Elsevier

Child Abuse & Neglect

Volume 38, Issue 12, December 2014, Pages 2021-2032
Child Abuse & Neglect

Adverse childhood experiences as risk factors for serious mental disorders and inpatient hospitalization among adolescents

https://doi.org/10.1016/j.chiabu.2014.10.008Get rights and content

Introduction

Psychiatric hospitalization is an intense and powerful intervention for patients and is highly expensive for society. Despite the individual and social costs of hospitalization, it is a common practice in the Finnish adolescent mental health care system (Fredriksson & Pelanteri, 2012). Hospitalized adolescents typically suffer from severe psychiatric disorders, have faced several traumatic life events and experience psychosocial difficulties with their families and peer groups (Gyllenberg et al., 2010, Sourander et al., 1995). Thus, it is important to identify the most prevalent and powerful childhood psychosocial risk factors for severe mental health disorders among high-risk adolescents to diminish personal agony, prevent the aggravation of psychiatric problems and reduce hospitalization and high health care costs.

Adolescence is a unique period of cognitive, emotional, social, and physical development. Adolescents are particularly vulnerable to the negative effects of exposure to adverse childhood experiences (ACEs, De Bellis, 2005), and many psychiatrically hospitalized adolescents have a history of several ACEs. The most frequently examined ACEs are emotional, physical and sexual abuse, neglect, being bullied and household dysfunction, including parental mental illness, alcohol or drug abuse, divorce, death and criminality. In a recent Finnish study of 508 adolescent psychiatric inpatients, 34.6% of patients (29.3% males and 38.3% females) reported being bullying victims (Mustanoja et al., 2011). The same research group reported that approximately 25% of hospitalized adolescents had been exposed to physical abuse, approximately 23% of girls and 3% of boys had been exposed to sexual abuse and 31% of girls and 28% of boys had witnessed intimate partner violence. For parent-related ACEs, 62% of boys and 46% of girls came from families that had experienced divorce. In addition, approximately 24% of girls and 13% of boys came from families with parental psychiatric problems, and 34% of girls and 28% of boys came from families with parental substance use problems; 26% of boys and 18% of girls had been exposed to parental unemployment, and11% of boys and 6% of girls had experienced the death of one or both parents. Sexual abuse was the highest risk factor for suicide attempts and non-suicidal self-injuries. Further, for girls, exposure to multiple ACEs was associated with both events. Among the deceased adolescents in the study (n = 16), ACEs were most notable among those who had died due to accidents or injuries (Isohookana, Riala, Hakko, & Räsänen, 2012). In a large American child and adolescent psychiatric inpatient study (N = 1,079), individuals with a history of physical and/or sexual abuse were more likely to be diagnosed with multiple disorders, use more medication and be treated with antipsychotic medication than non-traumatized patients. Additionally, physical and sexual abuse are independently associated with longer treatment periods (Keeshin et al., 2014).

Adolescent health experiences cannot be separated from their social, physical and psychological environment (Välimaa, 2000). Thus, several studies have emphasized the importance of the social context in which the child develops (Appleyard et al., 2010, Sperry and Widom, 2013). For adolescents, the most significant relationships are with parents and siblings, followed by peers (Higgins & McCabe, 2000). Family plays a key role in an adolescent's individuation and identity formation by providing a forum to explore new roles and values (Noach, Kerr, & Olah, 1999) and helping adolescents socialize (Newman, Harrison, Dashiff, & Davies, 2008). School is an environment in which an adolescent spends most of his/her daytime, and life satisfaction is related to feeling safe and social contacts (Horstmanshof, Punch, & Creed, 2008). The most influential aspect of social support in promoting individual well-being is perceived support: the perception that others provide support when there are stressful challenges. In contrast, social isolation is associated with poor psychological functioning (Thompson, 2014), and low perceived social support is associated with severe psychopathology. A recent study by Kumar and George (2013) found that suicide attempters experienced significantly lower levels of social support than their age- and sex-matched controls. Further, individuals who had documented histories of childhood physical and sexual abuse or neglect reported significantly lower levels of social support in adulthood than a matched control group who had no trauma history (Sperry & Widom, 2013). Traumatic event exposure may also affect the ability to maintain relationships, thus leading to low social support. Research has suggested that abuse and neglect hinders the child's social cognition development, which may lead to problems with social adjustment, as observed by difficulties getting along with other people (Koizumi & Takagishi, 2014). One common example of these difficulties is bullying and being a victim of bullying because children who live in an environment with intimate partner violence or experience other types of family-related maltreatment may be inclined to become bullies, victims of bullying or bully victims (Baldry, 2003, Bauer et al., 2006, Bowes et al., 2009, Mustanoja et al., 2011).

There is a strong relationship between ACEs and mental health problems. Adversities such as childhood physical and sexual abuse or neglect are risk factors for emotional and behavioral problems, including depression, anxiety, posttraumatic stress disorder (PTSD) symptoms, suicide attempts, eating disorders, conduct disorder and other disruptive and violent behavior (Dube et al., 2001, Gilbert et al., 2009, Widom et al., 2007).

