“Child maltreatment” – sexual, physical, and emotional abuse and neglect as potential predictors of suicidal behaviour among adolescents – an acute problem in Poland

Introduction

Suicide and the sources of such self-destructive behaviour among the adolescent population [1, 2] constitute an acute problem in Poland [3] as well as globally [4]. In a view of the above, an attempt was made to present selected predictors of suicidal behaviour based on an analysis of scientific findings in the area of suicidology, to increase the awareness of the medical personnel of general paediatric clinics and other (including non-medical professionals) about suicide risks in this particular social group.
One of the leading causes of suicide among adolescents is, apart from psychological and cognitive factors [5], being exposed to violence in childhood and adolescence. Abuse of children is a very common and underestimated phenomenon, but it often remains unreported to official institutions, undetected, or ignored. It is believed that cases of sexual abuse declared by victims are 30 times more numerous than incidents reported in official statistics, whereas the scale of physical abuse may be even 75 times higher [6]. According to a country-wide report conducted in Poland in 2018, which diagnosed the scale of child maltreatment among pupils aged 11 to 17 years, more than half of the respondents (57%) fell victim to peer violence, 41% – to violence from a significant other, and 20% admitted to having experienced sexual incrimination (being recruited for sexual purposes on the Internet or exhibitionism); 7% of pupils experienced sexual abuse [7]. In 2018, 4909 children in Poland suffered from physical or psychological abuse in their family homes [8]. Another project, “Adverse Childhood Experiences”, was conducted in Poland in 2016 in a group of 1772 students (20.46 ±1.24 years old) on behalf of the World Health Organisation and the Polish Ministry of Health [9, 10]. In that project, 41% of participants declared to have experienced emotional violence, 17% – physical violence other than smacks, and 5% claimed to have been sexually maltreated. The main goal of the project was to diagnose the scale of violence experienced in childhood and how such experiences influence risky behaviour. The most noteworthy is violence inflicted on children by their most significant others [7, 9, 10]. It is difficult to determine which age group suffers from violence most often. Data from feedback depend on the responding group. According to violence victims, the largest percentage of maltreatment victims are aged 10 to 14 years (53.6%). On the other hand, according to offenders, violence as most often experienced by children aged 5 to 9 years (37.1%) and 10 to 14 years (30.6%). Adolescents aged between 15 and 18 years are the least affected by violence both according to victims and offenders. In the opinion of witnesses, violence was most often directed at children aged 10 to 14 years (34.3%) and 15 to 18 years (28.2%) [11]. Analysis of the findings of research conducted among psychiatric patients suggests that the scale of the problem significantly exceeds the above numbers [1, 4].
The consequences of violence outlive the period of time during which it is experienced. Childhood traumas are often pushed into the unconscious, and they affect the functioning of the maltreated person later in life [12, 13]. Violence victims may develop emotional detachment, stupor states, or anxious and depressive states as a result of distorted relationships, especially if violence was experienced from the most significant others [5, 14, 15], which is explained by Bowlby’s theory of attachment [16]. According to that theory, attachment (an emotional relationship between an attachment figure and a child driven by biological mechanisms) to a child’s primary caregiver determines future interpersonal relationships. It also affects one’s perception of oneself and at the same time one’s psychological health later in life [16]. This internal operating model develops in the first year of a child’s life. Its main objective is to create and prolong a close relationship with a person [5]. This is vital for the understanding of the future consequences of violence inflicted by parents on their child at an early stage of the child’s life. This theory is not the only explanation for the relationship between parents and their children in the context of suicidal risk. In paediatrics, special attention is paid to the approach presented, i.a. by Jankowska, according to which family dysfunction and instability hinders the upbringing process, destroying and blocking the development of the young person. Such a family is a source of chronic stress for a child at every stage of its development, becoming a predictor of suicidal behaviour [17].
If the processes of developing an internal operating model [16] and effective emotion regulation, which are dependent on a good relationship with an attachment figure formed in childhood, are distorted and feelings of loneliness and confusion are experienced [17], adolescents may develop suicidal thoughts or other self-aggressive behaviour. It has also been confirmed that there is a link between the number of forms of violence and abuse and the risk of suicide [1, 17]. The correlation between suicidal behaviour and such variables as gender, age, psychopathology of caregivers, and, what is important, pre-existing self-mutilation, which were not related to a history of suicidal self-harm before, are also significant [15, 18]. It is essential to understand the causes behind self-destructive behaviour among adolescents in order to implement optimal preventive measures, firstly in their most immediate environment: in the family, at school, and among peers, and secondly in the society in general [19]. It is also vital to raise the awareness of medical and non-medical professionals, including nurses working at general paediatric clinics, of the acute problem of adolescent suicide. Due to the many factors determining suicide, only a few predictors related to violence were taken into account.

