Child Abuse & Neglect 33 (2009) 139147

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Child Abuse & Neglect

The relationship between child abuse, parental divorce, and lifetime mental disorders and suicidality in a nationally representative adult sample
Tracie O. A a, , Jonathan Boman b , William Fleisher b , Jitender Sareen a,b
a b

Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada

a r t i c l e

i n f o

a b s t r a c t
Objectives: To determine how the experiences of child abuse and parental divorce are related to long-term mental health outcomes using a nationally representative adult sample after adjusting for sociodemographic variables and parental psychopathology. Methods: Data were drawn from the National Comorbidity Survey (NCS, n = 5,877; age 1554 years; response rate 82.4%). Logistic regression models were used to determine the odds of experiencing lifetime psychiatric disorders and suicidal ideation and attempts. Results: Parental divorce alone was associated with some psychiatric disorders after adjusting for sociodemographic variables (AOR ranging from 1.30 to 2.37), while child abuse alone was associated with psychiatric disorders (AOR ranging from 1.39 to 6.07) and suicidal ideation (AOR = 2.08; 95% CI = 1.572.77) and attempts (AOR = 1.54; 95% CI = 1.022.31) after adjusting for sociodemographic variables. However, having experienced both parental divorce and child abuse together resulted in signicantly increased odds for lifetime PTSD (AOR = 9.87; 95% CI = 6.6914.55), conduct disorder (AOR = 4.01; 95% CI = 2.925.51) and suicide attempts (AOR = 2.74; 95% CI = 1.844.08) compared to having experienced either parental divorce or child abuse alone. These results were attenuated when further adjusting for parental psychopathology. Conclusions: When the experience of parental divorce is accompanied with child abuse, the associations with some poor mental health outcomes are signicantly greater compared to the impact of either parental divorce or child abuse on its own. Therefore, parental divorce is an additional childhood adversity that signicantly contributes to poor mental health outcomes especially when in combination with child abuse. Parental psychopathology attenuated these relationships suggesting that it may be one possible mechanism to explain the relationships between child abuse, parental divorce, and psychiatric disorders and suicide attempts. 2009 Elsevier Ltd. All rights reserved.

Article history: Received 9 April 2008 Received in revised form 30 September 2008 Accepted 3 December 2008 Keywords: Child abuse Parental divorce Child physical abuse Physical maltreatment Child sexual abuse Witnessing domestic violence Parental psychopathology Mental disorder Suicidal ideation Suicide attempts Psychiatric disorders

Preparation of this article was supported by (1) SSHRC Canada Graduate Scholarship (A), (2) CIHR operating grant (Sareen), a CIHR New Investigator Award (Sareen), (3) Manitoba Research Council Establishment Grant (Sareen). The National Comorbidity Survey (Dr. R.C. Kessler, Principal Investigator) was sponsored by the U.S. National Institute of Mental Health, the National Institute of Drug and Alcohol Abuse, and the W.T. Grant Foundation. Corresponding author address: PZ-430 771 Bannatyne Avenue, Winnipeg, Manitoba, Canada R3E 3N4. 0145-2134/$ see front matter 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.chiabu.2008.12.009

