This article was downloaded by: [University of Bristol] On: 22 February 2015, At: 04:07 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Child Sexual Abuse Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wcsa20
Correlates of Sexual Abuse in a Sample of Adolescent Girls Admitted to Psychiatric Inpatient Care a
b
c
a
Juha Kanamüller , Kaisa Riala , Maija Nivala , Helinä Hakko & c
Pirkko Räsänen a
Oulu University Hospital, Oulu, Finland
b
Helsinki University Central Hospital, Helsinki, Finland
c
University of Oulu, Oulu, Finland Accepted author version posted online: 07 Aug 2014.Published online: 28 Oct 2014.
Click for updates To cite this article: Juha Kanamüller, Kaisa Riala, Maija Nivala, Helinä Hakko & Pirkko Räsänen (2014) Correlates of Sexual Abuse in a Sample of Adolescent Girls Admitted to Psychiatric Inpatient Care, Journal of Child Sexual Abuse, 23:7, 804-823, DOI: 10.1080/10538712.2014.950401 To link to this article: http://dx.doi.org/10.1080/10538712.2014.950401
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [University of Bristol] at 04:07 22 February 2015
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Journal of Child Sexual Abuse, 23:804–823, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1053-8712 print/1547-0679 online DOI: 10.1080/10538712.2014.950401
RESEARCH ON OUTCOMES AND CHARACTERISTICS OF VICTIMS OF ABUSE
Downloaded by [University of Bristol] at 04:07 22 February 2015
Correlates of Sexual Abuse in a Sample of Adolescent Girls Admitted to Psychiatric Inpatient Care JUHA KANAMÜLLER Oulu University Hospital, Oulu, Finland
KAISA RIALA Helsinki University Central Hospital, Helsinki, Finland
MAIJA NIVALA University of Oulu, Oulu, Finland
HELINÄ HAKKO Oulu University Hospital, Oulu, Finland
PIRKKO RÄSÄNEN University of Oulu, Oulu, Finland
We examined correlations of child sexual abuse among 300 adolescent girls in psychiatric inpatient treatment. Diagnostic and Statistical Manual of Mental Disorders (4th ed.)-based psychiatric diagnoses were obtained from the Schedule for Affective Disorder and Schizophrenia for School-Age Children—Present and Lifetime and from data on family and behavioral characteristics from the European Addiction Severity Index (EuropASI). A total of 79 girls (26.3%) had experienced child sexual abuse during their lifetime. Child sexual abuse was associated with an adolescent’s home environment, sibling status, smoking, posttraumatic stress disorder diagnosis, self-mutilating behavior, and suicidal behavior. Received 6 January 2014; revised 19 January 2014; accepted 10 April 2014. Address correspondence to Kaisa Riala, Department of Adolescent Psychiatry, Helsinki University Central Hospital, 00029, Helsinki, Finland. E-mail: [email protected] Color versions of one or more of the figures in the article can be found online at www. tandfonline.com/wcsa. 804
CSA in Girls in Psychiatric Inpatient Care
805
At least 62% of the perpetrators were acquaintances of the victims. Correlates of child sexual abuse can be used to identify child sexual abuse victims and persons at heightened risk for child sexual abuse.
Downloaded by [University of Bristol] at 04:07 22 February 2015
KEYWORDS sexual abuse, risk factor, mental health, clinical sample, adolescent, female, suicidal behavior, anxiety disorders
Child sexual abuse (CSA) is a global problem with an overall estimated prevalence of 127 in 1,000 in self-report studies and 4 in 1,000 in informant studies (Stoltenborgh, van Ijzendoorn, Euser, & Bakermans-Kranenburg, 2011). In Finland the prevalence of CSA experiences varies between 0.7%– 4.6% for men and 1.8%–7.5% for women, and there would appear to be a decline in the prevalence of CSA (Laaksonen et al., 2011). Known risk factors for CSA are physical or emotional neglect/abuse and not growing up with both biological parents (Laaksonen et al., 2011). Low parental education and low family income have also been associated with sexual abuse (Hussey, Chang & Kotch, 2006). A longitudinal study based on both officially recorded and self-reported child abuse and neglect showed that maternal youth, parental death, and unwanted pregnancy increase the risk for child sexual abuse (Brown, Cohen, Johnson & Salzinger, 1998). Based on a large community sample, Walsh, MacMillan, and Jamieson (2002) reported an elevated risk for extra- and intrafamilial sexual abuse if either one or both parents had a history of psychiatric disorders. Problematic alcohol use by family members increased the risk for extrafamilial sexual abuse in a study with a large community sample (Hanson et al, 2006). Manion and colleagues (1996) found significant differences regarding parents’ occupational status between a case group of sexually abused children and a control group of nonabused children, with mean occupational status being lower in the case group. A study by Boney-McCoy and Finkelhor (1995) identified poor child– parent relationship as a significant risk factor for sexual abuse among 10- to 16-year-old children (OR 2.44), and also Svedin, Back, and Söderback (2002) identified a link between family dysfunction and CSA.
