Polyvictimization in childhood and its adverse impacts across the lifespan: Introduction to the special issue

ABSTRACT

Although much empirical work has focused on the adverse impact of specific types of childhood victimization (e.g., sexual, physical, or emotional abuse), researchers and clinicians increasingly are recognizing the prevalence of polyvictimization, or exposure to multiple types of victimization. Polyvictimization during formative developmental periods may have detrimental and potentially lifelong biopsychosocial impacts over and above the effects of exposure to specific types of adversity. In this guest editorial, we summarize the key questions and findings for six empirical studies on polyvictimization included in this Special Issue of the Journal of Trauma & Dissociation. These empirical studies further our understanding of the nature, consequences, and assessment of polyvictimization. We conclude with recommendations for continued scientific research and clinical inquiry on polyvictimization.

KEYWORDS:

• Polyvictimization
• trauma
• abuse
• maltreatment
• childhood
• lifespan

Although extensive research has focused on the adverse impact of specific types of childhood victimization (e.g., sexual, physical or emotional abuse, and neglect; family and community violence) (D’Andrea, Ford, Stolbach, Spinazzola, & van der Kolk, 2012), researchers and clinicians increasingly have identified particularly high-risk sub-group of children and youth who have been exposed to several types of victimization (Finkelhor, Ormrod, & Turner, 2007a). These individuals often continue to experience additional victimization (Finkelhor, Ormrod, & Turner, 2007b), as well as severe and persistent biopsychosocial impairment (Finkelhor, Ormrod, & Turner, 2009; Turner, Shattuck, Finkelhor, & Hamby, 2016). Polyvictimization is a term that has been used to describe exposure to multiple types of victimization (Finkelhor et al., 2007a).

Polyvictimization during formative developmental periods (Grasso, Dierkhising, Branson, Ford, & Lee, 2016) may have a severe and potentially lifelong biopsychosocial impact (Andersen, Hughes, Zou, & Wilsnack, 2014; Charak et al., 2016; Hovens, Giltay, Spinhoven, van Hemert, & Penninx, 2015), over and above the effects of exposure to specific types of traumatic stressors and interpersonal adversity (Hamby, Smith, Mitchell, & Turner, 2016). However—and not surprisingly, given the complexity of victimization and related forms of traumatic stressors and adversity—many key questions regarding the nature and impact of polyvictimization remain in need of clarification and fuller answers. In this Special Issue of the Journal of Trauma and Dissociation, the results of six empirical studies are reported which help to further our understanding of the nature, consequences, and assessment of polyvictimization. As an introduction to the Special Issue, this commentary will summarize the questions addressed and key findings provided by the six empirical reports. We also will highlight future directions for clinical and scientific investigation and innovation with regard to polyvictimization.

How should polyvictimization be assessed and measured?

Polyvictimization has been operationalized in three principal ways. Over the past two decades, substantial evidence has demonstrated a dose–response relationship between physical and mental health problems and the cumulative impact of exposure to an increasing number of types or developmental epochs of victimization (Horan & Widom, 2015; Mustanski, Andrews, & Puckett, 2016; Nilsson, Gustafsson, & Svedin, 2012; Pereda & Gallardo-Pujol, 2014) or adversity (Finkelhor, Shattuck, Turner, & Hamby, 2015; Nurius, Green, Logan-Greene, & Borja, 2015; Ports, Ford, & Merrick, 2015). However, specific types of traumatic exposures also have been shown to account for impairment over and above the cumulative impact of the number of specific exposure types (Grasso et al., 2016; Ports et al., 2015; Wong, Clark, & Marlotte, 2016). A more nuanced approach to identifying the dimensions of traumatic adversity and victimization may be needed in order to determine the contribution of each specific type of adverse exposure, and its interaction with other co-occurring or subsequent types of victimization, in order to fully understand the self-protective adaptations and morbidity/impairment caused by different profiles of cumulative exposure to trauma and adversity (Ford, 2017; McLaughlin & Sheridan, 2016).

