doescher, Saver, Jackson, & Fishman, 2005).

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Cannon et al.

Intimate Partner Violence. Women were asked about exposure to physical, sexual, or
nonphysical IPV by a heterosexual or homosexual partner since age 18. As previously
described (Bonomi, Cannon, Anderson, Rivara, & Thompson, 2008), two well-validated
questionnaires were used to assess IPV exposure: five questions from the Behavioral Risk
Factor Surveillance System (BRFSS), which assessed exposure to physical, sexual, or
nonphysical abuse such as threats and chronic controlling behavior (Saltzman, Fanslow,
McMahon, & Shelley, 1999; Vest, Catlin, Chen, & Brownson, 2002); and 10 questions
from the Womens Experience with Battering Scale (WEB), which assessed the underlying
experience of fear and loss of power and control that may accompany exposure to abusive behavioral tactics (Smith, Earp, & DeVellis, 1995). Consistent with published scoring precedents, women who said they experienced any type of violence according to the
BRFSS questions or who had WEB scores that were 20 or higher (score range, 1060) were
considered positive for IPV (Bonomi et al., 2006; Thompson et al., 2006).

Child Abuse Exposures

Women were asked about their exposure to child physical abuse and child sexual abuse
using two questions from the BRFSS (Thompson et al., 2006). Women were also asked
whether they ever witnessed IPV between their parents or guardians and their spouses or
partners before age 18. For exact wording of these questions, see Table 1. Women who indicated they had experienced any of these abuse types were considered exposed to that
particular abuse type. From these questions, four exposure groups were constructed: (1) no
childhood exposures; (2) exposure to child abuse only; (3) witnessing IPV only; or (4) both
exposure to child abuse and witnessing IPV.

Statistical Analysis
Chi-square tests and analysis of variance (ANOVA) methods were used to compare the
demographic characteristics of women by child abuse exposure. Unadjusted means and
frequencies were estimated for each of the health indicators across abuse exposure groups.
For our multivariate analysis involving self-reported health outcomes: (1) generalized linear models with a log link were used to obtain prevalence ratios (PR) for each dichotomous
health outcome and for exposure to IPV in adulthood for exposed women compared with
unexposed women; and (2) ordinary least squares regression was used to estimate mean
TABLE 1.

Questions Assessing Childhood Exposure

Exposure

Question

Child physical abuse

Before you were 18, was there any time when you were
punched, kicked, choked, or received a more serious physical
punishment from a parent or other adult guardian?

Child sexual abuse

Before you were 18, did anyone ever touch you in a sexual
place or make you touch them when you did not want them
to?

Witness IPV as a child

As a child, did you ever see or hear one of your parents or

guardians being hit, slapped, punched, shoved, kicked, or
otherwise physically hurt by their spouse or partner?

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295

differences in SF-36 subscale and PCS and MCS scores. The multivariate models compare
the health of women with child abuse only (physical and/or sexual), witnessing IPV as a
child only, or child abuse and witnessing IPV to the health of women without these histories (reference group).
To compare annual health care utilization across the exposure groups, we used generalized estimating equations (GEE) with robust standard error estimates assuming an independent working correlation to account for correlation between multiple years of annual
health care utilization from the same woman. For binary outcomes assessing any use
of health services, GEE models with a log link were used to estimate relative risks (RR).
For counts of health care utilization (primary and specialty care visits and pharmacy fills),
regression models were used to estimate incident rate ratios (IRR).
The multivariate models were controlled for age and education. While both education
and income differed by exposure group, we chose to adjust for education as a representative measure of socioeconomic status because education was most strongly associated with
exposure group, and because there were more missing values for the household income
measure. We did not adjust for race/ethnicity since for nonbiologic outcomes, race/ethnicity associations are often due to confounding by socioeconomic status, and because
our sample did not afford a wide racial/ethnic distribution (82% White). As a sensitivity
analysis, we refit all models adjusting for age, education, income, and race. The main study
results were unchanged; therefore, we report the results of the primary data analysis.

