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The primary goal of this study is to conduct an empirical investigation of the association between an early life stressor such as childhood maltreatment and subsequent diagnosis of Type II diabetes in adulthood. This study will specifically explore if a relationship exists between the type and severity of childhood maltreatment encountered and participant's diabetes-related quality of life. To provide a context for the current study, background literature focusing on two dimensions that have received considerable attention in the psychological literature is first thoroughly reviewed: definition and effects of childhood maltreatment and the biopsychosocial aspect of Type II diabetes. The current study's purpose, hypotheses, method, and data analytic strategy will then be proposed.
Childhood maltreatment refers to, "any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child" (Centers for Disease Control [CDC], n.d., para. 1). In their report, Child Maltreatment Surveillance, Leeb, Paulozzo, Melanson, Simon, & Arias (2007) defined acts of commission as deliberate and intentional use of words or actions that cause harm, potential harm, or threat of harm to a child. Examples of acts of commission include physical, sexual, and/or psychological abuse. Acts of omission, on the other hand, are the failure to provide for a child's basic physical, emotional, or educational needs or to protect a child from harm (Leeb et al., 2007). Thus, acts of omission include physical, emotional, medical, or educational neglect, the failure to supervise or insufficient supervision, and/or exposure to a violent environment.
According to the most recent publication by the U.S. Department of Health and Human Services (USDHHS) on childhood maltreatment, an estimated 905,000 children were determined to be victims of abuse or neglect (USDHHS, 2006). Specifically, 64.2 percent of child victims experienced neglect, 16.0 percent were physically abused, 8.8 percent were sexually abused, and 6.6 percent were emotionally or psychologically maltreated. The report suggests that rates of victimization by maltreatment type have fluctuated only slightly during the past several years.
The long-term consequences of child maltreatment are significant and include the risk of alterations of brain structure and function, sexual risk taking behaviors, eating disorders, suicidal intent and behavior, lower self-esteem, adjustment problems, internalizing problems (i.e. anxiety and depressive disorders), externalizing problems (i.e. personality disorders and substance abuse), adult trauma, continuation of intergenerational violence and/or neglect, and developmental and cognitive disabilities (Anda, Felitti, Bremner, Walker, Whitfield, Perry, Dube, & Giles, 2006; Arata, Langhinrichsen-Rohling, Bowers, & O'Farrill-Swails, 2005; Bardone-Cone, Maldonado, Crosby, Mitchell, Wonderlich, Joiner, Crow, Peterson, Klein, & Grange, 2008; Johnson, Sheahan, & Chard, 2003; Kaplow & Widom, 2007; Kaslow, Okun, Young, Wyckoff, Thompson, Price, Bender, Twomey, Golding, Parker, 2002; Lewis, Jospitre, Griffing, Chu, Sage, Madry, & Primm, 2006; Medrano, Hatch, Zule, & Desmond, 2002; Smith, 1996; Sobsey, 2002; Taft, Marshall, Schumm, Panuzio, & Holtzworth-Munroe, 2008). A consistent relationship between abuse history and poorer overall health has also been demonstrated in a stratified, epidemiological sample of both men and women within the United States (Cromer and Sachs-Ericsson, 2006).
Childhood Maltreatment and Physical Health Problems
A consistent dose-relationship between abuse history, poorer overall health, and sustained losses in health-related quality of life has been well established (Cromer & Sachs-Ericsson, 2006; Golding, 1994; Corso, Edwards, Fange, & Mercy, 2008). Childhood sexual abuse has been associated with physical complaints such as migraine, irritable bowel syndrome, fibromyalgia, and chronic pain (Goldberg, Pachas, & Keith, 1999; Goodwin, Hoven, Murison, & Hotopf, 2003; Ross, 2005; Walker, Keegan, Gardner, Sullivan, Bernstein, & Katon, 1997). Furthermore, using data from the National Corbidity Study, a nationally representative general population study, Arnow (2004) found that abused children were likely to have pelvic and musculoskeletal pain as adults, and utilize health care services at a greater proportion in adulthood. However, a major limitation of these studies is exclusion of emotional and/or psychological abuse experienced in childhood. Additionally, results regarding the incidence of types of childhood maltreatment and diabetes have been mixed.
