A study by the University of Birmingham has shown that children who have experienced child abuse or neglect are four times more likely to develop serious mental illness such as psychoses, schizophrenia and bipolar disorder.
Researchers studied GP records dating between 1995 and 2018 of 217,758 patients aged under 18 who had experienced, or were suspected to have experienced, childhood maltreatment or related concerns, and then compared them to the records of 423,410 patients who had not.
The study, published today in The Lancet Psychiatry, found those patients who were maltreated were more than twice as likely to develop serious mental ill health such as psychoses, schizophrenia and bipolar disorder, or require a prescription to treat mental ill health, compared to those who have no recorded experience of maltreatment.
The researchers also found maltreated children were more than twice as likely to develop some form of mental illness, such as depression or anxiety.
Childhood maltreatment, defined as any form of physical, sexual or emotional abuse and neglect, is a global public health and human rights issue affecting more than one in three children aged under 18.
This was the biggest study of its kind to explore the association between abuse or neglect in childhood and the development of mental illness.
The researchers also found a clear under-recording of child maltreatment in GP records, and say potential opportunities to spot child maltreatment or implement management plans for these vulnerable individuals are being missed.
First author Dr Joht Singh Chandan, Academic Clinical Fellow in Public Health at the University of Birmingham’s Institute of Applied Health Research, said: “Our findings, along with evidence from other global studies, demonstrates the substantial burden of mental ill health following child abuse or neglect.
Researchers found children who were maltreated were more than twice as likely to develop serious mental ill health such as psychoses, schizophrenia and bipolar disorder
“Considering the prevalence of maltreatment, it is clear we are not doing enough to prevent and detect this important risk factor for mental ill health.”
“There is a desperate need to rethink our public health approach to preventing and detecting childhood maltreatment and its associated negative consequences.”
Corresponding author Julie Taylor, Professor of Child Protection at the University of Birmingham’s School of Nursing, said: “Services aiming to build resilience in survivors of maltreatment have shown great promise in the reduction in the development of mental ill health.
“Our study, the first if this size and magnitude to have been conducted in the UK, emphasises the importance of early intervention in abused or neglected children’s lives to prevent adverse outcomes.”
Corresponding author Dr Krish Nirantharakumar, also of the University of Birmingham, added:
“There is an important public health message to focus, not only on approaches that prevent or detect childhood maltreatment, but also to explore methods of prevention and detection of mental ill health in those who have experienced childhood maltreatment.
“Building resilience in children, families, local services and communities of those at risk might be a way of improving mental health outcomes.”
It is estimated that up to 30% of the general population have experienced childhood maltreatment (Hussey et al., 2006). Physical, sexual and emotional or psychological abuse and neglect are among the most common types of maltreatment encountered by children and young people (Finkelhor et al., 2013).
Experiences of childhood abuse and/or neglect precede the occurrence of psychiatric disorders in adult life, whereas 2.2% of incidents of childhood maltreatment result in fatalities (US Department of Health and Human Services, 2012).
The economic burden of childhood maltreatment in terms of health care and medical costs, losses in productivity, welfare and special education costs are estimated around $124 billion in the USA alone (Fang et al., 2012).
Over 800 000 people across the world die by suicide every year. Understanding, therefore, the major factors which underpin suicidality such as suicide attempts, thoughts and behaviors has been established as a global health and policy priority [World Health Organization (WHO), 2014].
Empirical research has shown strong links between several types of childhood maltreatment and adult suicidality among individuals in the community and those diagnosed with psychiatric disorders (Gal et al., 2012; Kim et al., 2013).
Consistent with the empirical findings, contemporary theories of suicidality have emphasized the role of childhood maltreatment, such as sexual and physical abuse, in the development of suicidality.
For example, the interpersonal theory of suicide suggests that severe types of childhood maltreatment, such as sexual and/or physical abuse, produce a state of habituation to pain and reduction of fear for death which gradually builds the person’s capability for suicide. Similarly, the Cry of pain model, and its antecessor, the Schematic Appraisals Model for Suicide (SAMS) suggest that childhood adversities give rise to increasingly worsening perceptions of defeat and entrapment which lead to suicidality as a means of escape (Johnson et al., 2008; Williams et al., 2005).
These meta-analyses, however, combined studies which were based on mixed samples of participants such as adolescents and adults, community and clinical samples.
On the other hand, methodological restrictions have been applied regarding the definition of childhood maltreatment (e.g. use of the Childhood Trauma Questionnaire exclusively; CTQ; Liu et al., 2017), the study design (e.g. prospective studies only) and the date of publication (conducted within the last decade; Zatti et al., 2017), leading to the exclusion of several relevant studies.
Moreover, little is known regarding the impact of demographic and clinical factors on the association between childhood maltreatment and suicidality. Although these studies are important, a comprehensive systematic review and meta-analysis would be particularly valuable for drawing important evidence-based conclusions and guiding future research priorities. We performed a comprehensive systematic review and meta-analysis of the association between childhood maltreatment and suicidality. We had two core objectives:
- To systematically quantify the association between different types of childhood maltreatment and suicidality, including suicide attempts and suicidal ideation.
