Adulthood Stressors, History of Childhood Adversity, and Risk of Perpetration of Intimate Partner Violence

Article (PDF Available)inAmerican journal of preventive medicine 40(2):128-38 · February 2011with37 Reads
DOI: 10.1016/j.amepre.2010.10.016 · Source: PubMed
Abstract
More than half a million U.S. women and more than 100,000 men are treated for injuries from intimate partner violence (IPV) annually, making IPV perpetration a major public health problem. However, little is known about causes of perpetration across the life course. This paper examines the role of "stress sensitization," whereby adult stressors increase risk for IPV perpetration most strongly in people with a history of childhood adversity. The study investigated a possible interaction effect between adulthood stressors and childhood adversities in risk of IPV perpetration, specifically, whether the difference in risk of IPV perpetration associated with past-year stressors varied by history of exposure to childhood adversity. Analyses were conducted in 2010 using de-identified data from 34,653 U.S. adults from the 2004-2005 follow-up wave of the National Epidemiologic Survey on Alcohol and Related Conditions. There was a significant stress sensitization effect. For men with high-level childhood adversity, past-year stressors were associated with an 8.8 percentage point (pp) increased risk of perpetrating compared to a 2.3 pp increased risk among men with low-level adversity. Women with high-level childhood adversity had a 14.3 pp increased risk compared with a 2.5 pp increased risk in the low-level adversity group. Individuals with recent stressors and histories of childhood adversity are at particularly elevated risk of IPV perpetration; therefore, prevention efforts should target this population. Treatment programs for IPV perpetrators, which have not been effective in reducing risk of perpetrating, may benefit from further investigating the role of stress and stress reactivity in perpetration.
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Adulthood Stressors, History of Childhood
Adversity, and Risk of Perpetration
of Intimate Partner Violence
Andrea L. Roberts, PhD, Katie A. McLaughlin, PhD, Kerith J. Conron, ScD,
Karestan C. Koenen, PhD
Background: More than half a million U.S. women and more than 100,000 men are treated for
injuries from intimate partner violence (IPV) annually, making IPV perpetration a major public
health problem. However, little is known about causes of perpetration across the life course.
Purpose: This paper examines the role of “stress sensitization,” whereby adult stressors increase
risk for IPV perpetration most strongly in people with a history of childhood adversity.
Methods: The study investigated a possible interaction effect between adulthood stressors and
childhood adversities in risk of IPV perpetration, specifıcally, whether the difference in risk of
IPV perpetration associated with past-year stressors varied by history of exposure to childhood
adversity. Analyses were conducted in 2010 using de-identifıed data from 34,653 U.S. adults
from the 2004 –2005 follow-up wave of the National Epidemiologic Survey on Alcohol and
Related Conditions.
Results: There was a signifıcant stress sensitization effect. For men with high-level childhood
adversity, past-year stressors were associated with an 8.8 percentage point (pp) increased risk of
perpetrating compared to a 2.3 pp increased risk among men with low-level adversity. Women with
high-level childhood adversity had a 14.3 pp increased risk compared with a 2.5 pp increased risk in
the low-level adversity group.
Conclusions: Individuals with recent stressors and histories of childhood adversity are at
particularly elevated risk of IPV perpetration; therefore, prevention efforts should target this
population. Treatment programs for IPV perpetrators, which have not been effective in reducing
risk of perpetrating, may benefıt from further investigating the role of stress and stress reactivity
in perpetration.
(Am J Prev Med 2011;40(2):128 –138) © 2011 American Journal of Preventive Medicine
I
ntimate partner violence (IPV) is a consequential
public health problem, with more than half a mil-
lion women and more than 100,000 men requiring
medical treatment for injuries sustained from IPV in
the U.S. annually.
1
Victimization is associated with
substantial physical and mental illness, including in-
jury, asthma, chronic pain, sexually transmitted infec-
tions, depression, suicidality, post-traumatic stress
disorder, and death.
2–7
A comprehensive understand-
ing of the etiology of IPV perpetration is critical to
inform prevention efforts.
Considerable evidence links IPV perpetration in
adulthood with childhood adversity, especially expo-
sure to violence, including physical abuse
8–11
and wit-
nessing IPV.
12–14
Although several theories explain
how exposure to childhood adversities increases risk of
IPV perpetration in adulthood,
12,14–18
the theory of
“stress sensitization,” whereby adverse childhood events
physiologically and psychologically sensitize individuals
to hyper-reactivity to later stressors, has not been
examined.
Heightened reactivity to stress is a potential mecha-
nism linking childhood adversities with IPV perpetra-
tion. Evidence indicates that childhood adversities in-
crease vulnerability to subsequent stress, through
From the Department of Society, Human Development, and Health (Rob-
erts, McLaughlin, Conron, Koenen), Harvard School of Public Health;
Department of Epidemiology (Koenen), Harvard School of Public Health;
Institute on Urban Health Research, Northeastern University (Conron),
Boston; Harvard Center on the Developing Child, Harvard University
(Koenen), Cambridge, Massachusetts
Address correspondence to: Andrea L. Roberts, PhD, Harvard School of
Public Health, Kresge Room 911, 677 Huntington Avenue, Boston MA
02115. E-mail: aroberts@hsph.harvard.edu.
0749-3797/$17.00
doi: 10.1016/j.amepre.2010.10.016
128 Am J Prev Med 2011;40(2):128–138 © 2011 American Journal of Preventive Medicine Published by Elsevier Inc.
Author's personal copy
sensitization of the central nervous system,
19
dysregu-
lation of the hypothalamic–pituitary–adrenal axis,
20,21
and effects on the prefrontal cortex that have an impact
on the threat-appraisal response system,
22
thereby in-
creasing liability to mood and anxiety disorders fol-
lowing adult stressful life events.