Diabetes is a chronic disease characterized by the deficiency or resistance to insulin, a hormone needed to convert sugar, starches and other food into energy needed for daily living. As such, insulin deficiency compromises the body tissues' access to essential nutrients for fuel or storage. According to the American Diabetes Association (ADA), there are 23.6 million children and adults in the United States, or 7.8% of the population, who have diabetes, many of which unaware that they have the disease (ADA, n.d., para. 2).
Diabetes occurs in two primary forms. Type I diabetes is characterized by absolute deficiency and typically occurs before the age of 30. Type II diabetes, however, is typified by insulin resistance with varying degrees of deficiencies in the body's ability to secrete insulin. Sedentary lifestyle and diet have been linked to the development of Type II diabetes. Other risk factors for this type of diabetes include obesity, pregnancy, metabolic syndrome, and various medications. Physiologic and emotional stress has also been thought to play a key role in the development of Type II diabetes specifically. Prolonged elevation of stress hormones, namely cortisol, glucagon, epinephrine, and growth hormone, increases blood glucose levels, which in turn places increased demands on the pancreas. Such stress ultimately leads to the inability of the pancreas to keep up with the body's need for insulin and high levels of glucose and insulin circulate in the bloodstream, setting the stage for Type II diabetes ("Diseases", 2006).
Role of Stress in the Onset of Diabetes - Animal Studies
Researchers have found that both a history and presence of existing stressors play a significant role in the onset and course of diabetes. Through the use of animal studies, researchers have been able to prospectively test the influence of stress on both types of diabetes. For example, Lehman, Rodin, McEwen, and Brinton (1991) investigated whether an environmental challenge promoted the expression of diabetes in bio-breeding rats. Researchers introduced a triad of stressors to the animals over a 14-week period, including rotation of the cage, vibration, and restraint in individual containers. They found that the administration of these stressors repeatedly increased the likelihood of the rats developing Type I diabetes as indicated by elevated blood sugar levels (Lehman et al., 1991).
One of the first observations that stress could contribute to the expression of Type II diabetes was made during metabolic studies of the native North African sand rat (psammonys obesus). Once fed with laboratory chow and allowed to become obese, the North African sand rat will eventually develop Type II diabetes in response to an environmental stressor (Surwit, Schenider, & Feinglos, 1992). Notably, Mikat, Hackel, Cruz, and Lebowitz (1972) administered an esophageal intubation of saline in an effort to control the dietary intake of the sand rat. This tube feeding resulted in an alteration of glucose tolerance and precipitated the onset of Type II diabetes in these rats. Similar research was done on the genetically obese (ob/ob) mouse, which is used as a prototype of Type II diabetes in humans because of its pattern of obesity, hyperinsulinemia, hyperglycemia, insulin resistance, and glucose intolerance (Surwit, Feinglos, Livingston, Kuhn, & McCubbin, 1984). To study the effects of environmental stress and sympathetic nervous system arousal on plasma glucose in ob/ob mice, Surwit et al. (1984) designed two experimental conditions. In the first condition, 15 ob/ob mice were shaken in their cage at a rate of 200 strokes per minute for five minutes. In the second condition, 16 ob/ob mice were injected with epinephrine bitartrate, a chemical whose effects mimic those of the stress response. Plasma glucose levels in mice from both conditions were found to be significantly elevated. The researchers concluded that environmental stress was partially responsible for the expression of the diabetic phenotype in this animal model of diabetes.
