Child Abuse and Other Traumatic Experiences, Alcohol Use Disorders,
and Health Problems in Adolescence and Young Adulthood
Duncan B. Clark, MD, PHD, Dawn L. Thatcher, and Christopher S. Martin
Pittsburgh Adolescent Alcohol Research Center, University of Pittsburgh
objective health indicators and consideration of alcohol use disorders (AUD).
(n¼668) were recruited from clinical and community sources. At baseline, we examined child abuse and other
traumas, AUD, health-related symptoms, physical findings, and blood assays. Subjects were assigned to Trauma
Classes (TC), including witnessing violence, physical abuse, and sexual abuse. Health outcomes were again
determined at 1-year and young adult follow-up.Results
with more health-related symptoms, increased age-adjusted body mass index, and stress-response immune
system indices. In adolescence and young adulthood, the relationships between TC and health-related symp-
toms were mediated by anxiety. AUD was associated with liver injury, and cigarette smoking with heart/lung
symptoms. ConclusionsChild abuse predicted persistently elevated health-related symptoms primarily
attributable to anxiety, and early signs of liver disease were attributable to AUD.
We prospectively examined the health effects of child abuse and other traumatic events, with
In adolescence, higher TC severity was associated
Key words adolescents; alcohol use; child abuse; health.
Child abuse has been found to predict mental disorders,
substance-related problems, and health risk behaviors
(Gilbert et al., 2009). Retrospective studies with adults
have suggested that child abuse leads to major physical
health problems (Brown, Young, Anda, Felitti, & Giles,
2006). Child abuse has been systematically related
to diminished subjective health quality and obesity
(Thomas, Hypponen, & Power, 2008). With some specific
conditions excepted (e.g., sexually transmitted diseases:
Wilson & Widom, 2009); however, few prospective
studies have examined whether child abuse leads to phys-
ical health problems. In addition, consideration of the
relationship between child abuse and later substance use
disorders is important for understanding health outcomes.
A few studies have examined the relationship between
child maltreatment and global health status. Hussey and
colleagues (Hussey, Chang, & Kotch, 2006) studied a
large sample of adolescents who, when follow-up in
young adulthood, completed a retrospective child abuse
questionnaire. Child abuse reports were associated with
poorer subjective health quality in adolescence. Among
378 adolescent enrolled in addictions treatment (Stevens,
Murphy, & McKnight, 2003), PTSD-like symptoms were
positively associated with subjective health symptoms.
Among 1041 children at high risk for child abuse and
neglect (Flaherty et al., 2006), child maltreatment at age
4 years predicted poorer overall child health at age 6 as
well as an increased incidence of illnesses requiring
Child abuse has been associated with overweight
status in some studies. In the Hussey study (2006), phys-
ical abuse, but not sexual abuse, was found to be asso-
ciated with overweight status by BMI in late adolescence.
Among 782 community subjects (Johnson, Cohen, Kasen,
& Brook, 2002), childhood sexual abuse (n¼22) was not
associated with adolescent or young adulthood obesity.
In a prospective study of female children with sexual
abuse (n¼84) and a comparison sample (n¼102),
those with a sexual abuse history showed a more rapid
increase in BMI during adolescence and a higher obesity
rate in young adulthood (Noll, Zeller, Tricket, & Putnam,
2007). Among over 9,000 children followed to middle
adulthood (Thomas et al., 2008), physical abuse, but not
sexual abuse, predicted increased BMI and higher rates of
All correspondence concerning this article should be addressed to Duncan B. Clark, MD, PhD, Western Psychiatric
Institute and Clinic, 3811 O’Hara Street, Pittsburgh, PA 1521, USA. E-mail: email@example.com
Journal of Pediatric Psychology 35(5) pp. 499–510, 2010
Advance Access publication December 4, 2009
Journal of Pediatric Psychology vol. 35 no. 5 ? The Author 2009. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
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obesity in middle adulthood. In the latter study, child
abuse did not predict type 2 diabetes in middle adulthood.
Comorbid obesity, high blood pressure, lipid abnormal-
ities, increased blood glucose, and diabetes mellitus have
been termed ‘‘metabolic syndrome’’ (Steinberger et al.,
2009). Given a relationship between child abuse and obes-
ity, one might expect that child abuse would predict
elevations in other metabolic syndrome indicators. This
possibility has not been studied.
Stressors have been found to induce changes in
immune functioning, and immune system indicators may
be relevant to understanding child abuse and health. In the
laboratory, immunoglobulin increases have been demon-
strated in response to acute stressors (Endresen et al.,
1991). Immunoglobulin increases have also been observed
in response to natural stressors. In young adults, school
exams predicted increases in plasma immunoglobulins
IgM, IgG, and IgA (Glaser, Mehl, Penn, & Speicher,
1986). A study comparing 14 girls with sexual abuse and
13 control girls (De Bellis, Burke, Trickett, & Putnam,
1996) did not observe significant group differences on
levels have not been previously studied in association
with child abuse.
