Psychological maltreatment and its relationship with substance abuse among university students in Kingston, Jamaica

Maus-tratos psicológicos e sua relação com o abuso de substâncias entre estudantes universitários em Kingston, Jamaica

Maltrato psicológico y su relación con abuso de sustancias en estudiantes universitarios en Kingston, Jamaica

Abstracts

The high prevalence of substance abuse in Jamaica, highlights the need to understand the drivers of substance abuse. Experiencing psychological maltreatment (emotional abuse and neglect) during childhood has been suggested to be a risk factor for substance abuse. This study investigates the relationship between childhood psychological maltreatment and adult substance abuse among Jamaican university students. Three hundred and eighty two (382) university students were selected using systematic sampling techniques. They completed a Kessler Psychological Distress Scale questionnaire, as well as items selected from the Adverse Childhood Experiences and CICAD Drug Use questionnaires. 66.7% had experienced psychological maltreatment. Chi-square analyses identified a significant relationship between experiencing psychological maltreatment and substance abuse (p<0.05). This research provides evidence in support of a link between exposure to childhood psychological maltreatment and substance abuse in adulthood.

Child abuse; Street drugs; Family relations; Students; Universities

Altas taxas de abuso de drogas ocorrem na Jamaica, o que ressalta a necessidade de entender os motivadores do abuso de substâncias. Experiências de maus-tratos psicológicos (abuso emocional e negligência) durante a infância têm sugerido representar um fator de risco para o abuso de drogas. Este estudo investiga a relação entre maus-tratos psicológicos na infância e abuso de substâncias na vida adulta entre estudantes universitários jamaicanos. Foram selecionados 382 estudantes universitários usando técnica de amostragem sistemática. Os estudantes completaram o questionário Kessler Psychological Distress Scale, bem como itens selecionados do Adverse Childhood Experiences e do questionário sobre uso de drogas do CICAD. Dos estudantes, 66,7% vivenciaram maus-tratos psicológicos. Análise de qui-quadrado identificou uma relação significativa entre os maus-tratos psicológicos e o abuso de substâncias (p<0,005). Esta pesquisa fornece evidências que mostram a relação entre exposição a maus-tratos psicológicos na infância e abuso de substâncias na juventude.

Maus-tratos infantis; Drogas ilícitas; Relações familiares; Estudantes; Universidades

En Jamaica existen altas tasas de abuso de drogas, lo que remarca la necesidad de comprender los motivadores para el abuso de sustancias. El experimentar maltrato psicológico (abuso emocional y negligencia) durante la infancia ha sido sugerido como un factor de riesgo para el abuso de sustancias. Este estudio investiga la relación entre maltrato psicológico infantil y el abuso de sustancias en la adultez entre estudiantes universitarios jamaiquinos. Trescientos ochenta y dos (382) estudiantes universitarios fueron seleccionados usando una técnica de muestreo sistemático. Ellos completaron el Cuestionario Escala de Distrés Psicológico de Kessler, así como ítems seleccionado de los cuestionarios de Experiencias Adversas en la Infancia y de Uso de Drogas de CICAD. El 66.7% había experimentado maltrato psicológico. El análisis de Chi-cuadrados identificó una relación significativa entre experimentar maltrato psicológico y abuso de sustancias (p<0.05). Esta investigación provee evidencia en apoyo de una asociación entre la exposición a maltrato psicológico infantil y abuso de sustancias en la adultez.

Maltrato a los niños; Drogas ilícitas; Relaciones familiares; Estudiantes; Universidades

INTRODUCTION

Substance abuse is a serious concern in Jamaica. A national survey conducted in 2001 identified that 12% of all respondents reported that they had abused at least one substance during their lifetime, with 6% reporting alcohol abuse.¹ This extensive level of substance abuse has numerous negative consequences, adversely affecting the quality of life of the abuser, their significant others, as well as the nation. Substance abuse is associated with increased health concerns, violence, loss of productivity, criminal activity, as well as high financial costs for the nation.

Jamaica's vulnerability to substance related problems, is typically three-fold, occurring as a result of its economic challenges, geographic location and cultural norms. The island is plagued by economic challenges, as demonstrated by an unemployment rate of 16.3%,² and an annual GDP per capita of USD$5562.24.³ Furthermore, Jamaica's geographic location within the Caribbean Sea facilitates a trans-shipment drug port from producers in South America to consumers in North America. Culturally, the use of alcohol and cannabis is widespread - both are endorsed for their 'medicinal' properties, while the latter is also utilized for Rastafarian religious practices.

