G Model CHIABU-2747; No. of Pages 13

ARTICLE IN PRESS Child Abuse & Neglect xxx (2014) xxx–xxx

Contents lists available at ScienceDirect

Child Abuse & Neglect

Youth victimization in Sweden: Prevalence, characteristics and relation to mental health and behavioral problems in young adulthood夽 Åsa K. Cater ∗ , Anna-Karin Andershed, Henrik Andershed School of Law, Psychology and Social Work, Örebro University, Sweden

a r t i c l e

i n f o

Article history: Received 26 November 2013 Received in revised form 18 February 2014 Accepted 3 March 2014 Available online xxx

Keywords: Violence Poly-victimization Child abuse Child neglect Mental health problems Behavioral problems

a b s t r a c t The present study examines multiple types of victimization simultaneously, their prevalence and characteristics in childhood and adolescence, and it examines the associations between victimization and poly-victimization on the one hand and single and multiple mental health and behavioral problems on the other. The sample consisted of 2,500 Swedish young adults (20–24 years) who provided detailed report of multiple types of lifetime victimization and current health and behaviors via an interview and a questionnaire. Results showed that it was more common to be victimized in adolescence than in childhood and more common to be victimized repeatedly rather than a single time, among both males and females. Males and females were victimized in noticeably different ways and partially at different places and by different perpetrators. With regard to mental health and behavioral problems, anxiety, post-traumatic stress, self-harm, and criminality were clearly overrepresented among both males and females who had experienced any type of victimization. Poly-victimization was related to single and multiple mental health and behavioral problems among both males and females. We conclude that professionals need to conduct thorough evaluations of victimization when completing mental health assessments among troubled youths, and that youth might benefit from the development of interventions for poly-victimized youth. © 2014 Elsevier Ltd. All rights reserved.

Introduction Child maltreatment has been defined as “acts of commission or omission by a parent or other caregiver that result in harm, potential for harm, or threat of harm to a child” (Gilbert et al., 2009). These acts can be physical; sexual; psychological/emotional, including verbal; and/or neglectful. Increasingly, witnessing intimate partner violence is also regarded as a ¨ form of child maltreatment. The current study embraces the definition from Butchart, Phinney Harvey, Mian, Furniss, and Kahane (2006), which has a wider focus. It includes acts in any setting perpetrated by anyone, known or unknown to the victimized. Furthermore, because property crimes is a particularly frequent type of victimization among youths and has been shown to have negative psychological impacts (Finkelhor, Ormrod, Turner, & Hamby, 2005), this type of victimization

夽 This study was financially supported by the National Board of Health and Welfare in Sweden. The findings and conclusions in this manuscript are those of the authors only. ∗ Corresponding author. http://dx.doi.org/10.1016/j.chiabu.2014.03.002 0145-2134/© 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Cater, Å. K., et al. Youth victimization in Sweden: Prevalence, characteristics and relation to mental health and behavioral problems in young adulthood. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.03.002

G Model CHIABU-2747; No. of Pages 13

ARTICLE IN PRESS

2

Å.K. Cater et al. / Child Abuse & Neglect xxx (2014) xxx–xxx

is also included in the present study. To stress that the present study encompasses this variety of victimization from birth to young adulthood, we use the term youth victimization. The purpose of the present study is to investigate the prevalence of such victimization, where it occurred, by whom and whether it is related to adult problems. The Prevalence of Victimization Recent studies of physical victimization by a parent or caretaker have documented prevalences of around 28% in the United States (Centers for Disease Control [CDC], 2014; Hussey, Chang, & Kotch, 2006), 25% in the United Kingdom (May-Chahal & Cawson, 2005), and about 29% in Eastern European countries (Gilbert et al., 2009). In Sweden, although corporal punishment of children was banned in 1979 through the Swedish Parental Act, prevalences of parental physical child victimization has been found to be between 15% and 22% (Annerbäck, Wingren, Svedin, & Gustafsson, 2010; Janson, Jernbro, & Långberg, 2011). Yearly prevalences of psychological/emotional, including verbal, victimization, have been found to be 10–11% in the United States (CDC, 2014; Finkelhor, Ormrod, et al., 2005; Gilbert et al., 2009), 4–9% in Western European countries, and up to 33% in Eastern European countries (Gilbert et al., 2009). Based on a meta-analysis, Stoltenborgh, Bakermans-Kranenburg, and van Ijzendoorn (2012) estimated that the global prevalence of self-reported child physical neglect was 16% and 18% for emotional neglect, although they found substantial differences in the prevalence of physical neglect for studies using different types of procedural characteristics and that various studies used different definitions and measurements. The prevalence of children witnessing intimate partner physical violence has been found to be between 8% and 25% internationally and between 6% and 12% in Sweden (e.g., Annerbäck et al., 2010; Gilbert et al., 2009; Miller, Cater, Howell, & Graham-Bermann, 2014). Yearly prevalences of between 26% and 30% for property crime victimization among youth have been found in the United States and Sweden (BRÅ, 2013; Finkelhor, Ormrod, et al., 2005). Although studies consistently find that more girls (3–31%) than boys (1–19%) are sexually victimized in the United States and in Europe (e.g., Collin-Vézina, Daigneault, & Hébert 2013; Costello, Erkanli, Fairbank, & Angold, 2002; Finkelhor, Ormrod, et al., 2005; Gilbert et al., 2009; Putnam, 2003), gender differences are less clear and consistent when it comes to physical or verbal victimization, neglect, witnessing of violence, and property crime (e.g., Annerbäck et al., 2010; BRÅ, 2013; May-Chahal, 2006). In sum, much more research is needed on potential gender differences in victimization (Gilbert et al., 2009). Many victimized children and adolescents are subjected to repeated and/or multiple types of abuse and neglect, sometimes also in several different contexts and by multiple perpetrators. Experiencing several types of victimization is usually referred to as poly-victimization (Finkelhor, Ormrod, & Turner, 2007). Studies show that different types of victimization often co-occur (Higgins & McCabe, 2000; Radford, Corral, Bradley, & Fisher, 2013) and that poly-victims comprise a substantial part of victimized children in international (Finkelhor et al., 2007; Robboy & Anderson, 2011) and in Swedish samples (Annerbäck, Sahlqvist, Svedin, Wingren, & Gustafsson, 2012). Poly-victimization seems more common among boys than girls, and it appears to be more common among older youth (Finkelhor, Turner, Hamby, & Ormrod, 2011). The Relation Between Victimization and Mental Health and Behavioral Problems Physical, sexual, or neglectful victimization as a child has been found to increase the risk of child mortality and morbidity and has long lasting effects on mental health (e.g., anxiety, depression, posttraumatic stress disorder symptoms, dissociation), physical health (e.g., overweight and obesity, drug and alcohol misuse, risky sexual behavior), violent and other criminal behavior, school problems, and social problems and social withdrawal (e.g., Gilbert et al., 2009; Hussey et al., 2006; Lansford et al., 2002; Lansford et al., 2007). Similarly, children and adolescents exposed to intimate partner violence or property crime are at risk for developing emotional and behavioral problems and of greater exposure to other adversities (Finkelhor, Ormrod, et al., 2005; Holt, Buckley, & Whelan, 2008). The few studies conducted on the impact of psychological/emotional, including verbal, victimization, indicate that such victimization is associated with anxiety, depression, and personality disorders (Johnson et al., 2001; Kent & Waller, 1998). Many of the risks also seem to continue into adulthood, as being victimized at a young age has been found to be related to symptoms of adult anxiety, depression, post-traumatic stress disorder, and impairment resulting from mental and physical health problems. Also, a greater percentage of those who have been victimized report lifetime alcohol problems and appear at greater risk for substance abuse than those who have not been victimized (Herrenkohl, Hong, Klika, Herrenkohl, & Russo, 2013; Tolin & Foa, 2006). Although some studies find that other social, family, and individual factors mediate the effects of physical victimization on adult mental health, sexual victimization consistently seems to be associated with increases in risks of later problems, especially among females (Fergusson, Boden, & Horwood, 2008; Simpson & Miller, 2002). Being subjected to poly-victimization seems to be related to even more adverse outcomes. The associations between victimization and health and behavioral problems have been shown to be stronger for children reporting multiple types of or repeated victimization, with cumulative effects depending on number of different types of victimization (Annerbäck et al., 2012; Petrenko, Friend, Garrido, Taussig, & Culhane, 2012). Thus, studies have documented a graded relationship between the number of types of abuse that a child is being victimized to, and alcoholism, drug abuse, depression, suicide attempt, smoking, poor self-rated health, multiple sexual relationships, sexually transmitted disease, physical inactivity, and severe obesity (Felitti et al., 1998). Furthermore, poly-victimization is highly predictive of ill-health and trauma symptoms, and when taken into account, can greatly reduce the association between single victimizations (e.g., sexual abuse) and Please cite this article in press as: Cater, Å. K., et al. Youth victimization in Sweden: Prevalence, characteristics and relation to mental health and behavioral problems in young adulthood. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.03.002

