CMAJ Child abuse study

Child abuse is a major public healthproblem worldwide with seriousadverse effects at later ages. The bestestimates of the prevalence of child abuse inCanada come from 2 representative samplesfrom Ontario, 1 from 1990 (Ontario HealthSupplement, n = 9953, age 15 yr)1 and 1from 20002001 (Ontario Child Health Study,n = 1893, age 2135 yr).2 The 1990 study indi-cated that 31% of males and 21% of femaleshad experienced physical child abuse, and 4%of males and 13% of females had experiencedsexual child abuse.1 Similar trends were notedin data collected in 20002001.2 Prevalence ofsexual abuse was found to be higher in theOntario Child Health Study, but this wasthought to be related to the inclusion of sexualabuse committed by anyone (e.g., adolescents),rather than only adults, as was the case withthe Ontario Health Supplement.1,2 Data fromQuebec collected in 2006 indicated that 23% ofmen and 17% of women had experienced phys-ical child abuse; 10% of men and 22% of

women had experienced sexual child abuse;and 22% of men and women had experiencedpsychological child abuse, including exposureto intimate partner violence.3,4 Unfortunately,these estimates are dated, restricted to only 2provinces, based on limited assessments ofchild abuse and, in the case of the Quebec data,involve a low response rate of 30%.

Although the association between child abuseand subsequent mental conditions (including dis-orders, suicidal ideation and suicide attempts) iswell established,59 we know little about differen-tial effects associated with several abuse typesand specific mental disorders, and we currentlyhave no nationally representative Canadian data.Filling this gap in knowledge would produce evidence-based Canadian findings that couldinform policy, prevention and intervention effortsspecifically aimed at reducing both child abuseand poor mental health outcomes.

Our overall objective was to extend our under-standing of the relation between child abuse andmental conditions (i.e., mental disorders, suicidal

Child abuse and mental disorders in Canada

Tracie O. Afifi PhD, Harriet L. MacMillan MD, Michael Boyle PhD, Tamara Taillieu MSc, Kristene Cheung BA,Jitender Sareen MD

Competing interests: Nonedeclared.

This article has been peerreviewed.

Correspondence to: Tracie Afifi, tracie .afifi @med .umanitoba.ca

CMAJ 2014. DOI:10.1503/cmaj.131792

ResearchCMAJ

Background: Nationally representative Cana-dian data on the prevalence of child abuseand its relation with mental disorders arelacking. We used contemporary, nationallyrepresentative data to examine the preva-lence of 3 types of child abuse (physical abuse,sexual abuse and exposure to intimate part-ner violence) and their association with 14men tal conditions, including suicidal ideationand suicide attempts.

Methods: We obtained data from the 2012Canadian Community Health Survey: MentalHealth, collected from the 10 provinces.Respondents aged 18 years and older wereasked about child abuse and were selected forthe study sample (n = 23 395). The survey hada multistage stratified cluster design (house-hold response rate 79.8%).

Results: The prevalence of any child abuse was32% (individual types ranged from 8% to26%). All types of child abuse were associated

with all mental conditions, including suicidalideation and suicide attempts, after adjust-ment for sociodemographic variables (adjustedodds ratios ranged from 1.4 to 7.9). We founda doseresponse relation, with increasingnumber of abuse types experienced corres -ponding with greater odds of mental condi-tions. Associations between child abuse andattention deficit disorder, suicidal ideation andsuicide attempts showed stronger effects forwomen than men.

Interpretation: We found robust associationsbetween child abuse and mental conditions.Health care providers, especially those assess-ing patients with mental health problems,need to be aware of the relation betweenspecific types of child abuse and certain men-tal conditions. Success in preventing childabuse could lead to reductions in the preva-lence of mental disorders, suicidal ideationand suicide attempts.

Abstract

2014 Canadian Medical Association or its licensors CMAJ 1

Early release, published at www.cmaj.ca on April 22, 2014. Subject to revision.

ideation and suicide attempts)68,1019 with a moredetailed examination of child abuse severity andmental health outcomes. We used a nationallyrepresentative Canadian sample to examine3 types of child abuse (physical abuse, sexualabuse and exposure to intimate partner violence)and 14 mental conditions, including suicidalideation and suicide attempts. The specificresearch objectives were to estimate the preva-lence of 3 types of physical abuse, sexual abuseand exposure to intimate partner violence; toexamine the association of mental conditionswith types of child abuse and number of childabuse types experienced; and to determinewhether sex differences exist in the associationsbetween child abuse and mental conditions.

Methods

Data and sampleWe obtained data from the master file of the2012 Canadian Community Health Survey:Mental Health.20 The 2012 Canadian Commun -ity Health Survey was a cross-sectional studythat used a multistage stratified cluster sam-pling design: it included a representative sam-ple of respondents aged 15 years and older living in the 10 provinces (n = 25 113) andexcluded residents in the 3 territories, residentsin indigenous communities, full-time membersof the Canadian Forces and people living ininstitutions (collectively less than 3% of theCanadian population).20 Most interviews (87%)

were conducted in person by trained lay inter-viewers using computer-assisted interviewing.20

The overall household-level response rate was79.8%, and the household and person responserate was 68.9%.20 Because of the sensitivenature of the items, the questions about childabuse were only asked for respondents aged18 years and older (n = 23 395). Respondentswere informed about privacy, confidentially andthe voluntary nature of the survey, and gavetheir consent to participate.21

Primary measurements

Child abusePhysical abuse, sexual abuse and exposure tointimate partner violence were assessed in the2012 Canadian Community Health Survey usingitems from the Childhood Experiences of Vio-lence Questionnaire, a valid and reliable tooldeveloped for assessing youth victimization.22 Allrespondents aged 18 years and older were askedto answer questions about childhood abuse thatoccurred before the age of 16 years. Responsesto questions about child abuse were scored on anordinal scale representing frequency of occur-rence (never, 12 times, 35 times, 610 times or> 10 times). In this study, binary classificationsof child abuse (present/absent) followed theguidelines of the Childhood Experiences of Vio-lence Questionnaire as follows. Physical abusewas classified as 1 or more of the following3 criteria: 1) being slapped on the face, head or

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Table 1: Prevalence of child abuse in Canada, by type

Variable

No. (%)*

p value Whole sample Men Women

Physical abuse

Slapped on face head or ears, hit or spanked 5 080 (22.3) 2 700 (26.0) 2 380 (18.6) < 0.001

Pushed, grabbed, shoved, something thrown at 2 550 (10.5) 1 300 (11.8) 1 250 (9.2) < 0.001

Kicked, bit, punched, choked, burned, attacked 2 450 (9.9) 1 350 (11.9) 1 100 (7.9) < 0.001

Any physical abuse 6 070 (26.1) 3 280 (31.0) 2 790 (21.3) < 0.001

Sexual abuse 2 760 (10.1) 640 (5.8) 2 110 (14.4) < 0.001

Exposure to intimate partner violence 1 900 (7.9) 730 (6.9) 1 170 (8.9) < 0.001

Any child abuse 7 700 (32.1) 3 610 (34.0) 4 090 (30.3) < 0.001

Number of child abuse types

No abuse 15 690 (68.0) 6 890 (66.1) 8 800 (69.8) < 0.001

1 type only 5 260 (22.3) 2 720 (25.8) 2 540 (19.0) < 0.001

2 types 1 790 (7.3) 720 (6.6) 1 070 (8.0) < 0.001

3 types 610 (2.4) 160 (1.5) 450 (3.2) < 0.001

*Unweighted numbers are rounded to a base of 10 for con!dentiality purposes according to Statistics Canada data release policies. Percentages are based on weighted numbers. 2 tests of signi!cance for the male and female comparison.

ears, or hit or spanked with something hard 3 ormore times; 2) being pushed, grabbed or shoved,or having something thrown at the respondent tohurt them 3 or more times; and 3) being kicked,bit, punched, choked, burned or physicallyattacked 1 or more times. Sexual abuse was clas-

sified as experiencing attempts or being forcedinto unwanted sexual activity by being threat-ened, held down or hurt in some way, and/or sex-ually touched meaning unwanted touching orgrabbing, kissing or fondling against the respon-dents will 1 or more times. Exposure to intimate

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Table 2: Sociodemographic variables by child abuse in Canada

Variable

No. (%)*

OR (95% CI) No child abuse Child abuse

Age, yr

1834 4 480 (74.6) 1 690 (25.4) 1.0

3549 3 060 (62.9) 1 955 (37.1) 1.7 (1.52.0)

5064 3 830 (62.5) 2 475 (37.5) 1.8 (1.52.0)

65 4 330 (72.9) 1 580 (27.1) 1.1 (0.961.2)

Education

No high school diploma 2 880 (70.9) 1 225 (29.1) 1.0

High school diploma 2 730 (70.4) 1 180 (29.6) 1.0 (0.91.2)

Some postsecondary education 960 (62.3) 540 (37.7) 1.5 (1.21.8)

Trade/college/university certi!cate/diploma 5 865 (67.2) 3 090 (32.8) 1.2 (1.01.4)

University degree (Bachelors or higher) 3 205 (66.8) 1 635 (33.2) 1.2 (1.01.4)

Income, $

29 999 3 760 (67.2) 1 995 (32.8) 1.0

30 00049 999 3 445 (68.9) 1 515 (31.1) 0.9 (0.81.1)

50 00079 999 3 710 (70.2) 1 765 (29.8) 0.9 (0.80.99)

80 000 4 780 (66.2) 2 425 (33.8) 1.0 (0.91.2)

Marital status

Married/common-law 8 310 (66.6) 4 060 (33.4) 1.0

Never married 4 120 (72.7) 1 860 (27.3) 0.8 (0.70.8)

Separated/divorced/widowed 3 245 (65.5) 1 760 (34.5) 1.1 (0.91.2)

Visible minority

No 13 225 (67.3) 6 360 (32.7) 1.0

Yes 2 435 (69.7) 1 315 (30.3) 0.9 (0.81.0)

Country of birth

Canada 12 770 (66.4) 6 360 (33.6) 1.0

Other than Canada 2 865 (71.7) 1 300 (28.3) 0.8 (0.70.9)

Province of residence

Manitoba 1 060 (60.0) 635 (40.0) 1.0

British Columbia 1 725 (64.2) 1 125 (35.8) 0.8 (0.71.0)

Alberta 1 605 (63.9) 990 (36.1) 0.8 (0.71.0)

Saskatchewan 1 070 (68.7) 480 (31.3) 0.7 (0.50.9)

Ontario 3 440 (68.0) 1 670 (32.0) 0.7 (0.60.9)

Quebec 2 890 (72.2) 1 190 (27.8) 0.6 (0.50.7)

New Brunswick 1 030 (66.2) 515 (33.8) 0.8 (0.60.9)

Nova Scotia 1 080 (66.9) 535 (33.1) 0.7 (0.60.9)

Prince Edward Island 755 (70.7) 270 (29.3) 0.6 (0.50.8)

Newfoundland and Labrador 1 040 (79.5) 290 (20.5) 0.4 (0.30.5)

Note: CI = con!dence interval, OR = odds ratio. *Unweighted numbers are rounded to a base of 5 for con!dentiality purposes according to Statistics Canada data release policies. Percentages are based on weighted numbers.

partner violence was classified as having seen orheard parents, step-parents or guardians hittingeach other or another adult in the home 3 ormore times.22 We also computed variables toclassify any child abuse (1 or more individualtypes of child abuse) and a count of the numberof child abuse types (ranging from 0 to 3).

Sociodemographic covariatesThe sociodemographic variables included ascovariates in the logistic regression models wereas follows: age, sex, visible minority, Canadianborn, highest level of education, past yearhousehold income, marital status and provinceof residence.

Mental health variables

Mental disordersLifetime diagnoses of several axis I disorderswere made using the World Health Organizationversion of the Composite International DiagnosticInterview and based on the criteria of the Diag-nostic and Statistical Manual of Mental Disorders,4th edition.23,24 The specific mental disordersincluded depression, bipolar disorder, generalizedanxiety disorder, alcohol abuse/ dependence, anddrug abuse/dependence (including nonmedicalsedatives or tranquilizers, nonmedical analgesics,nonmedical stimulants, cannabis, cocaine, clubdrugs such as ecstasy or ketamine, hallucinogens,heroin or opium, inhalant or solvents, and otherdrugs). Respondents meeting criteria for 1 ormore of these disorders were classified as havingany mental disorder. Additional mental disorderswere assessed using self-reports by asking therespondent if they had a long-term health condi-tion diagnosed by a health professional that hadlasted or was expected to last 6 months or longer(including obsessivecompulsive disorder, post-traumatic stress disorder, panic disorder, phobia, alearning disability, attention deficit disorder andan eating disorder). Respondents who reportedany of these mental conditions were classified ashaving 1 or more of these conditions.

Suicidal ideation and suicide attemptsSuicidal ideation was assessed with a questionthat asked if the respondent ever seriouslythought about committing suicide or taking hisor her own life (yes or no). Suicide attemptswere assessed with a question asking if therespondent had ever attempted suicide or tried totake his or her own life (yes or no).

Statistical analysisWe applied statistical weights to ensure that theestimates reflected the general Canadian popula-

tion. We used bootstrapping as a variance esti-mation technique to account for the complex sur-vey design. First, we estimated the overall andthen sex-specific prevalence of child abuse. Sec-ond, we determined the distribution of socio -demographic variables by any child abuse. Third,we computed logistic regression models to quan-tify the associations between child abuse andmental conditions. Models were first adjusted forsociodemographic variables (adjusted odds ratio[OR] 1) and then further adjusted for other typesof child abuse and other interview-diagnosedmental disorders (adjusted OR 2). Fourth, logis-tic regression models were computed to examinethe doseresponse relation between the numberof child abuse types and mental conditions ad -justing for sociodemographic variables. Finally,we tested for interactions between sex and thedifferent child abuse types, adjusting for socio -demographic variables, for each mental disorderand for suicidal ideation and suicide attempts.Significant models were determined with 95%confidence intervals (CIs) or p < 0.05.

Results

The prevalence of any of the 3 types of childabuse was 32.1%, with physical abuse beingmost common (26.1%), followed by sexualabuse (10.1%) and exposure to intimate partnerviolence (7.9%) (Table 1). Women were morelikely than men to have experienced sexual abuse(14.4% v. 5.8%, p < 0.001) and exposure to inti-mate partner violence (8.9% v. 6.9%, p < 0.001)as children. Men were more likely than womento have experienced physical child abuse (31.0%v. 21.3%, p < 0.001) and any child abuse (34.0%v. 30.3%, p < 0.001). Table 2 reports the distribu-tion of sociodemographic variables amongrespondents with and without a history of childabuse. Respondents aged 35 to 64 years weremore likely than those aged 18 to 34 years toreport having been abused as a child. Childabuse was less likely among respondents whowere never married than among respondents whowere married or in a common-law relationship.The provinces with the highest prevalence ofchild abuse were Manitoba (40.0%), BritishColumbia (35.8%) and Alberta (36.1%). Theprovince with the lowest prevalence of childabuse was Newfoundland and Labrador (20.5%).

In the models adjusting for sociodemo-graphic covariates, all child abuse types wereassociated with increased odds of all mentalconditions (Tables 3 and 4). After further adjust-ment for other child abuse types and mental dis-orders, most interview-diagnosed mental disor-ders and several self-reported mental conditions

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remained associated with physical and sexualabuse. However, obsessivecompulsive disorderremained associated only with sexual abuse.

Eating disorders remained associated with onlyphysical abuse. Posttraumatic stress disorderand learning disability remained associated with

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Table 3: Odds of interview-diagnosed mental condition from the Composite International Diagnostic Interview, by type of child abuse

Mental condition

Physical abuse

Sexual abuse

Exposure to intimate partner violence

Any child abuse

Slapped on face, head or ears, hit or spanked

Pushed, grabbed, shoved or something thrown at

Kicked, bit, punched,

choked, burned or attacked

Any physical abuse

Depression

Adjusted OR1 (95% CI)

2.3 (2.02.7) 2.8 (2.33.3) 2.8 (2.43.3) 2.5 (2.22.9) 3.2 (2.73.7) 2.2 (1.82.8) 2.9 (2.53.3)


1.3 (1.11.7) 1.2 (0.91.6) 1.2 (1.01.6) 1.6 (1.42.0) 1.9 (1.52.4) 0.9 (0.61.2) 2.2 (1.92.5)

Bipolar disorder


2.8 (2.13.7) 3.7 (2.85.0) 4.4 (3.35.9) 3.2 (2.54.2) 3.6 (2.64.8) 4.5 (3.26.3) 3.6 (2.74.9)


0.9 (0.51.4) 1.0 (0.61.8) 1.6 (1.02.4) 1.2 (0.91.7) 1.2 (0.81.8) 2.3 (1.34.3) 1.9 (1.32.7)

Generalized anxiety disorder


2.5 (2.12.9) 2.9 (2.43.4) 3.1 (2.63.7) 2.5 (2.22.9) 2.8 (2.43.4) 2.4 (2.02.9) 2.7 (2.33.1)


1.4 (1.11.7) 1.1 (0.91.5) 1.4 (1.11.8) 1.5 (1.31.8) 1.5 (1.21.9) 1.1 (0.81.4) 1.8 (1.52.1)

