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Running head: AN INTEGRATIVE REVIEW 1

An Integrative Review

Kimberli I. Johnson

Bon Secours Memorial College of Nursing

Nursing Research 4122

I PledgeKIJ
AN INTEGRATIVE REVIEW 2

Abstract

The purpose of this integrative review is to analyze the literature regarding the effects of

childhood abuse and the influence it has on mental illness in adulthood. Childhood abuse is

rarely reported, but when it is, there is an opportunity to get treatment for that individual.

Sometimes that is not the case, which could lead to mental illness in adulthood. The database that

was used was CINAHL (Cumulative Index of Nursing and Allied Health Literature) Complete,

within the EBSCO database search engine. The search yielded 556 articles, five of which met the

criteria. The five articles provide insight on the relationship between childhood abuse and the

onset of a mental illness in adulthood. The five articles all depicted many factors that needed to

be considered when exploring this topic, but all could satisfy the association between child abuse

and mental illness in adulthood. There were several limitations including the students inability

to write an integrative review, the year of publishings were limited to the last five years, and the

personal issues the student faced while writing this integrative review. Future research should be

done in variety of locations, so that the study can be accurately portrayed, and not using just one

method of obtaining information, which majority of the studies were responsible for. All five of

the studies were qualitative.


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An Integrative Review

The purpose of this integrative review is to search the literature regarding the effects of

childhood abuse and the influence it has on mental illness in adulthood. Children in all societies

are often neglected, maltreated, abused, intentionally or otherwise by their parents, siblings, and

in school (Saha et al., 2012). This progression causes children to grow up and predisposes them

to a mental health problem or possibly commit suicide. Reporting and treating are important

factors that could possibly help these children overcome obstacles they may face due to the

abuse. The researcher obtained several pieces of information on the relationship between

childhood abuse and the effects on mental health in adulthood, which answered the following

PICOT question: Does being physically and/or sexually abused influence the outcome of having

a mental illness in patients who have been abused as a child? The familys socioeconomic status

was a big factor when it came to getting help for children and the reason the history abuse was

carried over into adulthood. This topic interests the researcher due to the increase of child abuse

and the decrease in reporting which causes the individual to experience adulthood full of

hardships.

Research Design, Search Methods, and Search Outcomes

This integrative review focuses on five qualitative research articles. The website used to

obtain the articles was MyAthens, which is accessed through the BSMCON Library Databases.

The search engines that were utilized were EBSCO host, CINAHL complete, which has journals

related to nursing and health related publications. The terms that were searched in these

databases included abuse, childhood, adulthood, and mental illness. This search yielded

556 articles, with five only meeting the criteria and containing a wealth of pertinent information.
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To obtain current issues on this topic, the search was filtered to only articles between the

years of 2012 to 2017. Peer-reviewed articles narrowed the search. The search was conducted to

address the PICOT question at hand. The articles were narrowed down based on childhood abuse

and mental health in adulthood. The articles that were utilized in this review included five

qualitative articles that related to the original PICOT question.

Findings/Results

The findings and results of the five peer-reviewed articles identified an association with

child abuse and effects of mental health in adulthood (Easton et al, 2010; E. Fuller- Thomson,

2012; Horan & Widom, 2014; Saha et al, 2012; Unger & De Luca, 2014;). Table 1 provides a

summary of research. Research has found that child abuse and neglect puts individuals at risk

for a wide range of negative outcomes across the lifespan (Horan and Widom, 2014). The

researcher outline the review based on the following categories: anxiety, depression, and

sexuality.

Anxiety

Three qualitative studies indicated that anxiety was a major effect of child abuse (E.

Fuller-Thomson et al (2012); Saha et al (2012); Unger & De Luca (2014)) . A qualitative study

conducted by E. Fuller-Thomson et al (2012), found a relationship between child abuse and

anxiety disorders. The study wanted to examine some inconsistencies in previous studies that

were done on this topic. This study used data from the 2005 cycle of Canadian Community

Health Survey (CCHS) conducted by Statistics Canada. This survey provides health

determinants, health status, and health system utilization. The participants in this study were only

asked about childhood abuse. Respondents who did not have complete data were removed, so it
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did not skew the findings. This study asked participants if they were diagnosed by a health

professional so that data was accurate and unbiased. Again, the findings of this study

determined there was an association between child physical abuse and anxiety disorders in

adulthood.