Role of Stress in the Onset of Diabetes - Human Studies
Data gathered on the impact of life events on Types I diabetes in a human sample has yielded inconsistent results. An early study by Grant, Kyle, Teichman, and Mendels (1974) examined the relationship between the occurrence of life events and the course of illness in a group of 37 diabetic patients. Using Holmes and Rahe's Schedule of Recent Events (SRE), a scale in which 43 significant recent life events are assigned a numeric value of life change units as a measurement of life stress, Grant et al. (1974) found that of the 26 participants who had a positive correlation between undesirable life events and illness, 24 had a positive correlation between undesirable events scores and diabetic condition. This data suggests that negative events were primarily responsible between life events and changes in diabetic condition since the inclusion of neutral and positive events did not increase the magnitude of the correlations. Despite the significant results, this study had a number of limitations, including the utilization of a small sample size, difficulty in establishing reliable criteria for assessing subtle changes in the diabetic condition, lack of sufficient time to elapse between assessments for significant life changes to occur, and the lack of delineation of the types of diabetes studied (i.e. Type I vs. II).
However, in a more recent meta-analysis, Cosgrove (2004) found no evidence to support the hypothesis that life events cause or precipitate Type I diabetes. Using an electronic and manual literature search of appropriate key words (namely, 'diabetes and depression', 'diabetes and depressive', 'diabetes and life events', 'diabetes and stress') in the literature up to July 2003, Cosgrove (2004) aimed to establish whether there might be a link between depression, stress, or life events and the onset of Type I diabetes. A total of nine papers were found from the electronic and manual search. It was concluded that when the number and severity of life events was compared to controls in all nine reviewed studies, no differences were detected in the diabetics (Cosgrove, 2004). Though data from small, older studies and large, randomized studies showed that early losses in childhood increase the risk of developing Type I diabetes, no evidence was found to support the hypothesis that life events cause or precipitate this diagnosis. Meta-analyses with more recent studies have not been found studying the relationships between stressful life events in both types of diabetes. As such, it is unknown whether links have since been found by other researchers.
More consistent evidence was found supporting the notion that stressful circumstances precipitate Type II diabetes. In their study of environmental stress on Type II diabetics, McCleskey, Lewis, and Woodruff (1978) measured glucagon and glucose levels on 25 patients who were undergoing elective surgery, a physical stressor. Ten samples were obtained during pre-operative, intra-operative, and post-operative periods for each patient. It was found that throughout the sampling period, diabetic patients had two times the amount of glucagon (a hormone produced by the pancreas that stimulates the increase of blood sugar levels) in their body compared to their non-diabetic counterparts (McCleskey, Lewis, & Woodruff, 1978).
This effect was also found in Pima Indians, who have an approximately 60% chance of eventually developing Type II diabetes, compared with 5% of the Caucasian population (Surwit, Schenider, & Feinglos, 1992). The effects of a simple arithmetic task on blood glucose levels were studied in both Caucasian and Pima Indian samples. Surwit, McCubbin, Feinglos, Esposito-Del Puente, and Lillioja (1990) found that blood glucose was consistently higher during and following the stressful task in ten of 13 Pima Indians, concluding that altered glycemic responsivity to behavioral stressors anticipates the development of Type II diabetes in individuals who are genetically predisposed to the disease (Surwit et al., 1990).
Results from The Hoorn Study further illustrated the effects of stress on Type II diabetes. Mooy, De Vries, Grootenhuis, Boutner, and Heine (2000) analyzed data from a large population-based survey of 2,262 adults in the Netherlands upon which the researchers were able to explore whether chronic stress is positively associated with the prevalence of Type II diabetes. Analysis of data confirmed their hypothesis; a high number of rather common major life events that are correlated with chronic psychological stress, such as death of a spouse or relocation of residence, were indeed found to correspond to a significantly higher percentage of undetected diabetes (Mooy et al., 2000). Because the study was conducted in the Netherlands on a Caucasian, middle-aged population, it is uncertain whether these findings are generalizable to other demographics in different geographic regions.
