Susan Knoedel, a social worker at Veterans Hospital, helps people who have been doubly damaged by abuse.

Victims of both child abuse at home and of sexual assault as adults in the military, Knoedel's clients -- women ranging from their early 20s to their 70s -- need to find better ways to cope with their pain. Learning to live well with bad memories is the goal, but it is a slow, difficult process because of the multiple traumas they typically have endured.

"We see people who have had more than their share of traumatic, upsetting things happening in their life," Knoedel said. "Some of the women, what they've lived through in the military is just so horrendous that nobody would come out of it unscathed."

But it's the earlier victimization -- the histories of childhood sexual and/or physical abuse -- that appears to do the most lasting damage, compounding any later crimes, Knoedel and other local clinicians and researchers said.

"Earlier trauma is harder to cope with, because you don't have the ability to make sense of it," Knoedel said. "If you're 12, your brain is not developed enough to process it in the way that you need to. And nevermind if you're 6 or 7."

In that respect, Knoedel's work parallels ongoing research at UW-Madison about the lifelong health effects of childhood physical abuse.

It's no surprise that child abuse hurts children; what is startling, the researchers are discovering, is how much it can still hurt people as adults, they said.

Graduate student Kristen Springer is leading the work, using a tool known as the Wisconsin Longitudinal Study, which has periodically polled members of the same large group of state residents about their personal lives, interests and habits since they were high school seniors in 1957.

"(The survey) shows that childhood physical abuse continues to cause mental and physical health problems well into adulthood," said Springer, who holds master's degrees in public health and sociology. "The critical intervention needed is to prevent child abuse altogether."

\ Springer's work

Springer began studying WLS data on childhood abuse in 2001 with Dr. Molly Carnes, a physician at UW Hospital.

Their research makes it clear that respondents who suffered abuse growing up had poorer health as adults than nonabused study subjects, with increased risk of both physical and mental problems. They were twice as likely to have greater levels of anger, for example, and nearly twice as likely to suffer depression and anxiety, even after accounting for differences in sex, age and family background.

The abused respondents also had increased chances of developing physical problems, such as obesity, ulcers and bronchitis or emphysema. In many cases, the physical problems could be linked to certain behaviors or unhealthy habits.

"People who were abused as children were more likely to engage in risky health behaviors such as smoking, and they were more likely to be obese," Springer said. "They may cope with their abuse by overeating, not exercising or smoking."

The research also showed poor mental health can cause physical problems, even without adding bad habits.

Clinical depression, for example, can produce increased chances of heart disease and heart attacks. Depressed people may find it more difficult to visit a doctor or comply with treatment, Springer said, and depression and other mental illnesses can result in higher levels of stress hormones that tax the heart and increase cardiac problems.

Overall, Springer said, the research shows just how wide a net of lingering problems that child abuse can cast.

"The effects are so varied," she said.

Springer said she hopes her research also prompts physicians to be more curious about a patient's childhood history when treating physical ailments. That might require doctors to ask better questions during appointments, she said, or just be more aware of the role past abuse can play.

"It really seems that physicians still aren't getting the fact that child abuse can continue to cause some of these problems in adulthood," she said.

Springer and Carnes began presenting their findings at conferences in November 2001, and Springer won a national award last year for best paper by a graduate student from the Society for the Study of Social Problems. The paper now is undergoing required peer review for publication in a journal of internal medicine.

"I like to do research that has a policy implication, where you can do an intervention to help alleviate distress," she said. "I really like that this is (research) that could help children and middle-aged adults at the same time."

\ Knoedel's work

On the clinical end, Knoedel's work provides a template for treating abuse survivors. Counseling, support groups and medication are options.

"I think you encourage them to take little steps, but you don't push it," she said. "They already had control taken away from them in a big way at least once, so they need to be able to pace it themselves."

Knoedel said she teaches coping skills aimed at helping clients manage their problems through good health behaviors and positive thinking.

At no point, though, does she promise to make the hurt -- or the memories -- disappear.

"It doesn't ever go away," Knoedel said. "You won't ever no longer remember this. It just becomes more manageable with time."

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