OUTCOMES ASSOCIATED WITH CHILD SEXUAL ABUSE The impact of traumatic experiences in general, and CSA in particular, on mental health, substance-related, and behavioral outcomes has been widely researched. Several large-scale general population studies have noted a relationship between childhood trauma and psychotic disorders (Read, van Os, Morrison & Ross, 2005). Bebbington and colleagues (2004) used data from the second British National Survey of Psychiatric Morbidity to examine associations between psychotic disorders and a number of early victimization
Downloaded by [University of Bristol] at 04:07 22 February 2015
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J. Kanamüller et al.
experiences. In people with psychosis (age 16–74 years), there was a marked excess of victimizing experiences, and the largest odds ratio (adj. for current level of depression OR 7.4) was for sexual abuse (Bebbington et al., 2004). In addition to psychotic disorders, CSA has been found to be related to other psychopathologies. In a large sample based on the U.S. National Comorbidity Survey, Molnar, Buka, and Kessler (2001) found a significantly elevated risk for mood disorders, anxiety disorders, and substance disorders in females who had reported CSA compared to females who had not reported CSA. They identified outstanding odds ratios for posttraumatic stress disorder (PTSD; OR 10.2) and mania (OR 9.1). There is also evidence that CSA is associated with self-mutilating and suicidal behavior. In their longitudinal study, Noll, Horowitz, Bonanno, Trickett, and Putnam (2003) reported a fourfold risk for self-harming behavior, including suicidal behavior, in a group of young abused females compared to a group of young nonabused females. In their study both groups were recruited separately, the abused group was referred to by local protective services, and the control group was recruited by community advertising. Both groups were similar to each other in terms of ethnic group, age, predisclosed socioeconomic status (SES), family constellation (one- or two-parent families), zip codes, and other nonsexual traumas (Noll et al., 2003). An Australian longitudinal study using a school sample reported that CSA before the age of 16 increased the risk for bulimic disorders in young females by up to fivefold (Sanci et al., 2008).
SCOPE OF STUDY Previous research shows that CSA often occurs together with other problems in a child’s family environment, such as physical or emotional abuse, parental psychiatric disorders, or parental alcohol abuse (Brown et al., 1998; Hanson et. al., 2006; Laaksonen et al., 2011; Walsh et al., 2001). Furthermore, demographic and socioeconomic variables are associated with an increased risk for CSA (Hussey et al., 2006; Manion et al., 1996). In many cases, CSA has severe consequences for the victims, and it is correlated to psychiatric and behavioral problems (Bebbington et al., 2004; Molnar et al., 2001; Noll et al., 2003; Read et al., 2005; Sanci et al., 2008). An improved understanding of CSA risk factors as well as outcomes associated with CSA is important for the identification and targeting of individuals in programs designed to prevent further abuse. CSA victims might also benefit from interventions in alcohol abuse, substance abuse, or suicide prevention. Understanding psychiatric or behavioral correlates of CSA can raise awareness of the possibility of a history of abuse. The aim of our study is to examine family characteristics as well as psychiatric and behavioral characteristics with regard to possible associations to CSA. The study utilizes a large representative sample of adolescent female psychiatric inpatients admitted to Oulu University Hospital between
807
CSA in Girls in Psychiatric Inpatient Care
2001 and 2006. The catchment area of Oulu University Hospital covers the two northernmost provinces of Finland, Northern Ostrobothnia and Lapland, and all patients requiring acute-psychiatric inpatient care in this area were admitted to Oulu University Hospital.