Childhood Maltreatment and Diabetes
Thus far, with the exception of one study, the research discussed has demonstrated a positive correlation between a variety of recent or current environmental stressors, such as anesthesia, surgery, cognitive tasks, death of a loved one, and other significant losses, and the onset of Type I and/or II diabetes in animals and human beings. However, the literature is somewhat limited as to the relationship between a past environmental stressor, namely childhood maltreatment, and Type II diabetes in adulthood.
Numerous researchers examined the prevalence of medical problems in abused populations and have reported that diabetes is one of the most common health conditions among those who have experienced maltreatment. For example, using data drawn from the National Comorbidity Study conducted in the early 1990's, Sachs-Ericsson, Blazer, Plant, and Arnow (2005) examined the independent effects of childhood sexual and physical abuse on adult health status in a large community sample of 5,877 men and women. Sachs-Ericsson et al. (2005) found that childhood sexual and physical abuse was associated with the one-year prevalence of serious health problems for both men and women. Specifically, participants who experienced any form of childhood abuse were more likely to report having a medical condition, including AIDS, arthritis, asthma, bronchitis, cancer, diabetes, high blood pressure, kidney or liver disease, neurological problems, stroke, gastrointestinal disorders, or any other serious health problem (Sachs-Ericsson et al., 2005). Though data from this epidemiological study likely represents the U.S. demographics, a number of limitations exist. Specifically, the researchers did not report the prevalence of each disorder endorsed and thus, the actual incidence of diabetes in the population sample is unknown. Furthermore, Sachs-Ericsson et. al (2005) did not look at additional forms of maltreatment, such as verbal abuse, emotional abuse, and neglect.
Similarly, Walker, Gelfand, Katon, Koss, Von Korff, Bernstein, and Russo (1999) found a significant association between childhood maltreatment and adverse adult health outcomes. In particular, the researchers administered a survey to 1,225 women randomly selected from the membership of a large HMO in Washington State. Results indicated that women with childhood maltreatment histories were more likely to have an increased number of physician-coded ICD-9 diagnoses, grouped together as high blood pressure, diabetes, dermatitis, asthma, allergy, acne, and abnormal menstrual bleeding. Though the group of women in this study who reported threshold levels of sexual maltreatment had the poorest health outcomes, a major limitation of this study is the uncertainty as to whether additional forms of maltreatment were concomitantly experienced. Specifically, the authors do not establish whether sexual abuse solely was the cause of poorer health or is largely due to multiple forms of maltreatment in girls who were not properly protected in their early families. Moreover, Walker et al. (1999) do not differentiate between types of diabetes.
Gender differences have been established in the association between physical abuse in childhood and overall health problems in adulthood. Analysis of data from 16,000 individuals interviewed in the National Violence Against Women Survey found that female abuse victims were at greater risk for health problems than their male counterparts (Thompson, Kingree, & Desai, 2004). Furthermore, women with maltreatment history tend to have more distressing physical experiences, have an increased number of physician-coded diagnoses, and were more likely to engage in multiple health risk behaviors, including obesity - a significant risk factor associated with Type II diabetes (Trickett, Putnam, & Noll, 2005; Walker, Gelgand, Katon, Koss, Von Korff, Bernstein, & Russo, 1999). Moreover, sexual assault history throughout one's lifespan was also associated with chronic disease (i.e. diabetes, arthritis, and physical disability) in a sample of women from Los Angeles (Golding, 1994). Conversely, in their sample of 680 primary care patients, Norman, Means-Christensen, Craske, Sherbourne, Roy-Byrne, and Stein (2006) found that the experience of trauma significantly increased the odds of arthritis and diabetes for men, while trauma was associated with increased odds for digestive disorders and cancer in women. Although the data suggests that childhood maltreatment is related to adverse health outcomes in adulthood, they do not address as to why associations differed by gender.
Analyzing data from the Midlife Development in the United States Survey (MIDUS), Goodwin and Weisberg (2002) sought to determine the association between childhood emotional and physical abuse and the odds of self-reported diabetes among adults in the general population. Their results revealed that self-reported diabetes occurred in 4.8% of its representative sample of 3,032 adults aged 25-74 years. Childhood abuse was associated with significantly increased odds of self-reported diabetes, which persisted after adjusting for differences in socio-demographic characteristics and mental health status (Goodwin & Weisberg, 2002). Moreover, individuals who specifically reported maternal emotional abuse and maternal physical abuse had significantly higher rates of diabetes (Goodwin & Weisberg, 2002).
