Abstract
OBJECTIVES:
The objective of this study was to evaluate the association between different types of child maltreatment and the presence of psychiatric disorders in highly vulnerable children and adolescents served by a multidisciplinary program.
METHODS:
In total, 351 patients with a mean age of 12.47, of whom 68.7% were male and 82.1% lived in shelters, underwent psychiatric evaluations based on the Kiddie-Sads-Present and Lifetime Version. Two different methods were used to evaluate maltreatment: medical records were reviewed to identify previous diagnoses related to socioeconomic and psychosocial circumstances, and the Childhood Trauma Questionnaire was used to obtain a structured history of trauma. Bivariate associations were evaluated between psychiatric disorders and evidence of each type and the frequency of abuse.
RESULTS:
The most frequent psychiatric diagnoses were substance use disorders, affective disorders and specific disorders of early childhood, whereas 13.67% of the sample had no psychiatric diagnosis. All patients suffered neglect, and 58.4% experienced physical or sexual abuse. The presence of a history of multiple traumas was only associated with a diagnosis of substance use disorder. Mental retardation showed a strong positive association with reported physical abuse and emotional neglect. However, a negative correlation was found when we analyzed the presence of a history of multiple traumas and mental retardation.
CONCLUSION:
All children living in adverse conditions deserve careful assistance, but we found that physical abuse and emotional neglect were most strongly associated with mental retardation and multiple traumas with substance abuse.
Child Abuse; Psychiatric Disorders; Shelter; Community Programs; Follow-up Studies
INTRODUCTION
The World Health Organization defines child maltreatment as any act that promotes real or
potential damage to the health, dignity or development of a child (11. The United Nations Children's Fund (UNICEF). The State of The Worlds
Children 2005. New York (NY): UNICEF, 2004.). Child maltreatment can be classified into five categories: physical abuse, sexual abuse,
neglect and negligent treatment, emotional abuse and exploration (11. The United Nations Children's Fund (UNICEF). The State of The Worlds
Children 2005. New York (NY): UNICEF, 2004.). Global estimates indicate that 1 in 15 people under the age of 18 are victims of
maltreatment annually, or approximately 150 million individuals worldwide (22. Svevo-Cianci K, Hart K, Rubinson C. Protecting children from violence and
maltreatment: A qualitative comparative analysis assessing the implementation of U.N. CRC Article
19. Child Abuse Negl. 2010;34(1): 45-56,
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). In Brazil, the statistics on the prevalence of maltreatment in children and
adolescents have not been standardized, making cross-national comparisons difficult.
It is increasingly recognized that child maltreatment is one of the potential antecedents of
mental disorders. According to Zavaschia et al (33. Zavaschia MLS, Satlerb F, Poesterc D, Vargasd CV, Piazenskib R, Rohdee LAP, et
al. Associação entre trauma por perda na infância e depressão na vida adulta. Rev Bras
Psiquiatr. 2002;24(4):189-95, http://dx.doi.org/10.1590/S1516-44462002000400009.
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), 50% of
adults with a psychiatric disorder have suffered a form of child maltreatment, whereas others report
an increased risk of behavioral disorders among children exposed to physical abuse or domestic
violence (44. Herrenkohl TI, Sousa C, Tajima EA, Herrenkohl RC, Moylan CA. Intersection of
child abuse and children's exposure to domestic violence. Trauma Violence Abuse.
2008;9(2):84-99, http://dx.doi.org/10.1177/1524838008314797.
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5. Sternberg LJ, Lamb ME, Guterman E, Abbott CB. Effects of early and later family
violence on children's behavior problems and depression: a longitudinal multi-informant
perspective. Child Abuse Negl. 2006;30:283-306,
http://dx.doi.org/10.1016/j.chiabu.2005.10.008.
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-66. Wolfe DA, Crooks CV, Lee V, McIntyre-Smith A, Jaffe P. The effects of
children's exposure to domestic violence: A meta-analysis and critique. Clin Child Fam Psychol
Rev. 2003;6:171-87, http://dx.doi.org/10.1023/A:1024910416164.
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).
The occurrence of maltreatment in childhood and adolescence has been reported to be associated
with several childhood psychiatric disorders and later adult mood disorders (77. Spatz Widom C, DuMont K, Czaja SJ. A Prospective Investigation of Major
Depressive Disorder and Comorbidity in Abused and Neglected Children Grown Up. Arch Gen Psychiatry.
2007;64(1):49-56, http://dx.doi.org/10.1001/archpsyc.64.1.49.
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), anxiety disorders (88. Phillips NK, Hammen CL, Brennan PA, Najman JM, Bor W. Early Adversity and the
Prospective Prediction of Depressive and Anxiety Disorders in Adolescents. J Abnorm Child
Psychol. 2005;33(1):13-24, http://dx.doi.org/10.1007/s10802-005-0930-3.
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), substance use
disorders (99. Widom CS, Marmorstein NR, White HR. Childhood victimization and illicit drug use
in middle adulthood. Psychol Addict Behav. 2006;20(4):394-403,
http://dx.doi.org/10.1037/0893-164X.20.4.394.
