Childhood physical punishment and the onset of drinking problems: Evidence from metropolitan China

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Abstract

Background

Evidence in support of a suspected causal association linking childhood physical punishment (CPP) and later alcoholic beverage-related disturbances has been found in metropolitan China. Here, the focus shifts to the CPP association with the estimated risk of starting to drink, having the first drinking problem, and transitioning from first drink to the first drinking problem.

Methods

Data are from the World Mental Health Surveys-metropolitan China study, with representative samples of adult household residents living in two metropolitan cities, Beijing and Shanghai. Recalled information was available for early life experiences (including CPP, other childhood adversities, and parental alcohol and drug problems), as well as the onset age of drinking and drinking problems. Survival analyses were used to estimate the Hazard Ratio. A structural equation modeling approach was used to control for other inter-correlated childhood adversities.

Results

Cox proportional hazards modeling discloses statistically robust associations linking CPP with drinking and drinking problems, as well as more rapid transitions from first drink to first drinking problem, even after accounting for other childhood adversities and parental drinking problems. These associations cannot be attributed to a more general noxious family environment.

Conclusions

These results lay a foundation for future experimental studies on the possible causal relationship linking CPP with the onset of drinking problems and the transition from drinking to drinking problems.

Introduction

Drinking is one of the leading causes of disease burden globally (Murray and Lopez, 1997). Recent epidemiological surveys have found that drinking is common in China, where drinking problems including alcohol use disorders (AUD) are not rare (Cheng et al., 2010a, Hao et al., 2004). In this context, the identification of possible causes of drinking problems, especially those which may be potentially modified, is of interest because it may provide guidance for prevention and intervention strategies.

This is the third report on a suspected causal association that links harsh childhood physical punishment (CPP) with later drinking problems in metropolitan China. In the first report, a generalized linear model with logit link was used to study a multivariate profile of drinking responses observed in adulthood. The odds of alcohol dependence and associated clinical features in adulthood was found to depend on CPP history, even with family drinking problems taken into account (Cheng et al., 2010c). In the second report, a structural equations modeling (SEM) approach was used to evaluate the degree to which the level of alcohol dependence in adulthood might depend upon the CPP history vs. an alternative model in which the most prominent predictive or causal variable of interest is a generally noxious family environment with CPP and other childhood adversities bundled into the noxious environment construct. In that report, levels of alcohol dependence were found to depend on CPP history, even with a generally noxious family environment held constant via an SEM approach (Cheng et al., 2010b).

These investigations left uncertainty about the timing of onset of drinking and the timing of onset of alcohol dependence problems once drinking had started, and did not address some nuances introduced by Sartor and colleagues in their recent studies (Sartor et al., 2007a, Sartor et al., 2007b). For example, an excess odds on level of alcohol dependence might be mediated by earlier onset of the first drink, inasmuch as early-onset drinking per se might account for later excess risk of alcohol dependence (Dawson et al., 2008, DeWit et al., 2000, Kessler et al., 1997, Kuo et al., 2008, McGue et al., 2001, Rothman et al., 2008). Furthermore, alcohol dependence might emerge during the teen years, soon after drinking onset, or might be delayed until many years after the start of drinking. There are questions about the natural history of drinking and drinking problems, or “mechanisms” through which CPP might be linked to greater odds or higher levels of alcohol dependence. Accordingly, in this third report, we seek to answer these questions about the time course from early CPP to: (1) later onset of drinking to (2) later onset of alcohol problems.

It has been widely documented that childhood adversities are associated with drinking problems (see Cheng et al., 2010c). Possible developmental pathways included changes in the structure of the brain and the function of certain neurotransmitters and their receptors (e.g. GABA, Bremner et al., 1997, Teicher et al., 2006), as well as hormonal responses to stress (Carpenter et al., 2011, Heim et al., 2000). Social pathways also may link parenting deficiencies to drinking problems, perhaps via affiliation with deviant peers (Lloyd and Anthony, 2003), and other precocious antisocial behaviors (Jacob and Johnson, 1997).

Numerous studies have provided supportive evidence on the possibility that early CPP might accelerate time to drinking onset (e.g., Anda et al., 2002; Cheng et al., 2010c; Dube et al., 2006, Hamburger et al., 2008, Kaufman et al., 2007, Rothman et al., 2008). Dom et al. (2007) and Kendler et al. (2002) found earlier onset of drinking problems linked back to childhood adversity in general and to parental loss or separation, but did not study CPP in specific (Dom et al., 2007, Kendler et al., 2002). In this context, there are two alternative possibilities for the observed association linking CPP with early onset AUD. The first is that CPP is associated with both early initiation and more rapid progression; the second is that CPP is associated with early drinking initiation only. That is, once drinking starts, CPP is not associated with the progression from drinking to AUD. For example, the observed CPP–AUD association might be due to longer duration of drinking for people who experienced CPP. The latter scenario has been found by Sartor and colleagues in relation to childhood sexual abuse and parental divorce with respect to drinking outcomes. These adversities were associated with earlier initiation of drinking but not the progression from drinking to AUD (Sartor et al., 2007a, Sartor et al., 2007b). To the best of the authors’ knowledge, there has been no such study focused on CPP specifically in relation to drinking outcomes.