23–26
Childhood ad-
versities also are associated with increased negative
emotional reactivity to daily life stressors, reactivity
that persists into adulthood.
27,28
Although to date
stress sensitization effects have been examined almost
entirely in relation to mood and anxiety disorders, the
heightened emotional reactivity associated with child-
hood adversities may also increase risk of IPV perpe-
tration following adulthood stressors. Several stud-
ies
29–34
have found an association between stressful
events in adulthood and IPV perpetration, although
most have been clinic or convenience samples, or re-
stricted to specifıc ages.
This paper tests a stress sensitization model of IPV
perpetration by testing whether there is an interaction
between childhood adversities and past-year stressful life
events in increasing risk of IPV perpetration in the Na-
tional Epidemiologic Survey on Alcohol and Related
Conditions (NESARC), a large, nationally representative
survey of U.S. adults.
Methods
Data
The NESARC used a multistage sampling design that yielded a
representative sample of the civilian, non-institutionalized pop-
ulation aged 18 years residing in the U.S. at Wave 1 in 2001–
2002 (81% response).
35,36
The present 2010 study uses data
primarily from the Wave-2 follow-up interview (n34,653, re-
sponse rate, 86.7%; cumulative response, 70.2%),
36
conducted
in 2004–2005, which assessed IPV perpetration, childhood ad-
versities, and past-year stressors. For respondents present in
Wave 2, data from Wave 1 regarding childhood family struc-
ture, which was not assessed at Wave 2, are included. Informa-
tion about the population and sample frame has been published
elsewhere.
35
Measures
Perpetration of intimate partner violence. Respondents who were
married or in a romantic relationship in the past year were asked about
use of physical force with their partner. Six questions from the Conflict
Tactics Scales,
37
which have been validated in general population sam-
ples,
38
asked about respondents’ use of force with their partners and their
partners’ use of force with them in the past year. Respondents were
coded as perpetrators if they had (1) pushed, grabbed, or shoved;
(2) slapped, kicked, bitten, or punched; (3) threatened with a weap-
on; (4) cut or bruised; (5) forced sex; or (6) injured their partner
enough to require medical care.
38,39
Respondents were considered
to have perpetrated serious IPV if they had pushed, grabbed, or
shoved their partner once a month or more often, or had slapped,
kicked, bitten, or punched their partner more than once, or ever
had threatened with a weapon, cut or bruised, forced sex, or injured
enough to require medical care.
39
IPV victimization was coded
from responses about respondents’ partners’ use of force with
them.
Although perpetration was assessed only in respondents in a
past-year relationship, all respondents were included in the analy-
ses in case the likelihood of being in a relationship was influenced
by adversities or stressors. However, to facilitate comparisons with
other studies, the present study reports prevalence of perpetration
among respondents in a relationship.
Childhood Adversities Before Age 18 Years
Abuse and neglect. Physical abuse was defıned by frequency
of caregivers pushing, hitting, or bruising the respondent.
37
Respondents in the highest 10% were scored “high,” those with
lower levels were scored “some,” and those without physical
abuse were scored “none.” Emotional abuse was similarly mea-
sured with three questions about caregivers making hurtful
comments or threatening violence, and responses were grouped
in three levels similar to those for physical abuse.
40
Physical
neglect was measured by summing responses to fıve questions
regarding frequency of different types of neglect, and these also
were grouped in three levels.
41
Emotional neglect was measured
with fıve questions regarding types of support from family.
42
Respondents scoring in the lowest 10% of this scale were coded
as having high neglect; those in the next 25%, medium neglect;
and the remaining, no neglect. Respondents were considered to
have witnessed serious IPV if their mother’s partner fairly often
or very often pushed, grabbed, slapped, or threw something at
her; sometimes, fairly often,orvery often kicked, bit, or punched
her; or ever repeatedly hit her, or threatened or hurt her with a
weapon. Respondents were considered to have witnessed mild
IPV if they witnessed any lesser degree of IPV.
37,38
Sexual abuse
was assessed with four questions about unwanted sexual expe-
riences
43
and a question about sexual molestation before age 18
years, and it was coded as present or absent.
Family dysfunction and adversities. Because younger age at
experiencing events is associated with more serious sequelae,
44,45
events were coded as fırst occurring either before age 12 years or in
adolescence, ages 12–18 years, when this information was avail-
able. Events for which age was unavailable were coded simply
present or absent. Parents’ divorce or separation was coded as not
occurring in childhood, occurring before age 12 years, or from ages
12 to 18 years. Four circumstances regarding parents or other
adults living in the home during childhood were each coded di-
chotomously: problem drinking, problem drug use, imprisonment,
and mental illness, including attempted or completed suicide.