G Model CHIABU-2747; No. of Pages 13

ARTICLE IN PRESS Å.K. Cater et al. / Child Abuse & Neglect xxx (2014) xxx–xxx

3

symptomatology greatly (Finkelhor et al., 2007; Radford et al., 2013). Also, Jernbro, Svensson, Tindberg, and Janson (2012) found a strong association between child physical abuse and multiple psychosomatic symptoms. However, the possible relationship between multiple victimization and multiple problems is yet to be further investigated. In sum, the evidence for the association between victimization and health and behavioral problems is convincing. A note of caution, though, is the possibility of confounding variables and direction of effects. For example, just as research has shown that individuals who have been victimized in childhood and adolescence report greater mental health and behavioral problems than others, studies also demonstrate that children with psychological or physical difficulties are at greater risk for being victimized (Sentenac et al., 2012; Turner, Finkelhor, & Ormrod, 2010). Hence, one should be careful with conclusions concerning causality. Gaps in Knowledge and the Present Study We know a great deal about victimization among children and adolescents, and the association between victimization and mental health and behavioral problems in adolescence and in adulthood. There are, however, many related issues we know less about and that are crucial for our understanding of the consequences of victimization and for tailoring intervention strategies. There is still a need for large scale randomly selected normal population studies in different countries that focus on the prevalence of a wide range of types of victimization, separated by children and adolescents, and on the relationship between these various types of victimization and mental health and behavioral problems, with a focus on gender. More studies are also needed on the prevalence of poly-victimization and its relation with mental health and behavioral problems. Furthermore, the association between victimization and poly-victimization on the one hand and single and multiple mental health and behavioral problems on the other, has not been fully explored. Finally, very few studies have investigated gender differences and similarities in terms of single victimization, poly-victimization, and their relation with mental health and behavioral problems. In particular, whether there is a relationship between poly-victimization and multiple mental health and behavioral problems has not been investigated. The aim of the present study is to answer the following questions: How common are specific types of victimization (physical, verbal, sexual, neglectful, witnessing violence, and property crimes) in childhood and adolescence among males and females? Where do the various types of victimization occur, and are the locations different for males and females? Who are the perpetrators? Are they different for males and females? Are single and multiple mental health and behavioral problems overrepresented among the victimized, and are there differences between males and females? Is poly-victimization related to a greater overrepresentation of single and multiple mental health and behavioral problems, and is this the case among both males and females? Method Participants The data used in this study comes from the RESUMÉ-project, an acronym for the Swedish name of the Retrospective Study of Young Men’s and Women’s Experiences. It is a cross-sectional, retrospective study of a randomly selected Swedish sample of 2,500 young adults from the general population (1,186 [47.4%] males and 1,314 [52.6%] females), aged 20–24 years (M = 22.15; SD = 1.38; comparable to the 51.2% males and 48.8% females in the total Swedish population of the same age cohort). In the present sample, 58% were University students (to be compared with 44%, among all Swedish 24-yearolds, having conducted University level education). Participants were randomly selected from the Swedish population born during the years 1987–1991 using a national inhabitant register from the national statistics’ agency, Statistics Sweden. This register holds all Swedish citizens with name, social security number, address, etc. The sample was stratified proportionally by gender and county of residence; that is, an equal proportion of Sweden’s 21 counties’ men and women born between 1987 and 1991 were drawn from the register. The goal was to recruit until 2,500 individuals had been enrolled to the study. A total of 25,670 individuals were drawn from the register, of which 20,827 had a registered telephone number and thus could be contacted as a potential participant. Of these, 9,312 were contacted but never reached; 6,285 declined participation after they had been given the initial information; 479 could not participate because of being abroad, out traveling, feeling ill, etc.; and 296 individuals were not contacted because the target of 2,500 participants had been reached. A total of 4,455 individuals agreed to participate in the study, of which 1,955 were never included for various reasons (e.g., it was not possible to make an appointment to conduct the interview, the participant did not show up on the occasion for the interview, or the participant changed his/her mind and said no to participation after the interview was scheduled). Because of a disproportionate number of individuals accepting participation in the different strata and because of the time schedule for the overall data collection, there were some deviations from the goal of achieving a sample with equal proportions of men and women born between 1987 and 1991 in the respective strata. The largest of these deviations was that greater numbers of individuals than proportionate were included from two of the large urban areas, and smaller numbers of individuals than proportionate from two counties surrounding two of the large urban areas. To investigate whether the non-participants (of the 20,827 with a registered telephone number) differed from the participants on important dimensions, 15 randomly chosen non-participating men and 15 women were asked a few questions Please cite this article in press as: Cater, Å. K., et al. Youth victimization in Sweden: Prevalence, characteristics and relation to mental health and behavioral problems in young adulthood. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.03.002

