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December 2008, Volume 58, Issue 12

Opinion and Debate

Aftermath of child abuse: Need to reduce the burden of morbidity

Amin A. Muhammad Gadit  ( Memorial University of Newfoundland, St. John's, NL A1B 3V6, Canada. )

Child abuse is a much debated subject in Pakistan. A lot of work is being done by the local Paediatric Association in collaboration with the government. An extensive report was also published that highlighted the magnitude of this problem and made a number of suggestions and recommendations. A large chunk of child abuse problem remains hidden and what we see is just the tip of the iceberg. In other words, all the current good work is directed to the apparent figures while the 'hidden' mass is still deprived of the attention. There are still a number of 'silent' abuses that take place in homes and are not reported. However, the scars of this horrific act are found to be visible among adults who present to the psychiatric clinics with a number of mental health problems. Major Depression has been a common presentation among adults who come to the psychiatric out patient clinics. This clinical problem may probably be an extension of childhood depression that was reported among 65% of the abused children in a local study.1 Reportedly,2 adults of childhood abuse might continue to numb their emotions by using alcohol, drugs, self-harming behaviour or unhealthy eating habits. In a prospective study3 conducted on abused and neglected children, it was determined that child abuse and neglect were associated with increased risk for current major depressive disorder. Children who were physically abused or experienced multiple types of abuse were at increased risk of lifetime Major Depressive Disorder (MDD) whereas neglect increased risk for current MDD. In the same study, childhood sexual abuse was not associated with elevated risk of MDD.  Another study4 indicates that children who were sexually abused had higher risk of depressive disorders than those who were physically abused or neglected. Scientists believe that gene protects adults abused as children from depression. A study5 examined the moderation by genetic polymorphisms within the corticotrophin-releasing hormone type 1 receptor (CHRH1) gene on the effects of child abuse on adult depressive symptoms as a result of past child abuse. The resultant data supported the corticotrophin-releasing hormone hypothesis of depression and suggested that gene X environment interaction was important for the expression of depressive symptoms in adults with CRHR1 risk or protective alleles who have a history of child abuse. Post Traumatic Stress Disorder (PTSD) is another serious complication of childhood abuse with which the adults do present themselves in the psychiatric clinics. A study6 mentions that certain gene variations raise the risk considerably if the childhood trauma involved physical or sexual abuse. The gene in question is active in the biochemical make-up of the body's stress-response system. McLean Hospital researchers7 have identified four types of brain abnormalities linked to childhood abuse and neglect: 1) Limbic irritability-Abuse may cause disturbances in electrical impulses resulting in seizures or significant abnormalities on E.E.G. that in turn are associated with more aggression and self destructive behaviour 2) Arrested development of left hemisphere-This may contribute to the development of depression and increased risk of memory impairment 3) Deficient integration between the left and right hemispheres-This can result in dramatic shifts in mood and personality 4) Increased vermal activity- This can affect emotional balance.  Depression is associated with suicidal thoughts and even attempts. Impulsivity is regarded as a trait that predisposes an individual to engage in self-destructive behaviour in response to suicidal thoughts. A diasthesis-stress model of suicide has been proposed in which an impulsivity/aggression factor is part of the diasthesis that interacts with stressors that trigger the person to act.8 Clinical reports9 indicate acting-out behaviours, such promiscuity and inappropriate sexual behaviour among adults with a history of childhood abuse. A local study10 conducted in Pakistan exploring the characteristics of childhood sexual abuse among psychiatric patients reported recurrent severe depression (30.31%), phobic anxiety disorder (6.05%), obsessive compulsive disorder (6.07%), conversion disorder (12.14%), somatization/ hypochondriacal disorder (6.04%), sexual dysfunction (3.05%) and substance dependence (21.20%). In the same study, thirty-three out of the one hundred patients reported a history of child sexual abuse. One may come across a number of older studies that reflect on the magnitude of this problem. The question is: How well equipped our mental health professionals are to address this issue? There are a number of medications available that are effective in treating the symptoms of psychiatric disorders but mere suppression of symptoms is not the solution. We do not have general data on the effectiveness of psychotherapies on patients with traumatic backgrounds. Hence, we are not sure as to how many adult patients with history of childhood abuse were recognized by the professionals and the strategies adopted to help them. It appears that a huge burden of depressive illness among patients is attributable to child abuse. Should the professionals be re-sensitized with this grave issue? Should the policy makers be made aware of this problem? Is there a need to curb the menace of child abuse more forcefully by means of awareness through media and stricter legislations? Should the subject of child abuse with particular reference to its longer term sequelae be included in the postgraduate syllabus of mental health specialists? Should there be a room for family clinics and home visits by trained primary care workers with an aim and focus on primary prevention of child abuse? Finally, can we afford to increase the burden of mental health morbidity in Pakistan?

References

1. Gadit AA. Depression among abused children. J Coll Phys Surg Pak 1998; 8:174-6.
2. Koesler S. Adults of Child Abuse; (Online) 2007 (Cited 2008 Apr 9).
 Available from URL:
 http:www.associatedcontent.com/article/163416/adults_of_childhood_abuse.html.
3. Widom CS, DuMont K, Czaja SJ. A prospective investigation of Major Depressive Disorder and comorbidity in abused and neglected children grown up. Arch Gen Psychiatry 2007; 64: 49-56.
4. Brown J, Cohen P, Johnson JG, Smailes EM. Child abuse and neglect: specificity of effects on adolescent and young adult depression and suicidality. J Am Acad Child Adolesc Psychiatry 1999; 38: 1490-6.
5. Bradley RG, Binder EB, Epstein MP, Tang Y, Nair HP, Liu W, et al. Influence of Child Abuse on Adult Depression-Moderation by the Corticotropin-Releasing Hormone Receptor Gene. Arch Gen Psychiatry 2008; 65: 190-200.
6. Binder EB, Bradley RG, Liu W, Epstein MP, Deveau TC, Mercer KB et al. Association of FKBP5 Polymorphisms and Childhood Abuse with risk of Posttraumatic Stress Disorder Symptoms in adults. J Am Med Assoc 2008; 299: 1291-1305.
7. McLean Hospital. McLean researchers document brain damage linked to child abuse and neglect. (Online) 2000 (Cited 2008 Apr 9). Available from URL: http://www.mclean.harvard.edu/news/press/archived/20001214_child_abuse.php.
8. Mann JJ, Waternaux C, Haas GL, Malone KM. Toward a clinical model of suicidal behaviour in psychiatric patients. Am J Psychiatry 1999; 156: 181-9.
9. Widom CS. Victims of Childhood Sexual Abuse-Later Criminal Consequences. NIJ Research in Brief (Online) 1995 (Cited 2008 Apr 9) Available from URL: http://www.ncjrs.gov/txtfiles/abuse.txt.
10. Khalid N. The Characteristics of Childhood Sexual Abuse among Psychiatric Patients in Karachi-Pakistan. J Pak Psych Society, 2003; 1: 8-13.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: