Effects of childhood physical abuse on depression, problem drinking and perceived poor health status in adolescents living in rural Taiwan

Authors


Abstract

Aims:  The aim of the present study was to investigate the magnitude and independence of the effects of childhood physical abuse on adolescent depression, problem drinking and perceived poor mental health in Taiwanese indigenous and non-indigenous adolescents living in rural areas controlling for individual and familial characteristics.

Methods:  A sample of adolescents was randomly selected from junior high schools in the rural areas of southern Taiwan. The associations between childhood physical abuse and adolescent depression, problem drinking and perceived poor health status were examined on univariate and multivariate logistic regression.

Results:  Of the 1684 adolescents who completed the questionnaires, 374 (22.2%) reported that they had experienced physical abuse in childhood. Controlling for individual and familial factors, childhood physical abuse significantly increased the risk of depression, problem drinking and perceived poor health status in the present sample of adolescents on multivariate logistic regression.

Conclusion:  History of childhood physical abuse should be elicited from adolescents in treatment for depression, alcohol abuse or physical discomfort of unknown etiology. This finding may be of clinical benefit in terms of the design and implementation of intervention.

CHILDHOOD PHYSICAL ABUSE is an important issue for clinical professionals and researchers. Abundant research has shown that childhood physical abuse increases the risk of adolescent and adult depression,1–3 alcohol and illicit drug abuse,1,4–6 and poor physical health status.7,8 A number of individual and familial characteristics, however, may also influence the association between childhood physical abuse and adverse health status. For example, gender difference has been demonstrated in the association between history of physical abuse and major depression and illicit drug abuse/dependence.9 Adverse family factors, including familial dysfunction, poverty, and the quality and quantity of family support also influence the association between childhood physical abuse and health condition.3 The association between physical abuse and psychological problems, however, has seldom been examined in Asia.4,10 Further research is needed to examine the relationship between childhood physical abuse and adolescent health status in Asia by considering the effects of individual and familial factors.

Childhood maltreatment is an important health issue in indigenous adolescents.11 Further, it has been found that childhood physical abuse increases the risk of poor mental health in Native American and Alaskan tribes.12 The indigenous minority in Taiwan has suffered from inferior socioeconomic status as well as the destruction of individual traditional tribal social organization during the industrialization of, and economic development in, Taiwan. The health status of Taiwanese indigenous people is inferior to that of the rest of the national population.13 High prevalence of alcohol use disorders and areca quid chewing has also been demonstrated in Taiwanese indigenous adolescents.14 Further research into the effect of ethnicity in terms of the association between childhood physical abuse and adolescent health status will provide greater understanding of adolescent subjects outside North America.

The aim of the present study, therefore, was to investigate the magnitude and independence of the effects of childhood physical abuse on adolescent depression, problem drinking and perceived poor mental health in Taiwanese indigenous and non-indigenous adolescents living in rural areas by controlling for individual and familial characteristics.

METHODS

Participants

The current investigation was based on data from the Project for Health of Adolescents in Rural Taiwan, a research program studying the mental and physical health status of adolescents living in the rural areas of southern Taiwan. Adolescents from nine junior high schools in the rural areas of southern Taiwan were invited into the study. Of the nine randomly selected schools, six and three were junior high schools from the mountain region (n = 11) and plains area (n = 32), where the majority of students are indigenous and non-indigenous, respectively. Indigenous adolescents from the Paiwan, Bunun and Rukai tribes predominated. There were a total of 2079 adolescents in the nine junior high schools in 2003.

Of the enlisted students, 15 (0.7%) refused to participate in the study and 380 (18.3%) had incomplete items in the returned questionnaires. Thus, the results of questionnaires from 1684 adolescent students (827 boys and 857 girls, response rate 81.0%) were further analyzed. Their mean age was 14.4 ± 1.0 years (range: 13–18 years). A total of 756 participants (44.9%) were indigenous, 827 were male (49.1%), and 374 (22.2%) reported experiencing physical abuse during childhood. Regarding their family characteristics, 971 (57.7%) reported a paternal education level of ≤9 years of compulsory fundamental education, 1128 (67%) reported poor family function, 245 (14.5%) reported parents' habitual alcohol consumption (drinking alcohol twice a week or more), and 1090 (64.7%) reported that their father had no fixed employment. No statistically significant difference in the prevalence of childhood physical abuse was found between the indigenous (23.8%) and non-indigenous (20.9%) adolescents (χ2 = 2.034, P > 0.05).

