Child Abuse & Neglect 101 (2020) 104347

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Child Abuse & Neglect

journal homepage: www.elsevier.com/locate/chiabuneg

Effect of child abuse and neglect on risk behaviors in inner-city

T
minority female adolescents and young adults
Angela Diaza,b,*, Viswanathan Shankarc, Anne Nucci-Sacka, Lourdes Oriana Linaresa,
Anthony Salandya, Howard D. Stricklerc, Robert D. Burkc,d, Nicolas F. Schlechtc,e
a
Department of Pediatrics, Mount Sinai Adolescent Health Center, Icahn School of Medicine at Mount Sinai, Manhattan, NY, USA
b
Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, Manhattan, NY, USA
c
Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
d
Departments of Pediatrics, Microbiology & Immunology, and Obstetrics, Gynecology & Women’s Health, Albert Einstein College of Medicine, Bronx,
NY, USA
e
Department of Cancer Prevention & Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA

A R T IC LE I N F O ABS TRA CT

Keywords: Background: Over six million children each year are referred to child protective services for child
Child abuse and neglect abuse (sexual, physical and emotional) and neglect (physical and emotional).
Adolescent health Objective: While the relationship between child sexual abuse and sexually transmitted infections
Alcohol and drug use has been documented, there has been little research regarding the effects of other forms of
Depression
maltreatment.
Risk behaviors
Participants and setting: 882 inner-city females aged 12–20 years of age seen at a large adolescent
and young adult (AYA) health center in New York City between 2012–2017.
Methods: History of maltreatment was assessed using the Childhood Trauma Questionnaire.
Associations with depressive symptoms, antisocial behavior, peer deviancy, drug/alcohol use,
and risky sexual behaviors were assessed.
Results: History of maltreatment was common in our cohort of inner-city AYA females, with 59.6
% reporting any type of maltreatment, including sexual abuse (17.5 %), physical abuse (19.5 %)
or neglect (26.2 %), and emotional abuse (30.7 %) or neglect (40.4 %). We observed significant
associations between all forms of maltreatment and risk of depression, drug/alcohol use, anti-
social behaviors, peer deviancy, and risky sexual risk behaviors (including having a higher
number of sexual partners, having a sexual partner 5+ years older, and anal sex). Physical and
emotional abuse were associated with having unprotected sex while under the influence of
drugs/alcohol.
Conclusions and relevance: Reporting a history of maltreatment was associated with an increased
likelihood of engaging in risky sexual and antisocial behaviors, as well as depression in inner-city
female youth. These data highlight the broad, lingering repercussions of all types of child mal-
treatment.

Abbreviations: CDC, Centers for Disease Control and Prevention; CES-D, Center for Epidemiologic Studies-Depression; CTQ, Childhood Trauma
Questionnaire; CI, confidence interval; HPV, human papillomavirus; MSAHC, Mount Sinai Adolescent Health Center; AddHealth, National
Longitudinal Study of Adolescent to Adult Health; OR, odds ratio; STI, sexually transmitted infection
⁎
Corresponding author at: Mount Sinai Adolescent Health Center, 312-320 East 94th Street, New York, NY, 10128, USA.
E-mail address: angela.diaz@mountsinai.org (A. Diaz).

https://doi.org/10.1016/j.chiabu.2019.104347
Received 16 April 2019; Received in revised form 16 December 2019; Accepted 20 December 2019
0145-2134/ © 2019 Published by Elsevier Ltd.
A. Diaz, et al. Child Abuse & Neglect 101 (2020) 104347

1. Introduction

Increasingly, research has demonstrated that adolescent and young adult (AYA) females who were the victims of sexual abuse are
at higher risk of sexually transmitted infections (STIs) and unintended pregnancy (Noll, Shenk, & Putnam, 2009; Stoltenborgh, van
Ijzendoorn, Euser, & Bakermans-Kranenburg, 2011; Wilson & Widom, 2008, 2009). In addition, victims of sexual abuse are more
likely to engage in risky sexual behaviors during both adolescence and adulthood (Hillis, Anda, Felitti, & Marchbanks, 2001; Jones
et al., 2010; Senn, Carey, & Coury-Doniger, 2011; Senn, Carey, & Vanable, 2008; van Roode, Dickson, Herbison, & Paul, 2009;
Wekerle, Goldstein, Tanaka, & Tonmyr, 2017; Wilson, Emerson, Donenberg, & Pettineo, 2013). While past research concentrated on
the effects of female sexual child abuse, other types of child maltreatment, including nonsexual forms of abuse and neglect that
represent more than three-quarters of all reported cases of child maltreatment (Houck, Barker, Hadley, Menefee, & Brown, 2018;
Lansford et al., 2002; Negriff, Schneiderman, & Trickett, 2015; Norman et al., 2012; Thibodeau, Lavoie, Hebert, & Blais, 2017; Walsh,
Latzman, & Latzman, 2014) are increasingly recognized as having equivalent negative effects across indices of adolescent health
(Rivera, Bray, Guastaferro, Kugler, & Noll, 2018; Vachon, Krueger, Rogosch, & Cicchetti, 2015; Yoon, Voith, & Kobulsky, 2018),
including drug use, antisocial behavior, peer deviancy and psychopathology such as depressive symptoms (Oberlander et al., 2011).
As many as 20 % of U.S. children have experienced abuse or neglect over their lifetimes (Cummings & Berkowitz, 2014). Over six
million children are reported each year to child protective services for maltreatment, with the majority of reported cases occurring in
low-income, inner-city and minority populations (Diaz & Petersen, 2014). Cases of maltreatment are significantly higher for African-
American children than those for non-Hispanic White children (Lee et al., 2012; Wilson et al., 2013). In addition, children from low
socioeconomic status households experience some type of abuse and neglect at more than 5 times the rate of other children (Sedlak
et al., 2010).
Urban and minority youth also report engaging in risky sexual behaviors at higher rates than the general population (Kann et al.,
2016). Inner-city minority youth also experience negative sexual health outcomes at higher rates (Centers for Disease Control &
Prevention, 2016) including acquiring STIs (Barton, Braxton, & Davis, 2016). The two most common STIs, chlamydia, and gonorrhea
are more common among minority females than non-Hispanic White females of the same age (Centers for Disease Control &
Prevention, 2016).
As part of an ongoing cohort study to assess behavioral and psychosocial risk factors for human papillomavirus (HPV) infection in
sexually-active inner-city AYAs who received HPV vaccination at the Mount Sinai Adolescent Health Center (MSAHC) in New York,
we introduced a standardized self-report screening survey for child maltreatment, including questions on history of physical and
emotional abuse and neglect. We hypothesized that other forms of abuse and neglect will be associated with poorer psychosocial
functioning and higher sexual risk behaviors independent of sexual abuse. The study’s high risk and large sample size afforded us to
examine associations with risky psychosocial and sexual behaviors by type of maltreatment.