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The experience of childhood adversity is known to be associated with adult psychopathology in large community samples as well as in clinical populations (A, Brownridge, Cox, & Sareen, 2006; Chapman et al., 2004; Dube et al., 2001, 2003; Kessler, Davis, & Kendler, 1997). Furthermore, there appears to be a graded relationship between the number of childhood adverse experiences and the subsequent development of depressive disorders, substance use disorders and suicidality (A et al., 2008; Chapman et al., 2004; Dube et al., 2001, 2003; Enns et al., 2006). Parental divorce is also considered to be a signicant adverse childhood experience, in addition to the often-reported exposures to abuse, neglect or violence. There is a substantive body of literature regarding the impact of divorce on children. Children of divorced families are reported to demonstrate higher levels of problematic behaviours and adjustment problems compared to children of nondivorced families (Amato & Keith, 1991). Higher rates of pathology are seen in children and adolescents of divorced families, including internalizing and externalizing disorders and substance use disorders (Barrett & Turner, 2006; Fergusson, Horwood, & Lynskey, 1994; Lansford et al., 2006). Moreover, studies with long-term follow-up suggest a continuum between such childhood disorders and subsequent adult adjustment problems (Chase-Lansdale, Cherlin, & Kiernan, 1995; Rutter, Kim-Cohen, & Maughan, 2006). In cross-sectional surveys, childhood experience of parental divorce has been associated with increased rates of psychological distress in adulthood (Rodgers, Power, & Hope, 1997; Storksen, Roysamb, Gjessing, Moum, & Tambs, 2007). From a biological perspective, childhood experience of parental divorce has been associated with alterations in Hypothalamic Pituitary Axis functioning in young adults without psychopathology (Bloch, Peleg, Koren, Aner, & Klein, 2007). In a longitudinal study, the experience of parental divorce in early childhood was associated with elevated lifetime risk of major depression (Gilman, Kawachi, Fitzmaurice, & Buka, 2003). This relationship was more pronounced with exposure to parental conict, though childhood exposure to abuse and neglect was not accounted for in this study. Childhood experience of parental divorce is complicated by the complex difculties of families who divorce, frequently cooccurring with other adverse childhood experiences. Importantly, divorce alone is associated with an increased likelihood of experiencing child abuse and/or witnessing spousal abuse (Dong et al., 2004; Oliver, Kuhns, & Pomeranz, 2006). It is not clear if the childhood experience of parental divorce is associated with lifetime psychopathology independent of other childhood adversities, or to what impact the experience of both parental divorce and child abuse has on psychopathology. To our knowledge, no study has examined the relationship between parental divorce, child abuse, parental psychopathology, and mental health outcomes using a nationally representative sample. The current study uses a nationally representative adult sample to examine how the experiences of child physical maltreatment, child sexual abuse, neglect, witnessing domestic violence, and parental divorce are related to a range of lifetime DSM-III-R psychiatric disorders and suicidal ideation and attempts after adjusting for sociodemographic variables and parental psychopathology. It was hypothesized that: (1) respondents having experienced parental divorce would have increased odds of experiencing child abuse; (2) respondents having experienced parental divorce alone would signicantly increase the odds of lifetime psychiatric disorders and suicidal ideation and attempts after adjusting for sociodemographic variables; (3) respondents having experienced both parental divorce and child abuse would be associated with signicantly increased odds of psychopathology after adjusting for sociodemographic variables compared to having experienced parental divorce or child abuse alone; (4) when parental psychopathology was taken into account, the associations between parental divorce and child abuse with poor mental health outcomes would be attenuated. The sample used for the current research was drawn from the original National Comorbidity Survey (NCS) data. Although more contemporary data (NCS-R) are available, the more recent data does not include a measure of child neglect and does not include as detailed measures of child physical maltreatment and witnessing domestic violence relative to the NCS. Therefore, the NCS data were better able to address the objectives of the current research and were used for this investigation. Methods Sample and procedure The original NCS (n = 5,877; response rate 82.4%), a landmark mental health study of the United States general population, was conducted in early 1990s (Kessler et al., 1994). The NCS used a stratied, multistage, area probability sample design with statistical adjustments made for nonresponse bias (Kessler et al., 1997). The NCS assessed individuals aged 1554 years (response rate = 82.4%) and was representative of the American population on several census indicators (i.e., age, gender, race, education, marital status, region) (Kessler et al., 1994). The University of Michigan provided ethical approval for the primary data collection of the NCS (R.C. Kessler, personal communication, March 14, 2006). Details of the design of the survey have been published elsewhere (Kessler et al., 1994). The inclusion criteria for the current research was respondents living in two parent intact families until the age of at least 15 years and respondents experiencing parental divorce at age 15 years or younger. Respondents who lived in one parent families for reasons other than divorce (i.e., parental death, father unknown) were excluded from the analysis. Therefore, the total sample size used for this research was 5,159. Measures Parental divorce. Respondents were asked if they had lived with both parents until at least age 15 years. Those indicating that they had not lived with both parents because of parental separation or divorce were coded as experiencing parental divorce.

