Faculteit der Maatschappij- en Gedragswetenschappen Graduate School of Child Development and Education
The Risk for Intergenerational Transmission of Child Maltreatment:
A Multilevel Meta-Analysis
Master Forensische Orthopedagogiek
Graduate School of Child Development and Education
Universiteit van Amsterdam
Student: M. Schuts
Studentnummer: 6075789
Scriptiebegeleiders: Prof. dr. G. J. J. J. M. Stams, dr. M. Assink & Prof. dr. R. J. L. Lindauer
Tweede beoordelaar: dr. M. Assink
2
Abstract
The current study examined the risk for intergenerational transmission of child maltreatment by means of a multilevel meta-analysis. A total of 59 studies were reviewed, including 125 effect sizes, which provided information on child abuse and neglect in two or three generations. Effect sizes for the association between a history of maltreatment of parents and current maltreatment of their children ranged from r = .158 to r = .536, with a large overall r of .381after correction for publication bias, which indicates an almost three times higher risk for child maltreatment in children whose parents have a history of child maltreatment. There was a trend indicating that the risk for child maltreatment was higher for a parental history of abuse than a parental history of neglect. In Europa the risk for intergenerational transmission of child maltreatment proved to be higher than in three Anglo-Saxon countries (USA, Canada, Australia) and China.
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Introduction
Child maltreatment is a social problem of epidemic proportions that occurs worldwide and has negative impact on its victims. The meta-analysis by Stoltenborgh, Bakermans-Kranenburg, Alink and Van IJzendoorn (2012) demonstrates that the percentage of emotional abuse worldwide falls between 0.3% and 36.6%. For physical abuse, the percentages range between 0.3% and 22.6%, and for sexual abuse between 0.4% and 12.7%. These percentages vary significantly due to differences in assessment methods (self-report questionnaires or (non)professional informants who report on cases of maltreatment) and differences in the exposure to risks for maltreatment between countries (Stoltenborgh et al., 2012). The negative consequences of child maltreatment include underdeveloped emotion regulation, delinquent behavior, depression and anxiety disorders, suicidal behavior, alcohol and drug abuse, and so forth (Asscher, Van der Put, & Stams, 2015; Finzi-Dottan & Harel, 2014; Stouthamer-Loeber, Loeber, Homish, & Wei, 2001; Teeuw & Boer, 2013).
Both the prevalence and the consequences of child maltreatment vary between studies, which not only is explained by differences in target population and assessment methods, but also by the definition of child maltreatment. In 1999, the presidents of The International Society of the Prevention of Child Abuse and Neglect compared the definitions of child maltreatment from 58 countries and arrived at the following international definition: “Child abuse or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power” (WHO, 2002). In this overview, child maltreatment includes physical abuse, neglect, sexual abuse and emotional abuse.
Child maltreatment is multi-causally determined, which means that neighborhood characteristics, child and parent characteristics, family factors and the interaction of the
4 family with its social environment are all antecedents of child maltreatment (Belsky, 1993). Brown, Cohen, Johnson and Salzinger (1998) demonstrated that in particular the accumulation of risk factors causes child maltreatment. Two quantitative reviews support the multi-causal nature of child maltreatment, and showed family factors to be the most strongly associated with child maltreatment (Assink et al., 2016; Stith et al., 2009). The main role of family factors in child maltreatment is in line with Bronfenbrenner’s (1977) bio-ecological model, which assumes that proximal processes in the microsystem of the family, the everyday interaction between parent and child, have most explanatory power.
Research has shown that parents often pass on the parenting behaviors they have undergone themselves, meaning that parents raise their children the way they have been raised by their own parents (Bakermans-Kranenburg & Van IJzendoorn, 2009). When this cycle occurs over three generations or more, it is called intergenerational transmission (Van IJzendoorn, 1994). Finzi-Dottan and Harel (2014) found that the risk for child maltreatment was six times greater when parents had maltreatment experiences themselves. However, Kaufman and Zigler (1987) showed that most of the parents with a history of maltreatment did not maltreat their offspring, which is in line with a prospective study by Browne and Herbert (1989), who found that ‘only’ 7.6% of the parents with a history of maltreatment did maltreat their offspring. Stroufe and colleagues (2005), in contrast, found that 70% of the maltreated parents did abuse or neglect their children.
