Profiles of childhood trauma: epidemiological survey results of an educated young community cohort

INTRODUCTION

Childhood adverse experiences may have effects on health and well-being far into midlife and beyond, since development is a lifetime process.¹ Childhood trauma is one of the early life experiences that not only have detrimental effects during childhood but can have negative repercussions long into adulthood and in an advanced age. Childhood trauma or maltreatment encompasses any form of physical and/or emotional ill-treatment, sexual abuse, negligence or repeated trauma experienced during childhood or adolescence.² According to World Health Organization (WHO), nearly 3 in 4 children aged 2-4 years face psychological violence or/and physical punishment from their parents or caregivers and 1 in 13 men and 1 in 5 women have a history of sexual abuse.³ It is estimated that around 64% of children who experienced any sort of violence belonged to South Asia.⁴ In Pakistan, no official statistics on different types of childhood trauma were found after an extensive literature search. However, in 2023, a study declared 2227 case of child sexual abuse (CSA) with 54 % of the victims been girls.⁵ Moreover, the frequent type of trauma in male children was noted to be neglect and physical abuse while female children mostly suffered sexual abuse in Pakistan.⁶ Experiencing childhood traumas can lead to devastating effects throughout the life of a child. These events may occur as a single exposure (acute) or multiple repeated exposures (chronic).⁷ The traumatic events may take place at a larger level of a community, school or workplace to a smaller level of home.⁸ The common perpetrators responsible for child physical abuse, neglect and emotional abuse are reported to from their immediate family whereas sexual abuse was mostly committed by strangers.⁶

Various risk factors have been identified which makes a child prone to trauma including bullying, poverty, family conflict, caregiver disability or addiction, parent’s education, low living standard, single/divorced or remarried parents, child’s disability or birth defects, parent’s illness or mental health problems and living in joint family system.⁹ As a child, such traumas can result in childhood psychopathology, including attention deficit and hyperactive disorder (ADHD), depression and anxiety, personality disorders.⁷ Childhood trauma sufferers face problem in attachment relationships since their early days of life. Feeling unsafe or rejection adversely effects a child’s self-perception, trust in others and how he/she sees the world.⁷ Literature has revealed that adults who experience traumatic events during their childhood are at a higher risk of developing early onset of chronic disorders like diabetes, pre-diabetes, COPD, coronary heart diseases, cancer and depression.¹⁰ History of childhood trauma in adults has also been associated with hazardous health behaviors like smoking, alcohol intake; poor educational and financial achievements including escalation in high school/college dropouts, job problems, failure to honor debt; inclination towards illegal or criminal activities like breaking into someone’s house/ property, fighting, use of marijuana or other illegal substances and poor social relationships including relationships with parents, spouse and friends.¹¹ Pakistan, an under developing country, is struggling in the fields of health, education, social welfare and justice. There is no proper functional system of dealing with cases of childhood trauma. Moreover, child abuse specifically physical abuse is a part of societal norm. All these factors along with fear of shame honor and society taboos become barriers to reporting of childhood trauma cases.¹² Hence, under reporting of such cases is the main obstacle in determining the magnitude of childhood trauma in Pakistan.⁸ Although small efforts have been made by different local organizations and NGO’s but they are not sufficient.¹² Our study aimed to address this much needed grave issue by observing the prevalence of various types childhood trauma in Pakistan, which if identified and prevented at an early stage, can plays a pivotal role in amelioration of this problem. Thus, providing concise goals for pediatric centered public health efforts and the stakeholder to control this under reported problem in the country.

METHODS

This study with mixed method approach was conducted from August till December 2023, comprising young university students (18-25 years) at different public and private sector universities/teaching institutes of Karachi, Pakistan. Initially, the probability cluster sampling was done in order to select universities/teaching institutes. All the seven districts (Karachi Central, East, West, South, Keamari, Korangi and Malir) were taken as clusters from which four of the districts (Karachi East, South, Korangi and Malir) were selected via simple random sampling. Young adults enrolled in undergraduate degree courses in different universities/colleges located in the selected four districts were approached using non-probability convenient sampling to participate in the survey. Postgraduate students were excluded due to major variations in age groups and to avoid recall bias.