- To examine demographic, clinical and methodological factors that may influence the association between childhood maltreatment and suicidality in adults.
A total of 5370 articles were retrieved. Of these, 388 were duplicates and 4698 were excluded because they (a) did not focus on suicidality, (b) focused on any other childhood maltreatment sub-types other than abuse or neglect (e.g. bullying, parental divorce, loss/death of a loved one, separation from parents, witnessing violence) and (c) were non-empirical studies, leaving 284 articles eligible for full-text screening. An additional 216 studies were excluded as they either did not report data relevant to the link between childhood abuse and suicidality or were based on adolescents or veterans. A total of 68 independent studies were included in the review (see Fig. 1).
Descriptive characteristics of the studies
The characteristics of the 68 studies that were included in the review are detailed in Table 1. The vast majority of the studies were conducted in the United States (k = 29; 42.65%), followed by Canada (k = 7; 10.29%), Italy (k = 3; 4.41%), Turkey (k = 3; 4.41%), Germany (k = 3; 4.41%) and Brazil (k = 3; 4.41%). Fewer studies were conducted in the United Kingdom (k = 2; 2.94%), Australia (k = 2; 2.94%), New Zealand (k = 2; 2.94%), France (k = 2; 2.94%), Netherlands (k = 2; 2.94%), Poland (k = 2; 2.94%) and Korea (k = 2; 2.94%), whereas a single study (1.47%) was conducted in Argentina, Spain, Norway, Israel, Japan and South Africa. Stein et al. (2010) presented data that have been collected from 21 countries.
The age of the participants ranged between 18 and 93 years old (Mage = 40.26, s.d. = 8.69; 42.34% men). In total, 33 studies (n = 225.462) were based on community samples and 35 on clinical samples (n = 36.198). Twenty-one of the studies that utilized psychiatric patients focused on common types of mental health conditions, including anxiety, depression, post-traumatic stress disorder (PTSD) and 14 on severe types of mental health conditions, such as bipolar disorder and schizophrenia.
Childhood maltreatment was assessed using two main methods: (i) 44 studies used self-report questionnaires and (ii) 23 studies used clinical interviews and other objective methods (e.g. five studies retrieved relevant information by patient records; only one study by Fudalej et al. (2015) did not specify the tools utilized). The most common self-report measure was the CTQ. Similarly, suicide attempts and suicidal thoughts were assessed either using self-report questionnaires (k = 33 studies) or structured/semi-structured clinical interviews or other objective methods (k = 35, of which five studies retrieved relevant information by patient records).
Table 1 also presents the overall scores from the critical appraisal assessment of the studies. Almost half of the studies (k = 37) scored moderate to high in the critical appraisal assessment (met four or more criteria) whereas the remaining scored low (met fewer than four criteria).
Main meta-analyses: associations between types of childhood maltreatment and suicide attempts in adults
The pooled effects of the main analyses indicate that all types of childhood maltreatment (except for physical neglect which is only based on four studies) were associated with significantly increased odds for suicide attempts in adults (Table 2). Sexual abuse was associated with a three-fold increased risk for suicide attempts [k = 36, OR 3.17, 95% confidence interval (CI) 2.76–3.64, I2 = 68.1%] whereas physical and emotional abuse were associated with a 2.5-fold increased risk for suicide attempts (k = 30, OR 2.52, 95% CI 2.09–3.04, I2 = 74.3% and k = 12, OR 2.49, 95% CI 1.64–3.77, I2 = 93.2%, respectively). Emotional neglect was associated with 2.3-fold increased risk for suicide attempts whereas physical neglect was not significantly associated with an increased risk for suicide attempts (k = 6, OR 2.29, 95% CI 1.79–2.94, I2 = 19.2% and k = 4, OR 1.51, 95% CI 0.87–2.62, I2 = 62.3%, respectively). However, the two categories focused on neglect were based on a small number of studies which have distinguished emotional/physical abuse from emotional/physical neglect. Moreover, a considerable number of studies examined the association between a combined category of childhood abuse (without providing data on each separate form of abuse) and suicide attempts. We named this combined category as any child abuse and analyzed it separately because it contains unspecified features from more than one of the other categories. Any child abuse was associated with a two-fold increased risk for suicide attempts (k = 16, OR 2.09, 95% CI 1.67–2.60, I2 = 91.3%). Finally, complex abuse (repetitive incidents) in childhood showed the strongest association (increased the risk five times) with suicide attempts among adults (k = 7, OR 5.18, 95% CI 2.52–10.63, I2 = 90.9%). As indicated by the value of I2 statistic, heterogeneity was medium to high across all the main analyses.
University of Birmingham
Emma McKinney – University of Birmingham
The image is adapted from the University of Birmingham news release.
Original Research: Closed access
“The burden of mental ill health associated with childhood maltreatment in the UK, using The Health Improvement Network database: a population-based retrospective cohort study”. Chandan et al.
Lancet Psychiatry doi:10.1016/S2215-0366(19)30369-4.