No clear picture emerges from review studies examining the intergenerational transmission of maltreatment. For instance, the study by Ertem and colleagues (2000) report odds ratios for the chance of intergenerational transmission of maltreatment ranging between 1 and 38. The relative risk of child maltreatment was assumed to depend strongly on the quality of the study, which conclusion was supported in the review by Thornberry et al. (2012), who developed a comprehensive quality index to account for differences among
5 studies, including for instance the representativeness of the sample, the use of different sources of information across generations, a clear definition of maltreatment, assessment of maltreatment in the comparison group and the use of prospective data. Thornberry et al. (ibid.) concluded that most studies were of weak quality, violating several methodological standards, and concluded that support for the intergenerational transmission of maltreatment hypothesis is highly inconsistent, in particular in the methodologically stronger studies .
The two narrative review studies by Ertem et al. (2000) and Thornberry et al. (2012) were limited in explaining differences in the risks for intergenerational transmission of child maltreatment among studies, because no meta-analytic techniques were employed. It is therefore important to perform a meta-analysis to (1) reliably estimate the association between a history of maltreatment of parents and current maltreatment of their children, and (2) conduct moderator analyses to examine which factors may explain differences in the risk for intergenerational transmission of maltreatment among (and within) studies.
Information on the risk for intergenerational transmission of child maltreatment is important in view of preventive interventions for child maltreatment. If a history of maltreatment of a parent substantially increases the risk for maltreatment of his or her child, this parent should receive a preventive intervention to prevent child maltreatment targeting risk factors (e.g., insecure attachment representation) and protective factors (e.g., supportive relationships) that might reduce the chance for intergenerational transmission of maltreatment (Dixon, Browne, & Hamilton-Giachritsis, 2009; Egeland, Jacobvitz, & Sroufe, 1988; Leifer & Smith, 1990; Sroufe et al., 2005).
The main focus of this meta-analysis is to measure the chance of intergenerational transmission of child maltreatment. The moderators included in this study are the study quality index developed by Thornberry et al. (2012), the country where the study has been conducted, sample characteristics (age of both parents and children, and gender of the child),
6 type of parental and child maltreatment (e.g., abuse or neglect), and assessment method of child and parent maltreatment (questionnaire self-report or official registration).
Method
Literature Search
To find relevant studies, we searched for articles on intergenerational transmission and child maltreatment. Electronic databases were used to find data for this study, such as Psychological Abstracts International (PsychINFO), Web of Science and Google Scholar. The following keywords were combined in search strings that were combined: (maltreatment OR neglect OR abuse OR harsh parenting OR violence) AND (transmission OR intergenerational OR history,), which yielded 1344 manuscripts (limited to journals and English language, 1020 manuscripts). After screening for relevance, based on the inclusion criteria of this meta-analysis, 50 manuscripts were considered eligible. In addition, two reviews on intergenerational transmission of child maltreatment were consulted (Ertem, 2000; Thornberry, 2012) as well as two meta-analyses of risk factors for child maltreatment (Assink et al., 2016; Stith et al., 2009). In total, 59 studies were used for this research, and the total number of participants were 88,926 (including parents and children).
The following study inclusion criteria were specified: (1) studies had to report on an association between parent and child maltreatment across at least two generations; (2) studies had to contain statistical information on this association; (3) studies had to be published in English; (4) only studies in peer-reviewed scientific journals were included to preserve a minimum study quality.
Coding of studies
The following within and between study characteristics were coded as moderators: type of child and parent maltreatment (physical abuse, neglect, sexual abuse, emotional abuse and mixed, that is, physical abuse and neglect); assessment of child and parent maltreatment
7 (registered or questionnaire self-report); country (USA, Europe, China, Canada, and Australia); mean age of parents and children; percentage of male children; study quality index of Thornberry et al. (2012), including whether the study used different sources of information at G1/G2, had a clear definition of maltreatment, satisfactory participation and attrition, a representative sample and whether non-maltreatment was assessed for the comparison group. Appendix B shows all the studies that were included in this study.
