Association between the lived experience of intrafamily violence and common mental health disorders in adolescents

Abstract

Objective

To investigate the association of the endured /witnessed of intrafamily violence and common mental disorders (CMD) in adolescents.

Methods

This was a cross-sectional, analytical study conducted in a public school, located in the city of Salvador, Bahia, Brazil, with 230 students with ages between 10 and 19 years. The data were stored in a Microsoft Excel worksheet, and analyzes were performed using Data Analysis and Statistics Software.

Results

Students who had endured sexual violence were 11 times more likely to have a common mental disorder (CMD) (PR=11 and 95%CI=1.39-86.7), followed by those experiencing psychological violence, who were 4.8 times more likely to report a disorder (PR=4.8% and 95%CI=2.67-8.45), and those experiencing physical violence who were 2.2 times more likely (PR=4.8% and 95%CI =1.31-3.78).

Conclusion

Adolescents involved in the context of intrafamily violence, in psychological, physical, and sexual forms, are more likely to present CMD, as shown in the results.

Domestic violence; Exposure to violence; Sex offenses; Family; Mental disorders; Adolescent

Resumo

Objetivo

Investigar a associação da violência intrafamiliar vivenciada/presenciada e o transtorno mental comum em adolescentes.

Métodos

Trata-se de um estudo de corte transversal, de cunho analítico, sendo efetuado em uma escola pública, localizada na cidade de Salvador, Bahia, Brasil com 230 estudantes em idade entre 10 e 19 anos. Os dados foram armazenados no programa Microsoft Excel e as análises foram mensuradas com o auxílio do programa Data Analysis and Statistical Software.

Resultados

Verificou-se que escolares que vivenciaram a violência sexual apresentaram 11 vezes mais chances de apresentar Transtorno Mental Comum (TMC) (RP=11 e IC95%=1,39-86,7), seguida pela vivência de violência psicológica com 4,8 vezes mais chances de referir o transtorno (RP= 4,8% e IC95% = 2,67-8,45) e a física com 2,2 vezes mais chances (RP= 4,8% e IC95% = 1,31-3,78).

Conclusão

Conclui-se que adolescentes imersos no contexto de violência intrafamiliar, nas suas formas psicológica, física e sexual, conforme evidenciado nos resultados, possuem maiores chances para apresentar o TMC.

Violência doméstica; Exposição a violência; Delitos sexuais; Família; Transtornos mentais; Adolescente

Resumen

Objetivo

Investigar la relación entre la violencia intrafamiliar vivida/presenciada y el trastorno mental común en adolescentes.

Métodos

Se trata de un estudio de corte transversal, de carácter analítico, realizado en una escuela pública, ubicada en la ciudad de Salvador, estado de Bahia, Brasil, con 230 estudiantes de entre 10 y 19 años. Los datos se guardaron en el programa Microsoft Excel y los análisis fueron medidos con ayuda del programa Data Analysis and Statistical Software.

Resultados

Se verificó que los escolares que vivieron violencia sexual presentaron 11 veces más probabilidades de tener Trastorno Mental Común (TMC) (RP=11 e IC95 %=1,39-86,7), luego la vivencia de violencia psicológica con 4,8 veces más probabilidades de relatar el trastorno (RP= 4,8 % e IC95 % = 2,67-8,45) y la física con 2,2 veces más probabilidades (RP= 4,8 % e IC95 % = 1,31-3,78).

Conclusión

Se concluye que los adolescentes inmersos en contexto de violencia intrafamiliar, en su forma psicológica, física y sexual, según se evidenció en los resultados, tienen mayores probabilidades de presentar TMC.

Violencia domestica; Delitos sexuales; Exposición a la violencia; Família; Transtornos mentales; Adolescent

Introduction

Family violence is a phenomenon experienced by thousands of children and adolescents, in Brazil and around the world. These children, who are dependent on the care of the family, are more vulnerable to the injustice either directly endured violence, such as physical, psychological, or sexual abuse, and/or indirectly, witnessing aggression toward others. This experience entails a series of repercussions, especially on mental health, requiring a better understanding of this interface in order to promote care for this public.