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), antisocial behavior (1010. Johnson JG, Cohen P, Brown J, Smailes EM, Bernstein DP. Childhood maltreatment
increases risk for personality disorders during early adulthood. Arch Gen Psychiatry.
1999;56(7):600-06, http://dx.doi.org/10.1001/archpsyc.56.7.600.
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) and psychoses (1111. Arseneault L, Cannon M, Fisher HL, Polanczyk G, Moffitt TE, Caspi A. Childhood
trauma and children's emerging psychotic symptoms: A genetically sensitive longitudinal cohort
study. Am J Psychiatry. 2011;168(1):65-72.).
It has been hypothesized that exposure to physical or psychological trauma during early childhood
development can lead to structural changes in the central nervous system (CNS), which, in turn,
yield a greater predisposition for the development of mental disorders during adulthood in
genetically susceptible individuals (1212. Neigh GN, Gillespie CF, Nemeroff CB. The neurobiological toll of child abuse and
neglect. Trauma Violence Abuse. 2009;10(4):389-410,
http://dx.doi.org/10.1177/1524838009339758.
http://dx.doi.org/10.1177/15248380093397...
). For example,
hyperactivity of the hypothalamic axis can result in anatomical changes in the pituitary and adrenal
glands and reduced hippocampal volume (1212. Neigh GN, Gillespie CF, Nemeroff CB. The neurobiological toll of child abuse and
neglect. Trauma Violence Abuse. 2009;10(4):389-410,
http://dx.doi.org/10.1177/1524838009339758.
http://dx.doi.org/10.1177/15248380093397...
). Such changes may
impair the capacity to integrate sensory, emotional and cognitive capabilities, resulting in changes
in responses to stressful situations (1313. Lamont A. Effects of child abuse and neglect for children and adolescents.
Australian Institute of Family Studies 2010; 1-7.). These changes may
leave a child more vulnerable to future stressful situations. Moreover, the presence of a mental
disorder itself may increase the risk of exposure and the degree of vulnerability to stressful
situations.
Another important set of determinants of the effects of child maltreatment are environmental
factors. The environment, including culture, community integration, domestic violence and other
family psychosocial characteristics, may influence the occurrence of maltreatment or, alternatively,
may promote resilience and thus shape the future development of behavioral or psychiatric disorders
(1414. Cohen JK. Resilience and developmental psychopathology. Child Adolesc
Psychiatric Clin N Am. 2007;16(2):271-83,
http://dx.doi.org/10.1016/j.chc.2006.11.003.
http://dx.doi.org/10.1016/j.chc.2006.11....
,1616. Ogata K. Intellectual profile of sexually abused children in Japan: an analysis
of WISC-III Subtests compared with physically abused, neglect, and Non-maltreated children.
Psychology. 2011;2(3):169-72, http://dx.doi.org/10.4236/psych.2011.23027.
http://dx.doi.org/10.4236/psych.2011.230...
). For example,
the more supportive the family and environment are, the more resilient a child will be and, most
likely, the fewer psychiatric and behavioral problems that the child will experience later. Thus, it
is important to better understand the association between child maltreatment and behavioral problems
or psychiatric disorders in different cultures. In Latin America, and more specifically, in Brazil,
few studies have investigated the association between a history of child maltreatment and the
presence of mental disorders in adolescence and adulthood.
The evaluation of these possible associations in larger population samples and with a longitudinal follow-up could foster the adoption of stronger public health policies to prevent child abuse and could indirectly prevent the onset of avoidable psychiatric disorders.
The objective of this study was to evaluate the association between different types of child maltreatment and the presence of psychiatric disorders in highly vulnerable children and adolescents served by a multidisciplinary program for formerly homeless or court-referred children in São Paulo, Brazil. This study presents local data from São Paulo in the hope of contributing to the development of clinical approaches and public policies that may successfully address this issue.
METHODS
The data presented here were collected between September 2007 and September 2009 from patients
evaluated during the first 24 months of the operation of a community-based child mental health
program, The Equilibrium Project (TEP), which is designed to address the needs of children and
adolescents exposed to extreme psychosocial stressors in São Paulo, SP, Brazil. TEP is an initiative
that offers assessment and treatment by a multidisciplinary team staffed by the Department and
Institute of Psychiatry of the University of São Paulo, SP, working in partnership with the local
municipality (Prefeitura de São Paulo), educational system, social welfare system and
Children's Court (including the Guardianship Council and justice system). The development of
TEP and its operation have been previously described in greater detail (1717. Scivoletto S, da Silva TF, Rosenheck RA. Child psychiatry takes to the streets:
A developmental partnership between a university institute and children and adolescents from the
streets of Sao Paulo, Brazil. Child Abuse Negl. 2011;35(2):89-95,
http://dx.doi.org/10.1016/j.chiabu.2010.11.003.
http://dx.doi.org/10.1016/j.chiabu.2010....
).
Group shelter providers, the Children's Court and the Guardianship Council referred patients to TEP. To be eligible for the program, subjects had to be currently living with their families or legal parents or residing in a shelter or foster home.