An alternative to the cumulative approach is a categorical perspective that identifies individuals who are classified as polyvictims. This can be done by using a threshold representing whether the extent of exposure to different types of victimization exceeds an a priori criterion—either having more types of victimization than average for that sample, i.e., “one-above-the-mean” (Finkelhor et al., 2007a), or a percentile level (i.e., the 90th percentile—the 10% of persons in the sample who experienced the largest number of types of victimization) with some event types (e.g., sexual abuse) weighted higher for adversity (Cyr et al., 2013; Finkelhor et al., 2009; Turner, Finkelhor, & Ormrod, 2010). A second categorical method alternatively identifies mutually exclusive groups of individuals with similar profiles of victimization types using person-centered statistical analytic techniques (e.g., latent class analysis; LCA) (Ford, Elhai, Connor, & Frueh, 2010). Polyvictimization also has been identified based on the person’s entire childhood (or lifetime), or on recent experiences (typically the past year).

In this issue, Montagut and colleagues describe a study comparing the results of using these three categorical methods of classifying recent and lifetime polyvictims (i.e., the two a priori and the person-centered methods) with a large school-based sample of adolescents in Spain. Using the well validated Juvenile Victimization Questionnaire, they found that each operational definition and time frame yielded a different set of “polyvictims,” with the greatest amount of overlap unexpectedly occurring when the a priori one-above-the-mean criterion and the person-centered LCA approach were compared for lifetime polyvictimization, or when the a priori top 10% criterion and the LCA approach were compared for past-year polyvictimization. Although the specific youth identified by each approach as polyvictims differed, the demographics (age, gender, socioeconomic status, nationality) of the youth identified as polyvictims were comparable for all the approaches. And, while all of the polyvictims, regardless of how they were identified, tended to have experienced many forms of interpersonal violence, each individual polyvictim’s profile of victimization was unique. Lifetime polyvictims were most distinct from other youth in reporting sexual victimization and being assaulted or robbed, while the recent polyvictims tended to most often report victimization by caregivers, siblings, or peers. Thus, different “nets” can be cast to identify polyvictims, and each “net” will identify a different set of youths as polyvictims.

Distinguishing individuals who are classified as polyvictims by several approaches from those who only are identified by only one approach will address several research and clinical questions. For example, it is important to determine both whether the multi-method polyvictims are particularly adversely affected within and across all domains of biopsychosocial functioning. It also is crucial to clinically determine whether individuals who need assistance in preventing or recovering from victimization are being missed when only one of the approaches to identifying polyvictims is used. The findings by Montagut and colleagues also are a vital reminder that no two polyvictims can be assumed to be alike in their individual histories of victimization, let alone in their personal characteristics and the difficulties they face.

How are young children impacted when polyvictimization begins in early childhood?

Infants and toddlers are exposed to traumatic stressors and victimization more often than is commonly assumed (Briggs-Gowan et al., 2010; Briggs-Gowan, Ford, Fraleigh, McCarthy, & Carter, 2010), and they may develop severe biopsychosocial problems including post-traumatic stress disorder (PTSD) (Briggs-Gowan, Carter, & Ford, 2012; Scheeringa, Myers, Putnam, & Zeanah, 2012). Despite the fact that polyvictimization may begin in early childhood, most research and clinical studies on polyvictimization are based on the retrospective report of adults or adolescents on their own (Charak et al., 2016; Grasso et al., 2016; Turner et al., 2016) or (by parents) their child’s (Finkelhor, Turner, Shattuck, & Hamby, 2015) childhood history of victimization. In order to confirm those retrospective self- and parent-report findings, it is important to determine whether young children who are polyvictims can be identified based on contemporaneous evidence that is accumulated by an expert source. Although child protective services records are subject to inevitable inaccuracies and biases, they represent a valuable alternative data source for identifying victimized children (Horan & Widom, 2015).

Horn and colleagues collected an immediate and direct assessment of early childhood polyvictimization by extracting Child Protective Services records of maltreatment for toddlers (ages 3–4 years old) in foster care. In addition, they assessed the children’s executive function (i.e., cognitive abilities such as memory, processing speed, and verbal abilities), a critical aspect of child development that has been shown to be compromised by exposure to victimization in childhood (Lu et al., 2017) and polyvictimization specifically (Li et al., 2013). Polyvictimized toddlers who had substantial problems with executive function were found to be at heightened risk for clinically significant externalizing (disruptive behavior) problems, while polyvictims with low average or higher executive function skills tended to have at most mild behavior problems. Also, polyvictimization was unrelated to executive function, as well as to the child’s age or gender, number of out-of-home placements, and family socioeconomic status.