Given Jamaica's economic challenges and geographic location, drug supply reduction strategies have been anticipated to yield limited success. Instead, extensive efforts have been aimed at demand reduction through educating the nation about the consequences of substance abuse, as well as discouraging the cultural acceptability of substance use. However, substance abuse is still a major concern for the island, thereby highlighting the need to identify and target all potential risk factors. A potential driving force for substance abuse is hypothesized to be exposure to psychological maltreatment during childhood.^{4 - 5}

Psychological maltreatment involves repeated interactions between a parent and child, that are often verbal in nature, which negatively affect the emotional, social, cognitive or even physical development of a child.⁶ These interactions typically include acts of commission as well as omission. Thus, psychological maltreatment may consist of both emotional abuse, as well as emotional neglect. Emotional abuse refers to, verbal assaults on a child's sense of worth or well-being, or any humiliating, demeaning, or threatening behaviour directed toward a child by an older person.⁷ Emotional neglect refers to, the failure of caretakers to provide a child's basic psychological and emotional needs, such as love, encouragement, belonging and support.⁷ Emotional neglect involves rejecting, isolating and emotionally disregarding a child.

Psychological maltreatment is believed to be the most frequently experienced form of maltreatment, as it tends to accompany all other forms of maltreatment, like physical and sexual abuse.⁸ With this in mind, it is also the least likely to be reported by victims, as unlike cases involving physical or sexual abuse, victims are rarely able to display visible proof, and therefore lack a sense of legitimacy. In Jamaica, emotional abuse is punishable by law, and 2570 cases were reported between 2007-2011,⁹ but the impact of emotional neglect is not legally recognized.

Although Jamaican parenting techniques have become more lenient with time, a harsh authoritarian parenting style continues to prevail. While most parents now reserve spanking for the child's worst offenses, threats, humiliation, rejection and cursing continue to be utilized as a means of everyday disciplining. Parents lack the awareness that their everyday disciplining technique may be psychological maltreatment and tend to believe that the use of verbal disciplining has no lasting adverse effects. However, many researchers view psychological maltreatment to be highly detrimental, with the potential to have severe and lasting effects.¹⁰ Others have gone further to suggest that it is the psychological components of physical and sexual abuse that result in detrimental and long lasting effects.^{11 - 12}

Psychological maltreatment is believed to negatively affect the emotional, social and cognitive development of a child, making them more prone to substance abuse and other forms of psychopathology.^{11 - 12}

Psychological maltreatment of children is widespread in Jamaica, and this form of maltreatment is believed to affect the overall psychological adjustment of the child.¹³ As a result, victims may experience psychological distress, with symptoms of low self-esteem, depression and anxiety ⁴ that may result in substance abuse.¹⁴ However, it has been suggested that in a cultural environment, where harsh disciplining techniques are generally accepted, the adverse impact among recipients may be minimal.¹⁵ Therefore, the aim of this research is to determine if, among Jamaican university students, psychological maltreatment during childhood is associated with substance abuse in adulthood.

METHOD

This study is a subset of a larger research project that investigated the relationship between adverse childhood experiences and substance use in adulthood.¹⁶ Ethical approval was obtained from the ethical committee of the selected university as well as the Research Ethics Board at the Centre for Addiction and Mental Health (proposal number 141-2010). This segment of the research project utilized systematic sampling techniques to recruit students attending a selected university in Kingston, Jamaica. Students were required to be enrolled at the university, and be at least 18 years of age. The final sample consisted of 382 undergraduate students, between the ages 18 and 48 years. The questionnaire consisted of items from three main instruments, the emotional abuse and neglect scales from the Adverse Childhood Experiences questionnaire (ACE),¹⁷ the Kessler Psychological Distress Scale (K10),¹⁸ and selected questions from the CICAD-OAS drug use questionnaire.¹⁹

The emotional abuse and neglect scales from the Adverse Childhood Experience (ACE) questionnaire provided a measure of psychological maltreatment. These scales consisted of a total of seven items, five of which measured emotional neglect and two items measured emotional abuse. The items measuring emotional neglect were derived from the Childhood Trauma Questionnaire - a measurement tool that demonstrated good reliability and validity among university students.²⁰ The measures of emotional abuse have been found to demonstrate reliability and validity within international settings, and are widely used by the Centre for Disease Control.¹⁷