2. Methods

2.1. Study population and setting

The Mount Sinai Adolescent Health Center (MSAHC) uses a unique model that integrates medical, sexual and reproductive health,
dental, optical, and behavioral and mental health. The services provided cover a continuum of wellness, including health education
and risk reduction, as well as prevention and treatment services. All services are confidential and free to patients. The center is
located on the border of East Harlem and supports an underserved population of children, adolescents, and young adults (ages
10–24).
A full description of the study design has been published previously (Braun-Courville et al., 2014). Briefly, females were eligible to
participate if they: 1) were between 13 and 19 years of age at time of consent, 2) had ever engaged in vaginal or anal intercourse, and
3) intended to get or had already received an FDA approved HPV vaccine (GARDASIL®). Females pregnant at time of recruitment, or
who had terminated a pregnancy within the 4 weeks prior to enrollment, were asked to return at a later date and not included in the
current analysis. Participants returned every six months for gynecological examination and completed a self-administered ques-
tionnaire on sexual behaviors and psychosocial risk measures (described in more detail below). To assess the burden of child abuse
and neglect in the population, we used the Childhood Trauma Questionnaire (Bernstein & Fink, 1998) for subjects entering or returning
for a follow-up visit in the ongoing cohort surveillance study (Braun-Courville et al., 2014). Similarly, some scales (CES-D, peer
deviancy module, and sex under influence of drugs or alcohol) were introduced later in the study; these outcomes were analyzed at
enrollment for new subjects and at first assessment for returning subjects.

2.2. Ethics

Written informed consent was collected from all participants prior to enrollment. This study was approved by the Institutional
Review Board at The Icahn School of Medicine at Mount Sinai.

2.3. Assessment of child maltreatment type

The Childhood Trauma Questionnaire (CTQ)(Bernstein & Fink, 1998) is a 28-item self-report inventory that was used to assess
retrospectively if our research participants have been exposed to abuse (Sexual, Physical and Emotional) and neglect (Physical and

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A. Diaz, et al. Child Abuse & Neglect 101 (2020) 104347

Emotional) during their childhood. Study participants were asked to report based on their experiences ‘When I was growing up…”. The
CTQ has been validated extensively for use in retrospective studies as a screening tool for child abuse and neglect, and has been used
as the gold standard for testing of other child maltreatment survey tools and interview techniques (Bernstein et al., 2003; DiLillo
et al., 2006, 2010; Lobbestael, Arntz, Harkema-Schouten, & Bernstein, 2009). The scale includes 5 items representing each type of
abuse/neglect and a 3-item minimization/denial scale for detecting false-negative child maltreatment reports. Subjects responded to
statements about their childhood experiences, using a 5-point scale. The severity of each type of abuse and neglect was then
quantified and grouped to characterize none to minimal, low to moderate, and severe to extreme maltreatment using for following
cut-point (Bernstein & Fink, 1998): physical abuse (≤7, 8–9, ≥10); sexual abuse (≤5, 6–7, ≥8); emotional abuse (≤8, 9–12, ≥13);
physical neglect (≤7, 8–9, ≥10); and emotional neglect (≤9, 10–14, ≥15) respectively.