While individuals with child abuse have not been
reported to have diagnosed medical diseases in adoles-
cence and young adulthood, studies in later adulthood
have noted an association between child abuse and some
specific medical disease outcomes. Adults with child
maltreatment histories have been reported to show ele-
vated rates of liver disease, lung cancer and heart disease
(Dong, Dube, Felitti, Giles, & Anda, 2003; Dong et al.,
2004; Brown et al., 2006). These medical diseases may be
an indirect result of risky health behaviors, particularly
substance use disorders.
Childhood abuse has been found to be associated with
or to predict adolescent substance use disorders. Among
3,559 students in grades 7 through 12, Hamburger, Leeb,
and Swahn (2008) found that sexual abuse, physical
abuse, and witnessing violence were associated with
increased preteen alcohol use. Using data from the
National Longitudinal Study
(n¼12,748), Shin, Edwards, and Heeren (2009) found
physical abuse and sexual abuse were associated with
binge drinking. In a subset of the subjects described
here, sexual abuse, physical abuse, and other stressors
were more common among adolescents with AUD than
among control adolescents (Clark, Lesnick, & Hegedus,
1997a). Physical or sexual abuse accelerated the onset
of AUD and accounted for the relationship between AUD
and major depressive disorder (Clark, De Bellis, Lynch,
Cornelius, & Martin, 2003).
The adverse health consequences associated with
AUD, reflected by organ pathology and disease history,
have been more systematically studied in adults than
in adolescents. In adults, abnormalities found to be
caused by chronic alcohol dependence include elevated
liver injury indices (Allen, Fertig, Litten, Sillanaukee, &
Anton, 1997), elevated immunoglobulins (Mili, Flanders,
Boring, Annest, & DeStefano, 1992), elevated erythrocyte
mean cell volume (MCV) (Seppa, Sillanaukee & Koivula,
1992), and decreased electrolytes, such as calcium,
magnesium, phosphate, and potassium (Elisaf, Bairaktari,
Kalaizidia, & Siamopoulos, 1998). The medical records
of 417 adolescents with substance use disorders and
2082 demographically matched subjects, those with sub-
stance use disorders had more abdominal pain, sleep dis-
orders, and asthma (Mertens, Fisher, Fleming, & Weisner,
2007). In some of the subjects described here (Clark,
Lynch, Donovan, & Block, 2001), 128 adolescents with
AUD (compared with 131 controls) showed more
health-related symptoms (HS), laboratory tests indicating
liver injury, and some physical exam abnormalities. Thus,
some health problems reported by adolescents with
AUD have been verified by objective findings and may be
attributable to toxic alcohol effects on the liver and other
While adolescents with AUD evidence objective
indicators of some health problems, their subjective HS
seem disproportionately elevated. These HS may, to some
extent, reflect somatic anxiety symptoms (Ginsburg,
Riddle, & Davies, 2006). In prior reports on the present
sample (Clark et al., 1997b), adolescents with AUD were
observed to have elevated rates of anxiety disorders, includ-
ing PTSD. In our study of health problems among adoles-
cents with AUD (Clark et al., 2001), we found that an
index of negative emotionality was highly correlated with
HS, mediated the relationship between AUD and HS, and
was not correlated with serum liver enzyme levels or phys-
ical exam abnormalities. Among adult women (Lang et al.,
2008), child abuse was observed to lead to mental and
physical health difficulties through anxiety disorder symp-
toms. Child abuse may induce HS, at least in part, through
Prior research has had several shortcomings. In most
studies, the relationship between child abuse and
health outcomes has been determined exclusively with
cross-sectional or retrospective methods. In some studies,
decades have passed between recalled childhood events
and the adulthood assessment, amplifying the potential
for recall bias. The available studies on adolescents have
Clark, Thatcher, and Martin
for research on biochemical markers for problematic
drinking. Alcoholism: Clinical and Experimental
Research, 21, 244–247.
American Psychiatric Association. (1994). Diagnostic and
statistical manual of mental disorders (4th ed.).
Washington, DC: Author.
Arria, A. M., Dohey, M. A., Mezzich, A. C., Bukstein, O. G.,
& Van Thiel, D. H. (1995). Self-reported health
problems and physical symptomatology in adolescent
alcohol abusers. Journal of Adolescent Health, 16,
Baron, R.M., & Kenny, D.A. (1986). The mediator-
moderator variable distinction in considerations.