As part of the standard diagnostic procedures implemented in TEP, all subjects undergo an extensive, 4-week multidisciplinary assessment, which includes evaluations from a pediatrician, a psychiatrist, a psychologist, a neuropsychologist, an occupational therapist, a physiotherapist, an art therapist, a social worker, an educational therapist and a speech therapist. Whenever possible, family members are invited to attend an interview with a family therapist.
A child and adolescent psychiatrist conducted the psychiatric evaluation through a clinical
psychiatric assessment using the Kiddie-Sads-Present and Lifetime Version (K-SADS-PL) (1818. Kaufman J, Birmaher B, Brent D, Rao U, Flynn C, Moreci P, et al. Schedule for
affective disorders and Schizophrenia for school-age children- Present Lifetime Version (K-SADS-PL):
Initial Reliability and Validity Data. J Am Acad Child Adolesc Psychiatry. 1997;36(7):980-8,
http://dx.doi.org/10.1097/00004583-199707000-00021.
http://dx.doi.org/10.1097/00004583-19970...
,1919. Mercadante MT, Asbarh F, Rosário MC, Ayres AM, Ferrari MC, Assumpção FB, et
al. K-SADS, entrevista semi-estruturada para diagnóstico em psiquiatria da infância, versão
epidemiológica. 1a. ed. São Paulo: PROTOC - Hospital das Clínicas da FMUSP;
1995.).
Two different methods were used to evaluate maltreatment. First, available medical records were reviewed to identify previous reports reflecting socioeconomic and psychosocial circumstances and diagnostic codes specifically related to family and personal experiences that may influence health status (2020. World Health Organization. International Statistical Classification of Diseases and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.). These medical records were obtained from the legal proceedings of the Guardianship Council of São Paulo and the Children's Court.
Second, clinical assessments were complemented with information from current caregivers, the providers of previous services (such as the Children's Court, the Guardianship Council, foster care centers and other healthcare facilities), school reports and criminal justice system records. Thus, the final record of adverse events was based on the information obtained from each of these sources.
In addition, the Childhood Trauma Questionnaire (CTQ) was used to obtain a structured history of
trauma from the patients themselves. The CTQ is a 28-item self-report inventory for children over 12
years old. This questionnaire represents a screening tool for identifying exposure to five types of
maltreatment: emotional, physical and sexual abuse and emotional or physical neglect. The CTQ also
includes a three-item Minimization/Denial scale for identifying suspected false-negative trauma
reports (2121. Bernstein DP, Stein JA, Newcomb MD, Walke E, Pogge D, Ahluvalia T. Development
and validation of brief screening version of childhood trauma questionnaire. Child Abuse Negl.
2003;27(2):169-90, http://dx.doi.org/10.1016/S0145-2134(02)00541-0.
http://dx.doi.org/10.1016/S0145-2134(02)...
,2222. Grassi-Oliveiral R, SteinI LM, Pezzi JC. Tradução e validação de
conteúdo da versão em português do Childhood Trauma Questionnaire. Rev Saúde Pública.
2006;40(2):249-55, http://dx.doi.org/10.1590/S0034-89102006000200010.
http://dx.doi.org/10.1590/S0034-89102006...
). All
instruments used were translated into Portuguese and adapted for the Brazilian population. As our
sample includes children under 12 years old, in these cases, a professional TEP staff member
administered the questionnaire.
All diagnoses (psychiatric and social) were made following ICD-10 (International Statistical
Classification of Diseases and Related Health Problems, 10th edition) diagnostic criteria
(2020. World Health Organization. International Statistical Classification of Diseases
and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.) and were reviewed among the multidisciplinary team until
consensus was reached. More detailed information on psychiatric diagnoses in this sample has been
reported elsewhere (2323. Silva TF, Cunha PJ, Scivoletto S. High rates of psychiatric disorders in a
sample of Brazilian children and adolescents living under social vulnerability - urgent public
policies implications. Rev. Bras. Psiquiatr. 2010;32(2):195-6,
http://dx.doi.org/10.1590/S1516-44462010000200018.
http://dx.doi.org/10.1590/S1516-44462010...
).
Statistical analysis
Absolute and relative frequencies of psychiatric disorders and other potential correlates of abuse are presented, including gender, age, a family history of mental disorders, the current place of residence, school attendance and other adverse events.
Bivariate associations were then evaluated between psychiatric disorders and evidence of each of the following: problems related to the alleged sexual abuse of a child by a person within the primary support group (ICD-10, Z61.4) or outside of the primary support group (ICD-10 Z61.5) (2020. World Health Organization. International Statistical Classification of Diseases and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.), problems related to the alleged physical abuse of a child (ICD-10 Z61.6) (2020. World Health Organization. International Statistical Classification of Diseases and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.), institutional upbringing (ICD-10 Z62.2) (2020. World Health Organization. International Statistical Classification of Diseases and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.), the emotional neglect of a child (ICD-10 Z62.4) (2020. World Health Organization. International Statistical Classification of Diseases and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.), inadequate family support (ICD-10 Z63.2) (2020. World Health Organization. International Statistical Classification of Diseases and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.), a family history of mental disorder (ICD-10 Z81) (2020. World Health Organization. International Statistical Classification of Diseases and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.), a child's age, the number of different types of trauma (amount of trauma) and current place of residence.