The findings reported by Horn and colleagues demonstrate that polyvictimization not only has occurred in early childhood for many children who subsequently are placed in foster care, but also that a sub-group of polyvictimized children are at risk developmentally due to deficits in executive function. While the results do not indicate that polyvictimization leads to executive function deficits, they demonstrate that the combination of polyvictimization and executive function deficits can have distinct developmentally adverse effects on behavioral self-control as early as in toddlerhood. This finding is consistent with a meta-model of developmental psychopathology that proposes that distinct trajectories (Briggs-Gowan et al., 2012) must be empirically identified scientifically and clinically in order to characterize the impact of early childhood adversity on the emergence and consolidation of two key domains of biopsychosocial competence: affect regulation and executive functions (Ford, 2005; McLaughlin, 2016).

How does polyvictimization adversely impact high-risk adolescents?

Polyvictimization reaches epidemic levels by the time children grow into adolescence (Ford et al., 2010; McLaughlin et al., 2013). Youth who are troubled and have become involved in the juvenile justice (Cudmore, Cuevas, & Sabina, 2017; Ford, Grasso, Hawke, & Chapman, 2013) and children’s mental health (Cuevas, Finkelhor, Ormrod, & Turner, 2009; Ford, Connor, & Hawke, 2009; Ford, Wasser, & Connor, 2011; Segura, Pereda, Guilera, & Abad, 2016) systems are at high risk for polyvictimization. Adolescent polyvictims often have experienced multiple types of victimization in every epoch of development from early childhood through the school years and on into adolescence (Adams et al., 2016; Chan, 2013; Grasso et al., 2016). Polyvictimized adolescents also tend to have particularly severe symptoms of PTSD (Dong, Cao, Cheng, Cui, & Li, 2013; Ford et al., 2010, 2013; Segura et al., 2016; Soler, Paretilla, Kirchner, & Forns, 2012) and dissociation (Leibowitz, Laser, & Burton, 2011; Martinez-Taboas, Canino, Wang, Garcia, & Bravo, 2006; Teicher, Samson, Polcari, & McGreenery, 2006) (Adams et al., 2016; Grasso et al., 2016), It is not clear, however, whether, or how, PTSD and dissociation symptoms play a role in the developmental pathways from polyvictimization to the serious problems with addiction, anger, depression, and suicidality that compromise adolescents’ safety and development (Ford et al., 2010)

Ford and colleagues identified three sub-groups in a large sample of juvenile justice-involved youth, including polyvictims, youths with extensive exposure to violence, and youths with histories of mixed adversities including severe accidents, bullying, and the loss of close family members and friends to violent death or suicide. Despite these youths’ almost universal exposure to adversity, the polyvictims were found to be uniquely at risk for alcohol/drug use problems compared to their violence- and adversity-exposed peers. Moreover, a stronger relationship was found between PTSD symptoms and problems with anger, depression and anxiety, and somatic/health problems, and between dissociation symptoms and depression, anxiety, and suicidality, for the polyvictims than their violence- and adversity-exposed peers. Thus, youth in the juvenile justice system who are polyvictims not only are at risk for PTSD and dissociative symptoms, but the trauma-related symptoms are particularly likely to contribute to severe and dangerous emotional, behavioral, and self-harm problems for polyvictims. These findings highlight the importance of providing polyvictimized youth who become involved in juvenile justice with trauma-focused treatment that effectively addresses the symptoms of both PTSD and dissociation as well as related safety risks (Ford, Kerig, Desai, & Feierman, 2016).

Girls increasingly are involved in juvenile justice systems, yet the services they receive tend to be no different than those provided to boys (Leve, Chamberlain, & Kim, 2015). As Ford and colleagues, and prior studies (Ford et al., 2013), have shown, girls are substantially over-represented when polyvictim sub-groups are identified among juvenile justice-involved youth (e.g., comprising more than two-thirds of polyvictims but less than 20% of the juvenile justice population). Polyvictimized girls are at risk for suicidality (Grigorenko, Sullivan, & Chapman, 2015; Soler, Segura, Kirchner, & Forns, 2013), dissociation (Zona & Milan, 2011), and low levels of perceived self-competence (Soler, Kirchner, Paretilla, & Forns, 2013). Polyvictimized girls also may not experience the protective buffering of being in a stable low-adversity family that appears to protect polyvictimized boys from mental health problems (Nilsson et al., 2012). These findings suggest that polyvictim girls in juvenile justice settings may be at particularly high risk for severe mental health, posttraumatic stress, and dissociative problems.