Comparably, Saha et al (2012), wanted to explore the long-term consequences of

childhood abuse is the development of suicidal tendencies in adolescence or adulthood. This

study found that specific interventions helped teenagers and their family cope with their past.

Like the previous study, long-term mental health consequences of abuse in childhood includes

depression and anxiety, low self-esteem, difficulty establishing and maintain relationships, eating

disorders, and suicidal attempts. Saha et al (2012), presents individual therapy is directed

towards helping the adolescent to take control over their suicidal and anxious feelings and seek

out sources of support other than their parents.

The qualitative study, conducted by Saha et al (2012), included one individual, a 15-year-

old boy who was brought to an outpatient clinic. The study was conducted by having the boy

come to the clinic weekly for the first 2 months, followed by biweekly visits by the health

coordinator. Treatment aimed at family counseling at the clinic by the physician as well as at

home visits.

The qualitative study conducted by Unger and De Luca (2014), aimed at identifying the

insecure attachment style associated with childhood physical abuse. A history of physical abuse

was associated with attachment avoidance whole controlling for other forms of childhood abuse.

A second evaluation was conducted by the authors, which found significant relationships

between history of physical abuse and an undesirable view of self or anxiety in adulthood.
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Unlike the study by Saha et al (2012), the participants in the qualitative study conducted

by Ungar and De Luca (2014), included 552 females and 294 male university students from an

Introductory Psychology class. The participants completed several questionnaires intended to tap

the variables of interest. Demographics were completed, The Experiences in Close Relationships

Scale was used to evaluate anxiety and avoidance dimensions of attachment in adulthood.

Depression

Fuller-Thomson et al (2012) and Saha et al (2012), both determined one of the

consequences of child abuse was depression in adulthood. Fuller-Thomson et al (2012) had a

much larger sample size, including 12,481 respondents from the Canadian provinces of Manitoba

and Saskatchewan in Toronto Canada. The study found a relationship between child physical

abuse and anxiety disorders with factors of demographics, family background, current

socioeconomic status, and stressors. The individuals with the mental health issues are less likely

to seek medical care and less likely to receive a diagnosis, which leads them to a road of

depression.

While following a 15-year-old boys life, Saha et al (2012) highlighted the interactions in

children being subjected to neglect, maltreatment, and abuse, resulting in emotional health issues

in adolescence. The long-term abuse can cause impaired development with decreased cognitive,

language, and academic abilities. After continuously interviewing this patient, Saha et al (2012)

determined the consequences in adulthood as depression, anxiety, low self-esteem, and difficulty

establishing and maintaining relationships.


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Sexuality

Two qualitative studies found sexual trauma due to child abuse (Easton et al, 2010;

Horon and Widom, 2014). Easton et al (2010), conducted a semi-structured telephone interview

to study whether and how characteristics of childhood sexual child abuse and disclosure

influenced three dimensions if psychosexual function during adulthood. The sample included

165 adults who were sexually abused as children; all ranging from the age of 20 and older. The

purpose of the study was to understand variability in psychosocial functioning among adults who

were sexually abused as children. The study determined that two factors affected all the

dimensions of psychosocial dysfunction: age at the time of abuse and telling someone at the time

of the abuse. It was determined that sexual trauma was due to their understanding of the sexual

implications of abuse.

Horon and Widom (2014), used a study based on cohort design study. The purpose of the

study was to examine whether the ages of onset of four risk behaviors sexual intercourse,

alcohol use, drug use and criminal activity mediate relationship between child maltreatment

and outcomes in middle adulthood. This study used abused and non-abused children. Due to the

child abuse, some participants reported engaging in risky behaviors such as sexual intercourse

(97.2%), alcohol use (78.8), and drug use (69.4), and more than half of the sample (50.4) had a

criminal arrest. This study found that child abuse and neglect plays in relation to early-onset risk

behaviors. Horon and Widom (2014), was the only study to determine that victims of childhood

abuse are more likely to engage in sexual activity and to be arrested at an earlier age.