The Kessler Psychological Distress scale is a screen for anxious and depressive symptoms typically associated with a number psychological disorders, thereby providing a measure of psychological distress.¹⁸ It consists of 10 items, each with five response options. This scale has been validated cross-culturally and is a key instrument used in World Health Organization (WHO) international surveys. High scores on this scale are indicative of an increased likelihood of a psychological disorder.²¹

Six questions were selected from the CICAD-OAS Drug Use Questionnaire to determine rates of drug use and abuse (as per the DSM-IV definition) among participants. These items have been previously utilized in the Caribbean, and were found to demonstrate adequate levels of validity.¹⁹ The CICAD-OAS drug use questionnaire provided a measure of drug use and drug related problems within the past 12 months and 30 days.

Systematic sampling techniques were used to recruit students from a selected university in Jamaica. University faculties were selected using a table of random numbers, and every third student observed within the vicinity of the faculty office was invited to participate. Students who had previously completed the questionnaire were not permitted to participate a second time. Participants signed an informed consent form prior to completing the questionnaires. Data analysis was completed using the Statistical Package for the Social Sciences (SPSS), Version 19.

RESULTS

The sample consisted of 103 male and 278 female (n=382) undergraduate students, with an average age of 21.27 years (SD=4.39). Psychological maltreatment was reported by 66.7% of the students, while emotional abuse was reported by 64.7% (62 males and 185 females), and emotional neglect by 20.1 % (18 males and 58 females). Of note, only 4.4% of those who were psychologically maltreated sought professional treatment, and 52.8 % of students did not realize that their childhood experiences had met the criteria for maltreatment.

Moderate to severe levels of psychological distress were reported by 34% of the sample (see Table 1). The findings reveal that 73.8% of those who were currently experiencing moderate to severe psychological distress had experienced emotional abuse during childhood.

Table 1.
Levels of psychological distress by gender. Kingston, Jamaica, 2012

Gender	Minimal	Mild	Moderate	Severe
	f (%)	f (%)	f (%)	f (%)
Females	113 (29.8%)	69 (18.2%)	43 (11.3%)	53 (14.0%)
Males	44 (11.6%)	24 (6.3%)	15 (4%)	18 (4.7%)
Total	157 (41.4%)	93 (24.5%)	58 (15.3%)	71 (18.7%)

The data also revealed that exposure to psychological maltreatment during childhood was associated with higher levels of psychological distress during adulthood: X ² (3, n=364) =11.926, p<.01. In addition, emotional abuse, X² (3, n=368) = 8.576, p<.05, and emotional neglect, X² (3, n=364) =21.175, p<.0001, also individually exhibited significant relationships.

The use of psychoactive substances was explored, with the data showing that, within the past year, cannabis was the most frequently used illicit substance (10.3%), and alcohol the most frequently used licit substance (37.4%) (see Table 2).

Table 2.
Frequency of substance use within the past 12 months and 30 days. Kingston, Jamaica, 2012

Type of ssubstance	Past 12 months f (%)	Past 30 days f (%)
Cannabis	39 (10.3)*	18 (4.7)
Tobacco/Cigarettes	34 (8.9)*	24 (6.3)*
Alcohol	142 (37.4)*	92 (24.2)*
Cocaine	3 (0.8)†	3 (0.8)†
Ecstasy	4 (1.1)*	3 (0.8)*
Heroin	3 (0.8)‡	3 (0.8)‡
Inhalants	7 (1.8)*	5 (1.3)*
Prescription drugs (Unprescribed)	13 (3.4)*	7 (1.9)‡

The dysfunctional behaviours exhibited by participants as a result of their substance use were assessed based on the DSM-IV criteria of substance abuse. Of the respondents, 13.6% (29 females and 23 males) were found to be substance abusers. Chi-square analysis identified a significant relationship between psychological distress during adulthood, and substance abuse: X² (3, n=368) = 29.376, p<.0001). Further, a significant relationship between childhood psychological maltreatment and adult substance abuse was also identified (see Table 3).

Table 3.
Chi-square analysis of substance abuse and psychological maltreatment. Kingston, Jamaica, 2012 (n=378)

		Substance abuse		X 2	P
	n	No	Yes
Psychological maltreatment				8.262	0.004
Not psychologically maltreated	126	118	8
Psychologically maltreated	252	209	43

DISCUSSION

The impact of psychological maltreatment is rarely studied compared to the extensive research conducted on other forms of maltreatment (such as physical and sexual abuse), which are often perceived to be more detrimental to the victims. The current study represents one of the earliest efforts to understand the effects of psychological maltreatment within a Caribbean setting. It was discovered that two in every three students had experienced psychological maltreatment during childhood, and therefore it is important to identify whether this exposure increases the likelihood of substance abuse during adulthood.

Substance use was found to be widespread among participants and, consistent with previous research, alcohol, cannabis and tobacco were most frequently consumed.¹ The current study found that those experiencing psychological distress in adulthood were more prone to substance abuse. This provides some credence to aspects of the self-medication hypothesis, as participants may have been using psychoactive substances as a maladaptive means of coping with emotional challenges.²² With this in mind, it is important to note that the use of drugs to alleviate psychological distress increases the risk of substance abuse.²³

Exposure to psychological maltreatment (such as emotional abuse and neglect) during childhood was associated with increased levels of psychological distress and subsequent substance abuse during adulthood. This is supported in previous research, which suggests that psychological distress may partially mediate the relationship between psychological maltreatment during childhood, and substance abuse in adulthood.²⁴ Thus, while not all who have experienced psychological maltreatment will abuse substances, the likelihood increases once psychological distress develops as a result of psychological maltreatment.

Some researchers believe that emotional abuse is a cultural construct, and therefore harsh parenting techniques, when deemed acceptable, will have a minimal impact on recipients.¹⁵ However, the current study has demonstrated that, although psychological maltreatment is widespread and culturally acceptable to a degree, Jamaican participants reported increased incidents of adverse consequences (i.e. substance abuse). Furthermore, 73.8% of the students who reported substance abuse were not aware that their experience had met the criteria of abuse, however, they demonstrated adverse effects nonetheless.

The negative impact of psychological maltreatment is believed to occur when a child internalizes negative messages, becomes insecurely attached, and develops maladaptive interpersonal schemas that facilitate dysfunctional behaviour.²⁵ These schemas may cause the individual to believe that he or she is worthless, people are abusive, and the world is an unsafe place. ²⁵ As a result, there is an increase in psychological distress and, as demonstrated in the current study, the likelihood of substance abuse.

CONCLUSIONS

This study identified that within a selected university population in Kingston, Jamaica, two thirds of the students had experiences of psychological maltreatment. However, due to the cultural acceptability of this form of disciplining technique, over half of the students who had experienced psychological maltreatment (52.8%) were unaware that their experiences had met the threshold, to be described as maltreatment. Furthermore, experiencing psychological maltreatment during childhood was found to be associated with an increased likelihood of experiencing psychological distress in adulthood. It was also concluded that students from a selected university in Kingston Jamaica, who had experienced psychological maltreatment during childhood had an increased risk of becoming a substance abuser in adulthood.

Limitations

The sample was limited to university students, therefore results cannot be generalized to the Jamaican population as a whole. University students are considered to have higher levels of drive and resilience than the typical population, in order to achieve university level studies. Additional consideration should be given to the tendency of participants to under-or over-report incidents of maltreatment. Thus, the results must be interpreted with caution.

Recommendations

The findings of the current study suggest that reducing levels of childhood psychological maltreatment in Jamaica could potentially be met with decreased substance abuse later in adulthood. However, monitoring and preventing psychological maltreatment will not be an easy task, as it is rarely reported, and often occurs within the privacy of one's home. Despite this, national education efforts highlighting the adverse effects of childhood psychological maltreatment and encouraging alternative methods of discipline should be undertaken as a demand reduction strategy. Parents should be educated about the potential adverse consequences of psychological maltreatment as a means of reducing drug abuse in Jamaica.

ACKNOWLEDGEMENTS

Special thanks to the Organization of America States (OAS), Inter-American Drug Control Commission (CICAD), the Government of Canada/DFAIT and the Centre for Addiction and Mental Health (CAMH) - Toronto/Canada for supporting and endorsing this project financially and technically; to the selected Universities in Latin America and the Caribbean for their invaluable support; as well as other collaborators and the students who participated in this research.

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Publication Dates

• Publication in this collection
  2015