Significance, Nature, and Direction of the Association Between Child Sexual Abuse and Conduct Disorder: A Systematic Review.

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Significance, Nature, and Direction of the Association Between Child Sexual Abuse and Conduct Disorder: A Systematic Review Roberto Maniglio Trauma Violence Abuse published online 12 March 2014 DOI: 10.1177/1524838014526068 The online version of this article can be found at: http://tva.sagepub.com/content/early/2014/02/25/1524838014526068

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Article

Significance, Nature, and Direction of the Association Between Child Sexual Abuse and Conduct Disorder: A Systematic Review

TRAUMA, VIOLENCE, & ABUSE 1-17 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1524838014526068 tva.sagepub.com

Roberto Maniglio1

Abstract To elucidate the significance, nature, and direction of the potential relationship between child sexual abuse and conduct disorder, all the pertinent studies were reviewed. Ten databases were searched. Blind assessments of study eligibility and quality were performed by two independent researchers. Thirty-six studies including 185,358 participants and meeting minimum quality criteria that were enough to ensure objectivity and to not invalidate results were analyzed. Across the majority of studies, conduct disorder was significantly and directly related to child sexual abuse, especially repeated sexual molestation and abuse involving penetration, even after controlling for various sociodemographic, family, and clinical variables. The association between child sexual abuse and conduct disorder was not confounded by other risk factors, such as gender, socioeconomic status, school achievement, substance problems, physical abuse, parental antisocial behavior or substance problems, parent–child relationships, and family disruption, conflict, or violence. Evidence for a significant interactive effect between child sexual abuse and monoamine oxidase A gene on conduct disorder was scant. Early sexual abuse might predispose to the subsequent onset of conduct disorder which, in turn, may lead to further sexual victimization through association with sexually abusive peers or involvement in dangerous situations or sexual survival strategies. Keywords child abuse, sexual abuse, child abuse, physical abuse, child abuse

Introduction There is increasing awareness of conduct disorder because it is one of the most common forms of childhood psychopathology (Connor, 2002; Loeber, Burke, Lahey, Winters, & Zera, 2000; Lyman & Campbell, 1996) that can persist into adulthood and escalate into antisocial personality disorder (Frick, 1998; Loeber, Burke, & Pardini, 2009; Lahey, Waldman, & McBurnett, 1999). This disorder can strongly affect a child’s psychological, social, or educational functioning, leading to psychiatric comorbidity, disability in social functioning, association with deviant peers, delinquency, legal problems, poor academic and vocation achievement, suicidal behavior, and substance problems (Frick, 1998; Keenan, Loeber, & Green, 1999; Lahey & Waldman, 2012; Loeber et al., 2000). Additionally, conduct disorder imposes severe repercussions on families and society at large, especially direct and indirect economic costs associated with the mental health and social needs of youths with this disorder as well as with the significant disruption that these youths can cause to their families and society in general (e.g., child welfare system, social services, criminal justice system, law enforcement and police services, mental health and health care system, and lost productivity to society: Cohen & Piquero, 2009; Corso, Mercy, Simon, Finkelstein, & Miller, 2007; Miller, 2001).

Therefore, clarifying the factors that may predispose to conduct disorder should be a research priority. In fact, an extensive body of research has proposed several biological and environmental risk factors for conduct disorder, such as genetic influences, neurobiological factors, cognitive deficits, psychosocial factors, familial and peer influences, and school and neighborhood factors (Burke, Loeber, & Birmaher, 2002; Cappadocia, Desrocher, Pepler, & Schroeder, 2009; Holmes, Slaughter, & Kashani, 2001; Matthys, Vanderschuren, Schutter, & Lochman, 2012). In particular, it has been hypothesized that early trauma, especially childhood maltreatment, may produce immediate aggressive responses and conduct problems, such as antisocial and violent behaviors (Widom, 1989), that may represent tension-reducing activities, that is, behavioral strategies fulfilling a need to reduce painful abuse-related internal states (such

1

Department of History, Society, and Human Studies, University of Salento, Lecce, Italy

Corresponding Author: Roberto Maniglio, Department of History, Society, and Human Studies, University of Salento, Via Stampacchia 45/47, 73100 Lecce, Italy. Email: [email protected]


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TRAUMA, VIOLENCE, & ABUSE

as negative feelings, thoughts, memories, or affects: Maniglio, 2011a, 2011b; Briere, 1992; Briere & Elliot, 1994). In fact, on the basis of a partial review of the literature, some narrative reviews have suggested that child abuse, especially child sexual abuse, might predispose to the development of conduct problems (Burke et al., 2002; Cicchetti & Toth, 2005; Murray & Farrington, 2010; Putnam, 2003; Tyler, 2002), particularly in children with a genetic vulnerability conferred by a functional polymorphism in the promoter region of the gene encoding monoamine oxidase A (Kim-Cohen et al., 2006). Nevertheless, the large majority of these reviews did not systematically assess all of the published articles and lacked a formal quality assessment of included studies, thus failing to aggregate and analyze all of the pertinent studies having no important methodological limitations that could invalidate their results. Importantly, these reviews suggested that child sexual abuse may promote the onset of conduct disorder, thus implying a causal relationship, although they addressed studies that did not disentangle the temporal ordering of the two events; therefore, these reviews failed to consider the possibility that child sexual abuse may be an outcome of, rather than a risk factor for, conduct disorder. Additionally, all of these reviews did not focus exclusively on the potential relationship between child sexual abuse and conduct disorder specifically, since they considered the combination of either different risk factors for conduct disorder or different outcomes of child sexual abuse; thus, they failed to provide adequate explanation of the specific role of child sexual abuse in the development of conduct disorder or, conversely, of the specific role of conduct disorder in the onset of child sexual abuse. However, it is important to provide a systematic review of all pertinent literature as well as a formal quality assessment of included studies, because data coming from partial selection of literature and aggregation of findings from studies with important methodological limitations are vulnerable to several biases that may threaten the accuracy, reliability, and validity of the results obtained. Importantly, it is essential to examine child sexual abuse and conduct disorder in such a way as to elucidate the significance, nature, and direction of the potential relationship between child sexual abuse and conduct disorder. In sum, although several reviews on the relationship between child sexual abuse and a variety of psychiatric disorders have been performed (see Maniglio, 2009b), it is surprising that there are no systematic reviews focusing exclusively on the potential association between such traumatic experience and conduct disorder. In contrast, the severity of both child sexual abuse and conduct disorder as well as the current high levels of scientific and public interest in both these conditions impose careful consideration of such potential association in order to develop appropriate prevention and treatment strategies. Therefore, this article is aimed at elucidating, for the first time, the significance, nature, and direction of the potential relationship between child sexual abuse and conduct disorder, by addressing, in an evidence-based, objective, and balanced fashion, all the pertinent studies having no important methodological limitations that could invalidate their results.