To identify the independent association of these variables with psychiatric diagnosis, stepwise logistic regression with backward variable selection was used. All analyses were conducted using SPSS Inc. Released 2005 (SPSS for Windows, Version 14.0, Chicago, IL, USA) with type I error set at 5%.
Ethics
The Institutional Review Board (IRB) of the University of São Paulo (CAPPesq) approved the research protocol. All patients and their legal guardians signed informed consent forms prior to participation in this study.
RESULTS
Table 1) presents the sociodemographic characteristics of the sample and the frequencies of different types of child maltreatment. The sample was composed of 351 children (68.7% male, mean age = 12.47 years). When the children entered the program, 82.1% came from shelters, 15.4% were still living with their families and a small minority (2.3%) were living in the street but were referred to shelters immediately after first contact with TEP. All patients suffered neglect (100%), and 58.4% had documented or reported physical or sexual abuse. We found that 52.47% were subjected to physical abuse, and 18.95% were subjected to sexual abuse. Mental disorder in a family member was evident in 10.2% of the sample. We also found that 44.3% of the sample had received institutional education, i.e., a situation in which children were separated from their parents in early childhood and raised in a group shelter with formal supervision. Among the genders, we observed an average of more adverse events among females (mean 2.01 + standard deviation 1.134) than among males (mean 1.87 + standard deviation 1.038).
The most frequent psychiatric diagnoses were substance use disorders, affective disorders and specific disorders of early childhood. Only 48 children/adolescents (13.67%) in the sample had no psychiatric diagnosis (Table 2).
Correlates of each psychiatric diagnosis in logistic stepwise regression analyses are presented in Table 3).
Substance use disorder (SUD)
SUD was positively associated with a greater age at the time of program entry (odds ratio [OR] = 1.59) and exposure to multiple traumas, with each new trauma increasing the likelihood of SUD by 34% (OR = 1.34).
Affective disorder (AD)
The occurrence of physical abuse (ICD-10 Z61.6) (2020. World Health Organization. International Statistical Classification of Diseases and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.) increased the likelihood of AD by 62% (OR = 1.62).
Specific disorders of early childhood (SDEC)
There were positive associations between SDEC and a history of emotional neglect of a child (ICD-10 Z62.4) (2020. World Health Organization. International Statistical Classification of Diseases and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.) (OR = 1.68) and male gender (OR = 1.82).
Attention deficit hyperactivity disorder (ADHD)
ADHD was only associated with being male, which increased the odds of this disorder by 89% (OR = 1.89), but there was no association with any adverse event.
Conduct disorder (CD)
There was a positive association between CD and being male, which doubled the odds (OR = 2.1).
Mental retardation (MR) (2020. World Health Organization. International Statistical Classification of Diseases and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.)
The presence of physical abuse (ICD-10 Z61.6) (2020. World Health Organization. International Statistical Classification of Diseases and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.) increased the odds of having a diagnosis of MR 3.58 times (OR = 3.58), whereas those children who suffered from emotional neglect (ICD-10 Z62.4) (2020. World Health Organization. International Statistical Classification of Diseases and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.) had 5.59 times the likelihood of having a diagnosis of MR (OR = 5.59)
Anxiety disorder (AnD)
Patients who suffered emotional neglect (ICD-10 Z62.4) (2020. World Health Organization. International Statistical Classification of Diseases and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.) and those individuals who received their education in an institution (ICD-10 Z62.2) (2020. World Health Organization. International Statistical Classification of Diseases and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.) had an 86% reduced likelihood of AnD. In contrast, the presence of a history of physical abuse (ICD-10 Z61.6) (2020. World Health Organization. International Statistical Classification of Diseases and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.) and inadequate family support (ICD-10 Z63.2) (2020. World Health Organization. International Statistical Classification of Diseases and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.) slightly increased the odds of AnD by 2% (OR = 2.025) and 2.22% (OR = 2.22), respectively.
Pervasive developmental disorder (PDD)
A family history of mental disorder (ICD-10 Z81) (2020. World Health Organization. International Statistical Classification of Diseases and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.) increased the odds of PDD by 3.9 times, whereas age was negatively associated with PDD, such that for each year, the chance of PDD was reduced by 16% (OR = 0.84).
Schizophrenia (SZ) and impulse disorder (ID)
There were no associations between psychosocial circumstances and the diagnosis of either SZ or ID.
Children without a psychiatric diagnosis (WPD)
The children/adolescents who were not diagnosed with any psychiatric disorder were negatively associated with age and male gender. The chance of the absence of any psychiatric diagnosis was reduced by 26% (OR = 0.74) for each additional year of age. There was also a negative association between male gender and the presence of a psychiatric diagnosis. In this population, being male was associated with a 66% reduced likelihood of the chance of receiving a psychiatric diagnosis (OR = 0.34).