The data reveal the magnitude of the injustice that affects children and adolescents around the world. According to the Ministry of Women, Family and Human Rights, Dial 100 received 14% more reports in 2019 than the previous year, totaling more than 86.8 thousands cases of abuse in Brazil, most expressed by neglect (38%), psychological (23%), and physical (21%) violence.(¹)Throughout the world, it is estimated that more than 1 billion people between the ages of two and 17 are subjected to physical and/or psychological violence.(²,³)

In addition to directly suffering violence within their homes, many children and adolescents also witness other family members suffering from such injustice on a daily basis. The United Nations Children’s Fund (UNICEF) report, which compiles information from more than 30 countries, reported that one in every five children under five years of age have a mother who is abused by their partners.(⁴) A Brazilian study found that, among 1.3 million women who are physically assaulted, more than a quarter are perpetrated by (former) spouses.(⁵) It is important to reinforce that the lived experience of violence can occur by hearing or seeing aggressions between parents, or even from intervening in moments of aggression, a situation that can be a risk factor for suffering injustice, making this population even more vulnerable.(⁶,⁷)

Such reality worsened with the advent of the COVID-19 pandemic, where women, children, and adolescents were more exposed to endure violence. This information is corroborated by data collected by the electronic occurrence bulletin, available in the state of São Paulo during the pandemic period, which registered 5.5 thousand cases of domestic violence in the months between April and June of 2020.(⁸) Supporting the increase in cases in that same year, the police of a province in Hubei, China, the location of COVID-19 onset, reported that domestic violence cases tripled in the pandemic compared to the previous year, an increase that was also reported in Paris (36%), and France as a whole (32%).(⁹,¹⁰) This is explained by the social isolation that led to aggressors remaining in their homes, and the high levels of stress associated with remote work, distance learning, absence of leisure, and other elements.(¹¹) Therefore, it is perceived that the protective place against the coronavirus turned into a space of vulnerability for the occurrence or intensification of other injustice, such as domestic violence.

Even before the pandemic period, several studies revealed the interface between the lived experience of violence within the family and changes in the behavioral and mental state of children and adolescents. A study in Poland, conducted with people deprived of freedom, investigated behavioral changes in men who suffered from childhood abuse and neglect. It found that these men showed low self-esteem, and a greater propensity to be aggressive.(¹²) A national survey conducted with adolescents with a lived experience of violence, reported their suffering, which was expressed as deep sadness, suicidal ideation, self-harm behaviors, and impacts on school performance.(¹³) In addition to repercussions at the individual level, children and adolescents may have difficulties with socializing, alcohol and drug use, and conflictive relationships with their peers. Adolescents tend to reproduce the violent acts endured or and/or witnessed in their homes, in various spaces such as school, work, and the community.(¹⁴)

Considering that the abuse compromised the life and health of children and adolescents, it is important to consider that these adolescents continue to experience the injustice for more years, which suggests a greater susceptibility to presenting with signs and symptoms of psychological illness. This situation requires strategies for intervening in the scenario, and it is essential that health and education professionals, due to their recurrent contact with children and adolescents, either in care or in the school environment, articulate themselves as a network to face the injustice.(¹⁵-¹⁷) Therefore, these professionals must be prepared not only to deal with these situations, but also must be alert to identify signs of common mental disorders and/or experiences of violence in this population. Based on these considerations, and with the purpose of providing subsidies to prepare professionals to identify the repercussions of violence, especially at the psychological level, this study aimed to investigate the association of intrafamily violence either as endured or witnessed, and common mental disorders in adolescents.

Methods

This was a cross-sectional study, guided by the STROBE tool, conducted in a public school in the city of Salvador, Bahia, Brazil. The school was chosen because it provides a setting for socio-educational activities, in partnership with the Federal University of Bahia (UFBA).

The study sample consisted of 230 adolescents, aged between 10 and 19 years old, according to the WHO categorization. For the sample calculation, the statistical package R, version 3.3.1, was used, considering a margin of error of 5%, a significance level of 5%, and replacement of 20%.