The sample size was calculated using Open Epi with a prevalence of 81%, confidence level of 95% and 5% margin of error.¹³ The calculated sample size was 237 which was increased to 300 to strengthen the results. Prior to the survey, the rationale of the research was briefed including methods, their right to withdraw, voluntary nature of their participation and possible risk of emotional stress. Questionnaire was developed after an extensive literature search that explored the subjects’ experiences of childhood trauma in terms of various types including questions regarding socio-demographic variables such as age, gender, marital status, area of residence and monthly household income. Regarding questions related to childhood trauma, despite of the presence of various structured and validated Childhood Trauma Scales in the literature; we were convinced that a qualitative survey would reflect the most frequent types of traumas experienced by children of our region in a better way.² Hence, an open-ended question inquiring about the type/s of traumas experienced by the participants prior to the age of 18 years was asked in the questionnaire. The participants were allowed to give more than one answer. The open-ended answers were compiled according to correspondences and were explained in terms of frequencies and percentages. (Informed consent with study questionnaire is attached as annexure A and B respectively). Written informed consent was obtained before proceeding to the questionnaire. The study participants were assured for the confidentiality and anonymity, and efforts were made to ensure the secrecy of the obtained information.

Statistical analysis

SPSS Version 26.0 was used to enter and analyze data. Mean and SD were calculated for quantitative variables. Chi-square test of significance was applied for categorical variables that were two-tailed to examine the relationship between childhood trauma experience as a dichotomized variable and socio-demographic traits. P-value less than 0.05 was considered statistically significant with a level of significance was set at 0.05. For the open-ended question deemed to the types of childhood trauma, the information was picked up manually after thorough read of given answers and were compiled analogously for frequencies and percentages. MS Excel was used to construct figures.

RESULTS

Of the 300 subjects in the study, there were 134 (44.7%) males, 166 (55.3%) females with an overall mean age of 22.14±2 years. The majority of them, 91.7%, 81.3% and 62.3% were single, lived in an urban area and had monthly household income of more than one hundred thousand respectively. A total of 191 (63.6%) participants experienced any sort of trauma before the age of 18 years (Table 1). The relationship between childhood trauma experience and socio-demographic traits is tabulated in (Table 2) which shows that there was no significant difference between both the groups who had experienced childhood trauma and who did not.

Analyzing the results of the qualitative part of questionnaire, the most commonly reported profiles of childhood trauma were found six in number. As per the open-ended question, among the 191 participants who experienced any type of childhood trauma, 81% were physically and verbally abused by parents or guardian, 45% had a history of unlawful touch and/or sexual abuse, 31% reported separation and divorced of parents, 20% were abandoned by parents, 18% gave history of living with an alcoholic or a drug addict, 14% lived with a mentally ill adult. The (Figure 2) Others trauma types, such as serious ailment or accident and snatching were also stated but were less frequent (<3%). The percentages will not add up as participants were allowed to give more than one answer.

DISCUSSION

The present study aimed to explore the most common profiles of childhood trauma and its relationship with socio-demographic traits among young adults of university level. The results showed a slight increase of childhood trauma in females (66.3%) in contrast to males (60.4%), but no association were found between gender and history of childhood trauma (p=0.335). Similarly, a non-government organization (NGO) of Pakistan reported that out of all victims of childhood sexual abuse, 54 % were girls.⁵ Contrary to our findings, a study reported that the male participants experienced more childhood trauma in comparison of females.¹⁴ Physical abuse and neglect were reported to be more common in male children whereas female children suffered from sexual abuse in other studies.^6,15,16 The present study did not find any relationship between socioeconomic status and experience of childhood trauma in contrast to another study which reported that belonging to low socioeconomic status puts the child at a higher risk of experiencing childhood trauma.¹⁷