G Model CHIABU-2747; No. of Pages 13

ARTICLE IN PRESS

4

Å.K. Cater et al. / Child Abuse & Neglect xxx (2014) xxx–xxx

from the interview/questionnaire through a telephone interview and were then compared with the total sample of 2,500 participants. The analyses showed no significant differences between non-participants and participants in level of education, subjective well-being, prevalence of psychiatric diagnoses, alcohol risk use, criminality, or physical victimization. The non-significant differences varied between .00 and .04 in effect size (Cohen’s d). Thus, they were very small in magnitude and therefore not likely due to problems with power. The only significant (p < .001) difference was that none of the non-participants and 5.6% of the participants reported having been forced to participate in sexual activities. These findings indicate that the sample was not heavily biased on important variables. Measures Youth Victimization. Eleven items (see Table 2) were used to measure physical victimization (˛ = .86). Six of the items stemmed from the Juvenile Victimization Questionnaire (JVQ; Finkelhor, Hamby, Ormrod, & Turner, 2005; Hamby, Finkelhor, Ormrod, & Turner, 2004), modified to cover lifetime victimization and various perpetrators. The five additional items were added to cover other types of physical abuse assessed in other studies (e.g., Janson, Långberg, & Svensson, 2007; May-Chahal & Cawson, 2005). Two items (see Table 2) were used to measure verbal victimization (˛ = .58). One item was taken from the JVQ (Finkelhor, Hamby, et al., 2005; Hamby et al., 2004) and modified to cover lifetime victimization and various perpetrators and one to cover additional kinds of verbal maltreatment/abuse/victimization used in other studies (Janson et al., 2007; May-Chahal & Cawson, 2005). Seven items (see Table 2) were used to measure sexual victimization (˛ = .84). Five items were taken from the JVQ (Finkelhor, Hamby, et al., 2005; Hamby et al., 2004) and modified to cover lifetime victimization and various perpetrators. Two items were added from the NSPCC study (May-Chahal & Cawson, 2005). Five items (see Table 2) were used to measure neglect (˛ = .77), of which one item was taken from the JVQ (Finkelhor, Hamby, et al., 2005; Hamby et al., 2004), and the additional 4 items from other studies (e.g., May-Chahal & Cawson, 2005). Seven items (see Table 2) were used to measure witnessing of violence (˛ = .63). All items were taken from the JVQ (Finkelhor, Hamby, et al., 2005; Hamby et al., 2004) and modified to cover lifetime victimization and various perpetrators. Four items (see Table 2) were used to measure the frequency of exposure to different kinds of victimization to property crimes/offenses (˛ = .66). The four items were taken from the JVQ (Finkelhor, Hamby, et al., 2005; Hamby et al., 2004) and modified to cover lifetime victimization and various perpetrators. All items concerning youth victimization had the same 6-point response scale ranging from Zero times, One time, Two times, Three times, Four times, to Five times or more. In the present study, these responses were categorized into Zero times, One time, Two to four times, and Five times or more. The questions were framed to ask whether the person ever (lifetime) had experienced the different specific types of victimization. After responding to the questions in each category of victimization (e.g., all items concerning physical victimization), the participants were asked how old they were when it occurred (allowing the childhood/adolescence differentiation – see Table 1), where it happened (see Table 3), and who the perpetrator/-s were (see Table 4). Thus, these follow-up questions were asked concerning each group of questions for the various types of victimization, and not for each individual item. Mental Health and Behavioral Problems Anxiety and Depression symptoms. The Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983) was used to assess symptoms of anxiety and depression. The HADS consists of 14 items with two subscales; HADS-A measuring anxiety (7 items; ˛ = .79) and HADS-D measuring depression (7 items; ˛ = .69). All items use a past week time frame and a 4-point scale with slightly different wordings for different items but all ranging from 0 (Not endorsing the item) to 3 (Endorsing the item). Both anxiety and depression were categorized in the present study according to scoring guidelines into individuals without problems (below a summed score of eight) and individuals with at least mild problems (score of eight or higher). Post-traumatic stress symptoms. The Impact of Event Scale – Revised (IES-R; Weiss & Marmar, 2004), consisting of 22 items, was used to measure post-traumatic stress symptoms (˛ = .96). It is a self-report questionnaire measuring symptoms of avoidance, symptoms of intrusion, and symptoms of hyperarousal. All items are rated on a 5-point scale ranging from 0: Not at all to 4: extremely, and the timeframe is the last week. This variable was categorized according to scoring guidelines into individuals without problems (below a mean score of 1.8) and individuals likely to have post-traumatic problems (mean score of 1.8 or higher). Suicide attempts and Self-harm. The presence of suicide attempts was assessed through one item: “Have you ever attempted suicide?” A 5-point response scale was used (1: No, 2: Once, 3: A few times, 4: Many times regularly, and 5: Many times in a short period of time and then a long gap in between). The variable was categorized into presence (one or more suicide attempts) or absence of suicide attempts. The presence of self-harm was assessed through one item, “Have you ever purposely harmed yourself without wanting to die?,” using a 5-point response scale (1: No, 2: Once, 3: A few times, 4. Many times regularly, and 5: Many times in a short period of time and then a long gap in between). The variable was categorized into presence (one or more acts of self-harm) or absence of self-harm. Criminality. Past year offending was self-reported via a total of 19 items used in several other published studies (e.g., Andershed, Kerr, Stattin, & Levander, 2002) with the response scale; 1: No, that has not happened, 2: 1 time, 3: 2–3 times, 4: Please cite this article in press as: Cater, Å. K., et al. Youth victimization in Sweden: Prevalence, characteristics and relation to mental health and behavioral problems in young adulthood. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.03.002

G Model

ARTICLE IN PRESS

CHIABU-2747; No. of Pages 13

Å.K. Cater et al. / Child Abuse & Neglect xxx (2014) xxx–xxx

5

4–10 times, and 5: More than 10 times. The 19 items measure concrete acts of criminality in terms of minor and serious violent and property offenses, vandalism, and substance-related offenses. An alpha was not calculated for criminality because it was not intended to measure a homogenous concept. This variable was categorized so that individuals who responded that they had committed any of the criminal acts assessed on four occasions or more were considered as exhibiting criminal behavior. Alcohol risk use. The Alcohol Use Disorders Identification Test (AUDIT; Allen, Litten, Fertig, & Babor, 1997) was used to measure risky alcohol consumption. It comprises 10 items (␣ = .80) of which the majority uses a 5-point scale ranging from 0 = Never to 4 = Daily or almost daily. This variable was categorized according to scoring guidelines into individuals without risk use (summed score of 0–7) and individuals with a risk use (score of 8–40). Procedure The data collection was conducted during the year of 2011, starting in March and ending in December. The recruiting, interviewing, and administration of the questionnaire were conducted by trained interviewers at a survey and marketing company under the commission of the research group in charge of the project. The researchers in charge informed both the recruiters and interview/questionnaire (I/Q) administrators about the background and purpose of the study, and they all had training from the company for the task at hand. The 30 I/Q administrators collecting the data were selected based on previous experience with interviews of a sensitive nature (i.e., covering topics such as abuse, neglect, and criminality) and were no younger than 30 years old. Participants were recruited via telephone. The recruiters followed a manuscript about the background and purpose of the project that was developed by the researchers of the project in collaboration with the survey company. If the person contacted chose to participate in the study, the recruiter informed him/her that s/he could choose the time and location for answering the survey and whether a male or female I/Q administrator was preferred. Most participants chose to be interviewed and fill out the questionnaire either at home, in a public place such as a library, or in the office of the company responsible for conducting the interviews. At the time of the interview, the I/Q administrators first gave both written and oral information about the study. The majority of the questions were administered as a self-report questionnaire. Meanwhile, the interviewer stayed nearby and was helpful with any questions. At the end, a few questions were asked again by the I/Q administrator (e.g., whether any questions were difficult to answer) and the participants were informed that they could contact professionals within the project if they had negative emotions as a result of the I/Q. The participants received a compensation consisting of a voucher (for a value of 400 SEK). Each session took approximately 90 minutes. The study has been evaluated and approved by an ethics committee (#2010/463). Results How Common are Various Types of Victimization? Table 1 shows prevalence of various types of victimization among males and females. As seen in Table 1, being victimized physically, witnessing violence, and property crimes were significantly more common among males than females, whereas being victimized verbally, sexually, or by neglect was significantly more common among females. These gender differences were also present when looking at childhood versus adolescent victimization in all cases except for witnessing violence in childhood. As shown in Table 1, it was more common to be victimized in adolescence than in childhood for all types of victimizations. This finding was true among both males and females.

Table 1 Prevalence (%) of various types of victimization with z-tests for gender differences. Childhood (0–12 yearsa )

Number of times of victimization

Adolescence (13–18 yearsa )

Type of victimization

Any (lifetime)b

♂

♀

♂

♀

♂

♀

♂

♀

♂

♀

♂

♀

♂

♀

♂

♀

♂

Physical Verbal Sexual Neglect Witnessing violence Property crimes

68.2* 39.5 7.5 8.6 47.7* 57.8*

48.0 51.1* 33.3* 13.1* 36.4 51.9

31.5* 27.0 1.5 6.5 11.5 24.3*

24.7 35.0* 7.1* 11.8* 9.2 20.7

3.1 3.7 0.5 0.3 1.0 4.0

4.6 4.6 1.4 0.5 2.0 4.7

7.5 5.8 0.6 0.6 3.5 9.6

6.8 7.3 2.1 1.4 2.7 7.6

20.9 17.5 0.4 5.6 7.0 10.7

13.3 23.1 3.6 9.9 4.5 8.4

68.2* 39.5 7.5 8.6 47.7* 57.7*

48.0 51.1* 33.3* 13.0* 36.4 51.9

9.7 7.7 3.2 0.9 10.1 13.7

11.0 9.7 10.3 0.7 14.7 15.9

19.6 9.1 2.9 1.1 16.1 25.3

15.4 11.7 12.6 1.7 11.6 22.7

38.9 22.7 1.4 6.6 21.5 18.7

Any

1 time

2–4 times

5+ times

Any

1 time

2–4 times

5+ times

♀ 21.6 29.7 10.4 10.6 10.1 13.3

Note: ♂, males; ♀, females. a Age at victimization. b Any time up until current age (i.e., 20–24). * Signficantly (p < .05) higher prevalence compared to the other gender. All p-values were Bonferroni corrected.