Sexual abuse

It is difficult to define sexual abuse. Some definitions describe behaviour, while others, the intentions of the offender. Many borderline situations may be interpreted in extreme ways, e.g. tenderness and care expressed by a parent in physical contact may be considered as harassment [11]. Ebert et al. understand sexual abuse as a relationship between an adult and a child or between two children, one of whom is significantly older and more dominant, involving sexual behaviour [20]. Sexual abuse is defined as the abuse of a child by an adult in order to satisfy the adult’s sexual needs. Attempts are made to explain the definition in more detail. A sexually abused child is considered to be every human being at the age of absolute protection if a sexually mature person, by wilful act or neglect of their social duties, including the duties arising from specific responsibility for the child, allows the child’s engagement in any activity of sexual nature [21]. Importantly, the definition lacks the element of the victim’s protest, because a child is not always developed enough to be able to refuse or has no awareness of the offender’s behaviour [11]. According to research conducted by Radziwiłłowicz and Lewandowska, 25% of psychiatric patients aged 13 to 17 years who performed self-aggressive acts had experienced sexual abuse, and 2/3 of those patients tried to commit suicide at least once [15]. Also, a major percentage of patients are diagnosed with depressive disorders or depressive episodes [15, 22, 23]. There are numerous different factors that predispose to sexual abuse of children and adolescents. They include the following: marriage and family conflict, physical violence, disability, acquiescence and passivity, adoption, or the abused person’s interest in sex. Once an immature person experiences sexual harm, his or her childhood comes to an end because of psychological unpreparedness. It is estimated that nearly 20% of adolescents aged 14 to 16 years (SEYLE project) are past their sexual initiation [24]. According to a study conducted by Gambadauro et al., early exposure to sex is linked to depressive disorders and suicidal behaviour [25]. Sexual harassment results in a wide range of emotional changes [24] – young people meet some or all of the criteria of posttraumatic stress (PTSD). Psychological consequences are more severe if the offender is a very close person. This triggers fear, anger, and a sense of lack of agency in an adolescent. On the other hand, the victim tries to save the most precious bond in his or her life, namely the relationship with the caregiver. Consequently, the victim may try to distort reality, ignore what happens to him or her, or shift guilt from the abuser to the abused, which generates a sense of guilt, anxiety disorders, somatic symptoms, problems with one’s emotionality, alienation from the surrounding world, and a sense of helplessness. Being sexually abused in childhood and adolescence causes serious and prolonged consequences, such as victimisation and re-victimisation [26], aversion to sex, difficulties in establishing social relationships, or self-aggression [15], reduced self-esteem, tendency to addiction, and depressive and anxiety disorders [3, 27], in some victims leading to suicidal thoughts followed by suicidal behaviour. According to studies, boys are less tolerant to such harm. In girls, suicidal tendencies increase threefold, while in boys – tenfold [1]. One of the largest meta-analyses, carried out by Angelikas et al., clearly indicates that sexual abuse is associated with increased odds for suicide ideation and fourfold increased odds for suicide plans in young people [28]. These are important findings because suicide plans, especially when they occur during peak suicide ideation, can lead to suicide attempts and deaths by suicide. Research results show that children and adolescents are exposed to various kinds of sexual abuse, which calls for an unconventional approach to the problem, outside the existing stereotypes, especially given the fact that its scale is underestimated while its consequences may often be tragic and irreversible [26, 27, 29].