Assessment

Abuse Assessment Screen Questionnaire

The Abuse Assessment Screen Questionnaire (AAS) was a self-administered questionnaire on experience of being abused. The validity and reliability of the AAS were tested in a previous indigenous study in Taiwan.15 The AAS items with a yes/no answer were used in the present study to examine adolescents' experiences of childhood physical abuse. If a participant reported ever being struck, slapped, kicked or otherwise physically injured by family members during childhood, and, if the abrasions, bruises or pain lasted into the second day, the subject was classified as physically abused.

Zung Depression Scale

The Zung Depression Scale (ZDS) is a 4-point, 20-item, self-rated instrument assessing depression in the preceding month.16 The ZDS explores a variety of depressive symptoms such as depressed mood, sleep disturbance, weight loss, constipation, tachycardia, fatigue and decreased appetite. Subjects whose total ZDS score was (50 were considered depressed. The validity and reliability of the ZDS is well established for Taiwanese youth.17

Problem Drinking Experience Questionnaire

We developed the self-administered, three-item Problem Drinking Experience Questionnaire (PDEQ) to distinguish problem and experimental drinking. Initially the participant was asked, ‘Have you ever drunk alcohol in the preceding month?’ If the response was in the affirmative, responses were sought to two more questions, ‘Have you ever been drunk in the preceding month?’ and ‘Have you ever experienced conflict with others after drinking or ever been blamed for drinking by your families?’ Adolescents whose answered yes to any of the latter two questions were considered problem drinkers during the preceding month.

General Health Perception Scale

The self-administered General Health Perception Scale (GHPS), which was modified from the general health perception subscale of the Short Form 36 Health Survey,18 consisted of three 3-point items exploring participant perception of current general health status.19 The total score range was 3–9, with higher scores indicating better general health status. Where the total GHPS score was <6, the subjects' perceived health status was considered poor.

Family APGAR index

The self-administered Chinese-version family APGAR index,20 which measures satisfaction with aspects of family life, is based on the original version developed by Smilkstein.21 The 5-point response scales reflected frequency ranging from never to always. High scores indicate good family support. Where the APGAR score was ≤6, the family was considered to be low functioning.22

Adolescents' sociodemographic factors, including sex, age and ethnicity, were also ascertained. Parental drinking habits and paternal education level and occupation were also determined by participant self-report.

Procedure and statistical analysis

The protocol was approved by the Institutional Review Board of Kaohsiung Medical University. The purpose and procedure of the study were explained to the students in class, and they were encouraged to participate. Informed consent was obtained from the participants. The adolescents were asked to anonymously complete all self-administered questionnaires based on the explanations of the research assistants. Students who refused to participate could leave the blank questionnaires on their desk. All participants received a gift at the end of the assessment.

Data analysis was performed using SPSS version 12.0 (SPSS, Chicago, IL, USA). The rate of childhood physical abuse and the prevalence of the three adverse health indicators, depression, problem drinking and perceived poor health status, were calculated. Models estimating the relationships between childhood physical abuse and depression, problem drinking and perceived poor health status were derived using univariate and multivariate logistic regression. Full models were obtained by adding variables in a forward selection process, keeping variables that significantly improved the model fit based on χ2 test of differences between log-likelihoods (–2LL) of nested models. In order to examine the differences in the associations between physical abuse and the three health outcomes between the indigenous and non-indigenous adolescents, we also selected the interaction terms between physical abuse and indigenous ethnicity as an independent variable in multiple logistic regression. If the interaction terms between physical abuse and indigenous ethnicity were significantly associated with health outcome, this indicated that the associations between physical abuse and health outcomes were different between the indigenous and non-indigenous adolescents.

RESULTS

Indicators of poor health status

According to the afore-described definitions, 214 adolescents (12.7%) reported being depressed and 154 (9.1%) reported problem drinking in the preceding month, with 466 (27.7%) perceiving current poor health status.

Associations between physical abuse and adverse health indicators

The correlates of depression from univariate logistic regression analysis are presented in Table 1. The results indicate that adolescents who had the experience of childhood physical abuse, who were female, who perceived poor family function, and whose parents drank habitually were more likely to be depressed. Age, race, paternal educational level or paternal employment was not significantly associated with depression.

