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

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

3. 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

4. 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

5. 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),

6. 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

7. 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?

8. 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

9. 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)

10. 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

11. 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

12. Results Results from 108 women survivors
Mean age = 40.7 years (range 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%)

13. 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)

14. 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

15. 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*

16. Results BDI-II Significant Interactions Plots

17. 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*

18. 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.

19. Results PLC-C Significant Interactions Plots

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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),
Foa, E. B. (2000). Psychosocial treatment of posttraumatic stress disorder. Journal of Clinical Psychiatry, 61(Suppl 5),
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),
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),
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),
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),
Schneider, R., Baumrind, N., & Kimerling, R. (2007). Exposure to child abuse and risk for mental health problems in women. Violence & Victims, 22(5),
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),

27. 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

28. Author contact email: Adeline.Lee@monash.edu
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