METHOD
Downloaded by [University of Bristol] at 04:07 22 February 2015
Participants This study is part of the STUDY-70 project (Ilomäki, Södervall, Ilomäki, Hakko, & Räsänen, 2008). The original study sample consisted of 508 participants, 208 (40.9%) male and 300 (59.1%) female adolescent inpatients aged 13–17 years, consecutively admitted to the Department of Psychiatry of Oulu University Hospital, Finland, between April 2001 and May 2006. The adolescents were natives of Lapland and Northern Ostrobothnia. The majority of adolescents (98.2%) were Caucasians. Participants who were over 18 years old, mentally retarded, or had organic brain disorders were excluded from the study population. The study protocol was approved by the Ethics Committee of Oulu University Hospital, Finland.
Instruments SCHEDULE FOR AFFECTIVE DISORDER LIFETIME (K-SADS-PL)
AND
SCHIZOPHRENIA PRESENT
AND
The K-SADS-PL is a semistructured interview for the assessment of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994) psychiatric diagnoses in children and adolescents. It assesses past and present episodes of psychiatric disorders. Its retest-reliability is rated good to excellent (.77 to 1.00), and its concurrent validity and interrater agreement have been proven to be high (93% to 100%; Ambrosini, 2000; Kaufman et al., 1997). The instrument was applied by either the treating physician or by a trained medical student under the supervision of the treating physician. The data obtained with the K-SADS-PL integrates information given by the patient, the evaluation by the physician, and in some cases, information obtained from interviews with the parents. Parents were only interviewed if data from the patient interview was missing or was rated as unreliable. A full description of the instrument is available online (Kaufman, Birmaher, Brent, Rao, & Ryan, 1996). EUROPEAN ADDICTION SEVERITY INDEX (EUROPASI) The EuropASI is a structured face-to-face interview containing questions on multiple life domains and related problems: physical health, employment,
808
J. Kanamüller et al.
financial support, criminal behavior, family and social relations, psychiatric symptoms, and alcohol and substance use (Kokkevi & Hartgers, 1995). Scheurich and colleagues (2000) report moderate to good internal consistency (.69 to .92) for composite scores and moderate to excellent interrater reliability (intraclass correlation: .62 to .99). Mäkelä (2003) also approves individual items for use in describing clinical populations. Single items were used from the EuropASI to gather qualitative information about the participants and their sociodemographic background.
Downloaded by [University of Bristol] at 04:07 22 February 2015
MODIFIED FAGERSTRÖM TOLERANCE QUESTIONNAIRE (MFTQ) The mFTQ is a 7-item structured interview for the assessment of nicotine dependence and smoking habits among adolescents (Fagerström & Schneider, 1989). Its reliability ranges from .67 to .79 (Cronbach’s alpha; Chen et al., 2002), it showed reasonable criterion validity, and its test scores correlate with a nicotine metabolite in participants’ saliva (r = .40, p < .01; Prokhorov et al., 2000). The mFTQ measures smoking rate, frequency of inhalation, time between waking up and the first cigarette, the level of unwillingness to give up the first cigarette in the morning, difficulty of not smoking in places where smoking is not permitted, smoking despite health issues, and smoking frequency during the first two hours of the day compared to the rest of the day.
Measures SEXUAL
ABUSE ( YES / NO )
Information concerning CSA was based on three items. First, questions concerning an adolescent’s background were directed to parents/other adults during the adolescents’ hospitalization and were based on the background information aspect of the K-SADS-PL-interview. This item asked whether a child has faced any abuse in the earlier stages of his or her life. If the answer was positive, they were asked to specify further the type of abuse suffered (including sexual abuse). Participants were also asked about their relationship with the perpetrator and the consequences of the abuse. Second, the screening part for PTSD of the K-SADS-PL was used to ask the adolescent about various traumatic lifetime events. CSA was defined as isolated or repeated incidents of genital fondling, oral sex, or vaginal or anal intercourse. Third, in the EuropASI questionnaire, the issue of sexual abuse was included in questions concerning the adolescent’s relationship with his or her family members, sexual partner, or other close associates. The adolescent was also asked whether one or more of these associates had ever submitted them to mental, physical, or sexual abuse. CSA was defined here as any kind of sexual harassment or involuntary sex. In the present study, CSA was defined as being present if there was a positive answer to any of these questions.
CSA in Girls in Psychiatric Inpatient Care
809
Seventy-nine (26.3%) of all females (n = 300) reported CSA. Male patients were excluded from this study due to the small number of sexually abused cases (total N = 208, sexually abused cases n = 8).
