Child Abuse and Women’s Mental Health: Moderating Processes Dr. Adeline Lee DPscyh(Clin)

Presentation outline Background Research Questions & Aims Project 1-Women Survivors Design & Participants Measures Statistical Analyses Results Implications/Summary Limitations Conclusion

Background Adverse childhood ecology: Women exposed to childhood maltreatment have a higher risk of developing Mental Illnesses. PTSD, Depression and Anxiety Hospital admissions (suicide & self-injury) Adverse childhood ecology: Attachment with parents/caregiver Physiological vulnerabilities Current lack of standard definition

Background cont’ This Study’s Definition Child sexual abuse (CSA): adult involving child in any sexual activity Physical child abuse (PCA): adult physically injures a child intentionally Emotional child abuse (ECA): no adequate affection and attention Child neglect (CNeg): unmet basic needs Witnessing family violence (WFV) : witnessing or being aware of violence Multi-form abuse

Background cont’  inpatient admission CSA, PCA & ECA independently associated with  mental illnesses Multi-form abuse CSA, PCA and ECA: 23 fold increase risk of PTSD1  inpatient admission  risk of BPD and adult self harm 1Schneider, R., Baumrind, N., & Kimerling, R. (2007). Exposure to child abuse and risk for mental health problems in women. Violence & Victims, 22(5), 620-631.

Background cont’ However it is unclear whether: Different forms of maltreatment is related to specific psychiatric illnesses in adulthood The moderating interaction between different types of abuse when exploring women’s mental health Lack of studies on ECA, CNeg and WFV

Research Qs & Aims RQ: What is the relationship b/t forms of child abuse and severity in symptoms of depression, anxiety and PTSD? extent to which all five types of child abuse (PCA, ECA, CSA, CNeg and WFV) simultaneously predict depression, anxiety and post-traumatic stress symptoms RQ: What are the moderating interactions between the five different abuse types on the depression, anxiety and PTSD?

Design & Participants Cross sectional survey of 108 women who have experienced any form of childhood abuse Exclusion criteria: Non-English speakers & women deemed too unwell to participate by clinicians Recruitment - By referral from GP and other health practitioners - By advertisement/flyers in hospitals, medical community health centres and universities - By open advertisement in general media

Measures Childhood Maltreatment History Comprehensive Childhood Maltreatment Scale – Adult version (CCMS-A) Child sexual abuse (CSA) Physical child abuse (PCA) Emotional childhood abuse (ECA) Childhood neglect (CNeg) Witnessing family violence (WFV)

Measures cont’ Symptom severity of mental illnesses Beck Depression inventory 2nd Ed (BDI-II) Beck Anxiety Inventory (BAI) Post traumatic Stress Checklist- civilian version (PCL-C) Formal mental illness diagnoses MINI International Neuropsychiatric Interview (MINI) Help seeking behavior and experience What helped

Monash Alfred Psychriatry Reseacrh Centre Statistical Analyses Descriptive analyses such as percentages and means Hierarchical multiple linear regression analyses predict severity of depression, anxiety and PTSD and to assess for additional contributions of moderator-interactions among abuse types To understand the moderating relationship between abuse types on mental health, plots and post-hoc probing of significant interactions between abuse types was conducted 2/7/2018 Monash Alfred Psychriatry Reseacrh Centre

Results Results from 108 women survivors Mean age = 40.7 years (range 20-59 years) The majority of women: single/never married (42.1%) live alone / with unrelated other (35.5%) completed university degree (43.9%) part-time employed (28%) household yearly income over $12001 (86.8%)

Results CCMS-A Frequency (%) of women endorsing abuse type and CCMS-A mean (SD) N=107 *Participants reporting their caregivers at least ‘occasionally’ engaged in the behaviours within the CA subscales are classified as having experienced the corresponding CA types Child Abuse Type Frequency (%)* Mean CCMS-A Score (SD) Emotional Child Abuse 105 (98.1) 13.81 (7.3) Physical Child Abuse 98 (91.6) 5.66 (5.7) Witnessing Family Violence 101 (94.4) 4.60 (2.4) Child Neglect 83 (77.6) 5.1 (5.3) Child Sexual Abuse 67 (62.6) 10.92 (14.5) Total Score 40.01 (20.71)

Results BAI, BDI-II & PCL-C Total Mean Score 15.0 SD=9.9 Total Mean Score 15.0 SD=9.9 Total Mean Score 43.0 SD=16

Results BDI-II HMR (Interactions) Adj. R2 R2 Change  Step 1 CCMS-A Scales .13** .18** WFV   -.21* CNeg .30** CSA .24* Step 2 CCMS-A Scales .20 .14 -.28** .37** .25** PCAxWFV -.51**  ECAxWFV .31*

