**3. Understanding interaction of child abuse events and adult emerging syndromes in Mexico**

To determine the relationship between traumatic events in childhood and the presence of emerging syndromes in adulthood in the Mexican population, quantitative, correlational-comparative research was carried out. Voluntarily, 670 people participated. The age range was between 18 and 77 (*M* = 28.15, *SD* = 12.34); 266 (39.7%) men, 399 (59.6%) women, 3 (0.4%) other, 2 (0.3%) did not respond; 258 (38.5%) self-injured.

The study was approved by the Ethical Committee of Psychology School of Universidad de Monterrey (Ref. 19112020-PSI-CI). Data were collected online through approximately 30-min computerized questionnaires using the Qualtrics platform. Only age and gender were considered inclusion criteria. Participants were provided with informed consent and completed a sociodemographic questionnaire and several clinical measures. All participants voluntarily agreed to take part in the study without incentives and were recruited through mailing lists and social networks.

We used some Psychology research measures including a sociodemographic section. We also used the rating scales described below.

**Adverse experiences (AE).** Based on the 12 dichotomic items of the adverse experiences that occurred before 18 years used in the National Comorbidity Scale-Replication (NCS-R) conducted by Green et al. [7], in this study we included: and then the groups of adverse experience. We included three interpersonal losses (parental death, parental divorce, and parental split-up); four types of family maladaptation (parental mental illness—major depression, generalized anxiety disorder, panic disorder, antisocial personality; parental substance use, parental criminality—robberies, arrests for criminal activity; and violence); three types of maltreatment (physical abuse; sexual abuse—erotic caress, rape intent, rape; and neglect); other children adversities (physical illness risking minor life; economic adversity to cover basic needs; and any adversity). Additionally, we asked for family stability through the number of split-ups (divorces or living with other people). We also asked separately for the biological death of the father and the mother. We also inquire for three different types of sexual abuse. The total number of items was 18.

**PTSD Checklist for DSM-5.** A 20-item self-report measure based on DSM-5 criteria for PTSD and was created to assess the presence and severity of post-traumatic stress symptoms (PTSD) that cannot be explained or attributed to other conditions, e.g., substance abuse, medical conditions, bereavement, among others [93]. We used the Mexican Spanish adaptation with a satisfactory consistency (α = .**943** ) [94]. The items are rated on a Likert-type scale ranging from zero (not at all) to four (totally) and assess symptoms of re-experiencing (e.g., unwanted, and disturbing recurring memories of the stressful experience; α *= .***861** ); avoidance (e.g., avoiding memories, thoughts, or feelings related to the stressful experience; arousal (e.g., irritable behavior, angry outbursts, or acting aggressively); and cognitive disturbances (e.g., having difficulty concentrating). The severity index ranges from 0 to 80.

#### *Sexual Abuse in Childhood: Emerging Syndromes in Adulthood DOI: http://dx.doi.org/10.5772/intechopen.105888*

**Inventory of Statements About Self-Injury (ISAS).** The scale is divided into two sections: the first one assesses lifetime frequency of 12 non-suicidal self-injury (NSSI) behaviors performed "intentionally (i.e., on purpose) and without suicidal intent." The behaviors assessed are banging/hitting self, biting, burning, carving, cutting, wound picking, needle-sticking, pinching, hair pulling, rubbing skin against rough surfaces, severe scratching, and swallowing chemicals. Participants are asked to estimate the number of times they have performed each behavior. Five additional questions assess descriptive and contextual factors, including age of onset, the experience of pain during NSSI, whether NSSI is performed alone or around others, and time between the urge to self-injure and the act [95]. In addition, some ad-hoc questions are added, such as the number of self-harms in the last year [96, 97]. We used the Mexican Spanish validated version [98]. The second section is 39 items of self-report grouped into two factors: interpersonal (e.g., reassuring myself) and intrapersonal (e.g., demonstrating that I do not need the help of others), both with adequate internal consistency (α = 0.88 and α = 0.80, respectively), with three possible Likert-type response categories: zero (not at all relevant), one (somewhat relevant) and two (very relevant). Functions associated with these two NSSI factors include affect regulation, self-punishment, anti-dissociation/feeling generation, anti-suicide, and marking distress in Intrapersonal, while interpersonal boundaries, self-care, sensation seeking, peer bonding, interpersonal influence, toughness, revenge, and autonomy constitute Interpersonal.

