Child sexual abuse is considered a modifiable risk factor for mental disorders across the life course. However the long-term consequences of other forms of child maltreatment have not yet been systematically examined. The aim of this study was to summarise the evidence relating to the possible relationship between child physical abuse, emotional abuse, and neglect, and subsequent mental and physical health outcomes.
Methods and Findings
A systematic review was conducted using the Medline, EMBASE, and PsycINFO electronic databases up to 26 June 2012. Published cohort, cross-sectional, and case-control studies that examined non-sexual child maltreatment as a risk factor for loss of health were included. All meta-analyses were based on quality-effects models. Out of 285 articles assessed for eligibility, 124 studies satisfied the pre-determined inclusion criteria for meta-analysis. Statistically significant associations were observed between physical abuse, emotional abuse, and neglect and depressive disorders (physical abuse [odds ratio (OR) = 1.54; 95% CI 1.16–2.04], emotional abuse [OR = 3.06; 95% CI 2.43–3.85], and neglect [OR = 2.11; 95% CI 1.61–2.77]); drug use (physical abuse [OR = 1.92; 95% CI 1.67–2.20], emotional abuse [OR = 1.41; 95% CI 1.11–1.79], and neglect [OR = 1.36; 95% CI 1.21–1.54]); suicide attempts (physical abuse [OR = 3.40; 95% CI 2.17–5.32], emotional abuse [OR = 3.37; 95% CI 2.44–4.67], and neglect [OR = 1.95; 95% CI 1.13–3.37]); and sexually transmitted infections and risky sexual behaviour (physical abuse [OR = 1.78; 95% CI 1.50–2.10], emotional abuse [OR = 1.75; 95% CI 1.49–2.04], and neglect [OR = 1.57; 95% CI 1.39–1.78]). Evidence for causality was assessed using Bradford Hill criteria. While suggestive evidence exists for a relationship between maltreatment and chronic diseases and lifestyle risk factors, more research is required to confirm these relationships.
This overview of the evidence suggests a causal relationship between non-sexual child maltreatment and a range of mental disorders, drug use, suicide attempts, sexually transmitted infections, and risky sexual behaviour. All forms of child maltreatment should be considered important risks to health with a sizeable impact on major contributors to the burden of disease in all parts of the world. The awareness of the serious long-term consequences of child maltreatment should encourage better identification of those at risk and the development of effective interventions to protect children from violence.
Please see later in the article for the Editors' Summary
Child maltreatment—the abuse and neglect of children—is a global problem. There are four types of child maltreatment—sexual abuse (the involvement of a child in sexual activity that he or she does not understand, is unable to give consent to, or is not developmentally prepared for), physical abuse (the use of physical force that harms the child's health, survival, development, or dignity), emotional abuse (the failure to provide a supportive environment by, for example, verbally threatening the child), and neglect (the failure to provide for all aspects of the child's well-being). Most child maltreatment is perpetrated by parents or parental guardians, many of whom were maltreated themselves as children. Other risk factors for parents abusing their children include poverty, mental health problems, and alcohol and drug misuse. Although there is considerable uncertainty about the frequency and severity of child maltreatment, according to the World Health Organization (WHO) about 20% of women and 5%–10% of men report being sexually abused as children, and the prevalence of physical abuse in childhood may be 25%–50%.
Why Was This Study Done?
Child maltreatment has a large public health impact. Sometimes this impact is immediate and direct (injuries and deaths), but, more often, it is long-term, affecting emotional development and overall health. For child sexual abuse, the relationship between abuse and mental disorders in adult life is well-established. Exposure to other forms of child maltreatment has also been associated with a wide range of psychological and behavioral problems, but the health consequences of physical abuse, emotional abuse, and neglect have not been systematically examined. A better understanding of the long-term health effects of child maltreatment is needed to inform maltreatment prevention strategies and to improve treatment for children who have been abused or neglected. In this systematic review and meta-analysis, the researchers quantify the association between exposure to physical abuse, emotional abuse, and neglect in childhood and mental health and physical health outcomes in later life. A systematic review uses predefined criteria to identify all the research on a given topic; a meta-analysis is a statistical approach that combines the results of several studies.
What Did the Researchers Do and Find?
The researchers identified 124 studies that investigated the relationship between child physical abuse, emotional abuse, or neglect and various health outcomes. Their meta-analysis of data from these studies provides suggestive evidence that child physical abuse, emotional abuse, and neglect are causally linked to mental and physical health outcomes. For example, emotionally abused individuals had a three-fold higher risk of developing a depressive disorder than non-abused individuals (an odds ratio [OR] of 3.06). Physically abused and neglected individuals also had a higher risk of developing a depressive disorder than non-abused individuals (ORs of 1.54 and 2.11, respectively). Other mental health disorders associated with child physical abuse, emotional abuse, or neglect included anxiety disorders, drug abuse, and suicidal behavior. Individuals who had been non-sexually maltreated as children also had a higher risk of sexually transmitted diseases and/or risky sexual behavior than non-maltreated individuals. Finally, there was weak and inconsistent evidence that child maltreatment increased the risk of chronic diseases and lifestyle risk factors such as smoking.
What Do These Findings Mean?
By providing suggestive evidence of a causal link between non-sexual child maltreatment and mental health disorders, drug use, suicide attempts, and sexually transmitted diseases and risky sexual behavior, these findings contribute to our understanding of the non-injury health impacts of child maltreatment. Although most of the studies included in the meta-analysis were undertaken in high-income countries, the findings suggest that this link occurs in both high- and low-to-middle-income countries. They also suggest that neglect may be as harmful as physical and emotional abuse. However, they need to be interpreted carefully because of the limitations of this meta-analysis, which include the possibility that children who have been abused may share other, unrecognized factors that are actually the cause of their later mental health problems. Importantly, this confirmation that physical abuse, emotional abuse, and neglect in childhood are important risk factors for a range of health problems draws attention to the need to develop evidence-based strategies for preventing child maltreatment both to reduce childhood suffering and to alleviate an important risk factor for later health problems.
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001349.
- The World Health Organization provides information on child maltreatment and its prevention (in several languages); Preventing Child Maltreatment: A Guide to Taking Action and Generating Evidence is a 2006 report produced by WHO and the International Society for Prevention of Child Abuse and Neglect
- The US Centers for Disease Control and Prevention provides information on child maltreatment and links to additional resources
- The National Society for the Prevention of Cruelty to Children (NSPCC) is a not-for-profit organization that aims to end all cruelty to children in the UK; Childline is a resource provided by the NSPCC that provides help, information, and support to children who are being abused
- The Hideout is a UK-based website that helps children and young people understand domestic abuse
- Childhelp is a US not-for-profit organization dedicated to helping victims of child abuse and neglect; its website includes a selection of personal stories about child maltreatment
Citation: Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T (2012) The Long-Term Health Consequences of Child Physical Abuse, Emotional Abuse, and Neglect: A Systematic Review and Meta-Analysis. PLoS Med 9(11): e1001349. doi:10.1371/journal.pmed.1001349
Academic Editor: Mark Tomlinson, Stellenbosch University, South Africa
Received: March 20, 2012; Accepted: October 17, 2012; Published: November 27, 2012
Copyright: © 2012 Norman et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This work was supported by a University of Queensland Start-up-Grant. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Alexander Butchart is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: ACE, Adverse Childhood Experiences; BMI, body mass index; CI, confidence interval; DSM, Diagnostic and Statistical Manual of Mental Disorders; HSV2, herpes simplex virus type 2; OR, odds ratio; PTSD, post-traumatic stress disorder; STI, sexually transmitted infection; WHO, World Health Organization
Child maltreatment is defined as all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment, or commercial or other exploitation of children that results in actual or potential harm to a child's health, survival, development, or dignity in the context of a relationship of responsibility, trust, or power . Four types of maltreatment are commonly recognised: sexual abuse, physical abuse, emotional abuse (also referred to as psychological abuse), and neglect (Table 1).
There is a great deal of uncertainty around estimates of the frequency and severity of child maltreatment worldwide. Furthermore, much violence against children remains largely hidden and unreported because of fear and stigma and the societal acceptance of this type of violence . Globally, prevalence of reported child sexual abuse varies from 2% to 62%, with some of this variation explained by a number of methodological factors including definition of abuse, method of data collection, and type of sample assessed . In high-income countries, the annual prevalence of physical abuse ranges from 4% to 16%, and approximately 10% of children are neglected or emotionally abused . Eighty percent of this maltreatment is perpetrated by parents or parental guardians , and poverty, mental health problems, low educational achievement, alcohol and drug misuse, having been maltreated oneself as a child, and family breakdown or violence between other family members are all important risk factors for parents abusing their children .
There is growing recognition that different forms of interpersonal violence have a large public health impact . In children, the consequences of violence can vary widely. Physical injuries and, in extreme cases, death are direct consequences. World Health Organization (WHO) estimates of child homicide suggest that infants and very young children are at greatest risk, with rates for the 0- to 4-y age group about double those for 5- to 14-y-olds as a result of their dependency and vulnerability . However, in the majority of non-fatal cases, the direct physical injury causes less morbidity to the child than the long-term impact of the violence on the child's neurological, cognitive, and emotional development and overall health .
Child maltreatment is a major public health problem, yet a lack of understanding of its serious lifelong consequences and of the cost and burden on society has hampered investment in prevention policies and programs. In order to effectively respond to the problem, the WHO 2006 report on prevention of child maltreatment  recommended expanding the scientific evidence base for the magnitude, consequences, and preventability of child maltreatment.
The relationship between child sexual abuse and adverse psychological consequences in adults is well established –, and in the WHO comparative risk assessment study, Andrews and colleagues  carried out a systematic review and meta-analysis summarising the evidence of a relationship between child sexual abuse and subsequent mental disorders. This review is currently being updated in the new iteration of the Global Burden of Diseases, Injuries, and Risk Factors Study, aiming to provide global estimates of attributable burden for 1990 to 2010 , but other forms of child maltreatment have been omitted.
Exposure to non-sexual child maltreatment, namely, physical abuse, emotional abuse, and neglect, is associated with increased risk of a wide range of psychological and behavioural problems, including depression, alcohol abuse, anxiety, and suicidal behaviour, and with increased risk of HIV and herpes simplex virus type 2 (HSV2) infection –. However, the long-term health consequences of these other forms of child maltreatment have not been systematically examined. To address these omissions, clarify the present state of empirical research, and enable the quantification of the health impacts of child neglect, physical abuse, and emotional abuse at the population level using burden of disease and comparative risk assessment methodology, we conducted a systematic review of the scientific literature and quantitative meta-analyses. To the best of our knowledge, this is the first meta-analysis to summarise the evidence for associations between individual types of non-sexual child maltreatment and outcomes related to mental and physical health.
General recommendations from the PRISMA 2009 revision , with regard to processing and reporting of results, were taken into account (Text S1). The meta-analysis conforms to the guidelines outlined by the Meta-analysis of Observational Studies in Epidemiology recommendations . Methods and inclusion criteria were specified in advance and documented in a review protocol (Text S2).
Inclusion and Exclusion Criteria
This systematic review and meta-analysis incorporated retrospective and prospective cohort, cross-sectional, and case-control studies meeting the following inclusion criteria: (1) the study reported original, empirical research published in a peer-reviewed journal, (2) the study considered non-sexual child maltreatment as a potential risk factor for loss of health, and (3) the related health outcomes or behavioural risk factors were among those listed in the Global Burden of Diseases, Injuries, and Risk Factors Study . Studies reporting exposure only to combined types of abuse were excluded. Included studies reported odds ratios (ORs) and confidence intervals (CIs) comparing those exposed and not exposed by type of abuse or, alternatively, provided the information from which effect sizes and confidence intervals could be calculated (Text S2).
Three electronic databases (Medline, EMBASE, and PsycINFO up to 26 June 2012) were searched using full text and Medical Subject Headings (MeSH) terms to identify studies reporting an association between non-sexual child maltreatment and health outcomes (Text S2). Truncation of terms was used to capture variation in terminology. The search was not restricted to the English language, nor restricted by any other means. Searches were conducted using synonyms and combinations of the following search terms: “maltreatment”, “physical abuse”, “psychological abuse”, and “emotional abuse”, and automatic explosion of the terms “child abuse” and “child neglect”. The search was also not restricted to any particular health outcome. Instead, the broader terms “risk”, “adverse effect”, “consequences”, “harm”, and “association” were used to encompass all studies that investigated any adverse outcome of non-sexual child maltreatment. In addition, reference lists of selected studies were screened for any other relevant study, and additional studies were also identified through contact with study authors. Articles in languages other than English were translated.
Data Collection and Quality Assessment
The full-text article of any study that appeared to meet the inclusion criteria was retrieved for closer examination. Two reviewers (R. E. N. and M. B.) independently assessed articles for eligibility. Disagreements were resolved by consensus. The coders were not masked to the journals or authors of the studies reviewed. A standardised data extraction sheet was developed, and data retrieved included publication details, country where study was conducted, methodological characteristics such as sample size and study design, exposure and outcome measures, type of abuse, and health outcomes (Text S2). The data extraction sheet included a quality assessment tool (Table 2) to rate the methodological quality of each study based on the Newcastle-Ottawa Scale for assessing the quality of observational studies . Quality assessment was completed independently by two reviewers, and disagreements were resolved by discussion. One author was contacted for further information.
Weighted summary measures were computed using MetaXL, version 1.2 , a tool for meta-analysis in Microsoft Excel, with ORs chosen as the principal summary measure. Heterogeneity was quantitatively assessed using the Cochran's Q and I2 statistics to evaluate whether the pooled studies represent a homogeneous distribution of effect sizes. Evidence of publication bias was investigated by means of funnel plots using the standard error on the y-axis .
Meta-analyses were complicated by the presence of significant heterogeneity in the data, likely due to a combination of true variance in these relationships and variability produced by differences in the methodology used to measure exposure and outcomes. We hypothesised that effect size may differ according to the methodological quality of the studies. MetaXL implements a process to explicitly address study heterogeneity caused by differences in study quality. This so-called quality effects (Doi and Thalib) model  is a modified version of the fixed-effects inverse variance method that additionally allows giving greater weight to studies of high quality versus studies of lesser quality by using the quality scores assigned to each study to weigh studies not only according to sample size but also by study quality ,. Forest plots were made to visualise individual as well as pooled effects.
To address the effects of important study characteristics and explore heterogeneity, we additionally conducted several pre-specified subgroup analyses (depending on data availability) by the following: gender of participants in the sample, geographic location (high income versus low-to-middle income), type of sample (population-based versus non-representative samples), measurement of abuse (self-reported versus official records), assessment of health outcome (structured clinical interview versus self-reported), prospective versus retrospective assessment of abuse and neglect, and appropriate adjustment versus no or inadequate adjustment for confounders.
Out of 285 articles assessed for eligibility, 124 studies provided evidence of a relationship between non-sexual child maltreatment and various health outcomes for use in subsequent meta-analyses (Figure 1). The majority (n = 112) were from Western Europe, North America, Australia, and New Zealand. Data from low- and middle-income countries were sparse. Only 16 studies used a prospective cohort design that followed abused or neglected children over time to identify later health outcomes (Table 3). The remaining studies included cohort, cross-sectional, and case-control studies that measured the maltreatment retrospectively, usually by self-report in adolescence or adulthood. Most of the studies included in our meta-analysis presented data from regional or nationally representative samples (Table 3). The results of primary meta-analyses are presented in Tables 4–6, with Figures S1, S2, S3, S4, S5, S6, S7, S8, S9, S10, S11, S12, S13, S14, S15, S16, S17, S18, S19, S20, S21, S22, S23, S24, S25, S26, S27, S28, S29, S30, S31, S32, S33, S34, S35, S36, S37, S38, S39, S40, S41, S42 showing the forest plots of these meta-analyses. Details of subgroup analyses are presented in Tables S1, S2, S3, S4, S5, S6, S7, S8, S9, S10, S11.
Physically abused (OR = 1.54; 95% CI 1.16–2.04), emotionally abused (OR = 3.06; 95% CI 2.43–3.85), and neglected (OR = 2.11; 95% CI 1.61–2.77) individuals were found to have a higher risk of developing depressive disorders than non-abused individuals (Table 4; Figures S1, S2, S3). The test for heterogeneity was highly significant, with p<0.01 for both abuse types and neglect. Funnel plots indicate the possibility of publication bias for physical abuse, as it appears that some smaller, less precise studies have a greater effect size than the larger studies, and there are no smaller studies to the left (negative) side of the graph, suggesting that some negative studies may never have been published (Figure S4).
For physical abuse, emotional abuse, and neglect, OR estimates in males were higher than in females, but the difference was not statistically significant (Table S1). The odds of developing depressive disorders with exposure to physical abuse were greatest in prospective studies. Although the OR point estimate was higher in subgroup analyses of studies where exposure to physical abuse was court-substantiated by official records—which would include the more severe cases of abuse (OR = 2.41; 95% CI 1.32–4.41)—compared with self-reported physical abuse (OR = 1.56; 95% CI 1.11–2.19) and physical punishment (OR = 1.20; 95% CI 0.88–1.61), the 95% CIs were overlapping, and these differences were not statistically significant. There was a stronger association between physical abuse and a diagnosis of major depressive disorder using structured interviews (OR = 1.82; 95% CI 1.44–2.30) than when depressive disorders were diagnosed by symptom scales (OR = 1.52; 95% CI 1.03–2.24), but again these differences were not statistically significant (Table S1). Restricting the physical abuse analysis to studies from high-income countries increased the odds of developing depressive disorders to 1.58 (95% CI 1.18–2.12), but the association was not significant in low-to-middle-income countries (Table S1).
However, for neglect in childhood, similar odds of developing depressive disorders were observed in high- and low-to-middle-income countries. Data from two studies suggest a dose–response relationship, with depression more likely with frequent neglect compared with neglect that occurred only sometimes in childhood ,. A dose–response relationship was also reported for emotional abuse and depressive disorders, but not for physical abuse and depressive disorders (Table S1).
Physical abuse (OR = 1.51; 95% CI 1.27–1.79), emotional abuse (OR = 3.21; 95% CI 2.05–5.03), and neglect (OR = 1.82; 95% CI 1.51–2.20) were associated with a significantly increased risk of anxiety disorders (Figures S5, S6, S7, S8). For physical abuse, significant associations were also observed with post-traumatic stress disorder (PTSD) and panic disorder diagnoses (Table S2). A dose–response relationship was observed with physical abuse but not with emotional abuse and neglect , with anxiety disorders more likely with frequent physical abuse than with abuse that occurred only sometimes in childhood (Table S2). Physical abuse, emotional abuse, and neglect were also associated with an almost 3-fold increased risk of developing eating disorders (Figures S9, S10, S11, S12), and physical abuse was associated with a 5-fold increased risk of developing bulimia nervosa meeting Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria. Most of the evidence came from retrospective studies, and only one prospective study  reported a strong association with neglect in childhood (Table S3). A dose–response relationship was also observed, with bulimia nervosa more likely with more severe and repeated physical abuse  (Table S3).
Physical abuse and neglect were also associated with a doubling of the odds of childhood behavioural and conduct disorders (Figures S13, S14, S15). With respect to physical abuse, higher odds of developing conduct and childhood behavioural disorders were observed in prospective than in retrospective studies, but differences were not statistically significant. Studies with non-representative samples had significantly increased effect size for the association between physical abuse and childhood behavioural problems and conduct disorder (OR = 5.98; 95% CI 2.73–13.10) compared with population-based studies (OR = 2.02; 95% CI 1.58–2.58) (Table S4).
Physical abuse significantly increased the risk of alcohol problem drinking (risky drinking, alcohol abuse/dependence, binge drinking) (OR = 1.26; 95% CI 1.03–1.55) (Figure S16) and non-problem drinking (current or ever alcohol use), but the effect did not persist in prospective studies (Table S5). In a subgroup analysis, physical abuse was also significantly associated with a diagnosis of alcohol abuse/dependence meeting DSM criteria (OR = 1.40; 95% CI 1.21–1.64) (Table S5). Alcohol problem drinking was also associated with emotional abuse (OR = 1.27; 95% CI 1.11–1.46) (Figure S17) but not with neglect in childhood (OR = 1.09; 95% CI 0.87–1.35) (Figure S18). For alcohol problems, there was no evidence of a dose–response relationship with respect to frequency of abuse and neglect (Table S5) . Gender differences were observed, with the effect of physical abuse on alcohol problems stronger among males, and with females at an increased risk of alcohol problem drinking with exposure to neglect in childhood, but with overlapping confidence intervals (Table S5). Publication bias did not appear to play a role in the association between physical abuse and alcohol problem drinking (Figure S19).
Although primary analyses suggest an increased risk of drug use associated with physical abuse (OR = 1.92; 95% CI 1.67–2.20), emotional abuse (OR = 1.41; 95% CI 1.11–1.79), and neglect (OR = 1.36; 95% CI 1.21–1.54) (Figures S20, S21, S22, S23), there was only borderline significance in prospective studies, with a stronger consistent association observed in retrospective studies, albeit with overlapping confidence intervals (Table S6). A dose–response relationship between emotional abuse and neglect and drug use was not consistently seen.
Physically abused (OR = 3.00; 95% CI 2.07–4.33), emotionally abused (OR = 3.08; 95% CI 2.42–3.93), and neglected (OR = 1.85; 95% CI 1.25–2.73) individuals had a significantly increased risk of suicidal behaviour compared with non-abused individuals (Table 4). These significant associations continued in subgroup analyses by type of suicidal behaviour, with physically abused (OR = 3.40; 95% CI 2.17–5.32), emotionally abused (OR = 3.37; 95% CI 2.44–4.67), and neglected (OR = 1.95; 95% CI 1.13–3.37) individuals at a significantly increased risk of suicide attempt (Figures S24, S25, S26, S27) and suicide ideation (Table S7). There were no prospective studies investigating non-sexual child maltreatment and suicide attempt or ideation. Only one prospective study  was found investigating the association between self-inflicted injuries and exposure to physical abuse and neglect. Six studies ,– presented the results by gender for physical abuse and suicide attempt and ideation, but no statistically significant differences were observed. One study showed that exposure to frequent childhood neglect was more strongly associated with suicidal behaviour than exposure to neglect that occurred sometimes  (Table S7).
Sexually Transmitted Infections and Risky Sexual Behaviour
Physically abused (OR = 1.78; 95% CI 1.50–2.10), emotionally abused (OR = 1.75; 95% CI 1.49–2.04), and neglected (OR = 1.57; 95% CI 1.39–1.78) individuals were found to have a significantly higher risk of sexually transmitted infections (STIs) and/or risky sexual behaviour than non-abused individuals (Table 5; Figures S28, S29, S30, S31). For physical abuse and neglect, the association with STIs and risky sexual behaviour was significant in prospective and retrospective studies (Table S8). HIV infection was about twice as common in physically abused (OR = 2.51; 95% CI 1.16–5.42), emotionally abused (OR = 1.82; 95% CI 1.34–2.47), and neglected (OR = 2.50; 95% CI 0.77–8.15) individuals as in controls, although for neglect the difference did not reach conventional levels of significance, probably because of weak statistical power. Physical abuse was also associated with an increased risk of other STIs (OR = 1.53; 95% CI 1.13–2.07) and risky sexual behaviour (OR = 1.95; 95% CI 1.58–2.40) (Table 5). A dose–response relationship was observed for HIV infection, with a larger effect size reported with more frequent physical and emotional abuse in childhood  (Table S8).
Chronic Diseases, Lifestyle Risk Factors, and Other Physical Health Outcomes
With regard to obesity, a significantly increased risk was observed for physical (OR = 1.32; 95% CI 1.06–1.64) and emotional abuse (OR = 1.24; 95% CI 1.13–1.36) but not for neglect (OR = 1.07; 95% CI 0.97–1.19) in the primary analysis (Figures S32, S33, S34, S35). Subgroup analysis by assessment of outcome indicated that neglect was associated with a higher risk of developing self-reported obesity, but there was no association with obesity defined by waist circumference or body mass index (BMI) measurements (Table S9). In the subgroup analysis by ascertainment of exposure to physical abuse, there was a strong association with obesity in one prospective study, but the magnitude of the effect was reduced in retrospective studies (Table S9). A dose–response relationship between physical and emotional abuse and obesity has been observed  (Table S9).
Physical (OR = 1.78; 95% CI 1.26–2.52) (Figure S36) and emotional abuse (OR = 1.65; 95% CI 1.46–1.87) (Figure S37) were associated with a significantly increased risk of current smoking, but the association was not significant for neglect in childhood (OR = 1.20; 95% CI 0.98–1.48). One study showed a dose response, with smoking more likely with physical abuse that occurred 3–5 times than with abuse that occurred 1–2 times, but this relationship did not continue into those who had been abused more than six times compared with those who had been abused 3–5 times  (Table S10).
Forty-two studies investigated the relationship between non-sexual child maltreatment and lifestyle risk factors, chronic diseases, and other physical health outcomes in adulthood. There is suggestive evidence of a significant association between child physical abuse and arthritis, ulcers, and headache/migraine in adulthood. However, for most other outcomes, including type 2 diabetes (Table S11; Figures S39, S40, S41, S42), hypertension, low exercise, cardiovascular diseases, respiratory diseases, neurological disorders, and cancer, these associations were mostly weak and inconsistent, with little adjustment for lifetime confounders. Pooled estimates were statistically significant in only a limited number of cases (Table 6). A recent prospective investigation of a group of individuals with documented histories of child abuse and neglect followed into middle adulthood provides some evidence that child abuse and neglect may increase the risk of a range of directly measured physical health outcomes after controlling for mental health problems, substance use, smoking, and BMI  (Table 7). However, there were insufficient studies examining the association between non-sexual child maltreatment and some of these health outcomes, including anaemia, underweight/malnutrition, hepatitis C, tuberculosis, hearing loss, vision loss, oral health, diarrhoea, allergies, uterine leiomyoma, back pain, breast cancer, and schizophrenia, to undergo meta-analysis (Table 7).
To the best of our knowledge, this article presents the first systematic review and meta-analysis of published studies assessing the association between non-sexual child maltreatment and mental and physical health outcomes. We identified 124 studies that examined the association between physical abuse, emotional abuse, and neglect in childhood and various health outcomes.
Does Non-Sexual Child Maltreatment Cause Adverse Health Outcomes?
Evidence for a causal relationship between non-sexual child maltreatment and health outcomes was evaluated within the Bradford Hill framework on the grounds of the following important criteria: strength and consistency of the association, the temporal relationship of the association, evidence of a biological gradient or dose–response relationship, biological plausibility, and consideration of alternate explanations  (Table S12).
Both prospective and retrospective studies consistently showed an association between exposure to child physical abuse, emotional abuse, and neglect and adverse health outcomes. The availability of prospective studies provides conclusive evidence of a temporal relationship between exposure to non-sexual child maltreatment and the later development of mental health outcomes, drug use, and STIs and risky sexual behaviour, as in these studies abuse and neglect preceded the onset of health problems in adulthood.
However, only 16 studies were prospective, while the majority of the studies were cross-sectional and relied on adult retrospective report of abuse and neglect in childhood. By definition, these studies cannot prove a temporal relationship between exposure to child maltreatment and the onset of health outcomes. Furthermore, retrospective, self-reported information regarding abuse in childhood may be subject to recall bias, where those with adjustment problems may be more prone to recall or disclose exposure to abuse and neglect. In many cases participants were asked to report on events that would have occurred many years before, and the issue of potentially unreliable recall threatens the validity of the published literature on child maltreatment. At least with respect to child sexual abuse, evidence suggests moderate to good consistency of reports over time . It has also been suggested that biases are probably towards under-reporting rather than over-reporting of abuse . Nevertheless, given that retrospective reports were often the only measure of abuse available, particularly with regard to emotional abuse, we accepted these within the context of the limitations stated.
Although the strength of prospective studies includes the temporal ordering of maltreatment and subsequent health outcomes, with an objective measurement of exposure to abuse, these studies are usually conducted in non-representative samples. Official cases of abuse may only detect those who come to professional attention, and this may alter the strength of the association between non-sexual child maltreatment and adult morbidity. These official cases are also generally skewed towards the lower end of the socioeconomic spectrum and may not be generalisable to child abuse and neglect cases that occur in middle- or upper-class children . Those participants who have been identified by child protection agencies as having been exposed to physical abuse or neglect may have received interventions to prevent later pathology. Furthermore, some individuals in the “never maltreated” category may actually have experienced maltreatment, given that child maltreatment tends to be under-reported. The validity of the various study designs to investigate the long-term health consequences of child maltreatment has been a source of ongoing debate ,. In this meta-analysis we have included prospective and retrospective studies. The subgroup analyses show that with both methodologies there is robust evidence of a significant association between child non-sexual maltreatment and various health outcomes.
Strength of the Association
Associations between child physical abuse, emotional abuse, and neglect and mental disorders, drug use, and suicidal behaviour have been reported in prospective studies and/or large population-based studies. The strength of the relationship between abuse and mental disorders was generally reduced when the effects of important mediating variables were taken into account. Despite some variability, overall, child physical abuse, emotional abuse, and neglect were found to approximately double the likelihood of adverse mental health outcomes when combined in a meta-analysis.
Consistency of the Association
As shown in the forest plots of the effects by study, there was strong consistency and agreement in the estimated effect measures across studies, particularly for neglect and physical abuse, although we suspect publication bias for some of the outcomes. Risk estimates were comparable across different types of samples, for both non-representative and representative populations (Tables S1, S2, S3, S4 and S6, S7, S8). The findings persisted across different study designs, samples, and geographic regions investigated. It can be concluded that there is a highly consistent association between child physical abuse, emotional abuse, and neglect and adverse mental health outcomes, drug use, and STIs and risky sexual behaviour. We did not observe evidence of strong consistent associations for alcohol problems, chronic diseases, or lifestyle risk factors.
We found evidence of a dose–response relationship between adverse health outcomes and non-sexual child maltreatment, such that those experiencing more severe abuse or neglect were at greater risk of developing mental disorders than those experiencing less severe maltreatment . In the Chapman et al.  study, increasing severity of childhood adversity corresponded with poorer mental health outcomes. Consistent dose–response relationships with repeated, frequent, or severe abuse have been reported for mental disorders and physical abuse ,, and emotional abuse and neglect ,. Furthermore, there is evidence to suggest that experiencing multiple types of maltreatment may carry more severe consequences, with those exposed to multiple types of abuse at increased odds of developing mental disorders ,, and the risk increases with the magnitude of multiple abuse . Dose–response relationships with repeated frequent or severe abuse have also been reported for STIs and physical and emotional abuse , obesity and emotional and physical abuse , and smoking and physical abuse .
With respect to biological plausibility, animal models of mental disorders do not exist, making it particularly difficult to understand the underlying biological mechanisms. Progress in understanding has to be made by association and inference rather than experimental data . There are nevertheless several potential mechanisms that may explain the observed association between abuse and neglect in childhood and increased risk of mental health problems. Neurobiological development can be physiologically altered by maltreatment during a child's early years, which can in turn negatively affect a child's physical, cognitive, emotional, and social growth, leading to psychological, behavioural, and learning problems that persist throughout the life course ,. Moreover, cumulative trauma may further increase risk , and some victims of abuse may try to manage the subsequent distress through the use of alcohol, prescription medication, tobacco, or other drugs.
There is emerging evidence that the origins of most adult disease are found among developmental and biological disruptions in childhood. These early life experiences can affect adult mental and physical health either by cumulative damage over time or by the biological embedding of adversities during sensitive developmental periods . There is generally a lag of many years before early adverse experiences are expressed in the form of disease . Andrews and colleagues concluded that despite the lack of a biological link between child sexual abuse and mental disorders, a causal relationship was plausible , and that child maltreatment is most likely a contributory cause that acts via other intermediates.
Consideration of Alternate Explanations
It is important to note that the role of genes, environment, and gene–environment interactions in the causation of mental disorders is not well understood. Twin studies provide one of the best ways to examine the interplay between genetic and environmental influences , but to the best of our knowledge, these are only available for child sexual abuse. The relationship between abuse and neglect in childhood and subsequent health effects is complex. Although childhood abuse and neglect does result in adverse health outcomes, these outcomes are not independent of broader socioeconomic contexts. Lifestyle factors, access to health care, and neighbourhood characteristics may act as mediators between child abuse and neglect and long-term health consequences –. Exposure to child maltreatment often co-occurs within the context of other family dysfunction, social deprivation, and other environmental stressors that are also associated with mental disorders. Child maltreatment may be a marker of other family problems that together lead to the development of mental disorders. In addition, findings from many studies do not take into account the likely contribution of hereditary influences on the predisposition to mental disorders. Children of depressed parents may be at greater risk of depression through both exposure to maltreatment by their parents and genetic predisposition . Hence, some of the effect of child abuse and neglect on mental disorders may still be explained by confounding. However, the effect of abuse on mental disorders remained significant in the majority of studies included in these meta-analyses after controlling for these co-occurring factors.
Assessment of Causality
In summary, there was robust evidence of significant associations between exposure to non-sexual child maltreatment and increased likelihood of a range of mental disorders, suicide attempts, drug use, STIs, and risky sexual behaviour. An increase in the likelihood of alcohol problem use was not consistently seen. There is weak to limited evidence suggesting a relationship between non-sexual child maltreatment and certain physical disorders and risk factors (Table 8), but more research is required to confirm these relationships.
Although these findings and conclusions seem to be relatively consistent and robust, they should be interpreted in light of a number of limitations of our analysis.