Alcohol abuse/dependence


2.4 (2.12.7) 2.3 (2.02.7) 2.2 (1.92.5) 2.5 (2.22.8) 2.5 (2.12.9) 2.0 (1.72.5) 2.5 (2.22.8)


1.8 (1.52.1) 1.0 (0.81.3) 1.1 (0.91.4) 1.9 (1.62.2) 1.5 (1.21.7) 0.9 (0.71.2) 2.0 (1.82.2)

Drug abuse/dependence


3.3 (2.84.0) 3.4 (2.84.2) 3.2 (2.73.9) 3.3 (2.83.9) 3.8 (3.14.6) 3.3 (2.64.1) 3.4 (2.94.0)


1.7 (1.42.2) 1.1 (0.91.5) 1.3 (1.01.6) 1.8 (1.52.2) 1.9 (1.52.4) 1.4 (1.11.8) 2.3 (1.92.8)

Suicidal ideation


3.3 (2.93.7) 3.7 (3.24.4) 4.3 (3.75.0) 3.5 (3.14.0) 4.6 (4.05.4) 3.8 (3.24.5) 4.1 (3.74.7)


1.6 (1.31.9) 1.0 (0.81.2) 1.6 (1.32.0) 1.8 (1.52.2) 2.3 (1.92.8) 1.5 (1.22.1) 2.9 (2.53.3)

Suicide attempts


4.6 (3.56.0) 5.8 (4.57.5) 6.6 (5.28.5) 4.7 (3.66.2) 7.9 (6.110.1) 6.3 (4.88.2) 6.1 (4.68.0)


1.4 (1.02.0) 1.0 (0.71.4) 1.8 (1.32.6) 1.6 (1.12.3) 3.0 (2.14.2) 2.1 (1.43.2) 3.7 (2.75.1)

Any diagnosis from the Composite International Diagnostic Interview


2.8 (2.53.1) 3.2 (2.83.8) 3.1 (2.73.6) 2.9 (2.63.2) 3.5 (3.14.1) 2.9 (2.43.4) 3.1 (2.83.4)


1.9 (1.72.2) 1.3 (1.01.6) 1.5 (1.21.7) 2.3 (2.12.6) 2.5 (2.13.0) 1.3 (1.01.6) NA

Note: adjusted OR1 = odds ratios adjusted for age, sex, visible minority status, Canadian born status, education, income, marital status and province; adjusted OR2 (all models except for any physical abuse and child abuse) = odds ratios adjusted for sociodemographic variables listed above, other types of child maltreatment, and other diagnosed mental disorder from the Composite International Diagnostic Interview; adjusted OR2 (for any physical abuse models) = odds ratios adjusted for sociodemographic variables listed above, sexual abuse and exposure intimate partner violence, and other diagnosed mental disorder from the Composite International Diagnostic Interview; adjusted OR2 (for any child abuse models) = odds ratios adjusted for sociodemographic variables listed above and other diagnosed mental disorder from the Composite International Diagnostic Interview; CI = con!dence interval; NA = not applicable.

sexual abuse and certain individual types ofphysical abuse. Bipolar disorder remained asso-ciated with exposure to intimate partner vio-

lence and one individual type of physical abuse.All 3 types of abuse remained associated withdrug abuse/dependence, suicidal ideation and

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Table 4: Odds of self-reported mental conditions, by type of child abuse

Mental condition

Physical abuse

Sexual abuse

Exposure to intimate partner violence

Any child abuse

Slapped on face, head or ears, hit or spanked

Pushed, grabbed, shoved or something thrown at

Kicked, bit, punched,

choked, burned or attacked

Any physical abuse

Obsessivecompulsive disorder


2.6 (1.64.0) 3.5 (2.25.4) 3.8 (2.45.9) 3.1 (2.04.9) 4.1 (2.56.6) 3.7 (2.36.0) 3.0 (1.84.8)


1.0 (0.61.6) 1.4 (0.82.5) 1.3 (0.72.6) 1.4 (0.92.2) 1.9 (1.23.0) 1.4 (0.82.4) 1.7 (1.02.9)

Panic disorder


1.9 (1.52.4) 2.3 (1.83.0) 2.8 (2.23.6) 2.2 (1.72.7) 2.9 (2.33.7) 1.8 (1.32.3) 2.2 (1.72.8)


1.0 (0.71.4) 1.1 (0.71.6) 1.8 (1.22.5) 1.4 (1.11.8) 1.7 (1.22.2) 0.8 (0.51.1) 1.5 (1.21.9)

