Child Abuse in Russia

Child abuse has been rarely discussed in the Russian literature. Several booklets were published in the period 1990-2016 but today the topic is largely avoided. Physical abuse may be implicated in pathogenesis of various conditions including obsessive-compulsive, autism spectrum and attention deficit hyperactivity disorders. Child abuse can have long-lasting consequences also for initially typical individuals. Children regularly punished for impulsivity, hyperactivity or hysteric behavior would modify it to avoid repeated trauma or to cope with it. The adaptive or maladaptive conduct may be obsessive-compulsive and/or compatible with autism spectrum disorder: impaired communication, abnormal eye contact, stereotypies. Some repetitive behaviors seen in autism can be described as obsessive/ compulsive. Among others, binge eating and alcohol drinking may be compulsive. In conditions of collectivism and social pressure to be “normal” like everybody, individuals with communication abnormalities have motives to contact with peers to avoid stigmatization as outsiders. Binge drinking is used by some adolescents to overcome communication barriers. Besides, loitering with drinking companies is a way of escape from domestic violence. In conclusion, child abuse can modify behavior and trajectories of some conditions giving rise to atypical conduct more or less compatible with autism spectrum or obsessive-compulsive disorders, sometimes predisposing to excessive alcohol consumption.

not only the perpetrator but also victim is sometimes blamed [16].Detection of abuse often depends on victims.It is easier to denounce a socially unprotected abuser e.g., an alcoholic.Otherwise, various tools are applied to prevent a disclosure: denial of facts, allegations of slander and/or mental abnormality in the victim, threats and intimidation, appeals to preserve honor of the family or nation.The intergenerational transmission of violence is recognizable in many families [3].The attitude of some professionals and a part of the population is tolerant [2,6].Authorities, teachers and neighbors in apartment buildings did not react to some known cases of child maltreatment.There is neither official standpoint nor agreed policies [4,7], nor adequate victim services; investigations are started mainly on official request.This means that many victims continue living in conditions of abuse potentially harmful for their physical and mental health [3].The main way to solve problems of child abuse in RF has been a placement in an orphanage [2], which is often disliked by children, especially those with special needs, fearing bullying.The institutionalization implies that not the abuser but the victim is removed from the familiar environment, suffers deprivation and discomfort [16].Admittedly, the system of social support is developing; the crisis centers for women and children being opened.
An attempt is made here to analyze how certain psychopathological conditions develop in the settings delineated above.At the risk of punishments, a child may "dig in his heels and be negative" [17].In particular, autistic children are at an increased risk of victimization.Some cases of autism spectrum disorder (ASD) are caused by intrinsic factors while others may be induced or exacerbated by an environmental impact such as the physical abuse.Given the association of autistic traits in adults with the abuse in their childhood, studies identifying causal mechanisms can contribute to prevention [18].Furthermore, the child neglect, psychological and to a lesser degree physical abuse are associated with attention deficit hyperactivity disorder (ADHD) [19].It can be reasonably assumed that children regularly punished for impulsivity, hyperactivity or hysteric fits would modify their behavior to prevent repeating trauma or to cope with it.Repression of traumatic or shameful events as a defense mechanism, common in neuroses, is apparently involved in the pathogenesis.Physically abused children are known to exhibit repetitive compulsive behaviors e.g., occasional overeating.Both ASD and obsessive-

Introduction
This is an update and continuation of the preceding article [1].Child abuse has been rarely discussed in the Russian literature.Several booklets were published in the period 1990-2016 [2][3][4][5][6][7] but today the topic is largely avoided.Some writings provide little insight or are compiled from foreign sources.Discussing physical abuse, the accent is often on visible injuries: bruises, burns and fractures.Of note, an abuse can continue for years with cerebral concussions, burns of oral mucosa/esophagus and intoxications without externally visible injuries, exemplified by the case report below.According to some analyses, the prevalence of family violence in the Russian Federation (RF) during last decades has been 45-70 times higher than, for example, in the United Kingdom and France [4].According to a recent report, about 40% of all serious violent crimes in RF are committed within families; 14% of children are subjected to physical abuse, 2 million are regularly beaten by parents while 10% of them lose their lives as a result [8].According to other sources, 40% of children are beaten in families [9]; 31% of children experience sexual abuse and 41% suffer cruel punishments [3].It was reported in 2016 that the General Prosecutor's Office of RF records about 2 million children beaten by their parents yearly, whereas 10% of the cases end in death, of which about 2 thousand by suicide [2].Yet in 2017 Vladimir Putin has signed into law an amendment that decriminalizes some forms of domestic violence [10].Apropos, physical abuse was described in his biographies [11][12][13][14].It has been hypothesized that Putin is re-enacting his own and his family's traumas in conditions of an intergenerational traumatic chain [13,15].There is a "danger of blundering into a nuclear war" [15] thanks to that case of child maltreatment.
Reverting to the topic, the self-referral rate of victims of domestic violence in RF is low; among reasons are distrust of authorities, fears of humiliations and of a breach of secrecy.In case of disclosure, ISSN: 2330-2178 compulsive disorder (OCD) involves repetitive activities.In an environment tolerating annoying behaviors, a child would preserve ADHD or hysteric features, or evolve in a typical way.In conditions of domestic violence, regularly punishing impulsivity, hyperactivity or hysteric fits, a child would be "trained" towards abnormal behaviors that might be compatible with autistic and/or obsessive-compulsive patterns.In particular, alcohol drinking may be an "obsessive passion" or compulsion [20,21].The literature focusing on family violence and alcohol abuse consistently shows a positive association between these events both for adolescents and for adults; references are in [22].

Case report
A 3-5 years old boy was sent with a nanny to a suburb during three periods May-September.There was almost no contact with other children, which did not contribute to his physical development and communicative skills.There was a head trauma, burns of oral mucosa, esophagus and genital area with hot soup; consequences being felt at an older age.The nanny gave alcohol to the child probably not to be disturbed at night.When the boy was 7 years old, his mother remarried.The following risk factors of child maltreatment [23] were present: young age of the stepfather, the poor social support and family history of maltreatment -the perpetrator had been beaten by his father.The abuse was administered by slapping in the face and head, under the pretext of punishment or without any pretext whatever.At that time, the boy was noticed to have autistic traits: communication deficits, failure to develop peer relationships and motor clumsiness.Impulsivity and hyperactivity were initially observed but regularly punished and largely disappeared, being replaced by obsessivecompulsive symptoms and behaviors such as binge eating.Aside from small doses received during parties at home, the boy did not consume alcohol until the age of 13 years.In the subsequent year, his alcohol consumption increased up to 250 ml of vodka plus beer or equivalent quantities of wine at one session.At the age of 23 years the patient underwent an intramuscular implantation of disulphiram preparation Esperal, which was followed by an 8-month-long abstinence, interrupted after provocations from friends and co-workers, which was typical for the Soviet-time collectivism partly preserved until today.The patient has discontinued the alcohol overconsumption at the age of about 35 years, when it had become incompatible with his professional duties.

