Childhood maltreatment and its relation with depression and anxiety among psychiatric patients in Riyadh - KSA.

Objectives: Abuse can occur at any stage of childhood leaving an impact on the individual's future mental health. It could be verbal, physical, and emotional. In this research, we focus on determining the correlation of childhood abuse and psychiatric patients with specific aims of identifying the link between depression and anxiety towards child maltreatment.
Methods: This cross-sectional study was conducted in a psychiatric clinic among 155 depression and anxiety male and female patients who were randomly selected with age ranging from 20 to 50 plus years. The data were collected by a printed survey distributed manually.
Results: Survey of 155 patients showed that (66.5%) raised with both parents. The punishment witnessed by patients in the household was physical (35.5%), emotional (26.5%), and verbal (18.1%). (51.6%) of the patients answered "yes'' when they were asked whether if their caregiver acted in a way scared patients' of getting hurt. Caregivers react to mistakes (X 2 = 17.665; P = 0.007), caregiver acted in a way that made patients afraid of getting hurt (X 2 = 8.396; P = 0.015). Other variables did not significantly influence anxiety and depression (All > 0.05).
Conclusion: Overall, gender and growing with both parents may not affect the psychology of an individual, but maltreatment in childhood (e.g., resorting to physical punishments, constant threats from the caregiver) increases the chances of getting depression/anxiety in adulthood. Regarding our research, childhood maltreatment memories hunt adults in their future leading to psychological damage. Consequently, recognition of childhood maltreatment in family and PHC physicians' clinic might aid in treatment, selection, and management. General Objective: • To determine the correlation of childhood abuse with psychiatric patients in Riyadh - Kingdom of Saudi Arabia (KSA). Specific Objective: • To identify the link between depression and anxiety to childhood maltreatment.• To identify the correlation of childhood maltreatment with depression.• To identify the correlation of childhood maltreatment with anxiety. Settings and Design: A cross-sectional study consisted of 155 psychiatric patients randomly selected from the University Medical Centre, Riyadh, capital of Saudi Arabia, in January 2020. The samples contained psychiatric patients with depression and anxiety male and female ranging from 20 to 50 plus years. All participants voluntarily participated in this study. Methods and Material: Collection instrument is a self-administered, pre-coded, pre-tested questionnaire devolved mainly for the purpose of this study after consultation from literature and an epidemiologist containing data pertaining to diagnosis, socioeconomic states, and educational level. Statistical Analysis Used: Data were analysed using Statistical Packages for Social Sciences (SPSS) version 23 and Microsoft Excel to generate tables and charts with P < 0.05 considered significant. Data presentation tables are given below. All qualitative variables were presented in terms of numbers and percentages. The relationship between depression and anxiety among the basic demographic data and characteristics of patients during childhood maltreatment had been conducted using Chi-square test. A P < 0·05 was considered statistically significant. Data analyses were performed using SPSS version 21.
Conclusion: The study concludes that the presence of maltreatment in childhood (e.g., resorting to physical punishments, constant threats from the caregiver) does in fact increase the chances of acquiring depression or anxiety in adulthood, while other factors (e.g., gender, presence of both parents) do not play a major role compared to maltreatment of the child. The psychological state of children must be well taken care of, and they should be brought up within a supportive healthy environment by a civilized parenting method. Based on our research, childhood maltreatment memories will hunt adults in their future and cause them serious psychological damage. That is why, the recognition of childhood maltreatment in family and primary health care (PHC) physicians' clinic might aid in treatment, selection, and management. Copyright:

Introduction

Child maltreatment defined according to World Health Organisation (WHO) as all types of physical, emotional, sexual abuse and neglect, which causes harm to the child’s health.[1] In Saudi Arabia, physical abuse and neglect was shown to be the most prevalent maltreatment.[2] Any experience of maltreatment during childhood may reflect on the child’s physical, mental, and social health later.[3] According to WHO, depression is recognized as a consequence of maltreatment.[1]

Depressive symptoms scored higher rates in participants with childhood maltreatment.[4] Psychological abuse has the strongest association with depression and anxiety.[5] Majority of primary-care physicians agreed that child abuse is still underreported in Kingdom of Saudi Arabia (KSA) due to physicians’ lack of knowledge.[3] Primary health care (PHC) physicians are the first to contact injured children and hence play a crucial role in early identification and intervention.[6]

Results

In this study, we recruited 155 psychiatric patients in a random psychiatric clinic in Riyadh, Saudi Arabia. Ethical approval is obtained from the “University Medical Center”, date of approval is: (1-10-2019). Table 1 presented the basic demographic data of 155 patients. The most commonly known age group was between 30 and 39 years (40.6%) with slightly higher number of males (51.6%). We further observed that two third (66.5%) of them grew up with both parents.