2.4. Assessment of sexual behaviors and psychosocial factors

Self-administered questionnaires consisting of items to assess risk behaviors are completed at enrollment and every six months as
part of the base study protocol. These included questions regarding demographics, recent and lifetime history of sexual behaviors,
contraceptive use, history of pregnancies, STIs and anogenital warts, and use of cigarettes, alcohol, and illicit substances. The risk of
alcohol and substance abuse was also assessed using the 6-item American Academy of Pediatrics' Committee on Substance Abuse
behavioral health screening scale (CRAFFT) (Knight, Sherritt, Shrier, Harris, & Chang, 2002). A CRAFFT score of 2 or more was
considered positive, indicating a need for additional screening for alcohol and drug/substance abuse and dependence (Knight et al.,
2002). History of unprotected sex while under the influence of drugs or alcohol, and having sex in exchange for money was also
asked.
In addition, the questionnaires included a number of validated scales to assess depressive symptoms and antisocial behavior.
Depression was assessed using the 20-item Center for Epidemiologic Studies-Depression (CES-D)(Gotlib & Cane, 1989) scale that has
been previously validated for female AYA populations including minority groups (Garrison, Addy, Jackson, McKeown, & Waller,
1991; Roberts, Lewinsohn, & Seeley, 1991; Rushton, Forcier, & Schectman, 2002). A CES-D score of 16 or more was considered as
positive for depression based on evidence from population studies (Lewinsohn, Seeley, Roberts, & Allen, 1997).
Antisocial behavior was measured using the 13-item Antisocial/Delinquency/Violence module of the National Longitudinal Study of
Adolescent Health (ADDHealth), including lying, delinquent acts (stealing, trespassing, graffiti), and use of violence (physical fights,
using a weapon) in the past 12 months (Kathleen, Udry, Bearman, & Harris, 2009). An antisocial index score of 3 or more was defined
as positive, while a score less than or equal to 2 was considered as none or mild (Pechorro, Moreira, Basto-Pereira, Oliveira, & Ray,
2019). This cutoff was found to be associated with risk of HPV in a previous study in this population (Linares et al., 2015).
Peer deviance and delinquency behaviors were assessed using the 17-item Chicago Youth Development Study Self-Report
Delinquency Scale adapted from the ADDHealth study survey. This scale evaluated involvement with deviant peers by asking youth to
report the extent to which their friends engaged in 17 delinquent behaviors in the prior 3 months, including violent behaviors, drug,
and alcohol use, and getting arrested (Miller, Gorman-Smith, Sullivan, Orpinas, & Simon, 2009). Peer deviancy was defined on a
categorical scale with any report of being involved in gang fights, rape, cocaine use, or getting arrested considered as severe peer
deviancy, while a report of any of the other 14 delinquent behaviors was considered as mild or moderate peer deviancy.
Sexual behavior outcomes were abstracted as collected in the study questionnaire and included: lifetime number of sexual
partners (1, 2, 3–4, 5–9, 10+), anal sex (never vs. ever), and ever having unprotected sex while under influence of drugs or alcohol
(no vs. yes).

2.5. Clinical history and physical exam

All study participants received a comprehensive gynecological examination that included: sexual, reproductive, behavioral and
psychosocial history, immunization update, blood and urine testing/screening (as indicated), and age-specific health education. All
subjects were screened for evidence of sexual and physical abuse annually by trained adolescent medicine physicians, and suspected
cases were referred immediately for counseling with a mental health expert at MSAHC.

2.6. Statistical analyses

Distribution of demographic, social and behavioral characteristics were numerically presented as frequencies and percentages. We
examined the distribution of the CTQ by severity (none-minimal vs. low-moderate vs. severe) for each of the five maltreatment types
(sexual abuse, physical abuse, emotional abuse, physical neglect and emotion neglect)(Litrownik et al., 2005). The distribution of five
types of maltreatment by response variables are provided in the supplemental material.
Cross-sectional associations between reported maltreatment type, depression and risky behaviors were examined using multi-
variable logistic regression for binary outcomes adjusting for age, race/ethnicity, lifetime number of sexual partners and psychosocial
indicators including socio-economic-status (using previously described index (Linares et al., 2015), family support (operationalized as
an adult in the household), and educational attainment (operationalized as attending school or college) for all outcomes except
lifetime sexual partners. In addition, CTQ minimization/denial scale variable was added in all models as a covariate to address
underreporting. Exposure to maltreatment type was categorized as follows: (i) those reporting exposure to any single maltreatment
type (primary exposed group), (ii) those reporting exposure to other types of maltreatment (adjusting variable), and (iii) those
reporting no abuse or neglect (reference group).

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A. Diaz, et al. Child Abuse & Neglect 101 (2020) 104347

Odds ratios (OR) and 95 % confidence intervals (CI) were estimated for the above psychosocial and sexual outcomes, by com-
paring subjects reporting none-to-minimal vs. low-to-extreme maltreatment type, assuming independent relationships between each
maltreatment type. Cumulative logit models were fit to assess the associations between maltreatment exposure and ordinal response
variables: peer deviancy (severe, mild-moderate or none), and lifetime number of sexual partners (10+, 5–9, 3–4, 2 or ≤1).
Proportional odds assumptions were examined using the score test. For models that did not pass the proportional odds test, an
unconstrained partial proportional odds model was fit and assessed using either Hosmer-Lemeshow or Pearson goodness of fit tests
(Ananth & Kleinbaum, 1997; Hosmer, Lemeshow, & Sturdivant, 2013). P-values of < 0.05 were considered to have poor fit.
To further examine the effects of physical and emotional abuse and neglect remained in the absence of sexual abuse we repeated
the analyses above excluding AYAs who reported a history of sexual abuse. In addition, we ran sensitivity analyses with multiple
imputation using a fully-conditional specification approach, under a missing at random assumption, with 10 imputed data sets to
accommodate for missing data.
All participants completed the measures once, including 38 % who completed the survey at enrollment (visit 1), 33 % within the
first year (between visits 2 and 5), and the remaining at a later visit. Given the varied assessment over visits, we evaluated if there
were any cohort effects (i.e., due to the staggered administration of the surveys) but did not find any significant differences.

