|Year : 2016 | Volume
| Issue : 1 | Page : 50-55
Association between childhood abuse and psychiatric morbidities among hospitalized patients
Kshirod Kumar Mishra, Ramdas Ransing, Praveen Khairkar, Sakekar Gajanan
Department of Psychiatry, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
|Date of Web Publication||17-Feb-2016|
Prof. Kshirod Kumar Mishra
Department of Psychiatry, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha - 442 102, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Childhood abuse has been linked with increased risk of adult psychiatric disorders including major depression, substance abuse, anxiety disorders, posttraumatic stress disorder, and personality disorders. However, only a few from India attempted to study long-term consequences of childhood abuse. Our study aimed to understand the role of physical, sexual, and emotional abuse along with psychiatric co-morbidities in hospitalized patients. Materials and Methods: Patients admitted to psychiatric inpatient services in the age group of 14-45 years for the 1 st time were evaluated for a history of physical, sexual, and emotional abuse on the basis of retrospective chart review. Semi-structured Performa was used to evaluate the patient with a history of child abuse, and they were diagnosed according to International Classification of Diseases-10 diagnostic criteria. Result: The prevalence of child abuse in our inpatient services was 43.29%; emotional abuse (61.9%) was most commonly reported among patient followed by physical (21.43%) and sexual abuse (16.67%). We observed a significant difference in terms of length of hospital stay between abuse (10.29 ± 6.01 days) and nonabuse group (5.90 ± 2.43 days) (t = 4.902, df = 95, P < 0.0001). The boys experienced physical abuse at a younger age (7.43 ± 2.50 years) than girls (13.50 ± 0.70 years). The sexual abuse and emotional abuse were reported at a younger age in girls than boys. We found high prevalence of substance use disorders (40.47%), psychosis (19.04%), and mood disorder (28.57%) among abuse group. Conclusions: The study findings highlight the developing importance of the different forms of abuse on adult psychiatric diagnosis in India. The abused patients are at high risk of the development of psychiatric disorder than the nonabuse group. The increased length of hospitalization among abused group reflects severity and complexity of child abuse. The early detection of social factors contributing to child abuse may be helpful in the prevention of child abuse. Further research is warranted in longitudinal prospective for better understanding the impact of child abuse on psychiatric diagnosis in Indian settings.
Keywords: Child abuse, psychiatric diagnosis, psychiatric inpatients
|How to cite this article:|
Mishra KK, Ransing R, Khairkar P, Gajanan S. Association between childhood abuse and psychiatric morbidities among hospitalized patients. Indian J Soc Psychiatry 2016;32:50-5
|How to cite this URL:|
Mishra KK, Ransing R, Khairkar P, Gajanan S. Association between childhood abuse and psychiatric morbidities among hospitalized patients. Indian J Soc Psychiatry [serial online] 2016 [cited 2020 Feb 26];32:50-5. Available from: http://www.indjsp.org/text.asp?2016/32/1/50/176769
| Introduction|| |
"Childhood should be carefree, playing in the sun; not living a nightmare in the darkness of the soul" - quoted by Dave Pelzer.  Failure of assurance to care may be the beginning of evils such as child abuse. According to the World Health Organization (WHO): "Child abuse or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child's health, survival, development or dignity in the context of relationship of responsibility, trust or power".  Such a violence may occur in places such as homes, schools, orphanages, residential care facilities, on the streets, in the workplace, in prisons, and in places of detection.
Child abuse is one of the most vital social problems increasing every day in India. As per a national study (2007), 69% of children reported to have been physically abused; of these 54.68% were boys. About 53% children faced one or more type of sexual abuse, of which 21.90% had severe forms of sexual abuse. Across the country, every second a child is being subjected to one or more form of abuse; among them in 83% of cases the abuser were parents.  However, unfortunately, most of the abuse remains underreported due to social and cultural barriers, poor public awareness about issues, poor response of the government and nongovernment organization to child abuse, poor understanding about consequences of abuse among medical and psychiatric communities, stigma, and unavoidable legal barriers for protection. 
Consequences of child abuse are serious, long lasting, wide, and ranging from anxiety disorder to suicide attempt. Retrospective studies have been undertaken to understand the consequence of child abuse that include substance use disorder,  suicide, , depression  schizophrenia and psychotic disorders, , anxiety disorders,  somatoform disorder and dissociation disorder,  and attention deficit hyperactivity disorder.  Abusers have low self-esteem, feeling of isolation and stigma, a tendency toward victimization, and are more prone to substance as well as nonsubstance abuse. ,
Child abuse sensitizes the neural circuits mediated through hippocampus and hypothalamo-pituitary axis. Even if a child shows no signs of distress or mental illness at the time of occurrence of early life exposure to abusive stressor, it sensitizes the subjects to future adult stressors. Hence, stress-sensitized individual to multiple stressors in adulthood may lead to various psychiatric disorders at a younger age than in the nonabuse group.
The recent published review by Carr et al.  gives an idea about the unique effect of early life stress on the development of psychopathology among adults and the importance of precipitating, predisposing and perpetuating factors for psychiatric disorders. In their study, they found mood and anxiety disorders linked with physical and sexual abuse, emotional abuse with personality disorder and schizophrenia, whereas physical neglect was linked with personality factors. These factors are not only accountable for the onset of psychiatric disorders but responsible for maintenance and increase in the recurrence of psychiatric disorders along with severity. 
However, the relationship between child abuse and psychiatric morbidities has not been studied in the Indian context to the best of our knowledge. These consequences of abuse depend on internal factors such as individual's sensitivity to stress and other external factors such as legal issues, cultural factors, family environment, primary support group, etc. ,
The present study was aimed to understand: (1) The relationship between childhood abuse and psychiatric disorder along with various psychiatric co-morbidities retrospectively and (2) the relation between age of abuse and age at the time of onset of psychiatric disorders.
| Materials and Methods|| |
The study was approved by the Institutional Ethics Committee of a tertiary care rural hospital and has been carried out in accordance with the Declaration of Helsinki. Informed consent was obtained from each participant.
The participants comprised inpatients who were admitted during the period of 6 months w.e.f March 1, 2013 to August 31, 2013. The history of childhood abuse was documented for all patients along with the length of hospital stay and was reported by caregivers or patients or both. A semi-structured performa was used for the assessment of patients for physical, sexual, and emotional abuse. World Health Organization criteria for the categorization of child abuse was used in the present study.  Psychiatric diagnosis was made as per International Classification of Diseases-10 diagnostic criteria.
The inclusion criteria were: (1) Patients between the age group of 14 and 45 years (2) those willing to participate in the study through written consent. Exclusion criteria were: (1) Patients with a history of pervasive developmental disorder or mental retardation (2) history of organic brain disease (3) those not willing to participate in the study. The admitted patient was assessed independently for history of child abuse by two trained psychiatrist, blinded to each other.
All analyzes were performed using the statistical package for social sciences (SPSS 20.0, SPSS Inc., Chicago IL, USA). Categorical variables were compared by using Chi-square test and fisher exact test whichever applicable. Student's t-test and one-way ANOVA were used for comparing the continuous variables. The significance level of all tests was set at 0.05.
| Results|| |
Of 123 admitted patients in psychiatric services, only 97 patients were included in the study considering inclusion and exclusion criteria. The 42 patients with past history of child abuse were enrolled in abuse group, whereas 55 patients were enrolled in nonabuse group. In the abuse group mean age at the time of the first hospitalization was (24.55 ± 7.26) years in comparison with (31.33 ± 8.73) years in nonabuse group. The mean age of the first admission in psychiatric services was (28.05 ± 5.49 years) for male patients, whereas for the female patients it was (23.64 ± 7.33 years). Thus, the patient with past history of any type of abuse was admitted at a younger age than the comparison group.
There was no statistically significant difference observed among abuse and nonabuse group in terms of their religion and marital status [Table 1]. We observed significant difference in terms of length of hospital stay between abuse (10.29 ± 6.01 days) and nonabuse group (5.90 ± 2.43 days) (t = 4.902, df = 95, P < 0.0001).
