RUNNING HEAD: An Integrative Review 1

Integrative Literature Review

Bethany Porter

Bon Secours Memorial College of Nursing

Nursing Research NUR4122

April 2, 2017

I pledge
AN INTEGRATIVE REVIEW 2

Abstract

The goal of this review is to evaluate the literature pertaining to the effect of

childhood sexual abuse on mental health. Any kind of abuse is traumatic and life

changing, especially to a child; the effects can be so damaging that it can affect their

mental health well into adulthood. Its a saddening reality that sexual abuse is not an

uncommon occurrence in our day and age, and there has been an increasing amount of

research done in recent years that measures the long-term effects on the victims.

The search for literature was conducted using EBSCO, PubMed and Google Scholar. The

search yielded 212 articles, 5 of which met the research criteria. The results of these

articles all supported the claim that victims of sexual abuse in childhood experience

mental illness more often that those who dont. They also went into detail regarding

specific types of mental illness that were more common in victims, and factors that may

have perpetuated the effects. Limitations to this review include the researchers lack of

experience and knowledge, and the large number of appropriate articles that were

unavailable due to additional cost. Additional research should be done to further identify

interventions that help at-risk victims avoid future mental health issues.
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An Integrative Review

Women and men who have diagnosed psychiatric illnesses are often found to have

had physical or sexual abuse occur in their childhood. There have been a number of

studies done to support the correlation of sexual abuse and mental illness, and the

purpose of this integrative review is to gather supportive literature pertaining to the

researchers PICO question: Does childhood sexual assault influence the mental health of

its victims over the course of their lives, and to what extent? The sheer frequency of

sexual abuse is shocking to the researcher, and the aim of this research was to get a better

picture on how it effects the lives of its victims, and how that knowledge can prove

effective in helping those who have been through it.

Design and Search Methods

This integrative literature review was written as a class assignment, and focuses on

five articles selected by the researcher. In searching for appropriate and useful articles,

the research used EBSCO and PubMed, which yielded few results, and then Google

Scholar, which provided a generous selection of relevant articles. Search terms included

sexual abuse, childhood, pediatric, and mental illness. The search yielded, in total,

212 articles.

To narrow down the articles, the search was aimed at articles published from 2007-

2017. Unfortunately, many of the articles didnt quite relate to the research question, or

were inaccessible. The researcher removed the time range and found articles that, while

not considered current, still provided valuable statistics and insight to the topic. It was

decided that the newness of the research was not the top priority when searching for

articles, nor was it detrimental to the integrity of the data. Other factors to narrow down
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the search included being originally published in English, being published in academic

journals, and relevance to the topic.

Findings/Results

The findings of the five studies supported the assertion that sexual abuse

contributes to mental illness in adults (Campbell, Dworkin, & Cabral, 2009; Molnar,

Buka, & Kessler, 2001; Saunders, Villeponteaux, Lipovsky, Kilpatrick, & Veronen,

1992; Sugaya, Hasin, Olfson, Lin, Grant, & Blanco, 2012; Spataro, Mullen, Burgess,

Wells & Moss, 2004). A summary of this research is represented in Table 1. This review

is presented in two categories: types of mental illness, effects on men vs. women, and

using a ecological model.

Types of Mental Illness

Of the five articles, four of them were quantitative studies. In addition to analyzing

the likelihood of developing mental illness, the studies spent a great deal of time

categorizing the type of mental illness that the victims developed. It was suggested that

child sexual assault (CSA) causes disruptions in the development of a childs sense of

self, leading to difficulty in relating to others, inability to regulate reactions to stressful

events, and other interpersonal and emotional challenges that make psychiatric disorders

more likely (Molnar et al, 2001, pg. 753). While that specific theory remains to be seen,

theres a clear correlation between child sexual abuse and serious mental health problems

in both childhood and adult life (Spataro et al, 2004).

