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 Childhood physical abuse and sexual abuse have been associated with a wide range of physical, emotional, social, and cognitive impairments in later life (1,2)— impairments that may result in increased health care costs and, more importantly, in human suffering. The association between sexual abuse and psychiatric disorders is well documented (3,4). The association between physical abuse and emotional impairment has received far less investigation (5), although the relation has been documented in at least one community survey (6). Child abuse research has often focused on symptomology, rarely on the functional disability that may stem from such problems as depression and alcohol abuse. From an intervention or treatment perspective, it can be argued that social functioning conveys additional information, compared with symptomology alone (7). In addition, measures of disability are often used to identify service needs (8). Studies of mental health problems have shown that psychiatric disorders can lead to a level of disability equal to that of physical illness (9). Thus, Briere advocated for broader perspectives, promoting the identification of overarching constructs and core effects of abuse in contrast to symptoms (10). Researchers who have examined functional disability and its correlation with a reported history of abuse have done so mostly using clinical samples (5,11–13). Abuse exposure during childhood and adulthood was found to have an association with disability. For instance, patients who were exposed to abuse had significantly higher psychosocial and total disability scores, compared with patients who had not been exposed to abuse (11). These studies investigated several types of abuse combined and often including lifelong exposure. Similar analysis conducted on randomly selected members of a health maintenance organization found an association between exposure to abuse in childhood and functional disability (14). Although these studies have usefully explored the association, they had some methodological limitations, including the use of clinical samples, small sample size, and the absence of a comparison group. In addition, with a few exceptions, the analysis of the association between disability and abuse rarely distinguished between disability due to mental health problems and that due to physical health problems (14). In research on exposure to abuse, it is particularly critical to consider childhood stressors that result in symptoms similar to the ones documented for abuse exposure. Children of substance-abusing parents and abused children share symptoms of aggression, somatization, and suicidality (15,16). In addition, the risk of developing psychopathology is greater for children of parents with mental health problems (17). Women are the focus of this study for several reasons. They are more likely to develop mental health disorders (18) and more likely to experience sexual abuse (19). Further, the association between experiencing abuse and mental disorders has been shown in one study to be stronger for women than for men (6). This article investigates the association between childhood adversity—childhood physical and sexual abuse, family psychiatric and substance use history, and socioeconomic disadvantage—and disability due to mental health problems. We conducted the analysis on data from girls and women aged 15 to 64 years. To reduce the response burden, not all questions were asked of older respondents. MethodsA comprehensive description of the study design is presented elsewhere (20). Briefly, the OHS was conducted in 1990 with funding provided by the Ontario Ministry of Health. Homeless people, people in institutions, foreign service personnel, First Nations people living on Reserves, and people located in extremely remote areas were excluded from the sample. A supplement to the OHS, the OHSUP was conducted to estimate the prevalence of psychiatric disorder and its correlates in the population. One randomly selected household member from OHS-participating households was included in the OHSUP. In face-to-face interviews, respondents were asked several questions regarding limitations in work or school performance or restriction in work opportunities because of “a problem with your emotions, nerves or mental health,” as well as questions about difficulties or limitations in everyday activities (housework, leisure activities, getting around the neighbourhood, getting out of the home, personal care, and child care). If a respondent endorsed any of these questions, she was deemed disabled. “Parental psychiatric disorder” was