All students that were enrolled and attending school activities who were provided on a list by the school were included in the study, and those who did not show up after three scheduling attempts for data collection were excluded. For further information about the research and authorization for data collection, the students and their guardians were sent the Terms of Free and Informed Assent Form and the Terms of Free and Informed Consent Form, respectively. After agreeing to participate in the research, and signing of the terms, data collection began with the students.

Data collection occurred in November of 2018, guided by a semi-structured form, containing aspects related to the experience of witnessing violence, using the question, “have you ever witnessed episodes of violence between family members?” Aspects related to the endured violence were addressed using the question, “have you ever endured an episode of violence within your family?”. This form contained options of expressions grouped into types of violence, based on the most prevalent forms of abuse experienced by adolescents, according to the literature. These included: swearing/humiliation (psychological violence); pinching/slapping, kicking/punching, stabbing, shooting, burning (physical); and unwanted touching of the body or sex (sexual). The response options were dichotomized (yes/no). A self-report questionnaire (SRQ-20) was used, which is a 20-item screening instrument for mental disorders. The (yes/no) questions are related the symptoms: somatic (poor digestion, constant stomach pain, headache); depressive (anxiety, sadness, lack of appetite, feeling of uselessness, failure, worthlessness, suicidal ideation, difficulty thinking clearly, and difficulty performing daily activities with satisfaction); and anxiety (easily startled, tension, sleeps poorly, nervousness, restlessness, hand tremors, difficulty in school, and difficulty deciding what to do). Individuals were considered to have a CMD when seven or more items were positive for males, and more than eight items for females.(¹⁸) The form was administered by members of the research groups linked to the macro project (undergraduate students, master’s students, nursing and social work professionals), who received proper training from research professors with extensive experience in the data collection process.

The data were catalogued in Microsoft Excel 2007 and further analyzed in Stata version 12. The findings were referred to as absolute and relative frequencies. For the bivariate analysis, contingency tables with X2 (chi square) or Fisher’s Exact were used to determine differences between proportions, considering a p<0.05 for statistical significance. The magnitude of the association between variables was expressed as a prevalence ratio (PR) and relative confidence interval (CI), using 95% CI. Logistic regression was used to obtain the Odds Ratio estimation with 95% CI, with adjustment for variables, using the backward method.

This research followed the requirements of resolutions 466/2012 and 580/2018 (Certificate of Ethical Review Submission: 19576913.4.0000.5531), regulated by the National Health Council (NHC).

The project was approved by the Research Ethics Committee of the School of Nursing of the Universidade Federal da Bahia (CEPEE/UFBA), opinion no. 384208/2013, and originated from a macro project entitled, “University and public school: seeking strategies to face the factors that interfere in the teaching/learning process”.

Results

The study had the participation of 230 adolescents, of whom 52.2% (n= 120) were identified with a CMD, and for whom the expressions and types of violence were investigated. The bivariate analysis (Table 1) shows that, regardless of the form of intrafamily violence (psychological, physical, or sexual), experiencing the injustice increases the chances of having CMD when compared to those adolescents who did not witness or endured the phenomenon. The schoolchildren who endured sexual violence were 11 times more likely to develop CMD (PR=11 and 95%CI = 1.39-86.7), followed by those experiencing psychological violence who were 4.8 times more likely to report the disorder (PR= 4.8% and 95%CI = 2.67 - 8.45), and those experiencing physical violence, who were 2.2 times more likely (PR= 4.8% and 95%CI = 1.31 - 3.78). For adolescents with a history of intrafamilial violence, a more significant increase in the incidence of CMD was identified in context of living through violence than in the witnessing context. Discrete differences were identified in the forms of psychological and physical violence, unlike sexual violence, with a discrepancy almost three times greater.