In a study conducted by Benjamin Saunders et al (1992), it was suggested that the

most frequent mental health issues reported by women who experienced CSA were the

development of a major depressive episode, an anxiety disorder, a sexual disorder, and

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suicidal intentions. This study took it further and determined from their data that a

womans mental illness as an adult varied in severity based on the type of sexual assault

they experienced in childhood. For instance, a woman who had been molested as a child

may be more at risk for a major depression episode, agoraphobia, an obsessive-

compulsive disorder, social phobia, sexual disorders, suicidal ideation, and suicide

attempt (Saunders et al, 1992, pg.197). A woman who experienced rape as a child, on

the other hand, was more likely to have the same disorders, with the addition of

agoraphobia and social phobia. This data was collected using voluntary sampling, and

each participant was assessed via the Incident Classification Interview (ICI) and the

National Institute of Mental Health (NIMH) Diagnostic Interview Schedule (DIS). The

results of these assessments were analyzed by the researchers and presented on four Chi-

squared tables.

Another quantitative study indicated that CSA victims were more likely to

experience depression, generalized anxiety disorder, panic disorder, phobias, and PTSD

(Molnar et al, 2001). This study took a different approach by adding different factors of

the assault, such as frequency of subsequent assaults, whether or not the assault was

reported, and what the home environment was like, and compared those variables to the

outcome (the mental issues experienced by the victims, if any). For instance, among those

sexually abused, the prevalence of lifetime psychiatric disorders was higher than among

those who did not report CSA (Molnar et al, 2001, pg.754). An example of this is their

data showing that women who suffer from lifetime alcohol dependence was 15.6% in

women who reported their assault, compared to the 7.6% in women who did not. The

participants for this study were derived using stratified, multistage area probability
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sampling, and the respondents were administered a modified version of the Composite

International Diagnostic Interview (CIDI). The risk factors were asked about in a second

part of the survey to the individuals who tested positive for a diagnosis in the CIDI. All

analyses were done using SAS, a software suite designed for advanced analytics and

multivariate analyses. Discrete time-event survival analysis was used to model the timing

and occurrence of outcomes, so that the models predicted only psychiatric disorders that

occurred after the first instance of CSA. Separate data sets were created for each disorder,

and they were further analyzed using logistic regression.

The researcher included an article that focused on child physical abuse instead of

sexual abuse to compare any similarities or differences in results. Similar to the research

conducted by Saunders et al (1992), this study compared the type and severity of mental

illness to the severity of the abuse; however, the measurement of severity was

determined by how it was perceived by the victim: Even types of physical abuse that

seem to be less severe from a physical perspective may, if they occur repeatedly, have

substantial adverse consequences on later mental health (Sugaya et al, 2013, pg.5). This

study associates childhood physical abuse (CPA) with ADHD, PTSD, bipolar disorder,

panic disorder, generalized anxiety disorder, substance abuse, and major depressive

disorder. The researchers also suggest that these disorders share common etiological

pathways: Candidate common pathological pathways could include impaired

development of the hippocampus, which is crucial for learning and memory

consolidation; disrupted functioning of prefrontal cortex inhibitory activity, which is

essential for behavior regulation; and increased activity of amygdala-related circuitry,

which is involved in rapid emotional response (Sugaya et al, 2013, pg.5). These changes
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in the physiological pathways are thought to be caused by intense, chronic stress as a

result of abuse. This study drew a nationally representative sample of the U.S. adult

population. The participants completed two surveys: the first was used to determine the

presence of psychiatric illness through the use of the Diagnostic and Statistical Manual of

Mental Disorders (DSM-MD), and the second asked questions about childhood

adversities that occurred in their first 17 years of life. These questions were adapted from

the Adverse Childhood Experiences study (ACE study), and CPA was considered present

when the participant mentioned being hit, slapped, shoved, grabbed, or pushed; or having

been hit so hard that they had marks, bruises, or injured by their parents or adults living

in the home. This data was analyzed by the researchers and presented to the reader

through discussion.