recorded if the respondent reported that one or both parents suffered from one or more of major depression, schizophrenia, or mania. The characteristic “parental substance abuse” indicated that the respondent reported one or both parents as having had alcohol and (or) drug abuse problems. The variable “parental education,” a proxy for childhood socioeconomic status, was dichotomized as having completed high school or not. Respondents’ age and current income were included as control variables. Income was treated as dichotomous (low or not); it was an OHUSP-derived variable from questions regarding income level, household size, and urban or rural residence. Unlike the remainder of the OHSUP interview, questions about physical and sexual abuse by an adult while the person was “growing up” were self-completed in private and returned to the interviewer in a sealed envelope. The definition of physical abuse covered exposure to 6 acts, including being pushed, grabbed, shoved, or physically attacked. Sexual abuse was defined as exposure to one or more of 4 acts ranging from repeated indecent exposure to being sexually attacked. The abuse measures are detailed elsewhere (19). The psychometric properties of the Child Maltreatment History Self-Report questions were tested in a clinical sample of 34 adolescents. Test–retest reliability kappas were 0.75 for physical abuse, 0.78 for severe physical abuse, and 1.0 for both sexual abuse and severe physical abuse (HL MacMillan and J Fleming, unpublished data). Analysis Cases were weighted to obtain unbiased point estimates according to the probability of selection (20). Analyses were run with Survey Data Analysis Software (SUDAAN) for Windows (21). The sample was not sufficiently large to investigate abuse types separately, so some women in the physical abuse group would also have experienced sexual abuse, and vice versa. We used logistic regression to test the strength of the associations between the adverse childhood experience variables and disability due to mental health problems. All variables were entered into the equation simultaneously. We tested 3 models (physical abuse, sexual abuse, and any abuse), since the associations of different abuse types with disability may have differed. ResultsThe sample consists of 4239 girls and women between age 15 and 64 years. Approximately 3% of the respondents identified themselves as having a disability due to mental health problems. Their mean age was 36 years (SE 0.31). Most were married (73%), and 42% worked for pay. Table 1 shows the characteristics of the sample by disability status.
Table 2 presents the association (crude OR) of each characteristic with disability due to mental health problems. Taken separately, childhood exposure to physical abuse, sexual abuse, any abuse, parental substance abuse, and parental psychiatric disorder significantly increased the likelihood of disability two-to threefold. Parental education showed no significant association. Sexual abuse showed the strongest association, followed by physical abuse.
The associations (adjusted ORs) of the variables of interest with disability for the physical abuse, sexual abuse, and any abuse models are outlined in Table 3. In all models, after controlling for respondents’ age and current income, we observed parental psychiatric disorder and abuse (physical abuse OR = 2.29, sexual abuse OR = 3.31, and any abuse OR = 2.36) to be significantly related to disability.
DiscussionAs hypothesized, we found that disability due to mental health problems was associated with adverse experiences in childhood (physical, sexual, and any abuse as well as parental psychiatric disorder). Because earlier research focused on sexual abuse or the combined effect of physical and sexual abuse during the course of the lifespan, it is noteworthy that our results showed that physical abuse also had a strong association with disability due to mental health problems. The association remained after we controlled for other childhood adversities. Further, these data were specific to disability caused by mental health problems; earlier studies of the association between childhood abuse and functional limitations did not always specify the cause of the disability. Interestingly, our analysis did not find parental substance abuse problems to be significantly associated with disability due to mental health problems in the adjusted models. Parental substance abuse has been associated with increased risk of developing substance abuse disorder and (or) mental disorder in the child. In addition, the comorbidity of substance abuse disorder and psychiatric disorder is often reported (22). Age was not significant in any of our models. Other research has shown increased age to be associated with improved social functioning (7). Some investigators have hypothesized that this relation with age is due to social role restrictions for younger women (23). Among the strengths of this study are the large sample size, rigorous methodology, and sophisticated sampling and weighting techniques that provide representative estimates of the general population. The disability measures are easy to understand and replicate. They provide a broad conceptualization of disability, including limitations in several life domains. Abuse was assessed by several items, rigorously defined from a questionnaire with acceptable psychometric properties; and the abuse analysis was limited to childhood abuse. The data contained many important control variables that were not included in earlier studies. Because it is cross-sectional, this study cannot address the question of whether there is a causal relation between abuse and disability. It has been suggested, for example, that there may be a biological predisposition both to being abused and to developing health problems (24). This study could not take biological factors into account. The questions about childhood adversities were all retrospective in nature, which raises the potential for recall bias. However, research suggests that significant experiences in childhood can be recalled accurately (25). Our study results have both policy and clinical implications. The lifetime estimate of mental illness for men and women combined is 20% in Canada (18). However, only 3% of the women in this study reported limited functioning due to mental health problems. This finding suggests that not all women with a diagnosed mental illness have activity limitations, which has important service implications. Our findings can assist in increasing the awareness about the relation between exposure to child abuse and disability. The results should offer further evidence for policy-makers of the need to make child abuse a priority area for prevention and intervention. In terms of future research in this area, prospective longitudinal studies are needed to examine the mechanism by which exposure to maltreatment is associated with disability in women. A study that involves a community-based sample and includes both self-report and record data about exposure to abuse would be important. In this study, disability was not attributable to a specific mental health diagnosis. Further study is needed to investigate whether there is a particular diagnosis of psychopathology that leads to disability. In addition, research needs to delineate the specific pathways leading from childhood abuse to mental health problems to disability. However, such studies are difficult to implement on a large scale, and the cost is high. For this reason, Trickett and McBride-Chang suggest that researchers reanalyze existing data, where possible (26). At times, the sample size would be large enough to conduct more detailed analyses that were up to date with the current stage of knowledge. However, some journals would need to change their rules for submissions, since reanalyzed data would often be more than 5 years old. In conclusion, this study provides a better understanding of the relation between childhood exposure to abuse, both physical and sexual, and disability due to mental health problems. Preventing abuse should be a priority area for intervention and policy. Funding and SupportDr MacMillan is supported by the Wyeth Canada-Canadian Institutes of Health Research (CIHR) Clinical Research Chair in Women’s Mental Health. This research was supported by the following CIHR institutes: Gender and Health; Aging; Human Development, Child and Youth Health; Neurosciences, Mental Health and Addiction; and Population and Public Health. References1. Cicchetti D, Toth SL. A developmental psychopathology perspective on child abuse and neglect. J Am Acad Child Adolesc Psychiatry 1995;34:541–65. 2. MacMillan HL. Child maltreatment: what we know in the year 2000. Can J Psychiatry 2000;45:702–9. 3. Jumper SA. A meta-analysis of the relationship of child sexual abuse to adult psychological adjustment. Child Abuse Negl 1995;19:715–28. 4. Neuman DA, Houskamp BM, Pollack VE, Briere J. The long-term sequelae of childhood sexual abuse in women: a meta analytic review. Child Maltreatment 1996;1:6–16. 5. Leserman J, Drossman DA, Li Z, Toomey TC, Nachman G, Glogau L. Sexual and physical abuse history in gastroenterology practice: how types of abuse impact health status. Psychosom Med 1996;58:4–15. 