Please cite this article in press as: Cater, Å. K., et al. Youth victimization in Sweden: Prevalence, characteristics and relation to mental health and behavioral problems in young adulthood. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.03.002

G Model CHIABU-2747; No. of Pages 13

ARTICLE IN PRESS

6

Å.K. Cater et al. / Child Abuse & Neglect xxx (2014) xxx–xxx

In terms of repeated victimization, is it evident from Table 1 that being victimized more than once was more common than being victimized a single time for all types of victimization, in both childhood and adolescence, and among males and females. How Common Are Various Specific Types of Victimization? To achieve a more nuanced picture of the various types of victimization, we looked at the individual items within the broader six types of victimization (see Table 2). The gender differences observed on category-level were present also in most specific forms of victimization. The only significant specific kind of victimization that was significant in the opposite gender direction than for the broader category (within witnessing violence) was seeing a parent getting hit, slapped, punched, or beat up, which was significantly more often reported by females than by males. Where Did the Various Types of Victimization Occur? Table 3 presents the prevalence of where the various types of victimization occurred. The locations were the same for males and females, but the order of locations were different between genders. At home was the most common location among females and only third most common among males. Also, for verbal victimization, two different public settings (at school/preschool or day care and public place) were among the three most common locations to be victimized for both males and females, with another public setting, youth center, sports club, or at any other organized leisure activity, being the third most common among males. The home was the second most common place for females. Both males and females reported a public place being the most common for sexual victimization, and a friend’s or relative’s house was the second most common. However, while the third most common location to be sexually victimized among males was the House of somebody I did not know, At home was, once again, the third most common location among females. In terms of witnessing violence, the most common location to be victimized for both genders was a Public place. At school/preschool or day care was the second most reported among males and the third among females. The third most common location for witnessing violence was a Youth center, sports club or at any other organized leisure activity for males, and At home was the second most common place for this type of victimization among females. In terms of Property crimes, the three most common locations to be victimized were At school/preschool or day care; Public place; and At home, for both males and females. The order of locations, however, were different between genders, where, again, At home was a more common location for females to be victimized. Neglect was not included in these descriptive statistics because questions were not asked about where this happened. The assumption was that neglect occurred in relation to the home environment. Who was the Perpetrator of the Various Types of Victimization? Table 4 presents the prevalence of who the perpetrator/s was/were for the various types of victimization. As seen in Table 4, the most common perpetrator of physical victimization was Other children and adolescents at school or work for both males and females. Males reported A group of children or adults and Stranger as the second and third most common perpetrators of Physical victimization, while females reported Biological father and Boyfriend/girlfriend/partner/date at the time. The most common perpetrator of verbal victimization was also Other children and adolescents at school or work for both males and females. Males reported the second and third most common perpetrators of verbal victimization to be A group of children or adults and Sibling respectively, among females, the second most common perpetrator was Boyfriend/girlfriend/partner/date at the time and A group of children or adults was the third. A Stranger and unspecified Other were reported as being among the three most common perpetrators of sexual victimization among both males and females, males reported Other children and adolescents at school or work being the most common perpetrator of such victimization and females a Boyfriend/girlfriend/partner/date at the time the second most common. The three most common perpetrators victimizing both males and females to witnessing violence and property crimes were A group of children or adults, Other children and adolescents at school or work and Stranger, although in slightly different orders. Neglect was not included in these descriptive statistics because questions were not asked about who were guilty of the neglect. The assumption was that neglect was enacted by those who were expected to provide physical and emotional care. Are Mental Health and Behavioral Problems Overrepresented Among the Victimized? In Table 5, those who were victimized are compared with those who were not in terms of how common it was with various mental health and behavioral problems among males and females separately. For these analyses, the participants were categorized, within each of the separate types of victimizations (i.e., physical, verbal, etc.), into a non-victimized group (labeled “No” in Table 5) and victimized group (labeled “Yes” in Table 5). To be included in the victimized group, the participant had been victimized two times or more, because a very large proportion of the total sample would otherwise be categorized as victimized and because repeated victimization has a stronger relationship with mental health and behavioral problems according to previous research. Mental health and behavioral problems were generally, with a few exceptions, overrepresented among those who had been victimized by any of the six types of victimization (see Table 5). This was true for anxiety, post-traumatic stress, and Please cite this article in press as: Cater, Å. K., et al. Youth victimization in Sweden: Prevalence, characteristics and relation to mental health and behavioral problems in young adulthood. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.03.002

G Model CHIABU-2747; No. of Pages 13

ARTICLE IN PRESS Å.K. Cater et al. / Child Abuse & Neglect xxx (2014) xxx–xxx

7

Table 2 Prevalence (%) of specific types of victimization within categories with z-tests for gender differences. Number of times of victimization Type of victimization and specific victimization question asked Physical (Has anyone ever. . .) hit or attacked you on purpose with an object or weapon? attacked you on purpose with anything that can give burns? hit or attacked you without using an object or weapon? thrown, shoved or pushed you down on the ground? held you around the neck so it was hard for you to breathe? spanked you on your bottom or hit you with a belt? beaten or hit you? tried to hurt your private parts on purpose by hitting or kicking you there? picked on you by chasing you or grabbing your hair or clothes or by making you do something you didn’t want to do? Not including spanking on your bottom or hitting you with a belt, has anyone ever hit, abused, or physically hurt you in any way? Have you ever been attacked by a gang? Verbal (Have you ever. . .) gotten scared or felt really bad because grown-ups in your life called you names, said mean things to you, or said that they didn’t want you? been afraid or felt really sad or miserable because someone threatened to give up on you but didn’t do so? Sexual (Has anyone ever. . .) touched your private parts when you didn’t want it or make you touch their private parts or forced you to have sex? made you do sexual things? hugged or kissed you in a sexual way against your will or in a way that made you feel uncomfortable/bad? tried to force you to have sex, that is sexual intercourse of any kind, even if it didn’t happen? made you look at their genitals, using physical force or surprised you by exposing themselves to you? hurt you by saying or writing something sexual about you or your body or taking pornographic pictures or film you? made you watch or listen to when others performed sexual or pornographic activities or shown you pornographic pictures or films against your will or in a way that made you uncomfortable/bad? Neglect (When you were a child. . .) did you get neglected? were you ever given away, abandoned or left alone to take care of yourself and/or your siblings, or were you allowed to stay in dangerous places or in dangerous situations or was the physical environment in your home dangerous? was your home or your clothes ever so dirty or ragged that you found it unpleasant or embarrassing? did you ever have serious concerns, or were you ever sad or worried without having anyone that could help you, listen to you, comfort you and take your concerns seriously and protect you against threats? did it ever happen that you did not go out with friends or have friends over to play because it was so dirty or messy at your home?

Any

1

2–4

5+

♂

♀

♂

♀

♂

♀

♂

17.5*

10.7

9.5

5.1

5.1

2.7

2.9

2.9

6.2*

3.7

4.0

2.5

2.1

0.8

0.1

0.4

*

23.3

16.6

9.7

11.7

7.1

17.5

6.5

*

44.0 18.0*

24.4 12.3

18.9 10.8

10.6 7.4

13.6 4.8

6.9 3.0

11.5 2.4

6.9 1.9

8.3 40.2* 13.7*

10.4 25.0 2.1

3.5 14.2 5.1

3.7 10.4 1.3

2.7 12.9 5.5

3.1 6.8 0.5

2.1 31.1 3.1

3.6 7.8 0.3

20.0

17.3

8.7

7.5

5.8

4.4

5.5

5.4

22.9*

13.5

8.9

4.9

8.0

3.7

6.0

4.9

21.0*

5.9

14.1

4.1

4.6

1.0

2.3

0.8

36.7

48.9*

7.6

9.7

9.0

11.3

20.1

27.9

15.7

14.5

5.4

3.3

4.4

3.8

5.9

7.4

1.9

16.4*

1.4

8.8

0.2

3.9

0.3

3.7

1.3 3.1

9.5* 19.3*

0.9 1.7

4.6 9.8

0.2 0.9

2.2 5.5

0.2 0.5

2.7 4.0

2.1

15.1*

1.5

8.6

0.5

3.6

0.1

2.9

1.6

*

8.6

0.9

5.5

0.4

3.0

0.3

1.1

1.4

6.4*

0.7

3.2

0.3

1.9

0.4

1.3

1.2

2.3

0.6

1.1

0.3

0.1

0.3

1.1

1.5 2.5

3.7* 4.5

0.3 0.2

0.3 0.3

0.3 0.3

0.7 0.9

0.9 2.0

2.7 3.3

1.6

1.8

0.5

0.2

0.3

0.4

0.8

1.2

4.9

9.9*

0.6

0.6

0.9

1.5

3.4

7.8

4.1

4.7

0.3

0.3

0.9

0.9

2.9

3.5

45.8

♀

Please cite this article in press as: Cater, Å. K., et al. Youth victimization in Sweden: Prevalence, characteristics and relation to mental health and behavioral problems in young adulthood. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.03.002