RESULTS
Characteristics of Women
Forty percent (n = 1,434/3,568) of women reported exposure to child abuse and/or witnessing IPV before age 18; 23% (802/3,568) were exposed to child abuse only, 7% (265/3,568)
witnessed IPV only, and 10% (367/3,568) had an exposure to abuse and witnessing IPV before age 18. Some significant group differences emerged between the exposure groups and
the no exposures group for age, income, education, and race, and are denoted in Table 2.
Women in the child abuse only group (Mean = 46.7 years) and the combined exposures
group (Mean = 46.3 years) were older than women in the no exposures group (Mean = 44.6
years). Women in the witness IPV only group were more likely to have a lower household
income and to be a high school graduate or less than the no exposures group. Furthermore,
women in both the witness IPV only group and the combined exposures group were less
likely to be White than women in the no exposures group.

Multivariate Models of Self-Reported Adult Health

by Childhood Abuse Exposure
Table 3 reports mean SF-36 scores and frequencies of the dichotomous health indicators (prevalence of fair/poor health, depressive symptoms, and social connectedness) by
child abuse exposure. After adjustment for age and education, women with exposure to
child abuse and/or witnessing IPV had significantly lower SF-36 subscale and summary
scores compared with unexposed women, with the most pronounced differences reported
between unexposed women and women with exposure to both child abuse and witnessing IPV. Specifically, women with both exposures had SF-36 subscale scores ranging
from 3.49 points lower (emotional functioning) to 4.12 points lower (mental health) than

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TABLE 2.

Cannon et al.

Characteristics of Women at Time of Survey

No Childhood
Exposures

Childhood
Abuse Only

Witness
IPV Only

Childhood Abuse
and Witness IPV

N = 2,134

N = 802

N = 265

N = 367

46.7 (11.3)

44.7 (12.3)

46.3 (11.0)

Mean age at survey (SD) 44.6 (13.1)

Household income (%)
<$25,000

12.0

11.0

14.7

12.0

$25,000$49,999

26.5

29.3

33.3

26.0

$50,000$74,999

25.7

24.5

24.4

31.8

>$75,000

35.7

35.2

27.5

30.2

Employed at least part

time (%)

80.1

79.7

80.4

81.2

High school graduate

or less (%)

12.4

11.7

19.3

13.9

White (%)

83.3

84.1

74.6

76.3

Have children in the

home (%)

31.7

32.8

31.3

35.4

p < .05; comparison to no childhood exposure group.

p < .01; comparison to no childhood exposure group.

women with no childhood exposures. Moreover, women in the combined exposures group
had SF-36 summary scores ranging from 2.70 points lower (physical component) to 3.75
points lower (mental component) than women in the no exposure group. Women with
both exposures had 1.34 more symptoms and a higher body mass index (difference in
BMI = 1.94), and they were 1.76 times as likely to report fair/poor health, 1.96 times as
likely to report depressive symptoms, and 2.55 times as likely to report severe depressive
symptoms as women with neither exposure. Finally, women with both exposures were
1.55 times as likely to report that they did not trust people in their residential community.
In fact, for women in the combined exposures group, the only health indicator that was
not significantly different from women with no exposures was involvement in voluntary
groups.
The trends in the childhood abuse only group were similar to those in the combined
exposure group, but the point estimates were slightly attenuated. The estimates for these
two groups were not significantly different from each other, with the exception of the mean
number of symptoms reported by each group.
Women who witnessed IPV only during childhood had SF-36 subscale scores that were
lower than those for unexposed women (range: 1.90 points lower for mental health to 2.72
points lower for social functioning) and an MCS score that was, on average, 2.63 points
lower than women without either exposure. Furthermore, the witness IPV only group
reported 0.60 more symptoms and was 1.64 times as likely to report depressive symptoms
as the no exposures group.