Furthermore, data gathered from a sample of 130 patients (65 abused, 65 non-abused controls) drawn from an adult primary-care practice in a small, affluent, predominantly Caucasian community in northern New England revealed that patients with a history of victimization were more likely to report diabetes or endorse symptoms of this illness than non-abused participants (Kendall-Tackett & Marshall, 1999). Specifically, four patients in the abused group reported diabetes, with none in the control group. Interestingly, those patients in the abused group did not have a significantly higher family history of diabetes than those in the non-abused group and a higher percentage of patients in the abused group reported having three of more symptoms than did those in the control group. Kendall-Tackett and Marshall (1999) assert that although only four people identified themselves as having diabetes, this number should be interpreted in the broader context of incidence of diabetes in the general population. Nonetheless, this finding could have been due to chance and many of the symptoms endorsed could have been related to other diseases (Kendall-Tackett & Marshall, 1999). Additional limitations include the failure to differentiate between the types of abuse endured and the use of a non-empirically validated measure to gather data. Furthermore, the researchers did not specify which type of diabetes the participants were diagnosed with and did not indicate the severity of the disease.
Data from the Adverse Childhood Experiences Study (ACE), however, found alternative results. Researchers Felliti, Anda, Nordenberg, Williamson, Spitz, Edwards, Koss, and Marks (1998) mailed questionnaires about adverse childhood experiences to 9,508 adults who had completed a standardized medical evaluation at a large HMO in California. It was found that abuse and other types of household dysfunction were significantly related to the number of disease conditions, with the exception of diabetes. Specifically, when those who had experienced multiple forms of childhood maltreatment were compared to those with no experiences, the odds-ratio for the presence of diabetes was a non-significant 1.6 (Felliti et al., 1998). The researchers believe that their estimates of the long-term relationship between adverse childhood experiences and adult health are conservative. Specifically, it is likely that, consistent with well-documented longitudinal follow-up studies, that reports of childhood abuse were underestimated due to the premature mortality in persons with multiple adverse childhood exposures (Felliti et al., 1998).
Similarly, in a sample of 1,359 community-dwelling men and women aged 50 years or older, Stein and Barrett-Connor (2000) found no relationship between sexual assault history in participant's lifetime and reported rates of diabetes. Rather, a history of sexual assault was associated with an increased risk of arthritis and breast cancer in women and thyroid disease in men (Stein & Barrett-Connor, 2000). In this study, the researchers posit that the possibility of response bias is a major limitation. Namely, Stein and Barrett-Connor (2000) consider the likelihood that previously assaulted respondents have a greater tendency to visit doctors, leading to the increased opportunities for health conditions to be detected. Additional limitations include the lack of consideration for other types of abuse encountered in childhood.
The Link between Childhood Maltreatment and Diabetes
The above findings provide support for the hypothesis that childhood maltreatment may be associated with increased likelihood of the diagnosis of a medical condition, with the inclusion of diabetes in some studies. An essential question posed by this observation is by what mechanisms are adverse childhood experiences linked to health risk behaviors and adult diseases? A number of researchers have found that psychological stress, in particular, has been associated with the onset of Type II diabetes. This impact of stress on the etiology and course of Type II diabetes can be considered via the metabolic pathways by means of obesity and/or activation of the hypothalamic-pituitary-adrenal (HPA) axis, the gene-environment interaction, and the correlation of coping with diabetes and stressors.