Problem drinking or drug use was defıned for respondents to mean
substance use that led to physical, emotional, interpersonal, legal,
or work problems, or involved a lot of time spent drunk, high, or
hung over. Poverty was measured dichotomously based on receipt
of government aid.
Traumatic events. Two types of violence-related events were
each coded as occurring before age 12 years, occurring from ages 12
to 18 years, or not occurring in childhood: violent victimization in
the community, including assault, mugging, stalking, kidnapping,
and terrorism; and witnessing someone killed or seeing a dead
body.
Roberts et al / Am J Prev Med 2011;40(2):128 –138 129
February 2011
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Table 1. Prevalence of adverse childhood circumstances and adult stressors by perpetration of IPV
Men (n14,564) Women (n20,089)
Circumstances/stressors
Did not perpetrate
IPV (n14,049)
Perpetrated IPV
(n515)
Did not perpetrate
IPV (n18,921)
Perpetrated IPV
(n1168)
ADVERSE CHILDHOOD CIRCUMSTANCES
Abuse and neglect
Physical abuse 11.2 (0.4) 24.9 (2.1)*** 10.6 (0.3) 23.9 (1.5)***
Witness IPV 13.5 (0.4) 29.4 (2.3)*** 15.3 (0.4) 29.9 (1.6)***
Sexual abuse 5.4 (0.3) 13.1 (1.7)** 16.1 (0.4) 32.8 (1.6)***
Emotional abuse 9.4 (0.3) 17.5 (1.9)*** 11.1 (0.3) 21.6 (1.5)***
Emotional neglect 9.9 (0.3) 15.4 (2.0)* 12.2 (0.3) 17.1 (1.4)***
Physical neglect 9.4 (0.4) 17.6 (1.9)*** 10.0 (0.3) 16.1 (1.3)***
Problems of parent/adult in home
Problem alcohol user 20.1 (0.5) 30.0 (2.7)** 22.9 (0.5) 33.4 (1.8)***
Problem drug user 4.6 (0.2) 7.1 (1.3)* 4.5 (0.2) 11.5 (1.1)***
Imprisoned 6.9 (0.3) 13.6 (1.9)** 6.6 (0.3) 12.7 (1.3)***
Mental illness 6.2 (0.2) 7.8 (1.4) 7.2 (0.3) 13.9 (1.3)***
Family circumstances
Biological parents stopped living together 15.8 (0.4) 18.5 (2.3) 12.1 (0.4) 18.5 (1.4)***
Traumatic events
Victim of violence in the community 12.0 (0.4) 21.9 (2.2)*** 4.8 (0.2) 14.2 (1.4)***
See someone killed, see a dead body 12.3 (0.4) 17.8 (2.2)* 5.3 (0.2) 8.4 (1.0)*
Economic circumstances
Poverty 12.5 (0.4) 19.5 (2.0)** 12.8 (0.4) 30.0 (1.7)***
ADULTHOOD STRESSORS
Financial stressors
Financial crisis 3.1 (0.2) 8.0 (0.8)*** 4.2 (0.2) 12.6 (0.8)***
Fired/laid off 3.3 (0.2) 7.6 (1.0)*** 5.0 (0.2) 11.1 (1.2)***
Unemployed 1 month 3.3 (0.2) 6.3 (0.8)** 4.7 (0.2) 12.1 (1.0)***
Income below 150% of poverty 16.0 (0.5) 21.4 (2.4)** 24.2 (0.6) 34.3 (1.8)***
Changed job or hours 3.3 (0.2) 4.5 (0.4)* 4.5 (0.2) 8.4 (0.5)***
Relationship stressors
Moved, or someone new moved in 3.2 (0.2) 5.0 (0.4)*** 4.3 (0.2) 9.2 (0.6)***
Trouble with boss or coworker 3.3 (0.2) 6.7 (0.9)*** 4.9 (0.2) 10.5 (0.8)***
Serious problem with neighbor, friend 3.4 (0.2) 7.3 (1.2)** 4.6 (0.2) 14.8 (1.3)***
Child aged 5 years in house 3.2 (0.2) 6.2 (0.7)*** 4.5 (0.2) 10.7 (0.7)***
Loved one died 3.2 (0.2) 4.4 (0.3)** 4.7 (0.2) 6.5 (0.4)***
Loved one other trauma 3.5 (0.2) 4.0 (0.5) 5.1 (0.2) 6.8 (0.6)*
Crime and violence
Something stolen 3.3 (0.2) 6.1 (0.8)*** 4.7 (0.2) 11.9 (0.9)***
(continued on next page)
130 Roberts et al / Am J Prev Med 2011;40(2):128–138
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Adulthood Past-Year Stressful Life Events
The Alcohol Use Disorder and Associated Disabilities Interview
Schedule-IV assessed a wide range of stressful life events occur-
ring in the year before the interview.
36
Events that could logi-
cally be sequelae of IPV perpetration, such as trouble with the
law, were excluded. Economic stressors included experiencing a
fınancial crisis; being fıred or laid off; being unemployed for
more than 1 month; having family income below 150% of the
poverty line (lowest level) or below U.S. median income (middle
level), adjusted for family size; and changes in job responsibili-
ties. Interpersonal stressors included serious problems with a
neighbor, friend, or relative; problems with a boss or coworker;
death of a family member or close friend; and having a child
aged 5 years at home. Crime-related stressors included being
mugged or attacked, seeing someone killed or seeing a dead
body, being the victim of theft, and intentional damage to one’s
property. Other stressors included experiencing a serious ill-
ness, accident, or natural disaster; moving or having someone
new move in; and having any other extremely stressful experi-
ence as defıned by respondents.
Analyses
To investigate the effects of childhood adversities on risk of adult-
hood perpetration, a single multivariate log-linear model with IPV
perpetration as the dependent variable and all childhood adversi-
ties as independent variables was created. Because childhood ad-
versities may differ in the average strength of their association with
future perpetration, a childhood adversity score was created using
the risk ratio from this model rounded to one decimal place as a
multiplier for each adversity, which permitted different types of
adversities to have stronger or weaker relationships with perpetra-
tion. Next, to examine the impact of past-year stressors on risk of
perpetration, a single multivariate log-linear model with perpetra-
tion as the dependent variable and all adulthood stressors as inde-
pendent variables was created. Because stressors may also differ in
their average effects on perpetration, an adulthood stressor score
was created using the risk ratio of perpetration from this model
rounded to one decimal place as a multiplier for each stressor,
permitting stressors to vary in the strength of their association with
perpetration.
To test the theory of stress sensitization, a model with perpe-
tration as the dependent variable and childhood adversity score,
adulthood stressor score, and an interaction between adversity
and stressor as independent variables was created. To facilitate
comparison of risk differences across levels of childhood adver-
sity and adulthood stressors, respondents were grouped into
quartiles of childhood adversity and adulthood stressors. Ac-
cording to stress-sensitization theory, the difference in risk of
perpetrating IPV in adults with high versus low levels of adult-
hood stressors would be larger for individuals sensitized to
stress by childhood adversity. The interaction between adversity
and stressors was therefore assessed on the additive scale.
46
First, an adjusted risk of perpetrating for each combination of
the four adversity and four stressor levels was calculated, yield-
ing a 4-by-4 table. Next, a chi-square test of this table was
conducted to see if overall difference in risk of perpetrating
from stressors differed signifıcantly across quartiles of child-
hood adversity. Finally, using respondents in the lowest child-
hood adversity quartile as the reference group, we calculated
risk differences comparing the highest quartile of adulthood
stressors with the lowest quartile of stressors. This calculation
was then repeated for each of the other levels of childhood
adversity and these risk differences were compared with the
reference group using Student’s t-tests.
All analyses were conducted separately for men and women.
Further, the data were adjusted for age at interview, measured
continuously, and for race/ethnicity, which NESARC classifıed
as Hispanic, or non-Hispanic: black, American Indian/Native
Alaskan, Native Hawaiian/Pacifıc Islander, Asian, or white.
Two-sided tests with a p-value 0.05 were used to determine
signifıcance. Statistical analyses were conducted using fıve sets
of imputed data (iveWare 2009).
47,48
Variables were missing no
more than 1.1% of responses. Analyses were conducted using
SUDAAN software (release 9.0.3) to account for the nested sam-
pling design of the NESARC study, which may result in correlated
Table 1. (continued)
Men (n14,564) Women (n20,089)
Circumstances/stressors
Did not perpetrate
IPV (n14,049)
Perpetrated IPV
(n515)
Did not perpetrate
IPV (n18,921)
Perpetrated IPV
(n1168)
Property destroyed 3.4 (0.2) 6.1 (0.8)** 4.8 (0.2) 12.4 (1.2)***
Violent victimization in community 3.5 (0.2) 7.9 (1.8)* 5.2 (0.2) 15.6 (2.5)**
See someone killed, see a dead body 3.6 (0.2) 3.3 (0.8) 5.2 (0.2) 9.6 (1.4)**
Other
Illness, injury, or disaster 3.5 (0.2) 4.1 (0.8) 5.3 (0.2) 5.9 (0.9)
Other trauma to self 3.6 (0.2) 3.2 (1.8) 5.3 (0.2) 12.0 (3.0)*
Note: Sample included U.S. men and women aged 20 years (N34,653). Values are % (SE). Differences in mean age at interview were
evaluated with a t-test.
*p0.05; **p0.01; ***p0.001 (
2
test)
IPV, intimate partner violence
Roberts et al / Am J Prev Med 2011;40(2):128 –138 131
February 2011
Author's personal copy
responses, to weight the
data to reflect the U.S.
population, and to com-
bine results from the fıve
imputed data sets.
35
Results
Among respondents
married or in a roman-
tic relationship in the
past year (76.2% of
women and 85.6% of
men), women en-
dorsed past-year IPV
perpetration more of-
ten than men, with
7.0% (SE0.3) of
women and 4.2%
(SE0.2) of men self-
reporting perpetration
(
2
1
61.9, p0.001).
Serious IPV perpetra-
tion was also more
common among
women than men, with
2.2% (SE0.1) of
women and 1.2%
(SE0.1) of men en-
dorsing serious perpe-
tration (
2
1
24.3,
p0.001). Men and
women reported sim-
ilar levels of perpetrat-
ing the most-severe
acts: 0.55% (SE0.08,
n67) of men and
0.69% (SE0.08, n
115) of women re-
ported cutting or
bruising their partner,
and 0.41% (SE0.07,
n56) of men and
0.34% (SE0.06, n
60) of women re-
ported forcing sex.