DISCUSSION
This study examined the relationship between psychiatric diagnosis and four types of child maltreatment, a family history of mental disorders and sheltering among children and adolescents treated in an interdisciplinary community-based treatment program in São Paulo, Brazil. Significant associations were observed between diagnosis, several sociodemographic characteristics and specific types of child maltreatment.
Male gender was associated with diagnoses of ADHD, CD, SDEC and PDD. The literature notes
contradictions related to gender and association with specific types of mental disorders. In several
studies, male children exposed to domestic violence were found to have a greater predisposition to
both externalizing and internalizing symptoms of mental disorder (2525. Evans SE, Davies C, Dilillo D. Exposure to domestic violence: a meta-analysis of
child and adolescents outcomes. Aggression and Violent Behavior. 2008;13:131-40,
http://dx.doi.org/10.1016/j.avb.2008.02.005.
http://dx.doi.org/10.1016/j.avb.2008.02....
), whereas other reports noted that female children were more affected (2626. Sternberg KJ, Lamb ME, Greenbaum C, Cicchetti D, Dawud S, Cortes RM, et al.
Effects of domestic violence on children's behavior problems and depression. Developmental
Psychology. 1993;29:44-52, http://dx.doi.org/10.1037/0012-1649.29.1.44.
http://dx.doi.org/10.1037/0012-1649.29.1...
). Nevertheless, in our study, boys had a lower risk of having
any psychiatric disorder than girls did. This finding could reflect the higher prevalence of adverse
events among girls than boys, although the result was not statistically significant
(OR = 0.30). However, a greater number of resilience factors are associated with
female gender, including "cognitive skills", "adaptable personality" and "self-esteem" (2727. Cordovil C, Crujo M, Vilariça P, Da Silva PC. Resiliência em crianças
e adolescentes institucionalizados. Acta Med Port. 2011;24(S2):413-8.). The lower prevalence of psychiatric disorders among boys may
also be related to the lack of homogeneity within gender or differences in the proportions of
adverse events between genders in our sample.
In a recent study, Moylan (2828. Moylan CA Herrenkohl TI, Tajima EA, Herrenkohl RC, Russo MJ. The effects of
child abuse and exposure to domestic violence on adolescent internalizing and externalizing behavior
problems. J Fam Violence. 2010; 25(1):53-63,
http://dx.doi.org/10.1007/s10896-009-9269-9.
http://dx.doi.org/10.1007/s10896-009-926...
) concluded that girls were
more likely to internalize symptoms, whereas boys were more likely to externalize symptoms. Our
study indicates both externalization among males (in association with ADHD and CD) and
internalization (in association with SDEC). The associations between males and PDD and ADHD are
already well established in the literature (2525. Evans SE, Davies C, Dilillo D. Exposure to domestic violence: a meta-analysis of
child and adolescents outcomes. Aggression and Violent Behavior. 2008;13:131-40,
http://dx.doi.org/10.1016/j.avb.2008.02.005.
http://dx.doi.org/10.1016/j.avb.2008.02....
).
We observed negative associations between age and the disorders AD, PDD, SDEC, ADHD and WPD. That is, the younger the child was, the greater the probability of not having any psychiatric diagnosis or, when a diagnosis was present, the greater the likelihood of having one of these specific diagnoses. This finding was expected for PDD, ADHD and SDEC, in which symptoms typically appear earlier in childhood. The same age relationship was noted for the group without psychiatric disorder; the younger the child was, the lower the chance of being diagnosed with any psychiatric disorder. This finding could be explained by a shorter duration of exposure to abuse resulting in a lower risk of disorder. Additional research is needed to confirm this finding.
The presence of a history of multiple traumas was incrementally associated only with a diagnosis
of SUD. Others have observed that experiences of multiple episodes or types of abuse or chronic
exposure to abuse were generally associated with higher incidences of adverse effects on mental
health (2929. Flaherty E, Thompson R, Litrownik A, Zolotor A, Dubowitz H, Runyan D et al.
Adverse childhood exposures and reported child health at age 12. Academic Pediatrics.
2009;9(3):150-6, http://dx.doi.org/10.1016/j.acap.2008.11.003.
http://dx.doi.org/10.1016/j.acap.2008.11...
). In studies evaluating the physical health of
children, the occurrence of four or more experiences of abuse has been found to triple the
likelihood of poor physical health (2929. Flaherty E, Thompson R, Litrownik A, Zolotor A, Dubowitz H, Runyan D et al.
Adverse childhood exposures and reported child health at age 12. Academic Pediatrics.
2009;9(3):150-6, http://dx.doi.org/10.1016/j.acap.2008.11.003.
http://dx.doi.org/10.1016/j.acap.2008.11...
). Thus, we would have
expected a stronger association between multiple traumas and psychiatric disorders other than
substance abuse. However, the occurrence of multiple abuse exposures in the sample may have muted
this finding. In addition, the direction of causality may be bidirectional in substance abuse, with
abuse leading to substance abuse and substance abuse leading to further abuse.