G Model CHIABU-2747; No. of Pages 13

ARTICLE IN PRESS

8

Å.K. Cater et al. / Child Abuse & Neglect xxx (2014) xxx–xxx

Table 2 (Continued ) Number of times of victimization

Any

Type of victimization and specific victimization question asked Witnessing violence (Have you ever. . .) seen one of your parents get hit, slapped, punched, or beat up? seen, in real life, anyone get attacked on purpose with a stick, rock, gun, knife, or other thing that would hurt? seen, in real life, anyone get attacked or hit on purpose without using a stick, rock, gun, knife, or something that would hurt? seen someone murdered in real life? been in any place in real life where you could see or hear people being shot, bombs going off, or street riots? been in the middle of a war where you could hear real fighting with guns or bombs? Has anyone close to you been murdered, like a friend, neighbor or someone in your family? Property crimes (Has anyone ever. . .) used physical strength to take something away from you that you were carrying or wearing? stolen something from you and never given it back? broken or ruined any of your things on purpose? stolen anything from your home that belonged to your family or someone you live with?

1

2–4

5+

♂

♀

♂

♀

♂

♀

♂

♀

3.5

6.4*

2.3

3.0

0.8

1.2

0.4

2.2

*

19.8

12.9

7.3

7.1

6.2

3.7

6.3

2.1

42.3*

27.2

11.3

12.3

14.1

8.6

16.9

6.3

1.4 7.3*

0.6 3.8

0.8 3.4

0.4 2.7

0.1 2.3

0.0 0.7

0.5 1.6

0.2 0.4

1.2

0.3

0.6

0.2

0.1

0.0

0.5

0.1

4.0

5.2

3.0

4.1

0.8

0.7

0.4

0.4

24.1*

15.0

12.3

7.4

7.2

4.0

4.6

3.6

34.7 33.7* 23.1

33.3 23.1 20.2

15.7 15.4 13.4

16.5 11.0 13.8

15.5 12.8 7.6

13.0 7.8 5.7

3.5 5.5 2.1

3.8 4.3 0.7

Note: ♂, males; ♀, females. * Signficantly (p < .05) higher prevalence compared to the other gender. All p-values were Bonferroni corrected.

self-harm, among both males and females. Depression was significantly overrepresented in both males and females among those who had been verbally victimized. Among females, but not males, depression was also significantly overrepresented among those who had been victimized by any other type of victimization. Suicide attempts were significantly overrepresented among those who had experienced any of the six types of victimization among females. Among males, this was the case for all types of victimization except property crimes. With regard to behavioral problems, criminality was significantly overrepresented among those who had been victimized by any of the six types of victimization (see Table 5). This was true among both males and females. Furthermore, alcohol risk use was significantly overrepresented among those who had been victimized by any of the six types of victimization among males. Among females, this was not the case for those victimized by property crimes, but for all other types of victimization. Multiple problems were significantly overrepresented among both males and females who had been victimized through any of the six types of victimization, as seen in Table 5. Concerning gender differences, many similarities across gender appear but depression was clearly more often overrepresented among females (i.e., occurred in relation to a larger number of types of victimization) than among males.

Table 3 Prevalence (%) of where the various types of victimization occurred. Type of victimization Location At home Youth center, sports club or at any other organized leisure activity At school/preschool or day care Public place (e.g., park, store, restaurant, street, etc.) On the internet, by e-mail or phone Friend’s or relative’s house House of somebody I did not know At work Other place

Physical

Verbal

Sexual

Witnessing violence

Property crimes

♂

♀

♂

♀

♂

♀

♂

♀

♂

♀

17.7 11.2

44.3 5.2

11.7 17.0

25.1 9.8

16.7 3.3

18.1 4.2

8.2 10.0

17.8 2.4

38.3 10.7

46.6 7.2

53.8 58.7

38.7 39.4

86.0 24.5

78.8 17.7

13.3 35.6

7.3 39.7

28.4 79.4

13.5 73.5

45.2 38.7

31.4 41.5

1.6 7.5 6.3 0.2 0.4

1.7 13.8 4.1 1.9 1.1

10.9 9.4 3.8 0.2 0.0

12.9 8.2 1.0 1.6 0.1

7.8 28.9 17.8 0.0 3.3

7.7 39.3 16.3 3.1 1.1

1.4 8.2 7.2 0.7 2.7

0.8 9.8 6.3 1.6 3.1

2.1 4.3 4.4 0.5 1.1

1.2 9.5 4.8 0.7 1.7

Note: Percentages do not sum up to 100%, as multiple simultaneous response options were available. ♂, males; ♀, females.

Please cite this article in press as: Cater, Å. K., et al. Youth victimization in Sweden: Prevalence, characteristics and relation to mental health and behavioral problems in young adulthood. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.03.002

G Model

ARTICLE IN PRESS

CHIABU-2747; No. of Pages 13

Å.K. Cater et al. / Child Abuse & Neglect xxx (2014) xxx–xxx

9

Table 4 Prevalence (%) of perpetrator/s for the various types of victimization. Type of victimization

Physical

Verbal

Sexual

Witnessing violence

Property crimes

Perpetrator

♂

♀

♂

♀

♂

♀

♂

♀

♂

Biological mother Biological father Step-/adoptive/foster care parent/parent’s partner Day care personnel/baby-sitter/teacher or personnel at institution Sibling Other children and adolescents at school or work Current boyfriend/girlfriend/partner Boyfriend/girlfriend/partner/date at the time Previous (ex) boyfriend/girlfriend/partner A group of children or adults Friend Stranger I don’t know – it was on the internet, anonymous text message or similar Other

5.4 8.3 1.0

12.9 18.5 3.6

4.1 3.6 1.5

10.8 9.4 3.6

0.0 1.1 1.1

0.2 1.6 1.3

2.1 3.3 2.6

3.7 9.2 4.3

1.6 2.3 0.8

4.4 3.1 2.3

♀

1.6

2.0

4.0

2.7

0.0

1.6

0.7

0.4

0.7

0.1

8.6 57.8

14.6 41.2

6.8 82.5

7.9 77.4

1.1 27.8

2.0 12.4

1.4 32.0

3.5 16.8

9.7 46.7

12.3 32.7

0.5 2.0

2.0 15.8

0.6 3.4

1.5 11.4

2.2 11.1

1.3 24.4

0.2 0.3

0.6 2.2

0.1 1.6

1.1 6.4

0.9

5.2

2.1

3.0

5.6

6.0

0.3

1.0

1.5

3.2

31.4 3.1 18.1 1.5

12.9 5.2 14.9 1.4

19.2 1.9 1.1 3.8

11.3 1.5 0.7 4.9

2.2 12.2 22.2 5.6

4.0 8.2 23.5 5.5

45.9 1.9 30.1 4.0

36.0 3.9 32.9 2.7

23.2 3.6 17.0 5.7

15.9 5.4 22.9 5.1

3.2

5.2

5.1

3.9

21.1

31.3

6.7

10.8

11.5

15.5

Note: Percentages do not sum up to 100%, as multiple simultaneous response options were available. ♂, males; ♀, females.