When asked about
their own IPV victim-
ization, men and
women reported sim-
ilar levels, with 5.8%
(SE0.25) of men in
relationships report-
ing victimization and
Table 2. Risk of perpetrating intimate partner violence associated with adverse childhood
events
a
Adverse event Men (n14,564) Women (n20,089)
ABUSE AND NEGLECT
Physical abuse
None 1.00 (ref) 1.00 (ref)
Some 1.08 (0.81, 1.44) 1.37 (1.11, 1.69)
Serious 1.64 (1.11, 2.43)* 1.77 (1.37, 2.29)***
Witness IPV
None 1.00 (ref) 1.00 (ref)
Some 1.47 (1.09, 1.99) 1.04 (0.82, 1.33)
Serious 1.62 (1.12, 2.34)** 1.18 (0.95, 1.47)
Emotional abuse
None 1.00 (ref) 1.00 (ref)
Some 1.60 (1.16, 2.21) 1.62 (1.29, 2.03)
Serious 1.05 (0.63, 1.76)** 1.10 (0.81, 1.48)***
Sexual abuse 1.58 (1.13, 2.22)** 1.32 (1.13, 1.55)***
Physical neglect
None 1.00 (ref) 1.00 (ref)
Some 1.11 (0.87, 1.42) 1.22 (1.02, 1.46)
Serious 1.10 (0.76, 1.57) 0.93 (0.73, 1.18)*
Emotional neglect
Low 1.00 (ref) 1.00 (ref)
Medium 1.04 (0.80, 1.35) 1.22 (1.02, 1.47)
High 1.17 (0.81, 1.68) 1.13 (0.89, 1.44)
PROBLEMS OF PARENT/ADULT IN HOME
Mental illness 0.90 (0.61, 1.34) 1.27 (1.02, 1.58)*
Problem alcohol user 1.13 (0.85, 1.51) 0.98 (0.83, 1.17)
Problem drug user 0.82 (0.52, 1.30) 1.10 (0.87, 1.40)
Imprisoned 1.22 (0.81, 1.84) 0.94 (0.76, 1.16)
FAMILY PROBLEMS
Parents divorced or separated
Not in childhood 1.00 (ref) 1.00 (ref)
Before age 12 years 0.74 (0.48, 1.15) 1.19 (0.82, 1.45)
In adolescence 0.89 (0.64, 1.24) 1.00 (0.83, 1.20)
VIOLENCE EXPOSURE
Victim of violence in the community
Not in childhood 1.00 (ref) 1.00 (ref)
Before age 12 years 1.26 (0.95, 1.67) 1.56 (1.23, 1.98)
(continued on next page)
132 Roberts et al / Am J Prev Med 2011;40(2):128–138
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5.5% (SE0.24) of women reporting victimization
(
2
1
1.2, p0.29). Women were more likely to report be-
ing cut or bruised than were men. Among perpetrators,
more men than women reported IPV victimization, with
73.9% (SE2.2) of male perpetrators reporting victimiza-
tion and 56.1% (SE1.8) of female perpetrators reporting
victimization (
2
1
29.1, p0.001).
Every adverse childhood circumstance was signifı-
cantly more common among perpetrators than nonper-
petrators except for parent’s mental illness and parent’s
divorce among men (Table 1). For perpetrators, levels of
physical abuse, sexual abuse, emotional abuse, witnessing
IPV, and having a parent imprisoned were approximately
double those of nonperpetrators. Prevalence of every
adult fınancial, relationship, and crime stressor was ele-
vated among perpetrators, with the exception of seeing
someone killed/seeing a dead body and other trauma to a
loved one among men (Table 1).
Models of Childhood Adversities and Risk of
Perpetration
Physical abuse, emotional abuse, and sexual abuse were
signifıcant predictors of IPV perpetration for both gen-
ders in multivariate models, including all childhood ad-
versities. For men, witnessing IPV also predicted perpe-
tration. For women, physical neglect, mental illness of a
parent, violent victimization in the community, and pov-
erty predicted perpetration (Table 2).
Models of Adulthood Stressors and
Risk of Perpetration
Past–12-month stressors associated with risk of perpetra-
tion for both genders included fınancial crisis, a serious
problem with a neighbor or friend, and death of a loved one
(adjusted risk ratio [ARR] range1.19–1.90) (Table 3). For
men but not women, having a young child in the house
(ARR1.46) and being fıred (ARR1.45) were associated
with perpetration. For
women but not men,
being unemployed for
more than 1 month
(ARR1.24) and ex-
periencing any other
highly stressful event
(ARR1.66) were as-
sociated with perpe-
tration. Several stres-
sors, including low
income, moving or
someone new moving
in, and having some-
thing stolen, were sig-
nifıcantly associated
with perpetration
among women, but among men risk from these stres-
sors was slightly smaller and not signifıcant.