We found similar results of trauma experience among individuals living either in rural area or an urban region. Contrary to our results, another research revealed that children living in urban areas are twice likely to experience traumatic events than the rural areas children.¹⁸ In sum, 191 (63.6%) participants experienced any sort of childhood trauma before the age of 18 years. These findings are close to a study targeting young medical students of Pakistan which reported that 52.6% participants experienced at least one form of childhood traumatic events.¹⁹ The current study reported that majority of the participants (81%) experienced physical and verbal abuse in their childhood. Similarly, a report on prevalence of violence in Pakistan highlighted physical violence as one of the most common types of childhood trauma in children accounting for 74%.⁸ Conversely, data of the past ten years revealed that only 16.9% of the childhood abuse and neglect cases were noted to have suffered from physical abuse whereas the majority (70.5%) of the cases faced neglect as a form of childhood abuse.⁶ Khawaja et al mentioned in their research targeting school going adolescent that 33.7% of adolescents faced physical abuse in the past 12 months.²⁰ The findings of the current research revealed that 45% of the participants faced unlawful touch and sexual abuse during their childhood. In consistence, research conducted in Pakistan reported that 41% of university students encountered at least one form of sexual abuse in their childhood.¹³ However, research from Pakistan reported that only 15.5% of the young students suffered from sexual abuse.¹⁹ The cases of child sexual abuse are usually under reported in Pakistan because of a number of reasons including poverty, silence due to fear of the victim child and poor implementation of laws against child sexual abuse.²¹ In 2022, Gilani Research foundation Survey, reported that 60% of Pakistanis pronounced an increase divorce rate in the country due to colossal causative factors.²² Analogous to the report we also noted that around 31% of the participant’s parents got separated or divorced. Similarly, a US based study reported that 21.9% of the respondent’s parents were divorced or separated while a previous study conducted in 2017, reported that only 4.7% of the victims had history of divorce/separation of their parents.^17,19 We found that around 20% of the individuals were abandoned by their parents or guardian during childhood which was alarming. Though, a report in 2020, mentioned that only 3% of the children were abandonment by their parents in Pakistan which was not found to correspond with our results.⁶ It is necessary to dig deep to find out the main cause of the issue. Moreover, 18% participants of the present research gave history of living with an alcoholic or a drug addict and 14% lived with a mentally ill adult in their childhood. A United States based research noted that just over eight percent (8.1%) of the children gave history of living with a drug/ alcohol addict while 7.1% had lived with someone who was mentally ill, depressed or suicidal.¹⁷ Being a Muslim state we anticipated a low prevalence of the above two scenarios but the results depict that substance abuse and mental illness have an overwhelmed increase in our society irrespective of the socio-demographic status.

Limitations

Since the study data on childhood trauma self-reported in nature, possibility of underreporting and recall bias cannot be avoided. Besides, the sample was particularly from university level students, and therefore cannot be generalized for all Pakistani young adults. Further, the questionnaire was administered in a single moment in time, cause-and-effect relationship cannot be analyzed. Longitudinal studies at national and provincial levels, comprising of larger samples are recommended which will truly depict the prevalence and associated factors of childhood trauma in Pakistan. Regardless of the limitations, the study does suggest a way forward and provides basis for development and formulation of preventive strategies along with the formation and implementation of legislative measures against childhood trauma in Pakistan.