3. Results

3.1. Study population characteristics

The study sample consisted of 882 AYA females from a predominantly minority population with a median age of 18 years at entry
(with a mean of 17.6 years and standard deviation of 1.31), most of whom (65.5 %) were enrolled in middle or high school (Table 1).
Reflecting on the enrollment criteria, all participants were sexually active at the time of enrollment; nearly 40 % reported having
vaginal sex before the age of 14, and 41.2 % reported having had a total of two or more male sexual partners. Other high-risk sexual
behaviors included having unprotected sex while under the influence of drugs or alcohol (reported by 39.1 % of subjects) and having
sex in exchange for money, drugs, shelter, or food (1.6 %). Twenty-four percent of subjects reported having had sex with a partner at
least five years older.

3.2. Reported history of child maltreatment

History of maltreatment was reported by 59.6 % of subjects in our sample. Using established CTQ scale cut-points for abuse and
neglect described above, the prevalence of each type of maltreatment was the following: emotional abuse (30.7 %) / neglect (40.4 %),
physical abuse (19.5 %) / neglect (26.2 %), and sexual abuse (17.5 %; Fig. 1). Over a third (37.5 %) of AYA females reported being
victims of at least two maltreatment types, with almost 5 % reporting enduring all 5 types of maltreatment (Fig. 2). Given the
multiplicity of experiences that may be captured by self-reported emotional neglect, the proportion of the sample reporting only this
form of maltreatment was examined. The proportion reporting a history of emotional neglect only were 8.9 % (n = 79). Using the
CTQ denial scale, we assessed potential for underreporting of abuse/neglect; overall, 32 % of subjects exhibited some denial (score
1–3) with approximately 10 % exhibiting a high level of denial for any maltreatment.

3.3. Association between child maltreatment and psychosocial risk factors

Results from multivariable logistic regression analyses comparing single maltreatment type are shown for psychosocial factors
(Table 2) measured in the study cohort, adjusted for age, race/ethnicity, socio-economic status, family support, attending college or
school, exposure to other maltreatment types, and denial. We observed statistically significant increased odds of depression and drug/
alcohol use in AYA females reporting a history of all forms of maltreatment type. History of abuse and neglect was also significantly
associated with increased peer deviancy.

3.4. Association between child maltreatment and risky sexual behaviors

With respect to risky sexual behaviors, AYA females who reported a history of physical or emotional abuse during childhood were
more likely to: (i) report a higher number of lifetime sexual partners, (ii) have engaged in anal sex, (iii) report having had sex with an
older partner (≥5 years), and (iv) admit to ever having unprotected sex while under the influence of drugs or alcohol (after adjusting
for the same covariates as above), compared to those reporting no history of abuse or neglect (Table 3). No significant associations
were seen for age at first vaginal intercourse, use of contraception, and history of pregnancy (not shown).
Given the potentially pervasive impact of sexual abuse, we also assessed the effects of other forms of abuse and neglect among
(N = 726) AYAs who reported no history of sexual abuse (Tables 2 and 3). Physical and emotional abuse histories were significantly
associated with psychosocial factors and risky sexual behaviors among AYAs who reported these experiences, but not sexual abuse.
Similarly AYAs reporting physical and emotional neglect without sexual abuse showed significant associations with psychosocial
factors depression and drug or alcohol use. Estimates for all model covariates are provided in the supplemental material.

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A. Diaz, et al. Child Abuse & Neglect 101 (2020) 104347

Table 1
Study subject characteristics.
N %

Age mean (SD) 17.6 (1.31)

13-15 62 7.0
16-17 307 34.8
18-20 513 58.2
Race/Ethnicity *
Any Hispanic 533 60.5
Non-Hispanic African-American 315 35.8
Other non-Hispanic 33 3.8
Education
≤10th grade 209 23.7
11-12th grade 369 41.8
High-School Graduate 138 15.6
Some College 165 18.7
Vaginal Sex Lifetime Partners
1 517 58.8
2 210 23.9
3+ 153 17.4
Anal Sex Lifetime Partners
0 642 73.1
1 166 18.9
2+ 70 8.0
Age at first sexual intercourse
> 14 years 539 61.1
< 14 years 343 39.1
HPV vaccine at baseline
Vaccine naïve 107 12.1
1-3 doses 775 87.9
History of Pregnancy
No 584 66.2
Yes 219 24.8
Any contraception†
Most times to Always 636 72.1
Never/Rarely/sometimes 246 27.9
Condom use during vaginal intercourse
Most times to Always 397 46.4
Never/Rarely/Sometimes 458 53.6
Ever had sex with partner 5 years older or more
Never 566 64.2
Ever 212 24.0
Unprotected sex while under influence of drugs or alcohol
Never 545 61.8
Ever 337 39.1
Received money, drugs, shelter or food in exchange for sex
Never 868 98.4
Ever 14 1.6
Antisocial behavior
No 624 70.8
Yes 257 29.1
Alcohol/Substance use
No 566 64.2
Yes 310 35.2
Peer Deviancy
No 122 13.8
Mild/Moderate 559 63.4
Severe 201 22.8
Depression
No 646 73.2
Yes 236 26.8
Lifetime # of sexual partners
1 154 17.5
2 161 18.3
3-4 259 29.4
5-9 212 24.0
10+ 96 10.9

†Including hormonal and barrier contraceptive methods; ‡Including non-full term. Total N (%) may not add to
882 for all data.