Therefore, in a mixed-gender sample of juvenile justice-involved youth, Kerig and colleagues investigated the association between gender, polyvictimization, emotional numbing and callous unemotional traits, and dissociation and borderline personality traits, with severity of delinquency. Polyvictimization was strongly related to both emotional down-regulation (i.e., numbing and callous unemotional traits) and emotional dysregulation (i.e., dissociation and borderline traits)—and through them, to more severe delinquency—equally for boys and girls. However, the relationships between polyvictimization with delinquency for girls involved two completely independent paths involving either emotional down-regulation or dysregulation. For boys, however, emotional numbing was associated with emotional dysregulation (i.e., borderline traits as well as with callous unemotional traits). Thus, polyvictimized girls appear to be at risk for problems with delinquency either due to becoming emotionally shutdown or dysregulated, which may require distinct approaches to treatment and rehabilitation (Chamberlain & Leve, 2004; Chamberlain, Leve, & Degarmo, 2007). The findings also underscore the importance of careful screening for polyvictimization in juvenile justice (Ford et al., 2016), in order to provide interventions for both emotional numbing and dissociation before they lead to chronic emotional and behavioral dysregulation that is associated with incarceration and severe behavioral health problems in adulthood (Luntz & Widom, 1994; Lynch et al., 2014; Yanos, Czaja, & Widom, 2010). They also call into question the general stereotype of the delinquent youth as primarily emotionally numbed and callous and unemotional, as well as the gender-specific stereotype of troubled girls as primarily affectively dysregulated and boys as emotionally shutdown.

Understanding the impact of polyvictimization on the body and mind

The sequelae of traumatic victimization, including PTSD, often involve what at first glance seem to be directly contradictory attentional and behavioral adaptations: on the one hand, hypervigilance to potential threats; yet also an avoidance of contact with or awareness of the settings, situations, or cues that are associated with threat or danger (Ashley, Honzel, Larsen, Justus, & Swick, 2013; Bryant & Harvey, 1997). This apparent paradox has been resolved by postulating an over-arching tendency toward preoccupation with threat—including both attention directed toward and away from cues related to threat—in disorders in which anxiety plays a major role (Pine, 2007).

Herzog and colleagues applied this framework to examine the role of threat-related attention bias in victimization and polyvictimization. Using laboratory tests of attention and physiology (i.e., autonomic nervous system), they found that, in a nonclinical sample of young and mid-life women, those who had experienced a single type of interpersonal victimization differed from those who had experienced three or more victimization types (i.e., polyvictims). Women who had experienced one type of victimization showed a bias in attention toward threat-related cues (i.e., hypervigilance), while polyvictimized women showed an attention bias away from threat-related cues (i.e., avoidance). In addition, cues associated with relatively mild threats tended to elicit hypervigilance, while cues related to severe threats elicited avoidance. And polyvictims tended to avoid threat cues when their heart rate variability or “vagal tone” (a measure of adaptive regulation of physiological arousal) and heart rate (a measure of the extent of physiological arousal) was low. Thus, a sub-group polyvictims may shift from vigilance to threat cues to avoidance of threat cues in an attempt to modulate even when they experience only relatively mild levels of physiological stress/distress.

These findings suggest that re-victimization may compound the trauma-related coping adaptations that were elicited by earlier experiences of victimization, such that the person who now is a polyvictim may shift from hypervigilance to threat avoidance in an attempt to cope self-protection. This potential shift is strikingly similar to a pattern observed in adults with sub-threshold (i.e., hypervigilance) versus full (i.e., avoidance of threat) PTSD (Thomas, Goegan, Newman, Arndt, & Sears, 2013). Consistent with this view, Herzog and colleagues also found that PTSD symptoms—i.e., stress-related coping involving physiological arousal (Lanius et al., 2010)—were associated with hypervigilance, whereas it was dissociative symptoms—stress reactions that occur when arousal or distress exceed adaptive capacities (Ford, 2009)—that were related to threat avoidance. Polyvictimization thus may place individuals at risk for complex post-traumatic dysregulation in multiple biological, affective, cognitive, and behavioral domains (Ford, 2013).