Downloaded by [University of Bristol] at 04:07 22 February 2015
PERPETRATORS
OF SEXUAL ABUSE
Information on perpetrators was obtained from two sources: Background information section of the K-SADS-PL and the EuropASI. If information based on the K-SADS-PL or the EuropASI was unclear, the relationship between the adolescent and the perpetrator was defined from the adolescent’s hospital records. For the purpose of the present study, the information on perpetrators was then categorized into the categories “no information,” “stranger,” “acquaintance,” “relative,” “mother’s partner,” and “biological father.” Perpetrator categories were empirically derived from the sample. The information on perpetrators in our data is limited since the instruments used are not designed to gather this specific information. Due to the question format in the EuropASI, information on perpetrators was ambiguous in some cases. Namely, in the EuropASI, the participants are first asked whether they had ever or in the last 30 days had a troubled relationship with their mother, father, siblings, sexual partner, children, another important family, neighbors, or colleagues. In the next question, participants are asked whether “any of these persons mentioned before” had ever or in the past 30 days abused them psychologically, physically, or sexually. Given that there were multiple positive answers or no positive answer at all in the first question and the participant reported sexual abuse in the second question, it was impossible to determine exactly who the perpetrator was. However, since none of the potential perpetrators were strangers, in such cases the perpetrator was categorized as an “acquaintance.” FAMILY
CHARACTERISTICS AND DEMOGRAPHICS
Information on the home environment, family size, age status relative to siblings, domestic violence, and physical abuse was retrieved using the K-SADS-PL questionnaire. Place of residence, information on parents’ employment, and perceived psychological status of close relatives of the adolescent were gathered using the EuropASI questionnaire. ●
●
Place of residence describes the size of the patient’s residential area. Categories from EuropASI are: Large city (>100,000 inhabitants), Medium (10,000–100,000 inhabitants), and Small (rural; 100,000 City 10,000 – 100,000 Small town < 10,000 Home environment Both biological parents Single biological parent or blended family Foster home Child welfare placement Living alone/other Family size No siblings 1–2 siblings 3 or more siblings Age status relative to siblings Only child Oldest child Youngest child Not youngest, not oldest Employment of parents Perceived psychological status of close relatives Mother clinical condition substance abuse Father clinical condition substance abuse Siblings clinical condition substance abuse Witness to domestic violence Experienced physical abuse School related Failed class Teacher complained about behavior Expelled from school Kept in after school Mean grades 4–6 7–8 9–10
No (n = 221)
Group difference, p value
16 (20%) 16 (20%) 47 (59%)
47 (21%) 55 (24%) 119 (53%)
.640
24 25 4 16 10
108 59 15 21 18
(48%) (26%) (6%) (9%) (8%)
.017
3 (3%) 38 (48%) 38 (48%)
15 (6%) 122 (55%) 83 (37%)
.221
3 20 19 37 58
15 55 83 66 186
(6%) (25%) (37%) (30%) (84%)
.031
11 (13%) 17 (21%)
33 (14%) 34 (15%)
.827 .212
10 (12%) 24 (30%)
31 (14%) 55 (24%)
.761 .341
9 9 31 27
(11%) (11%) (39%) (34%)
26 18 61 52
(11%) (8%) (27%) (23%)
.929 .386 .054 .065
10 36 3 43
(12%) (45%) (3%) (54%)
16 (7%) 91 (41%) 2 (1%) 90 (40%)
.141 .497 .084 .035
25 (31%) 47 (59%) 2 (2%)
54 (24%) 131 (59%) 18 (8%)
.245
(30%) (31%) (5%) (20%) (12%)
(3%) (25%) (24%) (46%) (73%)
.035
with self-mutilative behavior (SMB). Suicidal behavior (including ideation and/or attempts) were also related to CSA (OR 2.0, 95% CI [1.1, 3.7]) and with the covariates with affective (OR 5.9, 95% CI [3.4, 10.3]) and psychotic (OR 4.4, 95% CI [1.9, 9.5]) disorders of adolescents.
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J. Kanamüller et al.