The presence of physical abuse (ICD-10 Z61.6) (2020. World Health Organization. International Statistical Classification of Diseases
and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.) was
positively associated with AnD (2.09%) and AD (62%). Inadequate family support (ICD-10 Z63.2) (2020. World Health Organization. International Statistical Classification of Diseases
and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.) and emotional neglect (ICD-10 Z62.4) (2020. World Health Organization. International Statistical Classification of Diseases
and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.) were each positively associated with AnD (2.35%) and SDEC (32%). Several
authors have previously hypothesized that children who suffer maltreatment would have a greater risk
of AnD. This association could be related to cognitive changes generated by the occurrence of
maltreatment. Thus, there would be increased apprehension in the perception of external events,
increasing vulnerability to the development of AnD (3030. McLaughlin KA, Green JG, Gruber MJ, Sampson NA, Zaslavsky AM, Kessler RC.
Childhood adversities and adult psychopathology in the National Comorbidity Survey Replication
(NCS-R) III: Associations with functional impairment related to DSM-IV disorders. Psychol Med. 2010;
40(5):847-59, http://dx.doi.org/10.1017/S0033291709991115.
http://dx.doi.org/10.1017/S0033291709991...
31. Bolger KE, Patterson CJ. Pathways from child maltreatment to internalizing
problems: Perceptions of control as mediators and moderators. Development and Psychopathology.
2001;13:913-40.-3232. Chorpita BF, Barlow DH. The development of anxiety: The role of control in the
early environment. Psychol Bull. 1998;124:3-21,
http://dx.doi.org/10.1037/0033-2909.124.1.3.
http://dx.doi.org/10.1037/0033-2909.124....
). In the case of inadequate family support, children may feel
chronically insecure and anxious, even though we noted a reduction in the likelihood of AnD in our
sample. Certain sample characteristics may explain this finding. In many cases, children came from
large families that no longer gave much attention to their children, and as a result, the children
experienced chronic neglect. During this period of extended neglect, the children may have developed
defense mechanisms that reduced their level of anxiety. This concept also deserves investigation in
future studies. Children who received their education in an institution had a reduced likelihood of
AnD, perhaps because of the protection provided in these institutions and the consequent removal of
the source of anxiety or fear.
Other notable findings are related to the diagnosis of MR. We found strong positive associations with reported physical abuse (ICD-10 Z61.6) (2020. World Health Organization. International Statistical Classification of Diseases and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.) (OR = 3.58) and emotional neglect (ICD-10 Z62.4) (2020. World Health Organization. International Statistical Classification of Diseases and Health Related Problems (The) ICD-10, Second Edition (2 ed.); 2004.) (OR = 5.59). However, a negative correlation was found when we analyzed the presence of a history of multiple traumas (OR = 0.47).
The association between maltreatment and the presence of physical or mental disability in the
literature is slightly inconsistent. This inconsistency reflects differences in the samples
evaluated and the lack of assessment of the presence of these deficiencies. Many studies focus on
studying how family psychosocial factors may trigger an increased risk of maltreatment. It is known
that the care of children with disabilities in itself may provoke high levels of family stress
(3333. Jaudes PK, Diamon LJ. The handicapped child and child abuse. Child Abuse Negl.
1985;9(3):341-7, http://dx.doi.org/10.1016/0145-2134(85)90030-4.
http://dx.doi.org/10.1016/0145-2134(85)9...
). The present study identified higher associations of MR
with only physical abuse and neglect. Similarly, a study published by the National Center for Child
Abuse and Neglect in 1993 and conducted in the USA indicated that children with physical or mental
disabilities were 1.7 times more likely to have suffered maltreatment compared with those children
without disabilities.
Sullivan and Knutson (3434. Sullivan PM, Knutson JF. Maltreatment and disabilities: A population-based
epidemiological study. Child Abuse Negl. 2000;24(10):1257-73,
http://dx.doi.org/10.1016/S0145-2134(00)00190-3.
http://dx.doi.org/10.1016/S0145-2134(00)...
) published a review that noted
the presence of a positive association between maltreatment and physical or mental disability, but
the strength of the associations varied according to the sample examined. For example, there was a
greater association when the determination of deficiency was based on a medical analysis or when the
samples were obtained from hospitals. Sullivan and Knutson (3535. Sullivan PM, Knutson JF. The association between child maltreatment and
disabilities in a Hospital-Based epidemiological study. Child Abuse Negl. 1998;22(4):271-88,
http://dx.doi.org/10.1016/S0145-2134(97)00175-0.
http://dx.doi.org/10.1016/S0145-2134(97)...
) provides relevant information for public health policy and medical practice, noting that
children with disabilities tend to suffer maltreatment at younger ages compared with children
without such disabilities. However, the reason for this difference was not identified.
Several studies (3636. Warfield ME, Krauss MW, Hauser-Cram P, Upshur CC, Shonkoff JP. Adaptation during
early childhood among mothers of children with disabilities. J Dev Behav Pediatr.
1999;20(1):9-16, http://dx.doi.org/10.1097/00004703-199902000-00002.
http://dx.doi.org/10.1097/00004703-19990...