Method In accordance with guidelines for systematic reviews (Centre for Reviews and Dissemination, 2008; Egger, Davey Smith, & Altman, 2001; Higgins & Green, 2006; Lipsey & Wilson, 2000; Petticrew & Roberts, 2006), a protocol was prospectively developed by the author, detailing the specific objectives, criteria for study selection, approach to abstracting data and assessing study quality, outcomes, and methods.

Data Sources A systematic review of research reports was performed in December 2011. Two methods were used to obtain relevant studies. First, 10 Internet-based databases (i.e., Cambridge Journals, JSTOR, PsycINFO, PubMed Central, Oxford Journals, Sagepub, ScienceDirect, Springer, Taylor and Francis online, and Wiley online Library) were searched for terms conduct disorder(s) and conduct problems combined with each of the following terms: child(ren/hood), adolescen(t/ts/ce), infancy, youth(s); along with each of the following terms: sex(ual/ually) abuse(d), sex(ual/ually) assault(s/ed), sex(ual) aggression(s), sex(ual) offence(s), incest(uous), rape(d). Second, further potentially relevant articles were identified by a manual search of reference lists from retrieved papers. No date limits were placed on the searches that were limited to full-text journal articles.

Study Selection Studies were included if they (1) sampled human participants; (2) were not literature reviews, dissertation papers, conference proceedings, editorials, letters, case reports, case series, or commentaries; (3) were published in full; (4) appeared in peer-reviewed journals; (5) had primary and sufficient data derived from longitudinal, cross-sectional, case–control, or cohort studies; (6) investigated the relationship between conduct disorder (in accordance with Diagnostic and Statistical Manual of Mental Disorders [DSM] or International Classification of Diseases diagnostic criteria) and a history of child sexual abuse specifically. These criteria were applied to all titles, abstracts, and full manuscripts.

Data Extraction and Quality Assessment For multiple studies with overlapping samples as well as for multiple publications of the same study, the one with the most complete or pertinent primary outcomes or data was used. Using the Newcastle-Ottawa Scale (Wells et al., 2006), that, compared to other quality assessment tools for observational studies, is quite comprehensive and has been partly validated, data were abstracted and study quality was assessed according to the following criteria: (1) adequacy of selection of the study groups (i.e., assessment of case definition or cohort exposure, selection of cases or exposed cohort, selection of controls or nonexposed cohort, definition of controls or nonexposed


Maniglio

3

cohort); (2) comparability of the groups on the basis of the design or analysis; (3) adequacy of ascertainment of either the exposure or the outcome of interest (i.e., ascertainment of exposure or assessment of outcome, definition of method of exposure ascertainment or follow-up period, ascertainment of nonresponse rates or losses of participants to follow-up). Across these criteria and their subsections, each study received up to 9 stars for methodological quality (maximum of one star for each item within the ‘‘selection’’ and ‘‘exposure/outcome’’ categories and maximum of two stars for the ‘‘comparability’’ section; see Table 1). Studies receiving no stars were rejected because they had important methodological limitations that could invalidate their results.

Procedure The assessment of all the papers by at least two researchers working independently may limit bias, minimize errors, improve reliability of findings, reduce the possibility that relevant reports will be discarded, and ensure that decisions and judgments are reproducible (Buscemi, Hartling, Vandermeer, Tjosvold, & Klassen, 2006; Edwards et al., 2002). Thus, two independent researchers, the author and a psychiatrist, professor of criminology, conducted study selection, data extraction, and quality assessment. Consistency to assessment of the validity of studies (Higgins & Green, 2006; Jadad et al., 1996) was ensured by the author who has an adequate understanding of the area under review as well as of the relevant methodological issues. Conversely, the presence of a second researcher who is not knowledgeable in the topic area made it possible to avoid the risk that the author, because of his expertise in the area under review, may have preformed opinions that can bias assessment of the validity of studies (Cooper & Ribble, 1989; Oxman & Guyatt, 1993). To protect against bias and ensure that judgments may be not affected by knowledge of the authors, institutions, journals, or results of a study (Jadad et al., 1996; Moher et al., 1998), blind assessments of study eligibility and quality were assured. Disagreements between reviewers occurred 16 times. Disagreements about study selection occurred nine times because of lack of additional information. In all these cases, agreement was achieved when the additional information was obtained. Additionally, seven studies created disagreements because they were ambiguous about some quality criteria, such as adequacy of ascertainment of either the exposure or outcome of interest. In all these cases, disagreements were discussed and resolved by consensus, after having reviewed the article and the review protocol (Centre for Reviews and Dissemination, 2008; Higgins & Green, 2006). The study selection process is illustrated in Figure 1. By the Internet-based search, 7,900 articles were identified. By reviewing the titles and abstracts of all these articles, 291 potentially relevant papers were retrieved for more detailed evaluation. By the manual search of reference lists of these 291 papers, additional 21 potentially relevant articles were identified and retrieved for detailed evaluation. Of all the potentially relevant papers, 36 fulfilled all inclusion criteria

and were assessed for study quality. Of these studies, none were rejected on the basis of quality assessment. Thus, all of these 36 studies were included in the present systematic review.

Results Description of Studies The 36 studies included in the present review were published between 1987 and 2011 and assessed a total of 185,358 participants. Of these studies, 15 compared participants with versus without conduct disorder on reports of child sexual abuse, whereas 21 compared participants with versus without histories of sexual abuse on measures of conduct disorder. The main characteristics and results of these studies are illustrated, respectively, in Tables 2 and 3. The majority of studies were conducted in the United States and recruited more than 100 participants drawn from clinical samples including both male and female participants. All but one of the studies used a cross-sectional retrospective design to ascertain conduct disorder and child sexual abuse. Sociodemographic, family, and clinical information, including diagnoses of conduct disorder and exposure to child sexual abuse, were obtained using clinical charts or forensic medical registers and/or investigator-authored or standardized interviews with the participants and/or their primary caregivers. To define conduct disorder, the large majority of the studies relied on the DSM, most commonly DSM (Third Edition, Revised; American Psychiatric Association, 1987) criteria. Definitions of child sexual abuse differed widely from study to study in regard to age cutoff point to define child abuse (e.g., before age 16), perpetrator age in relation to victim (e.g., perpetrator at least 5 years older than victim), relationship between perpetrator and victim (e.g., a parent or other relative of the victim), frequency of occurrence of abuse (e.g., at least two episodes of abuse), occurrence of the most recent episodes of abuse (e.g., within last year), presence of contact in the abuse experience (e.g., genital touching), specific types of sexual acts included in definition (e.g., anal or vaginal penetration), degree of sexual assault (e.g., actual, attempted, or threatened), and confirmation of abuse (e.g., medical evidence or admission by the perpetrator). To assess the potential association between child sexual abuse and conduct disorder, univariate (most commonly chisquare test) and/or multivariate (most commonly logistic regression) inferential statistics were used. The following variables were most frequently considered in multivariate analyses: gender, socioeconomic status or income, age of participants at study entrance, mood disorders, anxiety disorders, substance problems, monoamine oxidase A gene, childhood physical abuse, family dysfunction, conflict, or violence, parental antisocial personality or criminal behavior, and parental alcohol or substance problems. Quality assessment of included studies (Table 1) revealed that only one of these studies met all of the quality criteria and received 9 of 9 stars while many studies received 7 of 9 stars. The inadequacy of assessment or ascertainment of exposure or


