Longitudinal association between parental-to-child-Maltreatment and self-reported Generalized Anxiety Disorder symptoms in Pakistani Adolescents

Mental health disorders constitute 16% of the global burden of disease and injury in adolescents [1]. Statistics show one out of every five adolescents start experiencing at least one form of mental illness each year [2]. Individuals in the adolescent phase are emotionally, physically, socially, and mentally vulnerable as it is a crucial phase due to the initiation of transition from childhood to adulthood. This vulnerability leads to the development of many mental illnesses that might persist into adulthood, ultimately affecting an individual's overall health-related quality of life [3]. The most common mental illnesses encountered by adolescents include anxiety disorders (mainly generalized anxiety disorder-GAD), depression, and eating disorders [4].

GAD, defined as "excessive anxiety and worry, occurring more days than not for at least six months, about a number of events or activities,". GAD is a type of anxiety disorder characterized by continuous worry and anxiety along with several other symptoms such as: restlessness, functional impairment, sleep disturbance, gastrointestinal symptoms, chronic headaches and muscular cramps [5]. GAD symptoms are relatively common in adolescents, with a lifetime prevalence of 3% globally. If the time period is restricted to 3 months, the prevalence increases to 5% worldwide [6].

Estimates of GAD based on the symptomatology may vary worldwide; the reported prevalence of GAD in adolescents in the USA lies between 3 and 9%, whereas, in the United Kingdom, it is 0.7% [7]. Regionally more than a few studies have depicted the burden of GAD-related symptoms in children and adolescents. A study conducted in Urban India reported 20.9% GAD-related symptoms in children and adolescents [8]. In contrast, Iran reported a 0.54–20.18% burden among adolescents [9]. This vast range of prevalence reported by the aforementioned studies might be due several contextual and research methods. For example, the different cultural settings, different predefined diagnostic thresholds, availability of various tools to assess GAD based on symptomatology. The under-reporting of symptoms due to fear and stigma is another consideration [10].

There were limited studies in Pakistani settings that exhibited a definite burden of GAD-related symptoms in the adolescent population. One study conducted in Lahore, Pakistan, indicated 52% of adolescents have at least one symptom of GAD, whereas approximately 8% of adolescents have more than 4 GAD persistent symptoms [11].

Previous literature has highlighted multiple risk factors of GAD symptoms in adolescents. The most common factors include parent-to-child conflicts, parent–child relationship, parental control, hormonal changes (that occur during adolescence), genetic predisposition, stress, family conflicts, communication gap with parents, parental education, traumatic life experiences, academic stresses, physical changes, socioeconomic burden, conflicts in friendships and interpersonal relationships, succumbing to parental pressure, cultural norms and religious obligations [11‐14]. Moreover, age was also indicated as one of the prime risk factors leading to GAD symptoms; early adolescence was linked to a greater risk than late adolescence [15]. Among all these significant risk factors, traumatic childhood experience due to parent-to-child maltreatment of any sort, including physical, emotional, mental as well as neglect, was found to be one of the most reported risk factors leading to the occurrence of GAD symptoms [16]. For adults who experienced any variant of parent-to-child mistreatment, the burden is reported to be 30–40% [17]. Statistics reveal 4–16% of children are maltreated by parents every year and, one in ten is neglected or psychologically mistreated [18]. 13% is the reported prevalence of parent-to-child maltreatment in developing countries [19, 20]. According to a previous study, 43% of children in Pakistan self-reported parent-to-child maltreatment and, amongst these 57% were neglected, 49% were physically maltreated, and 50% suffered from emotional maltreatment [21]. Another study indicated 25.5% of physical abuse and 17.9% of emotional abuse by parents among Pakistani children [22]. Statistics on child maltreatment in the Pakistani population are alarming compared to global and developing countries' statistics. The difference in numbers can be accounted for by the use of strict measures by parents for disciplining and punishing a child. Moreover, the normalization of beating and physical means to control a child might also explain the contrast in Pakistani settings. As per a Pakistani study (n = 192,789), 74% of the parents of school-going children and adolescents didn't receive any formal education. They never went to school, hence are considered illiterate. Of the remaining 26% of parents, 52% fathers, 30% mothers, and 24% both parents received formal school education and were considered literate [23]. Low parental literacy rates in Pakistan might also explain parents' use of abusive activities due to a lack of awareness [24].

The development of anxiety disorders due to parent–child maltreatment can be understood from previous research detailing how continuous and frequent exposure to child maltreatment interrupts hypothalamic–pituitary–adrenal axis functioning and leads to neurobiochemical changes in the brain [25]. These changes include, an increase in thalamic grey matter volumes of the subcortical region of the brain which can result in the development of GAD symptoms [26, 27]. Moreover, parents' constant maltreatment can disrupt an adolescent's sense of safety resulting in various fears, apprehensions, cognitive deficits, and emotional vulnerability, leading to anxiety disorders [28]. GAD and related symptoms have major public health implications predominantly in adolescents. GAD is considered as a prodrome of chronic depression [29]. Moreover, GAD is linked with developing sleep disorders, eating disorders, and other psychological comorbidities [30]. The long-term effects of GAD symptoms personally, socially, and economically negatively influence a person wellbeing and quality of life. As depicted above, if the immediate diagnosis is not treated it can result in further comorbities creating further burden upon health care systems. Therefore, addressing GAD is a healthcare priority. The need is even more urgent within developing countries where stigma is a barrier to self reporting early symptoms of GAD. Furthermore, the escalating burden of anxiety disorders in adolescents, creates a need to identify predictors of GAD early so symptoms can be appropriately treated.

In Pakistani cultural settings where strict disciplinary measures are considered standard practice [21, 31], parent-to-child maltreatment is extremely prevalent. Parent-to-child maltreatment can lead to various anxiety disorders, including GAD. Adolescents constitute a large portion of the Pakistani population, and their psychosocial health must be adequately supported to prevent further detrimental consequences. There is currently a gap in research which neglects to appreciate the Pakistani context and how potential risk factors (namely parent-to-child maltreatment), can lead to anxiety disorders in adolescents.Furthermore, the definite burden of GAD symptoms and its association with parent-to-child maltreatment in adolescents has not been investigated within Pakistani conextx. Thus the aim of this study was to determine the incidence of GAD symptoms; and to determine the unified role of parental education and frequency of parent-to-child maltreatment onto risk of developing GAD symptoms along with other risk factors in Pakistani adolescents.

A total of 800 adolescents were recruited in the preliminary study, out of which 49 (6.12%) were lost to follow-up. The number of participants who were lost to follow up from each level of exposure, along with reasons of loss to follow up, is detailed in Fig. 1.

The baseline characteristics of the participants as per the frequency of childhood maltreatment are displayed in Table 1. The mean age of children in this study was 13.13 (1.84) years. There were no differences in the mean ages among all levels of exposure. Among infrequent to frequent maltreated children, 144 (62%) and 47 (64%) were males, suggesting that males are more likely to endure parent-to-child maltreatment. Occasionally 123 (53%) and frequently maltreated children 46 (63%) were also more likely to be the middle child in the family.

Specific familial characteristics were associated with severe childhood maltreatment. These characteristics include belonging to extended family (41%), presence of physical (39.73%), verbal (84.93%) and sibling abuse within the family (84.93), maternal history of domestic violence (45.21), parental use of substance abuse (44%) and stressful home environment (60.27%).

The occurrence of none to rare, occasional, and frequent parent-to-child maltreatment in the sample of 751 adolescents is 59% (n = 446), 31% (n = 232), and 10% (n = 73), respectively. The occurrence of GAD symptoms after two years of follow-up among frequently maltreated children is 42.5% (n = 31), whereas among occasionally maltreated and none to little-maltreated children, it is 15.1% (n = 35) and 9.5% (n = 42).

Multivariable analysis using Multiple Cox proportional algorithm, the association between GAD symptoms with parent-to-child mistreatment and other predictors, is given in Table 2. The standardized risk of GAD symptoms was increased twofold in females compared to males (RR: 2.22 CI 1.56–3.15). Likewise, children with a maternal history of domestic violence had a 1.34 times greater risk of developing GAD symptoms than children with no history of maternal domestic violence (RR: 1.34 CI 0.98–1.83) adjusted for other variables. A significant interaction between parental education status and frequency of parent-to-child maltreatment suggests that in children with either uneducated parent, the risk of GAD symptoms was 5.58 times (CI 1.40–21.97) among frequently maltreated as compared to none to rare maltreated children. In comparison, for children whose mother and father had no formal education, exposure to frequent childhood maltreatment by parents was associated with a seven-fold increase in risk (CI 2.20–24.04) of developing GAD symptoms compared to none to rare exposure to parent-to-child maltreatment (Fig. 2).

Childhood maltreatment was recognized as one of the potential risk factors associated with GAD. This study has observed an increasing trend between the incidence of self-reported generalized anxiety disorder (GAD) symptoms and parent-to-child maltreatment. A total of 14.8% of adolescents developed GAD symptoms, among which severely maltreated adolescents had a comparatively higher risk than mild and moderately maltreated adolescents. Previous literature reported almost half of the incidence of GAD symptoms in maltreated adolescents compared to this study [16]. The probable reason for this difference could be different disciplinary measures adopted by parents within Pakistan. According to previous data, multiple variants of childhood maltreatment including physical abuse [36], emotional trauma [37], sibling victimization, and bullying [38] are associated with the development of GAD symptoms in children and adolescents. The results of the present study depicted similar associated predictors of GAD.