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49.3 (10.2)
49.5 (9.5)
2.79 (2.40)

51.0 (8.4)
51.3 (8.7)
51.9 (8.5)

2.03 (2.11)
26.9 (6.3)

Social functioning

Physical component
summary
Mental component
summary
Number of symptoms*

Body mass index (kg/m2)

28.2 (7.4)

47.9 (10.2)

50.2 (9.1)

53.0 (8.1)

Mental health

49.7 (10.0)

52.4 (8.8)

Vitality

48.3 (8.8)

Mean (SD)

Mean (SD)

50.5 (7.5)

Childhood
Abuse Only
(N = 802)

No Childhood
Exposures
(N = 2,134)

27.7 (6.5)

2.71 (2.57)

49.2 (9.8)

50.0 (10.0)

48.1 (9.9)

51.0 (8.9)

49.8 (9.7)

48.4 (8.5)

Mean (SD)

Witness
IPV Only
(N = 265)

29.1 (8.1)

3.43 (2.80)

48.2 (10.8)

48.4 (10.1)

46.9 (10.4)

48.9 (10.9)

48.5 (10.0)

47.1 (9.6)

Mean (SD)

Childhood
Abuse and
Witness IPV
(N = 367)

2.31 (2.97,
1.65)
2.66 (3.42,
1.91)
2.89 (3.60,
2.19)
3.00 (3.75,
2.26)
1.72 (2.46,
0.97)
2.59 (3.32,
1.85)
0.71 (0.53,
0.89)
1.06 (0.52,
1.62)

B (95% CI)

Childhood
Abuse Only vs.
No Childhood
Exposures

Child Abuse Exposures

Self-Reported Health and Adult Exposure to IPV by Child Abuse Exposures

SF-36 subscale scores

Role emotional

TABLE 3.

2.01 (3.05,
0.97)
2.41 (3.60,
1.22)
1.90 (3.01,
0.79)
2.72 (3.89,
1.55)
1.07 (2.24,
0.10)
2.63 (3.78,
1.47)
0.60 (0.31,
0.89)
0.61 (0.25,
1.47)

B (95% CI)

Witness IPV
Only vs. No
Childhood
Exposures

(Continued)

3.49 (4.39,
2.58)
3.79 (4.82,
2.76)
4.12 (5.09,
3.16)
3.98 (5.00,
2.96)
2.70 (3.72,
1.69)
3.75 (4.76,
2.75)
1.34 (1.09,
1.59)
1.94 (1.19,
2.68)

B (95% CI)

Childhood
Abuse and
Witness IPV vs.
No Childhood
Exposures

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29.0
58.0

24.4
35.1

49.0

31.3

42.6

12.1

26.9

10.6

Witness
IPV Only
(N = 265)

67.3

36.5

43.6

21.0

31.1

13.1

Childhood
Abuse and
Witness IPV
(N = 367)

1.03 (0.91,
1.17)
1.26 (1.07,
1.47)
1.59 (1.42,
1.79)

1.55 (1.30,
1.85)
1.63 (1.28,
2.08)

1.37 (1.05,
1.80)

PR (95% CI)

Childhood
Abuse Only vs.
No Childhood
Exposures

Child Abuse Exposures

1.03 (0.84,
1.25)
1.24 (0.98,
1.56)
1.37 (1.13,
1.65)

1.64 (1.27,
2.12)
1.42 (0.97,
2.07)

1.39 (0.93,
2.08)

PR (95% CI)

Witness IPV
Only vs. No
Childhood
Exposures

1.08 (0.91,
1.28)
1.55 (1.28,
1.88)
1.84 (1.59,
2.12)

1.96 (1.58,
2.43)
2.55 (1.95,
3.34)

1.76 (1.27,
2.44)

PR (95% CI)

Childhood
Abuse and
Witness IPV vs.
No Childhood
Exposures

Note. Models adjusted for age and education.

*Symptoms included joint pain, back pain, insomnia, fatigue, abdominal pain, severe headache, numb hands or feet, diarrhea, constipation,
shortness of breath, pain in jaw or ears, dizziness, nausea or vomiting, and chest pain.

