Science & research

Making connections

A local researcher is working to find the links between child abuse and mental health

Dr. Tracie Afifi is one of Canada's leading mental health researchers.
Dr. Tracie Afifi is one of Canada's leading mental health researchers.
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Probing the link between gambling and mental health 

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Winnipeg Health Region
Wave, Summer 2014

Dr. Tracie Afifi's most recent research project certainly was a headline-grabber.

The study, published in April, reported that 32 per cent of Canadians (40 per cent in Manitoba) had experienced abuse as a child.

That finding - based on the first nationally representative investigation of child abuse in Canada - generated news coverage across the country.

And yet, these were not necessarily the most newsworthy numbers in the study.

"The numbers (on the prevalence of child abuse) weren't really a surprise because they're in keeping with data from the United States," says Afifi, an associate professor in the Departments of Community Health Sciences and Psychiatry, Faculty of Medicine, University of Manitoba.

The more significant finding, she says, is that many of those who suffer abuse as a child go on to experience mental health issues - such as depression, anxiety, substance abuse and suicide attempts - in later life.

"What was interesting to me is people were more interested in just the prevalence of child abuse, and they didn't really pay much attention to what the bulk of the paper was about, which was how abuse is associated with mental disorders," says Afifi, who is also principal investigator with the Manitoba Population Mental Health Research Group.

In fact, the study - produced along with co-investigators Drs. Harriet MacMillan, Michael Boyle, Jitender Sareen and researchers Tamara Taillieu and Kristene Cheung - suggests that those who are abused have a three times increased odds of experiencing a mental disorder and a six times increased odds of attempting suicide compared to individuals who did not experience abuse.

"From a public health standpoint, these findings highlight the urgent need to make prevention of child abuse a priority," says Afifi. "Also, success in preventing child abuse could lead to reductions in the prevalence of mental disorders, suicidal ideation, and suicide attempts," she says.

Canadian mental health researchers have long pondered the potential connections between child abuse and mental health issues in later life. But their research efforts have been hampered by the fact that there were no nationally representative Canadian data on the subject.

That changed with Statistics Canada's Canadian Community Health Survey: Mental Health 2012. It was the first time the agency had collected data on child abuse, and it opened the door for Afifi and her colleagues to take a closer look at the issue. 

As part of the data collection process, Statistics Canada interviewed thousands of Canadians, mostly in person, about their experiences with three categories of abuse: physical abuse, sexual abuse and exposure to intimate partner violence. The same respondents were also asked whether they had experienced any mental health issues. Once the surveys were completed, the information was placed in a database and made available to researchers.

Afifi and her colleagues then used a validated research tool to categorize the responses according to type and severity of abuse.

For physical abuse, the most severe classification involved being punched, kicked, choked, burned or physically attacked one or more times before age 18 by a guardian or parent. The moderate classification involved acts like being pushed, grabbed and shoved three or more times. The least severe classification was being slapped across the face, on the head or ears, or being spanked with something hard, such as spanked with an object, three or more times. Sexual abuse was defined as having been forced into unwanted sexual activity one or more times, and exposure to intimate violence was categorized as having seen parents or guardians hit each other three or more times. They also looked to see whether the respondents in question had experienced mental health disorders, such as depression, bipolar disorder, generalized anxiety disorder and alcohol and drug dependence.

Interestingly, one act not included in the Statistics Canada data or Afifi's study was the act of spanking a child by hitting him or her on the buttocks with a hand.

Although some experts, including Afifi, believe spanking should not be used on children of any age, the fact is that it is legal in Canada, and is considered an acceptable form of punishment by a number of Canadians. So, for the purposes of her current study, Afifi focused on acts that are deemed to be illegal. "You can't hit a child in the face or head, and you're not allowed to hit them with an object," she says. "These are not acceptable forms of violence, by law; therefore, we were very comfortable referring to them as physical abuse."

The importance of Afifi's research, funded by the Canadian Institutes of Health Research and Manitoba Research, cannot be underestimated. Statistics drive policy-making on how best to use limited resources for intervention and prevention programs for mental illness. In fact, informed, statistics-based mental health care is the raison d'être for the Manitoba Population Mental Health Research Group - the innovative coalition to which Afifi and many of the province's top mental health researchers belong.

Located at Health Sciences Centre Winnipeg's PsychHealth Centre at 771 Bannatyne Avenue, it is a nationally recognized leader in epidemiological mental health research. But it is the scope of the investigations being carried out by the group that sets it apart from other centres of mental health study in Canada, says Dr. Jitender Sareen, a professor of psychiatry in the Faculty of Medicine at the University of Manitoba and the research group's team leader.