Discussion/Implications
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The results of the research articles discussed the effects of childhood abuse on mental

health in adulthood. The articles provided different effects of child abuse on adulthood mental

health. The PICOT question specifically asked if there was a relationship between childhood

abuse and the effects on the mental health in adulthood? The qualitative study that was

completed by Unger and De Luca (2014), indicated that there is a relationship between child

abuse and the effects on adulthood based on the individual attachment to a person. While the

qualitative study done by Easton et al (2010), showed two factors negatively affected all the

dimensions of psychosexual functioning: age at the time of abuse and telling someone at the time

of the abuse. Being older at the time of the abuse increased the likelihood of being afraid of sex

and feeling of guilty during sex and increased the likelihood of being dissatisfied with sex during

adulthood. All the studies recognized the differences in obtaining data. One of the studies chose

a psychology class to gather data, another chose to get responses through a newspaper in a

community, and another chose to interview those that were abused and others that were not to

compare the outcome of abused and non-abused children.

The implications of the findings suggest that there is a huge public health problem which

is preventable, but extremely hard to deal with. There are several programs out there to assist

with nurturing relationships and to promote a safe environment that could possibly reduce the

maltreatment of children, which can be found on the Centers for Disease Control and Prevention

website. Although, there is limited research available on the association between child abuse and

the effects on mental illness in adulthood, there is still a need of reporting abuse from the victim

as well as healthcare providers, especially nurses and also the need of treatment for all victims of

child abuse.

Limitations
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There were several limitations that the researcher recognized that influenced this

integrative review. This is the first time the researcher has completed an integrative review, so a

lack of experience limited the researchers ability to accurately provide an integrative review.

The lack of time available to complete this assignment and the students personal life effected

the ability of focusing on the assignment 100 percent.

Conclusion

The findings in this integrative review highlight the association between child abuse and

the effects on the mental health in adulthood. Although, there were various factors that have to

be considered, overall treatment suggests a better outcome for adults who were abused as a child.

E. Fuller-Thomson et al (2012), concluded that child abuse has a significant impact on anxiety,

and the relationships that the individual has with others. Further research would help the

different methods that were used. Majority of the studies used a self-report method to gather

data, which creates a bias. Regarding the participants, the researcher believes using a broader

group. The studies focused on specific group and areas, which is a major limitation. Overall,

health care professionals and others could possibly benefit from the studies by having the ability

to recognize abuse and reporting it based on the signs and symptoms that were mentioned in the

previous articles. The major outcome of this is that there is an association between child abuse

and the overall mental health of adults. The earlier help is received the better the outcome for the

future.
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References

Easton, S. D., Coohey, C., Oleary, P., Zhang, Y., & Hua, L. (2010). The Effect of

Childhood Sexual Abuse on Psychosexual Functioning During Adulthood.

Journal of Family Violence, 26(1), 41-50. doi:10.1007/s10896-010-9340-6

Fuller-Thomson, E., Sohn, H., Brennenstuhl, S., & Baker, T. (2012). Is childhood

physical abuse associated with anxiety disorders among adults? Psychology,

Health & Medicine, 17(6), 735-746. doi:10.1080/13548506.2012.686618

Horan, J. M., & Widom, C. S. (2014). Does Age of Onset of Risk Behaviors Mediate the

Relationship Between Child Abuse and Neglect and Outcomes in Middle

Adulthood? Journal of Youth and Adolescence, 44(3), 670-682.

doi:10.1007/s10964-014-0161-4

Saha, I., Paul, B., Das, D. K., Dinda, J., Mukherjee, A., & Basu, S. (2012). Repeated

Abuse during Childhood and Adolescence Leading to Suicidal Behavior in an

Adolescent: A Case Report. Journal of Family Violence, 28(2), 213-217.

doi:10.1007/s10896-012-9481-x

Unger, J. A., & De Luca, R. V. (2014). The Relationship Between Childhood Physical

Abuse and Adult Attachment Styles. Journal of Family Violence, 29(3), 223-234.

doi:10.1007/s10896-014-9588-3
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Table 1 Qualitative and Quantitative Article Evaluation


First Author - Jo Ann M. Unger is a clinical psychologist and a full-time assistant
(Year)/Qualifications professor with the Department of Clinical Health Psychology at the
University of Manitoba.