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A. Diaz, et al. Child Abuse & Neglect 101 (2020) 104347

Fig. 1. Bar chart shows proportions of subjects exposed to each of the five types of abuse and neglect by severity of victimization (low, moderate and
severe).

Fig. 2. Sunburst plot showing combined history of child sexual abuse (red) by history of child physical abuse (light green) and neglect (dark green)
and child emotional abuse (light orange) and neglect (dark orange) reported by inner-city adolescent and young adult women (For interpretation of
the references to colour in this figure legend, the reader is referred to the web version of this article.).

4. Discussion

There is increasing support for the broad detrimental effects of all forms of child maltreatment on AYA health (Lansford et al.,
2002; Vachon et al., 2015). Emerging research indicates that exposure to child nonsexual abuse and neglect has long lasting con-
sequences on AYA psychosocial functioning and sexual behaviors (Negriff et al., 2015; Norman et al., 2012). Accordingly, identifying
childhood factors that predict high-risk behaviors during adolescence and early adulthood is a priority (Oshri, Tubman, & Burnette,
2012; Sedlak et al., 2010; Sena et al., 2015) particularly among inner-city minority youth that tend to engage in risky sexual
behaviors at higher rates than the general population (Kann et al., 2016).
In a large cohort of 882 inner-city minority AYA females, the current study examined the associations between type of child
maltreatment (encompassing three types of abuse and two types of neglect), psychosocial functioning (depression, antisocial be-
havior, peer deviancy, substance/alcohol use), and risky sex behaviors. The current data show not only that exposure to child
nonsexual (physical and emotional) abuse is associated with high-risk sexual, depression, and antisocial behaviors, but that these
associations are close in magnitude to that of exposure to child sexual abuse. Furthermore, our study demonstrates that exposure to
child neglect itself (physical and emotional) after adjusting for exposure to other forms of maltreatment, is associated with similar
detrimental outcomes, with associations often just as strong as those seen for child abuse victims.

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Table 2
Adjusted associations between history of child maltreatment type and psycho-social risk factors in sexually-active inner-city adolescent and young
adult females.
Maltreatment exposure* Depressive symptoms‡ Antisocial behavior Drug or Alcohol use|| Peer Deviancyβ

Sexual abuse Complete Case 5.1 (3.2, 8.5) 1.8 (1.1, 2.8) 3.0 (1.9, 4.6) 4.2 (2.6, 6.8)
CH = 3.1, p = 0.93 CH = 14.9,p = 0.06 CH = 5.9, p = 0.64 Cp = 1666.7, 0.19
MI estimates 5.2 (3.2, 8.5) 1.8 (1.1, 2.8) 3.0 (1.9, 4.6) 3.3 (2.1, 5.1)
Physical abuse Complete Case 4.9 (3.0, 7.9) 1.9 (1.2, 2.9) 3.4 (2.3, 5.3) 4.9 (3.1, 7.9)
CH = 6.9, p = 0.54 CH = 18.6, p = 0.02 CH = 5.8, p = 0.67 Cp = 1682.2, p = 0.16
MI estimates 4.9 (3.0, 7.9) 1.9 (1.2, 3.0) 3.5 (2.3, 5.4) 4.9 (3.1, 7.9)
Emotional abuse Complete Case 6.4 (4.0, 10.0) 1.7 (1.1, 2.5) 3.1 (2.1, 4.6) 3.0 (2.0, 4.4)
CH = 10.4, p = 0.23 CH = 12.2, p = 0.14 CH = 3.2, p = 0.92 Cp = 1681.1, p = .20
MI estimates 6.4 (4.1, 10.0) 1.7 (1.1, 2.5) 3.2 (2.2, 4.7) 3.0 (2.0, 4.4)
Physical neglect Complete Case 3.7 (2.3, 5.7) 1.6 (1.0, 2.4) 2.5 (1.7, 3.6) 2.3 (1.4, 3.6)
CH = 2.5 p = 0.96 CH = 9.3, p = 0.32 CH = 6.7, 0.56 Cp = 1674.9,p = 0.22
MI estimates 3.6 (2.3, 5.7) 1.6 (1.1, 2.4) 2.5 (1.7, 3.6) 2.2 (1.4, 3.5)
Emotional neglect Complete Case 4.4 (2.8, 6.7) 1.5 (1.0, 2.2) 2.0 (1.4, 2.9) 2.3 (1.5, 3.6)†
CH = 4.8, p = 0.78 CH = 9.3, p = 0.28 CH = 6.8, 0.55 Cp = 1652.5, 0.24
MI estimates 4.4 (2.8, 6.8) 1.5 (1.0,2.2) 2.0 (1.4, 3.0) 2.7 (1.7, 4.2)
Excluding subjects reporting no history of sexual abuse
Physical abuse Complete Case 2.7 (1.5, 4.9) 1.9 (1.1, 3.3) 3.1 (1.9, 5.2) 3.2 (1.9, 5.4)
CH = 3.9, p = 0.87 CH = 15.2, 0.06 CH = 3.1, p = 0.92 Cp = 1376.9, p = 0.29
MI estimates 2.7 (1.5, 4.8) 1.9 (1.1, 3.3) 3.1 (1.9, 5.2) 3.2 (1.9, 5.4)
Emotional abuse Complete Case 5.1 (3.1, 8.4) 1.5 (0.9, 2.4) 3.1 (2.0, 4.9) 2.4 (1.6, 3.8)
CH = 8.5, P=0.38 CH = 13.6, 0.09 CH = 2.2, p = 0.97 Cp = 1355.9, p = 0.45
MI estimates 5.1 (3.1, 8.4) 1.5 (102, 2.4) 3.2 (2.0, 4.9) 2.8 (1.7, 4.9)&
Physical neglect Complete Case 2.7 (1.6, 4.5) 1.6 (1.0, 2.5) 2.0 (1.3, 3.2) 1.3 (0.8, 1.9)
CH = 2.6, p = 0.95 CH = 19.8, 0.27 CH = 4.5, p = 0.80 Cp = 1389.6, p = 0.25
MI estimates 2.7 (1.6, 4.4) 1.6 (1.0, 2.5) 2.0 (1.3, 3.1) 1.3 (0.8, 1.9)
Emotional neglect Complete Case 3.5 (2.2, 5.5) 1.4 (0.9, 2.1) 1.8 (1.2, 2.8) 1.5 (1.0, 2.2)
CH = 3.9, p = 0.86 CH = 11.4, p = 0.17 CH = 6.8, p = 0.55 Cp = 1376.8, p = 0.22
MI estimates 3.5 (2.2, 5.5) 1.4 (0.9, 2.1) 1.8 (1.2, 2.8) 1.5 (1.0, 2.2)