Women vs Men

When gathering research for the topic, the researcher found that a great deal of the

literature available excluded men from the research and focused primarily on women.

While women are more likely to be sexually abused than men (Spataro et al, 2004), they

are also at-risk for developing mental illness after CSA.

The study conducted by Joseph Spataro et al (2004) was largely done to fill in the

gap of little data on male victims of CSA. The researchers, located in Victoria, Australia,

used convenience sampling to obtain 1,612 medical records from the Victorian Institute

of Forensic Medicine, which carries out all of the examinations of suspected cases of

childhood abuse in the state of Victoria. The names of these individuals were cross-linked

with a database of patients who were registered on the Victorian Psychiatric Case

Register. In the patients who had matches, full psychiatric records were extracted and
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examined, then analyzed. The statistical analyses were calculated using the Statistical

Package for the Social Sciences version 10, for Windows. That data was represented on

two Chi-squared tables. That research found that men were significantly more likely than

women to have had contact with mental health services, but were less likely to develop

certain mental disorders (Spataro et al, 2004). While the differences were not statistically

significant, the percentages of males to have been diagnosed were consistently below

those of females.

Another quantitative article addressed the psychopathology of male CSA victims;

Molnar et al (2001) measured both male and female data when conducting their research.

Their analyses of male data were done separately from the females throughout the study.

Because research suggests that there are sex differences in vulnerability to negative life

events, so it was expected that results would be different enough to warrant separate

models (Molnar et al, 2001, pg. 754). The results of these studies indicated multiple

differences in how men experience the aftermath of CSA than women. First, and

unsurprisingly, the researchers found a higher prevalence of isolated and chronic abuse in

females (13.5%) than in males (2.5%). It was also discovered that men were significantly

less likely to report their assault to authorities. In the analysis of mental illness, men were

less likely than women to develop mood disorders (depression, dysthymia) and most

anxiety disorders (agoraphobia, PTSD, panic attacks, simple phobias, social phobias).

However, the data showed men being almost twice as likely to develop substance

disorders, including problems with drugs/alcohol, drug/alcohol dependence, and severe

drug/alcohol dependence (Molnar et al, 2001.)

Using an Ecological Model

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Rebecca Campbell et al (2009) completed a qualitative study on the psychological

impact of adult sexual assault through an ecological theoretical perspective to understand

how factors at multiple levels of the social ecology contribute to post-assault sequelae

(Campbell et al, 2009, pg.225). While it is common knowledge that sexual assault can

negatively impact a womans mental health, a trauma response theoretical model has

been proposed as a useful framework to guide research and medical intervention. In this

study, the researchers unpacked the different factors of social ecology, using

Bronfenbrenners ecological theory of human development. The fundamental premise of

this model is that a CSA survivors mental health is shaped by many factors, not

necessarily just the event or the pre-existing individual characteristics.

In the study, there were five identified levels of the ecological model. The

individual was at the first level, and it was observed that characteristics of the victim

could influence their recovery process, as well as their coping processes. At the second

level was the assault itself; the severity, frequency, use of weapons, and amount of force

all could affect a womans psychological well-being. Third, the microsystem (or informal

sources of support) includes the use of family or friends in the victims psychological

recovery. The fourth focused on meso/exosystem factors, which were the use of rape

crisis centers, community mental health programs, etc. that can help lessen the victims

distress. The fifth, and final factor, was the chronosystem. This examines the cumulative

effects of multiple sequences of developmental transitions of the life course (Campbell

et al, 2009, pg.229). In theory, if there were multiple assaults over the course of a

womans life, it could affect how a woman might recover from them.
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By using the model and the identified factors, one could theoretically identify

predict or change an individuals response to an assault. For instance, in an individual

who has a negative or weak informal support system (microsystem factor), theyre more

likely to have multiple negative outcomes, such as PTSD, depression, and anxiety.