Background/Problem - Identify the insecure adult attachment style associated with


Statement childhood physical abuse

Conceptual/theoretical - Current conceptions of attachment are based on the work of John


Framework Bowlby and those who have since contributed to his attachment
theory
Design/ - Qualitative study
Method/Philosophical - Experiences in Close Relationships Scale (ECR) assess the
Underpinnings anxiety and avoidance dimensions of attachment in adulthood
- Comprehensive Child Maltreatment Scale (CCMS) assess the
history of physical abuse, psychological maltreatment, witnessing
violence, sexual abuse, and neglect.

Sample/ Setting/Ethical - 552 female and 294 male university students recruited from the
Considerations Introductory Psychology classes at the University of Manitoba

Major Variables Studied (and - Social support


their definition), if - Gender
appropriate

Measurement Tool/Data - Multidimensional Scale of Perceived Social Support


Collection Method - Comprehensive Child Maltreatment Scale

Data Analysis - Data Cleaning Procedures check data errors


- Data Screening Procedures analyzed outliers
- Descriptive Statistics

Findings/Discussion - Association between physical abuse and attachment avoidance

Appraisal/Worth to practice - Based on the findings, results have implications for individual
treatment approaches for child abuse victims
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First Author Scott D. Easton, PhD, 2011, School of Social Work, University of Iowa
(Year)/Qualifications
Background/Problem - How characteristics of childhood sexual abuse and disclosure influenced
Statement three dimensions of psychosexual functioning emotional, behavioral,
and evaluative during adulthood. There was a combination of problems
with the fear of sex, guilt, and problems with touch in adulthood.

Conceptual/theoretical - Conceptual framework; Whether characteristics of the sexual abuse


Framework (e.g., age at first abuse, severity) and disclosure (e.g., telling someone at
the same time of the abuse) are related to multiple dimensions of
psychosexual functioning in adulthood.
Design/ - Semi-structured telephone interviews conducted by the Centres Against
Method/Philosophical Sexual Assault in Victoria, Australia.
Underpinnings - Respondents were recruited from the community newspapers; posted at
community organizations including human service agencies, schools,
restaurants, and shops
- Interviewed over the phone by trained counselors and volunteers

Sample/ Setting/Ethical - 165 adults ages 20 and older sexually abused as children only
Considerations - Majority were female
- Completed high school or fewer years of education
- 20s (22.2%), 30s (33.9), 40s (23.6), and 50s or older (20.0)

Major Variables Studied (and - Age, gender, employment, or rural/urban residence were not related to
their definition), if appropriate the dependent variables
- Variables used: emotional dimension of sexual functioning whether the
sexual abuse resulted in being afraid of sex and in feeling guilty during
sex; Behavioral dimensions of sexual functioning whether the sexual
abuse resulted in having problems with being touched and in being
unable to be sexually aroused; Evaluative dimension whether the
abuse resulted in being dissatisfied with sex
Measurement Tool/Data - Data collection method: telephone interview
Collection Method

Data Analysis - GEE General Estimating Equation estimation procedure that


produces more efficient unbiased estimates by addressing the
correlations among multivariate binary dependent variables

Findings/Discussion - Respondents who were older at the time of the abuse were more likely to
experience problems related to the emotional dimension of sexual
functioning than the respondents who were younger
- Being injured during the sexual abuse also appeared to be related to
fear of sex
- Telling had a negative effect on feelings of guilt

Appraisal/Worth to - It is important when treating adults with histories of CSA who report
practice problems in sexual abuse functioning the following need to be assessed:
how old the clients were when they were abused, how severe the abuse
was, and whether they told someone.
- All three dimensions need to be assessed
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First Author Jacqueline M. Horan, PhD, 2014., Psychology Dept., John Jay College of
(Year)/Qualifications Criminal Justice; Forensic Psychology.
Background/Problem - Child maltreatment linked with risky behaviors in adulthood
Statement - Study examines whether the ages of onset of four risk behaviors
sexual intercourse, alcohol use, drug use, and criminal behavior
mediate relationship between child maltreatment and outcomes in
middle adulthood

Conceptual/theoretical - Theoretical framework


Framework - Previous research has not examined the extent to which the age of
onset of risk behaviors may serve as a pathway or mechanism linking
child maltreatment to long-term outcomes
Design/ - Cohort design study
Method/Philosophical - Abused and neglected children were matched with non-abused and
Underpinnings non-neglected children and followed prospectively into adulthood