Against this background, the aims of the study are: (1) to estimate the association linking CPP with the time of onset of drinking and of drinking problems for the population as a whole; (2) to estimate the association between CPP and the time from drinking initiation to the onset of drinking problems (i.e., via study of time to drinking problems once drinking has started). In this study, data are from the World Mental Health-metropolitan China survey (WMH-mC), a cross-sectional survey of household-dwelling adults in Beijing and Shanghai, China.

As indicated in many previous studies, childhood adversities are inter-correlated. Hence, work that is focused on one aspect may be artificial (Cheng et al., 2010b, Dong et al., 2004). For this reason, in this study, the research approach is one that couples SEM with survival analyses methods in order to take the inter-correlation into account in a fashion that does not violate assumptions of generalized linear models, which otherwise might introduce bias or inconsistency in estimation.

We alert readers that in some parts of the world the term “child abuse” might apply to experiences we have characterized as “physical punishment,” and these readers are invited to make a mental substitution of the term “child abuse” in our sentences that refer to “physical punishment.” Nonetheless, we note cross-national and sometimes within-country cultural variations in the use of these terms, which are not completely interchangeable. For example, in some parts of the world, whipping a child's buttocks with a paddle, a belt, or switches (a sheaf of small tree branches) is a usual and customary disciplinary practice that would not qualify as “child abuse” as defined in child protection laws, but it would qualify as a form of “harsh physical punishment” in virtually all parts of the world. However, we should clarify that our use of the term “punishment” does not imply that the child has violated a rule or is being punished for rule-breaking. In this context, our usage of the term “punishment” is in conformity with the Oxford American Thesaurus of Current English (Lindberg, 2002), in which “to punish” encompasses serious forms of “abuse,” but also harsh “smacking” and “slapping” with no implication that the child is being punished for breaking a rule. In some instances, the “punishment” might simply be the aggressive lashing out toward a child when one parent has been frustrated by the other parent. We invite our readers to conceptualize the “punishment” in this more general sense, mentally re-casting it as “child abuse” if the result is enhanced comprehension of the study evidence.

Section snippets

Study design and sample selection

Prior publications give detailed methods overviews (Shen et al., 2003, Shen et al., 2006). Here we provide a brief description.

Data were collected for the cross-sectional WMHS-mC, which used a stratified multi-stage probability sampling method to select household-dwelling adults, aged 18–70 living in Beijing and Shanghai. The Research Center for Contemporary China at Peking University directed the field work in both cities, which involved face-to-face interviews between November 2001 and

Results

Table 1 provides a description of sex and age of the sample, as well as means of the onset age of drinking and drinking problems for the CPP and non-CPP group, respectively. Individuals who experienced CPP are slightly younger (x¯=37.9 for the CPP group vs. x¯=41.5 for the non-CPP group, p = 0.02). A slightly larger proportion of males is found in the CPP group compared to the non-CPP group (59.7% vs. 51.4%, p = 0.08).

Kaplan–Meier estimators and resulting plots of the survival curves disclose that

Discussion

Main results of this study are summarized succinctly as follows. First, for the population under study as a whole, individuals who experienced CPP were found to be at a greater hazard of drinking and developing drinking-related problems (SMD and CFAD in this study). Based on the covariate-adjusted models, this association might not be due to parental drinking problems or other childhood adversities. Moreover, it is not explained by a generally noxious family environment. After accounting for

Role of funding source

We thank the WMH staff for assistance with instrumentation, fieldwork, and data analysis. These activities were supported by the United States National Institute of Mental Health (R01MH070884), the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the US Public Health Service (R13-MH066849, R01-MH069864, and R01 DA016558), the Fogarty International Center (FIRCA R03-TW006481), the Pan American Health Organization, the Eli Lilly & Company Foundation, Ortho-McNeil

Contributors

Author HGC designed the study, managed the literature searches, undertook the statistical analysis, and wrote the first draft of the manuscript. JCA advised data analysis and revised the manuscript. All authors contributed to and have approved the final manuscript.

Conflict of interest

All authors declare no conflicts of interest.

Acknowledgment

We thank the WMH staff for assistance with instrumentation, fieldwork, and data analysis.

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