The stress response is a physiological coping response that involves the HPA axis, the sympathetic nervous system, the neurotransmitter system, and then immune system. There is growing evidence that victims of various forms of abuse and stressors often experience biological changes, particularly in the neuroendocrine system implicated in the stress response, as well as the brain (Glaser, 2000; Goenjian, Pynoos, Steinberg, Endres, Abraham, Geffner, & Fairbanks, 2003; King, Mandansky, King, Fletcher, & Brewer, 2001; McEwen, 2000). The HPA axis is the primary mechanism studied in the literature on the neurobiology of stress and is estimated through the non-invasive measurement of cortisol in saliva samples. During psychological stress, cortisol is elevated beyond normal levels in response to adrenocorticotropic hormone from the pituitary, mobilizing energy stores, and facilitating behavioral responses to threat ("Diseases", 2006). In the presence of prolonged stress, especially in which the individual has difficulty coping, this physiological response may occur to an atypical extent and prove harmful. Dienstbier (1989) asserts that prolonged and/or extreme stress can create a vicious cycle of pathology, as individuals with a history of abuse may become even more vulnerable in the face of new victimization because they become "threat-sensitized", resulting in either an over- or under-reaction of the HPA system to new stressors. As Vaillancourt, Duku, Decatanzaro, Macmillan, Muir, and Schmidt (2008) cite, this process is best illustrated by Cicchetti and Rogosch's (2001) study of maltreated children attending a summer day camp. These authors found that in comparison to non-abused children, children who had been both sexually and physically abused, in addition to emotionally maltreated or neglected, exhibited higher morning cortisol levels, whereas a subgroup of children who had only been physically abused exhibited lower levels.
Recent evidence suggests that increased cortisol concentrations may contribute to the prevalence of metabolic syndromes, such as Type II diabetes. For example, in their assessment of 190 Type II diabetic patients who volunteered from a population study of 12,430 in suburban Germany, Oltmanns, Dodt, Schultes, Raspe, Schweiger, Born, Fehm, and Peters (2006), sought to assess the relationship between diabetes-associated metabolic disturbances and cortisol concentrations in patients with Type II diabetes. The target population comprised of men and women born between 1939 and 1958 who completed a postal questionnaire about their health status. Results demonstrated that in patients with Type II diabetes, those with the highest cortisol profiles had higher glucose levels and blood pressures (Oltmanns et al., 2006). Their findings suggest that HPA axis activity may play a role in the development of Type II diabetes-associated metabolic disturbances. Cartmell (2006) proposes a model by which this may occur. Namely, high levels of cortisol decreases metabolism of glucose and increase mobilization and metabolism of fats. This decreased metabolism of glucose contributes to increased blood glucose levels. Furthermore, increased blood fat levels contribute to insulin resistance. This increase level of blood glucose and fats are characteristic symptoms of diabetes (Cartmell, 2006).
Researchers Chiodini, Adda, Scillitani, Colleti, Morelli, Di Lembo, Epaminonda, Masserini, Beck-Peccoz, Orsi, Ambrosi, and Arosio (2007) extended the literature by studying HPA axis secretion of cortisol and chronic diabetic complications. An evaluation was conducted on HPA activity in a sample of 117 Type II diabetic patients with and without chronic complications and in a sample of 53 non-diabetic patients at a hospital in Italy. Chiodini et al. (2007) found that in diabetic subjects without chronic complications, HPA axis activity was comparable with that of non-diabetic patients, whereas in diabetic subjects with chronic complications, cortisol level was increased in respect to both diabetic subjects and control subjects. Though the design of their study did not look for a cause-effect relationship, Chiodini et al. (2007) purport that higher levels of cortisol, either due to a constitutive HPA axis activation or secondary to a chronic stress condition, may predispose an individual to the development of chronic diabetic complications.