Alternatively, someone who seeks assistance from a rape crisis center (meso/exosystem

factor) to help mitigate the negative effects is predicted to have less mental health distress

post-assault. This research is helpful in not only identifying potential risk-factors for

individuals who experienced CSA, but also in treating those who already suffer from a

mental illness from a previous assault. By identifying certain elements that are missing in

a persons social surroundings, medical professionals could fill in the gaps and help the

victims in their recovery and healing.

Discussion/Implications

As described in the results, childhood sexual assault can affect an individuals

mental health through adulthood. This can manifest itself in various ways, such as

depression, anxiety, or substance abuse. The research included in this review both

answers the PICOT question and supports pre-existing research stating the positive

correlation.

While the research regarding men who have experienced CSA is less robust than

that of females, the data is clear in stating that men are less likely than women to be

assaulted, less likely to develop depression and anxiety disorders, but more likely to

develop dependence on alcohol and/or drugs (Molnar et al, 2001). There is also research

indicating that the victims perceived severity of the attack can influence the severity of

the mental illness, which is useful to be aware of when assessing and treating the
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individual (Sugaya, 2012). Additional research on both of these topics could greatly add

to the treatments and interventions of those who are victims. Sadly, sexual assault is a

commonplace occurrence in our society, and it is in our best interest to help those who

have been affected by it.

Limitations/Conclusion

There were quite a few limitations with this review. The researcher is neither

knowledgeable nor experienced in research, so there was a great deal of effort put into

understanding the different components that up a literature review. There was also a bit

of difficulty that came with finding appropriate articles. There were a lot of studies done

regarding mental illness in children or adolescents that were related to sexual abuse, but

did not relevant to adults. Also, EBSCO and PubMed yielded surprisingly few articles

that were relevant to the topic. When using Google Scholars, there was a considerable

amount of articles to choose from, but many of them were inaccessible without payment.

The findings in this integrative review provided substantial evidence that victims of

sexual abuse have a higher prevalence of lifetime psychiatric disorders than those who

have not experienced such abuse (Molnar, Buka & Kessler, 2001). While this is not

necessarily new information, knowledge of the types of mental illnesses and identified

comorbidities can be useful in refining primary, secondary, and tertiary care. Because this

is a problem that will not be going away, research can and should be continued and built

upon to better serve the population of those who are victims.

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References

Campbell, R., Dworkin, E., & Cabral, G. (2009). An Ecological Model of the Impact of

Sexual Assault On Women's Mental Health. Trauma, Violence, & Abuse,10(3),

225-246. doi:10.1177/1524838009334456

Molnar, B. E., Buka, S. L., & Kessler, R. C. (2001). Child sexual abuse and subsequent

psychopathology: results from the National Comorbidity Survey. American

Journal of Public Health,91(5), 753-760. doi:10.2105/ajph.91.5.753

Saunders, B. E., Villeponteaux, L. A., Lipovsky, J. A., Kilpatrick, D. G., & Veronen, L.

J. (1992). Child Sexual Assault as a Risk Factor for Mental Disorders Among

Women: A Community Survey. Journal of Interpersonal Violence,7(2), 189-204.

doi:10.1177/088626092007002005

Spataro, J., Mullen, P. E., Burgess, P. M., Wells, D. L., & Moss, S. A. (2004). Impact of

child sexual abuse on mental health. British Journal of Psychiatry,184, 416-421.

doi:10.1192/bjp.184.5.416

Sugaya, L., Hasin, D. S., Olfson, M., Lin, K., Grant, B. F., & Blanco, C. (2012). Child