Is Poly-victimization Related to Greater Over-representation of Mental Health and Behavioral Problems? To investigate whether there was an association between numbers of types of victimization on the one hand, and mental health and behavioral problems on the other, we compared the prevalence of these variables as a function of number of types of victimization. For these analyses, the participants were categorized into groups based on number of types of victimizations (i.e., physical, verbal, etc.) from 0 up to 3 or more. The results are presented in Table 6 and show, to begin with, that it was significantly more common among females to not have been victimized at all (Males = 18.5%; Females = 27.0%), and that it was almost equally as common as having been victimized three times or more among males (30.1%) and females (28.5%). Table 5 Prevalence (%) of mental health and behavioral problems as a function of type and occurrence (z-tests within gender) of victimization. Type of victimization

Physical

♂ Type of problem Anxiety Depression Post-traumatic stress Suicide attempt Self-harm Criminality Alcohol risk use Multiple problemsa

♀

♂

♀

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

20.3* 6.9 4.0* 5.2* 13.8* 33.1* 55.5* 14.7*

21.9 5.2 4.0 3.4 18.6 6.0 28.2 8.2

40.3* 11.9* 17.5* 11.9* 36.4* 14.4* 38.0* 27.6*

12.1 4.7 0.4 2.0 6.3 22.9 46.3 5.8

28.9* 9.5* 7.7* 7.2* 19.9* 29.4* 53.7* 20.2*

21.0 4.5 2.4 2.3 15.3 7.0 27.9 7.7

39.5* 12.1* 18.0* 12.5* 39.2* 12.1* 37.6* 26.3*

16.2 6.0 2.2 3.3 9.6 24.1 47.9 9.2

45.1* 11.8 15.7* 11.8* 33.3* 43.1* 64.0* 37.3*

24.1 5.5 4.1 3.9 20.1 6.3 28.2 9.1

43.9* 14.9* 25.4* 15.5* 42.2* 18.5* 44.3* 36.3*

Neglect

Witnessing violence

♂ Anxiety Depression Post-traumatic stress Suicide attempt Self-harm Criminality Alcohol risk use Multiple problemsa

Sexual

♂

13.4 5.3 0.9 1.4 6.1 13.4 38.6 4.3

Type of victimization

Type of problem

Verbal

♀

♀

♂

Property crimes

♀

♂

♀

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

15.3 5.8 1.8 2.7 10.0 23.1 47.8 8.8

42.9* 11.0 14.3* 14.3* 17.6* 47.3* 59.3* 29.7*

25.8 6.2 5.5 4.8 22.3 7.6 30.2 11.6

49.4* 18.5* 34.6* 19.1* 45.7* 19.8* 43.5* 42.0*

14.5 5.7 1.5 3.4 9.5 16.8 42.4 6.5

22.4* 7.2 4.9* 4.0* 12.6* 38.6* 58.3* 16.8*

25.3 6.6 6.2 4.9 22.1 7.6 29.3 11.9

41.1* 11.6* 19.6* 12.6* 36.5* 14.7* 41.0* 28.1*

13.4 5.1 1.5 2.9 7.8 18.8 42.8 6.3

22.6* 7.7 4.4* 4.6 14.2* 32.8* 55.8* 15.5*

24.6 6.1 5.4 4.3 21.3 6.9 30.3 10.7

35.9* 10.6* 15.6* 10.6* 32.1* 13.1* 34.5 23.7*

Note: ♂, males; ♀, females. a Multiple problems = 3 or more of the above mental health and behavioral problems. * Signficantly (p < .05) higher prevalence as compared within gender (i.e., males No and Yes compared and females No and Yes compared). All p-values were Bonferroni corrected.

Please cite this article in press as: Cater, Å. K., et al. Youth victimization in Sweden: Prevalence, characteristics and relation to mental health and behavioral problems in young adulthood. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.03.002

G Model CHIABU-2747; No. of Pages 13

ARTICLE IN PRESS

10

Å.K. Cater et al. / Child Abuse & Neglect xxx (2014) xxx–xxx

Table 6 Prevalence (%) of mental health and behavioral problems as a function of number of types of victimization. Number of types of victimization Type of problem Prevalence out of total sample Anxiety Depression Post-traumatic stress Suicide attempts Self-harm Criminality Alcohol risk use Multiple problemsa

0

1

2

3+

♂

♀

♂

♀

♂

♀

♂

♀

18.5 6.8 3.6* 0.0 0.9 5.5 7.7* 30.7* 1.4

27.0* 14.9* 0.8 0.4 1.4 11.3* 2.3 22.6 2.0

26.2 13.2 4.8 0.6 2.3 5.1 17.7* 42.8* 4.2

27.0 23.1* 7.6 1.4 2.8 20.0* 5.1 29.2 8.5*

25.1* 16.4 5.7 1.3 1.7 9.4 25.5* 54.6* 8.7

17.5 32.2* 9.1 7.4* 4.8* 25.7* 13.9 38.6 17.4*

30.1 28.6 9.5 7.3 8.1 19.6 41.5* 59.0* 22.7

28.5 44.9* 13.4 24.3* 16.0* 43.0* 16.6 38.8 33.4*

Note: To be counted as having being subject to one type of victimization the participant had to have reported that he/she had been subject to that type of victimization at least two times. ♂, males; ♀, females. a Multiple problems = 3 or more of the above mental health and behavioral problems. * Signficantly (p < .05) higher prevalence compared to the other gender. All p-values were Bonferroni corrected.

As seen in Table 6, the trend that the higher the number of types of victimization, the higher the prevalence of problems was present among both males and females for all the mental health and behavioral problems studied. Also, as seen in the bottom of Table 6, the same trend was present for multiple problems, that is, the higher the number of types of victimization, the higher the prevalence of multiple problems. The trend was more pronounced among females than among males in anxiety, depression, post-traumatic stress, suicide attempts, self-harm, and multiple problems whereas it was more pronounced among males than among females in criminality and alcohol risk use. Discussion This is the largest study conducted in Sweden so far of the prevalence and characteristics of total life-time youth victimization and its relation to mental health and behavioral problems. In sum, and in line with previous research, we observed gender differences as to what type of victimization that was most prevalently reported, as well as where and by whom the participants were victimized. It was more common to be victimized in adolescence as compared to childhood, and more common to be victimized more than once than being victimized on a single occasion. Poly-victimization was similarly common among males and females. Anxiety, post-traumatic stress, self-harm, and criminality were clearly overrepresented among those who had experienced victimization among both males and females, while the patterns of problems such as depression, suicide attempts, and alcohol risk use were more diversified by gender. Reporting multiple mental health and behavioral problems was clearly overrepresented among those who had experienced any of the six types of victimization among both males and females. Finally, poly-victimization was related to a greater risk for single and multiple mental health and behavioral problems among both males and females. These findings contribute to the existing field of childhood and adolescent victimization research in several ways. First, it is clear that even though there are many similarities, girls and boys are also victimized in noticeably different ways when it comes to physical and verbal victimization, neglect, witnessing violence and property crime. Second, this study provides insight into the variety of the victimization that young people experience in different settings and by different perpetrators that research focusing on orthodox definitions of child maltreatment generally cannot provide. The inclusive measures used in this study provides information about higher levels of all types of victimization during lifetime than generally found in other studies for all types, except for male sexual victimization, which was within the range of what has been found in previous reviews, and for neglect, which was lower (cf. Annerbäck et al., 2010; Finkelhor et al., 2007; Gilbert et al., 2009; Hussey et al., 2006; Miller et al., 2014; Radford et al., 2013; Stoltenborgh et al., 2012). It thereby contributes to the literature by providing information about total youth victimization and about possible variations of specific victimization across the world. A third important contribution of this study to the field of child maltreatment research is the finding that multiple mental health and behavioral problems were more common among those who had experienced any of the six types of victimization among both males and females and that higher number of types of victimization increased the prevalence of multiple problems. Also, the relation between number of types of victimization and mental health and behavioral problems is stronger among females than among males for mental health problems and multiple problems, whereas it is stronger among males than among females for behavioral problems. In addition, this study provides detailed statistics on location of victimization and relation to perpetrator, which are not commonly studied. Strengths and Limitations The strengths of the present study relate to the utilization of previously used and mostly well-validated measures to assess all the variables in the present study, and the use of a relatively large and randomly selected nationwide sample from the general population. Given this, we argue that the conclusions of the study are relatively firm and generalizable to young adult populations in similar countries and cultures. Please cite this article in press as: Cater, Å. K., et al. Youth victimization in Sweden: Prevalence, characteristics and relation to mental health and behavioral problems in young adulthood. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.03.002