Cp- Pearson Goodness of fit Test Chi-square and corresponding p-value. MI- Multiple imputation.
* Odds ratios (95 % confidence intervals) are shown comparing none-to-minimal vs. low-to-extreme abuse or neglect for those with the mal-
treatment type shown compared to those reporting no abuse or neglect (reference group), adjusting for age, race/ethnicity, lifetime number of
sexual partners (for selected outcomes), psychosocial indicators, denial, and exposure to other forms of abuse or neglect.
‡
CES-D score (> 16).
||
CRAFFT scale (> 1).
β
ADDHealth Peer Deviancy score (severe vs. mild + moderate vs. none).
†
Estimates by partial proportional odds model shown for Severe vs Mild/Moderate/None, those for Severe/Mild/Moderate vs None were 1.2
(0.7–1.9) [MI estimates: 1.3 (0.8, 2.1)] for Emotional neglect.
&
Estimates by partial proportional odds model shown for Severe vs Mild/Moderate/None, those for Severe/Mild/Moderate vs None MI estimates:
2.2 (1.1, 4.7)] CH Hosmer and Lemeshow Goodness-of-Fit Test Chi-square with 8 degrees of freedom, and corresponding p-value.

From an intervention perspective, a broad vulnerability skill-based approach (Houck et al., 2018) such as increasing emotion self-
regulation and coping with negative affect, may help mitigate the impact of child abuse and neglect on co-occurring sexual risk-
taking, depression, peer deviance, and substance/alcohol use (Cary & McMillen, 2012; Jones et al., 2013; Proctor et al., 2017; Wilson
& Widom, 2011). Adding to recent studies about the harmful effects of sexual and nonsexual abuse on AYA risky sexual practices
(Abajobir, Kisely, Williams, Strathearn, & Najman, 2018; Thibodeau et al., 2017; Thompson et al., 2017; Werner et al., 2018) our
study expands emerging literature to an urban inner-city female AYA clinic population (Wekerle et al., 2017). This is important as the
majority of reported cases of abuse and neglect occur in low-income, inner-city and minority populations (Diaz & Petersen, 2014).
Rates of STIs are also highest among inner-city minority youth (Braxton et al., 2018).
The results from this study require validation; we acknowledge that external validity may be confined to individuals who are more
receptive to receiving medical and psychological care as the study sample was comprised of AYA patients who were seeking services
from MSAHC, and had consented to participate in a prospective HPV research study (Carey, Senn, Vanable, Coury-Doniger, & Urban,
2008). All subjects were sexually active at the time of enrollment, and therefore more likely to present with sexual risk behaviors than
other AYA female populations. Child abuse victims also have an increased risk of re-victimization (Barnes, Noll, Putnam, & Trickett,
2009; Finkelhor, Ormrod, & Turner, 2007). While we did not assess for incidents of new sexual or physical abuse in our study, those
with a history of abuse were more likely to report having had older sexual partners (≥5 years). While such reports may be indicative
of problematic relationships, it is unknown whether they constituted abuse as timing was not ascertained. Mediational analyses will
be needed to identify direct and indirect influences underlying linkages between child maltreatment history and later risky sexual
practices (Yoon et al., 2018).
There are also limitations surrounding measurement of child abuse and neglect. First, it was impossible to verify the temporal
order with reported history of both risk behaviors and abuse/neglect, making it difficult to establish causation. Second, the gathering
of information around maltreatment experiences, such as involvement with child protection services, timing, and sequence of

