St Georges Hospital Medical School, London, and UK & Coventry Primary Care Trust, Coventry
St Georges Hospital Medical School, London, UK
Correspondence: Ms Heather Sequeira, Department of Psychiatry of Disability, Jenner Wing, Cranmer Terrace, London SW17 0RE, UK. E-mail: heathersequeira{at}onetel.net.uk
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ABSTRACT |
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Aims To identify symptoms of psychological disturbance in adults with and without a confirmed history of sexual abuse.
Method The study used a matched (1:1) casecontrol design comparing 54 adults who had experienced sexual abuse with 54 adults with no reported history of abuse. The two groups were selected from a community population of adults with learning disabilities living in residential care, and compared for selected psychiatric diagnoses and for scores on measures of disturbed behaviour.
Results Sexual abuse was associated with increased rates of mental illness and behavioural problems, and with symptoms of post-traumatic stress. Psychological reactions to abuse were similar to those observed in the general population, but with the addition of stereotypical behaviour.The more serious the abuse, the more severe the symptoms that were reported.
Conclusions The study provides the first evidence from a controlled study that sexual abuse is associated with a higher incidence of psychiatric and behavioural disorder in people with learning disabilities.
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INTRODUCTION |
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This study investigates the hypothesis that adults with learning disabilities who have experienced sexual abuse will exhibit higher levels of behavioural and mental psychiatric difficulties than a matched comparison group who are not known to have experienced sexual abuse. The relationship between the nature of the abuse and subsequent symptoms is also examined.
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METHOD |
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Assignment to study groups
The sexual abuse sample comprised individuals for whom the occurrence of
sexual abuse was proved, highly probable or probable, as defined by Brown
& Turk (1992). Hereafter,
proved, highly probable and probable abuse are referred to simply as abuse.
Cases where the standard of evidence indicated possible sexual abuse or abuse
of unknown status were excluded. The matched comparison group comprised
individuals for whom there was no evidence or suspicion that sexual abuse had
ever occurred.
Matching criteria
Participants were assigned to the sexual abuse sample on the evidence of
the occurrence of abuse and were provisionally matched with non-abused
comparison participants for gender, degree of learning disability, age (within
a 5-year age band) and communication ability. The validity of data used for
matching was confirmed when participants were interviewed. The degree of
learning disability was established using the Wechsler Abbreviated Scale of
Intelligence (WASI; Wechsler,
1999) or the Wechsler Adult Intelligence Scale Revised
(WAISR; Wechsler,
1981), and communication ability was confirmed by talking with the
individual and support staff. Details of the matched and unmatched
characteristics of the groups are shown in
Table 1.
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Measures
Respondent and informant measures (see below) were completed during
interviews with keyworkers and clients (where the degree of learning
disability permitted). The ratings of abuse were made independently of ratings
of psychopathological symptoms and challenging behaviour. However, the mental
health assessor was not masked to the group membership.
Behaviour
The Aberrant Behavior Checklist Community (ABCC;
Aman et al, 1995) is
an informant-based measure of challenging behaviour. It consists of five
sub-scales: I, irritability, agitation, crying; II, lethargy, social
withdrawal; III, stereotypical behaviour; IV, hyperactivity, non-compliance;
and V, inappropriate speech. Reliability and validity data are well
established (e.g. Aman et al,
1987).
As the ABCC does not include items related to sexual behaviour, the sexual behaviour domain from the Adaptive Behavior Scale Residential and Community (ABSRC; Nihira et al, 1993) was used in addition.
Mental health problems
ICD10 diagnosis. The Psychiatric Assessment Schedule for
Adults with Developmental Disabilities (PASADD;
Moss et al, 1997) is
a semi-structured present-state interview designed to establish whether
individuals with learning disabilities fulfil criteria for a specified
ICD10 diagnosis (World Health
Organization, 1992). It consists of both respondent and informant
interviews which can be processed separately or together. In our study, when
participants could give a valid interview (28 in the abuse group
and 36 in the comparison group), the two interviews were processed together to
provide more complete diagnostic information. If the participant had severe
learning disabilities, poor linguistic ability or gave inconsistent or
insufficient information in response to PASADD questions, the informant
interview was used alone. Although the abuse and comparison groups were
matched on language ability, fewer of those in the abuse group gave full
responses in the PASADD interview. The implication of this is that
psychiatric disorder may be underdiagnosed, particularly in those who have
been abused. Some ICD10 disorders, for example anxiety disorders
(F4041), require evidence of autonomic features that might not be
noticeable to informants and therefore would not have been identified in
participants from informant interviews alone.
Symptom type scores. The PASADD also provides symptom type scores (i.e. symptom constellations); neurotic, depressive and total symptom type scores were analysed to give a measure of severity of depressive and anxiety symptoms and general psychiatric disturbance.