Type II diabetes is now a well-recognized syndrome characteristic of hyperglycemia, insulin resistance, obesity, dyslipidemia, and hypertension (Sridhar & Madhu, 2001). One theory that purports the biological plausibility of a stress-diabetes association has been formulated by Swiss researcher, Dr. Per Björntorp. Björntorp (1997) postulated that stress could be responsible for sympathetic nervous system activation, hormone abnormalities, and obesity. This theory states that perceived psychological stress with a defeatist or helplessness reaction leads to an activation of the HPA axis. This in turn results in endocrine abnormalities, including increased cortisol and decreased sex steroid levels that disrupt the actions of insulin. In addition, this hormonal imbalance causes visceral adiposity, which plays an important role in diabetes and cardiovascular disease by contributing to the development of insulin resistance (Cartmell, 2006).
Researchers of The Hoorn Study described above tested Björntorp's theory and found only partial support (Mooy et al., 2000). Specifically, the accumulation of visceral fat did not seem to be the major mediating factor between stress and diabetes and fasting insulin concentration, which is an approximation of insulin resistance, was not higher in the individuals in their sample who had experienced more stressful events.
The significance of this study is its potential to provide medical practitioners with information regarding the impact of past psychosocial factors, such as childhood maltreatment, on the current physical health of Type II diabetics. Diabetes and its complications affect a significant portion of the United States population and has become the fifth leading cause of death in the country (Florida Department of Health, 2008). As researchers continue to look for the cause(s) of diabetes and methods to treat, prevent, or cure the disorder, it is vital that practitioners take a holistic and comprehensive approach to assessing the diabetic's life. As long as abuse and other potentially damaging experiences in childhood contribute to the development of risk factors, then these childhood exposures should be recognized as the basic causes of morbidity and mortality in adult life (Felliti et al., 1998). Major limitations of past literature include lack of specificity of type of diabetes, family history, and self-reported diabetes without data on physiological measures. In addition to replication, future studies should include detailed studies on diabetes-type, a ruling-out of serious medical conditions that could potentially act as confounds, and identify maltreatment subtypes experienced.
This study aims to uncover a relationship between childhood maltreatment and adult physical health, namely with Type II diabetes, so as to assist with screening and intervention. If doctors caring for adults who suffer from a medical condition associated with diabetes are unaware of this relationship, they will neither obtain early maltreatment history nor make appropriate patient referrals leading to higher health care utilization and poorer outcomes (Arnow, 2004; Springer, Sheridan, Kuo, & Carnes, 2003).
Research Questions and Hypotheses
This study aims to answer the following questions: Is a history of childhood maltreatment associated with diabetes-related quality of life? If so, is a decrease in diabetes-related quality of life associated with an increase in the types of childhood maltreatment experienced? It is hypothesized that the more types of abuse endured during childhood (i.e. physical, emotional, and/or sexual, neglect, and/or the witnessing of family violence), the more chronic and severe an individual's diabetes will be and the greater impact of their illness on their reported quality of life.
Data will be collected from individuals with Type II diabetes, recruited from psychiatric practices located in Plant City and Tampa, Florida. Participants will be recruited from these sites due to likelihood that patients receiving psychiatric care have a history of childhood maltreatment. Participants will be included in the study if they are aged 40 and older, as non-insulin dependent diabetes appears after this age. Participants will be excluded from the study if they have additional existing physical conditions which may negatively impact their quality of life, as discussed in the Measures section. A projected sample size of 100 total participants has been chosen, using a sample size calculation provided by a statistics consultant.
Details regarding the study will be posted in the form of a flyer (Appendix D) in the waiting rooms of the psychiatric practices. Patients interested in participating in the study will inform the front office staff, who will provide the prospective participant with a packet including informed consent and all measures. Specifically, the informed consent will include the purpose of the research, the procedures to be followed, risks and discomforts as well as potential benefits associated with participation, and alternative procedures or treatments, if any, to the study procedures or treatments.
Once potential participants have read the consent document, have their questions are answered, and agree to participate in the research, the informed consent document will be signed, dated, and stored in a secure location. Participants will then be asked to fill out the questionnaires either in the waiting room or in a more private location of the office as they wait for their appointment. Once completed, participants will place the questionnaires in an attached blank envelope and placed in a collection box. A notation will be made in their chart signifying that they have completed the study so as to avoid duplicates.