One of the findings of our study indicated that gender has a significant role in the occurrence of GAD symptoms. The risk of GAD symptoms was found to be increased in females as compared to males. Various studies showed agreement with this finding, indicating how anxiety disorders, especially GAD, are associated with a greater burden in females than males [39, 40]. The likely reason for this association could be a higher tendency of females to worry and ruminate [41]. Moreover, their genetic makeup and hormonal changes during ovulation and menstruation could be another consideration making females more vulnerable top GAD symptoms [41, 42]. In comparison, males tend to have a lesser tendency to develop GAD symptoms due to cultural norms that promote greater stoicism and less expressiveness which leads to less endorsement and acceptance of anxiety symptoms. Moreover, it is socially acceptable for females to express fear and anxiety but not for males who are expected to be brave [40].

It was evident from this study that the history of maternal domestic violence was another factor that played an essential role in the development of GAD symptoms in adolescents. This finding was consistent with previously research. Previous findings have demonstrated how interparental violence, specifically maternal violence, can increase children and adolescents' vulnerability to developing GAD symptoms [43, 44]. Void of a protective shield by parents and family that helps in neutralizing stresses of adolescents is affected by interparental violence, which might be why exposure to maternal violence is a significant predictor of GAD symptoms [44].

The results also revealed that GAD symptoms were higher among moderately or severely maltreated adolescents whose parents had no formal schooling. Certain studies have previously shown agreement with this interaction, suggesting that child abuse and GAD symptoms are associated with the level of parental education [24, 45]. It was also reported that parent-to-child maltreatment is common among adolescents with fathers with lower education levels or no education [24]. One plausible explanation for this interaction is that uneducated parents expect their children to do well for the family economically to raise the standard of living; hence they impose disciplinary measures and resort to physical and emotional abuse, leading to the development of GAD symptoms in adolescents [24]. Moreover, lack of adequate parenting skills, anger management, and adequate communication skills in uneducated parents might be the reason for practicing punitive disciplinary practices [31] that could lead to anxiety disorders in adolescents. Moreover, lack of adequate education results in a dearth of knowledge, skills and competence which are essential for understanding adolescents cognitive functioning as well as meeting their safety, developmental and wellbeing needswhich may contribute to parent-to-child maltreatment [46].

One of the significant strengths of this study is the sufficient sample size with negligible loss to follow-up. An adequate follow-up period of 2 years to ensure adequate time for the development of outcome and the rigor of a prospective cohort study design to establish temporality and causality are the most prominent strengths of this study. Moreover, a multicluster approach was used to target participants from diverse backgrounds. This can assist to ensure generalizability/ external validity of the study.The limitations of the study include: the subjectivity of the outcome and primary exposure. Moreover, few variables of this study did not have any definite definition and were conceptualized and assessed based on operational definitions. Certain potential risk factors and predictors of GAD based on symptoms reported by literature like socioeconomic status, intergenerational abuse, history of parents' psychiatric illness, etc., were insignificant in this study.

The present study's findings suggest that the frequency of parent-to-child maltreatment is significantly associated with an increased risk of developing GAD symptoms. Parental education was also shown to play a crucial role in maltreatment practices. Intervention strategies should be designed to educate and enlighten uneducated and unaware parents regarding the consequences of parent-to-child maltreatment. This is particularly significant in Pakistani settings, as adopting discplianry action on a child is culturally acceptable. These cultural practices emphasize the need to develop and implement policies and rigorous measures to ensure such practices arereduced and stopped. The results of this study also indicated that girls are more vulnerable to developing GAD symptoms; hence adequate emotional support, timely treatment, and counseling should be provided to them to prevent long-term adverse consequences. In Pakistan, where the girls are considered responsibility bearers and have certain restrictions imposed on them, proactive identification and treatment of symptoms isneeded. Moreover, the findings of this study emphasize children who witness maternal domestic violence are more prone to develop symptoms of GAD. Hence a safe home environment should be ensured for the wellbeing and protection of children. The results also indicate that evaluation for the GAD symptoms should be a priority for adolescents with a history of moderate to severe maltreatment. Moreover, it also emphasizes the need for clinicians and mental health workers to be aware of the childhood maltreatment histories of potential patients presenting with GAD symptoms to be appropriately addressed and treated.