Research reportDevelopment of a retrospective interview measure of parental maltreatment using the Childhood Experience of Care and Abuse (CECA) instrument — A life-course study of adult chronic depression — 1
Introduction
We are concerned with the well established association of neglect and abuse during childhood and adolescence and increased risk of adult depression (e.g. Anderson et al., 2002, Bifulco et al., 1994, Brown, 2001a, Maughan and Kim-Cohen, 2004). There is evidence this particularly holds for chronic episodes defined as lasting 12 months or more. A London study of 400 adult women with a child at home and living in Islington, an inner city area, found those with such early maltreatment had a four-fold increase in risk of a chronic episode compared with a two-fold one for episodes of any length (Brown and Moran, 1994; see also Merikangas et al., 1994, Paykel et al., 2001, Surtees et al., 1986, Durbin et al., 2000, Lara and Klein, 1999, Kendler et al., 1997).
The rate of chronic episodes across populations varies and this may be linked to rates of disadvantage. The National Comorbidity Survey found that disadvantaged ethnic groups show differences in psychiatric morbidity in terms of the persistence of disorders (Breslau et al., 2005), and educational and marital status appear to be related in a similar way (Bracke, 1998). It is notable that work based on the influential Virginia twin enquiry, using a sampling frame based on car ownership, found only 2% of onsets of depression had not recovered by 1 year (Kendler et al., 1997). Bearing in mind this variability, a reasonably representative finding is that of 24% of men and women between 18 and 64 with a new episode of major depression were still depressed (using DSM-3-R criteria) after 12 months in a prospective population study in the Netherlands (Spijker et al., 2002). The rates of experiencing early maltreatment, like risk of chronic depression, also vary among studies, but with many studies reporting rates of around one fifth, the proportion found in the London sample mentioned earlier (Brown, 2001b).
Clinical characteristics have not so far proved of much importance in explaining course of depression, with evidence pointing to a key role for psychosocial factors, and it is with these we will be concerned (e.g. Durbin et al., 2000, Riso et al., 2002). While we deal with the experience of women in the general population, much the same appears to hold for patient samples with respect to psychosocial vulnerability (e.g. Brown et al., 1994, Hays et al., 1997, Van Londen et al., 1998).
This paper will focus entirely on the link of maltreatment with adult depression and leave to a later paper to explore how this link relates to the broad array of other early experiences within the family such as parental discord and financial problems of the family (Cicchetti and Carlson, 1989, Starr and Wolfe, 1991, Trickett and McBride-Chang, 1995). But for both tasks it is essential to deal with the implications of the findings from behavioural genetic studies that siblings often have different experiences of their parents (Caspi et al., 2004, Daniels and Plomin, 1985, Dunn and Plomin, 1991). To our knowledge it is unknown how far such differential experience holds for the more extreme behaviour covered by parental abuse and neglect and since our data largely concerns sister pairs we are able to consider this. To the extent they are treated differently data on sister pairs will allow us to consider in a later paper the extent that family-wide factors such as parental discord contribute to risk of adult depression independently of parental maltreatment.
We will be particularly concerned with two other issues raised by the current literature. First, early maltreatment can take a number of forms (Garbaroni et al., 1986) with children with one form often exposed to at least one other (Coid et al., 2003, Fergusson and Mullen, 1999, Finkelhor and Dziuba-Leatherman, 1994, Fleming et al., 1997, Hill et al., 2001, Madu and Peltzer, 2000, Mullen et al., 1996, Mullen, 2003). There is also some evidence that emotional abuse and neglect may be the key factors of aetiological importance (e.g. Dong et al., 2003, Garbarino and Collins, 1999, McGee et al., 1997). Despite this, in recent years there has been an overwhelming emphasis on sexual and physical abuse. A good deal of research will therefore have missed some of the maltreated, and failed to document other maltreatment occurring to those with sexual and physical abuse (Brown, 2001b, Fergusson and Mullen, 1999). Second, relatively few studies have dealt with depression in terms of its course (Merikangas et al., 1994). Most depressive disorders are relatively brief (Rao et al., 1999) and taking course into account may throw some light on a number of puzzling results in the research literature. For example, work using the Dunedin birth cohort has found conduct disorder in girls is unrelated to depression at age 21 (Bardone et al., 1998: see also Hofstra et al., 2002). This is surprising as longer follow-up studies have regularly documented such a link (e.g. Robins, 1986, Quinton et al., 1990). In our third paper we argue that such a finding may relate to a failure to take account of depressive disorders taking a chronic course (Brown et al., 2007b).
For the measurement of maltreatment in childhood and adolescence we have employed an extended version of a semi-structured interview, the Childhood Experience of Care and Abuse instrument (CECA) that covers retrospectively all commonly discussed aspects of maltreatment occurring in childhood and adolescence to age 17 (Bifulco et al., 1994). There are a number of other similar instruments (e.g. Brown, 2001b, Brown et al., 1999, Kaplan et al., 1999), but to our knowledge only one uses throughout intensive questioning and investigator-based ratings (Finkehor et al., 1994). There is considerable concern about the effectiveness of such retrospective accounts. Our next paper is devoted to this question and some of the relevant data utilises material obtained by questioning sisters about each other (Brown et al. 2007a).
The goals of this first paper are:
- i.
To present a new simplified index of parental maltreatment based on CECA scales.
- ii.
To show the extent to which the experience of pairs of sisters differ and how far this is associated with adult chronic depression.
Section snippets
Samples and data collection
The great majority of women in the UK are registered at local health centres and records of two in Islington in North London were used to select women. A postal questionnaire, accompanied by an introductory letter from the doctors supporting the research, was sent to women no older than 50 to obtain further basic information such as the age of any sisters. The response rate, after reminder letters, was similar to that achieved in an earlier exercise at a different London health centre. An
General approach
For most analyses in this paper the total 198 women are used since aetiological findings concerning parental variables are very similar for the high-risk and comparison series, but any suggestion of a difference will be noted. By contrast, the frequency of adverse family experiences is bound to differ because of our selection procedures and details will be given. The original CECA index combined parental ratings, but in the light of evidence of the importance of the mother for risk of
Discussion
The present study using a binary index has shown parental maltreatment is highly associated with the experience of an adult chronic depressive episode, but by contrast much less for depressive onsets in general.
Role of funding source
Funding was provided by the Medical Research Council who had no involvement in the design, collection, analysis and interpretation of the data, the writing of the report, and in the decision to submit for publication.
Conflict of interest
No conflict of interest.
Acknowledgements
Funding was from the Medical Research Council. We would like to acknowledge the help from Antonia Bifulco, Ann Brackenridge, Amanda Lillie, Julie Jarvis, Ruth Robinson, Hedy Wax and Anna Westlake. We are indebted to Islington general practitioners and health visitors for permitting selection of subjects from their registration lists, and, of course, the women themselves who gave up hours of their time to help with the research.
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