,3333. Jaudes PK, Diamon LJ. The handicapped child and child abuse. Child Abuse Negl.
1985;9(3):341-7, http://dx.doi.org/10.1016/0145-2134(85)90030-4.
http://dx.doi.org/10.1016/0145-2134(85)9...
) have reported relatively different results. In a longitudinal study performed using
children under 5 years old, Warfield concluded that the presence of a diagnosis of MR or cognitive
limitation had no association with the occurrence of maltreatment (3636. Warfield ME, Krauss MW, Hauser-Cram P, Upshur CC, Shonkoff JP. Adaptation during
early childhood among mothers of children with disabilities. J Dev Behav Pediatr.
1999;20(1):9-16, http://dx.doi.org/10.1097/00004703-199902000-00002.
http://dx.doi.org/10.1097/00004703-19990...
). In our study, there was also no association between the presence of MR and the
occurrence of multiple forms of maltreatment, but there were strong associations with physical abuse
and emotional neglect. In a more recent study, Jaudes and Diamon (3333. Jaudes PK, Diamon LJ. The handicapped child and child abuse. Child Abuse Negl.
1985;9(3):341-7, http://dx.doi.org/10.1016/0145-2134(85)90030-4.
http://dx.doi.org/10.1016/0145-2134(85)9...
) found a similar result, reporting that the presence of a diagnosis of MR or cognitive
impairment at any age was not significantly associated with the occurrence of maltreatment. Most
studies tend to evaluate the presence of both physical and mental disabilities. In cases of multiple
disabilities in the same child, Benedict et al. (3737. Benedict M, White R, Wulff L, Hall B. Reported maltreatment in children with
multiple disabilities. Child Abuse Negl. 1990;14(2):207-17,
http://dx.doi.org/10.1016/0145-2134(90)90031-N.
http://dx.doi.org/10.1016/0145-2134(90)9...
)
demonstrated a reduced risk of physical abuse and neglect. In such cases, the explanation offered
was a greater coping capacity or resilience in these families regarding the conditions of their
children, i.e., a reduced discrepancy between the family's expectations and the actual
capabilities of their children. In contrast, the families of children served by TEP are typically
relatively dysfunctional, as reflected by the fact that in many cases, the children are removed from
their families. It was thus expected that in this context, we would find a stronger association
between the presence of MR (children who need more care and supervision) and the occurrence of
physical abuse and emotional neglect.
Limitations
The first limitation concerns the identification of maltreatment in this population. Underreporting is understandably common but does not necessarily invalidate the results, although this issue must be acknowledged (3838. The United Nations Children's Fund (UNICEF). Progress for Children: a report card on child protection. UNICEF Division of Communication 2009.). We used multiple sources of information to minimize the risk of underreporting.
Most studies have difficulties in determining the exact date of the onset of exposure to trauma.
Such information can be important because the earlier the occurrence of trauma is, the more
potentially serious are the effects on the CNS, which might increase vulnerability to mental
disorders in adulthood (1313. Lamont A. Effects of child abuse and neglect for children and adolescents.
Australian Institute of Family Studies 2010; 1-7.). Maternal depression and
psychoactive substance use during pregnancy may function as the first stressor to which a child is
exposed (1212. Neigh GN, Gillespie CF, Nemeroff CB. The neurobiological toll of child abuse and
neglect. Trauma Violence Abuse. 2009;10(4):389-410,
http://dx.doi.org/10.1177/1524838009339758.
http://dx.doi.org/10.1177/15248380093397...
). In this study, it was not possible to pinpoint
the exact age of maltreatment onset, but the families of all children faced poor housing situations,
and many also had family histories of psychiatric problems, suggesting that adverse events had
occurred since pregnancy.
This is a cross-sectional study; thus, the suggested cause-and-effect relationships between abuse and its adverse consequences are not conclusive. An association between the two may occur independently due to confounding factors, or one may predispose to the occurrence of the other. Longitudinal studies are needed for more precise causal assessment. In addition, virtually all of the children had both psychiatric disorders and exposure to trauma or neglect, so we lacked a reference group with no psychiatric diagnosis or trauma, which might have yielded more robust contrasts. This study may be best considered as comparing the distinct association between child maltreatment and different psychiatric disorders in a sample in which nearly all of the children were exposed to trauma and exhibited evidence of a psychiatric disorder.
According to Famularo et al. in 1996 (3939. Famularo R, Fenton T, Kinscherff R, Augustyn M. Psychiatric comorbidity in
childhood post traumatic stress disorder. Child Abuse Negl.1996;20(10):953-61,
http://dx.doi.org/10.1016/0145-2134(96)00084-1.
http://dx.doi.org/10.1016/0145-2134(96)0...
), 35% of child
victims of maltreatment had a diagnosis of post-traumatic stress disorder (PTSD). This disorder has
great variation in symptoms and clinical presentation, with mood fluctuation, anxiety and even
psychotic symptoms. PTSD is seldom diagnosed in infancy and may thus be underestimated by
professionals who work directly with traumatized children and adolescents (4040. Ziegler MF, Greenwald MH, DeGuzman MA, Simon HK. Posttraumatic stress responses
in children: Awareness and practice among a sample of pediatric emergency care providers.