4


Ackerman, Newton, McPherson, Jones, and Dykman (1998) Afifi, McMillan, Asmundson, Pietrzak, and Sareen (2011) Booth and Zhang (1996) Bushnell, Wells, and Oakley-Browne (1992) Chen, Thrane, Whitbeck, Johnson, and Hoyt (2007) Cohen et al. (1996) Crowley, Mikulich, Ehlers, Hall, and Whitmore (2003) Cutajar et al. (2010) Dadds, Smith, Webber, and Robinson (1991) Derringer, Krueger, Irons, and Iacono (2010) Dinwiddie et al. (2000) Feitel, Margetson, Chamas, and Lipman (1992) Fergusson, Horwood, and Lynskey (1996) Fergusson, Boden, Horwood, Miller, and Kennedy (2011) Green, Russo, Navratil, and Loeber (1999) Guzder, Paris, Zelkowitz, and Feldman (1999) Haapasalo and Kankkonen (1997) Kendler, Gardner, and Prescott (2002)

Source

Selection of Cases or Exposed Cohort –

*

* *

–

* –

* * *

* *

* *

* *

– *

*

–

– –

–

* –

* * –

– –

– –

* *

– –

*

*

*

*

*

*

* *

*

– –

* *

–

*

*

*

–

Selection of Controls or Unexposed Cohort

Selection

Assessment of Case Definition or Cohort Exposure

Table 1. Quality Assessment of Studies.

*

*

*

*

*

*

* *

*

– –

* *

*

*

*

*

*

Definition of Controls or Unexposed Cohort

**

–

–

–

**

**

** –

**

** *

– –

**

–

**

**

–

–

–

*

*

*

–

– –

–

– –

* –

–

–

–

–

*

*

*

*

*

*

*

* *

*

– –

* *

*

*

*

*

*

Definition of Method of Exposure Ascertainment or Follow-Up

Groups Matched or Confounders Adjusted For Ascertainment of Exposure or Outcome

Exposure or Outcome

Comparability

*

*

*

*

*

*

* *

*

– –

* *

*

*

*

*

*

Ascertainment of Nonresponse Rates or Losses

(continued)

7/9

4/9

7/9

7/9

8/9

7/9

7/9 5/9

7/9

4/9 3/9

7/9 4/9

5/9

5/9

7/9

7/9

5/9

Stars Received

5


* * – * * – – * – – *

* * * – * –

*

– – * * * – – – * –

– – * – – –

–

Selection of Cases or Exposed Cohort

–

Assessment of Case Definition or Cohort Exposure

*

* –

* *

*

–

* *

* –

– –

* *

* –

*

Selection of Controls or Unexposed Cohort

Selection

*

* *

* *

*

–

* *

* *

* *

* *

* *

*

Definition of Controls or Unexposed Cohort

*

– **

** **

–

–

** **

** **

** –

– **

** **

**

–

– –

* –

–

–

* –

– –

* –

– –

– –

–

*

* *

* *

*

–

* *

* *

* *

* *

* *

*

Definition of Method of Exposure Ascertainment or Follow-Up

Groups Matched or Confounders Adjusted For Ascertainment of Exposure or Outcome

Exposure or Outcome

Comparability

*

* *

* *

*

–

* *

* *

* *

* *

* *

*

Ascertainment of Nonresponse Rates or Losses

6/9

5/9 5/9

9/9 6/9

5/9

1/9

8/9 7/9

7/9 5/9

7/9 3/9

6/9 8/9

7/9 5/9

7/9

Stars Received

Note. * ¼ Study received a Newcastle-Ottawa Scale star for criteria; ** ¼ Study received two Newcastle-Ottawa Scale stars; – ¼ Study not received a Newcastle-Ottawa Scale star for criteria; n.a. ¼ Newcastle-Ottawa Scale criteria not applicable to the study.

Kessler, Davis, and Kendler (1997) Kunitz et al. (1999) Lanktree, Briere, and Zaidi (1991) Livingston (1987) Livingston, Lawson, and Jones (1993) McLeer et al. (1998) Morris, and Bihan (1991) Nelson et al. (2002) Romano, Zoccolillo and Paquette (2006) Romero et al. (2009) Sansonnet-Hayden, Haley, Marriage, and Fine (1987) Schulenberg & Soundy (2000) Simic and Fombonne (2001) Spencer et al. (2005) Sullivan, Bulik, Carter, and Joyce (1995) Walrath et al. (2003) Whitbeck, Chen, Hoyt, Tyler, and Johnson (2004) Young et al. (2006)

Source

Table 1. (continued)

6


Cambridge (n=422)

Jstor (n=352)

Oxford (n=96)

PsycInfo (n=132)

PubMed Central (n=793)

SagePub (n=710)

Science Direct (n=2,081)

Articles identified and screened for retrieval (n=7,900)

Articles retrieved for more detailed evaluation (n=291)

Articles identified from reference lists of retrieved articles and retrieved for detailed evaluation (n=21)

Articles included for quality assessment (n=36)

Springer (n=1,404)

Taylor & Francis (n=257)

Wiley Library (n=1,653)

Articles excluded on title or abstract review (n=7,588): duplicate or notresearch articles; no focus or assessment of conduct disorderor child sexual abuse Articles excluded on full-text review (n=276): duplicate, incomplete, or not original data; no use of DSM or ICD criteria; no assessment of child sexual abuse-conduct disorder association Articles rejected on quality assessment (n=0)

Articles included (n=36)

Figure 1. Summary of study selection process.

outcomes of interest (i.e., absence of some independent validation and/or blind assessment, such as more than one process, time, secure record, or person to extract information and ascertain or assess exposure or outcomes of interest) was the most common methodological limitation across studies.