Physical abuse

There is no single coherent theoretical concept explaining the occurrence of violence between relatives in the family. Various theories and concepts focus on individual factors that may increase the risk of violence. They prove that both the initiation of acts of violence and the changes they may undergo are conditioned by the processes taking place in the human organism, psyche, and social groups [30].
Physical abuse is defined as intentional behaviour that leads to bodily harm, but it may occur even without such harm. The analysis of global reports on the relationship between physical violence and the risk of suicide by Angelikas et al. indicated that physical abuse was associated with a 2-fold increase in the odds for suicide attempts [28]. In turn, studies conducted in Poland indicate, i.a. a relationship between abuse and psychiatric disorders. It is estimated that 71.7% of adolescent psychiatric patients have experienced physical abuse. A large percentage of them have attempted suicide [15]. The factors that increase the risk of physical abuse of minors are associated with the abuser’s character (authoritarian, low self-esteem, with depressive disorders and central nervous system disorders), his or her social interactions (faulty communication), and the social and cultural context (poverty, social position, stress, family conflict). The abuser’s own childhood as well as the viscous circle of faulty socialisation are also of vital importance [31]. It is estimated that 80% of children who witnessed domestic violence and 75.9% of children who experienced violence in childhood become abusers in their adult life [32]. Disability, premature birth, chronic diseases, and developmental delays in a child also increase the risk of domestic violence [21, 33]. The time of the COVID-19 pandemic is also associated with an ascending scale of violence against children in the family. The pandemic has increased the risk of violence against children, especially among families with a history of violence in the past and families experiencing stress and economic instability [34]. Physical violence, especially frequent or permanent, results in destructive psychological changes [15, 35] and a broad spectrum of psychosomatic disorders, making it very difficult for the medical personnel of general paediatric clinics to diagnose a child’s condition. The real cause of disorders may be extremely hard to determine. It has been observed that the hippocampus of individuals who have experienced physical abuse is reduced, which may significantly affect the efficacy of emotional processes, memory, and learning, determining the future of a young person. Like victims of other kinds of maltreatment, individuals exposed to physical violence are more likely to develop depressive disorders and suicidal tendencies [15] as well as social difficulties [36]. It should be noted that exposure to faulty parental care solidifies childhood trauma. Violence and victimisation still constitute a destructive problem for children and youths, not only in Poland but also globally. Studies conducted in the last few decades have significantly improved the understanding of the origin, trajectory, and long-term consequences of child maltreatment [37].