Table 1. Correlates of depression on univariate logistic regression
 Depressed n (%)Not depressed n (%)OR95%CI
  1. CI, confidence interval; OR, odds ratio.

Physical abuse    
 Yes72 (33.6)302 (20.5)1.9611.438–2.275
 No142 (66.4)1168 (79.5)1.0 
Age (years), mean ± SD14.4 ± 1.014.4 ± 1.01.0220.880–1.188
Race    
 Indigenous99 (46.3)657 (44.7)1.0650.799–1.420
 Non-indigenous115 (53.7)813 (55.3)1.0 
Gender    
 Male87 (40.7)740 (50.3)0.6760.505–0.904
 Female127 (59.3)730 (49.7)1.0 
Family function on APGAR    
 Poor185 (86.4)943 (64.1)3.5612.374–5.341
 Good29 (13.6)527 (35.9)1.0 
Habitual parental alcohol consumption    
 Yes43 (20.1)202 (13.7)1.5781.095–2.276
 No171 (80.0)1268 (86.3)1.0 
Paternal education level (years)    
 >987 (40.7)626 (42.6)0.9240.690–1.236
 ≤9127 (59.3)844 (57.4)1.0 
Paternal employment    
 Not fixed87 (40.7)507 (34.5)1.3010.971–1.744
 Fixed127 (59.3)963 (65.5)1.0 

The correlates of problem drinking from univariate logistic regression analysis are presented in Table 2. The results indicate that adolescents who had the experience of childhood physical abuse, who were older, indigenous and male, whose parents drank habitually, and whose father's education level and employment were ≤9 years and not fixed, respectively, were more likely to be problem drinkers. Family function was not significantly associated with problematic drinking.

Table 2. Correlates of problem drinking on univariate logistic regression
 Problem drinkingOR95%CI
YesNo
n (%) n (%)
  1. CI, confidence interval; OR, odds ratio.

Physical abuse    
 Yes70 (45.5)304 (19.9)3.3602.389–4.725
 No84 (54.5)1226 (80.1)1.0 
Age (years), mean ± SD14.7 ± 0.914.4 ± 1.01.4651.230–1.746
Race    
 Indigenous106 (68.8)650 (42.5)2.9902.095–4.267
 Non-indigenous48 (31.2)880 (57.5)1.0 
Gender    
 Male89 (57.8)738 (48.2)1.4691.051–2.054
 Female65 (42.2)792 (51.8)1.0 
Family function on APGAR    
 Poor112 (72.7)1016 (66.4)1.3490.932–1.953
 Good42 (27.3)514 (33.6)1.0 
Habitual parental alcohol consumption    
 Yes42 (27.3)203 (13.3)2.4511.669–3.599
 No112 (72.7)1327 (86.7)1.0 
Paternal education level (years)    
 >947 (30.5)666 (43.5)0.5700.399–0.815
 ≤9107 (69.5)864 (56.5)1.0 
Paternal employment    
 Not fixed70 (45.5)524 (34.2)1.6001.145–2.235
 Fixed84 (54.5)1006 (65.8)1.0 

The correlates of perceived poor health status on univariate logistic regression analysis are presented in Table 3. The results indicate that adolescents who had the experience of childhood physical abuse, who were female, who perceived poor family function, whose parents drank habitually, and whose father had no fixed job were more likely to perceive their health status to be poor. Age, race, or paternal educational level was not significantly associated with perceived poor health status.

Table 3. Correlates of perceived poor health status on univariate logistic regression
 Perceived health statusOR95%CI
PoorGood
n (%) n (%)
  1. CI, confidence interval; OR, odds ratio.

Physical abuse    
 Yes144 (30.9)230 (18.9)1.9211.506–2.450
 No322 (69.1)988 (81.1)1.0 
Age (years), mean ± SD14.5 ± 1.014.4 ± 1.01.1130.995–1.244
Race    
 Indigenous209 (44.8)547 (44.9)0.9980.805–1.236
 Non-indigenous257 (55.2)671 (55.1)1.0 
Gender    
 Male176 (37.8)651 (53.4)0.5290.425–0.658
 Female290 (62.2)567 (46.6)1.0 
Family function on APGAR    
 Poor359 (77.0)769 (63.1)1.9591.533–2.503
 Good107 (23.0)449 (36.9)1.0 
Habitual parental alcohol consumption    
 Yes93 (20.0)152 (12.5)1.7491.317–2.322
 No373 (80.0)1066 (87.5)1.0 
Paternal education level (years)    
 >9192 (41.2)521 (42.8)0.9370.755–1.164
 ≤9274 (58.8)697 (57.2)1.0 
Paternal employment    
 Not fixed182 (39.1)412 (33.8)1.2541.005–1.563
 Fixed284 (60.9)806 (66.2)1.0 