Discussion
Physical abuse and other childhood adversities are implicated in the pathogenesis of various conditions including ADHD [24][25][26][27][28][29][30].Presumably, children regularly punished for impulsivity, hyperactivity or hysterical fits would modify their behavior to prevent repeated trauma or to cope with it.The adaptive or maladaptive conduct may be obsessive-compulsive and/or compatible with ASD in terms of DSM-5: failure to initiate or respond to social interactions, poorly integrated communication, abnormal eye contact, deficits of developing and maintaining relationships, reduced sharing of emotions.The causeeffect relationship is bidirectional: autistic traits enhance the risk of child abuse and bullying while the violence reinforces abnormal behaviors.The youth with ASD were found to be at an increased risk of victimization [18,31].Symptoms compatible with ASD were observed after a childhood head trauma [32].Some grossly neglected children showed autistic-like behavior [33].
Non-functional repetitive movements seen in ASD and OCD can be described as catatonic [34,35].Stereotypies and other repetitive activities were found in 19.4-61.1% cases of ASD [36].A metaanalysis revealed that the median prevalence of motor stereotypies in ASD was 51.8% [37].Catatonia is associated with schizophrenic disorders; however, it is now described in different conditions [36,38].Childhood autism was not uniformly accepted in Russia as a separate entity, being often diagnosed and treated as childhood schizophrenia [39,40].Russian psychiatrists tended to diagnose schizophrenia more frequently than foreign colleagues both in children and in adults [41,42].Schizophrenia was regarded to be a lifelong disease persisting despite remissions.Consequently, many patients remained registered at local psychiatric units (dispensaries) throughout their lives, which contributed to stigmatization [42].Antipsychotic drugs were recommended for all forms of schizophrenia including the sluggish variety [43,44].Overextended diagnostic criteria of sluggish schizophrenia were used for compulsory hospitalization of dissidents; but many people having nothing to do with politics have been affected as well.Symptoms of neuroses and personality disorders, unusual interests and eccentricity were presented as diagnostic criteria of schizophrenia.The sluggish variety was reportedly the most common form of the disease: up to 50% of all cases [43,45].Existence of subclinical or even asymptomatic schizophrenia was postulated as well [46][47][48].The entity was additionally expanded by so-called schizophrenic reactions, a concept that allows diagnosing reactive conditions as "psychogenic exacerbations" of the disease that had been non-manifest prior to an exposure to environmental stress [49].This topic is tackled here because abnormal behaviors in victims of child abuse may be misdiagnosed as schizophrenia.Abusive caregivers often disguise maltreatment and, at the same time, may exaggerate and provoke abnormal behaviors in their victims.
The symptoms of ADHD, ASD and OCD are partly overlapping [50][51][52][53].There is a hypothesis that ADHD and ASD are manifestations of the same overarching condition [54]; whereas differences are partly caused by environmental factors.Impulsivity and hyperactivity act provokingly on some abusers [3].In an environment tolerating annoying behaviors, a child would preserve ADHD or hysteric symptoms, or evolve in a more typical way.Under the impact of violence, maladaptive behaviors might come to the fore, being to some extent compatible with autistic and/or obsessive-compulsive patterns.As mentioned above, alcohol drinking may be an "obsessive passion" or compulsion [20,21].Alcohol abuse was observed in 34% of OCD patients [55].Low prevalence of substance abuse in adults with autism has been reported but there may be an underestimation [56].Undoubtedly, "avoidance of social situations is a common trait in people with ASD" [57].However, this statement is more relevant for milieus where such avoidance is tolerated.In conditions of collectivism, under the pressure to be "normal" like everybody, as it has been in the former Soviet Union [41], individuals with communication abnormalities would strive for contacts to avoid stigmatization as outsiders.Obstinate refusal to indulge in drinking companies was regarded as peculiar and insulting behavior [58].Admittedly, this attitude seems to be changing these days.Anyway, the binge drinking is often used to overcome communication barriers.Some individuals with high-functioning autism deliberately drink alcohol to cope with anxiety, to maintain friendships and gain access to relationships [56,59].Emotional disturbances in young people predisposing to alcoholism may result from rejection by parents for not fulfilling their expectations.Drinking helps them to overcome the feeling of inadequacy [60].Finally, the pastime with bottle companions is a way of escape from domestic violence and uncomfortable atmosphere at home.According to the author's observations since the 1960s, binge drinking was started by many schoolchildren from 13-14 years onwards.Fortunately, there is an improvement tendency: young people consume mainly beer today but less vodka and fortified wine than during the Soviet period [61].
The hypothesis discussed here is that some autistic individuals may be physically abused children with ADHD, histrionic and some other disorders, or initially typical ones.Some adaptive or maladaptive behaviors might be compatible with ASD: motor stereotypes and repetitive movements such as rocking, head banging, hair pulling, nose-picking, binge eating or drinking as well as impaired communication and abnormal eye contact [5].The behaviors developed by abused children may be interpreted by the social environment as a mental abnormality or defectiveness [3,16].A case is known to us when abusive caregivers intended to send a child with mild autistic traits to a school for mentally retarded [1].In this connection, the heritability of ASD has a non-genetic mechanism in some cases: children of deviant parents are exposed to the maltreatment, hence acquiring deviant traits themselves.Other features compatible with ASD may result from sublimation as a defense mechanism such as atypical interests or studies of special subjects beyond the school program [62].It may be speculated that individuals with some disorders or neuroses (for example, OCD) were on average more often beaten during their childhood than those with other conditions e.g., hysteria.An adolescent regularly punished for hysteric behavior might discontinue it but start obsessive activities.Finally, it should be mentioned that some children with ADHD exposed to trauma develop borderline personality disorder [28].Apparently, the latter development is more probable in disorganized conditions with haphazard traumas rather than under impact of regular and targeted physical abuse.This topic needs further research.

Conclusion
There is evidence in favor of associations of child maltreatment with adverse mental health, physical health and social outcomes, deficient communicative skills, substance abuse and, in particular, overuse of alcohol.Trajectories of certain conditions may depend on extrinsic factors: in an environment tolerating impulsivity, hyperactivity, hysterical or otherwise annoying behaviors, a child would preserve initial symptoms or evolve in a more typical way.In conditions of physical abuse, consistently punishing behaviors regarded by abusers to be undesirable, a child would develop adaptive conduct to avoid the trauma or to cope with it.Child abuse can have long-lasting consequences also for initially typical individuals.In conditions of collectivism, under the social pressure to be "normal" like everybody, adolescents with communication difficulties have strong motives to contact with peers to avoid stigmatization as outsiders.Alcohol is used by some of them to overcome communication barriers.Besides, loitering with drinking companies is a way of escape from domestic violence.In conclusion, child abuse may be a causative or contributory factor of behaviors more or less compatible with autism spectrum and/or obsessive-compulsive disorders, sometimes predisposing to binge drinking.