Polyvictimization in the Internet era

As technology increasingly permeates not just urban centers but also the traditionally more remote rural places across the globe, victimization has become increasingly technologized and therefore ubiquitous. More than two-thirds of adults in the United States use the Internet (79% of these use Facebook; Greenwood, Perrin, & Duggan, 2016) and nearly three-quarters of teens own a smartphone and use at least one social media website (American Academy of Pediatrics, 2016). Hamby and colleagues take an important first step in addressing the challenges technology poses to our safety and privacy as individuals with a survey of media-based (digital) polyvictimization in a rural population living in southeastern U.S.A. Based on focus groups and qualitative interviews with teens and adults, they identified 11 specific types of digital victimization, including financial scams, hacking, stalking, impersonation, privacy violations, exclusion, and aggression. Almost three in four adults surveyed had experienced at least one of these forms of digital victimization, and consistent with a polyvictimization framework, having a history of in-person victimization doubled the risk of digital victimization. Moreover, digital polyvictimization was equally or more strongly associated with PTSD and anxiety/dysphoria symptoms and problems with health-related quality of life and family well-being than in-person polyvictimization. Study findings suggest that the psychological harm that can be done on the Internet or other media warrants careful assessment and dedicated prevention efforts, as it can be just as severe, or worse, than the harm caused by face-to-face victimization.

Next steps and future directions for studies on polyvictimization

The insights provided by these Special Issue articles attest to the importance of continued scientific research and clinical inquiry concerning the nature and biopsychosocial impact of polyvictimization, beginning in the formative years of childhood (Briggs-Gowan et al., 2010) and adolescence (Grasso et al., 2016), and extending across the lifespan through mid-life and older adulthood (Hamby et al., 2016). Much more clarity is needed as to the different profiles of adversity/victimization that may have distinct outcomes and require correspondingly carefully targeted prevention and therapeutic interventions. The role that specific forms of victimization play in moderating or exacerbating the effects of exposure to differing combinations of multiple types of adversity and victimization requires careful testing.

We also need to better understand the continuities and discontinuities in polyvictimization within and across key developmental epochs and transitions, both for each individual and in the aggregate. The form(s) polyvictimization takes, and the impacts that it has on development and functioning, for populations that are at particular risk for adversity (e.g., people of color, persons of minority sexual identity, homeless persons and families, commercially sexually trafficked youth and adults, immigrants and refugees, developmentally disabled children and adults; people and communities living in poverty or exposed to natural or human-made disasters). These nuances are the translational key to creating targeted interventions (Courtois & Ford, 2009; Ford & Courtois, 2013) enabling polyvictims to recover from traumatic stress, dissociation, and emotion down-regulation and dysregulation while harnessing or developing the resources (Guerra, Ocaranza, & Weinberger, 2016) and “resilience portfolios” (Hamby et al., 2016, p. 217) needed to restore health and self-regulation (Ford, 2013).

The goal of this Special Issue of the Journal of Trauma and Dissociation has been to increase awareness of and interest in polyvictimization by clinicians and researchers. We hope this Issue has helped to move this important emerging line of theory, research, and clinical practice toward increasing rigor, consistency, and internal and external validity in defining, conceptualizing, measuring, preventing, and clinically assessing and treating polyvictimization and its sequelae.

Additional information

Funding

Julian Ford discloses a financial interest as co-owner of Advanced Trauma Solutions, Inc. (ATS), which is licensed by the University of Connecticut to disseminate the TARGET intervention. ATS had no involvement in this article. Brianna Delker has no conflict of interest. Support for writing this article was provided by a grant from the Substance Abuse and Mental Health Services Administration, National Child Traumatic Stress Network, Center for Trauma Recovery and Juvenile Justice (1U79SM080013-01) and Center for the Treatment of Developmental Trauma Disorders (1U79SM080044-01), Julian Ford, Principal Investigator.