Posttraumatic stress disorder


3.1 (2.14.5) 5.2 (3.67.6) 4.9 (3.37.1) 3.3 (2.24.8) 7.0 (5.19.7) 4.5 (3.16.7) 4.4 (3.06.3)


0.8 (0.51.2) 2.2 (1.43.3) 1.2 (0.81.9) 1.2 (0.81.8) 2.9 (2.04.3) 1.4 (0.92.2) 2.5 (1.73.7)

Phobias


3.2 (2.05.3) 3.1 (1.75.8) 3.4 (1.96.0) 2.9 (1.84.6) 3.9 (2.26.9) 3.7 (1.97.2) 3.2 (2.15.1)


1.5 (1.02.4) 1.0 (0.61.9) 1.0 (0.61.7) 1.3 (0.82.0) 2.0 (1.13.5) 1.8 (1.13.2) 2.3 (1.53.6)

Attention de!cit disorder


1.7 (1.32.3) 2.6 (1.93.6) 2.7 (1.93.7) 2.1 (1.62.7) 2.9 (2.14.0) 1.8 (1.22.5) 2.2 (1.72.8)


0.9 (0.71.2) 1.7 (1.12.5) 1.5 (1.02.4) 1.5 (1.12.0) 1.7 (1.22.4) 0.8 (0.51.2) 1.7 (1.32.2)

Eating disorders


3.7 (2.16.7) 3.0 (1.56.0) 5.2 (2.710.0) 4.3 (2.57.6) 4.1 (2.27.6) 3.4 (1.76.7) 4.7 (2.68.5)


1.9 (1.03.6) 0.5 (0.21.3) 2.8 (1.08.0) 2.3 (1.24.5) 1.6 (0.83.2) 1.1 (0.52.5) 3.0 (1.75.2)

Learning disability


1.4 (1.11.8) 2.1 (1.62.8) 2.6 (2.03.4) 1.6 (1.32.0) 2.3 (1.73.1) 2.3 (1.63.3) 1.7 (1.32.1)


0.7 (0.50.9) 1.3 (0.91.9) 1.8 (1.22.7) 1.1 (0.81.4) 1.5 (1.12.1) 1.3 (0.92.1) 1.4 (1.11.7)

Any self-reported mental condition


2.1 (1.72.4) 2.9 (2.43.5) 3.2 (2.63.9) 2.2 (1.92.6) 3.4 (2.84.1) 2.5 (2.03.1) 2.3 (2.02.7)


1.0 (0.81.1) 1.4 (1.11.8) 1.6 (1.22.0) 1.3 (1.11.5) 1.9 (1.62.4) 1.1 (0.91.4) 1.7 (1.52.0)

Note: adjusted OR1 = odds ratios adjusted for age, sex, visible minority status, Canadian born status, education, income, marital status and province; adjusted OR2 (all models except for any physical abuse and child abuse) = odds ratios adjusted for sociodemographic variables listed above, other types of child abuse and any diagnosed mental disorders from the Composite International Diagnostic Interview; adjusted OR2 (for any physical abuse models) = odds ratios adjusted for sociodemographic variables listed above, sexual abuse and exposure intimate partner violence, and any diagnosed mental disorders from the Composite International Diagnostic Interview; adjusted OR2 (for any child abuse models) = odds ratios adjusted for sociodemographic variables listed above and any diagnosed mental disorders from the Composite International Diagnostic Interview; CI = con!dence interval.

suicide attempts. There was a general trend ofincreasing number of child abuse types experi-enced corresponding with greater odds of men-tal conditions, indicating a doseresponse rela-tion (Table 5).

Significant sex-related effects were onlynoted between attention deficit disorder andexposure to intimate partner violence (adjusted

OR for the interaction term: 2.0, 95% CI 1.04.1) and any child abuse (adjusted OR for theinteraction term: 1.8, 95% CI 1.03.1), witheffects being greater for women. Sex-relatedeffects were found for several child abuse typesand suicidal ideation and suicide attempts, withhigher prevalence noted among women in allcases (Table 6).