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These individuals were compared to the respondents indicating living in an intact two parent family until at least the age of 15 years. Child physical maltreatment. Child physical maltreatment was measured using amalgamated items from Conict Tactic Scales (CTS) (Straus, Hamby, Finkelhor, Moore, & Runyan, 1998). The CTS has been widely used and is a reliable and valid measure of family violence (Straus, 1979). The respondents were asked if a parent did any of the following to them: kicked, bit, hit with a st, hit or tried to hit with something, beat up, choked, burned, or scalded. The respondent indicated whether any of the acts of physical maltreatment occurred never, rarely, sometimes, or often. Those who reported that any of the aforementioned acts of violence had occurred rarely, sometimes, or often were categorized as having experienced child physical maltreatment. Child sexual abuse. Child sexual abuse was assessed using the following two questions: (1) did anyone ever have sexual intercourse with you or penetrate your body with a nger or object against your will through use of threats, force or when you were too young to understand and (2) other than rape, were you ever touched inappropriately when you did not want to be touched. Respondents endorsing either or both of these events occurring at the age of 16 years or younger were considered to have experienced child sexual abuse. Witnessing domestic violence. Respondents were asked if their parents did any of the following to each other while they were growing up: kicked, bit, hit with a st, hit or tried to hit with something, beat up, choked, burned, or scalded. Witnessing domestic violence was considered present if the respondent indicated these events occurred rarely, sometimes, or often. Child neglect. Respondents were asked if they were seriously neglected as a child (yes or no). Parental divorce and child abuse variable. A categorical variable was computed based on parental divorce and having experienced child abuse including physical maltreatment, sexual abuse, neglect, or witnessing domestic violence as a child. Of the total sample, 65% (n = 3,123) of the respondents indicated that they did not experience parental divorce or child abuse, 13% (n = 674) of the respondents reported experiencing parental divorce only, 15% (n = 873) of the respondents indicated having experienced child abuse only, and 8% (n = 489) of the respondents reported having experienced parental divorce and child abuse. Psychiatric disorders. Trained interviewers using the Composite International Diagnostic Interview 1.1 (CIDI) assessed the presence of psychiatric disorders based on the criteria of the Diagnostic and Statistical Manual 3rd edition revised (DSM III-R). The CIDI has conrmed validity and reliability (World Health Organization, 1990). The lifetime psychiatric disorders assessed included: major depression, dysthymia, bipolar I disorder, agoraphobia, social phobia, simple phobia, generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), panic disorder, alcohol abuse/dependence, drug abuse/dependence, conduct disorder, antisocial personality disorder, and adult antisocial behaviour. Additional variables were also computed to indicate any mood disorder (including major depression, dysthymia, and bipolar I disorder), any anxiety disorder (including agoraphobia, social phobia, simple phobia, GAD, PTSD, and panic disorder), any disruptive disorder (including conduct disorder, antisocial personality disorder, and adult antisocial behaviour), any substance use disorder (including alcohol abuse/dependence and drug abuse/dependence), any internalizing disorder (including any mood disorder and any anxiety disorder), and any externalizing disorder (including any disruptive disorder and any substance use disorder). In addition, a variable of having any psychiatric disorder variable (yes or no) was created which included any of the aforementioned psychiatric disorders. As well, psychiatric comorbidity was measured as having two or more psychiatric disorders (yes or no). Paternal and maternal psychopathology was also assessed and included in models as an additional control variable. The assessment of parental psychopathology was based on the Family History Research Diagnostic Criteria Interview (Endicott, Andreason, & Spitzer, 1978). Respondents were asked if their biological mothers and/or fathers had been hospitalized for mood problems, anxiety or nervousness, or substance use problems during their childhood. A dichotomous variable was calculated to indicate the presence or absence of parental psychopathology. Suicidal ideation and attempts. Suicidal ideation and attempts were measured using two questions that asked the respondent if they had ever: (1) thought about committing suicide, and (2) attempted suicide. Sociodemographic variables. Since child abuse, parental divorce, parental psychopathology, and mental health outcomes may be associated with sociodemographic characteristics, the variables of age, marital status, sex, education, current household annual income, and ethnicity were included as covariates in the analyses. The age of the respondent was measured in years. Marital status was coded as married, separated/divorced/widowed, or never-married. Sex was measured as male or female. Education was measured in number of years of formal education. Current household annual income was measured in US dollars. Ethnicity was coded as White, Black, Hispanic, or other.