G Model CHIABU-2747; No. of Pages 13

ARTICLE IN PRESS Å.K. Cater et al. / Child Abuse & Neglect xxx (2014) xxx–xxx

11

Even though it is highly evident that victimization is related to health and behavioral problems in a very broad sense, the direction of associations can be questioned, especially when using retrospective assessment as in the present study. We know from previous research that children and adolescents with high levels of health and behavioral problems, such as the problems assessed here, are at greater risk for victimization (Sentenac et al., 2012; Turner et al., 2010). Our findings, and those of others, could also be a result of other underlying factors that have not been controlled for and that are causing both the victimization and the health and behavioral problems. There is nothing in our data that explicitly shows that the higher levels of mental health or behavioral problems reported by those who stated they had been victimized emerged as a result of that victimization. Nevertheless, we argue that the knowledge of the co-occurrence of problems and victimization is relevant when approaching young adults in need of support, regardless of the directions of causality. Whether the problems are posing the individual at greater risk for victimization, or the victimization is increasing the risk for mental health and behavioral problems, or that all these problems are due to shared confounding variables, both issues need to be taken into account in order to improve interventions. Limitations of the study relate to the sole reliance on self-reports and particularly in terms of the various youth victimization measures; the reliance of retrospective self-report from young adulthood back to early childhood. We know that people exhibit difficulties recalling previous experiences, in that they are often inaccurate with regard to timing and magnitude of events and experiences, or that there are recency, bias or interpretation issues that interfere with what could be considered a correct report (see e.g., Hardt & Rutter, 2004; Henry, Moffitt, Caspi, Langley, & Silva, 1994). With regard to retrospective reports of victimization, though, findings suggest that false positives are scarce and an underestimation should be expected (Hardt & Rutter, 2004). This could, of course, affect our results and conclusions. The retrospective design also means that some types of victimization, such as victimization on the internet, might be more common among youths today than reported in the present sample of young adults. Furthermore, the relatively large rate of drop-outs and persons declining participation after the randomized selection but before the I/Q administration is a limitation of the study because it resulted in a slightly biased selection of participants. As presented in the “Method” section, the participants ended up somewhat more urban and highly educated as compared to the total population, based on national official statistics. However, the tests for differences between the 2,500 participants and a random selection of 30 non-participants on demographic and problem variables showed no substantial differences that would suggest a strong bias, indicating that the participating individuals were not very different on important variables from those who chose not to participate. Clinical Implications and Directions for Future Research To protect children’s health and welfare, early detection of victimization is essential. The current study provides important information about the specific risks for boys and girls respectively. For example, several of our findings indicate that girls are more victimized by family members and boyfriends and boys by peers, which raises questions about how society can improve protection of youth from different kinds of perpetrators. The links found between number of types of victimization and mental health and behavioral problems call for special attention to poly-victimized youth. Being more pronounced among females, this association calls for special attention to poly-victimized girls. The majority of the young adults in this study reported victimization, and mental health and behavior problems were more common among them, regardless of in which way they had been victimized. Although we cannot draw conclusions about causality or the direction of the relationships found between victimization in youth and adult health, this indicates the importance of clinicians conducting a thorough evaluation of past victimization when completing mental health assessments for troubled young people. Finally, these results raise questions about whether youth could be helped by support interventions developed to address poly-victimization in addition to those developed specifically for abused children and child witnesses to parental violence. Our study shows low prevalence of neglect compared to, for instance, Hussey et al.’s study (2006) of young American adults, in which having been left home alone as a child was reported by 41.5% of respondents and physical neglect by 11.8%. This finding can be of particular interest for policy makers. For instance, the roles of Sweden’s relatively generously paid universal parental leave for both parents (Ray, Gornick, & Schmitt 2009), general parental education since 1979 and wellused family-oriented child health service with increasing psychosocial ambitions (Petersson, Petersson, & Håkansson, 2003) for protecting children against neglect by general family support could be investigated and similar policies tried as means for reducing child neglect in other countries. Our findings on the prevalence and characteristics of youth single- and poly-victimization and their relations to adult mental health and behavioral problems could be tested further by including testimony from children at different ages, either by prospective longitudinal designs or by cross-sectional studies that could minimize risks of memory related difficulties. In particular, whether the results found in this study in terms of single and multiple mental health and behavioral problems are equally related to intra- and extra-familial victimization is an important task for future research to test. Specifically, although our finding that females report more sexual victimization confirms previous research (e.g., Collin-Vézina et al., 2013; Gilbert et al., 2009; Putnam, 2003), males reporting more physical and property victimization and witnessing violence and females more verbal victimization and neglect clearly needs to be further explored in future studies. To gain supplementary insight into the gender differences found in this study, future research employing qualitative methods may be useful for understanding the subjective experiences that boys and girls attach to single- and poly-victimization. Please cite this article in press as: Cater, Å. K., et al. Youth victimization in Sweden: Prevalence, characteristics and relation to mental health and behavioral problems in young adulthood. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.03.002