Journal of Personality and Social Psychology, 51,
Brown, D. W., Young, K. E., Anda, R. F., Felitti, V. J.,
& Giles, W. H. (2006). Re: Asthma and the risk of
lung cancer. Cancer Causes & Control, 17(3), 349–350.
Clark, D. B., De Bellis, M. D., Lynch, K. G., Cornelius, J.,
& Martin, C.S. (2003). Physical and sexual abuse,
depression and alcohol use disorders in adolescents.
Drug and Alcohol Dependence, 69, 51–60.
Clark, D. B., & Donovan, J. E. (1994). Reliability and
validity of the Hamilton Anxiety Rating Scale in an
adolescent sample. Journal of the American Academy of
Child and Adolescent Psychiatry, 33, 354–360.
Clark, D. B., Lesnick, L., & Hegedus, A. (1997a). Trauma
and other stressors in adolescent alcohol dependence
and abuse. Journal of the American Academy of Child
and Adolescent Psychiatry, 36(12), 1744–1751.
Clark, D. B., Lynch, K. G., Donovan, J. E., & Block, G. D.
(2001). Health problems in adolescents with alcohol
use disorders: Self-report, liver injury, and physical
examination findings and correlates. Alcoholism:
Clinical and Experimental Research, 25(9), 1350–1359.
Clark, D. B., Pollock, N., Bukstein, O. G., Mezzich, A. C.,
Bromberger, J. T., & Donovan, J. E. (1997b).
Gender and comorbid psychopathology in adolescents
with alcohol dependence. Journal of the American
Academy of Child and Adolescent Psychiatry, 36,
De Bellis, M.D., Burke, L., Trickett, P.K., & Putnam, F.W.
(1996). Antinuclear antibodies and thyroid function in
sexually abused girls. Journal of Traumatic Stress, 9(2),
Dong, M., Dube, S. R., Felitti, V. J., Giles, W. H.,
& Anda, R. F. (2003). Adverse childhood experiences
and self-reported liver disease. Archives of Internal
Medicine, 163(16), 1949–1956.
Dong, M., Giles, W. H., Felitti, V. J., Dube, S. R.,
Williams, J. E., Chapman, D. P., et al. (2004). Insights
into causal pathways for ischemic heart disease:
Adverse childhood experiences study. Circulation,
Dubowitz, H., & Bennett, S. (2007). Physical abuse and
neglect of children. Lancet, 369, 1891–1899.
Elisaf, M., Bairaktari, E., Kalaitzidia, R.,
& Siamopoulos, K. C. (1998). Hypomagnesemia in
alcoholic patients. Alcoholism: Clinical and
Experimental Research, 22, 134.
Endresen, I. M., Relling, G. B., Tonder, O., Myking, O.,
Walther, B. T., & Ursin, H. (1991). Brief uncontrol-
lable stress and psychological parameters influence
human plasma concentrations of IgM and comple-
ment component C3. Behavioral Medicine, 17(4),
Flaherty, E. G., Thompson, R., Litrownik, A. J.,
Theodore, A., English, D. J., Black, M. M., et al.
(2006). Effect of early childhood adversity on child
health. Archives of Pediatrics & Adolescent Medicine,
Gilbert, R., Widom, C. S., Browne, K., Fergusson, D.,
Webb, E., & Janson, S. (2009). Burden and conse-
quences of child maltreatment in high-income coun-
tries. Lancet, 373, 68–81.
Ginsburg, G.S., Riddle, M.A., & Davies, M. (2006).
Somatic symptoms in children and adolescents
with anxiety disorders. Journal of the American
Academy of Child and Adolescent Psychiatry, 45(10),
Glaser, R., Mehl, V. S., Penn, G., & Speicher, C. E. (1986).
Stress-associated changes in plasma immunoglobulin
levels. International Journal of Psychosomatics, 33(2),
Gonzalez–Quintela, A., Alende, R., Gude, F., Campos, J.,
Rey, J., Meijide, L. M., et al. (2007). Serum levels of
immunoglobulins (IgG, IgA, IgM) in a general adult
population and their relationship with alcohol
consumption, smoking and common metabolic
abnormalities. Clinical and Experimental Immunology,
Hamburger, M. E., Leeb, R. T., & Swahn, M. H. (2008).
Childhood maltreatment and early alcohol use among
high-risk adolescents. Journal of Studies on Alcohol and
Drugs, 69, 291–295.
Hamilton, M. (1959). The assessment of anxiety states by
rating. The British Journal of Medical Psychology, 32,
Hollingshead, A. B. (1975). Two Factor Index of Social
Status. New Haven, CT: Hollingshead.