There was statistically significant difference in terms of education of male patient in abuse group (12.05 ± 2.54) and nonabuse group (14.03 ± 3.81, P = 0.043). However, there was no difference observed among female patients [Table 2] and [Figure 1]. Among the abuse group, most of the patients enrolled in our study reported emotional abuse (61.9%), followed by physical (21.43%) and sexual abuse (16.67%) [Figure 2].
|Table 2: Age-wise distribution of abuse and nonabuse group at the time of the first admission |
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[Table 3] depicts statistically significant difference in urban area between abused and nonabused group (χ2 = 0.048, P < 0.05). There were no differences between male and female patients in the rural area. One-way ANOVA test was used to compare the age of abuse among different types of abuse between male and female patients. Statistically significant difference was observed in mean age of physical abuse among male (7.43 ± 2.50 years) than female (13.50 ± 0.70 years), P = 0.014. The mean age for emotional abuse among male was (13.27 ± 3.43 years) and female was (10.93 ± 4.30 years). The mean age of sexual abuse among female was (14.80 ± 6.45 years) and male was (15.00 ± 1.41 years) [Table 4] and [Figure 3]. On comparison of mean age of abuse and types of abuse, we found a significant difference only among male patient (P = 0.001, significant) [Figure 3].
|Figure 3: Mean age of abuse among (a) male patients and (b) female patients|
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The risk of psychiatric illness is significantly higher in the abused group than nonabused group except for neurotic disorders. The abused group showed a higher prevalence of substance use disorders (40.47%), psychosis (19.04%), and mood disorder (28.57%), than nonabused group substance abuse (23.63%), psychosis (12.72%), and mood disorder (20%). The difference in both group was significant (χ2 = 8.85, df = 3, P = 0.031). The risk of neurotic disorder is found it be increased in nonabused group than absused [Table 5].
|Table 5: Prevalence of psychiatric co-morbidities among abused and nonabused group |
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| Discussion|| |
In the present retrospective study, we observed the prevalence of reported childhood abuse in inpatients was 43.29% (42/97), which is much higher than the studies conducted by Koola et al. (19.04%)  and Keeshin et al. (36%)  among the hospitalized patients. It suggests that the severity and complexity of child abuse are more in India as compared to Western countries. Our findings are in accordance with the result of previous research findings which suggest patients with a history of child abuse are more likely to get hospitalized at a younger age than nonabused. ,,
It implies that child abuse has distinct potential to increase vulnerability to psychiatric co-morbidities, severity of illness, treatment failure, and outcome of illness. Thus, child abuse can leave a lasting signature on the individual's mental health and functional reorganization of a brain network. ,
We observed that males were being abused physically at a younger age than females, whereas the females were abused both emotionally and sexually at a younger age than males. Our finding does not differ in terms of age of abuse than the recently published study of Brazilian adolescents.  The reason for emotional and sexual abuse among females may be due to decreasing child sex ratio (919 female child per 1000 male child in 2011 census as compared to 927 female child per 1000 male child), parent's preference for male child resulting into increased female feticide.  Younger age of physical abuse among male patient may be explained by certain social norms. It may be an expression of either heightened expression of protection of girl child or lessened protection of the male child. In India, the girl child is monitored closely till marriage to ensure "purity of marriage." , On other hand, boys being less monitored which may impose pressure and sense of responsibility on them leading to younger physical abuse among boys. Our findings appear to be influenced by these sociocultural factors demonstrating the necessity of further evaluation in a larger sample.