Stress Sensitization Model
Analyses found evidence for stress sensitization effects
in predicting IPV for both genders. As hypothesized,
the risk of perpetrating IPV among individuals ex-
posed to high levels of past-year stressors as compared
to low levels of past-year stressors was signifıcantly
greater among respondents with a history of childhood
adversity (women,
9
2
115.7, p0.001; men,
9
2
32.4,
p0.001; Table 4). For men with the least childhood
adversity, the risk of perpetrating was 3.5% for men in the
highest-stressor quartile and 0.9% for men in the lowest-
stressor quartile, for a risk difference of 2.6 percentage
points (pp) (ref). The risk difference between highest and
lowest stressor was 5.7 pp for the low-middle level of
childhood adversity (t⫽⫺0.02, p0.1, compared with
the referent); 2.4 pp for the middle-high level (t1.6,
p0.1); and 10.6 pp for the highest level (t4.1, p0.001;
Figures 1 and 2). Among women, the same pattern was
observed: The risk difference was 2.3 pp for women with
the least childhood adversity (ref); 4.8 pp for low-middle
adversity (t–1.1, p0.3 compared with the referent);
8.5 pp for middle-high adversity (t3.2, p0.01); and
13.6 pp for women with high adversity (t5.5, p0.001).
Discussion
Our major fınding is that there is an interaction between
recent stressors and childhood adversity, such that indi-
viduals exposed both to recent stressors and childhood
adversity are at greater risk of IPV perpetration than
would be predicted by an additive effect of stressors and
childhood adversity alone. Prior work has examined the
effects of childhood adversity and recent adult stressors sep-
Table 2. (continued)
Adverse event Men (n14,564) Women (n20,089)
In adolescence 1.23 (0.72, 2.13) 1.24 (0.78, 1.96)**
See someone killed, see a dead body
Not in childhood 1.00 (ref) 1.00 (ref)
Before age 12 years 1.01 (0.74, 1.38) 1.03 (0.79, 1.35)
In adolescence 1.16 (0.73, 1.83) 0.79 (0.55, 1.15)
ECONOMIC CIRCUMSTANCES
Poverty 1.03 (0.78, 1.34) 1.37 (1.14, 1.65)
Note: Sample included U.S. men and women aged 20 years (N34,653). Values are adjusted risk ratio (95% CI).
a
One multivariable model for each gender, adjusted for age at interview and race/ethnicity
*p0.05; **p0.01; ***p0.001 (Wald F test)
IPV, intimate partner violence
Roberts et al / Am J Prev Med 2011;40(2):128 –138 133
February 2011
Author's personal copy
arately and found that
both predict perpetra-
tion. However, the
current results show
that association of re-
cent stressors and IPV
perpetration is stron-
gest among individu-
als with high levels of
childhood adversity,
which has not been
previously demon-
strated. The current
fındings extend the
stress sensitization lit-
erature from mood
and anxiety disor-
ders
23,24,26,49
into the
realm of externalizing
behaviors, suggesting
a broad effect of child-
hood stress sensitiza-
tion on adult mental
health and behaviors.
The stress sensitiza-
tion effect found was
most pronounced at
high levels of stressors,
that is, the risk differ-
ence for the highest-
level childhood adver-
sity group versus the
lower-level groups
was largest among
people experiencing
the most adult stres-
sors. In prior research,
stress sensitization has
been investigated in
three distinct manifes-
tations. First, studies have found that exposure to childhood
adversities lowers the stress threshold at which negative se-
quelae, such as depression
24
or bipolar episodes,
49
occur, such
that minor stressors trigger these events. Second, stress sen-
sitization has been investigated with regard to increasing the
severity of mental illness sequelae.
23
Finally, stress sensitiza-
tion has been found to increase likelihood of mental illness
following exposure to major stressors.
26
The current fınd-
ings support this third conceptualization. Small differences
in stressors were not associated with greater risk for IPV
perpetration among individuals with childhood adversity.
The stress sensitization hypothesis was supported for
both men and women. These fındings concur with a
growing body of research showing commonalities across
genders in IPV perpetration in high-income coun-
tries.
50–55
Overall, there were striking similarities in the
adjusted models for both genders in terms of which child-
hood events were risk factors for perpetration, which
adulthood stressors were associated with perpetration,
and the magnitude of these associations. That the preva-
lence of IPV perpetration, including serious perpetration,
was somewhat higher in women than men is consistent
with prior work,
8,9,12,56–59
as is the fınding that women
are victimized by the most-severe acts more often than
men.