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Statistical analysis First, descriptive statistics were used to understand the sample and prevalence of sociodemographic variables, parental divorce, child abuse, and mental health outcomes. Second, logistic regressions were used to determine the associations between parental divorce and child abuse while adjusting for sociodemographic variables. Third, logistic regression models were used to determine the association between the four level categorical child abuse and parental divorce independent variable (neither parental divorce or child abuse, parental divorce only, child abuse only, and both parental divorce and child abuse) and lifetime psychiatric disorders (dependent variables) while adjusting for sociodemographic variables. These models were then run again adjusting for parental psychopathology as well as sociodemographic variables. Finally, logistic regression models were used to determine the association between parental divorce only, child abuse only, and parental divorce and child abuse together (independent variable) with suicidal ideation and attempts (dependent variables) rst adjusting for sociodemographic variables, any psychiatric disorder, and psychiatric comorbidity and then adjusting for sociodemographic disorders, any psychiatric disorder, psychiatric comorbidity, and parental psychopathology. Due to the stratied, multistage sampling design of the NCS, Taylor series linearization was performed to estimate designbased standard errors (Shah, Barnswell, & Bieler, 1995). The 95% condence intervals are presented for all odds ratios. For more conservative estimates, p values less than .01 have also been reported. Results Among the 5,159 respondents, 65% did not experience parental divorce or child abuse, 13% reported parental divorce only, 15% reported child abuse only, and 8% experienced both parental divorce and child abuse. The sociodemographic proles for each group are presented in Table 1. When investigating sociodemographic variables with categories of parental divorce and child abuse, differences were found among all sociodemographic variables. Table 2 contains the logistic regression results for the associations between parental divorce and child abuse. The results indicate that parental divorce compared to living in an intact two parent family was associated with increased odds of all individual types of child abuse. Table 3 contains the prevalence and adjusted odds ratios for the relationships between parental divorce and child abuse (independent variable) with all lifetime internalizing psychiatric disorders (dependent variables). In the models adjusting for sociodemographic variables, having experienced parental divorce only was associated with increased odds of having any
Table 1 Sociodemographic characteristics of the sample. Neither parental divorce nor child abuse (n = 3,123) % (SE) Gender*** Male Female Age*** 1524 years 2534 years 3544 years 4554 years Marital status*** Married Separated/widowed/divorced Never-married Household income*** $0$19,999 $20,000$34,999 $35,000$69,999 $70,000 or more Education*** 011 years 12 years 1315 years 16 years or more Ethnicity*** White Black Hispanic Other
***

Parental divorce only (n = 674) % (SE) 54.9 (2.86) 45.1 (2.86) 41.7 (2.66) 30.2 (2.87) 18.9 (2.54) 9.1 (1.88) 50.7 (2.87) 7.8 (1.50) 41.4 (2.65) 33.6 (2.51) 25.4 (2.66) 28.6 (2.66) 12.4 (2.10) 28.2 (2.27) 37.0 (2.92) 23.4 (2.33) 11.4 (2.16) 66.3 (2.75) 21.7 (2.57) 10.4 (1.52) 1.6 (.47)

Child abuse only (n = 873) % (SE) 38.4 (2.54) 61.6 (2.54) 14.9 (1.49) 32.4 (2.49) 32.9 (2.47) 19.9 (2.10) 65.9 (2.32) 13.7 (1.58) 20.4 (1.92) 28.3 (2.19) 21.8 (2.06) 34.2 (2.45) 15.8 (2.22) 18.4 (2.00) 36.5 (2.45) 21.9 (2.03) 23.3 (2.38) 75.9 (2.18) 9.0 (1.49) 13.2 (1.74) 1.9 (.48)

Parental divorce and child abuse (n = 489) % (SE) 41.0 (3.21) 59.0 (3.21) 35.4 (2.81) 35.1 (3.00) 18.6 (2.71) 10.9 (2.19) 49.6 (3.13) 18.3 (2.91) 32.1 (2.71) 38.0 (2.95) 27.4 (2.91) 25.2 (2.73) 9.4 (1.93) 32.8 (2.83) 36.8 (3.02) 20.3 (2.51) 10.1 (2.31) 73.8 (2.73) 14.3 (2.41) 9.3 (1.54) 2.5 (.73)

52.6 (1.37) 47.4 (1.37) 23.1 (.93) 29.1 (1.26) 29.9 (1.31) 17.9 (1.15) 61.6 (1.27) 10.8 (.87) 27.6 (1.08) 20.3 (1.02) 24.1 (1.14) 40.1 (1.36) 15.5 (1.00) 18.1 (.97) 34.8 (1.31) 23.4 (1.15) 23.8 (1.20) 80.7 (1.08) 7.8 (.78) 7.4 (.68) 4.1 (.55)

Chi square value signicant at p < .01.

T.O. A et al. / Child Abuse & Neglect 33 (2009) 139147 Table 2 The associations between child abuse and parental divorce. Child abuse variables Two parent families (% (n)) Child physical maltreatment Child sexual abuse Child neglect Witnessing domestic violence Any child abuse 8.4 (398) 6.2 (311) 1.4 (82) 9.0 (443) 18.9 (873) Parental divorce Parental divorce (% (n)) 17.3 (207) 12.7 (188) 7.0 (99) 26.3 (314) 38.7 (489)

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Parental divorce versus two parent families (AOR (95% CI)) 2.49 (1.873.32)* 2.62 (1.973.49)* 6.07 (3.859.57)* 3.60 (2.794.64)* 2.94 (2.363.66)*

AOR = odds ratios adjusted for sex, age, marital status, education, income, race; unweighted n; weighted percents. * p < .01.