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A. Diaz, et al. Child Abuse & Neglect 101 (2020) 104347

Table 3
Adjusted associations between history of child maltreatment type and risky sexual behaviors in inner-city adolescent and young adult females.
Maltreatment exposure* Lifetime # of sexual partnersβ Anal sex ever Sexual partner ≥5 years Unprotected sex under
older‡ influence||

Sexual abuse Complete Case 2.3 (1.3, 4.2)† 1.7 (1.0, 2.7) 1.9 (1.1, 3.3) 1.4 (0.9, 2.1)
Cp = 1326.3, p = 0.04 CH = 3.9, p = 0.87 CH = 3.4, p = 0.90 CH = 7.1, p = 0.52
MI estimates 2.3 (1.3, 4.2)† 1.7 (1.0, 2.7) 2.1 (1.3, 3.6) 1.3 ((0.9, 2.1)
Physical abuse Complete Case 1.6 (1.1, 2.3) 2.1 (1.3, 3.3) 2.0 (1.2, 3.4) 1.6 (1.1, 2.5)
Cp = 1318.9, p = 0.02 CH = 9.5, p = 0.30 CH = 4.1, p = 0.85 CH = 4.2, p = 0.83
MI estimates 1.6 (1.0, 2.4) 2.1 (1.3, 3.3) 2.2 (1.3, 3.7) 1.6 (1.1, 2.4)
Emotional abuse Complete Case 1.5 (1.1, 2.1) 1.8 (1.2, 2.7) 1.8 (1.1, 2.8) 1.5 (1.0, 2.1)
Cp = 1344.9, p = 0.01 CH = 10.1, p = 0.26 CH = 3.2, p = 0.92 CH = 4.2, p = 0.84
MI estimates 1.5 (1.1, 2.2) 1.8 (1.1, 2.7) 1.9 (1.2, 3.1) 1.4 (1.0, 2.1)
Physical neglect Complete Case 1.4 (1.0, 1.9) 1.5 (1.0, 2.3) 1.5 (0.9, 2.4) 1.3 (0.9, 1.8)
Cp = 1385.7, p = 0.01 CH10.1, p = 0.26 CH = 5.1, p = 0.74 CH = 8.7, p = 0.36
MI estimates 1.4 (1.0, 1.9) 1.5 (1.0, 2.3) 1.6 (1.0, 2.6) 1.2 (0.8, 1.8)
Emotional neglect Complete Case 1.5 (1.1, 2.1) 1.6 (1.1, 2.4) 1.6 (1.0, 2.6) 1.1 (0.8, 1.6)
Cp = 1336.7, p = 0.02 CH = 8.3, p = 0.41 CH = 3.2, p = 0.92 CH = 11.6, p = 0.17
MI estimates 1.6 (1.1, 2.1) 1.6 (1.1, 2.4) 1.8 (1.1, 2.8) 1.1 (0.8, 1.6)
Excluding subjects reporting no history of sexual abuse
Physical abuse Complete Case 1.6 (1.0, 2.4) 2.4 (1.4, 4.1) 2.4 (1.3, 4.5) 2.0 (1.2, 3.4)
Cp = 1194.0, p = 0.01 CH = 9.7, p = 0.28 CH = 1.6, p = 0.99 CH = 14.2, p = 0.08
MI estimates 1.6 (1.0, 2.4) 2.4 (1.4, 4.1) 2.5 (1.3, 4.9) 2.0 (1.2, 3.4)
Emotional abuse Complete Case 1.6 (1.1, 2.2) 2.0 (1.2, 3.2) 1.8 (1.0, 3.0) 1.5 (1.0, 2.3)
Cp = 1219.50, p = 0.01 CH = 10.7, p = 0.22 CH = 3.1, p = 0.93 CH = 8.6, p = 0.37
MI estimates 1.5 (1.1, 2.2) 2.0 (1.2, 3.2) 1.8 (1.0, 3.1) 1.5 (1.0, 2.4)
Physical neglect Complete Case 1.4 (0.9, 1.9) 1.3 (0.8, 2.1) 1.4 (0.8,2.3) 1.3 (0.9, 2.0)
Cp = 1231.2, p = 0.01 CH = 1.9, p = 0.98 CH = 3.3, p = 0.91 CH = 10.1, p = 0.25
MI estimates 1.4 (1.0, 1.9) 1.2 (0.8, 2.0) 1.4 (0.8, 2.4) 1.3 (0.8, 2.0)
Emotional neglect Complete Case 1.6 (1.1, 2.2) 1.5 (0.9, 2.3) 1.6 (0.9, 2.6) 1.2 (0.8, 1.7)
Cp = 1212.2, p = 0.01 CH = 12.3, p = 0.14 CH3.9, p = 0.87 CH = 5.8, p = 0.56
MI estimates 1.5 (1.1, 2.1) 1.5 (1.0, 2.3) 1.7 (1.0, 2.8) 1.2 (0.8, 1.7)

Significant associations are shown in bold.