1,60
These studies are limited to high-income coun-
tries, however, and therefore fındings may not hold for
countries in which women’s status is substantially lower
Table 3. Risk of perpetrating intimate partner violence associated with past–12-month
adulthood stressors
a
Men (n14,564) Women (n20,089)
FINANCIAL STRESSORS
Financial crisis 1.72 (1.30, 2.28)*** 1.52 (1.31, 1.77)***
Fired/laid off 1.45 (1.03, 2.04)* 0.96 (0.74, 1.25)
Unemployed >1 month 0.98 (0.67, 1.44) 1.24 (1.00, 1.52)*
Income
Below 150% of poverty 1.14 (0.83, 1.56) 1.33 (1.12, 1.59)***
Below U.S. median 1.19 (0.95, 1.49) 1.28 (1.07, 1.52)
Above U.S. median 1.00 (ref) 1.00 (ref)
Changed job or hours 0.78 (0.62, 0.99)* 0.89 (0.75, 1.06)
RELATIONSHIP STRESSORS
Serious problem with neighbor, friend 1.46 (1.02, 2.07)* 1.90 (1.56, 2.32)***
Trouble with boss or coworker 1.35 (1.00, 1.84) 1.16 (0.96, 1.41)
Loved one died 1.28 (1.04, 1.58)* 1.19 (1.02, 1.39)*
Loved one, other trauma 0.97 (0.71, 1.31) 1.04 (0.85, 1.28)
Child aged <5 years in house 1.46 (1.10, 1.94)* 1.15 (0.99, 1.34)
CRIME AND VIOLENCE
Something stolen 1.24 (0.91, 1.60) 1.31 (1.09, 1.59)**
Property destroyed 1.16 (0.84, 1.60) 1.26 (0.99, 1.60)
Violent victimization in community 1.43 (0.83, 2.47) 1.09 (0.68, 1.74)
See someone killed, see a dead body 0.75 (0.43, 1.30) 1.02 (0.76, 1.38)
OTHER STRESSORS
Illness, injury, or disaster 1.09 (0.74, 1.62) 0.99 (0.74, 1.33)
Moved, or someone new moved in 1.15 (0.93, 1.42) 1.19 (1.02, 1.40)*
Self, other trauma 0.70 (0.21, 2.28) 1.66 (1.07, 2.58)*
Note: Sample included U.S. men and women aged 20 years (N34,653). Values are adjusted risk ratio
(95% CI).
a
One multivariable model for each gender, adjusted for age at interview and race/ethnicity
*p0.05; **p0.01; ***p0.001 (Wald F test)
134 Roberts et al / Am J Prev Med 2011;40(2):128–138
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Author's personal copy
than men’s or in which violence against women is
condoned.
Our fındings are subject to four main limitations. First,
childhood experiences and IPV perpetration were retro-
spectively self-reported. Retrospective-
61
and self-
reporting
9,38
can lead to under-reporting, which could
attenuate relationships between adversities or stressors
and perpetration. In contrast, social desirability bias
could cause overestimation of the adversity–IPV associ-
ation if both adversity and IPV are under-reported. Sec-
ond, recall bias may lead to overestimation of the associ-
ation between stressors, adversities and perpetration, if
perpetrators better recall these negative events. Third, the
chronology of past-year perpetration and stressors was
not established, although stressors that logically could
result from perpetration were excluded. Fourth, other
factors such as poor social functioning,
15,17
aggressive-
ness,
18
or personality disorders
18,62
may be common
causes of both stressors and perpetration.
The role of stress sensitization in IPV perpetration has
implications for theory, research, and practice. The cur-
rent fındings highlight the importance of a life course
perspective on IPV perpetration. Existing studies primar-
ily focus on either childhood or adulthood predictors,
and rarely examine sets of factors across life stages. Re-
search examining both childhood and adulthood risk
factors has viewed adulthood factors, such as mental ill-
ness,
11,62,63
substance use,
11,64
and community violence
65
primarily as mediators of childhood adversity. Thus,
when examined in conjunction with childhood circum-
stances, adulthood circumstances have been considered
mainly as consequences of the childhood environment.
The current results suggest that considering adulthood
Table 4. Risk of perpetrating intimate partner violence by level of childhood adversity and adulthood stressors
Childhood adversity
Adulthood past–12-month stressors
Men (%) (n14,564) Women (%) (n20,089)
Lowest
stressors
Low-
middle
stressors
Middle-
high
stressors
Highest
stressors
Lowest
stressors
Low-
middle
stressors
Middle-
high
stressors
Highest
stressors
Lowest adversity 0.9 (1674) 1.1 (1144) 2.3 (741) 3.5 (322) 0.6 (2268) 1.7 (1334) 1.9 (943) 2.9 (464)
Low-middle adversity 1.4 (1076) 1.6 (1035) 3.3 (811) 5.8 (561) 1.8 (1349) 2.3 (1401) 2.6 (1394) 6.7 (1015)
Middle-high adversity 2.6 (480) 3.5 (785) 3.3 (1052) 5.0 (1237) 1.9 (1003) 5.0 (1353) 5.2 (1327) 10.4 (1234)
Highest adversity 2.9 (420) 3.1 (670) 6.8 (1035) 13.6 (1521) 3.3 (402) 2.9 (934) 10.0 (1358) 16.9 (2310)
Note: Sample included U.S. men and women aged 20 years (N34,653). Values are % (n).
Adjusted for race/ethnicity and age at interview
Figure 1. Prevalence of perpetrating intimate partner vio-
lence by level of adulthood stressor and childhood adver-
sity, U.S. 2004 –2005, men
a
Adjusted for race/ethnicity and age
Figure 2. Prevalence of perpetrating intimate partner vio-
lence by level of adulthood stressor and childhood adver-
sity, U.S. 2004 –2005, women
a
Adjusted for race/ethnicity and age
Roberts et al / Am J Prev Med 2011;40(2):128 –138 135
February 2011
Author's personal copy
circumstances as precipitators of perpetration in the con-
text of childhood adversity represents a fruitful area of
study.
66,67
Our fındings further suggest that research on IPV per-
petration may benefıt from examining neural, physio-
logic, and neuroendocrine response to stressors in IPV
perpetrators compared with nonperpetrators to identify
biological mechanisms. Prior work examining reactivity
in perpetrators has focused on differences in cardiovas-
cular reactivity among types of perpetrators, with contra-
dictory fındings.