physical abuse and adult mental health: A national study. Journal of Traumatic

Stress,25(4), 384-392. doi:10.1002/jts.21719

 RUNNING HEAD: An Integrative Review
First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to
practice
13
Spataro (2004) Victorian Institute of Forensic Mental Health, Department of Psychological Medicine, Monash University.
There is a lack of prospective studies and data on male victims of sexual assault, and subsequent psychopathology.
There is a link between childhood sexual abuse and mental health problems as an adult.
The researchers wanted to investigate the psychological effects of a childhood sexual assault in males and females, as well as
subsequent treatment for mental disorders using a prospective cohort design.
Quantitative Study
The Child Sexual Abuse Cohort
1,612 children (1,327 female, 285 males)
Cluster sample
Individuals in the sample were not aware of the study. Ethical approval was granted by three independent bodies: the Monash
University Standing Committee of Ethics in Research on Humans, the Department of Human Services Ethics Committee and the
Victorian Institute of Forensic Medicine Ethics Committee.
Sample group = children aged 16 and under at the time of sexual assault, born between 1950 and 1991.
Control group = individuals born between 1950 and 1991.
A sample of children was obtained from the Victorian Institute of Forensic Medicine whose record indicated sexual abuse.
That cohort was cross-matched with the individuals listed in the Victorian Psychiatric Case Registry, and any matches were
recorded and analyzed.
Predominately done using the Statistical Package for the Social Sciences version 10 for Windows
The extent to which the sample and control group differed was analyzed using t-tests, and Chi-squared analyses were conducted
to determine any categorical variables.
The STATA Release 6 for Windows was used to further analyze the data, looking to obtain relative risks, confidence intervals
and P values.
When compared to the population controls, the male sexual abuse cases were significantly higher in instances of anxiety
disorders, personality disorders, organic disorders, and conduct disorders.
The female cases were much more likely than the controls to have major affective disorders, anxiety disorders, personality
disorders, organic disorders, and conduct disorders.
Children who are victims of sexual assault are more likely to develop psychiatric issues than others their age.
 AN INTEGRATIVE REVIEW
First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to
practice
14
Molnar (2001) the Harvard School of Public Health
This study examines the relationship between child sexual abuse and subsequent onset of psychiatric disorders.
The study accounts for other childhood adversities, CSA type, an chronicity of the abuse.
Not discussed
Quantitative
The participants were interviewed, and in the individuals who answered positive on the first portion of the survey were given
additional questions to further individualize the data.
8,098 participants were pulled using stratified, multistage area probability sampling.
Those selected were between the ages of 15-54, and were part of the non-institutionalized civilian population.
The 8,098 that participated were part of the 82.4% of individuals who responded to the survey.
Study group = The individuals who had positive diagnoses in the initial interview, approx. 5,877 men and women.
Control variables = Used to characterize the types of abuse experienced by the participants.
A modified version of the Composite International Diagnostic Interview (CIDI)
National Comorbidity Survey (NCS)
All analyses were conducted with SAS
Discrete, time-event survival analysis was used to model the occurrence and timing of outcomes
Separate data sets were created for each disorder, and rearranged into a person-year format.
Stratified analyses were conducted to further examine the relationship between CSA and psychiatric disorders independent of
other adversities.
The overall prevalence of sexual assault was higher for females that males.
Among those sexually abused, the prevalence of lifetime psychiatric disorders was higher than among those who did not report
CSA.
The results of this study support previous findings of a strong relationship between CSA and psychopathology, among both men
and women.
These results suggest the need for public health prevention programs to reduce CSA and to develop efficacious treatments.
 AN INTEGRATIVE REVIEW
First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to
practice
15
Sugaya (2012) New York State Psychiatric Institute
This study characterizes adults who report being physically abused during childhood, and examines associates of reported type
and frequency of abuse with mental health.
Assesses CPA in relation to adult psychiatric morbidity, drawing on data from the National Epidemiologic Survey on Alcohol
and Related Conditions (NESARC), a large, nationally representative sample of US adults.
Assesses sociodemographic correlates of adults who reported being physically abused during childhood
Examines the effects of different types of CPA and frequency of assault on later mental health
Determines the co-occurrence of other childhood adversities in adults with a history of CPA