Calculating effect sizes
The correlation coefficient was chosen as the effect size. When the data were not correlation coefficients, we converted them into correlation coefficients based on the formulas of Lipsey and Wilson (2001) and DeCoster (2008). Odds ratios, proportions, means and standard deviations, chi-squares, and so forth were converted to r.
In this research we examined whether the effect sizes fell within the “normal range.” An effect size was considered “extreme” when it is more than 3.29 standard deviations above or below the mean (Tabachnik & Fidel, 2013). We found two effect sizes that could be considered “extreme” (3.42, 3.56), and they were therefore considered outliers (Field, 2012). To minimize the effect of these outliers, they were replaced with the highest value that fell within the normal range.
Statistical analysis
We coded more effect sizes per study, and therefore conducted multi-level meta-analysis in order to account for statistical dependency of effect sizes (see Houben, Van den Noortgate, & Kuppens, 2015). With the use of a three-level meta-analytic model, it is possible to calculate and test the variance of effect sizes between studies (level 3) within studies (level 2), and random sampling error (level 1) (Cheung, 2014; Hox, 2002; Van den Noortgate, López-López, Martin-Martinez, & Sánchez-Meca, 2013, 2014). The overall effect size is considered to be heterogeneous if there is significant level 2 and/or level 3 variance.
8 In assessing inter-rater reliability, all studies were looked into by two researchers resulting in an inter-coder reliability of at least Kappa .80 for all variables.
Missing data
We searched exhaustively for primary studies, meeting the inclusion criteria. Further, we contacted authors of studies by e-mail when their research lacked information to compute effect sizes (e.g., Sidebotham, 2001). Nevertheless, it is possible that relevant studies are missing due to publication bias. To check for publication bias, we used Egger’s regression method (Egger, Smith, Schneider, & Minder, 1997) to test the degree of funnel plot asymmetry. If there is no publication bias, the distribution of effect sizes is shaped as a symmetrical funnel, with the standard error on the y-axis and the effect size (r) on the x-axis. In case of funnel plot asymmetry, we applied the “trim-and-fill” method by inserting estimated effect sizes representing effects from missing studies (Duval & Tweedie, 2000). The trim-and-fill method restores the symmetry of an asymmetrical funnel plot (Weinhandl & Duval, 2012), providing an estimate of a ‘true’’ overall effect size that may not be affected by publication bias, thus showing the degree to which publication bias may have had an effect on the results (Nakagawa & Santos, 2012). Since the overall effect after the trim and fill procedure can only be used as an indication of publication bias by comparing it with the observed effect size, the observed (original) overall effect is the one that should be primarily considered.
Results
A total of 59 eligible studies (k) were used for research on intergenerational transmission of maltreatment. The studies were published between 1975 and 2016 (median year of publication was 1997). Studies were conducted in USA (k = 47), Europe (k = 7), China (k = 1), Canada (k = 3) and Australia (k = 1).
9 The total number of effect sizes was 125 (over the 59 studies). The overall effect across all the studies was r = .327, which can be seen as a moderately to largely significant effect. This correlation was converted into an odds ratio, OR = 2.366, representing the risk of intergenerational transmission of maltreatment. In other words, the probability that a parent with a history of maltreatment will maltreat his or her own child is more than twice as high as that probability for a parent who does not have a history of child maltreatment. A funnel-plot shows there is the possibility of a publication bias (see Figure 1.). The results of the Egger’s regression test confirm, in an objective way, that the funnel is asymmetrical, as the intercept significantly deviates from zero (intercept = -3,088; p = .001). Through the trim-and-fill method, effect sizes were inserted to the funnel-plot to see what the result would be if there were no publication bias. After application of this procedure, the correlation was slightly higher (i.e., r = .381 with an OR = 2.764).
Figure 1. Funnel Plot
10 A three-level meta-analysis has been conducted to identify the variance of the effect sizes within and between studies. A homogeneity test allows measurement of how much variance is present between studies (level 3) and within studies (level 2). The overall effect of the variance at level two and three is, respectively .006 and .058. The data proved to be heterogeneous given the significant within and between study variances. This implies that the overall effect may have been influenced by several factors. Therefore, a moderator analysis was conducted to determine what caused the differences in effect sizes. The results of the analysis are shown in Table 1.