**Acquired Capability with Rehearsal for Suicide Scale (ACWRSS).** A seven-item self-report was developed to capture the key facets of acquired capability for suicide [99]. Items are rated from zero (not at all) to eight (very strongly); higher scores demonstrate an increased risk of suicide [100]. The scale assesses reduced fear associated with death (e.g., Imagining my own death is very scary), increased pain tolerance (e.g., I can tolerate pain much more than I used to), and mental rehearsal of suicide (e.g., It has crossed my mind what it would be like to die). It correlates significantly with previous suicide attempts and nonsuicidal self-harm thoughts and episodes and has excellent non-clinical internal consistency (α = 0.91).

Using the statistical package for Social Sciences (SPSS 28v), we first checked if the assumptions were met for all parametric tests conducted. Additionally, descriptive analyzes were carried out to present frequencies and percentages of adverse events in childhood (ACE). We then carried out the reliability analyses of the instruments. In addition, we performed multiple correlation analyses (Pearson's r). We then decided to conduct an exploratory factor analysis of the Adverse Events in Childhood, specifically looking for sexual abuse to carry out predictive and explanatory models based on the interaction of the variables in the study.

### **3.1 What we found**

We initially found that 299 (44.6%) did not experience any traumatic events, but 371 (55.4%) experienced one (109, 16.3%) to 18 (.1%), and of those, 350 (94.3%) participants experience from one to seven adverse events; and 112 (16.7%) more than four adverse childhood event (ACE). In **Table 1,** we present the frequencies and percentages of the adverse events in childhood reported by the participants (*M* = 1.71, *SD* = 2.37). Family instability and biological father death were the most common reported adverse childhood events.

Relationships between variables are shown in **Table 2**. Correlations between variables have shown theoretically expected directions. For instance, Total Adverse


#### **Table 1.**

*N = 670.*

*Frequency of adverse events in childhood.*

Events correlated positively with all emerging psychopathological syndromes in adulthood. The correlations with ACE from highest to lowest association are PTSD, NSSI Intrapersonal, Preparedness to Suicide, and NSSI Interpersonal. Regarding Preparedness to Suicide, NSSI Intrapersonal is followed by PTSD and NSSI Interpersonal.

Then, we decided to work with the ACE and carried out an exploratory factor analysis (EFA) to group the adverse events once the number of times they occurred was recorded. A six-factor model was driven. First, the Kaiser-Meyer-Olkin sample adequacy index (KMO = 0.834) and Bartlett's sphericity test were calculated, which were statistically significant [χ<sup>2</sup> (231) = 4018.09, *p* < .001], indicating the feasibility of performing a factorial analysis. Next, a maximum likelihood analysis with Varimax rotation was performed specifying six factors. Finally, an exploratory factor analysis was performed using the rotated components method given the six-dimensional structure initially considered, which explained 55.76% of the variance, with a large effect size (η<sup>2</sup> = 78.9%). The Cronbach's alpha indicated good internal reliability for


*Note: NSSI = Nonsuicidal Self-Injury*

*\*The correlation is significant at the 0.05 level (bilateral).*

*\*\*The correlation is significant at the 0.01 level (bilateral).*

#### **Table 2.**

*Means, standard deviations, and correlations between variables in the study.*

the total scale (α = .829) and each factor: 1 Parents' Mental Health (α = .669); 2 Sexual Abuse (α = .633); 3 Family Violence (α = .650); 4, Family instability (α = .666); 5 Absent Parents (α = .639); and 6 Adversity (α= .615).

