Child physical abuse and concurrence of other types of child abuse in Sweden—Associations with health and risk behaviors
Introduction
Child physical abuse (CPA) is a major public health and social-welfare problem around the world because of its high prevalence and its association with adverse health and social outcomes (Gilbert et al., 2009, Hazen et al., 2009). In 1979, Sweden became the first country in the world to prohibit all corporal punishment of children. Attitudes toward physical punishment and the use of violence in bringing up children have changed markedly in Sweden during the last 50 years and especially since the law was passed (Gilbert et al., 2009, Janson, 2001, Janson et al., 2007). In a study we carried out in 2010, 15% of the children 13–17 years old reported experiencing CPA (Annerback, Wingren, Svedin, & Gustafsson, 2010). This study also showed a high number of unreported cases and that only 7% of exposed children had told any authority such as school, social services, health care or police about the physical abuse. Thus, even though corporal punishment in Sweden has decreased markedly, violence against children remains a public-health and a social welfare problem in Sweden as well as in other high-income countries (Annerback et al., 2010, Gilbert et al., 2009).
Earlier research has revealed that experience of CPA is strongly associated with poor health status. Individuals with a history of physical abuse often experience poor mental and/or physical health in adulthood (Bonomi et al., 2008, Widom et al., 2007).
There are strong associations between CPA and health compromising behaviors such as use of tobacco, alcohol and drugs (Becker and Grilo, 2006, Simantov et al., 2000). Risk-taking behaviors among teenagers such as delinquency and sexual risk-taking have also been shown to be associated with having a history of CPA (Mason et al., 1998, Pelcovitz et al., 1994). Studies show that these associations with CPA are also prevalent in connection with Child Sexual Abuse (CSA) and witnessing parental Intimate Partner Violence (IPV) (McFarlane et al., 2003, Simantov et al., 2000). In some studies CPA and CSA were found to be associated with self-injurious and repeated suicidal behaviors (Yates et al., 2008, Ystgaard et al., 2004). A review article published in 2009 states, however, that there is only weak support for the association between CSA and self-injurious behaviors and that the association is especially weak for CPA (Gilbert et al., 2009).
Exposure to peer-victimization in the form of bullying is another type of child abuse that is associated with poor health expressed in the form of depression, suicidality and social anxiety (Abada et al., 2008, Gren-Landell, 2010, Klomek et al., 2007). Even if bullying behavior decreases when children get older it is still a considerable problem among high school students (Klomek et al., 2007).
As described above, previous research has shown that CPA causes in addition to immediate physical and psychological damage, effects in the child's future life and is associated with poor health and risk-taking behaviors. This cannot be explained by any single cause since health depends on a complex web of different factors (Kendall-Tackett, 2002).
This study has its focus on violence perpetrated by a parent or other care-givers, as there are reasons to believe that this causes damage in different ways than does violence against children executed by other adults. Attachment theory provides a basic and universal explanation of implications of CPA and also points to the difference between being exposed to violence by parents and to violence committed by other adults. If the person who should represent the Secure Base for a child is the same person who hurts the child this will seriously harm the vital relationship between child and parent. The individual's Internal Working Model (IWM), which is an essential part of personality development, will risk being adversely affected. This will have life-long impact since IWM refers to the framework by which individuals perceive stressful situations, the action of others and their own capacity to influence their own situation (Bowlby, 1988, Broberg et al., 2003). Theories about shame show that victims of abuse often live with external shame, a sense of being disgraced by the abuse. This can affect the psychobiological maturation and functioning and result in being prone to shame and to psychopathology for the rest of the individual's life. Such delayed effects may become a “source of later inter-personal relationship difficulties including violence” (Gilbert & Andrews, 1998). In Sweden where all violence against children has been banned for more than 30 years and where corporal punishment is regarded as a crime, exposure to violence from a parent has come to be viewed as a deviant experience. This experience may be perceived as marginalization and exclusion in the society. These background theories give a fundamental base for the present study but are not directly explored; only the later expressions were obtained in the form of self-reported poor health and risk behaviors.
Repeated exposure to abuse has been shown to lead to worse adverse outcomes than single or isolated experiences, which is also true for other types of traumatic experiences that are repeated (Cloitre et al., 2009, Finkelhor et al., 2009, Gilbert et al., 2009, Gustafsson et al., 2009).
There is growing evidence that demonstrates that different types of abuse often co-occur. Research shows that exposure to multiple types of abuse is associated with worse effects on health than exposure to single forms of abuse. Research focusing on only one type of exposure could therefore have serious limitations arising from the underestimation of the full burden of child abuse and overestimation of the impact of one single type (Bensley et al., 1999, Ford et al., 2010, Hahm et al., 2009, Hazen et al., 2009, Ney et al., 1994, Westenberg and Garnefski, 2003).
Poor health has been shown to be linked to socioeconomic factors (Richter, Moor, & van Lenthe, 2010) and it is therefore necessary to control for such factors in order to get knowledge about how much the abuse independently contributes to the outcome of poor health.
The main objective of this study was to investigate the relationship between child physical abuse (CPA) perpetrated by parents/caregivers and physical health problems, mental health problems and risk-taking behaviors among Swedish adolescents. Since we hypothesize that multiple abuse has a stronger association with bad health and risk-taking behaviors than CPA alone, we also examined the participant's experiences of other types of abuse and how these alone and in addition to CPA were associated with health status and risk-taking behaviors.
Section snippets
Material and method
This cross-sectional study of a study population consisting of all the pupils (n = 7,262) in 2 different grades in schools in Södermanland County in Sweden in 2008 was conducted by the Centre of Public Health in cooperation with Centre for Clinical Research, County Council in Södermanland.
All the schools in the county with pupils in grade 9 (ca 15 years old) in compulsory school and grade 2 (ca 17 years old) in upper secondary school were invited to participate in the surveys. (Upper secondary
Definitions used
Child physical abuse. Physical violence against a child executed by a parent or a caretaker.
Caretaker. A parent or a person who, instead of the parent, had the responsibility for the child at the time of the abuse.
Child. A person younger than 18 years.
Child abuse variables
Child physical abuse (CPA) was coded in two categories. CPA I was indicated if the child answered “Yes once” and CPA 2 “Yes several times” (i.e., more than once) to the question “Have you been boxed on the ear/been hit by an adult?” and the
Results
Of the total sample of 5,933 children, 966 (16.3%) reported experience of CPA and 417 of these (7.0% of all children) reported that they had been hit more than once. CPA was the most frequently reported type of abuse and experience of IPV was the second most common. Of the total group 739 (12.5%) reported IPV and 253 of these (4.3% of all children) reported that violence had occurred between the adults in the family more than twice. Bullying was reported by 551 (9.3% of all children) and of
Discussion
In this cross-sectional study, we examined associations between CPA as well as other types of abuse/concurrent abuse and self-reported health and risk-taking behaviors among Swedish boys and girls 15 and 17 years old. The study is based on information from a “normal” population (i.e., a non-clinical material) of young people and the study-design provides us with knowledge of adolescent's health and behavioral problems based on their own reports. It gives information also on cases within the
Conclusion
Despite the limitations mentioned above, our study provides strong evidence that child abuse is a serious public health problem based on the clear links seen between abuse and poor health and behavioral problems. Consistent with other studies showing a graded relationship between experiences of abuse and poor health/risk-taking behaviors our study shows poorer outcomes for repeated abuse and multiple abuse in the form of CPA in combination with other types of abuse.
These findings indicate that
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