This meta-analysis may be subject to publication bias because non-significant findings are less likely to be published . This problem is increased when statistical models are employed because often only significant estimates are reported in many studies. This may result in the association between child abuse and neglect and outcomes being overstated, particularly for depressive disorders and anxiety, where publication bias may have played a role. For some of the other conditions there were too few studies to make conclusions with respect to publication bias.
The analysis also suffers from inconsistencies in how child abuse and neglect are defined and measured across the studies, as shown in Table 3. In studies using child protection records, exposure to physical abuse was defined to include injuries such as bruises, welts, burns, abrasions, lacerations, wounds, cuts, and fractures. Some studies used the Barnett-Cicchetti Maltreatment Classification System  which defines physical abuse as a caregiver or responsible adult inflicting physical injury upon a child by other than accidental means. In other studies physical abuse was defined as having been hit, kicked, or punched so hard that the individual had marks or bruising or needed medical attention. Some studies referred to physical punishment ,, and corporal punishment , which may exclude more severe physical abuse, as well as physical assault by caregivers . Emotional abuse definitions also varied considerably and included verbal abuse and being humiliated by a caregiver. Most studies involving neglect referred simply to “neglect”, while others distinguished between physical and emotional neglect. Similarly, definitions of childhood were not consistent across studies. The complexity of defining and measuring child abuse has been noted in several studies –.
Measurement bias with respect to health outcomes and the questionable reliability of self-reported data may also have affected the results. We dealt with this issue in the meta-analysis by adjusting the quality score and performing subgroup analyses. For mental disorders, studies using well-validated and standardised diagnostic instruments were assigned a higher quality score than studies using self-report symptom scales.
Another limitation of meta-analyses of observational studies is that, since individuals cannot be randomly allocated to case groups, the influence of confounding variables cannot be fully evaluated. While most studies presented multivariable adjusted ORs controlling for a range of socio-demographic and study design variables, a few studies presented unadjusted associations between child maltreatment and health outcomes, or adjusted for age and sex only. We again dealt with this issue in our meta-analysis by adjusting the quality score of studies with inadequate control for confounding and by carrying out separate analyses depending on data availability. Some studies also statistically controlled for exposure to other forms of maltreatment by including the different types of abuse in the same model in order to determine the independent contribution of each abuse type. Generally, in studies presenting results from various unadjusted and adjusted models, the association between abuse and physical and mental health outcomes was attenuated when controlling for the effects of mediating variables – and other forms of abuse –. However, findings from a recent prospective cohort study indicate that for some physical health outcomes additional control for socioeconomic status, unhealthy behaviour, smoking, and mental health problems seems to play varying roles in attenuating or intensifying these complex relationships . Furthermore, we cannot exclude that residual confounding or unmeasured potential confounders may still remain. Despite evidence of weak associations between non-sexual child maltreatment and chronic diseases, further studies are needed that ensure adequate adjustment for lifetime confounders, because the attributable burden would be appreciable.
Significant heterogeneity exists in the primary analysis of physical and emotional abuse, even after our attempts to control for study quality in quality effects models, and the heterogeneity remained significant in most of the subgroup analyses. Given this situation, combining the effects may not be justified. With respect to neglect, pooled estimates in primary and subgroup analyses did not show significant heterogeneity for many outcomes.
Inconsistencies in the measurement and definition of child maltreatment highlight the importance of international efforts to standardise studies to enhance the comparability of findings. These include defining the cutoff age for childhood (0–18 y, as specified by the United Nations), and breaking this period into smaller age bands that can reflect age-specific patterns . Researchers should select methodologies and instruments with international comparisons in mind. Identical questionnaires, research designs, and interviewing techniques should ideally be used for surveys in different countries . In reality, however, all survey methods will require at least some adaptation to local conditions, and efforts to ensure comparability should involve choosing definitions of abuse and neglect, and questionnaire items, that represent an advanced level of knowledge . To minimise how participants' subjective perceptions and definitions shape the answers, it is recommended that self-report studies clearly specify the behaviours and experiences being investigated, and that each sub-type of abuse and neglect is explored using multiple behaviourally specific questions, instead of a single-item “label question” .
Examples of international efforts to increase comparability across studies include the WHO's establishment of a global adverse childhood experiences research network, and the International Society for Prevention of Child Abuse and Neglect's Child Abuse Screening Tools (ICAST). The WHO network has developed an international version of the Adverse Childhood Experiences (ACE) questionnaire (the ACE International Questionnaire), for administration to people aged 18 y and older, which is currently being validated through trial implementation as part of broader health surveys in several countries . The ICAST initiative has involved the development of three instruments that ask parents about their use of different behaviours for discipline, young adults (18–24 y) about their exposure to child abuse and neglect in childhood, and older children about their own recent experiences of violence .
Child maltreatment deserves increased investment in preventive and treatment strategies. Currently, there is a paucity of evidence-based interventions to reduce child maltreatment. Further research is urgently needed to identify programs that reduce the prevalence of child maltreatment, thereby alleviating an important risk factor for later health problems. Evidence-based systemic interventions that improve parenting strategies and family functioning may be more effective and economical than attempting to treat the wide-ranging deleterious health outcomes in adulthood that arise from maltreatment in the early years of life ,.
A broad range of protective factors have been identified that assist in promoting resilience in children exposed to adversity. Self control, problem-solving skills, secure relationships with caregivers, and safe schools and neighbourhoods are known to reduce the risk of adverse consequences in children exposed to trauma ,. There is mounting evidence that exposure to childhood adversity interacting with particular genetic dispositions such as the short allele of the serotonin transporter gene  and genes involved in the regulation of the hypothalamic–pituitary axis , can result in problems with stress regulation and increased risk of anxiety and depression. Epigenetic changes have also been postulated as a mechanism by which transgenerational resilience or vulnerability may occur . In spite of the increased knowledge in this field, it remains a challenge to translate this research into interventions at a population level that can reduce the vulnerability of children exposed to maltreatment .
This overview of the evidence suggests a causal relationship between non-sexual child maltreatment and a range of mental disorders, drug use, suicide attempts, sexually transmitted infections, and risky sexual behaviour. There is also emerging evidence that neglect in childhood may be as harmful as physical and emotional abuse. Although these conclusions have been drawn before from single empirical studies, in this article they are demonstrated in aggregate quantitative effects, to our knowledge for the first time.
This review contributes to a better understanding and measurement of the non-injury health impacts of child maltreatment globally and enables quantification of the burden attributable to physical and emotional abuse and neglect at the population level using comparative risk assessment methodology . All forms of child maltreatment should be considered as part of the cluster of interpersonal violence risk factors in future global comparative risk assessments. Attributable burden is likely to be substantial, given the high prevalence of these forms of child maltreatment, the strong associations reported in our analysis, and the fact that related health outcomes are among the leading causes of disease burden globally. Despite the magnitude of the problem and increasing awareness of its high social costs, preventing child maltreatment is not a political priority in most countries. It is imperative that epidemiology and public health approaches find their proper place at the forefront of national and international efforts to understand and prevent child maltreatment .
Forest plot for quality-effect meta-analysis of the association between physical abuse and depressive disorders. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Forest plot for quality-effect meta-analysis of the association between emotional abuse and depressive disorders. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Forest plot for quality-effect meta-analysis of the association between neglect and depressive disorders. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Funnel plots to aid assessment of publication bias for depressive disorders and physical abuse.
Forest plot for quality-effect meta-analysis of the association between physical abuse and anxiety. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Forest plot for quality-effect meta-analysis of the association between emotional abuse and anxiety. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Forest plot for quality-effect meta-analysis of the association between neglect and anxiety. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Funnel plot to aid assessment of publication bias for anxiety and physical abuse.
Forest plot for quality-effect meta-analysis of the association between physical abuse and eating disorders. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Forest plot for quality-effect meta-analysis of the association between emotional abuse and eating disorders. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Forest plot for quality-effect meta-analysis of the association between neglect and eating disorders. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Funnel plot to aid assessment of publication bias for eating disorders and physical abuse.
Forest plot for quality-effect meta-analysis of the association between physical abuse and conduct/childhood behavioural disorders. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Forest plot for quality-effect meta-analysis of the association between neglect and conduct/childhood behavioural disorders. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Funnel plot to aid assessment of publication bias for childhood behavioural/conduct disorders and physical abuse.
Forest plot for quality-effect meta-analysis of the association between physical abuse and alcohol problem drinking. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Forest plot for quality-effect meta-analysis of the association between emotional abuse and alcohol problem drinking. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Forest plot for quality-effect meta-analysis of the association between neglect and alcohol problem drinking. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Funnel plot to aid assessment of publication bias for alcohol problem drinking and physical abuse.
Forest plot for quality-effect meta-analysis of the association between physical abuse and drug use. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Forest plot for quality-effect meta-analysis of the association between emotional abuse and drug use. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Forest plot for quality-effect meta-analysis of the association between neglect and drug use. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Funnel plot to aid assessment of publication bias for drug use and physical abuse.
Forest plot for quality-effect meta-analysis of the association between physical abuse and suicide attempt. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Forest plot for quality-effect meta-analysis of the association between emotional abuse and suicide attempt. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Forest plot for quality-effect meta-analysis of the association between neglect and suicide attempt. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Funnel plot to aid assessment of publication bias for suicide attempt and physical abuse.
Forest plot for quality-effect meta-analysis of the association between physical abuse and sexually transmitted infections/risky sexual behaviour. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Forest plot for quality-effect meta-analysis of the association between emotional abuse and sexually transmitted infections/risky sexual behaviour. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Forest plot for quality-effect meta-analysis of the association between neglect and sexually transmitted infections/risky sexual behaviour. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Funnel plot to aid assessment of publication bias for sexually transmitted infections/risky sexual behaviour and physical abuse.
Forest plot for quality-effect meta-analysis of the association between physical abuse and obesity. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Forest plot for quality-effect meta-analysis of the association between emotional abuse and obesity. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Forest plot for quality-effect meta-analysis of the association between neglect and obesity. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Funnel plot to aid assessment of publication bias for obesity and neglect.
Forest plot for quality-effect meta-analysis of the association between physical abuse and current smoking. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Forest plot for quality-effect meta-analysis of the association between emotional abuse and current smoking. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Funnel plot to aid assessment of publication bias for current smoking and physical abuse.
Forest plot for quality-effect meta-analysis of the association between physical abuse and type 2 diabetes. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Forest plot for quality-effect meta-analysis of the association between emotional abuse and type 2 diabetes. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Forest plot for quality-effect meta-analysis of the association between neglect and type 2 diabetes. Studies are represented by symbols, the area of which is proportional to the study's weight in the analysis. Output for ORs is set to the (natural) log scale.
Funnel plot to aid assessment of publication bias for type 2 diabetes and neglect.
Depressive disorders subgroup analyses.
Anxiety disorders subgroup analyses.
Eating disorders subgroup analyses.
Childhood behavioural/conduct disorders subgroup analyses.
Alcohol use subgroup analyses.
Drug use subgroup analyses.
Suicidal behaviour subgroup analyses.
Sexually transmitted infections and risky sexual behaviour subgroup analyses.
Obesity subgroup analyses.
Tobacco smoking subgroup analyses.
Type 2 diabetes subgroup analyses.
Evaluation of the evidence for a causal relationship within the Bradford Hill framework for prospective and retrospective studies.
Sophie Moore is gratefully acknowledged for her contribution to the systematic review. Lars Eriksson and Keryl Michener, University of Queensland Health Sciences Library, are thanked for their assistance in designing the search strategy.