Potential subjects will also be given a copy of the informed consent document so they can carefully review the document and discuss the research with the significant others and/or physician and develop questions to ask at their next psychiatric appointment and subsequent meeting with the researcher.
Once informed consent has been obtained, each participant from either group is to complete a demographics questionnaire, as well as two measures that explore maltreatment in childhood and diabetes quality of life. These measures are to be self-administered and anonymous.
The demographics questionnaire (Appendix A) will inquire about participant's age, height, and weight. This information will be used to obtain a measure of their body mass index (BMI). The BMI provides a standardized measure, and thus, reliable indicator of body fatness for most people and is used to screen for weight categories, such as obese, that may lead to health problems (CDC, n.d., para. 2). Since obesity is known to be a significant predictor leading to poorer quality of life (Sundaram, Kavookjian, Patrick, Miller, Madhavan, and Scott, 2007), it is important for the purposes of this study to exlude those participants who fall into this weight categories so as to avoid confounding variables. The demographics questionnaire will also include exclusionary criteria consisting of a variety of chronic physical conditions. In their research on comorbidity of chronic diseases, Rijken, van Kerhof, Dekker, and Schellevis (2005) note that the presence of multiple comorbid conditions complicates the question how a specific disease is related to quality of life and other outcome variables. It has been found that arthritis, osteoarthritis, cardiovascular diseases, chest pain, stroke, respiratory diseases, and cancer significantly reduces the quality of life in patients with Type II diabetes (Bowker, Pohar, & Johnson, 2006; Maddigan, Feeny, & Johnson, 2005; Miksch, Hermann, Rolz, Joos, Szecsenyi, Ose, & Rosemann, 2009; Rijken et al., 2005; Stone, Khunti, Squire, & Paul, 2008; de Visser, Bilo, Groenier, de Visser, & Meyboom-de Jong, 2002). Therefore it is vital for patients with these comorbid conditions to be excluded from the present study so as to accurately ascertain the impact of childhood maltreatment on their diabetes-related quality of life.
Maltreatment status is to be measured using the Childhood Trauma Questionnaire (CTQ; Bernstein et al, 2003; Scher et al., 2001). The CTQ is a self-report instrument that consists of five subscales assessing emotional, physical, and sexual abuse, as well as emotional and physical neglect. Rather than duration and intensity of traumatic experiences, the extent of the maltreatment is measured using a score that is calculated for each subscale and reflects the total number of items endorses. Each subscale score is categorized into four groups: none or minimal, low to moderate, moderate to severe, and severe to extreme (Bernstein and Fink, 1998). The CTQ has been well validated in both clinical and non-clinical populations. Furthermore, it has excellent reliability (.70-.93) for all subscales, with the lowest reliability for physical neglect and the highest for sexual abuse (Bernstein and Fink, 1998; Paivio and Cramer, 2004).
The Diabetes-39 questionnaire (D-39; Appendix C; Boyer & Earp, 1997) specifically asks patients to indicate the impact of items on their quality of life and elicits responses that reflect the individual burden of diabetes and its impact on the overall life of the patient. The instrument consists of 39 items and covers five dimensions of the patient's lives: energy and mobility (15 items), diabetes control (12 items), anxiety and worry (4 items), social burden (5 items), and sexual functioning (3 items). Reliability of the D-39 instrument as measured by Cronbach's coefficient alpha ranged from 0.82 to 0.93. In a review of health outcome measures for diabetes, Garratt, Schmidt, and Fitzpatrick (2002) note that this instrument has good evidence for reliability, and internal and external construct validity.
Proposed Data Analytic Strategy
To measure the degree of relationship between childhood maltreatment and diabetes-related quality of life, two continuous variables, the Pearson's product moment correlation coefficient 'r' will be calculated. The coefficient of determination, or 'r2', will also be calculated so as to ascertain how much of the variability (if any) in diabetes-related quality of life is explained by the variability in childhood maltreatment. After computing the 'r', it will be tested for significance with alpha set at .05.
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