Summary of the Findings of Studies on Participants With Conduct Disorder Fifteen studies compared participants with conduct disorder to participants without conduct disorder on histories of child sexual abuse (Table 2). Of these studies, 6 assessed the potential association between child sexual abuse and conduct disorder only at univariate level, 7 considered such association only at multivariate level, while 2 considered both levels of analysis. In 5 studies, a history of child sexual abuse was significantly associated with conduct disorder at univariate level, whereas in 7 studies controlling for confounders at multivariate level, child sexual abuse independently predicted conduct disorder after considering a variety of sociodemographic and clinical variables. In the 3 studies providing odds ratio values, participants with conduct disorder were nearly 2 times more likely to report having experienced child sexual abuse or recent sexual victimization compared to participants without conduct disorder. In the only one study considering different forms of child sexual abuse (i.e. isolated vs. repeated sexual molestation or rape; Kessler, Davis, & Kendler, 1997), only repeated sexual molestation predicted conduct disorder.

In one study (Derringer, Krueger, Irons, & Iacono, 2010), but not in another (Young et al., 2006), there was evidence for a significant interactive effect between monoamine oxidase A gene and child sexual abuse exposure on conduct disorder; in fact, individuals with low-activity monoamine oxidase A allele who reported a history of child sexual abuse had a greater number of conduct disorder symptoms. In one of the two studies disentangling the temporal ordering of abuse and conduct disorder (Kessler et al., 1997), discrete–time survival models (with person-years as the unit of analysis and time-lagged relationships) revealed that early sexual molestation predicted the subsequent onset of conduct disorder after considering sociodemographic variables, other adversities that occurred prior to the onset of conduct disorder, and other disorders that occurred prior to sexual abuse or between the onset of abuse and conduct disorder. In the other study (Chen, Thrane, Whitbeck, Johnson, & Hoyt, 2007), age of onset of conduct disorder (childhood vs. adolescent onset) among homeless and runaway adolescents had significant indirect effect on sexual victimization since being on one’s own.

Summary of the Findings of Studies on Participants With Abuse Histories Twenty-one studies compared participants with histories of child sexual abuse to participants without abuse histories on measures of conduct disorder (Table 3). Of these studies, 13 considered the potential association between child sexual abuse


7


United States 150 (13–22, 18 + 2; 2%) Canada 94 (7–12, 10; 14%)

Feitel et al. (1992)

Finland

United States 1,942 (36 + 8; 100%)

Haapasalo and Kankkonen (1997)

Kendler et al. (2002)

16 (24–50, 35 + 8; 0%)

DICA-R: L DSM-IIIR CD K-SADS: C DSMIII-R CD SEDQ: DSM-III-R CD before15

United States 841 (29%)

Derringer et al. (2010)

Guzder et al. (1999)

I: DSM-III-R CD before15

United States 98 (14–18; 39%)

Crowley et al. (2003)

I: DSM-IV CD before 18

DISC-IV: L DSM-IV CD

United States 219 (12–19, 17; 46%) United States 411 (16–19, 17 + 1; 54%)

Booth and Zhang (1996) Chen et al. (2007)

CSA Assessment & Definition

I: actual or attempted sex acts, oral sex, masturbation, intercourse, molestation, touching, fondling, penetration, permission or coercion to do pornography, prostitute, touch or watch parts, hear or watch sex acts or material by a caregiver or other in youth I: unwanted sex touching, fondling, attempted or actual intercourse, or coercion to touch sex parts before 16

I: past contact sex abuse

CARI: past actual or attempted sex touching, denuding, fondling, penetration, or coercion to do pornography or hear or watch sex acts, parts, or material TAA: physically threatened or forced sex contact by anyone before 16 (before 13, any sex contact by anyone > 5 years) DICA-R: any sex abuse in youth

I: unwanted sex touching, fondling, or attempted or actual intercourse in youth DISC-R: C DSM-III- AHS: any sex abuse in youth R CD DISC-R: C DSM-III- I: any unwanted sex act or R CD experience, sex assault, or rape since on own

AUDADIS-IV: L DSM-IV CD

United States 34,653 (20; 27.5%)

Country

CD Assessment & Definition

Afifi et al. (2011)

Source

Participants (age range, mean + SD; %F)

CSA þ BS: p < .05

p < .001

P < .05

Univariate CSA-CD Association

DD genetic risk, AD, DD, SUD, education, parental loss, family functioning, neuroticism, selfesteem, social support, divorce, marital problems, difficulties, stress, trauma

Gender, discipline, MAOA

Gender, living situations, CPA, SUD at home Age, gender, CD onset, abuse by caretakers, deviant peers, time on streets, age on own, sex or nonsex survival

Age, education, income, marital status, race, MD, AD, SUD, PD

Variables Controlled

Table 2. Studies Comparing Conduct-Disordered Versus Nondisordered Participants on Child Sexual Abuse Histories: Main Characteristics and Significant Associations.

p < .05

(continued)

CSA þ low MAOA: p ¼ .007

CSA þ survival sex: p < .05

M: OR ¼ 1.95, p .001; F: OR ¼ 2.19, p .001 OR ¼ 1.83, p < .05

Multivariate CSACD Association

8


United States 428 (16–19, 17 + 1; 56%)


Young et al. (2006)

I: last year or prior sex abuse

R: any past sex abuse

I: sex touching, fondling, or penetration before 15

I: isolated or repeated rape or sex molestation in youth


CARI: past actual or attempted sex touch, fondling, denuding, penetration, coercion to do pornography or hear or watch sex acts, parts, or material

p < .001

p < .0001


Age, gender, sex orientation, DD, PTSD, SUD, abuse by caretakers, age on own, time on streets, sex or nonsex survival MAOA

Age, gender, race, detention, MD, AD, SUD, absence from home, CVA, own or relative’s trauma, witnessing trauma, victimization, family SES, parental death or absence or divorce, parental DD or GAD or SUD or APD Age, gender, SES, migration, community type, camp size, CPA, parental AAD


p < .05

p < .05

p ¼ .0024

Repeated sex molestation: OR ¼ 1.77


Note. AAD ¼ alcohol abuse or dependence; AD ¼ anxiety disorders; AHS ¼ Adolescent Health Survey; APD ¼ antisocial personality disorder; AUDADIS ¼ Associated Disabilities Interview Schedule; BS ¼ borderline symptoms; C ¼ current; CARI ¼ Colorado Adolescent Rearing Inventory; CD ¼ conduct disorder; CPA ¼ child physical abuse; CSA ¼ child sexual abuse; CVA ¼ childhood verbal abuse; DD ¼ depressive disorder; DICA ¼ Diagnostic Interview for Children and Adolescents; DIS ¼ Diagnostic Interview Schedule; DISC ¼ Diagnostic Interview Schedule for Children; DSM ¼ Diagnostic and Statistical Manual of Mental Disorders; GAD ¼ generalized anxiety disorder; I ¼ interview; ICD ¼ International Classification of Diseases; K-SADS ¼ Schedule for Affective Disorders and Schizophrenia; L ¼ lifetime; MAOA ¼ monoamine oxidase A gene; MD ¼ mood disorders; OR ¼ odds ratio; PD ¼ personality disorders; PTSD ¼ posttraumatic stress disorder; SD ¼ standard deviation; SEDQ ¼ Self-Evaluation of Difficulties Questionnaire; SES ¼ socioeconomic status; SUD ¼ substance use disorders; TAA ¼ Trauma Assessment for Adults; M ¼ male; F ¼ female.