Table 1

Basic demographic characteristics of psychiatric patients (n=155)

Study variables	n (%)
Age group
20-29 years	38 (24.5%)
30-39 years	63 (40.6%)
40-49 years	36 (23.2%)
≥50 years	18 (11.6%)
Gender
Female	75 (48.4%)
Male	80 (51.6%)
Grew with both parents
Yes	103 (66.5%)
No	52 (33.5%)

Figure 1 showed the prevalence of anxiety and depression among psychiatric patients due to childhood abuse. It was revealed that the prevalence of depression has been detected in 27.1% of patients (objective 1), while the prevalence of anxiety has been detected in 29% (objective 2), whereas patients with both anxiety and depression were found among 29.7% (objective 3).

Figure 1

Prevalence of childhood anxiety and depression

Table 2 described the characteristics of patients toward childhood maltreatment. Based on the results, the most frequently mentioned childhood punishment witnessed by patients in the household was physical (35.5%), followed by emotional (26.5%) and verbal (18.1%). We also observed that 37.4% of the patients had required medical assistance, resulting to conflict with caregiver. When asked how often they experienced embarrassing moment in front of other people due to their caregiver action, a little over half of them stated “sometimes.” Furthermore, 35.5% of the patients revealed that their caregivers felt ashamed of them based on their action. The most commonly mentioned is caregivers react to mistakes was either explaining the mistakes done (29%) or physical punishment (29%). When asked how often the caregiver paid attention to what they say, more than a half of them (57.4%) stated “sometimes.” When caregiver acted in a way that made patients afraid of getting hurt (51.6%) said “yes.”

Table 2

Characteristics of patients with regard to childhood maltreatment (n=155)

Statement	n (%)
Harshest punishment you have witnessed in the household
Physical	55 (35.5%)
Emotional	41 (26.5%)
Verbal	28 (18.1%)
None of the above	31 (20.0%)
Required medical attention after a conflict with caregiver
No	97 (62.6%)
Yes	58 (37.4%)
How often does your caregiver say very personal and embarrassing things about you in front of other people?
Never	57 (36.8%)
Sometimes	77 (49.7%)
Always	21 (13.5%)
Does your caregiver act like they are ashamed of you?
No	100 (64.5%)
Yes	55 (35.5%)
When you do mistakes, how does your caregiver react?
Explain	45 (29.0%)
Physical punishment	45 (29.0%)
Verbal punishment	37 (23.9%)
Emotional punishment	28 (18.1%)
How often does your caregiver pay attention to what you say?
Always	29 (18.7%)
Sometimes	89 (57.4%)
Never	37 (23.9%)
Did a parent or caregiver act in a way that made you afraid of getting hurt?
No	75 (48.4%)
Yes	80 (51.6%)

When measuring the relationship between anxiety and depression in relation to the basic demographic data and the characteristics of the patients toward childhood maltreatment [Table 3], we have learned that caregivers reaction to mistakes (X2 = 17.665; P = 0.007) and the act of parents/caregivers that made patients afraid of getting hurt (X2 = 8.396; P = 0.015) significantly influenced childhood anxiety and depression. Other variables included in the test did not significantly influence anxiety and depression (All > 0.05).

Table 3

Relationship between anxiety and depression among the basic demographic data, and the characteristics of patients with regard to childhood maltreatment (n=133)*