Conceived and designed the experiments: REN TV. Performed the experiments: REN MB RD. Analyzed the data: REN MB. Wrote the first draft of the manuscript: REN. Contributed to the writing of the manuscript: REN MB RD AB JS TV. ICMJE criteria for authorship read and met: REN MB RD AB JS TV. Agree with manuscript results and conclusions: REN MB RD AB JS TV.
- 1. Krug EG, Dahlberg LL, Mercy JA, Zwi A, Lozano R (2002) World report on violence and health. Geneva: World Health Organization.
- 2. Pinheiro PS (2006) World report on violence against children. New York: United Nations.
- 3. Andrews G, Corry J, Slade T, Issakidis C, Swanston H (2004) Child sexual abuse. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, editors. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: World Health Organization. pp. 1851–1940.
- 4. Gilbert R, Widom CS, Browne K, Fergusson D, Webb E, et al. (2009) Burden and consequences of child maltreatment in high-income countries. Lancet 373: 68–81. doi: 10.1016/s0140-6736(08)61706-7
- 5. Butchart A, Phinney Harvey A, Kahane T, Mian M, Furniss T (2006) Preventing child maltreatment: a guide to action and generating evidence. Geneva: World Health Organization and International Society for Prevention of Child Abuse and Neglect.
- 6. Norman R, Schneider M, Bradshaw D, Jewkes R, Abrahams N, et al. (2010) Interpersonal violence: an important risk factor for disease and injury in South Africa. Popul Health Metr 8: 32. doi: 10.1186/1478-7954-8-32
- 7. Browne A, Finkelhor DA (1986) Impact of child sexual abuse: a review of the research. Psychol Bull 99: 66–77. doi: 10.1037//0033-2909.99.1.66
- 8. Kendall-Tackett K, Williams L, Finkelhor D (1993) Impact of sexual abuse on children: a review and synthesis of recent empirical studies. Psychol Bull 113: 164–180. doi: 10.1037//0033-2909.113.1.164
- 9. Polusny M, Follette V (1995) Long-term correlates of child sexual abuse: theory and review of the empirical literature. Appl Prev Psychol 4: 143–166. doi: 10.1016/s0962-1849(05)80055-1
- 10. Murray CJ, Lopez AD, Black R, Mathers CD, Shibuya K, et al. (2007) Global burden of disease 2005: call for collaborators. Lancet 370: 109–110. doi: 10.1016/s0140-6736(07)61064-2
- 11. Desai S, Arias I, Thompson MP, Basile KC (2002) Childhood victimization and subsequent adult revictimization assessed in a nationally representative sample of women and men. Violence Vict 17: 639–653. doi: 10.1891/vivi.17.6.639.33725
- 12. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, et al. (1998) Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) study. Am J Prev Med 14: 245–258. doi: 10.1016/s0749-3797(98)00017-8
- 13. Jewkes RK, Dunkle K, Nduna M, Jama PN, Puren A (2010) Associations between childhood adversity and depression, substance abuse and HIV and HSV2 incident infections in rural South African youth. Child Abuse Negl 34: 833–841. doi: 10.1016/j.chiabu.2010.05.002
- 14. Runyan D, Wattam C, Ikeda R, Hassan F, Ramiro L (2002) Child abuse and neglect by parents and other caregivers. In: Krug EG Dahlberg LL, Mercy JA, Zwi AB, Lozano R, editors. World report on violence and health. Geneva: World Health Organization.
- 15. Moher D, Liberati A, Tetzlaff J, Altman D (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6: e1000097 doi:10.1371/journal.pmed.1000097.
- 16. Stroup D, Berlin J, Morton S, Ingram O, Williamson G, et al. (2000) Meta-analysis of observational studies in epidemiology. A proposal for reporting. JAMA 283: 2008–2012. doi: 10.1001/jama.283.15.2008
- 17. Wells G, Shea B, O'Connell D, Petersen J, Welch V, et al.. (2012) The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. Ottawa: Ottawa Hospital Research Institute. Available: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed 1 November 2012.
- 18. Barendregt J, Doi SA (2012) MetaXL version 1.2 [computer program]. Brisbane: EpiGear International.
- 19. Sterne JAC, Egger M (2001) Funnel plots for detecting bias in meta-analysis: guidelines on choice of axis. J Clin Epidemiol 54: 1046–1055. doi: 10.1016/s0895-4356(01)00377-8
- 20. Doi SAR, Thalib L (2008) A quality-effects model for meta-analysis. Epidemiology 19: 94–100 doi:110.1097/EDE.1090b1013e31815c31824e31817.
- 21. Doi SAR, Barendregt JJ, Mozurkewich EL (2011) Meta-analysis of heterogeneous clinical trials: an empirical example. Contemp Clin Trials 32: 288–298. doi: 10.1016/j.cct.2012.09.001
- 22. Hovens JGFM, Wiersma JE, Giltay EJ, van Oppen P, Spinhoven P, et al. (2010) Childhood life events and childhood trauma in adult patients with depressive, anxiety and comorbid disorders vs. controls. Acta Psychiatr Scand 122: 66–74. doi: 10.1111/j.1600-0447.2009.01491.x
- 23. Johnson JG, Cohen P, Kasen S, Brook JS (2002) Childhood adversities associated with risk for eating disorders or weight problems during adolescence or early adulthood. Am J Psychiatry 159: 394–400. doi: 10.1176/appi.ajp.159.3.394
- 24. Welch SL, Fairburn CG (1996) Childhood sexual and physical abuse as risk factors for the development of bulimia nervosa: a community-based case control study. Child Abuse Negl 20: 633–642. doi: 10.1016/0145-2134(96)00051-8
- 25. Yates TM, Carlson EA, Egeland B (2008) A prospective study of child maltreatment and self-injurious behavior in a community sample. Dev Psychopathol 20: 651–671. doi: 10.1017/s0954579408000321
- 26. Afifi TO, Enns MW, Cox BJ, Asmundson GJG, Stein MB, et al. (2008) Population attributable fractions of psychiatric disorders and suicide ideation and attempts associated with adverse childhood experiences. Am J Public Health 98: 946–952. doi: 10.2105/ajph.2007.120253
- 27. Brezo J, Paris J, Vitaro F, Hébert M, Tremblay RE, et al. (2008) Predicting suicide attempts in young adults with histories of childhood abuse. Br J Psychiatry 193: 134–139. doi: 10.1192/bjp.bp.107.037994
- 28. Duke NN, Pettingell SL, McMorris BJ, Borowsky IW (2010) Adolescent violence perpetration: associations with multiple types of adverse childhood experiences. Pediatrics 125: e778–e786. doi: 10.1542/peds.2009-0597
- 29. Mullen PE, Martin JL, Anderson JC, Romans SE, Herbison GP (1996) The long-term impact of the physical, emotional, and sexual abuse of children: a community study. Child Abuse Negl 20: 7–21. doi: 10.1016/0145-2134(95)00112-3
- 30. Silverman AB, Reinherz HZ, Giaconia RM (1996) The long-term sequelae of child and adolescent abuse: a longitudinal community study. Child Abuse Negl 20: 709–723. doi: 10.1016/0145-2134(96)00059-2
- 31. Williamson DF, Thompson TJ, Anda RF, Dietz WH, Felitti V (2002) Body weight and obesity in adults and self-reported abuse in childhood. Int J Obes 26: 1075–1082. doi: 10.1038/sj.ijo.0802038
- 32. Roberts ME, Fuemmeler BF, McClernon FJ, Beckham JC (2008) Association between trauma exposure and smoking in a population-based sample of young adults. J Adolesc Health 42: 266–274. doi: 10.1016/j.jadohealth.2007.08.029
- 33. Widom CS, Czaja SJ, Bentley T, Johnson MS (2012) A prospective investigation of physical health outcomes in abused and neglected children: new findings from a 30-year follow-up. Am J Public Health 102: 1135–1144. doi: 10.2105/ajph.2011.300636
- 34. Hill AB (1965) The environment and disease: association or causation? Proc R Soc Med 58: 295–300.
- 35. Fergusson DM, Mullen PE (1999) Childhood sexual abuse: an evidence based perspective. Thousand Oaks (California): SAGE.
- 36. Maughan B, Rutter M (1997) Retrospective reporting of childhood adversity: issues in assessing long-term recall. J Personal Disord 11: 19–33. doi: 10.1521/pedi.19184.108.40.206
- 37. Widom CS, Raphael KG, DuMont KA (2004) The case for prospective longitudinal studies in child maltreatment research: commentary on Dube, Williamson, Thompson, Felitti, and Anda (2004). Child Abuse Negl 28: 715–722. doi: 10.1016/j.chiabu.2004.03.009
- 38. Kendall-Tackett K, Becker-Blease K (2004) The importance of retrospective findings in child maltreatment research. Child Abuse Negl 28: 723–727. doi: 10.1016/j.chiabu.2004.02.002
- 39. Wise LA, Zierler S, Krieger N, Harlow BL (2001) Adult onset of major depressive disorder in relation to early life violent victimisation: a case-control study. Lancet 358: 881–887. doi: 10.1016/s0140-6736(01)06072-x
- 40. Chapman DP, Whitfield CL, Felitti VJ, Dube SR, Edwards VJ, et al. (2004) Adverse childhood experiences and the risk of depressive disorders in adulthood. J Affect Disord 82: 217–225. doi: 10.1016/j.jad.2003.12.013
- 41. Fergusson D, Boden J, Horwood L (2008) Exposure to childhood sexual and physical abuse and adjustment in early adulthood. Child Abuse Negl 32: 607–619. doi: 10.1016/j.chiabu.2006.12.018
- 42. Schoemaker C, Smit F, Bijl RV, Vollebergh WAM (2002) Bulimia nervosa following psychological and multiple child abuse: support for the self-medication hypothesis in a population-based cohort study. Int J Eat Disord 32: 381–388. doi: 10.1002/eat.10102
- 43. Widom CS, DuMont K, Czaja SJ (2007) A prospective investigation of major depressive disorder and comorbidity in abused and neglected children grown up. Arch Gen Psychiatry 64: 49–56. doi: 10.1001/archpsyc.64.1.49
- 44. Wijma K, Samelius L, Wingren G, Wijma B (2007) The association between ill-health and abuse: a cross-sectional population based study. Scand J Psychol 48: 567–575. doi: 10.1111/j.1467-9450.2007.00553.x
- 45. Glaser D (2000) Child abuse and neglect and the brain—a review. J Child Psychol Psychiatry 41: 97–116. doi: 10.1017/s0021963099004990
- 46. Lee V, Hoaken P (2007) Cognition, emotion, and neurobiological development: mediating the relation between maltreatment and aggression. Child Maltreat 12: 281–298. doi: 10.1177/1077559507303778
- 47. Shevlin M, Dorahy MJ, Adamson G (2007) Trauma and psychosis: an analysis of the National Comorbidity Survey. Am J Psychiatry 164: 166–169. doi: 10.1176/appi.ajp.164.1.166
- 48. Shonkoff JP, Boyce WT, McEwen BS (2009) Neuroscience, molecular biology, and the childhood roots of health disparities. Building a new framework for health promotion and disease prevention. JAMA 301: 2252–2259. doi: 10.1001/jama.2009.754
- 49. Horwitz AV, Widom CS, McLaughlin J, White HR (2001) The impact of childhood abuse and neglect on adult mental health: a prospective study. J Health Soc Behav 42: 184–201. doi: 10.2307/3090177
- 50. Mullen P, Martin J, Anderson J, Romans S, Herbison GP (1993) Childhood sexual abuse and mental health in adult life. Br J Psychiatry 163: 721–732. doi: 10.1192/bjp.163.6.721
- 51. Turner R, Wheaton B, Lloyd D (1995) The epidemiology of stress. Am Sociol Rev 60: 104–125. doi: 10.2307/2096348
- 52. Young S, Bang H (2004) The file-drawer problem, revisited. Science 306: 1133–1134. doi: 10.1126/science.306.5699.1133d
- 53. Barnett D, Manly JT, Cicchetti D (1993) Defining child maltreatment: the interface between policy and research. In: Cicchetti D, Toth SL, editors. Advances in applied developmental psychology: child abuse, child development and social policy. Norwood (New Jersey): Ablex Publishing.