The abused patients had spent fewer years of education reflecting the lower cognitive functions among them than nonabused patients. Abuse in any form appears to have a pervasive impact in cognitive functions particularly specific deficit in verbal memory, IQ, working memory, attention, response prevention, and emotion discrimination. , The traumatic experiences in childhood have been found to be associated with learning disabilities. ,
We observed the difference of length of hospital stay among abused patients to be approximately 5 days more than nonabused ones which was 3 days more from the study of Keeshin et al.  The increased length of stay reflects the complexities and severity of psychiatric illness among adults with a history of childhood abuse. The history of child abuse may increase the likelihood constellation of numerous nonoverlapping symptoms leading to multiple diagnoses requiring application more than medication.  The additional reason in our study may be due to delayed referral for psychiatric consultation, stigma about mental illness, and lower economic status.
Another important finding in our study was that women in urban areas reported a history of child abuse more commonly than rural women. The possibilities of such difference may be a higher rate of literacy in urban areas, availability of protective and legal services, and awareness about child abuse. On the other hand, it may be an indicator of growing crime against women in urban areas. Cultural values in a rural area may be one of the protective factors for abuse in rural areas. In an African study, the community, household, caregiver, child-level factors have a potential influence on child abuse and are key factors in the prevention of child abuse. 
The most frequent psychiatric diagnosis among the abused group was substance use disorders and mood disorder which supports most of the previous study findings. In one of the study by Scomparini et al.  higher rates of substance use disorder and mood disorder were found among abused than nonabused population.  In their study, abused patient had most frequent diagnosis of substance use disorder (63.4%), depressive disorder (40.3%), and posttraumatic stress disorder (PTSD) (29.2%) which was much higher than our study findings.  Surprisingly, we found a lower occurrence of neurotic disorders among those with a history of child abuse than Western studies which may imply habituation and ability to perceive traumatic events less distressing in India.  The religious belief among Indian population appears a mediating factor in the development of PTSD and neurotic disorders.  The "sense of coherence" and the ability to see the traumatizing event as meaningful (due to one's karma or Allah's will) makes it easier to adapt it to an existing schemata. 
We observed a higher prevalence of emotional abuse (61.9%) followed by physical (21.43%) and sexual abuse (16.67%) among hospitalized adults which differs from child abuse in community level. Interestingly, The National Study on Child Abuse reported the prevalence of physical abuse was up to 69% in 13 states of India with higher prevalence among boys (54.68%), sexual abuse (53.22%) with equal percentage among boys and girls and emotional abuse was 50% with equal prevalence in both sexes. The most likely explanation for low reporting of physical abuse in India than Western countries is the difference in cultural and social norms about specific events. Even though in India physical punishment is illegal, it is still being accepted in most of school and home by primary caregivers.
Though a hospitalized patient represents the tip of iceberg of child abuse in community, the finding in the present study may be indicative of the potential link between the pattern of child abuse and psychiatric co-morbidities, utilization of psychiatric services, and outcome of their illness. However, there is a growing need to study the relation between psychiatric illness and child abuse in the Indian context on a large scale to understand the impact of ecological, social, and cultural factors.
| Conclusion|| |
The present study highlights the importance of child abuse as a preventable social factor responsible for increase in vulnerability to psychiatric disorders besides genetic predisposition and other biological factors in this world of science and technology. Our finding suggests that age, sex, and locality may be valuable for the stratification of patients with a psychiatric diagnosis in the Indian context. Our study appears useful in better understanding of child abuse, psychopathology and may help in predicting prognosis of the adult psychiatric disorder. Future studies are indicated in understanding the potential effects of child abuse on the clinical course of psychiatric illness along with specific relationship between the subtype of child abuse and psychiatric disorder. More research is necessary to study management perspective of the psychiatric patient with histories of child abuse to prevent co-morbidities and relapse.
Our study has few limitations such as small sample size (n = 97) and retrospective study design. The possibility of reporting bias could not be ruled out; it is more likely that most of the subjects may under report or over report their type of abuse. In most of the patients, more than one type of abuse was observed and most of time, clinician and patient felt difficulty in prioritizing type of abuse and severity. Thus, one should generalize the findings to outpatients with caution.
We are thankful to all participants and their caregivers. We are also thankful to Dr. Grigo Omityah, Dr. Sarkar Dipayan, and Mr. Rushikesh Khilare for their valuable contribution for the collection of data.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]