The significant factors were further examined using forward multivariate logistic regression (Table 4). Model 1 indicate that childhood physical abuse still increased risk of depression, problem drinking, and perceived poor health status. Adolescents who were female and who perceived family function as poor were more likely to be depressed. Adolescents who were older, indigenous and male, and whose parents drank habitually were more likely to be problem drinkers. Adolescents who were female, perceived family function as poor, and whose parents drank habitually were more likely to perceive their own health status as poor. In model 2 we further selected the interaction term between physical abuse and indigenous ethnicity in multivariate logistic regression. The interaction term was not significantly associated with any health indicators, which indicated that no difference in the association of physical abuse with depression, alcohol drinking or perceived poor health status existed between indigenous and non-indigenous adolescents.

Table 4. Significant factors in childhood abuse on multivariate logistic regression
 DepressionProblem drinkingPerceived poor health status
Model 1Model 2Model 1Model 2Model IModel I
AOR95%CIAOR95%CIAOR95%CIAOR95%CIAOR95%CIAOR95%CI
  1. AOR, adjusted odds ratio; CI, confidence interval.

Physical abuse1.7311.261–2.3741.4600.960–2.2213.3512.346–4.7872.9181.600–5.3221.7471.360–2.2451.9191.391–2.647
Age1.5141.261–1.8171.5231.267–1.830
Indigenous ethnicity3.0172.088–4.3612.7611.714–4.448
Male0.6790.505–0.9120.6810.507–0.9161.5941.123–2.2631.5951.123–2.2660.5220.417–0.6520.5200.415–0.650
Poor family function3.3402.220–5.0243.3612.234–5.0561.7751.380–2.2831.7691.375–2.276
Habitual parental alcohol consumption1.8241.261–1.8171.8211.210–2.7411.5381.146–2.0641.5531.157–2.086
Physical abuse × Indigenous ethnicity  1.4040.831–2.370  1.2390.587–2.616  0.8210.535–1.261

DISCUSSION

The present results indicate that childhood physical abuse increases the risk of depression, problem drinking, and perception of poor health status in adolescents living in rural Taiwan after controlling for individual and familial characteristics. From a traditional Chinese perspective, corporal punishment is commonly seen by parents as a legitimate and effective form of discipline, and it is not generally perceived as abusive.23 To differentiate normative corporal punishment for the purpose of discipline from physical abuse, this study used a strict definition of physical abuse, where the abrasions, bruises or pain caused by the physical impact must have lasted into the second day.

Given that parental alcohol abuse increased the risk of child abuse and neglect,24 and that alcohol abuse was very prevalent among Taiwanese indigenous people,25,26 one might have predicted that childhood physical abuse might be more prevalent among Taiwanese indigenous adolescents than among non-indigenous ones. The present study, however, did not find a difference in the prevalence of childhood physical abuse between Taiwanese indigenous and non-indigenous adolescents. Meanwhile, although the present study found that more indigenous adolescents had problem drinking than non-indigenous ones, no difference in the association of physical abuse with depression, alcohol drinking or perceived poor health status was found between indigenous and non-indigenous adolescents. The results indicate that childhood physical abuse is a common experience that needs monitoring and intervention among adolescents living in rural Taiwan, regardless of ethnicity. Due to the geographic isolation and a shortage of trained personnel in the community, however, indigenous adolescents have poorer access to health-care service and fewer sources of education than non-indigenous ones,27,28 and thus physical abuse and its adverse effects on health might be more difficult to detect and treat in indigenous adolescents than non-indigenous ones. Thus, we suggest that sufficient resources and funds should be invested in the prevention of and intervention for childhood physical abuse and its adverse effects on health. In contrast, another study found that indigenous adolescents were more likely to experience childhood sexual abuse than non-indigenous ones,29 which indicated that indigenous children might have a higher risk of encountering specific types of abuse than non-indigenous ones.