TABLE 2 Logistic Regression Model for Sexual Abuse as Criterion Criterion variable Sexual abuse
Predictor variables
OR
95% CI
Age when hospitalized 1.53 [1.19, 1.95] Age status relative to siblings Other 1.00 Middle child 2.47 [1.40, 4.34] Home environment Both biological parents 1.00 One biological parent or blended family 2.08 [1.06, 4.08] Foster home 1.70 [0.48, 5.96] Child welfare placement 3.70 [1.62, 8.42] Living alone/other 1.73 [0.68, 4.40]
p value
R2
Journal of Child Sexual Abuse Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wcsa20
Correlates of Sexual Abuse in a Sample of Adolescent Girls Admitted to Psychiatric Inpatient Care a
b
c
a
Juha Kanamüller , Kaisa Riala , Maija Nivala , Helinä Hakko & c
Pirkko Räsänen a
Oulu University Hospital, Oulu, Finland
b
Helsinki University Central Hospital, Helsinki, Finland
c
University of Oulu, Oulu, Finland Accepted author version posted online: 07 Aug 2014.Published online: 28 Oct 2014.
Click for updates To cite this article: Juha Kanamüller, Kaisa Riala, Maija Nivala, Helinä Hakko & Pirkko Räsänen (2014) Correlates of Sexual Abuse in a Sample of Adolescent Girls Admitted to Psychiatric Inpatient Care, Journal of Child Sexual Abuse, 23:7, 804-823, DOI: 10.1080/10538712.2014.950401 To link to this article: http://dx.doi.org/10.1080/10538712.2014.950401
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [University of Bristol] at 04:07 22 February 2015
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Journal of Child Sexual Abuse, 23:804–823, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1053-8712 print/1547-0679 online DOI: 10.1080/10538712.2014.950401
RESEARCH ON OUTCOMES AND CHARACTERISTICS OF VICTIMS OF ABUSE
Downloaded by [University of Bristol] at 04:07 22 February 2015
Correlates of Sexual Abuse in a Sample of Adolescent Girls Admitted to Psychiatric Inpatient Care JUHA KANAMÜLLER Oulu University Hospital, Oulu, Finland
KAISA RIALA Helsinki University Central Hospital, Helsinki, Finland
MAIJA NIVALA University of Oulu, Oulu, Finland
HELINÄ HAKKO Oulu University Hospital, Oulu, Finland
PIRKKO RÄSÄNEN University of Oulu, Oulu, Finland
We examined correlations of child sexual abuse among 300 adolescent girls in psychiatric inpatient treatment. Diagnostic and Statistical Manual of Mental Disorders (4th ed.)-based psychiatric diagnoses were obtained from the Schedule for Affective Disorder and Schizophrenia for School-Age Children—Present and Lifetime and from data on family and behavioral characteristics from the European Addiction Severity Index (EuropASI). A total of 79 girls (26.3%) had experienced child sexual abuse during their lifetime. Child sexual abuse was associated with an adolescent’s home environment, sibling status, smoking, posttraumatic stress disorder diagnosis, self-mutilating behavior, and suicidal behavior. Received 6 January 2014; revised 19 January 2014; accepted 10 April 2014. Address correspondence to Kaisa Riala, Department of Adolescent Psychiatry, Helsinki University Central Hospital, 00029, Helsinki, Finland. E-mail: [email protected] Color versions of one or more of the figures in the article can be found online at www. tandfonline.com/wcsa. 804
CSA in Girls in Psychiatric Inpatient Care
805
At least 62% of the perpetrators were acquaintances of the victims. Correlates of child sexual abuse can be used to identify child sexual abuse victims and persons at heightened risk for child sexual abuse.
Downloaded by [University of Bristol] at 04:07 22 February 2015
KEYWORDS sexual abuse, risk factor, mental health, clinical sample, adolescent, female, suicidal behavior, anxiety disorders
Child sexual abuse (CSA) is a global problem with an overall estimated prevalence of 127 in 1,000 in self-report studies and 4 in 1,000 in informant studies (Stoltenborgh, van Ijzendoorn, Euser, & Bakermans-Kranenburg, 2011). In Finland the prevalence of CSA experiences varies between 0.7%– 4.6% for men and 1.8%–7.5% for women, and there would appear to be a decline in the prevalence of CSA (Laaksonen et al., 2011). Known risk factors for CSA are physical or emotional neglect/abuse and not growing up with both biological parents (Laaksonen et al., 2011). Low parental education and low family income have also been associated with sexual abuse (Hussey, Chang & Kotch, 2006). A longitudinal study based on both officially recorded and self-reported child abuse and neglect showed that maternal youth, parental death, and unwanted pregnancy increase the risk for child sexual abuse (Brown, Cohen, Johnson & Salzinger, 1998). Based on a large community sample, Walsh, MacMillan, and Jamieson (2002) reported an elevated risk for extra- and intrafamilial sexual abuse if either one or both parents had a history of psychiatric disorders. Problematic alcohol use by family members increased the risk for extrafamilial sexual abuse in a study with a large community sample (Hanson et al, 2006). Manion and colleagues (1996) found significant differences regarding parents’ occupational status between a case group of sexually abused children and a control group of nonabused children, with mean occupational status being lower in the case group. A study by Boney-McCoy and Finkelhor (1995) identified poor child– parent relationship as a significant risk factor for sexual abuse among 10- to 16-year-old children (OR 2.44), and also Svedin, Back, and Söderback (2002) identified a link between family dysfunction and CSA.