Post-traumatic symptoms
Clinical symptoms of post-traumatic stress disorder (PTSD) were assessed
using the PTSD Check List for Children/Parent Report (PCLC/PR;
Ford et al, 1999). A
key informant rates the extent to which, during the past month, an individual
has presented with each of the 17 DSMIV clinical PTSD symptoms
(DSMIV diagnosis of PTSD requires at least one re-experiencing symptom
out of five, at least three avoidance and psychic numbing symptoms out of
seven, and at least two hyperarousal symptoms out of five:
American Psychiatric Association,
1994). A score of 3 on any item indicates the presence of a
clinical-level symptom. Total scores on the instrument can also be
calculated.
Statistical analysis
Non-parametric statistics (Wilcoxon signed ranks test for comparisons
between matched groups; MannWhitney U test for comparisons
between independent subgroups; 2 for proportions and
Spearmans
for correlations) were used for all analyses as the
data were not normally distributed. The computer package SYSTAT 9 was used to
calculate statistics.
Significance levels and multiple testing
The significance level was set at 0.05. In the comparisons between the
abused and comparison samples, Bonferronis correction was applied when
multiple tests were used. However, the Bonferroni correction was not applied
when examining the variations related to abuse within the abused group, as
these were principally explorative analyses.
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RESULTS |
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Characteristics of the alleged perpetrator
Of the 54 cases of known abuse, 48 individuals (89%) were reported to have
been abused by males, 3 (5.5%) by females and 3 (5.5%) by both males and
females (2=75.0; P<0.001). Thirty-four (63%)
individuals were known to have experienced extrafamilial abuse and 20 (37%)
had experienced intrafamilial abuse. None was known to have experienced both
intrafamilial and extrafamilial abuse
(Table 4).
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Post-abuse events
Following the abuse, 33 (61%) individuals received no formal psychological
therapy; 21 individuals (39%) did receive therapy from a qualified
professional (psychologist, qualified psychotherapist/counsellor). In eight
cases the abuse led to a successful court conviction.
Characteristics of disturbance following abuse
Challenging behaviour
Table 5 presents the median
scores of the abused and comparison groups on the ABCC. Score on
sub-scales IIV (irritability, lethargy, stereotypical behaviour and
hyperactivity) were significantly higher in the abused group. There was no
group difference on sub-scale IV (inappropriate speech). In addition, a
significantly higher proportion of the abused group were reported to have
engaged in self-injurious behaviour during the previous 4 weeks, as measured
by items 50 (deliberately hurts self) and 52 (does physical violence to self)
on the ABCC: abused group n=24, comparison group
n=11; 2=8.167, P=0.004.
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Sexualised behaviour
The median scores for the ABSRC sexual behaviour domain were
significantly higher in the abused group (2.50) than in the comparison group
(1.0; Z=3.217, P=0.001). A small minority
(n=3) in both groups were reported to have been overaggressive
sexually in the past 4 weeks (from item 25 on the ABSRC) and although
more of those in the abused sample were reported to engage in inappropriate
masturbation (14 compared with 5 controls, 2=5.173), the
difference was non-significant after the Bonferroni correction was applied
(P=0.023, adjusted probability level 0.0166).
Mental health problems
When all categories of diagnosis assessed by the PASADD were
combined, the proportion meeting diagnostic criteria for any psychiatric
diagnosis was significantly higher in the abused group (6 depression, 5
hypersomnia, 1 panic disorder) compared with the control group (2 depression,
0 hypersomnia, 1 specific phobia). This finding remained significant
(P=<0.0125) after the Bonferroni adjustment had been applied.
However, there was no significant difference for any single diagnosis.
Median scores for depression, neurotic and total symptom type scores on the PASADD interview were found to be significantly higher in the abused group compared with the matched controls (Table 6).
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Post-traumatic symptoms
On the informant form of the PCLC/PR, 19 of the 54 abused
individuals demonstrated symptoms consistent with a DSMIV diagnosis of
PTSD. Only two people in the comparison group met these criteria for PTSD.
Participants in the abused group also rated significantly higher on clinical
symptoms of PTSD (PCLC/PR total score: abused group median 36.0, range
1899; comparison group median 20, range 1746;
Z=5172, P<0.0001).
Variables related to abuse
Time elapsed since abuse
No significant correlation was found between the time elapsed since the
last known abuse and the score on any of the measures used.
Severity and rate of abuse
Significant positive correlations were found between the severity of the
abusive acts experienced (1 touch only, 2 masturbation, 3 oral sex, 4
penetration) and the severity of symptoms on the ABC sub-scales of
irritability and hyperactivity, and the PASADD scores for depression
symptoms and neurotic symptoms and the total symptom score
(Table 7). No significant
relationship was found with PTSD symptoms.
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Rate of abuse was significantly related to the PASADD total score for mental health symptoms: this was significantly higher for those abused more than once (median 22) compared with those abused only once (median 15; P=0.042). The PASADD depression score was also significantly higher for those abused on two or more occasions (median 10) compared with those abused only once (median 4; P=0.024). No significant relationship was found between rate of abuse and PTSD symptoms.
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DISCUSSION |
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Although total ratings of inappropriate sexual behaviour on the ABSRC were significantly higher in the abused group, there was no group difference in specific behaviours such as sexually aggressive behaviour or inappropriate masturbation.