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Table 5: Odds of mental conditions, by number of child abuse types

Adjusted OR (95% CI);* number of child abuse types

Mental condition No abuse 1 type 2 types 3 types

Interview-diagnosed mental disorders

Depression 1.0 2.6a (2.23.0) 3.2a (2.64.0) 5.3b (3.97.0)

Bipolar 1.0 2.3a (1.63.2) 6.2b (4.19.3) 8.0b (5.112.6)

Generalized anxiety disorder 1.0 2.2a (1.82.6) 3.0b (2.53.7) 5.9c (4.47.9)

Alcohol abuse/dependence 1.0 2.2a (1.92.5) 3.1b (2.63.7) 4.5c (3.36.2)

Drug abuse/dependence 1.0 2.6a (2.23.1) 4.7b (3.66.0) 10.8c (7.815.0)

Any mental disorder 1.0 2.6a (2.32.9) 4.0b (3.34.7) 8.3c (6.211.0)

Suicide

Suicidal ideation 1.0 3.2a (2.73.7) 5.0b (4.16.0) 13.8c (10.418.2)

Suicide attempts 1.0 3.4a (2.44.8) 7.5b (5.510.3) 27.2c (18.240.6)

Self-reported mental conditions

Obsessivecompulsive disorder 1.0 1.6a (0.92.8) 4.5b (2.58.2) 8.9b (4.318.2)

Panic disorder 1.0 1.8a (1.32.3) 2.5b (1.83.4) 4.4c (3.16.3)

Posttraumatic stress disorder 1.0 2.5a (1.54.1) 5.2b (3.38.1) 16.6c (9.828.2)

Phobias 1.0 2.2a (1.33.6) 3.0a (1.75.2) 9.9b (4.024.6)

Attention-de!cit disorder 1.0 1.9a (1.42.5) 2.5a,b (1.83.5) 4.0b (2.36.9)

Eating disorders 1.0 3.6a (1.77.5) 4.7a,b (2.110.6) 10.8b (4.327.1)

Learning disability 1.0 1.2a (0.91.5) 2.5b (1.73.6) 3.2b (2.05.1)

Any self-reported mental disorder 1.0 1.7a (1.42.0) 2.8b (2.33.5) 6.8c (4.89.7)

Note: adjusted OR = odds ratios adjusted for age, sex, visible minority status, Canadian-born status, education, income, marital status and province; CI = con!dence interval. *Adjusted ORs with different superscripts differ signi!cantly at p < 0.05.

Table 6: Interaction terms between sex and type of abuse for associations with suicidal ideation and suicide attempts

Adjusted OR (95% CI), interaction terms*

Type of abuse Suicidal ideation Suicide attempts

Physical abuse

Slapped on face, head or ears, hit or spanked 1.5 (1.11.9) 1.7 (1.02.7)

Pushed, grabbed, shoved or something thrown at 1.3 (0.981.8) 2.0 (1.34.0)

Kicked, bit, punched, choked, burned or attacked 1.7 (1.23.3) 2.0 (1.23.2)

Any physical abuse 1.5 (1.11.9) 1.7 (1.02.9)

Sexual abuse 1.3 (0.91.8) 1.5 (0.92.6)

Exposure to intimate partner violence 1.0 (0.71.5) 1.2 (0.62.1)

Any child abuse 1.6 (1.22.0) 1.8 (1.03.1)

Note: adjusted OR = odds ratios adjusted for age, visible minority status, Canadian-born status, education, income, marital status and province; CI = con!dence interval. *For signi!cant interaction terms, effects were stronger for women than men.

InterpretationWe found strong associations between childabuse and mental conditions. In Canada, 32%of the adult population has experienced physi-cal abuse, sexual abuse and/or exposure to inti-mate partner violence in childhood. All 3 typesof child abuse were associated with all types ofinterview-diagnosed mental disorders, self-reported mental conditions, suicidal ideationand suicide attempts in models adjusting forsocio demographic variables. These modelsindicate that the relation between all 3 types ofchild abuse and mental conditions are robust.The strongest findings were for drug abuse/dependence, suicidal ideation and suicide at -tempts, with all 3 types of child abuse remain-ing significantly associated with these outcomesin the most adjusted models. For other mentalconditions in the most adjusted models adjust-ing for co-occurring types of child abuse andcomorbid mental disorders, specific associa-tions were noted between certain types of childabuse and certain mental health disorders. Wefound a doseresponse relation, with a trend ofmore types of child abuse corresponding withgreater odds of mental conditions. Associationsof some child abuse types with suicidal ideationand suicide attempts were stronger amongwomen than men.