DISC-IV: L DSM-IV CD

DISC-R: C DSM-III- I: any unwanted sex act or R CD experience, sex assault, or rape since on own

I: C ICD-10 CD

UK

337 (6–18; 40%)

R: C DSM-III-R CD

United States 18 (14–17, 15; 56%)

Schulenberg and Soundy (2000) Simic and Fombonne (2001) Whitbeck et al. (2004)

DIS: DSM-III-R CD before 15



United States 734 (28%)

United States 5,877 (15–54)

Country

Participants (age range, mean + SD; %F)

Kunitz et al. (1999)

Kessler et al. (1997)

Source


9


United States 105 (12–18, 15 + 2; 69.5%) Australia 2,688 (80%)

Cohen et al. (1996)

New Zealand 398 (30; 0%) I: attempted or actual unwanted genital contact, masturbation, sex propositions, exposure, undressing, fondling, or intercourse before 16 United States 49 (13–17, I: past attempted or actual sex 15; 100%) molestation, fondling, touching, or intercourse United States 35 (48.5%) R: actual sex contact, fondling, or intercourse on or before 16 by anyone 5 years United States 100 (6–12) R: any proven past sex abuse

Fergusson et al. (2011)

Livingston (1987)

Lanktree et al. (1991)

Green et al. (1999)

New Zealand 1,019 (18)

Fergusson et al. (1996)

I: attempted or actual unwanted genital contact, masturbation, sex propositions, exposure, undressing, fondling, or intercourse before 16

I: any forced sex act or intercourse before 18

Australia

Dinwiddie et al. (2000)

DICA: C DSM-III CD

R: C DSM-III-R

DISC: C DSM-IV CD

CSA þ CPA: p ¼ .05

MAOA, cognitive ability, maternal age, paternal education, family SES or functioning, parents change, parental SUD or VC

Gender, ethnicity, maternal age or education, family SES or functioning, PBA, parents change, stepparents, parental MI, or SUD or VC

p < .002; intercourse: OR ¼ 4.5, p < .001

SRDI: DSM-IV CD at 16-18

SRED: DSM-III-R CD at 14-16

Birth cohort, parental AAD

M: OR ¼ 3.27, p < .001; F: OR ¼ 5.47, p < .001; F co-twins: OR ¼ 2.69; F & co-twins: OR ¼ 10.90; F: OR ¼ 3.73

P < .009


SSAGA: L DSM-IIIR CD

RPBC: DSM-III CD

R at 34 + 11: 12- to OR: 6.32, p < .001 43-year ICD CD

R at 10 + 4: proven attempted or actual sex contact or penetration before 16 R: past proven sex abuse by father or stepfather

Australia

DICA-R: L DSM-IIIR CD

p < .05; CSA þ DD: p < .001; CSA þ SUD: p < .01; CSA þ ED: p < .001

I: any proven past coerced sex contact by any adult

CSA þ CPA: p ¼. 05


DICA-R: C DSMIII-R CD DIS: DSM-III-R CD before 15


R: any proven past sex abuse by anyone > 4 years I: intrafamilial sex contact or attempted or actual intercourse when growing up


Dadds et al. (1991)

48 (14 + 1.5; 100%) 5,946 (27– 89; 65%)

United States 204 (7–13; 64%) New Zealand 301 (18–44; 100%)

Ackerman et al. (1998) Bushnell et al. (1992)

Cutajar et al. (2010)

Country

Source

Participants (Age Range, Mean + SD; %F)

Table 3. Studies Comparing Sexually Abused Versus Nonabused Participants on Conduct Disorder Measures: Main Characteristics and Significant Associations.

(continued)

M: OR ¼ 3.23; M co-twins: OR ¼ 2.05; F: OR ¼ 3.38; F & cotwins: OR ¼ 7.58 p < .001; intercourse: OR ¼ 11.9, p < .001; no intercourse: OR ¼ 5.0, p < .001 CSA þ low MAOA: p < .05


10


p ¼ .028 OR ¼ 10.27 CSA þ BN: p ¼ .03

DISC: C DSM-III CD R: L ICD-9 CD SCID: L DSM-III-R CD R: L DSM-IV CD

Birth weight, gestational age, maternal age, SES

Gender, age, race, intact family, CPA, PTSD, PS, BD duration, familial MD

K-SADS: L DSM-IV CD

gender, CPA, CN, stepparents, parental AAD or VC

Gender, age, ADHD, CPA, home VC


DD, CEA, CEN, CPA, CPN

F: HR ¼ 6.62; M: HR ¼ 2.48

p ¼ .0199

M vs F: p ¼ .007



SSAGA: L DSM-IV CD

K-SADS: L DSM-III-R CD R: L DSM-III-R CD

DICA-R: C DSMIII-R CD


OR ¼ 7.65

CSA þ BD þ CPA: OR ¼ 3.8, p < .05

CSA þ DD: OR ¼ 2.60

intercourse: OR ¼ 7.69

CSA in older M: p < .05


Note. AAD ¼ alcohol abuse or dependence; ADHD ¼ attention deficit hyperactivity disorder; BD ¼ bipolar disorder; BN ¼ bulimia nervosa; C ¼ current; CD ¼ conduct disorder; CEA ¼ child emotional abuse; CEN ¼ child emotional neglect; CN ¼ childhood neglect; CPA ¼ child physical abuse; CPN ¼ child physical neglect; CSA ¼ child sexual abuse; CTQ ¼ Childhood Trauma Questionnaire; DD ¼ depressive disorder; DICA ¼ Diagnostic Interview for Children and Adolescents; DIS ¼ Diagnostic Interview Schedule; DISC ¼ Diagnostic Interview Schedule for Children; DSM ¼ Diagnostic and Statistical Manual of Mental Disorders; ED ¼ eating disorders; HR ¼ hazard ratio; I ¼ interview; ICD ¼ International Classification of Diseases; K-SADS ¼ Schedule for Affective Disorders and Schizophrenia; L ¼ lifetime; MAOA ¼ monoamine oxidase A gene; MD ¼ mood disorders; MI ¼ mental illness; OR ¼ odds ratio; PBA ¼ parental bonding or attachment; PD ¼ personality disorders; PS ¼ psychotic symptoms; PTSD ¼ posttraumatic stress disorder; R ¼ records; RR ¼ relative risk; SCID ¼ Structured Clinical Interview for DSM; SD ¼ standard deviation; SES ¼ socioeconomic status; SRDI ¼ Self-Report Delinquency Instrument; SRED ¼ Self-Report Early Delinquency; SSAGA ¼ Semi-Structured Assessment for the Genetics of Alcoholism; SUDs ¼ substance use disorders; VC ¼ violence or conflict; M¼ male; F ¼ female.