OUTCOMES ASSOCIATED WITH CHILD SEXUAL ABUSE The impact of traumatic experiences in general, and CSA in particular, on mental health, substance-related, and behavioral outcomes has been widely researched. Several large-scale general population studies have noted a relationship between childhood trauma and psychotic disorders (Read, van Os, Morrison & Ross, 2005). Bebbington and colleagues (2004) used data from the second British National Survey of Psychiatric Morbidity to examine associations between psychotic disorders and a number of early victimization
Downloaded by [University of Bristol] at 04:07 22 February 2015
806
J. Kanamüller et al.
experiences. In people with psychosis (age 16–74 years), there was a marked excess of victimizing experiences, and the largest odds ratio (adj. for current level of depression OR 7.4) was for sexual abuse (Bebbington et al., 2004). In addition to psychotic disorders, CSA has been found to be related to other psychopathologies. In a large sample based on the U.S. National Comorbidity Survey, Molnar, Buka, and Kessler (2001) found a significantly elevated risk for mood disorders, anxiety disorders, and substance disorders in females who had reported CSA compared to females who had not reported CSA. They identified outstanding odds ratios for posttraumatic stress disorder (PTSD; OR 10.2) and mania (OR 9.1). There is also evidence that CSA is associated with self-mutilating and suicidal behavior. In their longitudinal study, Noll, Horowitz, Bonanno, Trickett, and Putnam (2003) reported a fourfold risk for self-harming behavior, including suicidal behavior, in a group of young abused females compared to a group of young nonabused females. In their study both groups were recruited separately, the abused group was referred to by local protective services, and the control group was recruited by community advertising. Both groups were similar to each other in terms of ethnic group, age, predisclosed socioeconomic status (SES), family constellation (one- or two-parent families), zip codes, and other nonsexual traumas (Noll et al., 2003). An Australian longitudinal study using a school sample reported that CSA before the age of 16 increased the risk for bulimic disorders in young females by up to fivefold (Sanci et al., 2008).
SCOPE OF STUDY Previous research shows that CSA often occurs together with other problems in a child’s family environment, such as physical or emotional abuse, parental psychiatric disorders, or parental alcohol abuse (Brown et al., 1998; Hanson et. al., 2006; Laaksonen et al., 2011; Walsh et al., 2001). Furthermore, demographic and socioeconomic variables are associated with an increased risk for CSA (Hussey et al., 2006; Manion et al., 1996). In many cases, CSA has severe consequences for the victims, and it is correlated to psychiatric and behavioral problems (Bebbington et al., 2004; Molnar et al., 2001; Noll et al., 2003; Read et al., 2005; Sanci et al., 2008). An improved understanding of CSA risk factors as well as outcomes associated with CSA is important for the identification and targeting of individuals in programs designed to prevent further abuse. CSA victims might also benefit from interventions in alcohol abuse, substance abuse, or suicide prevention. Understanding psychiatric or behavioral correlates of CSA can raise awareness of the possibility of a history of abuse. The aim of our study is to examine family characteristics as well as psychiatric and behavioral characteristics with regard to possible associations to CSA. The study utilizes a large representative sample of adolescent female psychiatric inpatients admitted to Oulu University Hospital between
807
CSA in Girls in Psychiatric Inpatient Care
2001 and 2006. The catchment area of Oulu University Hospital covers the two northernmost provinces of Finland, Northern Ostrobothnia and Lapland, and all patients requiring acute-psychiatric inpatient care in this area were admitted to Oulu University Hospital.