The results of the moderator analysis show that “type” of maltreatment was not significant, although it can be seen as a trend. Parents who had been neglected did have a slightly lower probability of passing on maltreatment. Finally, results under “country of study” show that intergenerational transmission of maltreatment was strongest in Europe.
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Table 1
Significant Results for Continues and Categorical Moderators (Bivariate Models)
Moderatorvariables # Studies # ES Intercept (95% CI) /
Mean Z (95% CI)
Mean r β (95% CI) F (df1, df2)a pb Level
2-variance
Level 3-variance
Overall effect before T&F 59 125 .339 (.273, .404) *** .327*** - - - .007*** .054***
Overall effect after T&F 74 153 .401 (.342, .461) *** .381*** - - - .006*** .058***
Type of parental abuse
Physical abuse (RC) 38 53 .349 (.275, .423)*** .335 F(4, 120) = 2.029 .095+ .007*** .055***
Neglect 9 13 .258 (.162, .354)*** .278 -.091 (-.170, -.012)*
Sexual abuse 20 30 .310 (.228, .393)*** .300 -.039 (-.102, .024)
Emotional abuse 5 11 .276 (.171, .380)*** .269 -.073 (-.159, .012)
Mixed (physical abuse & neglect) 11 18 .396 (.256, .536)*** .377 .047 (-.105, .198)
Type of child abuse
Physical abuse (RC) 31 47 .346 (.264, .429)*** .333 F(4, 120) = .816 .517 .008*** .053***
Neglect 10 22 .281 (.181, .382) *** .274 -.065 (-.147, .017)
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Emotional abuse 4 7 .288 (.154, .422) *** .280 -.058 (-.179, .063)
Mixed (physical abuse & neglect) 14 33 .377 (.246, .508) *** .360 .031 (-.124, .185)
Parental abuse registered
No (RC) 53 116 .335 (.267, .403)*** .323 F(1, 123) = .204 .652 .007*** .055***
Yes 7 9 .368 (.224, .513)*** .352 .033 (-.111, .177)
Child abuse registered
No (RC) 12 24 .345 (.253, .437) *** .332 F(1, 123) = 0.038 .846 .008*** .054*** Yes 50 101 .337 (.270, .405) *** .325 -.008 (-.087, .072) Country of study USA (RC) 47 103 .302 (.232, .371) *** .293 F(4, 120) = 2.476 .048* .007*** .047*** Europe 7 12 .598 (.417, .779) *** .536 .296 (.102, .490) ** China 1 1 .419 (-.045, .883) * .396 .117 (-.351, .586) Canada 3 6 .332 (.058, .606) ** .320 .031 (-.252, .313) Australia 1 3 .159 (-.290, .608) .158 -.142 (-.596, .312)
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Mean age of sample in years (parents) 36 59 .333 (.256, .409) *** 29.324 .007 (-.005, .020) F(1, 57) = 1.342 .251 .012*** .037**
Percentage of male children in the sample 29 53 .306 (.216, .395) *** 33.511% .002 (-.001, .006) F(1, 51) = 2.181 .146 .013*** .043**
Percentage of female children in the sample 29 53 .306 (.215, .396) *** 66.454% -.002 (-.006, .001) F(1, 51) = 2.165 .147 .013*** .043**
Study quality 59 125 .340 (.274; .407) *** 2.168 -.007 (-.060; .046) F(1, 123) = .067 .797 .007 .055
Note. # Studies = number of studies; # ES = number of effect sizes; Mean Z = mean effect size (Fisher’s Z); CI = Confidence Interval ; r = Mean effect size (Pearson’s correlation); β = estimated
regression coefficient; RC = Reference category; Level 2-variance = residual variance between effect sizes within studies; Level 3-variance = residual variance between studies.
a
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Discussion
This meta-analysis established that there is a medium to large risk for intergenerational transmission of maltreatment, even after controlling for methodological quality of the studies, different sample and study characteristics, and type of maltreatment (i.e., physical abuse, neglect, sexual abuse, emotional abuse). A trend emerged indicating that if a parent did have a history of neglect, the risk for intergenerational transmission of maltreatment was weaker compared to other types of maltreatment, in particular physical abuse. Finally, we found an indication of publication bias by means of a funnel plot and trim-and-fill procedure. The risk for intergenerational transmission of child maltreatment proved to be somewhat stronger after the adjustment for publication bias.
