Childhood abuse is not only a case of bruises and broken bones: The role of abuse in unexplained gastrointestinal symptoms in children

Introduction

Childhood abuse is common. In the United States about 6 million children are reported to Child Protective Services (CPS) each year or 46 cases per 1000 children. Furthermore, for every child that CPS identifies as abused or neglected, 3– 40 cases go unreported (1,2). In Europe, statistics are similar. For example, the Netherlands has 30 cases per 1000 children or more than 100,000 CPS referrals a year (3). In about 1/5 of all cases medical personnel refers the family to CPS usually due to childhood abuse related injuries (4). However, childhood abuse has negative sequelae for health beyond broken bones and bruises. Long-term ill-health is twice as common in adults with a history of childhood abuse compared to their peers (5). Long-term health problems seem to be non-specific including neurological, musculoskeletal, respiratory, cardiovascular and gastrointestinal problems (5). Some of these problems are obvious long-term consequences and may reflect poor self-care behaviors among survivors. For example, heart disease does not tend to develop until midlife or later for most people and may be caused by poor eating habits, lack of exercise or smoking, arguably in part due to the psychological distress associated with abuse. Other health problems observed in adulthood survivors of childhood abuse, are common in children as well such as chronic pain. Unfortunately, few studies in children have looked at the immediate health consequences of abuse, but those who do find abuse to be associated with poor health(6).

Childhood abuse and functional gastrointestinal disorders

One of the most widely studied health effects of childhood abuse is adult functional gastrointestinal disorders (FGID). The association between adult FGIDs and childhood abuse is so robust that some experts have recommended screening for childhood abuse in all FGID patients, specifically those with abdominal pain (7). However, studies in children are lacking despite the high prevalence of FGIDs in childhood. If an FGID diagnosis in children is an indicator of possible abuse, this is of utmost importance to know as children may still be in the abusive relation.

Our group conducted the first study to link abuse to childhood gastrointestinal symptoms without a known cause (8). The study collected Child Protective Services (CPS) allegations of abuse and parental reports of unexplained abdominal pain, nausea and vomiting at 2 year intervals over the child's life (starting at the age of 4 or 6) as well as self-reports of abuse and gastrointestinal symptoms at age 12. We observed that children who had at least one CPS sexual abuse allegation were more likely to suffer from unexplained abdominal pain. In fact, two-thirds of youth who had a history of sexual abuse suffered from unexplained abdominal pain. CPS reported sexual abuse preceded or coincided with first time symptom report in over 90% of cases, indicating that abuse may influence symptom reports rather than symptoms increasing the chances of being abused. In addition, self reported history of sexual, physical, or psychological abuse increased the likelihood of suffering from unexplained abdominal pain and nausea/vomiting. It makes perfect sense that the abuse that is remembered has a larger impact on health than official reports from CPS. The attributable risk percentage of all abuse was close to 22% which means that 1/5 of symptomatic children would not suffer from abdominal pain if no abuse occurred. Although no screening for FGID was performed in the study, the results suggest that children, similar to adults, who present with pain-related FGID may be at increased risk of having suffered some form of abuse.

Currently it is not completely clear why children who have been abused are at increased risk of FGIDs in childhood or adulthood. It has been proposed that abuse may prime the child to become hyper-responsive to stress. Abuse is associated with increased reactivity of the HPA axis, indicating hyper-arousal of the stress response (7) which can manifest itself in increased colonic functioning and visceral hypersensitivity-two hallmark causes of FGIDs. We found that psychological distress largely mediated the relation between abuse and gastrointestinal symptoms (8). In addition, there is evidence for synergistic effects of abuse and FGID on lasting changes to the cortico-limbic pain systems in the brain which activates feelings of anxiety and hypervigilance to symptoms. Thus, changes in both the brain and the HPA axis may explain the association between abuse and FGID (7).

Given the large literature linking childhood abuse to FGID in adults (7), as well as our recent findings that abuse may also be associated with childhood symptoms, screening for abuse in patients with unexplained gastrointestinal symptoms seems warranted. Although about half of general pediatricians acknowledge treating a child who has been abused in the past year (9), most physicians do not routinely ask about abuse history (<6%) (10). Informal discussions with many specialists in motility brought to light that almost no cases of child abuse were seen among FGID patients. This shows that many pediatricians are not comfortable asking about abuse without an obvious outward injury such as bruises and broken bones. Despite the completely healthy outward appearance of many FGID patients, child abuse should be on the radar of the pediatrician, especially if other risk factors exist. The American Academy of Pediatrics identified the following risk factors for abuse (11): (1) Children with emotional, behavioral, or health issues including disabilities, (2) Preterm birth, and unwanted or unplanned children, (3) Reduced parental capacity to deal with stress due to: low self-esteem, substance/ alcohol abuse, young maternal/paternal age, isolation, low levels of social support, poverty, unemployment, single parenting, parental depression, or parental history of abuse, (4) Parental negative view of themselves or their children, (5) Parental lack of knowledge about child-rearing, and (6) child shares residence with non-biologically related male (e.g., stepfather). It is not known whether any of these risk factors predict a history of abuse in children with FGIDs; but in lieu of better methods, they may provide guidance to screen for childhood abuse at least in families with one or more of these risk factors.

Conclusion

Screening for childhood abuse in FGID patients is obviously beneficial as it may identify children who are in an abusive situation. But even if childhood abuse is identified and stopped, the child will be changed forever. Many survivors learn to transcend their negative experiences, leading happy and productive lives and sometimes even giving a voice to other unidentified victims. But others may not fare as well and are at increased risk of mental and health problems. Thus, identification is necessary not only to stop current abuse, but also to treat the psychological sequelae of abuse and to prevent long-term negative consequences including pain.