Table 1
Association between endured and witnessed intra familial violence and Common Mental Disorders in adolescents (n=230)

Variables	n(%)	Prevalence ratio (PR)	95% CI
Witnessed psychological violence
Yes	87(64.9)	3.5	2.03 - 6.12
No	33(34.3)	1
Endured psychological violence
Yes	70(73.6)	4.8	2.67 - 8.45
No	50(37.0)	1
Witnessed physical violence
Yes	58(61.0)	1.8	1.08 - 3.14
No	62(45.9)	1
Endured physical violence
Yes	75(61.4)	2.2	1.31 - 3.78
No	45(41.6)	1
Witnessed sexual violence
Yes	4(80.0)	3.7	0.41 - 34.15
No	116(51.5)	1
Endured sexual violence
Yes	11(91.6)	11	1.39 - 86.7
No	109(50.0)	1

Discussion

The study showed that, regardless of the form of intrafamily violence, adolescents who endured such injustice were more likely to develop CMD. A cross-sectional national study, with adult patients who sought psychoanalytic psychotherapy, showed that the current level of psychological distress of these individuals was positively associated to trauma suffered during childhood.(¹⁹) This is confirmed by a prospective international survey with 919 adolescents and their caregivers, which evidences that enduring violence during childhood and adolescence is a risk for developing psychopathologies, such as depression, generalized anxiety, post-traumatic stress disorder (PTSD), antisocial personality, and attention deficit disorder.²⁰⁾

This scenario suggests the development of CMD in individuals who had lived experience of abuse during childhood and adolescence. Studies conducted during the pandemic period showed a substantial increase in violence, which may consequently contribute to mental illness.(⁸-¹⁰)

The main forms of intrafamily violence identified in this study demonstrated that adolescents who live experience of sexual violence were more likely to present CMD. Research conducted in Florianópolis at the regional reference site for child and adolescent care, using secondary data from the Information System on Diseases of Compulsory Declaration (SINAN), showed that children who were sexually assaulted developed mental disorders, behavioral disorders and post-traumatic stress disorder, in addition to committing suicide.(²¹) An international longitudinal study of 1,268 adolescents and young adults showed that the of the exposure to sexual violence in childhood and/or adolescence was associated with depression, anxiety, and PTSD, and although no difference was found between those who experienced it in early childhood, childhood, or adolescence; the effects of the abuse were more severe the longer the duration of enduring violence.(²²) Similarly, a study in Finland with more than 10,000 adults who were abused in childhood showed that a single episode of sexual violence was associated with psychopathological symptoms, which increased the risk of psychopathological symptoms when repeated experiences of these injustices were reported.(²³) The longer the time of exposure to the injustice, the greater the chance of developing some type of psychological disorder, especially when this practice was perpetrated by a family member, who should be the provider of protection and care.

Following sexual violence, those experiencing psychological violence type presented the highest chance of developing CMD. This can be caused by the fact that psychological violence, by means of derogatory/offensive words and constant threats, can damage the child and/or adolescent, affecting his/her self-esteem and contributing to the development of symptoms such as fear, anxiety, insomnia, and others. In agreement with these findings, the findings of a literature review indicated that most of the studies analyzed on the effects of psychological family violence on individuals’ mental health, focused on negative states for emotional well-being in adulthood, such as depressive symptoms, anxiety, and post-traumatic stress symptoms.(¹⁴)At the international level, a study based on a literature search and research results with Cuban families described multiple harmful psychological consequences for the victims of intrafamily violence, and considered shock, temporary paralysis, and denial of the aggression as immediate reaction effects, followed by disorientation, loneliness, depression, vulnerability, and helplessness.

In addition to these consequences, the victim may also develop a delayed reaction, defined as PTSD, which consists of a series of emotional disturbances, such as nightmares, insomnia, depressive disorder, anxiety, feelings of guilt, and others.(²⁴) The combination of all these manifestations, which initially can be manifested individually or in a grouped manner, has the potential to produce in victims of violence serious mental problems, such as CMD.