Although measurement and assessment ofchild abuse across studies are not directly com-parable, the prevalence of child abuse in Canadareported in this study is similar to findings fromnational surveys from the United States andprovincial findings from Ontario and Quebec.25,7,11

The current findings are also consistent with pre-vious studies that found robust relations withspecific types of child abuse and mental condi-tions, including suicidal ideation and suicideattempts.57,10,13,16,18,19 What the current study addsis the assessment of a greater number of childabuse types along with more mental conditionsin one study. Importantly, the least severe type ofphysical abuse (being slapped on the face, heador ears, or hit or spanked with something hard)showed a strong association with all mental con-ditions in models adjusting for sociodemo-graphic covariates.

Strengths and limitationsStrengths of the study include the following: thedata are current and nationally representative atthe provincial level in Canada, the large sampleallowed for several sophisticated and high-pow-ered models to be conducted, and several types ofchild abuse and mental conditions were assessed.

However, the data from this study are cross-sectional and retrospective in nature. Inferences

regarding causation cannot be made, and under-lying mechanisms in the relation are not clearfrom these data. It may be that for some peoplea direct relation does exist between child abuseand mental disorders. It may also be the casethat behavioural issues for some children couldbe associated with mental disorders and thatbehavioural problems could increase the likeli-hood of child abuse. Longitudinal data are nec-essary to clarify the possible underlying mech -anisms in the association between child abuseand mental disorders. With regard to the retro-spective nature of the data, there is debate aboutaccurate recall of traumatic memories. Recall ofsexual abuse in particular is controversial. How-ever, evidence suggests that retrospective recallof adverse childhood events provides valid andreliable survey data.2527

Three of the major types of child maltreat-ment were assessed, but measures of neglect andemotional abuse were not included in the survey.Canadian data on these additional types of childmaltreatment are needed.

Although several mental conditions wereassessed in the survey, many important disorders(e.g., personality disorders) were not included,and several disorders were assessed using self-reported diagnoses. Self-reported data to deter-mine prevalence of mental conditions has beenused in other studies;28 it is considered a reliableapproach for assessment in community sam-ples,29 albeit with limitations. The self-reportedmental conditions included here are consideredto be less biased because they were based onself-reported diagnosis by a health professional.

ConclusionOur findings indicate that 32% of the adult pop-ulation in Canada has experienced child abuse(i.e., physical abuse, sexual abuse and/or expo-sure to intimate partner violence) and that childabuse has robust associations with mental condi-tions. Child abuse is an important public healthproblem globally, including in Canada. Allhealth care providers should be aware of therelation between specific types of child abuseand certain mental conditions. Clinicians work-ing in the mental health field should be skilledin assessing patients for exposure to abuse andshould understand the implications for treat-ment. In addition, all clinicians need to be famil-iar with the mandatory reporting requirementsfor their province or territory. From a publichealth standpoint, these findings highlight theurgent need to make prevention of child abuse apriority in Canada. Success in preventing childabuse could lead to reductions in the prevalenceof mental disorders.

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Affiliations: Departments of Community Health Sciences(Afifi, Sareen), Psychiatry (Afifi, Sareen), Family Social Sci-ences (Afifi), Applied Health Sciences (Taillieu), Psychology(Cheung, Sareen). University of Manitoba, Winnipeg, Man.;Department of Psychiatry and Behavioural Neurosciences(MacMillan, Boyle), Department of Pediatrics (MacMillan),McMaster University, Hamilton, Ont.

Contributors: Tracie Afifi developed the research questions,designed and supervised the statistical analysis, interpretedthe findings and wrote sections of the manuscript. HarrietMacMillan and Michael Boyle assisted with the developmentof the research questions, interpreted the findings and wrotesections of the manuscript. Tamara Taillieu and KristeneCheung developed the research questions, designed and con-ducted the statistical analysis, and revised the manuscript.Jitender Sareen developed the research questions, designedthe statistical analysis, interpreted the findings and revisedthe manuscript. All of the authors approved the final versionsubmitted for publication.

Funding: Preparation of this article was supported by aCanadian Institutes of Health Research (CIHR) operatinggrant (Afifi, MacMillan, Boyle and Sareen), a CIHR NewInvestigator award (Afifi), a Manitoba Health ResearchCouncil establishment grant (Afifi) and a Manitoba HealthResearch Council Chair Award (Sareen). Harriet MacMillanis supported by the Chedoke Health Chair in Child Psychia-try. Michael Boyle is a Canada Research Chair in the SocialDeterminants of Child Health.

Acknowledgement: Statistics Canada collected and pro-vided the data for academic purposes, but the analyses are thesole responsibility of the authors. The opinions expressed donot represent the views of Statistics Canada.

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