41.3

13.1

24.3

40.3

8.1

Severely depressed

Social connectedness
Not active in voluntary
groups
Do not trust people in
community
Exposure to IPV since
age 18

15.9

Depression, CES-D
Depressive symptoms

10.0

Childhood
Abuse Only
(N = 802)

No Childhood
Exposures
(N = 2,134)

7.0

(Continued)

General health
Fair/Poor

TABLE 3.

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299

Prevalence of IPV by Child Abuse Exposure Group

Table 3 also reports lifetime adult IPV prevalence (since age 18) by child abuse exposures.
After adjusting for age and education, women who were exposed to both child abuse and
witnessing IPV were 1.84 times as likely to report IPV victimization in adulthood compared to women with no exposures. Women who had exposure to child abuse only were
1.59 times more likely to report adult IPV, and women who had witnessed IPV only were
1.37 times more likely to report adult IPV than women with neither exposure.

Adjusted Annual Health Care Utilization

Table 4 reports health services utilization by child abuse exposures. Women contributed
an average of 7.4 women-years to the analysis (range 111). In models adjusted for age,
education, and calendar year, women with exposure to child abuse with or without witnessing IPV utilized significantly more health services than women with no exposures.
Specifically, women with exposures to both child abuse and witnessing IPV had higher
health services use across 4 areas: mental health (RR = 1.84; 95% CI = 1.512.23); emergency department (RR = 1.77; 95% CI = 1.432.18); primary care (RR = 1.17; 95% CI =
1.091.25); and pharmacy fills (RR = 1.26; 95% CI = 1.131.41).
The estimated increase in health care utilization for women in the child abuse only group
was similar to the combined exposures group, with the point estimates slightly attenuated
for women with child abuse only. However, women with exposure to child abuse only had
significantly higher health services use than women with no exposures in two additional
areas that were not significant for the combined exposures group: hospital outpatient (RR
= 1.21; 95% CI = 1.061.38); and specialty care (RR = 1.18; 95% CI = 1.091.28).
The witnessing IPV only group used more health services than the no exposure group in
two areas: emergency department (RR = 1.42, 95% CI = 1.101.85); and primary care (RR
= 1.09; 95% CI = 1.011.17).

DISCUSSION
This study is the first, to our knowledge, to examine the long-term effects of child abuse
and witnessing IPV before age 18 on multiple indicators of adult health status, substantiated by a range of objective health care utilization indicators, as well as the effects of these
adverse child abuse exposures on the relationship outcome of IPVusing a broad definition of IPV that includes physical, sexual, and nonphysical types of abuse. Results of this
study show clear, long-lasting, adverse health status, relationship, and health utilization
effects of child abuse exposure and witnessing IPV as a child.
In accordance with other studies (Dube et al., 2002) and as we had hypothesized, we did
find evidence for the effects of witnessing IPV only before age 18 on adult health status.
Though the differences for these women were fewer and less pronounced than for those
who had exposure to child abuse (in either the child abuse only or combined groups), it
is important to note that merely witnessing IPV during childhood can have adverse health
outcomes well into adulthood.
As we had predicted, childhood abuse (with or without exposure to witnessing IPV) was
associated with lower self-rated health in adulthood on multiple indicators. Other studies
have documented the adult health effects of child physical and/or sexual abuse experienced
before age 18 (Batten et al., 2004; Bensley et al., 2003; Bonomi, Cannon, et al., 2008;

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11.7 (15.0)

Pharmacy (no. of fills)

14.8 (18.8)

1.7 (3.0)

3.5 (3.4)

Mean (SD)

5.2

10.3

5.0

14.3

7.35 (3.69)

5,690

774

Childhood
Abuse Only

12.3 (14.6)

1.4 (2.6)

3.3 (3.0)

Mean (SD)

5.9

9.6

5.5

7.5

7.38 (3.67)

1,830

248

Witness
IPV Only

Note. Models adjusted for age, education, and calendar year.