Factor	Depression n (%) (n=42)	Anxiety n (%) (n=45)	Both n (%) (n=46)	χ 2	P §
Age group
20-29 years	12 (28.6%)	13 (28.9%)	08 (17.4%)	3.411	0.492
30-39 years	14 (33.3%)	18 (40.0%)	23 (50.0%)
≥40 years	16 (38.1%)	14 (31.1%)	15 (32.6%)
Gender
Female	23 (54.8%)	24 (53.3%)	17 (37.0%)	3.528	0.171
Male	19 (45.2%)	21 (46.7%)	29 (63.0%)
Grew with both parents
Yes	31 (73.8%)	33 (73.3%)	25 (54.3%)	5.021	0.081
No	11 (26.2%)	12 (26.7%)	21 (45.7%)
Harshest punishment you have witnessed in the household
Physical	18 (42.9%)	20 (44.4%)	10 (21.7%)	11.291	0.080
Emotional	13 (31.0%)	13 (28.9%)	12 (26.1%)
Verbal	06 (14.3%)	08 (17.8%)	11 (23.9%)
None of the above	05 (11.9%)	04 (08.9%)	13 (28.3%)
Required medical attention after a conflict with caregiver
No	23 (54.8%)	27 (60.0%)	33 (71.7%)	2.865	0.239
Yes	19 (45.2%)	18 (40.0%)	13 (28.3%)
Experienced embarrassing moments from caregiver in front of other people
Never	15 (35.7%)	15 (33.3%)	17 (37.0%)	0.880	0.927
Sometimes	20 (47.6%)	25 (55.6%)	23 (50.0%)
Always	07 (16.7%)	05 (11.1%)	06 (13.0%)
Does your caregiver act like they are ashamed of you?
No	27 (64.3%)	30 (66.7%)	26 (56.5%)	1.090	0.580
Yes	15 (35.7%)	15 (33.3%)	20 (43.5%)
When you do mistakes, how does your caregiver react?
Explain	08 (19.0%)	07 (15.6%)	20 (43.5%)	17.665	0.007**
Physical punishment	18 (42.9%)	15 (33.3%)	10 (21.7%)
Verbal punishment	12 (28.6%)	10 (22.2%)	06 (13.0%)
Emotional punishment	04 (09.5%)	13 (28.9%)	10 (21.7%)
How often does your caregiver pay attention to what you say?
Always	06 (14.3%)	06 (13.3%)	10 (21.7%)	2.431	0.657
Sometimes	25 (59.5%)	30 (66.7%)	24 (52.2%)
Never	11 (26.2%)	09 (20.0%)	12 (26.1%)
Did a parent/caregiver act that made you afraid of getting hurt?
No	15 (35.7%)	17 (37.8%)	29 (63.0%)	8.396	0.015**
Yes	27 (64.3%)	28 (62.2%)	17 (37.0%)

*Participants who declined to answer questions regarding the mental disorder diagnosis during childhood were excluded from the analysis. §P has been calculated using Chi-square test. **Significant at P<0.05 level.

Discussion

Data have shown that nearly half of the participants were from middle age and this goes in line with a previous study done by[7] which stated that depressed older adults reported high rates of childhood abuse. Majority of them were males which was not expected because females are usually more sensitive, and this is not in line with the study by[8] which indicated that most of the patients were females and this contradiction was perhaps due to different locations of the study. Most participants that were diagnosed with depression and anxiety have grown with both parents which was way too far from our expectations which included parents divorcement as a main reason for depression and anxiety, and this goes in contrary with previous study by[9] that showed children in divorced groups had lower security scores on the Attachment Q–Set instrument.[10]

Majority of participants diagnosed with depression witnessed physical punishment as the harshest punishment in the household, which was expected, and this goes in line with the study done by[11] that indicated physical punishment was associated with increased odds of major depression. This can be due to the lack of awareness by caregivers in terms of grounding the children, so they resort to the uncivilized action which is physical punishment. Unfortunately, some of them needed medical attention due to the physical punishment they got. As family and primary care physicians are the first line in health care to provide victims of abuse and neglect the care they need. Early detection and intervention could prevent the consequences of harmful effect of child abuse.

The majority of participants diagnosed with depression mentioned that sometimes their mother\father say very personal or embarrassing things about them in front of people, which was expected, and this goes in line with other research conducted by[12] which indicated that social anxiety and embarrassment are difficult to disentangle at the autonomic level.

This result could be due to the fact that the parents are not aware of the effect of emotional embarrassment and its relationship with psychiatric illnesses. Primary care and family physicians have a continuous relationship with their patients as they are known to be first contact in the health field so raising awareness regarding child maltreatment could help reduce and prevent later on consequences.

The highest frequency of depression diagnosed in participants indicated that their caregiver does not act like they are ashamed of them, this goes against our expectations because we expected that some of the emotional punishment that comes from the parents will include acting like if they are ashamed of their children in front of others. Majority of participants diagnosed with depression revealed that their parents or caregiver have acted in a manner which made them feel afraid of getting hurt which was expected. In conclusion our study showed a strong relation between child maltreatment with anxiety and depression on their adulthood life we would like to emphasize on the crucial role of primary care and family physicians for the early detection, intervention, and prevention of the future consequences of child maltreatment.

Recommendation

This should raise the awareness of the correlation between childhood abuse and depression/anxiety among primary care and family physicians as well as society. As family and PHC physicians are the first line encountering these types of patients, it is suggested that they should be able to screen and diagnose these patients as an early intervention in order to provide them the help they need. Parents must use the modern educational methods to raise their children which include: giving them more attention and spending more time with them, avoid embarrassing them in front of others, avoid acting as if they are ashamed of their children even if they did a mistake, and never act in harsh ways that will make them afraid of getting hurt by you. Further investigations should be performed by researchers regarding family history of depression and anxiety.

Financial support and sponsorship

Almaarefa university research committee.

Conflicts of interest

There are no conflicts of interest.