Stereotypical behaviour
The main difference in symptoms found in the abused group compared with
non-intellectually disabled samples was the presence of stereotypical
behaviour (repetitive rocking and odd or bizarre behaviours). These symptoms
have not typically been reported as sequelae of abuse in other studies.
However, increases in stereotyped behaviours have been reported in studies of
individuals with learning disabilities who have been bereaved
(Hollins & Esterhuyzen,
1997; Bonell-Pascual et
al, 1999), and therefore the increase may not be specific to
those who have been abused. Cognitive, emotional and developmental factors
associated with learning disabilities may affect the presentation of
psychopathological disorder in people with learning disabilities and may
mediate responses to both sexual trauma and bereavement.
Mental health problems
The proportion of individuals meeting diagnostic criteria for the
psychiatric diagnoses assessed in this study by the PASADD (depression,
anxiety disorders and hypersomnia) was significantly higher in the abused
group. This indicates support for the hypothesis that the overall incidence of
ICD10 psychiatric disorder is higher in people who have been abused. In
addition, the proportion of individuals presenting with the constellation of
symptoms consistent with DSMIV diagnostic criteria for PTSD was
significantly higher in the abused group. No group difference in the
proportions of individuals fulfilling ICD10 criteria for depression
(F32), anxiety disorders (F4041) or hypersomnia (F51.1) was found when
each diagnosis was considered independently. However, significant differences
were found between the two groups for severity of depression and anxiety
symptoms (PASADD symptom type scores). This finding indicates that
although abused individuals may not fulfil ICD10 criteria for specific
diagnoses, they are nevertheless presenting with higher levels of depressive
and neurotic symptoms compared with a non-abused comparison group.
In many ways the symptom profiles reported for abused adults without learning disabilities are similar to those found among the learning-disabled sample studied here, evidenced by the findings of a higher incidence of psychiatric disorder (Silverman et al, 1996), PTSD (Kilpatrick et al, 1987), depressive symptoms (Diaz et al, 2002) and anxiety (Nelson et al, 2002).
Variables related to abuse
Time elapsed since abuse
Studies of child abuse in the general population have reported inconsistent
results regarding the relationship between time since abuse and level of
psychological disturbance. Many studies (e.g.
Mannarino & Cohen, 1986)
have reported a decrease in PTSD symptoms over time. However, Calam et
al (1998) found a
substantial increase over time in levels of anxiety, depression, lack of
interaction with peers and sexualised behaviour in sexually abused children.
Our study of people with learning disabilities found no significant
correlation between the time elapsed since last known abuse and score on any
of the measures used. One possible explanation for the variation of results
reported may be a disparity in the availability of psychotherapy and
psychological service provision for different populations. The validity of
talking treatments for people with learning disabilities is only now gaining
recognition (e.g. Hollins & Sinason,
2000; Sinason,
2002), and it is important to note that the majority of the people
in the abused sample in our study had not received any psychological or
psychotherapeutic intervention following sexual abuse.
Severity of abuse
More severe forms of abuse (e.g. involving penetration) were associated
with greater severity of disturbance. This finding is also reported in studies
of child abuse in the general population (e.g.
Rodriguez et al,
1996). In addition, the finding from our study that repeated
occurrence of abuse is associated with increased severity of disturbance has
also been reported in studies in the general population (e.g.
Rodriguez et al,
1996).
Scientific method and reliability
Although the retrospective casecontrol design of the study is
appropriate to address the hypothesis considered, it does not detect causal or
temporal relationships between abuse and psychological disturbance. Although
the study found that individuals who had been abused presented with more
disturbance than those who had not, it may be that abuse is simply a marker
for a more turbulent background, or that disturbed behaviour might increase
the likelihood of sexual abuse occurring: for example, some behaviours may
place individuals in highrisk situations, and other characteristics may make
them more vulnerable to potential abusers. Longitudinal studies are needed to
detect any causal relationship.
It is important to be aware of potential bias when evaluating the findings of any study. In this study the following possible sources of bias are identified. First, the samples were selected from residential services. It may therefore be questioned whether the findings generalise to people with learning disabilities who live independently, with their family of origin or in secure psychiatric settings. Second, people with psychological symptoms may be more inclined to attribute their symptoms to abusive experiences or may be more likely to report abusive experiences. These points have not been addressed in this paper and perhaps warrant further study in the general population and intellectually disabled groups. Third, neither informants nor respondents were masked to the general purpose of the study (although they were not aware of the specific hypotheses being tested). It could therefore be argued that participants exaggerated the reporting of disturbance in the abuse group to please the assessor. Although the extent of this bias cannot be established, there is some indication that it is only limited, from the failure to find a significant difference between the abused and comparison groups on the variable inappropriate speech (from the ABCC). Had participants been tending to exaggerate the level of psychological disturbance they could be expected to report an increase in difficulties in all the areas examined, rather than just those identified as related to sexual abuse. It should be acknowledged that this source of potential bias is also a difficulty in much of the literature looking at the effects of sexual abuse in other populations.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication January 9, 2003. Revision received June 6, 2003. Accepted for publication June 19, 2003.
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