The present study found that childhood physical abuse, female gender and poor family function had independent effects on adolescent depression. A transactional model of abuse, familial and personal characteristics, and development of adolescent vulnerability leading to depression, explains these results. McCann et al. have suggested that five content areas are affected by victimization: self-esteem, sense of power, trust, intimacy, and safety.30 Traumatic experiences increase adolescent vulnerability to depression by reducing social support and negatively affecting adolescent social, emotional and cognitive development.2 Further, cognitive style characterized by learned helplessness may also contribute to the presence of depression in adolescents who suffer chronic maltreatment in their childhood.31 Thus, detecting history of childhood physical abuse is essential for the design and implementation of intervention for adolescents who have experienced traumatic events of this type.

Libby et al. addressed the issue of parental substance use and individual factors that could mediate or moderate the relationship between childhood physical abuse and alcohol and drug use disorders into adulthood.12 In the present study, childhood physical maltreatment significantly increased the risk of adolescent problem drinking after controlling for ethnicity, age, gender and habitual parental alcohol abuse, a finding that is in line with the results of other research.32 Two hypotheses account for the association between childhood physical abuse and problem drinking. First, according to the self-medication hypothesis for psychological disturbance, alcohol and drugs offer a readily available method for achieving avoidance of distressing emotions and physical arousal related to the memory of childhood physical abuse.33 Second, according to the theoretical model based on developmental psychopathology, inappropriate development at one stage has a ripple effect on subsequent development.5 Deficits in cognitive, social, emotional and behavioral functioning associated with maltreatment can lead to adverse outcomes such as poor adaptation to school and negative peer relationships.34 Drugs may then be used to cope with a wide range of problems such as poor school performance or negative peer relationships.35 Considering these two points of view, ascertaining history of childhood physical abuse is vital to the effective implementation of treatment strategies for adolescent problem drinkers. In the present study indigenous adolescents were more likely to be problem drinkers than their non-indigenous counterparts, a finding that is congruent with available results from the relevant literature.14 Childhood physical abuse, however, still had an independent effect on adolescent problem drinking in the present study.

In the present study adolescents who had experienced childhood physical abuse were more likely to perceive their own health status as poor. In the review by Thompson et al., relationships were demonstrated between physical abuse in childhood and several potential mediators of the association between child abuse and adult health problems.36 These mediators included insecure attachment patterns and greater aggression, deficits in receptive/expressive language and poor academic achievement, and increased likelihood of risky sexual behavior, physical inactivity and smoking, each with potential and actual negative medical, psychosocial and general health consequences.37 In turn, an association has been demonstrated between these potential mediators and health problems. Childhood abuse is also considered to be linked to somatic discomforts, such as irritable bowel syndrome, because it causes a tendency to dissociate, which results in a general increase in physical symptoms.8 Intervening at an early stage may reduce a child's likelihood of developing long-term health sequelae, and also decrease the public health burden of child abuse by ameliorating future health problems.36

Some potential limitations of this study should be considered. First, the cross-sectional nature of the investigation limited our ability to draw conclusions about the causal relationship between physical abuse and adverse health status. Second, collection of information concerning physical abuse presents significant challenges to researchers because it is typically a covert and affectively charged activity. One way of overcoming this problem is to provide a non-clinical community sample with the opportunity to anonymously disclose their experiences of physical abuse.5 This method also has limitations, however, because there is no way to validate the information given in the survey. Third, we did not examine the severity of the stress experienced by physically abused children, which may vary (i.e. chronicity, severity, and presence of threat) and, therefore, have a differential impact in terms of a child's psychological functioning. Fourth, emotional impairment may influence memory of events, but there is little scientific evidence to support the claim that recall of childhood experiences is altered by psychiatric symptoms or disorder.38

CONCLUSION

The present observations may be helpful in the design and implementation of strategies. The present results support the notion that experience of physical abuse elevates the risk for adolescent adverse health status, and highlight the importance of monitoring this risk burden into adolescence. History of childhood physical abuse should be elicited from adolescents who are in treatment for depression, alcohol abuse or physical discomfort with etiology unknown. It appears reasonable to suggest that interventions that address cognitive distortions with respect to perceived responsibility for childhood physical abuse, and which increase tolerance of reminders for that maltreatment and the related negative affective states, improve active coping strategies, enhance problem-solving, safety and social skills, and optimize parental and other social support, will improve both mental and physical symptoms in youths who have suffered this childhood physical abuse.

Ancillary