1.4 (2.6)

4.0

ED

Specialty care (no. of

visits)

8.6

Hospital outpatient

2.9 (2.8)

4.7

Inpatient

Primary care (no. of

visits)

8.2

Mental health services

Mean (SD)

Any service utilization

Ambulatory services

7.43 (3.74)

14,532

Number of women-years

Follow-up time, mean

(SD)

1,957

Number of women

No
Childhood
Exposures

15.4 (18.7)

1.5 (2.6)

3.5 (3.2)

Mean (SD)

7.1

9.8

5.6

15.0

7.42 (3.62)

2,626

354

Childhood
Abuse and
Witness IPV

1.22 (1.12, 1.34)

1.18 (1.09, 1.28)

1.16 (1.10, 1.23)

IRR (95% CI)

1.32 (1.11, 1.57)

1.21 (1.06, 1.38)

1.08 (0.92, 1.26)

1.73 (1.48, 2.03)

RR (95% CI)

Childhood
Abuse Only vs.
No Childhood
Exposures

Child Abuse Exposures

TABLE 4. Adjusted Health Services Utilization by Child Abuse Exposures

1.01 (0.89, 1.15)

0.96 (0.84, 1.09)

1.09 (1.01, 1.17)

IRR (95% CI)

1.42 (1.10, 1.85)

1.11 (0.91, 1.37)

1.11 (0.84, 1.47)

0.93 (0.70, 1.24)

RR (95% CI)

Witness IPV
Only vs. No
Childhood
Exposures

1.26 (1.13, 1.41)

1.00 (0.95, 1.11)

1.17 (1.09, 1.25)

IRR (95% CI)

1.77 (1.43, 2.18)

1.14 (0.96, 1.36)

1.15 (0.94, 1.41)

1.84 (1.51, 2.23)

RR (95% CI)

Childhood Abuse
and Witness IPV
vs. No Childhood
Exposures

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Carlson et al., 2003; McCauley et al., 1997; Moeller et al., 1993; Nicolaidis et al., 2004;
Walker et al., 1999). While not significantly different from the child abuse only group,
the most pronounced differences in health status in our study were seen for women who
had exposure to both child abuse and witnessing IPV before age 18a finding in support
of both our hypothesis and of the graded association between multiple adverse events in
childhood and poor adult health (Bensley et al., 2003; Bonomi, Anderson, et al., 2008;
Bonomi, Cannon, et al., 2008; Dong, Anda, Dube, Giles, & Felitti, 2003; Dube et al., 2003;
Edwards et al., 2003; Felitti et al., 1998). Irving and Ferraro (2006) suggest that the detrimental health effects of multiple types of childhood abuse exposures accrue over time, thus
leading to poorer adult health than if exposed to only one adverse childhood experience
(Irving & Ferraro, 2006). Other researchers suggest that the amplified health effects that
result from multiple adverse childhood experiences are due to the exposure of the developing brain to the stress response, which thus impairs multiple brain structures and functions
(Bremner, 2003).
Two more recent studies found that childhood maltreatment experiences can exert powerful influences even on perceptions of well-being in adulthood. Namely, Edwards, Anda,
Felitti, and Shanta (2004) found that traumatic experiences during childhood affected adult
perceptions of health-related quality of life decades later. Corso, Edwards, Fang, and Mercy
(2008) found the same, but moreover, they reported that losses in health-related quality of
life were sustained; adults in their study who self-reported any form of childhood maltreatment had an average loss of 0.03 quality adjusted life years, or a loss of 11 days over
their remaining life expectancy.
Like other studies (Bensley et al., 2003; Thompson et al., 2006; Whitfield et al., 2003),
we found that women who had witnessed IPV only during childhood were more likely to
report adult IPV victimization than women with no abuse exposures. Also in support of
prior research, women with exposure to childhood abuse only also were more likely to
report IPV victimization (Bensley et al., 2003; Coid et al., 2001; Nicolaidis et al., 2004;
Thompson et al., 2006; Whitfield et al., 2003). Though we found similar health effects
across the exposure groups compared with nonabused women, women with both exposures
had the largest increased risk of adult IPV victimizationa finding that corroborates prior
research (Bensley et al., 2003; Whitfield et al., 2003).
Finally, concurrent with the extant literature (Chartier et al., 2007; Tang et al., 2006), we
found that women who had experienced child abuse had higher rates of health care utilization. To our knowledge, we are the first to report that women who had witnessed IPV during childhood (without the presence of child abuse) used more emergency department and
primary care services than women with no abuse exposure. As for women who experienced
both child abuse and witnessing IPV, we found that they also had higher rates of health care
utilization, a finding that supports existing research (Anda et al., 2008). However, we did
not find the most pronounced service use in women with both exposures, a finding that runs
contrary to the graded relationship that Anda et al. (2008) found between the number of
adverse childhood experiences and risk for number of classes of drugs used.
This study was not without limitations. First, our child abuse measurement approach
was limited. Specifically, we relied on self-reports of abuse and witnessing IPV before
age 18reliance on retrospective reports may lead to conservative findings because of
nondisclosed abuse (Widom, DuMont, & Czaja, 2007). However, self-reported abuse is an
extremely common method for gathering abuse exposure information. Moreover, because
our primary study was focused on IPV exposure after age 18, we did not ask about the full
range of child maltreatment (e.g., neglect, verbal abuse), nor the severity or frequency of