- 54. Afifi TO, Brownridge DA, Cox BJ, Sareen J (2006) Physical punishment, childhood abuse and psychiatric disorders. Child Abuse Negl 30: 1093–1103. doi: 10.1016/j.chiabu.2006.04.006
- 55. Afifi TO, Mota NP, Dasiewicz P, MacMillan HL, Sareen J (2012) Physical punishment and mental disorders: results from a nationally representative US sample. Pediatrics 130: 1–9. doi: 10.1542/peds.2011-2947
- 56. Straus MA, Kantor GK (1994) Corporal punishment of adolescents by parents: a risk factor in the epidemiology of depression, suicide, alcohol abuse, child abuse, and wife beating. Adolescence 29: 543–561.
- 57. Duncan RD, Saunders BE, Kilpatrick DG, Hanson RF, Resnick HS (1996) Childhood physical assault as a risk factor for PTSD, depression, and substance abuse: findings from a national survey. Am J Orthopsychiatry 66: 437–448. doi: 10.1037/h0080194
- 58. Finkelhor D (1994) Current information on the scope and nature of child sexual abuse. Future Child 4: 31–53. doi: 10.2307/1602522
- 59. Giavonnoni JM (1989) Definitional issues in child maltreatment. In: Cicchetti D, Carlson V, editors. Child maltreatment: theory and research on the causes and consequences of child abuse and neglect. New York: Cambridge University Press. pp. 3–37.
- 60. Mash EJ, Wolfe DA (1991) Methodological issues in research on physical child abuse. Crim Justice Behav 18: 8–29. doi: 10.1177/0093854891018001003
- 61. Fuller-Thomson E, Baker TM, Brennenstuhl S (2010) Investigating the association between childhood physical abuse and migraine. Headache 50: 749–760. doi: 10.1111/j.1526-4610.2010.01626.x
- 62. Fuller-Thomson E, Brennenstuhl S (2009) Making a link between childhood physical abuse and cancer: results from a regional representative survey. Cancer 115: 3341–3350. doi: 10.1002/cncr.24372
- 63. Fuller-Thomson E, Brennenstuhl S, Frank J (2010) The association between childhood physical abuse and heart disease in adulthood: findings from a representative community sample. Child Abuse Negl 34: 689–698. doi: 10.1016/j.chiabu.2010.02.005
- 64. Goodwin RD, Fergusson DM, Horwood LJ (2005) Childhood abuse and familial violence and the risk of panic attacks and panic disorder in young adulthood. Psychol Med 35: 881–890. doi: 10.1017/s0033291704003265
- 65. Goodwin RD, Hoven CW, Murison R, Hotopf M (2003) Association between childhood physical abuse and gastrointestinal disorders and migraine in adulthood. Am J Public Health 93: 1065–1067. doi: 10.2105/ajph.93.7.1065
- 66. Goodwin RD, Stein MB (2004) Association between childhood trauma and physical disorders among adults in the United States. Psychol Med 34: 509–520. doi: 10.1017/s003329170300134x
- 67. Goodwin RD, Wamboldt FS (2012) Childhood physical abuse and respiratory disease in the community: the role of mental health and cigarette smoking. Nicotine Tob Res 14: 91–97. doi: 10.1093/ntr/ntr126
- 68. Goodwin RD, Wamboldt MZ, Pine DS (2003) Lung disease and internalizing disorders: is childhood abuse a shared etiologic factor? J Psychosom Res 55: 215–219. doi: 10.1016/s0022-3999(02)00497-x
- 69. Libby AM, Orton HD, Novins DK, Spicer P, Buchwald D, et al. (2004) Childhood physical and sexual abuse and subsequent alcohol and drug use disorders in two American-Indian tribes. J Stud Alcohol 65: 74–83. doi: 10.1017/s0033291704003599
- 70. Macmillan HL, Fleming JE, Streiner DL, Lin E, Boyle MH, et al. (2001) Childhood abuse and lifetime psychopathology in a community sample. Am J Psychiatry 158: 1878–1883. doi: 10.1176/appi.ajp.158.11.1878
- 71. Nichols HB, Harlow BL (2004) Childhood abuse and risk of smoking onset. J Epidemiol Community Health 58: 402–406. doi: 10.1136/jech.2003.008870
- 72. Strine TW, Dube SR, Edwards VJ, Prehn AW, Rasmussen S, et al. (2012) Associations between adverse childhood experiences, psychological distress, and adult alcohol problems. Am J Health Behav 36: 408–423. doi: 10.5993/ajhb.36.3.11
- 73. Cougle JR, Timpano KR, Sachs-Ericsson N, Keough ME, Riccardi CJ (2010) Examining the unique relationships between anxiety disorders and childhood physical and sexual abuse in the National Comorbidity Survey-Replication. Psychiatry Res 177: 150–155. doi: 10.1016/j.psychres.2009.03.008
- 74. Fuemmeler BF, Dedert E, McClernon FJ, Beckham JC (2009) Adverse childhood events are associated with obesity and disordered eating: results from a U.S. population-based survey of young adults. J Trauma Stress 22: 329–333. doi: 10.1002/jts.20421
- 75. Griffin ML, Amodeo M (2010) Predicting long-term outcomes for women physically abused in childhood: contribution of abuse severity versus family environment. Child Abuse Negl 34: 724–733. doi: 10.1016/j.chiabu.2010.03.005
- 76. Haydon AA, Hussey JM, Halpern CT (2011) Childhood abuse and neglect and the risk of STDs in early adulthood. Perspect Sex Reprod Health 43: 16–22. doi: 10.1363/4301611
- 77. Jirapramukpitak T, Prince M, Harpham T (2005) The experience of abuse and mental health in the young Thai population. A preliminary survey. Soc Psychiatry Psychiatr Epidemiol 40: 955–963. doi: 10.1007/s00127-005-0983-1
- 78. Rich-Edwards JW, Spiegelman D, Hibert ENL, Jun H-J, Todd TJ, et al. (2010) Abuse in childhood and adolescence as a predictor of type 2 diabetes in adult women. Am J Prev Med 39: 529–536. doi: 10.1016/j.amepre.2010.09.007
- 79. Schneider R, Baumrind N, Kimerling R (2007) Exposure to child abuse and risk for mental health problems in women. Violence Vict 22: 620–631. doi: 10.1891/088667007782312140
- 80. Finkelhor D (1994) The international epidemiology of child sexual abuse. Child Abuse Negl 18: 409–417. doi: 10.1016/0145-2134(94)90026-4
- 81. Stoltenborgh M, van Ljzendoorn MH, Euser EM, Bakermans-Kranenburg MJ (2011) A global perspective on child sexual abuse: meta-analysis of prevalence around the world. Child Maltreat 16: 79–101. doi: 10.1177/1077559511403920
- 82. Anda RF, Butchart A, Felitti VJ, Brown DW (2010) Building a framework for global surveillance of the public health implications of adverse childhood experiences. Am J Prev Med 39: 93–98. doi: 10.1016/j.amepre.2010.03.015
- 83. Runyan DK, Dunne MP, Zolotor AJ (2009) Introduction to the development of the ISPCAN child abuse screening tools. Child Abuse Negl 33: 842–845. doi: 10.1016/j.chiabu.2009.08.003
- 84. Scott J, Varghese D, McGrath J (2010) As the twig is bent, the tree inclines: adult mental health consequences of childhood adversity. Arch Gen Psychiatry 67: 111–112. doi: 10.1001/archgenpsychiatry.2009.188
- 85. Masten AS (2001) Ordinary magic. Resilience processes in development. Am Psychol 56: 227–238. doi: 10.1037//0003-066x.56.3.227
- 86. Masten AS (2007) Resilience in developing systems: progress and promise as the fourth wave rises. Dev Psychopathol 19: 921–930. doi: 10.1017/s0954579407000442
- 87. Caspi A, Sugden K, Moffitt TE, Taylor A, Craig IW, et al. (2003) Influence of life stress on depression: moderation by a polymorphism in the 5-HTT gene. Science 301: 386–389. doi: 10.1126/science.1083968
- 88. Cicchetti D (2010) Resilience under conditions of extreme stress: a multilevel perspective. World Psychiatry 9: 145–154.
- 89. Yehuda R, Flory JD, Pratchett LC, Buxbaum J, Ising M, et al. (2010) Putative biological mechanisms for the association between early life adversity and the subsequent development of PTSD. Psychopharmacology (Berl) 212: 405–417. doi: 10.1007/s00213-010-1969-6
- 90. Meaney MJ (2010) Epigenetics and the biological definition of gene x environment interactions. Child Dev 81: 41–79. doi: 10.1111/j.1467-8624.2009.01381.x
- 91. Sapienza JK, Masten AS (2011) Understanding and promoting resilience in children and youth. Curr Opin Psychiatry 24: 267–273. doi: 10.1097/yco.0b013e32834776a8
- 92. Ezzati M, Lopez A, Rodgers A, Vander Hoorn S, Murray C (2002) Selected major risk factors and global and regional burden of disease. Lancet 360: 1347–1360. doi: 10.1016/s0140-6736(02)11403-6
- 93. Butchart A (2008) Epidemiology: the major missing element in the global response to child maltreatment? Am J Prev Med 34: S103–S105.
- 94. Anda RF, Croft JB, Felitti VJ, Nordenberg D, Giles WH, et al. (1999) Adverse childhood experiences and smoking during adolescence and adulthood. JAMA 282: 1652–1658. doi: 10.1001/jama.282.17.1652
- 95. Astin MC, Ogland-Hand SM, Coleman EM, Foy DS (1995) Posttraumatic stress disorder and childhood abuse in battered women: comparisons with maritally distressed women. J Consult Clin Psychol 63: 308–312. doi: 10.1037/0022-006x.63.2.308
- 96. Bennett EM, Kemper KJ (1994) Is abuse during childhood a risk factor for developing substance abuse problems as an adult? J Dev Behav Pediatr 15: 426–429. doi: 10.1097/00004703-199412000-00006
- 97. Bensley LS, Van Eenwyk J, Simmons KW (2000) Self-reported childhood sexual and physical abuse and adult HIV-risk behaviors and heavy drinking. Am J Prev Med 18: 151–158. doi: 10.1016/s0749-3797(99)00084-7
- 98. Bentley T, Widom CS (2009) A 30-year follow-up of the effects of child abuse and neglect on obesity in adulthood. Obesity (Silver Spring) 17: 1900–1905. doi: 10.1038/oby.2009.160
- 99. Bonomi AE, Cannon EA, Anderson ML, Rivara FP, Thompson RS (2008) Association between self-reported health and physical and/or sexual abuse experienced before age 18. Child Abuse Negl 32: 693–701. doi: 10.1016/j.chiabu.2007.10.004
- 100. Boynton-Jarrett R, Rich-Edwards JW, Jun H-J, Hibert EN, Wright RJ (2011) Abuse in childhood and risk of uterine leiomyoma: the role of emotional support in biologic resilience. Epidemiology 22: 6–14. doi: 10.1097/ede.0b013e3181ffb172
- 101. Bremner JD, Southwick SM, Johnson DR, Yehuda R, Charney DS (1993) Childhood physical abuse and combat-related posttraumatic stress disorder in Vietnam veterans. Am J Psychiatry 150: 235–239.
