exposure is also associated with aggressive behavior, as is verbal aggression by parents (Margolin and Gordis, 2000; Vissing et al., 1991). Sexual abuse leads to more internalizing childhood behaviors, including fear and withdrawn behavior (for reviews, see Brown and Anderson, 1991; Grilo et al., 1999; Kendall-Tackett et al., 1993; Margolin and Gordis, 2000; NRC, 1993; Taussig and Litrownik, 1997). As they mature into adolescence and adulthood, children who are sexually abused may display inappropriate sexual behaviors. A meta-analysis found a strong effect size (d=.6) for child sexual abuse on sexual promiscuity (defined as early involvement in sexual activity and/or prostitution, Paolucci et al., 2001).
Childhood maltreatment is also associated with use of alcohol and drugs (Felitti et al., 1998; NRC, 1993; Silverman et al., 2001), as well as with substance use disorders (see later section). Many believe that substance use is initiated in the teen years as a coping device to temper symptoms of anxiety, depression, and the effects of dysregulated stress symptoms (De Bellis, 2001). Victims of child maltreatment are also at risk for delinquency and running away (NRC, 1993; Wolfe et al., 2001). Although a link between childhood maltreatment and serious violence12 has been proposed, a recent Surgeon General report found only a small effect size (r<.20) for a relationship between the two (US DHHS, 2001b).
The effects of child maltreatment and its relationship to suicide are compounded by the intergenerational transmission of abusive parenting. A recent two-site study by Brent and colleagues (in press) found a 6-fold increased risk of suicide attempts among offspring of suicide attempters versus non-attempters, and that the familial transmission was more likely if the attempting parent had been sexually abused as a child. Thus, abuse is not only a risk factor for suicide for those abused as children, but also for their subsequent children.
While early assumptions about the inevitability of intergenerational transmission have been discounted, the experience of abuse in childhood is one of the most commonly agreed upon risk factors for subsequent abusive parenting (Kaufman and Zigler, 1987; NRC, 1993). The variability in transmission, however, provides an opportunity to examine protective factors that break this cycle. These include effective therapeutic intervention either in childhood or adulthood, the presence of significant others, and insight into one’s own childhood experience of abuse (e.g., Egeland et al., 1988). Prevention of child maltreatment and treatment of its victims/