METHOD
Downloaded by [University of Bristol] at 04:07 22 February 2015
Participants This study is part of the STUDY-70 project (Ilomäki, Södervall, Ilomäki, Hakko, & Räsänen, 2008). The original study sample consisted of 508 participants, 208 (40.9%) male and 300 (59.1%) female adolescent inpatients aged 13–17 years, consecutively admitted to the Department of Psychiatry of Oulu University Hospital, Finland, between April 2001 and May 2006. The adolescents were natives of Lapland and Northern Ostrobothnia. The majority of adolescents (98.2%) were Caucasians. Participants who were over 18 years old, mentally retarded, or had organic brain disorders were excluded from the study population. The study protocol was approved by the Ethics Committee of Oulu University Hospital, Finland.
Instruments SCHEDULE FOR AFFECTIVE DISORDER LIFETIME (K-SADS-PL)
AND
SCHIZOPHRENIA PRESENT
AND
The K-SADS-PL is a semistructured interview for the assessment of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994) psychiatric diagnoses in children and adolescents. It assesses past and present episodes of psychiatric disorders. Its retest-reliability is rated good to excellent (.77 to 1.00), and its concurrent validity and interrater agreement have been proven to be high (93% to 100%; Ambrosini, 2000; Kaufman et al., 1997). The instrument was applied by either the treating physician or by a trained medical student under the supervision of the treating physician. The data obtained with the K-SADS-PL integrates information given by the patient, the evaluation by the physician, and in some cases, information obtained from interviews with the parents. Parents were only interviewed if data from the patient interview was missing or was rated as unreliable. A full description of the instrument is available online (Kaufman, Birmaher, Brent, Rao, & Ryan, 1996). EUROPEAN ADDICTION SEVERITY INDEX (EUROPASI) The EuropASI is a structured face-to-face interview containing questions on multiple life domains and related problems: physical health, employment,
808
J. Kanamüller et al.
financial support, criminal behavior, family and social relations, psychiatric symptoms, and alcohol and substance use (Kokkevi & Hartgers, 1995). Scheurich and colleagues (2000) report moderate to good internal consistency (.69 to .92) for composite scores and moderate to excellent interrater reliability (intraclass correlation: .62 to .99). Mäkelä (2003) also approves individual items for use in describing clinical populations. Single items were used from the EuropASI to gather qualitative information about the participants and their sociodemographic background.
Downloaded by [University of Bristol] at 04:07 22 February 2015
MODIFIED FAGERSTRÖM TOLERANCE QUESTIONNAIRE (MFTQ) The mFTQ is a 7-item structured interview for the assessment of nicotine dependence and smoking habits among adolescents (Fagerström & Schneider, 1989). Its reliability ranges from .67 to .79 (Cronbach’s alpha; Chen et al., 2002), it showed reasonable criterion validity, and its test scores correlate with a nicotine metabolite in participants’ saliva (r = .40, p < .01; Prokhorov et al., 2000). The mFTQ measures smoking rate, frequency of inhalation, time between waking up and the first cigarette, the level of unwillingness to give up the first cigarette in the morning, difficulty of not smoking in places where smoking is not permitted, smoking despite health issues, and smoking frequency during the first two hours of the day compared to the rest of the day.
Measures SEXUAL
ABUSE ( YES / NO )
Information concerning CSA was based on three items. First, questions concerning an adolescent’s background were directed to parents/other adults during the adolescents’ hospitalization and were based on the background information aspect of the K-SADS-PL-interview. This item asked whether a child has faced any abuse in the earlier stages of his or her life. If the answer was positive, they were asked to specify further the type of abuse suffered (including sexual abuse). Participants were also asked about their relationship with the perpetrator and the consequences of the abuse. Second, the screening part for PTSD of the K-SADS-PL was used to ask the adolescent about various traumatic lifetime events. CSA was defined as isolated or repeated incidents of genital fondling, oral sex, or vaginal or anal intercourse. Third, in the EuropASI questionnaire, the issue of sexual abuse was included in questions concerning the adolescent’s relationship with his or her family members, sexual partner, or other close associates. The adolescent was also asked whether one or more of these associates had ever submitted them to mental, physical, or sexual abuse. CSA was defined here as any kind of sexual harassment or involuntary sex. In the present study, CSA was defined as being present if there was a positive answer to any of these questions.
CSA in Girls in Psychiatric Inpatient Care
809
Seventy-nine (26.3%) of all females (n = 300) reported CSA. Male patients were excluded from this study due to the small number of sexually abused cases (total N = 208, sexually abused cases n = 8).