- 102. Brown J, Cohen P, Johnson JG, Smailes EM (1999) Childhood abuse and neglect: specificity and effects on adolescent and young adult depression and suicidality. J Am Acad Child Adolesc Psychiatry 38: 1490–1496. doi: 10.1097/00004583-199912000-00009
- 103. Chartier MJ, Walker JR, Naimark B (2009) Health risk behaviors and mental health problems as mediators of the relationship between childhood abuse and adult health. Am J Public Health 99: 847–854. doi: 10.2105/ajph.2007.122408
- 104. Cohen P, Brown J, Smailes E (2001) Child abuse and neglect and the development of mental disorders in the general population. Dev Psychopathol 13: 981–999.
- 105. Coid J, Petruckevitch A, Chung W-S, Richardson J, Moorey S, et al. (2003) Abusive experiences and psychiatric morbidity in women primary care attenders. Br J Psychiatry 183: 332–339. doi: 10.1192/bjp.183.4.332
- 106. Conroy E, Degenhardt L, Mattick RP, Nelson EC (2009) Child maltreatment as a risk factor for opioid dependence: comparison of family characteristics and type and severity of child maltreatment with a matched control group. Child Abuse Negl 33: 343–352. doi: 10.1016/j.chiabu.2008.09.009
- 107. Courtney EA, Kushwaha M, Johnson JG (2008) Childhood emotional abuse and risk for hopelessness and depressive symptoms during adolescence. J Emot Abuse 8: 281–298. doi: 10.1080/10926790802262572
- 108. Dong M, Giles WH, Felitti VJ, Dube SR, Williams JE, et al. (2004) Insights into causal pathways for ischemic heart disease: adverse childhood experiences study. Circulation 110: 1761–1766. doi: 10.1161/01.cir.0000143074.54995.7f
- 109. Draper B, Pfaff JJ, Pirkis J, Snowdon J, Lautenschlager NT, et al. (2008) Long-term effects of childhood abuse on the quality of life and health of older people: results from the depression and early prevention of suicide in general practice project. J Am Geriatr Soc 56: 262–271. doi: 10.1111/j.1532-5415.2007.01537.x
- 110. Dube SR, Anda RF, Felitti VJ, Chapman DP, Williamson DF, et al. (2001) Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the adverse childhood experiences study. JAMA 286: 3089–3096. doi: 10.1001/jama.286.24.3089
- 111. Dube SR, Felitti VJ, Dong M, Chapman DP, Giles WH, et al. (2003) Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics 111: 564–572. doi: 10.1542/peds.111.3.564
- 112. Dube SR, Miller JW, Brown DW, Giles WH, Felitti VJ, et al. (2006) Adverse childhood experiences and the association with ever using alcohol and initiating alcohol use during adolescence. J Adolesc Health 38: 444.e441–444.e410. doi: 10.1016/j.jadohealth.2005.06.006
- 113. Egeland B, Yates T, Appleyard K, van Dulmen M (2002) The long-term consequences of maltreatment in the early years: a developmental pathway model to antisocial behavior. Child Serv: Soc Pol Res Prac 5: 249–260. doi: 10.1207/s15326918cs0504_2
- 114. Enns MW, Cox BJ, Afifi TO, De Graaf R, Ten Have M, et al. (2006) Childhood adversities and risk for suicidal ideation and attempts: a longitudinal population-based study. Psychol Med 36: 1769–1778. doi: 10.1017/s0033291706008646
- 115. Evans-Campbell T, Lindhorst T, Huang B, Walters KL (2006) Interpersonal violence in the lives of urban American Indian and Alaska Native women: implications for health, mental health, and help-seeking. Am J Public Health 96: 1416–1422. doi: 10.2105/ajph.2004.054213
- 116. Fergusson DM, Boden JM, Horwood LJ (2008) The developmental antecedents of illicit drug use: evidence from a 25-year longitudinal study. Drug Alcohol Depend 96: 165–177. doi: 10.1016/j.drugalcdep.2008.03.003
- 117. Flisher A, Ziervogel C, Chalton D, Leger P, Robertson B (1996) Risk-taking behaviour of Cape Peninsula high-school students. Part X. Multivariate relationships among behaviours. S Afr Med J 86: 1094–1098.
- 118. Fujiwara T, Kawakami N (2011) World Mental Health Japan Survey Group (2011) Association of childhood adversities with the first onset of mental disorders in Japan: results from the World Mental Health Japan, 2002–2004. J Psychiatr Res 45: 481–487. doi: 10.1016/j.jpsychires.2010.08.002
- 119. Fuller-Thomson E, Stefanyk M, Brennenstuhl S (2009) The robust association between childhood physical abuse and osteoarthritis in adulthood: findings from a representative community sample. Arthritis Rheum 61: 1554–1562. doi: 10.1002/art.24871
- 120. Fuller-Thomson E, Bottoms J, Brennenstuhl S, Hurd M (2011) Is childhood physical abuse associated with peptic ulcer disease? Findings from a population-based study. J Interpers Violence 26: 3225–3247. doi: 10.1177/0886260510393007
- 121. Gal G, Levav I, Gross R (2011) Psychopathology among adults abused during childhood or adolescence: results from the Israel-based World Mental Health Survey. J Nerv Ment Dis 199: 222–229. doi: 10.1097/nmd.0b013e31820c7543
- 122. Goodwin RD, Weisberg SP (2002) Childhood abuse and diabetes in the community. Diabetes Care 25: 801–802. doi: 10.2337/diacare.25.4.801
- 123. Gould DA, Stevens NG, Ward NG, Carlin AS, Sowell HE, et al. (1994) Self-reported childhood abuse in an adult population in a primary care setting. Prevalence, correlates, and associated suicide attempts. Arch Fam Med 3: 252–256. doi: 10.1001/archfami.3.3.252
- 124. Green JG, McLaughlin KA, Berglund PA, Gruber MJ, Sampson NA, et al. (2010) Childhood adversities and adult psychiatric disorders in the national comorbidity survey replication I: associations with first onset of DSM-IV disorders. Arch Gen Psychiatry 67: 113–123. doi: 10.1001/archgenpsychiatry.2009.186
- 125. Gunstad J, Paul RH, Spitznagel MB, Cohen RA, Williams LM, et al. (2006) Exposure to early life trauma is associated with adult obesity. Psychiatry Res 142: 31–37. doi: 10.1016/j.psychres.2005.11.007
- 126. Hamburger ME, Leeb RT, Swahn MH (2008) Childhood maltreatment and early alcohol use among high-risk adolescents. J Stud Alcohol Drugs 69: 291–295.
- 127. Hanson RF, Saunders B, Kilpatrick D, Resnick H, Crouch JA, et al. (2001) Impact of childhood rape and aggravated assault on adult mental health. Am J Orthopsychiatry 71: 108–119. doi: 10.1037/0002-94220.127.116.11
- 128. Hillis SD, Anda RF, Felitti V, Nordenberg D, Marchbanks P (2000) Adverse childhood experiences and sexually transmitted diseases in men and women: a retrospective study. Pediatrics 106: E11. doi: 10.1542/peds.106.1.e11
- 129. Huang S, Trapido E, Fleming L, Arheart K, Crandall L, et al. (2011) The long-term effects of childhood maltreatment experiences on subsequent illicit drug use and drug-related problems in young adulthood. Addict Behav 36: 95–102. doi: 10.1016/j.addbeh.2010.09.001
- 130. Jeon HJ, Roh M-S, Kim K-H, Lee J-R, Lee D, et al. (2009) Early trauma and lifetime suicidal behavior in a nationwide sample of Korean medical students. J Affect Disord 119: 210–214. doi: 10.1016/j.jad.2009.03.002
- 131. Juang KD, Wang SJ, Fuh JL, Lu SR, Chen YS (2004) Association between adolescent chronic daily headache and childhood adversity: a community-based study. Cephalalgia 24: 54–59. doi: 10.1111/j.1468-2982.2004.00643.x
- 132. Jun H-J, Rich-Edwards JW, Boynton-Jarrett R, Austin SB, Frazier AL, et al. (2008) Child abuse and smoking among young women: the importance of severity, accumulation, and timing. J Adolesc Health 43: 55–63. doi: 10.1016/j.jadohealth.2007.12.003
- 133. Kaplan SJ, Pelcovitz D, Salzinger S, Weiner M, Mandel FS, et al. (1998) Adolescent physical abuse: risk for adolescent psychiatric disorders. Am J Psychiatry 155: 954–959. doi: 10.1177/088626099014009005
- 134. Kerr T, Stoltz J-A, Marshall BDL, Lai C, Strathdee SA, et al. (2009) Childhood trauma and injection drug use among high-risk youth. J Adolesc Health 45: 300–302. doi: 10.1016/j.jadohealth.2009.03.007
- 135. Lau JTF, Chan KK, Lam PKW, Choi PYW, Lai KYC (2003) Psychological correlates of physical abuse in Hong Kong Chinese adolescents. Child Abuse Negl 27: 63–75. doi: 10.1016/s0145-2134(02)00507-0
- 136. Levitan RD, Rector NA, Sheldon T, Goering P (2003) Childhood adversities associated with major depression and/or anxiety disorders in a community sample of Ontario: issues of co-morbidity and specificity. Depress Anxiety 17: 34–42. doi: 10.1002/da.10077
- 137. Libby AM, Orton HD, Novins DK, Beals J, Manson SM, et al. (2005) Childhood physical and sexual abuse and subsequent depressive and anxiety disorders for two American Indian tribes. Psychol Med 35: 329–340. doi: 10.1017/s0033291704003599
- 138. Lissau I, Sorensen TI (1994) Parental neglect during childhood and increased risk of obesity in young adulthood. Lancet 343: 324–327. doi: 10.1016/s0140-6736(94)91163-0
- 139. Logan JE, Leeb RT, Barker LE (2009) Gender-specific mental and behavioral outcomes among physically abused high-risk seventh-grade youths. Public Health Reports 124: 234–245.
