parental verbal and physical abuse, parental substance use problems, and having dependents for women.

The lifetime rate of depression was 19.2 percent for those with no childhood sexual abuse and 39.3 percent for those who had experienced abuse (odds ratio = 1.8; Molnar, Buka, and Kessler, 2001). Rates of dysthymia, mania, and posttraumatic stress disorder were also significantly higher for sexually abused women but not for men. The impact of childhood sexual abuse was especially strong for those who had no other adversities; their odds for depression were 3.8 (95 percent confidence interval). For those who reported 5 or more adversities, the odds of depression were 1.7 (95 percent confidence level). There was some evidence that chronic sexual abuse led to higher rates of some disorders (Molnar, Buka, and Kessler, 2001).

Parental psychopathology, especially among mothers, was the most significant family adversity associated with abuse (Molnar, Buka, and Kessler, 2001) and warrants further investigation. However, finding high rates of disorder with abuse but no other risk factors emphasizes the importance of the negative effects of abuse. The persistence of negative effects of child maltreatment is seen in studies that assess functioning across periods of development. For example, the Virginia Longitudinal Study of Child Maltreatment found that of 107 maltreated children who were followed from middle childhood through early adolescence, fewer that 5 percent were functioning well consistently over time (Bolger and Patterson, 2003).

Understanding the factors that influence the linkage between child maltreatment and problem outcomes starts by distinguishing different levels of abuse. In particular, abuse that starts early and is chronic is linked with pervasive and persistent problems across domains of functioning. Children abused in infancy show difficulties in areas that include affect regulation (e.g., high negative affect, blunted affect), hypervigilance, emotional lability, disruptions in their attachment relations, and self-system deficits (e.g., more negative self-representations) (Ialongo, Rogosch, et al., 2006).

The most effective approach to reducing the effects of maltreatment is to prevent its occurrence. Because of the pervasive mental, emotional, and behavioral problems for which maltreated children are at risk, programs that prevent abuse have the potential to avert multiple disorders and promote healthy development across multiple domains of functioning. There is evidence, for example, that a home visiting program for economically poor, single parents has been effective in reducing the occurrence of child abuse (Olds, 2006; see Box 6-1) and that a population-level approach to strengthening parenting reduces rates of abuse in the community (Prinz, Sanders, et al., 2009). Interventions are also aimed at mitigating the impact of abuse after it has occurred. Several randomized trials with maltreated children demonstrated that infant and preschool psychotherapy and a home visiting program were successful in markedly reducing rates of insecure attachment

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