Until the research group was formed six years ago, says Sareen, no one was doing in-depth epidemiological work - sifting through huge amounts of population health data - to reveal broad-sweeping, evidence-based insights about mental health in Canada. Now, says Sareen, the group's leading investigators - including Afifi and Drs. Laurence Katz, Sarvesh Logsetty, James Bolton and Murray Enns - are advancing our knowledge of mental health by providing empirical evidence at the population level that will improve prevention and treatment.

"People know now more than ever that mental health is an important health-care priority, but our group is really moving toward developing strategies about what we can do to improve care for people suffering from mental illness."

Afifi's work underscores the point. At the age of 37, she has already established herself as one of Canada's leading experts in mental health research. In addition to her groundbreaking research on child abuse, she has also conducted major studies into problem gambling, another area of interest. Over the last five years, she has published several research papers on the subject, and is involved in a study into the relationship between problem gambling and child abuse.

The main priority right now, though, is a follow-up study, also funded by the Canadian Institutes of Health Research and Manitoba Research, on the work published last spring. It could have far-reaching implications for how prevention and intervention strategies are developed for treating mental illness, including gambling addiction.

As Afifi explains, there is evidence to suggest that abuse can lead to mental health issues in a number of ways. "There is brain imaging research that shows that it (abuse) actually changes how your brain grows and develops. And so having your brain change can have an impact on physical and mental health outcomes," she says, noting this may be especially true for children under five years of age because they experience rapid brain development. In addition, repeated abuse can lead to chronic stress, anxiety, fear, shame, and reduced self-esteem, leading to mental health issues.  
Yet, while her last study suggests that some who suffered abuse in their youth also experienced mental health issues in later life, it also revealed that many adults who were mistreated as children didn't develop serious mental disorders. The question is, why?

"Preventing child abuse from occurring is a top priority, but so is preventing mental disorders after abuse is experienced," says Afifi. "Fortunately, not everyone who experiences child abuse will develop a mental disorder. We think of these individuals as being 'resilient.'"

And that's the focus of her current research - trying to learn from individuals deemed to be resilient.

"There's not a lot of research in the area of protective factors related to resilience following child maltreatment," she says. "So we want to take what we learn from what can be a protective factor and start thinking about intervention and prevention strategies for both child abuse and mental illness."

Many variables could be a factor in whether someone who suffers child abuse is resilient and goes on to have a relatively healthy life and sense of overall well-being. The challenge is finding them, says Afifi.

"Are there protective factors in their environment? Was it a relationship? Was it something to do with characteristics of their personality? Was there something in their school or community that is associated with having a better outcome even though they've experienced abuse?"

At this stage, Afifi is poring over the same Statistics Canada data that she used in her earlier study to find the answers.

When completed, Afifi hopes her research will be used to inform health professionals, and policy makers, and encourage parents to use positive parenting approaches that do not include physical acts, including spanking.

Sareen says Afifi's latest research project on resiliency will no doubt shed new light on the connections between child abuse and mental health. "Where we're at in the field now is similar to the 1960s and 1970s with smoking and lung cancer, when people were starting to get the idea that smoking has long-term negative impacts on physical health and mortality," he says.

Adds Afifi: "We know that child abuse is bad, so what we need to do now is focus on how we can prevent child abuse from happening, and how to help people who have been abused recover from it."

Afifi is reticent to make predictions about what makes some individuals more resilient to the trauma of child abuse than others. "At this point, we're looking at population-level data for people who would be categorized as abused, examining whether or not they have a mental disorder and whether they have a high quality of life."

She says they have yet to determine what portion of the 32 per cent of respondents in the Canadian Mental Health Survey who suffered child abuse could be considered resilient. "We're looking at different things like education, personality characteristics, family relationships and the influence of community to find correlations."

Afifi expects to conclude her study within the next year, and a number of research partner organizations - like Healthy Child Manitoba - are eager to learn the results. That's because if Afifi can identify consistent factors that promote resiliency, policy-makers in the health-care system, along with mental health-care providers, can develop strategies to help victims of abuse and lessen their chances of struggling with mental illness.

"The way I see it is that when a child is abused, there's a big potential for their development to be negatively affected," Afifi says. "My belief is if you can prevent the abuse from occurring, you can change the trajectory of the child's life."

Joel Schlesinger is a Winnipeg writer.

Wave: Summer 2014

About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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