G Model CHIABU-2747; No. of Pages 13

ARTICLE IN PRESS

12

Å.K. Cater et al. / Child Abuse & Neglect xxx (2014) xxx–xxx

References Allen, J. P., Litten, R., Fertig, J., & Babor, T. (1997). A review of research on the Alcohol Use Disorders Identification Test (AUDIT). Alcoholism: Clinical and Experimental Research, 21, 613–619. Andershed, H., Kerr, M., Stattin, H., & Levander, S. (2002). Psychopathic traits in non-referred youths: A new assessment tool. In E. Blaauw, & L. Sheridan (Eds.), Psychopaths: Current international perspectives (pp. 131–158). The Hague: Elsevier. Annerbäck, E. M., Sahlqvist, L., Svedin, C. G., Wingren, G., & Gustafsson, P. A. (2012). Child physical abuse and concurrence of other types of child abuse in Sweden – Associations with health and risk behaviors. Child Abuse & Neglect, 36, 585–595. http://dx.doi.org/10.1016/j.chiabu.2012.05.006 Annerbäck, E.-M., Wingren, G., Svedin, C. G., & Gustafsson, P. A. (2010). Prevalence and characteristics of child physical abuse in Sweden – Findings from a population-based youth survey. Acta Paediatrica, 99, 1229–1236. http://dx.doi.org/10.1111/j.1651-2227.2010.01792.x BRÅ. (2013). Brott bland ungdomar i årskurs 9: Resultat från Skolundersökningen om brott åren 1995-2011 [Crimes among youth in 9th grade: Results from the school survey about crimes 1995–2011]. Brottsförebyggande rådet Rapport 2013:3. ¨ T., & Kahane, T. (2006). Preventing child maltreatment: A guide to taking action and generating evidence. Butchart, A., Phinney Harvey, A., Mian, M., Furniss, Geneva, Switzerland: World Health Organization. Centers for Disease Control. (2014). Adverse Childhood Experiences (ACE) Study: Data and statistics. Retrieved from www.cdc.gov Collin-Vézina, D., Daigneault, I., & Hébert, M. (2013). Lessons learned from child sexual abuse research: Prevalence, outcomes, and preventive strategies. Child and Adolescent Psychiatry and Mental Health, 7, 22. http://dx.doi.org/10.1186/1753-2000-7-22 Costello, E. J., Erkanli, A., Fairbank, J. A., & Angold, A. (2002). The prevalence of potentially traumatic events in childhood and adolescence. Journal of Traumatic Stress, 15(2), 99–112. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults – The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14, 245–258. Fergusson, D. M., Boden, J. M., & Horwood, L. J. (2008). Exposure to childhood sexual and physical abuse and adjustment in early adulthood. Child Abuse & Neglect, 32, 607–619. http://dx.doi.org/10.1016/j.chiabu.2006.12.018 Finkelhor, D., Hamby, S., Ormrod, R., & Turner, H. (2005). The Juvenile Victimization Questionnaire: Reliability, validity, and national norms. Child Abuse & Neglect, 29, 383–412. http://dx.doi.org/10.1016/j.chiabu.2004.11.001 Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2007). Poly-victimization: A neglected component in child victimization. Child Abuse & Neglect, 31, 7–26. http://dx.doi.org/10.1016/j.chiabu.2006.06.008 Finkelhor, D., Ormrod, R., Turner, H., & Hamby, S. (2005). The victimization of children and youth: A comprehensive, national survey. Child Maltreatment, 10, 5–25. http://dx.doi.org/10.1177/1077559504271287 Finkelhor, D., Turner, H., Hamby, S., & Ormrod, R. (2011, October). Polyvictimization: Children’s exposure to multiple types of violence, crime, and abuse. Juvenile Justice Bulletin. Gilbert, R., Spatz Widom, C., Browne, K., Fergusson, D., Webb, E., & Janson, S. (2009). Burden and consequences of child maltreatment in high-income countries. The Lancet, 373, 68–81. http://dx.doi.org/10.1016/S0140-6736(08)61706-7 Hamby, S. L., Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2004). The Juvenile Victimization Questionnaire (JVQ): Administration and scoring manual. Durham: University of New Hampshire, Crimes Against Children Research Center. Hardt, J., & Rutter, M. (2004). Validity of adult retrospective reports of adverse childhood experiences: Review of the evidence. Journal of Child Psychology and Psychiatry, 45, 260–273. Henry, B., Moffitt, T. E., Caspi, A., Langley, J., & Silva, P. A. (1994). On the “remembrance of things past”: A longitudinal evaluation of the retrospective method. Psychological Assessment, 6, 92–101. Herrenkohl, T. I., Hong, S., Klika, J. B., Herrenkohl, R. C., & Russo, M. J. (2013). Developmental impacts of child abuse and neglect related to adult mental health, substance use, and physical health. Journal of Family Violence, 28, 191–199. http://dx.doi.org/10.1007/s10896-012-9474-9 Higgins, D. J., & McCabe, M. P. (2000). Relationships between different types of maltreatment during childhood and adjustment in adulthood. Child Maltreatment, 5, 261–272. Holt, S., Buckley, H., & Whelan, S. (2008). The impact of exposure to domestic violence on children and young people: A review of the literature. Child Abuse & Neglect, 32, 797–810. http://dx.doi.org/10.1016/j.chiabu.2008.02.004 Hussey, J. M., Chang, J. J., & Kotch, J. B. (2006). Child maltreatment in the United States: Prevalence, risk factors, and adolescent health consequences. Pediatrics, 118, 933–942. http://dx.doi.org/10.1542/peds.2005-2452 Janson, S., Jernbro, C., & Långberg, B. (2011). Kroppslig bestraffning och annan kränkning av barn i Sverige - en nationell kartläggning 2011 [Physical punishment and other types of violation of children in Sweden – A national survey 2011]. Stiftelsen Allmänna Barnhuset. Janson, S., Långberg, B., & Svensson, B. (2007). Våld mot barn 2006-2007 – en nationell kartläggning [Violence against children – A national survey in Sweden 2006–2007]. Stiftelsen Allmänna Barnhuset och Karlstad universitet 2007:4. Jernbro, C., Svensson, B., Tindberg, Y., & Janson, S. (2012). Multiple psychosomatic symptoms can indicate child physical abuse – Results from a study of Swedish schoolchildren. Acta Paediatrica, 101, 324–329. http://dx.doi.org/10.1111/j.1651-2227.2011.02518.x Johnson, J. G., Cohen, P., Smailes, E. M., Skodol, A. E., Brown, J., & Oldham, J. M. (2001). Childhood verbal abuse and risk for personality disorders during adolescence and early adulthood. Comprehensive Psychiatry, 42, 16–23. http://dx.doi.org/10.1053/comp.2001.19755 Kent, A., & Waller, G. (1998). The impact of childhood emotional abuse: An extension of the Child Abuse and Trauma Scale. Child Abuse & Neglect, 22, 393–399. http://dx.doi.org/10.1016/S0145-2134(98)00007-6 Lansford, J. E., Dodge, K. A., Pettit, G. S., Bates, J. E., Crozier, J., & Kaplow, J. (2002). A 12-year prospective study of the long-term effects of early child physical maltreatment on psychological, behavioral, and academic problems in adolescence. Archives of Pediatrics and Adolescent Medicine, 156, 824–830. Lansford, J. E., Miller-Johnson, S., Berlin, L. J., Dodge, K. A., Bates, J. E., & Pettit, G. S. (2007). Early physical abuse and later violent delinquency: A prospective longitudinal study. Child Maltreatment, 12, 233–245. http://dx.doi.org/10.1177/1077559507301841 May-Chahal, C. (2006). Gender and child maltreatment: The evidence base, social work and society. The International Online-Only Journal, 4. ISSN: 1613-8953. May-Chahal, C., & Cawson, P. (2005). Measuring child maltreatment in the United Kingdom: A study of the prevalence of child abuse and neglect. Child Abuse & Neglect, 29, 969–984. http://dx.doi.org/10.1016/j.chiabu.2004.05.009 Miller, L. E., Cater, Å. K., Howell, K. H., & Graham-Bermann, S. A. (2014). Perpetration patterns and environmental contexts of IPV in Sweden: Relationships with adult mental health. Child Abuse & Neglect, 38, 147–158. http://dx.doi.org/10.1016/j.chiabu.2013.10.023 Petersson, C., Petersson, K., & Håkansson, A. (2003). General parental education in Sweden: Participants and non-participants. Scandinavian Journal of Primary Health Care, 21, 43–46. Petrenko, C. L. M., Friend, A., Garrido, E. F., Taussig, H. N., & Culhane, S. E. (2012). Does subtype matter? Assessing the effects of maltreatment on functioning in preadolescent youth in out-of-home care. Child Abuse & Neglect, 36, 633–644. http://dx.doi.org/10.1016/j.chiabu.2012.07.001 Putnam, F. W. (2003). Ten-year research update review: Child sexual abuse. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 269–278. Radford, L., Corral, S., Bradley, C., & Fisher, H. L. (2013). The prevalence and impact of child maltreatment and other types of victimization in the UK: Findings from a population survey of caregivers, children and young people and young adults. Child Abuse & Neglect, 37, 801–813. http://dx.doi.org/10.1016/j.chiabu.2013.02.004 Ray, R., Gornick, J. C., & Schmitt, J. (2009). Parental leave policies in 21 countries assessing generosity and gender equality. Washington, DC: Center for Economic and Policy Research. Robboy, J., & Anderson, K. G. (2011). Intergenerational child abuse and coping. Journal of Interpersonal Violence, 26, 3526–3541. http://dx.doi.org/10.1177/0886260511403758

Please cite this article in press as: Cater, Å. K., et al. Youth victimization in Sweden: Prevalence, characteristics and relation to mental health and behavioral problems in young adulthood. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.03.002

G Model CHIABU-2747; No. of Pages 13

ARTICLE IN PRESS Å.K. Cater et al. / Child Abuse & Neglect xxx (2014) xxx–xxx

13

Sentenac, M., Arnaud, C., Gavin, A., Molcho, M., Gabhainn, S. N., & Godeau, E. (2012). Peer victimization among school-aged children with chronic conditions. Epidemiologic Reviews, 34, 120–128. Simpson, T. L., & Miller, W. R. (2002). Concomitance between childhood sexual and physical abuse and substance use problems. A review. Clinical Psychology Review, 22, 27–77. Stoltenborgh, M., Bakermans-Kranenburg, M. J., & van Ijzendoorn, M. H. (2012). The neglect of child neglect: A meta-analytic review of the prevalence of neglect. Social Psychiatry and Psychiatric Epidemiology, 48, 345–355. http://dx.doi.org/10.1007/s00127-012-0549-y Tolin, D. F., & Foa, E. B. (2006). Sex differences in trauma and posttraumatic stress disorder: A quantitative review of 25 years of research. Psychological Bulletin, 132, 959–992. Turner, H. A., Finkelhor, D., & Ormrod, R. (2010). Child mental health problems as risk factors for victimization. Child Maltreatment, 15, 132–143. Weiss, D. S., & Marmar, C. R. (2004). The impact of event scale-revised. Assessing Psychological Trauma and PTSD, 2, 168–189. Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67, 361–370.

Please cite this article in press as: Cater, Å. K., et al. Youth victimization in Sweden: Prevalence, characteristics and relation to mental health and behavioral problems in young adulthood. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.03.002