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Cannon et al.

the abuse types we investigated; it is therefore unclear to what extent or with what regularity women suffered physical and sexual abuse, as well as other types of abuse. Limitations
in our child abuse measurement approach preclude seamless comparison with other studies
whose assessment was more comprehensive (e.g., Felitti et al., 1998). In addition to child
abuse measurement limitations, study generalizability may be limited by the prevailing
characteristics of the sample; the sample was mostly employed, highly educated, White,
and entirely insured. Furthermore, combining childhood physical and sexual abuse into one
analytic group results in a loss of specificity, as the two types of abuse have been shown
to have differing impacts on health and health utilization (e.g., Bonomi, Anderson, et al.,
2008; Bonomi, Cannon, et al., 2008). However, the results of the current article can be
interpreted with the knowledge of these previous reports of health effects by child abuse
type. Lastly, our response rate was relatively low, but a propensity score analysis showed
that women with and without abuse histories were equally likely to participate in the telephone survey (Bonomi, Cannon, et al., 2008; Rivara et al., 2007).
Notwithstanding these limitations, the results of this study have important primary
and secondary prevention implications. Primary prevention efforts within the health care
system to provide support to parents with young children (including prenatal home visits; education about healthy discipline strategies; and skill building in problem solving,
anger management, communication, and relationships with adults) can significantly improve parenting skills, reduce parenting stress, improve the parental relationship, and
thus reduce the risk of child abuse and/or witnessing IPV and ensuing consequences, not
only for childrens adult health status, health care utilization, and social functioning but
also for the health of their relationships (Huebner, 2002; Johnston, Huebner, Anderson,
Tyll, & Thompson, 2006; Olds et al., 1997). Furthermore, screening adults within the
health care setting for child abuse exposures as part of a risk assessment for IPV may
help to primarily prevent negative relationship outcomes (Whitfield et al., 2003). Lastly,
screening adults for child abuse exposures and implementing subsequent individual and
group psychotherapeutic interventions can be an integral part of secondary prevention
of long-term health effects of adverse childhood experiences. Indeed, such interventions
have been shown to improve mental health, curb symptomalogy, and improve the quality
of life of adults with child abuse exposures (Kessler, White, & Nelson, 2003; Martsolf
& Draucker, 2005).

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Acknowledgments. This manuscript was developed with support from the Agency for Healthcare
Research and Quality and the Group Health Foundation. The authors thank the study interviewers for
interviewing thousands of women.
Correspondence regarding this article should be directed to Amy E. Bonomi, PhD, MPH, Human
Development and Family Science, The Ohio State University, 135 Campbell Hall, 1787 Neil Ave.,
Columbus, OH 43210. E-mail: bonomi.1@osu.edu

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