mood disorder, depression, dysthymia, bipolar I, and PTSD, while having experienced parental divorce and child abuse was associated with increased odds of all internalizing psychiatric disorders. When adjusting for sociodemographic variables and parental psychopathology, having experienced parental divorce only remained signicantly associated with dysthymia and PTSD, while having experience parental divorce and child abuse remained signicant associated with all internalizing psychiatric disorders with the exception of GAD, panic disorder, and agoraphobia. When investigating differences between parental divorce only, child abuse only, and parental divorce with child abuse, an additive effect between parental divorce and child abuse was found for any anxiety disorder and PTSD when adjusting for sociodemographic variables. However, the effects of the relationships decreased when also adjusting for parental psychopathology. Interaction effects between parental divorce and child abuse were tested in the internalizing disorders models, but signicant interaction effects were not found. Table 4 contains the prevalence and adjusted odds ratios for the relationships between parental divorce and child abuse (independent variable) with lifetime externalizing disorders (dependent variables). In the models adjusting for sociodemographic variables, having experienced parental divorce only was associated with increased odds of having any disruptive disorder, conduct disorder, alcohol abuse/dependence, and drug abuse/dependence, while parental divorce and child abuse was associated with increased odds of all externalizing psychiatric disorders. When adjusting for sociodemographic variables and parental psychopathology, having experienced parental divorce only was no longer associated with any externalizing psychiatric disorders, while having experienced parental divorce and child abuse remained signicantly associated with all externalizing psychiatric disorders. When investigating differences between parental divorce only, child abuse only, and parental divorce with child abuse, an additive effect between parental divorce and child abuse was found for any disruptive disorder and conduct disorder when adjusting for sociodemographic variables. However, these relationships were no longer signicant when also adjusting for parental psychopathology. Interactions effects between parental divorce and child abuse disorders were tested in the externalizing disorders models, but signicant interactions effects were not found. Table 5 contains the prevalence and adjusted odds ratios for the relationships between parental divorce and child abuse (independent variable) with suicidal ideation and attempts (dependent variables). Having experienced parental divorce only was not associated with suicidal ideation or attempts in any adjusted models. However, having experienced parental divorce and child abuse was associated with suicidal ideation and attempts even after adjusting for sociodemographic variables, any psychiatric disorder, psychiatric comorbidity, and parental psychopathology. In addition, an additive effect between parental divorce and child abuse was found for suicide attempts after adjusting for sociodemographic variables, any psychiatric disorder, and psychiatric comorbidity. However, this effect was reduced when further adjusting for parental psychopathology. Interaction effects between parental divorce and child abuse were tested in the suicide models, but statistically signicant interaction effects were not found. Discussion The results from the present study are consistent with previous research that indicates that experiencing parental divorce within childhood is associated with increased odds of child abuse (Dong et al., 2004; Oliver et al., 2006) and poor mental health outcomes in adult samples (Cherlin, Chase-Lansdale, & McRae, 1998; Fergusson, Boden, & Horwood, 2007; Gilman et al., 2003; Hope, Power, & Rodgers, 1998; Huurre, Junkkari, & Aro, 2006; Rodgers et al., 1997). However, the current ndings also extend the literature in several important ways. The main novel nding from the current study indicates that, in a nationally representative adult sample, the relationships between child abuse and some individual lifetime psychiatric disorders were signicantly elevated when accompanied with parental divorce after adjusting for sociodemographic variables. More specically, having experienced both parental divorce and child abuse together resulted in signicantly increased odds of meeting criteria for lifetime PTSD and conduct disorder compared to having experienced either parental divorce or child abuse alone. When further adjusting for reported parental psychopathology, the additive effects of parental divorce and child abuse on lifetime PTSD and conduct disorder were attenuated. This nding highlights the potential role that parental psychopathology, an additional childhood adversity, may have on the relationship between child abuse, parental divorce, and lifetime psychiatric disorders among offspring. Previous research has indicated that parental psychopathology is associated with marital status or marital transitions (A, Cox, & Enns, 2006; Wade & Cairney, 2000; Wade & Pevalin, 2004), parental abuse