68,69
Other pathways involved in stress
response have not been explored. For example, the or-
bitofrontal cortex may regulate aggression in response to
threat or frustration; such aggression can be triggered
more readily if the regulatory systems involved in this
response are damaged from prior trauma.
70,71
The
hypothalamic–pituitary–adrenal axis; the neurotrans-
mitters serotonin,
-amino butyric acid (GABA), and
dopamine; and functionality of these neurotransmitters’
receptors also have been implicated in aggression,
70,72
and dysregulation of these systems has been associated
with stress reactivity from childhood adversity.
73–75
In terms of practice, the current results indicate that
intervention programs may want to explore more exten-
sively the role of stress and reaction to stress in perpetra-
tion, particularly among individuals with histories of
childhood maltreatment. Existing treatments for IPV
perpetrators, primarily the Duluth model and cognitive–
behavioral therapy, are no more effective than arrest
alone in preventing subsequent perpetration.
76–79
Stress
management training,
80
mindfulness training,
81–83
and
psychotherapy
84
reduce reactivity to stress and therefore
may be useful in treating perpetrators.
Dr. Andrea Roberts is supported by the Harvard Training Pro-
gram in Psychiatric Genetics and Translational Research (grant
T32MH017119). Dr. Katie McLaughlin is supported by the
Robert Wood Johnson Foundation (grant 053572). Dr. Kerith
Conron is supported by the Institute on Urban Health Research
and CSAT (grants TI19574 and TI18880). Dr. Karestan Koenen
is supported by NIH (grants MH078928, DA022720, and
MH086309), the Kaiser Family Foundation, and a Junior Fac-
ulty Sabbatical from Harvard School of Public Health.
No fınancial disclosures were reported by the authors of this
paper.
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    • "The Adverse Childhood Experiences (ACE) study found higher levels of traumatic experiences in the general population than previously imagined. Among the approximately 17,000 adults surveyed, just over 50% reported having experienced at least one form of childhood adversity (Roberts, McLaughlin, Conron, & Koenen, 2011). These included physical, emotional or sexual abuse; witnessing their mother treated violently; having a parent with substance abuse or mental health issues; or, living in a household with an adult who had spent time in prison. "
    Article · Apr 2016
    • "Some researchers suggest that the limited effectiveness of prevention and intervention efforts is the result of the oversimplification of antecedents to perpetration , especially the contextual factors at the time of perpetration (Bell and Naugle 2008). Stress, the individualized response to challenging situations , is associated with increased risk for IPV (Capaldi et al. 2012; Cano and Vivian 2001; Mason and Smithey 2012; Roberts et al. 2011). However, few studies have examined specific stressors, which are the events that trigger the stress response, as antecedents to IPV perpetration (Langhinrichsen-Rohling et al. 2012a; Elkins et al. 2013; Whitaker 2013; Byun 2012; Shortt et al. 2013). "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Contextual factors, such as exposure to stressors, may be antecedents to IPV perpetration. These contextual factors may be amenable to modification through intervention and prevention. However, few studies have examined specific contextual factors. To begin to address this gap, we examined the associations between financial stressors and three types of physical IPV perpetration. Methods: This analysis used data from Wave IV of The National Longitudinal Study of Adolescent to Adult Health. We used logistic regression to examine the associations of financial stressors and each type of IPV (minor, severe, causing injury), and multinomial logit regression to examine the associations of financial stressors and patterns of co-occurring types of IPV perpetration (only minor; only severe; minor and severe; minor, severe, and causing injury; compared with no perpetration). Results: Fewer men perpetrated threats/minor physical IPV (6.7 %) or severe physical IPV (3.4 %) compared with women (11.4 % and 8.8 %, respectively). However, among physical IPV perpetrators, a higher percentage of men (32.0 %) than women (21.0 %) reported their partner was injured as a result of the IPV. In logistic regression models of each type of IPV perpetration, both the number of stressors experienced and several types of financial stressors were associated with perpetrating each type of IPV. Utilities nonpayment, housing nonpayment, food insecurity, and no phone service were associated with increased odds of perpetrating each form of IPV in adjusted analysis. Eviction was associated with perpetrating severe physical IPV but not threats/minor IPV or IPV causing injury. In multinomial logit regression comparing patterns of IPV perpetration to perpetrating no physical IPV, the relationships of financial stressors were less consistent. Food insecurity was associated with perpetrating only minor physical IPV. Comparatively, overall number of financial stressors and four types of financial stressors (utilities nonpayment, housing nonpayment, food insecurity, and disconnected phone service) were associated with perpetrating all three forms of physical IPV. Conclusions: Combined with prior research, our results suggested interventions to improve financial well-being may be a novel way to reduce physical IPV perpetration.
    Full-text · Article · Mar 2016
    • "Many of these factors and other adversities can exacerbate the link between child maltreatment and IPV (e.g. Foshee et al., 2005; Fergusson et al., 2006; Herrenkohl et al., 2008; Roberts et al., 2011). The intergenerational cycle of violence is situated within a larger system of stressors, such as poverty and racism, which can also be experienced across generations (Eckhardt et al., 2013). "
    Technical Report · Jan 2016
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