As we were particularly interested in sexual abuse implications in adulthood, we used this discriminative factor to determine those participants that experienced sexual abuse in childhood and found 124 (18.5%). Afterward, we conducted a multiple linear regression to determine the predicted value of the variables of sexual abuse, NSSI Interpersonal and Intrapersonal, on Preparedness for Suicide. The results indicated that NSSI and TEPT explained 26.4% of Preparedness for Suicide (**Table 3**).

Based on the results, as sexual abuse practically disappeared in the regression model, we decided to carry out two sequential mediation analyses to examine the interaction of variables using the computational tool macro-PROCESS (model 4, bootstrapping 10,000 samples, 95% CI) statistical program for Social Sciences (SPSS) [101]. For these analytic approaches, initially Sexual Abuse in Childhood was considered as the predictor variable (*X*), with Preparedness for Suicide as the output variable (*Y*), Post-traumatic Stress (*M1*) as the first mediating variable, and NSSI Interpersonal (*M2*) as the sequential mediating variable. The interaction of PTSD and NSSI Interpersonal on the direct effect of Sexual Abuse in Childhood on Preparedness for Suicide (completely standardized indirect effect [0.02, SE 0.007, 95% CI (.011; .037)] (**Figure 1**).

Afterward, a second mediation analysis was carried out considering Sexual Abuse as the predictor variable (*X*) with Preparedness for Suicide as the output variable (*Y*) testing again the same mediators: PTSD (*M1*) as the first mediating variable and NSSI Intrapersonal (*M2*) as the sequential mediating variable. The interaction of PTSD and NSSI Interpersonal on the direct effect of ACE Sexual Abuse on Preparedness


#### **Table 3.**

*Predictive regression model for Preparedness for Suicide of participants (n = 670).*

#### **Figure 1.**

*Sequential mediation analysis of Post-traumatic Stress (serial mediator 1) and NSSI Interpersonal (serial mediator 2) in the relation between Sexual Abuse in Childhood and Preparedness for Suicide. Direct effects after including the mediator are in brackets. \*\* p ≤ 0.001; \* p ≤ 0.05.*

#### **Figure 2.**

*Sequential mediation analysis of Post-traumatic Stress (serial mediator 1) and NSSI Intrapersonal (serial mediator 2) in the relation between Sexual Abuse in Childhood and Preparedness for Suicide. Direct effects after including the mediator are in brackets. \*\* p ≤ 0.001; \* p ≤ 0.05.*

for Suicide predicts a strong indirect effect (completely standardized indirect effect [0.02, SE 0.007, 95% CI (.011; .037)] (**Figure 2**).

#### **4. Conclusions**

Several important findings arose from our study. Considering that we were looking for emerging psychopathological syndromes in adulthood, particularly posttraumatic stress disorder, self-injurious behavior, and suicide risk when people are exposed to adverse events in childhood, particularly sexual abuse.

In this general population research, we found that 55.4% had at least one adverse childhood experience (ACE) and 94.3% of participants experienced from 1 to 7 adverse events, and 16.7% suffered more than 4 ACE. This data is close to 61% with at least one ACE and 16% that had four or more types (one in six adults)[102] so preventing early trauma is imperative.

In this Mexican sample, family instability (110, 16.4%) and biological father death (104, 15.5%) were the most common reported ACE, both having enduring health consequences across the life span. Family instability captures changes in family structure [103] and father's death—5% [104] in the UK, 4.5% [105, 106] in Denmark—diminishes personal mastery such as vision, purpose, commitment, belief, and selfknowledge—[107]. Additionally, losing at least one parent by the age of 15, 21.9% in our study is close to the 20% reported in China, Italy, and the Netherlands [108, 109]

#### *Sexual Abuse in Childhood: Emerging Syndromes in Adulthood DOI: http://dx.doi.org/10.5772/intechopen.105888*

associated with serious consequences in adjustment, particularly in behavioral problems, and negative implications in cognitive and educational outcomes [106, 107].