Results BDI-II Significant Interactions Plots

Results BAI HMR (Interactions) Adj. R2 R2 Change  Step 1 CCMS-A Scales .06* .11* WFV   -.24* CNeg .22* Step 2 CCMS-A Scales .05 .08 -.27*

Results PCL-C HMR (Interactions) Adj. R2 R2 Change  Step 1 CCMS-A Scales .12* .13* CNeg   .28** Step 2 CCMS-A Scales .15 .11 WFV -.24* .34** PCAxWFV -.50** ECAxWFV .33* Socio demographic Age was significantly correlated to PCL-C, therefore was entered in step of the PCL-C model. Age was only significant in the first step.

Results PLC-C Significant Interactions Plots

Implications / Summary High prevalence of depression, anxiety and post-traumatic stress in women survivors of child abuse Presence of multiple/co-occurring abuse types Impact of child neglect on depression and trauma after controlling for other child abuse types

Implications / Summary Interaction between child abuse types WFV and PCA Higher levels of physical child abuse were found to be associated with higher levels of depression and post-traumatic stress only when family violence was witnessed infrequently. Normalization of violence Lowers internalization Victims supporting each other

Implications / Summary Interaction between child abuse types WFV and ECA When family violence was frequently witnessed, higher levels of ECA were associated with higher levels of post-traumatic stress Dose response theory PCA and ECA are likely to co-occur with WFV Experience of physical abuse and emotional abuse are different or may have different mechanisms

Implications / Summary Clinical complexity as depression, anxiety and PTSD are highly comorbid disorders for child abuse survivors and have diagnostic symptoms in common Victims may not report their abuse experiences when presenting for assistance Consider comprehensive trauma assessment to more effectively identify, support and engage with survivors

Limitations Cross-sectional not causal Despite fulfilling power calculations will benefit from larger sample size to further explore interactions Retrospective assessment Generalizability as only focused on child abuse survivors

Conclusion Complex relationship found between child abuse and depression, anxiety and PTSD Future research to consider all forms of child abuse and account for interactions when assessing mental health outcomes Utilizing standardized assessment behavioral questions collects frequency and severity of abuse differentiates types of perpetrators Longitudinal studies

References Briere, J., & Scott, C. (2006). Principles of trauma therapy: A guide to symptoms, evaluation and treatment. California: Sage Publication. Carlin, A. S., Kemper, K., Ward, N. G., Sowell, H., & et al. (1994). The Effect of Differences in Objective and Subjective Definitions of Childhood Physical Abuse on Estimates of Its Incidence and Relationship to Psychopathology. Child Abuse & Neglect, 18(5), 393-399. Foa, E. B. (2000). Psychosocial treatment of posttraumatic stress disorder. Journal of Clinical Psychiatry, 61(Suppl 5), 43-48. Higgins, D., McCabe, M., & Ricciardelli, L. (2003). Child maltreatment, family characteristics and adult adjustment mediating and moderating processes. Journal of Aggression, Maltreatment & Trauma, 6(2), 61-86. Green, J., McLaughlin, K., Berglund, P., BGruber, M., Sampson, N., Zaslavsky, A., & Kessler, R. (2010). Childhood adversities and adult psychiatric disorder in the national comorbidity survey replication i associations with first onset of dsm-iv disorders. Archives of General Psychiatry, 67(2), 113-123. McLaughlin, K. A., Green, J. G. P., Gruber, M. J., Sampson, N. A., Zaslavsky, A. M., & Kessler, R. C. (2010). Childhood adversities and adult psychiatric disorders in the national comorbidity survey replication ii: Associations with persistence of dsm-iv disorders. Archives of General Psychiatry February, 67(2), 124-132. Miller, S., Wolff, M., & Scott, S. T. (2000). Eating Disorders, Child Maltreatment, and Post-Traumatic Stress in Women. Family Violence & Sexual Assault Bulletin, 16(4), 17-22. Schneider, R., Baumrind, N., & Kimerling, R. (2007). Exposure to child abuse and risk for mental health problems in women. Violence & Victims, 22(5), 620-631. Wilkinson, P., & Goodyear, I. (2011). Childhood adversity and allostatic overload of the hypothalamic–pituitary–adrenal axis: A vulnerability model for depressive disorders. Development and psychopathology, 23(4), 1017-1037.

Acknowledgments This research was supported by the Australian Postgraduate Award and Mental Health Postgraduate Scholarship Scheme, both from the Australian Government awarded to Dr. Adeline Lee

Author contact email: Adeline.Lee@monash.edu Thank You Questions… Author contact email: Adeline.Lee@monash.edu