Emotional abuse and neglect

Emotional abuse means purposeful triggering of emotions in a child with which the child cannot cope, and which disrupt his or her development and functioning. It is done in order to cause a certain reaction or lack of reaction. Emotional abuse also includes failure to ensure a supportive space for a child to develop. Poor socio-economic status, limited education of one or both parents, the fact that parents themselves experienced physical violence in their own childhood, as well as the number of children in the family are important risk factors increasing the frequency of parental abuse of children [21]. Emotional abuse is the most common and the most subtle type of maltreatment. According to a Polish study, nearly 67% of psychiatric patients have experienced emotional abuse [15]. The relatively high frequency of emotional abuse is because it coexists with other forms of violence and goes unpunished more often, being hard to detect and prove. Emotional abuse may be manifested in several ways. It is associated with repulsive and hostile attitude, manifestation of anger, permanent criticism, and failure to notice any good things about a child. Later, abused individuals may behave in the same way towards others. If parents do not show their love, failing to satisfy a child’s basic need, the child’s ability to establish satisfactory relationships will be compromised, which is a predictor of future self-aggressive behaviour [15]. Ignoring a child, inconsistent behaviour, e.g. punishing a certain situation one time and rewarding it another time, which causes confusion in a child, threatening to abandon a child or throw him or her out of the house (which causes a permanent sense of fear for one’s safety) or expecting a child to do things that are beyond his or her abilities are other forms of emotional abuse. Emotional maltreatment is correlated with suicide attempts in adult life [38]. Studies on peer-on-peer adolescent abuse suggest that for adolescents, alienation and social violence are much more difficult to cope with than other forms of maltreatment, such as beating, name calling, or cyberstalking [39]. There is a close correlation between the growth in social violence and the 28% increase in suicide attempts [24].
Neglect, being another form of violence, has similar consequences to emotional abuse. It is manifested as the emotional indifference of parents, making a child less able to establish successful relationships. In medical terms, neglect means failure to seek specialist help in the case of an illness, whereas in terms of upbringing, it means failure to impose behaviour and duties on a child that are adequate to his or her age. Neglect causes deficits not only in the psycho-emotional sphere but also in the somatic sphere. The latter include low body weight or developmental delays. Neglected individuals more frequently suffer from infections as a result of reduced body immunity. Adolescents who were neglected as children experience emotions that are impossible to deal with for a young person. They may develop an emotionally unstable borderline personality, which predisposes to suicidal behaviour [32]. Also, neglect frequently coexists with an increased level of dissociation [15]. Children who were emotionally neglected by parents tend to develop externalising behaviour, too [40]. Such adolescents more often belong to criminal groups and are more exposed to accidents and rape. They have more problems with social adjustment. Research conducted in a group of adult individuals has shown that adolescents who experienced neglect are more prone to suicidal behaviour later in life. In a group of women who were self-aggressive, 49% had experienced this kind of maltreatment as children [38]. Thus, neglect is one of the risk factors of suicide.
Regarding the causes behind suicide among adolescents, it is important to note the impact of a dysfunctional family on the functioning of adolescents and its close link to their risky behaviour [41]. In particular, the coexistence of various forms of child maltreatment in a family should be considered. A child raised in a family where abuse is permanent and adults behave in an aggressive and unpredictable manner may be inclined to suicidal behaviour. If a child chronically experiences violence and suffering, his or her emotional condition, social functioning, and self-identity may be significantly burdened. Posttraumatic disorders linked to “mutilation” by violence may result in suicidal attempts triggered by very strong and unspecific emotions.

Conclusions

Suicidal behaviour of adolescents should always be analysed in the context of the developmental specificity of the period of maturation as well as family and peer background. The general conclusion is that all types of violence potentially predispose to self-aggressive behaviour. However, understanding the multiple causes behind suicidal behaviour is fundamental. Such behaviour is determined by the interaction of biological, psychological, social, environmental, and cultural factors as well as underlying health conditions. The effective intervention, treatment, and support – timely and founded on scientific evidence – may help prevent both suicide and suicide attempts [4]. Suicides are a burden not only for the health care sector, but they have a complex effect on multiple areas of social life. The problem of suicide should be addressed comprehensively by various sectors and stakeholders in accordance with the National Health Program for 2021–2025 (the Regulation of the Council of Ministers, March 2021). The operational objectives of this program focus on addiction prevention and mental health promotion. Suicide prevention should be one of the fundamental goals of healthcare, including in general paediatric clinics, and it should be ensured, among other things, by identification and assessment of risk factors and by implementation and evaluation of interventions. The activities should be especially based on the development of competences not only of health care workers, but also of school system employees, social assistants, police officers, clergy, and other professional groups working with children, youths, and families in the aspect of early detection of any symptoms of suicidal behaviour.

Conflict of interest

The authors declare no conflict of interest.

References