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Table 3 Logistic regression results for parental divorce, child abuse, and lifetime internalizing psychiatric disorders. Neither parental divorce nor child abuse (n = 3,123) Any mood disorder % (n) AOR-1 (95% CI) AOR-2 (95% CI) Major depression % (n) AOR-1 (95% CI) AOR-2 (95% CI) Dysthymia % (n) AOR-1 (95% CI) AOR-2 (95% CI) Bipolar I % (n) AOR-1 (95% CI) AOR-2 (95% CI) Any anxiety disorder % (n) AOR-1 (95% CI) AOR-2 (95% CI) GAD % (n) AOR-1 (95% CI) AOR-2 (95% CI) Social phobia % (n) AOR-1 (95% CI) AOR-2 (95% CI) Simple phobia % (n) AOR-1 (95% CI) AOR-2 (95% CI) Panic disorder % (n) AOR-1 (95% CI) AOR-2 (95% CI) Agoraphobia % (n) AOR-1 (95% CI) AOR-2 (95% CI) PTSD % (n) AOR-1 (95% CI) AOR-2 (95% CI) 14.8 (693) 1.00 () 1.00 () 13.1 (601) 1.00 () 1.00 () 4.8 (241) 1.00 () 1.00 () .8 (36) 1.00 () 1.00 () 23.0 (989) 1.00 () 1.00 () 3.9 (171) 1.00 () 1.00 () 11.1 (487) 1.00 () 1.00 () 9.3 (389) 1.00 () 1.00 () 2.9 (120) 1.00 () 1.00 () 4.8 (191) 1.00 () 1.00 () 2.9 (135) 1.00 () 1.00 () Parental divorce only (n = 674) 19.8 (163) 1.66 (1.262.18)* , 1.35 (.941.93)* 16.2 (142) 1.46 (1.101.93)* , 1.25 (.851.83) 7.3 (44) 1.90 (1.232.94) 1.95 (1.123.40) 1.9 (13) 2.36 (1.075.18) 1.10 (.274.46) 27.6 (218) 1.28 (.991.66)* 1.23 (.871.74)* 4.1 (33) 1.36 (.832.24) 1.72 (.933.19) 13.4 (106) 1.20 (.901.61)* 1.07 (.731.57) 11.7 (90) 1.23 (.891.70)* 1.37 (.912.07) 2.7 (22) 1.16 (.672.02)* 1.46 (.742.90) 7.5 (54) 1.44 (.952.17)* 1.92 (1.153.20) 6.1 (40) 2.37 (1.354.18)* , 2.23 (1.034.82)* Child abuse only (n = 873) 33.8 (370) 2.71 (2.153.42) 2.59 (1.983.40) 29.4 (324) 2.56 (2.023.24) 2.49 (1.893.27) 11.1 (135) 2.11 (1.532.92) 2.34 (1.623.39) 2.7 (33) 3.59 (1.906.78) 3.35 (1.597.05) 41.4 (436) 2.18 (1.752.72)* , 2.24 (1.732.90) 9.3 (105) 2.16 (1.533.04) 2.38 (1.603.54) 20.7 (212) 2.01 (1.582.57) 1.91 (1.452.52) 14.5 (161) 1.39 (1.061.83) 1.42 (1.041.95) 4.7 (58) 1.50 (.982.29) 1.47 (.902.42) 9.3 (93) 1.82 (1.312.53) 1.79 (1.232.61) 16.7 (178) 6.07 (4.408.37)* , 6.40 (4.419.28) Parental divorce and child abuse (n = 489) 34.2 (194) 2.94 (2.233.89) 2.18 (1.483.20) 30.0 (169) 2.73 (2.063.62) 1.92 (1.292.84) 11.1 (71) 2.40 (1.613.59) 1.82 (1.003.30) 4.7 (22) 5.45 (2.6411.25) 4.44 (1.8410.73) 52.2 (273) 3.23 (2.444.29) 2.74 (1.814.15) 7.2 (41) 1.86 (1.182.95) 1.51 (.792.88) 23.6 (121) 2.20 (1.662.92) 1.60 (1.082.37) 19.7 (109) 1.97 (1.462.66) 1.89 (1.262.83) 6.7 (40) 2.29 (1.443.65) 1.83 (.983.43) 13.6 (66) 2.45 (1.543.88) 1.99 (.904.39) 24.4 (138) 9.87 (6.6914.55) 7.81 (4.5513.41)

AOR-1 = adjusted for sex, age, marital status, education, income, race; AOR-2 = adjusted for sex, age, marital status, education, income, race; parental psychopathology. * Denotes statistically different from divorce and abuse category at p < .05; unweighted n; weighted percents. Denotes statistically different from the neither divorce nor child abuse category at p < .01.

of their offspring (Walsh, MacMillan, & Jamieson, 2002; Walsh, MacMillan, & Jamieson, 2003), and psychopathology in their offspring (Pilowsky, Wickramaratne, Nomura, & Weissman, 2006). Therefore, parental psychopathology may provide one possible mechanism to explain the relationship between parental divorce, child abuse, and lifetime psychiatric disorders. Understanding parental psychopathology history may provide insight into family context and help to identify children at risk for other adverse childhood experiences and poor mental health outcomes. A slightly different trend was noted in the relationship between parental divorce, child abuse, and suicide attempts. Parental divorce alone was not associated with suicide attempts. However, child abuse only was associated with increased odds of lifetime suicide attempts. In addition, when child abuse was accompanied with parental divorce the odds of suicide attempts were signicantly increased compared to having experienced only child abuse. Therefore, an additive effect between parental divorce and child abuse was noted and made the experience of parental divorce in relation to suicide attempts only signicant when accompanied with child abuse.