In addition to the expressions described above, although physical violence showed a lower chance when compared to the other forms of violence, it also showed a relationship with CMD. A study reported that 65.5% of children and adolescents who suffered physical violence are likely to develop mental health problems, such as depression and anxiety, which are symptoms of CMD.(²⁵) An international research study with 104 individuals with a history of physical and sexual abuse showed that lived experienced of physical violence in adolescence was more strongly associated with depression and PTSD than when it occurred in childhood.(²⁶) Therefore, although the aggressions were committed to the individual’s body, the repercussions of this type of violence directly affect the mental health of those who experience it.

Therefore, enduring or witnessing such violence, regardless of the forms incurred, may develop and/or accentuate symptoms of psychological suffering or psychopathological manifestations in children/adolescents who are subjected to this injustice. Lived experience of violence generates serious complications in the lives of the victims, regardless of culture, social class, educational level, and racial-ethnic origin. Psychological impairment may result from such situation, which is expressed by depressive distress, such as sadness, persistent crying, hyperemotivity, feelings of not being understood, guilt, devaluation, and impotence.(²⁷)

Violence can make children and adolescents vulnerable to a condition of inferiority that can impact social relationships and the learning process, in addition to interfering with the ability to concentrate, solve problems, and deal with frustrations. Therefore, every sign of mistreatment presented by this population must be valued in order to reduce the risks during growth and the behavioral, emotional, and social development of these individuals.

Several cases reported in the media point to the scenario of invisibility and under protection of children/adolescents in Brazil.

One of these cases was reported in 2021, in which the child died after an alleged situation of violence perpetrated by the stepfather and covered up by the mother. Before the fatal outcome, although the child was taken to the hospital, the situation of violence had not been previously identified by family members/caregivers, and was not reported by professionals who had cared for the child. Child abuse can happen in different forms, so the health professional, along with family members, who are the closest figures to the victims, are required to notify and report to the protection agencies any suspicion of violence in childhood and adolescence.(²⁸) Situations such as these that are reported in the media lead us to reflect about the importance of a better family and professional qualification for the investigation of reasons that cause children to be hospitalized, preventing catastrophic outcomes in the lives of children/adolescents victims of intrafamily violence.

In addition to the context of vulnerability in which the child is immersed when experiencing violence, this situation can be mitigated when this individual is listened to when expressing his needs, particularities, and singularities. Qualified listening by professionals, who admit the child, whether in the education or health sector, is essential for the protection of the child. The National Policy for Integral Attention to Child Health (PNAISC) states that health care demands a look at the child as a whole, with a comprehensive attitude including attentive and qualified listening, individualized care, and the establishment of an implicit bond.(²⁹)

Communication with adolescents must be established, asking questions about their well-being in a more dynamic way, with language appropriate for this group of people. By establishing this interaction with the child, the professional develops a bond that enables the investigation of the experience of a possible injustice. (²⁹) Therefore, listening to children and adolescents is a sine qua non condition that mitigates the possibilities of the adolescent experiencing situations of violence.

Conclusion

The study revealed that adolescents immersed in the context of intrafamily violence, in its psychological, physical, and sexual forms, have increased chances of developing CMD, especially when lived experienced in the sexual form. According to the findings that point to the mental distress of adolescents in situations of violence, this study can contribute to preparation of family members and professionals who work with this population. Education and health professionals are particularly relevant, as they are in a strategic position to understand the interface between enduring abuse and the development of CMD, and to outline strategies for an early identification of these situations. The actions can be addressed both to those who experience the phenomenon, to prevent mental health repercussions, and to those who show signs of distress, who require care and investigation of the family relationship. The study is limited because it is a cross-sectional research design, which does not allow for the establishment of a cause-effect relationship between the dependent variable and the independent variables, as well as the fact that it was conducted in a single public school. Further studies should be conducted in other settings and with long-term monitoring, to determine the relationship between the variables in a more comprehensive way.

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Edited by

Associate Editor (Peer review process): Thiago da Silva Domingos. (https://orcid.org/0000-0002-1421-7468). Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil

Publication Dates

• Publication in this collection
  06 Feb 2023
• Date of issue
  2023

History

• Received
  18 Aug 2021
• Accepted
  20 June 2022