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PERPETRATORS
OF SEXUAL ABUSE
Information on perpetrators was obtained from two sources: Background information section of the K-SADS-PL and the EuropASI. If information based on the K-SADS-PL or the EuropASI was unclear, the relationship between the adolescent and the perpetrator was defined from the adolescent’s hospital records. For the purpose of the present study, the information on perpetrators was then categorized into the categories “no information,” “stranger,” “acquaintance,” “relative,” “mother’s partner,” and “biological father.” Perpetrator categories were empirically derived from the sample. The information on perpetrators in our data is limited since the instruments used are not designed to gather this specific information. Due to the question format in the EuropASI, information on perpetrators was ambiguous in some cases. Namely, in the EuropASI, the participants are first asked whether they had ever or in the last 30 days had a troubled relationship with their mother, father, siblings, sexual partner, children, another important family, neighbors, or colleagues. In the next question, participants are asked whether “any of these persons mentioned before” had ever or in the past 30 days abused them psychologically, physically, or sexually. Given that there were multiple positive answers or no positive answer at all in the first question and the participant reported sexual abuse in the second question, it was impossible to determine exactly who the perpetrator was. However, since none of the potential perpetrators were strangers, in such cases the perpetrator was categorized as an “acquaintance.” FAMILY
CHARACTERISTICS AND DEMOGRAPHICS
Information on the home environment, family size, age status relative to siblings, domestic violence, and physical abuse was retrieved using the K-SADS-PL questionnaire. Place of residence, information on parents’ employment, and perceived psychological status of close relatives of the adolescent were gathered using the EuropASI questionnaire. ●
●
Place of residence describes the size of the patient’s residential area. Categories from EuropASI are: Large city (>100,000 inhabitants), Medium (10,000–100,000 inhabitants), and Small (rural; 100,000 City 10,000 – 100,000 Small town < 10,000 Home environment Both biological parents Single biological parent or blended family Foster home Child welfare placement Living alone/other Family size No siblings 1–2 siblings 3 or more siblings Age status relative to siblings Only child Oldest child Youngest child Not youngest, not oldest Employment of parents Perceived psychological status of close relatives Mother clinical condition substance abuse Father clinical condition substance abuse Siblings clinical condition substance abuse Witness to domestic violence Experienced physical abuse School related Failed class Teacher complained about behavior Expelled from school Kept in after school Mean grades 4–6 7–8 9–10
No (n = 221)
Group difference, p value
16 (20%) 16 (20%) 47 (59%)
47 (21%) 55 (24%) 119 (53%)
.640
24 25 4 16 10
108 59 15 21 18
(48%) (26%) (6%) (9%) (8%)
.017
3 (3%) 38 (48%) 38 (48%)
15 (6%) 122 (55%) 83 (37%)
.221
3 20 19 37 58
15 55 83 66 186
(6%) (25%) (37%) (30%) (84%)
.031
11 (13%) 17 (21%)
33 (14%) 34 (15%)
.827 .212
10 (12%) 24 (30%)
31 (14%) 55 (24%)
.761 .341
9 9 31 27
(11%) (11%) (39%) (34%)
26 18 61 52
(11%) (8%) (27%) (23%)
.929 .386 .054 .065
10 36 3 43
(12%) (45%) (3%) (54%)
16 (7%) 91 (41%) 2 (1%) 90 (40%)
.141 .497 .084 .035
25 (31%) 47 (59%) 2 (2%)
54 (24%) 131 (59%) 18 (8%)
.245
(30%) (31%) (5%) (20%) (12%)
(3%) (25%) (24%) (46%) (73%)
.035
with self-mutilative behavior (SMB). Suicidal behavior (including ideation and/or attempts) were also related to CSA (OR 2.0, 95% CI [1.1, 3.7]) and with the covariates with affective (OR 5.9, 95% CI [3.4, 10.3]) and psychotic (OR 4.4, 95% CI [1.9, 9.5]) disorders of adolescents.
814
J. Kanamüller et al.
TABLE 2 Logistic Regression Model for Sexual Abuse as Criterion Criterion variable Sexual abuse
Predictor variables
OR
95% CI
Age when hospitalized 1.53 [1.19, 1.95] Age status relative to siblings Other 1.00 Middle child 2.47 [1.40, 4.34] Home environment Both biological parents 1.00 One biological parent or blended family 2.08 [1.06, 4.08] Foster home 1.70 [0.48, 5.96] Child welfare placement 3.70 [1.62, 8.42] Living alone/other 1.73 [0.68, 4.40]
p value
R2