SansonnetHayden et al. (1987) Spencer et al. (2005) Sullivan et al. (1995) Walrath et al. (2003)

Romero et al. (2009)

Romano et al. (2006)

Nelson et al. (2002)

United States 230 (6–16; 63%) United States 100 (4–2, 9 + 2; 17%) Australia 3,982 (30 + I: sex molestation, touching, rape, 2.5; 58%) or coercion to touch sex parts before 16 or any forced sex act or unwanted intercourse before 18 Canada 252 (14–22, CTQ: 1 or more sex acts, 17; 100%) contact, or coercion in childhood by older persons K-SADS: past genital fondling, United States 446 (7–17, oral sex, or intercourse 13 + 3; 47%) I: past actual sex touching, Canada 54 (13–17, fondling, or intercourse 15 + 1; 54) United 119,729 R: actually occurred or suspected Kingdom (19) sex abuse in youth New Zealand 87 (18–40; I: any forced sex act before 16 100%) I: any past sex abuse United States 3,479 (5– 17.5, 12 + 3; 34%)

McLeer et al. (1998) Morris, and Bihan (1991)

R: more than 1 proven last-year sex abuse by a parent or surrogate R: any proven past genital contact by males > 5 years R: any past sex abuse


Livingston et al. (1993)


Country

Participants (Age Range, Mean + SD; %F)

Source


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and conduct disorder only at univariate level, 4 assessed such association only at multivariate level, and 4 at both levels. In 12 studies, child sexual abuse was significantly associated with conduct disorder at univariate level, while in 4 studies controlling for confounders at multivariate level, child sexual abuse predicted conduct disorder after considering a variety of sociodemographic and clinical variables. In the six studies providing odds ratio values, participants with histories of child sexual abuse, compared to those without, were 2 to 12 times more likely to report conduct disorder. In three of these studies, increased risk of conduct disorder was associated with abuse involving intercourse (Fergusson, Horwood, & Lynskey, 1996; Nelson et al., 2002) and sexual abuse with cooccurring physical abuse (Romero et al., 2009). In two other studies (Ackerman, Newton, McPherson, Jones, & Dykman, 1998; Green, Russo, Navratil, & Loeber, 1999), conduct disorder was related to both sexual and physical abuse but not to either physical or sexual abuse only. In contrast, in one study (Livingston, Lawson, & Jones, 1993) conduct disorder was significantly associated with sexual abuse only but not with physical abuse, while in another study (Livingston, 1987), conduct disorder was related to physical abuse but not to sexual abuse. In the only study exploring temporal relationships between abuse and conduct disorder (Cutajar et al., 2010), participants who had been ascertained, on the basis of medical examinations, as having been sexually abused were significantly more likely than controls to have had contact with public mental health services for conduct disorder during a follow-up period ranging from 12 to 43 years. In two studies (Dinwiddie et al., 2000; Romano, Zoccolillo, & Paquette, 2006), the association between child sexual abuse and conduct disorder appeared to be at least in part indirect; in one of these studies (Romano et al., 2006), although a fourfold increase in the risk of having conduct disorder among pregnant women who had been sexually abused in childhood, sexual abuse was significantly associated with lifetime depression, which, in turn, was strongly related to lifetime conduct disorder. In another study (Fergusson, Boden, Horwood, Miller, & Kennedy, 2011), the association between abuse and conduct disorder was moderated by monoamine oxidase A genotype, while, in another one (Livingston et al., 1993), conduct disorder in sexually abused children was predicted by male gender and increasing age.

Discussion Thirty-six studies investigating the potential association between child sexual abuse and conduct disorder in 185,358 participants and meeting minimum quality criteria that were enough to ensure objectivity and to not invalidate results were analyzed in the present systematic review. Across the majority of studies, child sexual abuse was significantly and directly related to conduct disorder at either univariate or multivariate level even after controlling for a variety of sociodemographic, family, and clinical variables.

Odds ratio values ranged from nearly 2 to 12, with higher values reported for child sexual abuse involving intercourse. In fact, in all of the studies considering different forms of child sexual abuse (i.e., abuse with vs. without contact vs. abuse with vs. without intercourse or isolated vs. repeated molestation vs. rape), sexual abuse involving penetration and repeated sexual molestation were more strongly related to conduct disorder. Thus, it is possible that the relationship between child sexual abuse and conduct disorder may be moderated by severity of sexual abuse. This hypothesis is consistent with both theoretical models and empirical research, suggesting more negative outcomes in victims of more severe and traumatic forms of sexual victimization, such as those involving force, physical injury, higher frequency of sexual contact, or longer duration of abuse (Kaysen, Resick, & Wise, 2003; Maniglio, 2011c, 2013c; Polusny & Follette, 1995; Spaccarelli, 1994; Wolfe, Gentile, & Wolfe, 1989). In two but one of the three studies assessing the potential interactive effect of monoamine oxidase A gene, there was evidence for a significant interaction between exposure to child sexual abuse and low monoamine oxidase A activity. Although evidence is scant, one could speculate that the association between child sexual abuse and conduct disorder might be affected by monoamine oxidase A genotype, with individuals carrying a low-activity monoamine oxidase A allele being more responsive to the effects of child sexual abuse. In fact, other studies not included in the present review have suggested that exposure to child abuse in general may increase the risk for conduct disorder in individuals with low monoamine oxidase A activity (Caspi et al., 2002; Foley et al., 2004; Silva & Stanton, 1996). This hypothesis is consistent with the broader literature on Gene-by-Environment interactions between exposures to childhood maltreatment and monoamine oxidase A genotype in the development of psychopathology (Kim-Cohen et al., 2006). In all but one of the eight studies controlling for gender at multivariate level, the association between child sexual abuse and conduct disorder was not confounded by the sex of the participants. This result is consistent with the large majority of systematic reviews on the relationship between child sexual abuse and other psychiatric disorders (Maniglio, 2009b, 2010a, 2011a, 2011b, 2013a, 2013b, 2013c), although females with (Maniglio, 2013d) or without (Pereda, Guilera, Foros, & Go´mez-Benito, 2009; Tolin & Foa, 2006) conduct disorder may be more likely than males to be (or have been) sexually abused. Thus, the association between child sexual abuse and conduct disorder seems to be true for both sexes, although gender differences exist in rates of either child sexual abuse or conduct disorder (Loeber & Keenan, 1994; Zahn-Waxler, Shirtcliff, & Marceau, 2008; Zoccolillo, 1993). The five studies comparing, at univariate level only, participants reporting only sexual abuse or both sexual and physical abuse versus participants with physical abuse only provided conflicting results. In fact, although in two studies conduct disorder was significantly related to either sexual abuse only or physical abuse only, in two other studies conduct disorder was significantly related to both sexual and physical abuse but not