Physical abuse is related to major depression, alcohol dependence, and externalizing problems (Afifi et al., 2006, Miller-Perrin et al., 2009). Childhood sexual abuse is associated with a lifetime risk for depression, alcohol and drug dependences, panic disorder, PTSD, and suicidality (Dube et al., 2001, Dube et al., 2005). Among adolescents, sexual and physical abuse as well as serious neglect has traditionally been linked to internalizing problems (Schilling, Aseltine, & Gore, 2007). Recently, a study by Mills et al. (2013) found that emotional abuse (both with and without neglect) and multi-type maltreatment were associated with externalizing disorders.

Household dysfunction, including living in a family that experiences intimate partner violence, family psychiatric or substance use disorders and criminality, may cause emotional and behavioral problems in adolescence. Research has revealed relations between adolescent externalizing disorders and low family socioeconomic status (SES), parental divorce, living in a single-parent family and having one or both parents who have psychiatric or substance use disorders (Bratek et al., 2013, De Boer et al., 2012, Moffitt and Caspi, 2001). Parental depression and alcoholism have also been linked to internalizing problems in adolescence (Chassin et al., 1999, Hammen et al., 1999). Additionally, a family history of alcohol dependence predicted poor neuropsychological functioning in offspring (Dube et al., 2006). Adolescents who live in a home that experiences intimate partner violence exhibit clinical levels of anxiety and PTSD (Graham-Bermann & Levendosky, 1998). Findings from studies focused on ACEs indicate that they are highly correlated with each other (Felitti et al., 1998), and various types of maltreatment are usually repeatedly and simultaneously experienced (Trickett, 1998). According to prior research, there is a relationship between exposure to abuse, either at home or at school, and perceived social support from family and friends. Experiencing family violence induces problem behavior, which then appears in school-based social relationships. Negative peer relationships are predisposed to school bullying (Baldry, 2003, Bauer et al., 2006, Perren and Hornung, 2005) and both bullies and victims of bullying have reported low perceived social support from their parents (Perren & Hornung, 2005). Exposure to multiple types of maltreatment is associated with greater impairment than exposure to a single form of maltreatment (Higgins & McCabe, 2000). Exposure to multiple ACEs appears to be associated with severe behavioral problems (Rasmussen, Nielsen, Petersen, Christiansen, & Bilenberg, 2013), as well as suicide attempts (Kumar & George, 2013).

Section snippets

Current Study

Although ACEs are well-documented risk factors for psychiatric disorders among adults in the general population, more information is needed about ACEs and their relation to school bullying victimization and perceived social support among hospitalized adolescents who have severe psychiatric disorders. This study's aims were to: (a) investigate the prevalence of various ACEs (parental psychiatric and substance use problems, criminality, divorce, witnessing intimate partner violence, physical and

Participants and Procedure

The Kellokoski Hospital Adolescent Inpatient Follow-Up Study (KAIFUS) is a longitudinal, naturalistic study on clinical characteristics and the impact of treatment in a consecutive sample of adolescent psychiatric inpatient admissions in Southern Finland. The sample comprises adolescents admitted to Kellokoski Hospital for the first time between September 2006 and August 2010 (N = 395). The four inpatient wards at the hospital offer psychiatric care to 13–17-year-old citizens in the Hyvinkää

Data Analysis

We used Pearson's Chi-square tests (categorical variables) and Student's t-tests (continuous variables) to assess group differences between the inpatient and comparison groups. Bivariate correlation analyses and logistic regression analyses were performed to investigate the relationship between ACEs, school bullying victimization and perceived social support. A multinomial logistic regression model assessed the relationship between ACEs and internalizing or externalizing disorders for the

Sample Characteristics

The principal diagnosis distributions for the inpatient group were: mood (47.6%), conduct (23.3%), anxiety (13.6%), psychotic (7.8%), eating (5.8%), and alcohol abuse disorders (0.5%). Twenty-one (10.2%) patients had a principal diagnosis of PTSD (included in anxiety disorders). In total, 139 patients suffered from internalizing disorders and 49 patients had externalizing disorders. Sixty-four (31.1%) adolescents had no comorbid psychiatric disorder, 89 (43.2%) had one, and 53 (25.7%) had two

Discussion

The first aim of this study was to investigate the prevalence of ACEs, school bullying victimization, and perceived social support from family and friends among adolescent inpatient and comparison groups. More than 80% of the inpatient group reported that they had experienced at least one negative life event. In both groups, parental divorce was the most frequent ACE. The finding was not surprising given Finland's Official Statistics, which suggest that approximately one in every two marriages

Conclusions

Among the adolescent inpatient group, adverse childhood experiences, school bullying victimization and social relationship dysfunctions were associated with having a serious psychiatric disorder. The odds of being in the adolescent inpatient group increased with the cumulative number of ACEs. This study provides additional support for the importance of developing preventive interventions against school bullying, sexual abuse and other ACEs. Specific attention should be paid to family

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    This study has been funded by the Finnish Government through special research grants for hospital district to share, and is awarded to Minna Rytilä-Manninen.

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