The aim of the present study was to establish whether there is a risk for intergenerational transmission of child maltreatment, and if so, how great this risk is and which factors may moderate the association between a parental history of maltreatment and subsequent child maltreatment. We therefore did neither examine mechanisms (mediating factors) that may be responsible for the intergenerational transmission of maltreatment, such as social isolation of parents and their aggressive response biases (Berlin, Appleyard, & Dodge, 2011) or child-parent attachment relationships (Austin, 2010), nor studies examining possible protective factors (e.g., social support; Dixon, Brown, & Hamilton-Giachritsis, 2009) that may buffer against risks for intergenerational transmission of child maltreatment, although such mediators and protective factors may coincide with the moderators explaining heterogeneity of effect sizes for intergenerational transmission of maltreatment that were examined in the present study.
Often studies did lack official data on maltreatment, in particular with respect to parental history of maltreatment. Only since the 1960s more attention for child maltreatment has developed, as a result of improved health care (Putte, Lukkassen, Russel, & Teeuw,
15 2013) and a continuing civilization process that prohibits violence and fosters empathy (Pinker, 2011). In the 1960s, maltreatment was mostly considered as physical abuse, which is reflected in the literature of that period, like the book of Kempe (1963) “The Battered Child Syndrome.” Since then, interest in maltreatment has grown and in due course has also been directed towards the different types of maltreatment. The first and second generation of this meta-analytic study was born before the sixties.
This meta-analysis shows a larger effect of intergenerational transmission of maltreatment in Europe than in three Anglo-Saxon countries (i.e. USA, Canada, Australia) and China. One explanation would be that interventions targeting child maltreatment are less effective in Europe, making it more difficult for parents to break the intergenerational cycle of child maltreatment. However, such interpretation is not supported by the meta-analysis on effectiveness of interventions that aim to prevent child maltreatment by Euser, Alink, Stoltenborgh, Bakermans-Kranenburg and Van IJzendoorn (2015). Another possible explanation is a difference in the accessibility of health care or differences in policies of societal institutions, such as schools, to signal and prevent child maltreatment. Notably, a higher chance to identify child maltreatment could increase the odds of detecting intergenerational transmission of child maltreatment, whereas successful referral of parents with a history of child maltreatment to effective treatment may decrease the odds of actual intergenerational transmission of child maltreatment. It is important to notice that substantial differences exist in the organization and delivery of health care, for instance, between Europe and the USA (WHO, 2006). Finally, what counts as child maltreatment may vary among countries and could easily lead to differences in the risk for intergenerational transmission of child maltreatment.
Van der Ploeg and De Groot (2010) concluded that few tools are available to identify child maltreatment if not officially registered, although the range of questionnaires
16 assessing child maltreatment has recently been extended (Bartelink & Kooijman, 2013). However, Assink, van der Put and Stams (2015) established that most of the instruments, including questionnaires used in the studies included in this meta-analysis, lack validity and reliability, and therefore do not accurately assess child maltreatment. It is therefore plausible to suggest that the effect size for intergenerational transmission of maltreatment may be an underestimation of the true effect size due to the use of instruments that are not well-validated or lack the required psychometric properties.
This meta-analytic study has some limitations. First, intergenerational transmission of child maltreatment was established over two generations instead of three because the availability of studies on three generations was limited to only one study (i.e., Doumas, 1994), which was included in the meta-analysis. Second, the study quality was generally low, which can be considered as a floor effect (Lammers & Badia, 2005), and did not show much variance, rendering it difficult to find a significant association (i.e., moderator effect) between study quality and effect size. For these reasons a cautious interpretation of our study results in warranted.