T.O. A et al. / Child Abuse & Neglect 33 (2009) 139147 Table 4 Logistic regression results for parental divorce, child abuse, and lifetime externalizing psychiatric disorders. Neither parental divorce nor child abuse (n = 3,123) Any disruptive disorder % (n) AOR-1 (95% CI) AOR-2 (95% CI) Conduct disorder % (n) AOR-1 (95% CI) AOR-2 (95% CI) Adult antisocial behaviour % (n) AOR-1 (95% CI) AOR-2 (95% CI) Antisocial personality % (n) AOR-1 (95% CI) AOR-2 (95% CI) Any substance use % (n) AOR-1 (95% CI) AOR-2 (95% CI) Alcohol abuse/dependence % (n) AOR-1 (95% CI) AOR-2 (95% CI) Drug abuse/dependence % (n) AOR-1 (95% CI) AOR-2 (95% CI) 10.8 (414) 1.00 () 1.00 () 9.3 (348) 1.00 () 1.00 () 3.6 (155) 1.00 () 1.00 () 2.2 (89) 1.00 () 1.00 () 23.5 (1078) 1.00 () 1.00 () 20.9 (961) 1.00 () 1.00 () 8.9 (419) 1.00 () 1.00 () Parental divorce only (n = 674) 17.0 (140) 1.38 (1.031.86)* 1.02 (.661.58)* 15.1 (123) 1.42 (1.041.94)* .99 (.621.59)* 5.3 (42) 1.20 (.771.86)* .85 (.451.63) 3.4 (25) 1.27 (.722.24)* .69 (.281.69)* 27.5 (246) 1.28 (.991.66)* .95 (.671.36)* 25.1 (225) 1.30 (1.001.69)* .93 (.651.33)* 12.8 (109) 1.46 (1.081.98)* 1.15 (.751.77)* Child abuse only (n = 873)

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Parental divorce and child abuse (n = 489) 31.3 (168) 3.98 (2.925.42) 2.73 (1.754.24) 27.9 (145) 4.01 (2.925.51) 2.84 (1.804.49) 10.6 (64) 2.89 (1.924.36) 1.86 (1.053.29) 7.2 (41) 3.31 (2.025.44) 2.11 (1.054.24) 40.4 (224) 2.51 (1.873.38) 2.10 (1.413.12) 34.2 (188) 2.26 (1.673.05) 1.87 (1.252.78) 24.9 (140) 3.46 (2.544.70) 2.65 (1.764.01)

20.4 (217) 2.74 (2.073.63)* , 2.71 (1.943.78) 17.6 (177) 2.68 (1.993.60)* , 2.63 (1.853.73) 7.2 (93) 2.43 (1.683.53) 2.58 (1.674.00) 4.4 (53) 2.50 (1.544.07) 2.63 (1.504.61) 33.6 (397) 1.98 (1.572.49) 2.03 (1.552.66) 29.5 (350) 1.91 (1.512.41) 1.91 (1.452.51) 17.6 (211) 2.52 (1.953.25) 2.48 (1.833.34)

AOR-1 = adjusted for sex, age, marital status, education, income, race; AOR-2 = adjusted for sex, age, marital status, education, income, race; parental psychopathology. * Denotes statistically different from divorce and abuse category at p < .05; unweighted n; weighted percents. Denotes statistically different from the neither divorce nor child abuse category at p < .01.

The effects sizes for child abuse were notably larger than the effect sizes for parental divorce. In fact, with the exception of bipolar I disorder and PTSD, the adjusted odds ratios associated with parental divorce only and poor mental health outcomes were close to 1. These ndings conrm that parental divorce is an important adverse childhood experience. However, they may also suggest that when the experience of parental divorce is not accompanied with child abuse as measured in the current research, the increased odds of lifetime psychiatric disorders and suicide attempts associated with parental divorce may only be minimal. These ndings highlight the importance of developing proven efforts to prevent the occurrence of domestic violence and child abuse in families that experience marital discord.