CH Hosmer and Lemeshow Goodness-of-Fit Test Chi-square with 8 degrees of freedom, and corresponding p-value.
Cp Pearson Goodness of fit Test Chi-square and corresponding p-value. MI- Multiple imputation.
* Odds ratios (95 % confidence intervals) are shown comparing none-to-minimal vs. low-to-extreme abuse or neglect for those with the mal-
treatment type shown compared to those reporting no abuse or neglect (reference group), adjusting for age, race/ethnicity, lifetime number of
sexual partners (for selected outcomes), psychosocial indicators, denial, and exposure to other forms of abuse or neglect.
β
Estimates from proportional odds models (10+ vs < 10, ≥5 vs < 5, ≥3 vs < 3, ≥2 vs 1).
‡
Had ever had a sexual partner 5 years or older at enrollment (yes vs. no).
||
Unprotected sex while under influence of drugs or alcohol.
†
Estimate by partial proportional odds model for 10+ vs < 10; estimates for lower outcome categories were 1.2 (0.8–1.9) [MI: 1.2 (0.8, 1.9)]
for > = 5 vs < 5, 1.5 (0.9–1.8) [MI: 1.2 (0.8, 1.8)] for > = 3 vs < 3, and 1.5 (0.9–2.6) [MI: 1.5 (0.9, 2.5)] for > = 2 vs < 2.

maltreatment and concurrent poly-victimization, which were not assessed here, may have revealed additional components affecting
sexual and other health outcomes. Third, there is some controversy in the field regarding accuracy in recalling traumatic events that
occurred in childhood. However, there is strong evidence supporting the validity of retrospective measures (Kendall-Tackett &
Becker-Blease, 2004). Results from a large study of adults show recall of child abuse and neglect to be highly reliable when assessed
on two separate occasions, approximately a year apart (Dube, Williamson, Thompson, Felitti, & Anda, 2004). In addition, it’s im-
portant to note that the majority of evidence to date on the long-term effects of child abuse comes from retrospective studies in adults.

5. Conclusion

While research has demonstrated that AYA females who were the victims of sexual abuse are at higher risk of STIs (Stoltenborgh
et al., 2011; Wilson & Widom, 2008) growing evidence supports the detrimental effects of nonsexual types of abuse (physical and
emotional) and child neglect; which represent more than three-quarters of all reported cases of child maltreatment (Lansford et al.,
2002; Negriff et al., 2015; Norman et al., 2012; Vachon et al., 2015). Beyond the well-known effects of child sexual abuse, the current
data show the extensive burden across child nonsexual abuse and neglect types (adjusting for other forms of maltreatment) ranging
from a two- to four-fold increased risk on multiple indices of psychosocial dysfunction and sexual behavior. Inner-city AYA females
reporting a history nonsexual abuse (physical or emotional) types and neglect were significantly more likely to report depression,
using drugs or alcohol, engaging with peers who tend to have deviant or delinquent behaviors, having higher number and older
sexual partners, and having unprotected sex while under the influence of drugs or alcohol, compared to those reporting no history of
abuse or neglect. The findings suggest that intervening broadly with maltreated youth is important to reduce sexual risky behavior
among inner-city minority females (Barton et al., 2016).

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A. Diaz, et al. Child Abuse & Neglect 101 (2020) 104347

Funding

This work was supported in part by an R01 grant from the National Institute of Allergy and Infectious Diseases (AI072204 to AD,
NFS and RDB), and National Cancer Institute P30 grants to the Einstein Cancer Research Center (CA013330) and to Roswell Park
Comprehensive Cancer Center (CA016056). Additional funding was provided by the Icahn School of Medicine at Mount Sinai.

Author contributions

Drs. Diaz, Shankar, Nucci-Sack, Linares, Strickler, Burk, Schlecht conceptualized and designed the study.
Drs. Diaz, Nucci-Sack, Linares, Salandy, Strickler, Burk, Schlecht helped design or select the data collection instruments.
Drs. Diaz, Nucci-Sack, Linares, Salandy, Schlecht coordinated or supervised data collection.
Drs. Shankar, Schlecht conducted statistical analyses.
Drs. Diaz, Nucci-Sack, Linares, Salandy, Strickler, Burk helped with interpretation of the data.
Drs. Diaz, Shankar, Schlecht drafted the initial manuscript.
Drs. Diaz, Shankar, Nucci-Sack, Linares, Salandy, Strickler, Burk, Schlecht critically reviewed the manuscript.
Drs. Shankar and Schlecht had full access to all the data in the study and take responsibility for the integrity of the data and the
accuracy of the data analysis.

Financial disclosure

The authors have no financial relationships relevant to this article to disclose.

Declaration of Competing Interest

The authors have no conflicts of interest relevant to this article to disclose.

Acknowledgements

We thank the participants of this study, and study staff and volunteers at Mount Sinai Adolescent Health Center for their time and
effort spent enrolling participants with data entry. In addition, we thank Sarah Pickering for her help with managing the study, and
Christine Soghomonian with her help with database management.

Appendix A. Supplementary data

Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.chiabu.2019.
104347.

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