6. MacMillan HL, Fleming JE, Streiner DL, Lin E, Boyle MH, Jamieson E, and others. Childhood abuse and lifetime psychopathology in a community sample. Am J Psychiatry 2001;158:1878–83. 7. Casey PR, Tyrer PJ, Platt S. The relationship between social functioning and psychiatric symptomology in primary care. Soc Psychiatry 1985;20:5–9. 8. Goering P, Lin E, Campbell D, Boyle MH, Offord DR. Psychiatric disability in Ontario. Can J Psychiatry 1996;41:564–71. 9. Wells KB, Stewart A, Hays RD, Burnam MA, Rogers W, Daniels M, and others. The functioning and well-being of depressed patients. Results from the Medical Outcomes Study. JAMA 1989;262:914–9. 10. Briere J. Therapy for adults molested as children: beyond survival. New York: Springer; 1989. 11. Alexander RW, Bradley LA, Alarcon GS, Triana-Alexander M, Aaron LA, Alberts KR, and others. Sexual and physical abuse in women with fibromyalgia: association with outpatient health care utilization and pain medication usage. Arthritis Care Res 1998;11:102–15. 12. Leserman J, Li Z, Drossman DA, Hu YJ. Selected symptoms associated with sexual and physical abuse history among female patients with gastrointestinal disorders: the impact on subsequent health care visits. Psychol Med 1998;28:417–25. 13. Scarinci IC, McDonald-Haile J, Bradley LA, Richter JE. Altered pain perception and psychosocial features among women with gastrointestinal disorders and history of abuse: a preliminary model. Am J Med 1994;97:108–18. 14. Walker EA, Gelfand A, Katon WJ, Koss MP, Von Korff M, Bernstein D, and others. Adult health status of women with histories of childhood abuse and neglect. Am J Med 1999;107:332–9. 15. Domenico D, Windle M. Intrapersonal and interpersonal functioning among middle-aged female adult children of alcoholics. J Consult Clin Psychol 1993;61:659–66. 16. Williams OB, Corrigan PW. The differential effects of parental alcoholism and mental illness on their adult children. J Clin Psychol 1992;48:406–14. 17. Weissman MM, Gammon GD, John K, Merikangas KR, Warner V, Prusoff BA, and others. Children of depressed parents: increased psychopathology and early onset of major depression. Arch Gen Psychiatry 1987;44:847–53. 18. Health Canada. A report on mental illness in Canada 2002. Ottawa (ON): Health Canada; 2002. 19. MacMillan HL, Fleming JE, Trocmé N, Boyle MH, Wong M, Racine YA, and others. Prevalence of child physical and sexual abuse in the community. Results from the Ontario Health Supplement. JAMA 1997;278:131–5. 20. Boyle MH, Offord DR, Campbell D, Catlin G, Goering P, Lin E, and others. Mental health supplement to the Ontario Health Survey: methodology. Can J Psychiatry 1996;41:549–58. 21. Survey Data Analysis Software (SUDAAN) for Windows. Release 7.5.3. Park (NC): Research Triangle Institute; 1999. 22. Zimmermann P, Wittchen HU, Hofler M, Pfister H, Kessler RC, Lieb R. Primary anxiety disorders and the development of subsequent alcohol use disorders: a 4-year community study of adolescents and young adults. Psychol Med 2003;33:1211–22. 23. Hecht H, Wittchen HU. The frequency of social dysfunction in a general population sample and in patients with mental disorders. A comparison using the Social Interview Schedule (SIS). Soc Psychiatry Psychiatr Epidemiol 1988;23:17–29. 24. Palmer RL, Bramble D, Metcalfe M, Oppenheimer R, Smith J. Childhood sexual experiences with adults: adult male psychiatric patients and general practice attenders. Br J Psychiatry 1994;165:675–9. 25. Brewin CR, Andrews B, Gotlib IH. Psychopathology and early experiences: a reappraisal of retrospective reports. Psychol Bull 1993;113:82–98. 26. Trickett PK, McBride-Chang C. The developmental impact of different forms of child abuse and neglect. Dev Rev 1995;15:311–37. Author(s)Manuscript received April 2004, revised, and accepted March 2005. 1. Senior Research Advisor, Health Surveillance Division, Public Health Agency of Canada, Ottawa, Ontario. 2. Research Associate, Department of Psychiatry and Behavioural Neurosciences, Offord Centre for Child Studies, Faculty of Health Sciences, McMaster University, Hamilton, Ontario. 3. Manager, Special Populations, Centre for Chronic Disease Prevention and Control, Health Canada, Ottawa, Ontario. 4. Professor, Departments of Psychiatry and Behavioural Neurosciences and of Pediatrics, Offord Centre for Child Studies, Faculty of Health Sciences, McMaster University, Hamilton, Ontario. Address for correspondence: L Tonmyr, Injury and Child Malreatment Section, Health Surveillance and Epidemioloogy Division, Public Health Agency of Canada, Tunney’s Pasture, AL 1910C, Ottawa, ON K1A 0K9 e-mail: Lil_Tonmyr@phac-aspc.gc.ca
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