Pediatrics. 2005;115(5):1261-7, http://dx.doi.org/10.1542/peds.2004-1217.
http://dx.doi.org/10.1542/peds.2004-1217...
). The diagnosis of this disorder requires clear and objective information about
the people caring for these children over an extended period of time. Thus, PTSD diagnoses were
difficult to make in this sample. After a degree of time tracking, it is possible to identify cases
of PTSD, but in this cross-sectional research, it was not possible to identify any case, even after
the application of the K-SADS-PL.
Difficulties in controlling for other environmental and social factors add ambiguity to the
determination of causal relationships (1313. Lamont A. Effects of child abuse and neglect for children and adolescents.
Australian Institute of Family Studies 2010; 1-7.). Although we know
that other traumas (such as robbery, accidents or a history of injuries) could contribute to mental
disorders (1313. Lamont A. Effects of child abuse and neglect for children and adolescents.
Australian Institute of Family Studies 2010; 1-7.,1414. Cohen JK. Resilience and developmental psychopathology. Child Adolesc
Psychiatric Clin N Am. 2007;16(2):271-83,
http://dx.doi.org/10.1016/j.chc.2006.11.003.
http://dx.doi.org/10.1016/j.chc.2006.11....
), it
was not possible to identify and control for these events in this study, especially because the
children had been exposed to many different types of trauma and generally harsh life conditions.
However, this is the first study of the relationship between adverse events in childhood and mental
disorders in the population, and future studies may be able to take these other types of events into
account.
Even though this is a cross-sectional study, and thus, cause-and-effect relationships are not conclusive, significant associations were observed between psychiatric diagnosis and both sociodemographic characteristics and several specific types of child maltreatment.
Experiences of multiple abuse or chronic exposure to abuse appear to have adverse effects on mental health. However, in our study, exposure to multiple traumas was only associated with a greater risk of SUD.
All children living in adverse conditions deserve careful assistance, but we found that those children with MR are at greatest risk of physical abuse and emotional neglect. We know that in severe mental disorders, a history of childhood trauma can affect illness progression. This study indicates the importance of developing adequate public policies aimed at the prevention of child maltreatment, especially to reduce the risk of subsequent mental disabilities.
Conflicts of Interest: This study was partially funded by the Foundation of the Faculdade de Medicina (FFM), the National Institute for Developmental Psychiatry (INPD - supported by CNPq n° 573974/2008-0) and São Paulo Municipality. The funders did not have any influence on the design and conduct of the study; the collection, management, analysis and interpretation of the data; or the preparation, review and approval of the manuscript. Robert Rosenheck has received research support from Eli Lilly, Janssen Pharmaceutica, AstraZeneca and Wyeth Pharmaceuticals. He has been a consultant to GlaxoSmithKline, Bristol-Myers Squibb, Organon and Janssen Pharmaceutica. He has provided expert testimony for the plaintiffs in UFCW Local 1776 and Participating Employers Health and Welfare Fund et al vs. Eli Lilly and Company, for the respondent in Eli Lilly Canada Inc. vs. Novapharm Ltd. and the Minister of Health and for the Patent Medicines Prices Review Board of Canada in the matter of Janssen Ortho Inc. and "Risperdal Consta". Sandra Scivoletto has received research support from Janssen-Cilag Brazil, Novartis Brazil, Cristália Produtos Químicos Farmacêuticos (Cristália Pharmaceutical Chemicals), Eli Lilly Brazil, CNPq - Conselho Nacional de Desenvolvimento Científico e Tecnológico (National Council for Scientific and Technological Development), FUMCAD - Fundo Municipal da Criança e do Adolescente (Municipal Fund for Children and Adolescents), FAPESP - Fundação de Amparo à Pesquisa do Estado de São Paulo (Foundation for Research Support of the State of São Paulo) and FFM - Fundação Faculdade de Medicina (Medical School Foundation of the University of Sao Paulo). She has received fees as a speaker for GlaxoSmithKline Brazil, Instituto Américo Bairral de Psiquiatria Itapira, Colégio Santo Américo and Gerdau Company.
We would like to thank the São Paulo City Hall, public schools, foster centers and justice system that have been working together with The Equilibrium Project (TEP) and the University of São Paulo (USP). We also thank the entire team of the Equilibrium Program, and especially Tânia Takakura, MD, for her collaboration during data collection and initial analysis.
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» http://dx.doi.org/10.1097/00004703-199902000-00002 -
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40Ziegler MF, Greenwald MH, DeGuzman MA, Simon HK. Posttraumatic stress responses in children: Awareness and practice among a sample of pediatric emergency care providers. Pediatrics. 2005;115(5):1261-7, http://dx.doi.org/10.1542/peds.2004-1217.
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-
No potential conflict of interest was reported.
Publication Dates
-
Publication in this collection
2013
History
-
Received
12 Mar 2013 -
Reviewed
1 Apr 2013 -
Accepted
1 Apr 2013