Investigates associations of CPA with psychiatric disorders.
The NESARC drew a nationally representative sample of the US adult population and did interviews in two waves.
43,093 individuals who were over the age of 18 of the non-institutionalized civilian population in all 50 states.
All participants gave written consent to participate in the study.
Study group = the individuals from the sample were asked a series of questions via survey, and if they responded positively to
the first questions (indicating a psychiatric diagnosis), they were given a second wave of questions to further narrow down the
data.
Sociodemographic measures were used they included age, sex, race, ethnicity, nativity, marital status, education, place of
residence (urban or rural), region of the country, and type of health insurance.
All of the psychiatric diagnoses were made using the DSM-IV.
Any individuals with alcohol dependency were further evaluated using the Alcohol Use Disorder and Associated Disabilities
Interview Schedule (AUDADIS)
Weighted means, frequencies, odds ratios of sociodemographic correlates, and prevalence of lifetime and current psychiatric
disorders were computed using descriptive statistics.
The statistical results were displayed via four Chi-tables.
A history of CPA was reported by 8% of the sample.
84% of these victims have a lifetime history of at least one psychiatric disorder, and individuals with CPA had a higher overall
prevalence of psychiatric disorders and higher rates of suicide attempts.
The long-lasting, devastating effects of child physical abuse underscore the importance of developing public health policies
aimed at early recognition and prevention. This study can help aid that goal.
 AN INTEGRATIVE REVIEW
First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to
practice
16
Campbell (2009) Michigan State University
To examine the psychological impact of sexual assault through an ecological theoretical perspective to understand how factors at
multiple levels of the social ecology contribute to post-assault sequelae.
Bronfenbrenners ecological theory of human development.
Qualitative interpretive phenomenology
Not discussed
Multilevel Ecological Factors: Individual, assault, microsystem, meso-exosystem, macrosystem, and chronosystem.
Not discussed
Bronfenbrenners ecological theory of human development.
The negative mental health sequelae of sexual assault stems from multiple factors, not just characteristics of the victim.
Aspects of the assault itself, post-assault disclosures/help-seeking, and socioculture norms help shape the way in which trauma
affects the womens well-being.
All of the factors that weigh into a womans response to an assault can be isolated and assessed, and in theory, can be used to
help a woman in an area she is lacking.
A womans mental health post-assault is vulnerable, and the recovery/ability to cope can be affected by different aspects of the
victims life.
This method of evaluation should be considered when developing interventions or a plan of care for victims of sexual assault.
AN INTEGRATIVE REVIEW
First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
17
Saunders (1992) the National Institute of Justice, the US Department of Justice.
This study was designed to determine to what degree female victims of three types of sexual assault (rape,
molestation and non-contact assault) are at an increased risk for developing several major mental disorders,
according to the diagnostic criteria of the DSM-III.
This study was conducted as a part of a larger study assessing the lifetime mental health effects of different
types of criminal victimization.
This study was also designed to fill in certain gaps in previous research.
The assessment of the participants consisted of two structured interview schedules that were designed to
screen for incidents of serious criminal victimization that have occurred in the patients lifetime.
There was also a collection of comprehensive characteristic information about up to three victimization
experiences.
391 female adults, all residents of Charleston County in South Carolina.
These participants were recruited from a representative probability sample of 2,004 adult women that had
been selected for a different study.
Every participant gave consent and expressed a desire to participate in the study.
Race, marital status, income, education, and employment
Types of assault that women experienced (rape, molestation, noncontact)
Types of mental illnesses that they developed later in life
The Diagnostic and Statistical Manual of Mental Disorders, 3rd edition
Incident Classification Interview (ICI)
National Institute of Mental Health (NIMH) Diagnostic Interview Schedule (DIS)
Descriptive Statistics calculated by the researchers Chi0squared tables, standard variations, t-tests.
Women who experienced rape, molestation or non-contact assault were more likely to develop mental illness
than non-victims.
Women who experienced rape were at risk to have more severe psychiatric problems later in life.
Child sexual assault is not only a problem of personal tragedy, crime, violence, and morality, but is a very
serious public health problem due to its prevalence (1 in 3 children).
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