Hong, S., Nelesen, R. A., Krohn, P. L., Mills, P. J.,
& Dimsdale, J. E. (2006). The association of social
Health Problems in Adolescents
status and blood pressure with markers of vascular
inflammation. Psychosomatic Medicine, 68, 517–523.
Hussey, J. M., Chang, J. J., & Kotch, J. B. (2006). Child
maltreatment in the United States: Prevalence, risk
factors, and adolescent health consequences.
Pediatrics, 118(3), 933–942.
Johnson, J. G., Cohen, P., Kasen, S., & Brook, J. S. (2002).
Childhood adversities associated with risk for eating
disorders or weight problems during adolescence or
early adulthood. The American Journal of Psychiatry,
Kauffman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C.,
Moreci, P., et al. (1997). Schedule for affective
disorders and schizophrenia for school-age children –
present and lifetime version (K-SADS-PL): Initial
reliability and validity data. Journal of the American
Academy of Child and Adolescent Psychiatry, 30,
Kessler, R. C., Pecora, P. J., Williams, J., Hiripi, E.,
O’Brien, K., English, D., et al. (2008). Effects of
enhanced foster care on the long-term physical and
mental health of foster care alumni. Archives of General
Psychiatry, 65(6), 625–633.
Lang, A. J., Aarons, G. A., Gearity, J., Laffaye, C., Satz, L.,
Dresselhaus, T. R., et al. (2008). Direct and indirect
links between childhood maltreatment, posttraumatic
stress disorder, and women’s health. Behavioral
Medicine, 33, 125–135.
MacKinnon, D. P., & Luecken, L. J. (2008). How and for
whom? Mediation and moderation in health psychol-
ogy. Health Psychology, 27(2s), s99–s100.
Martin, C. S., Pollock, N. K., Lynch, K. G.,
& Bukstein, O. G. (2000). Inter-rater reliability of the
SCID alcohol use disorders section among adoles-
cents. Drug and Alcohol Dependence, 59, 173–176.
Mertens, J. R., Fisher, A. F., Fleming, M. F.,
& Weisner, C. M. (2007). Medical conditions of
adolescents in alcohol and drug treatment:
Comparison with matched controls. Journal of
Adolescent Health, 40, 173–179.
Murali, R., & Chen, E. (2005). Exposure to violence and
cardiovascular and neuroendocrine measures in
adolescents. Annals of Behavioral Medicine, 30(2),
Mili, F., Flanders, W. D., Boring, J. R., Annest, J. L.,
& DeStefano, F. (1992). The associations of alcohol
drinking and drinking cessation to measures of the
immune system in middle-aged men. Alcoholism:
Clinical and Experimental Research, 16, 688–694.
Noll, J. G., Zeller, M. H., Trickett, P. K., & Putnam, P. W.
(2007). Obesity risk for female victims of childhood
sexual abuse: A prospective study. Pediatrics, 120(1),
Runyan, D. K., Cox, C. E., Dubowitz, H., Newton, R. R.,
Upadhyaya, M., Kotch, J. B., et al. (2005). Describing
maltreatment: Do child protective service reports and
research definitions agree? Child Abuse & Neglect, 29,
Seppa, K., Sillanaukee, P., & Koivula, T. (1992).
Abnormalities of hematologic parameters in heavy
drinkers and alcoholics. Alcoholism: Clinical and
Experimental Research, 16, 117–121.
Shin, S. H., Edwards, E. M., & Heeren, T. (2009). Child
abuse and neglect: Relations to adolescent binge
drinking in the national longitudinal study of
Adolescent Health (AddHealth) Study. Addictive
Behaviors, 34(3), 277–280.
Steinberger, J., Daniels, S. R., Eckel, R. H., Hayman, L.,
Lustig, R. H., McCrindle, B., et al. (2009). Progress
and challenges in metabolic syndrome in children and
adoelscents. Circulation, 119, 628–647.
Stevens, S. J., Murphy, B. S., & McKnight, K. (2003).
Traumatic stress and gender differences in relationship
to substance abuse, mental health, physical health,
and HIV risk behavior in a sample of adolescents
enrolled in drug treatment. Child Maltreatment, 8(1),
Thatcher, D. L., & Clark, D. B. (2006). Cardiovascular
disease risk factors in adolescents with alcohol use
disorders. International Journal of Adolescent Medicine
and Health, 18, 151–157.
Thomas, C., Hypponen, E., & Power, C. (2008).
Obesity and type 2 diabetes risk in midadult life:
The role of childhood adversity. Pediatrics, 121,
Wilson, H. W., & Widom, C. S. (2009). Sexually trans-
mitted diseases among adults who had been abused
and neglected as children: A 30-year prospective
study. American Journal of Public Health, 99s,
Clark, Thatcher, and Martin