Table 5 Logistic regression results for parental divorce, child abuse, and lifetime suicidal ideation and attempts. Neither parental divorce nor child abuse (n = 3,123) Suicidal ideation % (n) AOR-1 (95% CI) AOR-2 (95% CI) Suicide attempts % (n) AOR-1 (95% CI) AOR-2 (95% CI) 8.5 (359) 1.00 () 1.00 () 2.6 (106) 1.00 () 1.00 () Parental divorce only (n = 674) 12.5 (29) 1.30 (.911.86)* .92 (.501.67)* 3.3 (106) .95 (.561.60)* .68 (.291.61)* Child abuse only (n = 873) 22.9 (83) 2.08 (1.572.77) 2.00 (1.442.79) 7.1 (29) 1.54 (1.022.31)* 1.52 (.962.40) Parental divorce and child abuse (n = 489) 28.1 (84) 2.22 (1.652.98) 1.73 (1.172.56) 14.8 (83) 2.74 (1.844.08) 2.05 (1.233.41)

AOR-1 = adjusted for sex, age, marital status, education, income, race, any lifetime psychiatric disorder and any lifetime psychiatric comorbidity; AOR2 = adjusted for sex, age, marital status, education, income, race, any lifetime psychiatric disorder and any lifetime psychiatric comorbidity, and parental psychopathology. * Denotes statistically different from divorce and abuse at p < .05; unweighted n; weighted percents. Denotes statistically different from the neither divorce nor child abuse category at p < .01.

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It is important to consider the limitations of the current study. The cross-sectional nature of the data prevents inference about causal relationships. Therefore, from these data it cannot be stated that parental divorce and child abuse cause poor mental health outcomes, but rather it can only be determined that an association exists between parental divorce, child abuse, and lifetime psychopathology. As well, the retrospective design of the survey may introduce a recall and reporting bias. However, although retrospective research may introduce some sampling error, there is evidence that supports the validity of accurate recall of adverse childhood events (Hardt & Rutter, 2004). Another limitation of the current research is the exclusion of personality disorders. Understanding the relationships between parental divorce, child abuse, and psychiatric disorders would have been enriched with the inclusion of personality disorders. In addition, the reporting of parental psychopathology was based on information provided from the respondent only, which could introduce source bias. Ideally, conrmation of parental psychopathology from an additional source would have improved the study design. Next, data were not available on multiple family transitions including parental remarriage and subsequent parental divorce or separation. Experiencing several family structure transitions during childhood may have an additional impact on child abuse and mental health outcomes. A longitudinal study design that includes data on remarriage and subsequent divorce would inform this research question. As well, the items from the CTS were used to assess child abuse in the current research. However, due to time constraints in conducting a large scale population-based survey, items from the CTS were amalgamated into a list rather than administering the full scale. The ability to measure child abuse would have been improved if it would have been possible to administer the complete CTS. Another limitation of the current research was that the NCS data did not assess emotional abuse. It is also important to note that the use of an overall child abuse variable that included child physical maltreatment, child sexual abuse, neglect, and witnessing domestic violence creates adequately powered models to investigate the relationships between child abuse, parental divorce, and several psychiatric disorders. However, the disadvantage of collapsing child abuse into one abuse variable is that we are unable to understand the impact of the individual types of child abuse on psychopathology. This should be considered with interpreting the results from this research. Finally, as previously mentioned the NCS data were used for the current study because these data include several important measures (i.e., child neglect) that were not available in the newer NCS-R. Therefore, the NCS allowed for a more comprehensive investigation of parental divorce, child abuse, and mental health outcomes. However, the limitation of using the NCS data is that the data are not as contemporary compared to the NCS-R. In conclusion, parental divorce and child abuse are adverse childhood events that increase the odds of lifetime psychiatric disorders. The effects sizes are larger in the relationships between child abuse and psychiatric outcomes compared to parental divorce and psychiatric outcomes. However, parental divorce is related to lifetime psychopathology independent of child physical maltreatment, child sexual abuse, neglect, and witnessing domestic violence. In addition, when the experience of child abuse is accompanied by parental divorce, the associations are signicantly greater than the impact of parental divorce or child abuse independently for some mental health outcomes. Furthermore, parental psychopathology is an important consideration since it was found to attenuate the relationships between parental divorce, child abuse, and psychiatric disorders and suicide attempts. Adverse childhood events are likely to co-occur rather than be experienced in isolation (Dong et al., 2004). When studying long-term effects of parental divorce it is important to also assess the co-occurrence of child abuse and parental psychopathology since they may be confounders in the relationship between parental divorce and poor mental health outcomes. All of these factors represent adverse childhood events which can have a long-term impact on mental health. To further understand family context and risk for psychiatric disorders and suicidal behaviour, mental health researchers and clinicians may want to assess parental divorce and parental psychopathology when inquiring about child abuse.

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