CONCLUSION

Childhood trauma is under reported in spite of the dreadful effects which may last long into adulthood resulting in poor mental and physical health. This study is an attempt to give an insight into the alarming situation of this public health issue. It reveals increased prevalence of childhood trauma cases in Pakistan which has been neglected for long. A proper functional child protection system in the country is the need of an hour.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Infurna FJ, Rivers CT, Reich J, Zautra AJ. Childhood Trauma and Personal Mastery: Their Influence on Emotional Reactivity to Everyday Events in a Community Sample of Middle-Aged Adults. PLoS One. 2015;10(4):e0121840.
2. 2. Zhang S, Lin X, Liu J, Pan Y, Zeng X, Chen F, et al. Prevalence of childhood trauma measured by the short form of the Childhood Trauma Questionnaire in people with substance use disorder: A meta-analysis. Psychiatr Res. 2020;294:113524
3. 3. Fact Sheets-Child Maltreatment. Available at: https://www.who.int/news-room/fact-sheets/detail/child-maltreatment. Accessed on 20 November 2023.
4. 4. Hillis S, Mercy J, Amobi A, Kress H. Global prevalence of past-year violence against children: a systematic review and minimum estimates. Pediatrics. 2016;137(3):2018-23.
5. 5. Bano M, Hameed W, Batool R. A compilation of statistics on child sexual abuse of reported cases in Pakistan: Sahil Six Months Cruel Numbers Report January-June 2023. Available at: https://sahil.org/wp-content/uploads/2023/08/Cruel-Number-Sixth-Month-Report-2023.pdf. Accessed on 20 November 2023.
6. 6. Zafar N, Naeem M, Zehra A, Khalid M. Ten years data of child abuse and neglect cases managed at the first hospital-based child protection unit in Pakistan. APJPCH. 2020;39(1):30-6.
7. 7. Dye H. The impact and long-term effects of childhood trauma. J Hum Behav Soc Environ. 2018; 28(3):381-92.
8. 8. Zakar DM. Prevailing situation of violence against children in Pakistan. Cell. 2016;332:4825266.
9. 9. Meinck F, Cluver LD, Boyes ME, Mhlongo EL. Risk and Protective Factors for Physical and Sexual Abuse of Children and Adolescents in Africa: A Review and Implications for Practice. Trauma Viol Abuse. 2015;16(1):81-107.
10. 10. Sonu S, Post S, Feinglass J. Adverse childhood experiences and the onset of chronic disease in young adulthood. Prevent Med. 2019;123:163-70.
11. 11. Copeland WE, Shanahan L, Hinesley J, Chan RF, Aberg KA, Fairbank JA, et al. Association of childhood trauma exposure with adult psychiatric disorders and functional outcomes. JAMA. 2018; 1(7):e184493.
12. 12. Mehnaz A. Child Abuse in Pakistan-Current Perspective. Nat J. 2018;3(4):115.
13. 13. Abbas SS, Jabeen T. Prevalence of child abuse among the university students: a retrospective cross-sectional study in University of the Punjab, Pakistan. Int Quart Community Health Edu. 2020; 40(2):125-34.
14. 14. Ashraf F, Niazi F, Masood A, Malik S. Gender comparisons and prevalence of child abuse and post-traumatic stress disorder symptoms in adolescents. JPMA. 2019;69(3):320-4.
15. 15. Sikandar Z, Hanif R, Sadia R. Childhood Traumas: A Significant Cause of Substance Use among Young Adults in Pakistan. Human Nat J Social Sci. 2023;4(2):469-580.
16. 16. Freisthler B, Maguire-Jack K. Understanding the Interplay Between Neighborhood Structural Factors, Social Processes, and Alcohol Outlets on Child Physical Abuse. Child Maltreat. 2015;20(4):268-77.
17. 17. Crouch E, Probst JC, Radcliff E, Bennett KJ, McKinney SH. Prevalence of adverse childhood experiences (ACEs) among US children. Child Abuse Neglect. 2019;92:209-18.
18. 18. Dobbins DL, Berenson LM, Chen H, Quandt SA, Laurienti PJ, Arcury TA. Adverse Childhood Experiences Among Low-Income, Latinx Children in Immigrant Families: Comparison of Children in Rural Farmworker and Urban Non-Farmworker Communities. J Immigrant Minor Health. 2022;24: 977-86
19. 19. Haaris Sheikh M, Naveed S, Waqas A, Tahir Jaura I. Association of adverse childhood experiences with functional identity and impulsivity among adults: a cross-sectional study. F1000 Res. 2017;6: 1978.
20. 20. Khawaja S, Khoja, A, Motwani K. Abuse among school going adolescents in three major cities of Pakistan: is it associated with school performances and mood disorders? JAMA. 2015;65(2):142-7.
21. 21. Khaliq J, Khattak RI. Prevalence of Child Sexual Abuse-Pakistan's Context. Technium Soc Sci J. 2020;9(1):671-7.
22. 22. Noor S, Noreen M, ul Haq I. Perceived influence of Divorce on Children: A Qualitative Secondary Data Analysis. Pak J Humanit Soc. 2023;11(2):1941-5.