Sample/ Setting/Ethical - Sample size 896


Considerations - 77 (8.6%) has documented histories of physical abuse
- 67 (7.5%) has histories of sexual abuse
- 404 (45.1%) has histories of neglect
- Small portion had documented histories of more than one type of
maltreatment
Major Variables Studied (and - Only court-substantiated cases involving children under age of 12 at
their definition), if appropriate the time of abuse and/or neglect were included

Measurement Tool/Data - Data collection was received by a sample of court-documented victims


Collection Method of child abuse/neglect

Data Analysis - MPlus 7.0 Structural equation modeling was utilized to test full models with
the mediating variable that supported by simple regression analysis
- Tucker -Lewis index

Findings/Discussion - Indications that abused and neglected children are more likely to
engage in sexual intercourse and criminal behavior
- Early engagement in risk behaviors mediated the relationship between
child abuse and neglect and several outcomes in middle adulthood.
Appraisal/Worth to practice - This study highlights the importance of child abuse and neglect plays in
relation to early-onset risk behaviors and later maladaptive functioning across
multiple domains
- More likely to engage in early-onset sexual activity and to be arrested at an
earlier age compared to non-maltreated youths
- Additional research needs to be done such as impacts of genetic and
environmental factors other than child abuse and neglect that may help with
the understanding of maladaptive results
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First Author E. Fuller-Thomson, PhD, 2012, Professor at the University of Toronto,


(Year)/Qualifications Toronto, ON, Canada
Background/Problem - Other studies have seen an association between childhood
Statement physical abuse and anxiety disorders with inconsistent results.
Study examined to determine the associate between CPA and
anxiety disorders, while controlling factors such as: demographics,
family background, current socioeconomic status, current
stressors, and current mood disorders.

Conceptual/theoretical - None noted


Framework

Design/ - Data from the 2005 cycle of the Canadian Community Health
Method/Philosophical Survey conducted by Statistics Canada;
Underpinnings - in depth interview
- Cluster design

Sample/ Setting/Ethical - Sample size 12,481 respondents from Canadian provinces of


Considerations Manitoba and Saskatchewan

Major Variables Studied - Demographics


(and their definition), if - Family background
appropriate - Current socioeconomic status
- Current stressors

Measurement Tool/Data - CCHS provides estimates of health determinants, health status,


Collection Method and health system utilization

Data Analysis - 7 logistic regression models

Findings/Discussion - This study found a relationship between CPA and adult anxiety disorders
with the factors of demographics, family background, current SES, and
stressors
- CPA and anxiety disorders controlled for a depression history
- Adults currently reporting anxiety disorders in the current study is lower
than that reported elsewhere
- Individuals with mental health issues are less likely to seek medical care
and less likely to receive a diagnosis

Appraisal/Worth to practice - Since this study used self-report of abuse history may have
introduced some response bias.
- Using a s diagnostic criteria may help with the getting accurate
information for the study.
- There may be an association between CPA and anxiety, explained
by co-morbid mood disorders
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First Author Indranil Saha, MD, 2012, MBBS (Cal), MD (Psychiatry), DPM.
(Year)/Qualifications Specializes in Neuropsychiatry
Background/Problem Long-term abuse consequences of childhood abuse are the
Statement development of suicidal tendencies.

Conceptual/theoretical - None noted


Framework

Design/ - A case report; interview with patient


Method/Philosophical
Underpinnings

Sample/ Setting/Ethical - One patient; interview with patient at local clinic and at home
Considerations

Major Variables Studied - Family socioeconomic characteristics


(and their definition), if - Incident
appropriate - Therapy

Measurement Tool/Data - Data: ongoing observation of child and family


Collection Method

Data Analysis

Findings/Discussion - Case highlights interactions that results in children being subjected


to neglect, maltreatment, and abuse resulting in emotional and
mental health issues in adolescence
- Long-term abuse can cause impaired brain development with
decreased cognitive, language, and academic abilities
- Adulthood consequences: depression, anxiety, low self-esteem,
difficulty establishing and maintaining relationships, eating
disorders and suicidal attempts

Appraisal/Worth to practice - Although this was probably not the best article it provided an
outcome of child abuse and neglect and the effects of it through
one persons eyes
- Could this be used alone to integrate this into practice probably not,
but it gives a different outlook unlike the other articles

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