As the association of sexual abuse is often found related to self-injurious and suicidal behavior, we conducted a linear multiple regression model and found NSSI Interpersonal and Intrapersonal predict them [110]. NSSI Interpersonal is negatively predicting preparedness for suicide which could be explained due to the social functions of this outward expression of distress and emotional pain that provides others' support, help-seeking and caring response, and fitness; generate excitement; and stop both, suicidal thoughts and feeling numb [111–114]. NSSI Intrapersonal positively predicted preparedness for suicide. This has also been reported in several studies related to future repetition of self-harm and prospective risk for suicide attempts [110–112, 115, 116]. This happens because sexual abuse is a form of child maltreatment strongly associated with suicidality [117, 118]. PTSD also predicted preparedness for suicide-related to different ACE, particularly sexual abuse [119–122].

In relation to the current debate about self-harm, these findings allow us to consider that effectively NSSI Interpersonal may be a deliberate way of harming oneself without the desire to die [57–59]; however, the NSSI Intrapersonal significantly predicts preparation for suicide, which indicates that this factor of self-injurious behavior is associated not only with suicidal thoughts [55, 123–126], but also to preparedness and attempt, possibly as the only way for definitive relief of pain, fear [61, 109, 127, 128], and suffering due to traumatic events [74–76].

Finally, the two sequential mediational models indicate that nonetheless, sexual abuse in childhood has a direct effect on preparedness for suicide, it also has a domino effect, that is, a series of related events, one following another. ACE sexual abuse predicts PTSD, but when this variable interacts with NSSI Interpersonal which provides significant emotional relief and generates feeling motives [129, 130], in turn, has a complete mediation effect in preparedness for suicide. When PTSD interacts with NSSI Intrapersonal, even though strongly predicts suicide [57, 125, 130], the interaction has a partial mediation effect on preparedness for suicide diminishing it considerably.

These findings indicate that the long-term negative effects of childhood traumatic events emerge as syndromes in adulthood: post-traumatic stress disorder, self-injurious behaviors, and suicidal behavior. Also, the interaction of PTSD with non-suicidal intrapersonal and interpersonal self-harm prevents the individual from being directly involved in preparing for suicide. Experiencing ACE, especially sexual abuse, has a traumatic impact, frequently developing PTSD which symptoms can make a person feel constantly afraid, isolated, with no hope or escape, which in turn can lead the person to self-injurious behavior.

Our outcomes indicate that the interaction of PTSD symptomatology predicts nonsuicidal self-injury, both NSSI interpersonal and intrapersonal, which, despite having different functions, mediate the direct effect of child sexual abuse on the preparation for suicide. So, coping with outward expression of distress and emotional pain to reduce tensions (interpersonal) or self-punishment (intrapersonal), prevent suicidality.

Some limitations to consider are the reliability of the retrospective assessment of childhood trauma experiences assessed in adulthood, may be influenced by uncontrolled recall bias. Despite our data was collected in a large and representative sample of nonclinical population, the results are not generalizable, but they are a good approach to what is happening in Mexican adults who had child sexual abuse.

All these findings have implications for clinical and social practice. It is important that when a person who suffered child sexual abuse seeks psychological care, it is necessary to assess the possible symptomatology of post-traumatic stress, and, where appropriate, the reasons and all functions that lead the person to self-harm, examining the presence of suicidal ideation, preparedness, or attempts, as well. This will allow to design therapeutic focused intervention to prevent suicide risk and NSSI cessation, to develop emotion regulation and interpersonal communication skills to provide hope in achieving a life free of psychic pain.

Future research is needed, including qualitative studies, to continue examining the adaptive functions of NSSI behavior interacting with PTSD to cope with suicidal thoughts and attempts, as well as exploring protective factors such as hope, social support, parenting styles and family dynamics.

Additionally, we need to enforce continuous efforts with families, implementing programs, activities, and procedures designed to carry out preventive measures particularly for sexual abuse that causes intentional harm and suffering to the children, whose consequences persist as emergent syndromes in adulthood.