12


either physical or sexual abuse only. However, in all but one of the eight studies controlling for child physical abuse at multivariate level, a history of child physical abuse did not confound the association between child sexual abuse and conduct disorder. This result is not consistent with reviews on other psychiatric populations, suggesting that child physical abuse may be not only confounded with child sexual abuse (Langeland & Hartgers, 1998; Maniglio, 2011c, 2013b; Santa Mina & Gallop, 1998; Schmidt, Humfress, & Treasure, 1997; Simpson & Miller, 2002) but also more strongly related to psychopathology than child sexual abuse (Klonsky & Moyer, 2008; Maniglio, 2013c; Rind, Tromovitch, & Bauserman, 1998; Weiss, Longhurst, & Mazure, 1999). Thus, it is possible that, in youths reporting sexual abuse and conduct disorder, the co-occurrence of physical maltreatment does not confer additional risk for poorer outcomes, although in this population physical abuse is highly frequent (Maniglio, 2013d) so much so that it might be considered a risk factor for conduct disorder (Burke et al., 2002; Murray & Farrington, 2010). It is noteworthy that all the other sociodemographic, family, and clinical variables did not confound the association between child sexual abuse and conduct disorder, given that, in general, many of these variables (e.g., low socioeconomic status, poor school achievement, substance problems, childhood neglect, parental antisocial behavior or substance problems, poor parent–child relationships, and family disruption, conflict, or violence) are considered risk factors for conduct disorder (Bassarath, 2001; Burke et al., 2002; Dodge & Pettit, 2003; Holmes et al., 2001; Murray & Farrington, 2010). In fact, these variables have been found to be nonsignificant in the large majority of systematic reviews that have investigated the effects of child sexual abuse in other psychiatric populations (Maniglio, 2009b, 2010a, 2011a, 2011b, 2013a, 2013b, 2013c).

Causality Issues and Methodological Limitations Although the results of this systematic review provide clear evidence that the relationship between child sexual abuse and conduct disorder does exist, findings must be interpreted with caution because they do not allow to clarify directionality and causality between child sexual abuse and conduct disorder. A reasonable way to settle directionality and causality issues is to conduct a true experiment assessing dose–response relationships in order to ascertain the change in effect on study participants caused by differing levels of either exposure to sexual abuse or doses of conduct disorder after a certain exposure time. In doing so, random assignment of participants to experimental or control conditions and long-term follow-up would provide insight into cause and effect by ascertaining whether experimentally induced increases (or reductions) in either child sexual abuse or conduct disorder are associated with higher (or lower) rates of one of these conditions. However, it is impossible to conduct such types of experiments since they would be unethical and illegal. Thus, it was impossible for the present review to settle directionality and causality by aggregating

randomized experiments assessing dose–response relationships between sexual abuse and conduct disorder. This review has some other limitations. Research reports that were not published in full or that were not peer reviewed (e.g., unpublished studies, records of ongoing research, conference abstracts, theses, or articles not published in peerreviewed journals) were not included, thus generating a risk of publication bias. For example, if those reports contained null results, the present review might be biased in the direction of significant association. Importantly, because of the large variety of methods, measures, and definitions of child sexual abuse and conduct disorder along with important differences in sociodemographic and clinical characteristics between participants across studies, formal meta-analyses were precluded, because genuine differences in effects would be obscured (Deeks, Higgins, & Altman, 2006; Dickersin & Berlin, 1992). In fact, many studies did not provide the opportunity to assess quantitatively the relationship between child sexual abuse and conduct disorder through meta-analysis, given that neither cases and controls were matched in the design for important sociodemographic variables nor confounders were adjusted for in the analysis. However, even if a meta-analysis was performed, the presence of methodological limitations in included studies would not allow causal inferences to be made because most studies had design, sampling, and/or measurement problems, such as designs inappropriate to prove causality, sampling biases, inadequate operationalization and measurement of abuse histories, or insufficient control for confounders. First of all, the majority of studies recruited individuals receiving psychiatric services in North America or Oceania, thus producing a high risk of sampling bias, given that results cannot be generalized to individuals living in other parts of the world or not receiving mental health services. Additionally, since a certain level of wellness was required to participate in included studies, the results cannot be generalized to those patients who were not recruited due to severe disabling conditions or intellectual deficits. Moreover, data coming from clinical samples have the potential to produce other biases that may threaten their validity. For example, individuals drawn from clinical samples may be more likely than nonclinical participants to recall early traumatic events, thus inflating the relationship between child abuse and adult psychopathology (Pope & Hudson, 1995); additionally, child maltreatment and family problems are highly confounded in clinical population (Maniglio, 2009b). Therefore, causality cannot be inferred from clinical samples. Furthermore, data about exposure to child sexual abuse were generally obtained by retrospective reporting and self-report measures, which may be influenced by recall bias and limit the reliability and validity of the histories obtained (Brewin, Andrews, & Gotlib, 1993; Goodman et al., 1999) because of the limitations of the individual’s memory (Grimes & Schulz, 2002; Hassan, 2006). Furthermore, most studies did not control for the overlap with comorbid disorders or other traumatic events that could be present in the participants’ lives. Thus, it