This study has clarified that the risk for intergenerational transmission of child maltreatment is substantial, and probably largest in the case of physical abuse. Parents with a history of maltreatment have a two to three times higher chance of maltreating their own children compared to parents with no history of maltreatment. It seems therefore important to refer parents with a history of maltreatment to interventions that provide parent training with a moderate length of 6 to 12 months and a moderate number of 16 to 30 sessions, because such interventions have been shown to yield the largest effects on reduction of child maltreatment compared to interventions only providing support (Euser et al., 2015). We need in particular keep an eye on established maltreatment, because Euser et al. (2015) showed
17 that interventions targeting maltreatment only had positive effects in maltreating instead of at risk families.
18 References
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21 Appendix B
References of Included Studies
Altemeier, W. A., O'Connor, S., Vietze, P. M., Sandler, H. M., & Sherrod, K. B. (1982). Antecedents of child abuse. Journal of Pediatrics, 100, 823-829.
Altemeier, W. A., O'Connor, S., Vietze, P. M., Sandler, H. M., & Sherrod, K. B. (1984). Prediction of child abuse: A prospective study of feasibility. Child Abuse & Neglect, 8, 393-400.
Altemeier, W. A., O'Connor, S., Sherrod, K. B., Tucker, D., & Vietze, P. (1986). Outcome of abuse during childhood among pregnant low income women. Child Abuse & Neglect, 10, 319-330.
Avery, L., Hutchinson, D., & Whitaker, K. (2002). Domestic violence and intergenerational rates of child sexual abuse: A case record analysis. Child & Adolescent Social Work Journal, 19, 77-90.
Baldwin, J. A., & Oliver, J. E. (1975). Epidemiology and family characteristics of severely- abused children. British Journal of Preventive & Social Medicine, 29, 205-221. Ball, J. D. (2009). Intergenerational transmission of abuse of incarcerated fathers: A study of
the measurement of abuse. Journal of Family Issues, 30, 371-390.
Banyard, V. L., Williams, L. M., & Siegel, J. A. (2003). Impact of complex trauma and depression on parenting: An exploration of mediating risk and protective factors. Child Maltreatment, 8, 334-339.
Bartlett, J. D. (2012). Young mothers, infant neglect and discontinuities in intergenerational cycles of maltreatment (Doctoral dissertation). Retrieved from http://www.cssp.org/ Bartlett, J. D., Raskin, M., Kotake, C., Nearing, K. D., & Easterbrooks, M. A. (2014) An
ecological analysis of infant neglect by adolescent mothers. Child Abuse & Neglect, 38, 723-734.
22 Berlin, L. J., Appleyard, K., & Dodge, K. A. (2011). Intergenerational continuity in child
maltreatment: Mediating mechanisms and implications for prevention. Child Development, 82, 162-176.
Caliso, J., & Milner, J. (1992). Childhood history of abuse and child abuse screening. Child Abuse & Neglect, 16, 647-659.
Chan, K. L. (2012). Evaluating the risk of child abuse: The child abuse risk assessment scale (CARAS). Journal of Interpersonal Violence, 27, 951-973. doi:
10.1177/0886260511423252
Conger, R. D., Burgess, R. L., & Barrett, C. (1979). Child abuse related to life change and perceptions of illness: Some preliminary findings. The Family Coordinator, 73-78. Coohey, C., & Braun, N. (1997). Toward an integrated framework for understanding child
physical abuse. Child Abuse & Neglect: The International Journal, 21, 1081-1094. Coohey, C. (2000). The role of friends, in-laws, and other kin in father-perpetrated child
physical abuse. Child Welfare, 79, 373-402.
Deblinger, E., Hathaway, C., Lippmann, J., & Steer, R. (1993). Psychosocial characteristics and correlates of symptom distress in non-offending mothers of sexually abused children. Journal of Interpersonal Violence, 8, 155-168.
Dilillo, D., Tremblay, G. C., & Peterson, L. (2000). Linking childhood sexual abuse and abusive parenting: The mediating role of maternal anger. Child Abuse & Neglect, 244, 767-779.
Disbrow, M. A., Doerr, H., & Caulfield, C. (1977). Measuring the components of parents' potential for child abuse and neglect. Child Abuse & Neglect, 1, 279, 296.
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