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13

is uncertain whether conduct disorder in children who had been sexually abused may be attributable to sexual abuse rather than any other adversity that may precede, accompany, or follow such traumatic experience (or, conversely, whether sexual victimization in youths with conduct disorder may be due to such disorder rather than any other psychiatric disorder that may precede, accompany, or follow conduct disorder). Importantly, most included studies have not considered other important antecedent or concurrent third variables, especially the negative family circumstances in which many abused children are raised (e.g., family violence or dysfunctional parenting), which may interact with or contribute to sexual abuse and/or conduct disorder (Maniglio, 2010b, 2012). Most importantly, the large majority of included studies did not examine child sexual abuse and conduct disorder in such a way as to ascertain whether first episode of abuse preceded or followed the onset of conduct disorder; thus, they were unable to establish causal relationships between the two events. Only one prospective study (Cutajar et al., 2010) and two cross-sectional studies (Chen et al., 2007; Kessler et al., 1997) were able to disentangle with certainty the temporal ordering of the two events in order to clarify the direction of the association between abuse and conduct disorder. In these studies, early sexual abuse in childhood was significantly related to the subsequent onset of conduct disorder (Cutajar et al., 2010; Kessler et al., 1997) even after controlling for other adversities and disorders that occurred prior to the onset of both conduct disorder and sexual abuse or between the two events (Kessler et al., 1997); conversely, childhood onset of conduct disorder (prior to age 10) had only an indirect effect on subsequent sexual victimization in adolescence through mostly involvement with sexual subsistence strategies (Chen et al., 2007). Because of these methodological limitations, the most plausible interpretation of the findings of the present review is that child sexual abuse is significantly associated with conduct disorder. Although such association could in theory be due to a direct or indirect causal effect or reverse causation, in considering the findings of the three studies exploring temporal relationships between abuse and conduct disorder, child sexual abuse may be considered a risk factor for the subsequent onset of conduct disorder. In fact, although both child sexual abuse and conduct disorder occur in childhood, in many cases, child sexual abuse may occur earlier than conduct disorder since the peak age in the onset of conduct disorder occurs after puberty (Connor, 2002; Frick, 1998; Murray & Farrington, 2010). In these cases, early sexual abuse might predispose (either directly or indirectly, either alone or in combination with other risk factors) to the subsequent onset of conduct disorder. This hypothesis is consistent with the broader literature on child sexual abuse and later psychopathology (Maniglio, 2009b). However, the risk of sexual abuse seems to be neither more specific to nor stronger for youths with conduct disorder, compared to other psychiatric populations. In fact, rates of child sexual abuse among youths with conduct disorder

have been found to be higher than those among healthy individuals but similar to or even lower than those among individuals with other psychiatric disorders (Maniglio, 2013d). However, reverse causation (i.e., conduct disorder contributing, either directly or indirectly, either alone or in combination with other risk factors, to subsequent exposure to sexual victimization) may be also possible. In fact, in some cases, conduct disorder may onset in early childhood, while sexual abuse may occur in adolescence. In these cases, conduct disorder might predispose the youth to be exposed to subsequent sexual victimization through association with sexually abusive peers or involvement in dangerous situations or sexual survival strategies (Breslau, Lucia, & Alvarado, 2006; Storr, Ialongo, Anthony, & Breslau, 2007; Torok, Darke, Kaye, & Ross, 2011; Whitbeck, Hoyt, Yoder, Cauce, & Paradise, 2001). This hypothesis is also consistent with the broader literature on early mental illness and later victimization (Maniglio, 2009a). In an attempt to reconcile these disparate hypotheses, one could also speculate that, in some cases, both the hypotheses may coexist, with the same child being sexually abused both before and after the onset of conduct disorder. In fact, the association between child sexual abuse and conduct disorder might also be explained through an interactive process involving reciprocal influences between child sexual abuse and conduct disorder (Kimonis & Frick, 2006), in which sexual abuse in early childhood may predispose a child to develop conduct disorder which, in turn, may place the same youth at a greater likelihood of experiencing further sexual victimization in adolescence. In light of the limitations of research in this area, several methodological advances are required, especially control for comorbid disorders and other traumatic events and use of prospective, longitudinal designs, in order to clarify the direction of the association between abuse and conduct disorder and establish causal relationships between the two events. However, the current evidence highlights the need for programs and services for children to focus not only on assessing and treating both sexual abuse and conduct disorder but also on reducing additional risk factors that may increase the likelihood of both these conditions.

Critical findings Studies on child sexual abuse and conduct disorder are reviewed for the first time. Child sexual abuse may be directly associated with conduct disorder in both sexes. Repeated abuse and penetration are more strongly associated with conduct disorder. Early sexual abuse alone or with other factors may predispose to conduct disorder. Conduct disorder may lead to sexual abuse through involvement in risky situations.


14


Implications for Practice, Policy, and Research Future research should clarify the direction of the association between child sexual abuse and conduct disorder. Future research should discover the causal mechanisms between child sexual abuse and conduct disorder. Future studies should use prospective, longitudinal designs and control for comorbid disorders and other traumatic events. Programs and services for children should assess and treat both sexual abuse and conduct disorder. Programs and services for children should reduce additional risk factors that may increase the likelihood of sexual abuse and conduct disorder. Acknowledgments I thank Alan Cavaiola for his help on obtaining some old articles and Oronzo Greco for his help on study selection and quality assessment.

Authors’ Note Roberto Maniglio had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Maniglio was involved with study concept and design, acquisition of data, analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript for important intellectual content, study supervision, and final approval of the version to be published. Oronzo Greco, MD, University of Salento, Lecce, Italy, has contributed to the work reported in the manuscript but does not fulfill authorship criteria. No compensation was received for such contribution.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biography Roberto Maniglio, PsyD, PhD, is a psychotherapist, a criminologist, a forensic psychopathologist, and a court-appointed expert. He teaches at the University of Salento, Lecce, Italy. His research interests include etiology and prevalence of psychiatric disorders, child abuse, family dysfunction, and sexual crimes.


Prevalence of sexual abuse among children with conduct disorder: a systematic review.

The association between historical childhood sexual abuse and later parenting stress: a systematic review.

Child sexual abuse and the media: a literature review.

The incidence and nature of child abuse.

The association between child and adolescent emotional disorder and poor attendance at school: a systematic review protocol.

Child Abuse in Iran: a systematic review and meta-analysis.

Prevalence and nature of child sexual abuse in the Netherlands: ethnic differences?

Adult Disclosure of Child Sexual Abuse: A Literature Review.

The nature of professional child abuse.

Child sexual abuse.

Reviewing the Association between the History of Parental Substance Abuse and the Rate of Child Abuse.

Assessing the association between childhood sexual abuse and adult sexual experiences in women with sexual difficulties.

Parental substance abuse and the nature of child maltreatment.

physical abuse and sexual dysfunction in patients with social anxiety disorder.

Consequences of child sexual abuse.

Child sexual abuse and HIV infection.

The consequences of child sexual abuse.

Child sexual abuse research: a methodological quagmire.

Association between bipolar spectrum disorder and bone health: a meta-analysis and systematic review protocol.

Association between pornography use and sexual risk behaviors in adult consumers: a systematic review.

Effects of Callous-Unemotional Traits on the Association Between Parenting and Child Conduct Problems.

Association between mother-child sexual communication and HPV vaccine uptake.

Child sexual abuse and the limits of responsibility.

Parenting Programs for the Prevention of Child Physical Abuse Recurrence: A Systematic Review and Meta-Analysis.