- 140. Nikulina V, Widom CS, Czaja S (2011) The role of childhood neglect and childhood poverty in predicting mental health, academic achievement and crime in adulthood. Am J Community Psychol 48: 309–321. doi: 10.1007/s10464-010-9385-y
- 141. Perkins DF, Luster T, Jank W (2002) Protective factors, physical abuse, and purging from community-wide surveys of female adolescents. J Adolesc Res 17: 377–400. doi: 10.1177/07458402017004004
- 142. Pillai A, Andrews T, Patel V (2009) Violence, psychological distress and the risk of suicidal behaviour in young people in India. Int J Epidemiol 38: 459–469. doi: 10.1093/ije/dyn166
- 143. Ramiro LS, Madrid BJ, Brown DW (2010) Adverse childhood experiences (ACE) and health-risk behaviors among adults in a developing country setting. Child Abuse Negl 34: 842–855. doi: 10.1016/j.chiabu.2010.02.012
- 144. Riley EH, Wright RJ, Jun HJ, Hibert EN, Rich-Edwards JW (2010) Hypertension in adult survivors of child abuse: observations from the Nurses' Health Study II. J Epidemiol Community Health 64: 413–418. doi: 10.1136/jech.2009.095109
- 145. Ritchie K, Jaussent I, Stewart R, Dupuy A-M, Courtet P, et al. (2009) Association of adverse childhood environment and 5-HTTLPR genotype with late-life depression. J Clin Psychiatry 70: 1281–1288. doi: 10.4088/jcp.08m04510
- 146. Rohde P, Ichikawa L, Simon GE, Ludman EJ, Linde JA, et al. (2008) Associations of child sexual and physical abuse with obesity and depression in middle-aged women. Child Abuse Negl 32: 878–887. doi: 10.1016/j.chiabu.2007.11.004
- 147. Romans S, Belaise C, Martin J, Morris E, Raffi A (2002) Childhood abuse and later medical disorders in women: an epidemiological study. Psychother Psychosom 71: 141–150. doi: 10.1159/000056281
- 148. Rubino IA, Nanni RC, Pozzi DM, Siracusano A (2009) Early adverse experiences in schizophrenia and unipolar depression. J Nerv Ment Dis 197: 65–68. doi: 10.1097/nmd.0b013e3181925342
- 149. Scott KM, Von Korff M, Alonso J, Angermeyer MC, Benjet C, et al. (2008) Childhood adversity, early-onset depressive/anxiety disorders, and adult-onset asthma. Psychosom Med 70: 1035–1043. doi: 10.1097/psy.0b013e318187a2fb
- 150. Scott KM, Von Korff M, Angermeyer MC, Benjet C, Bruffaerts R, et al. (2011) Association of childhood adversities and early-onset mental disorders with adult-onset chronic physical conditions. Arch Gen Psychiatry 68: 838–844. doi: 10.1001/archgenpsychiatry.2011.77
- 151. Sidhartha T, Jena S (2006) Suicidal behaviors in adolescents. Indian J Pediatr 73: 783–788. doi: 10.1007/bf02790385
- 152. Smith CA, Ireland TO, Thornberry TP (2005) Adolescent maltreatment and its impact on young adult antisocial behavior. Child Abuse Negl 29: 1099–1119. doi: 10.1016/j.chiabu.2005.02.011
- 153. Springer KW, Sheridan J, Kuo D, Carnes M (2007) Long-term physical and mental health consequences of childhood physical abuse: results from a large population-based sample of men and women. Child Abuse Negl 31: 517–530. doi: 10.1016/j.chiabu.2007.01.003
- 154. Springer KW (2009) Childhood physical abuse and midlife physical health: testing a multi-pathway life course model. Soc Sci Med 69: 138–146. doi: 10.1016/j.socscimed.2009.04.011
- 155. Stein MB, Walker JR, Anderson G, Hazen AL, Ross CA, et al. (1996) Childhood physical and sexual abuse in patients with anxiety disorders and in a community sample. Am J Psychiatry 153: 275–277.
- 156. Stein DJ, Scott K, Abad JMH, Aguilar-Gaxiola S, Alonso J, et al. (2010) Early childhood adversity and later hypertension: data from the World Mental Health Survey. Ann Clin Psychiatry 22: 19–28.
- 157. Thomas C, Hypponen E, Power C (2008) Obesity and type 2 diabetes risk in midadult life: the role of childhood adversity. Pediatrics 121: e1240–e1249. doi: 10.1542/peds.2007-2403
- 158. Thompson MP, Arias I, Basile KC, Dejai S (2002) The association between childhood physical and sexual victimization and health problems in adulthood in a nationally representative sample of women. J Interpers Violence 17: 1115–1129. doi: 10.1177/088626002236663
- 159. Thompson MP, Kingree JB, Desai S (2004) Gender differences in long-term health consequences of physical abuse of children: data from a nationally representative survey. Am J Public Health 94: 599–604. doi: 10.2105/ajph.94.4.599
- 160. Thompson R, Proctor LJ, English DJ, Dubowitz H, Narasimhan S, et al. (2012) Suicidal ideation in adolescence: examining the role of recent adverse experiences. J Adolesc 35: 175–186. doi: 10.1016/j.adolescence.2011.03.003
- 161. Timko C, Sutkowi A, Pavao J, Kimerling R (2008) Women's childhood and adult adverse experiences, mental health, and binge drinking: the California Women's Health Survey. Subst Abuse Treat Prev Policy 3: 15. doi: 10.1201/b13136-12
- 162. Trent L, Stander V, Thomsen C, Merrill L (2007) Alcohol abuse among U.S. Navy recruits who were maltreated in childhood. Alcohol Alcohol 42: 370–375. doi: 10.1093/alcalc/agm036
- 163. Turner C, Russell A, Brown W (2003) Prevalence of illicit drug use in young Australian women, patterns of use and associated risk factors. Addiction 98: 1419–1426. doi: 10.1046/j.1360-0443.2003.00525.x
- 164. Vander Weg MW (2011) Adverse childhood experiences and cigarette smoking: the 2009 Arkansas and Louisiana Behavioral Risk Factor Surveillance Systems. Nicotine Tob Res 13: 616–622. doi: 10.1093/ntr/ntr023
- 165. Von Korff M, Alonso J, Ormel J, Angermeyer M, Bruffaerts R, et al. (2009) Childhood psychosocial stressors and adult onset arthritis: broad spectrum risk factors and allostatic load. Pain 143: 76–83. doi: 10.1016/j.pain.2009.01.034
- 166. Wainwright NWJ, Surtees PG (2002) Childhood adversity, gender and depression over the life-course. J Affect Disord 72: 33–44. doi: 10.1016/s0165-0327(01)00420-7
- 167. Wan GWY, Leung PWL (2010) Factors accounting for youth suicide attempt in Hong Kong: a model building. J Adolesc 33: 575–582. doi: 10.1016/j.adolescence.2009.12.007
- 168. Widom CS, Ireland T, Glynn PJ (1995) Alcohol abuse in abused and neglected children followed-up: are they at increased risk? J Stud Alcohol 56: 207–217.
- 169. Widom C, Kuhns J (1996) Childhood victimization and subsequent risk for promiscuity, prostitution, and teenage pregnancy: a prospective study. Am J Public Health 86: 1607–1612. doi: 10.2105/ajph.86.11.1607
- 170. Widom CS, Weiler BL, Cottler LB (1999) Childhood victimization and drug abuse: a comparison of prospective and retrospective findings. J Consult Clin Psychol 67: 867–880. doi: 10.1037/0022-006x.67.6.867
- 171. Widom CS (1999) Posttraumatic stress disorder in abused and neglected children grown up. Am J Psychiatry 156: 1223–1229. doi: 10.1002/jts.20478
- 172. Wilson H, Widom CS (2008) An examination of risky sexual behavior and HIV in victims of child abuse and neglect: a 30-year follow-up. Health Psychol 27: 149–158. doi: 10.1037/0278-618.104.22.168
- 173. Wilson HW, Widom CS (2009) Sexually transmitted diseases among adults who had been abused and neglected as children: a 30-year prospective study. Am J Public Health 99 Suppl 1S197–S203. doi: 10.2105/ajph.2007.131599
- 174. Wilson HW, Widom CS (2011) Pathways from childhood abuse and neglect to HIV-risk sexual behavior in middle adulthood. J Consult Clin Psychol 79: 236–246. doi: 10.1037/a0022915
- 175. Wise LA, Palmer JR, Boggs DA, Adams-Campbell LL, Rosenberg L (2011) Abuse victimization and risk of breast cancer in the Black Women's Health Study [corrected]. Cancer Causes Control 22: 659–669. doi: 10.1007/s10552-011-9738-3
- 176. Young SYN, Hansen CJ, Gibson RL, Ryan MAK (2006) Risky alcohol use, age at onset of drinking, and adverse childhood experiences in young men entering the US marine corps. Arch Pediatr Adolesc Med 160: 1207–1214. doi: 10.1001/archpedi.160.12.1207
- 177. Benson PL (1990) The troubled journey: a portrait of 6th- to 12th-grade youth. Minneapolis (Minnesota): Search Institute.
- 178. Sinha A, Singh R (1993) The Adjustment Inventory for School Students (AISS). Agra (India): National Psychological Corporation.
- 179. Grant BF, Dawson DA, Stinson FS, Chou PS, Kay W, et al. (2003) The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV): reliability of alcohol consumption, tobacco use, family history of depression and psychiatric diagnostic modules in a general population sample. Drug Alcohol Depend 71: 7–16. doi: 10.1016/s0376-8716(03)00070-x
- 180. Saunders J, Aasland O, Babor TF, de la Fuente J, Grant M (1993) Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption—II. Addiction 88: 791–804. doi: 10.1111/j.1360-0443.1993.tb02093.x
- 181. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA (1998) The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med 158: 1789–1795. doi: 10.1001/archinte.158.16.1789
- 182. Beck AT, Steer RA, Brown GK (1996) Manual for the Beck Depression Inventory-II. San Antonio (Texas): Psychological Corporation.
- 183. Mayfield D, McLeod G, Hall P (1974) The CAGE questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry 131: 1121–1123.
- 184. Centers for Disease Control and Prevention (2000) Measuring healthy days: population assessment of health-related quality of life. Atlanta (Georgia): Centers for Disease Control and Prevention.
- 185. Kovacs M (1992) Children's depression inventory manual. North Tonawanda (New York): Multi-Health Systems.
- 186. Radloff LS (1977) The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1: 385–401. doi: 10.1177/014662167700100306
- 187. Kessler RC, Ustün TB (2004) The World Mental Health (WMH) survey initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Int J Methods Psychiatr Res 13: 93–121. doi: 10.1002/mpr.168
- 188. Lewis G, Pelosi A, Araya R, Dunn G (1992) Measuring psychiatric disorder in the community: a standardized assessment for use by lay interviewers. Psychol Med 22: 465–486. doi: 10.1017/s0033291700030415
- 189. Berk E, Black J, Locastro J, Wickis J, Simpson T, et al. (1989) Traumatogenicity: effects of self-reported noncombat trauma on MMPIs of male Vietnam combat and noncombat veterans treated for substance abuse. J Clin Psychol 45: 704–708. doi: 10.1002/1097-4679(198909)45:5<704::aid-jclp2270450504>3.0.co;2-6
- 190. Bernstein DP, Fink L, Handelsman L, Foote J, Lovejoy M, et al. (1994) Initial reliability and validity of a new retrospective measure of child abuse and neglect. Am J Psychiatry 151: 1132–1136.
- 191. Straus MA (1979) Measuring intrafamily conflict and violence: the Conflict Tactics (CT) Scales. J Marriage Fam 41: 75–88. doi: 10.2307/351733
- 192. Costello EJ, Edelbrock CS, Duncan MK, Kalas R (1984) Testing of the NIMH Diagnostic Interview Schedule for Children (DISC) in a clinical population: final report to the Center for Epidemiological Studies, NIMH. Pittsburgh (Pennsylvania): University of Pittsburgh.
- 193. Breton J, Bergeron L, Valla J, Berthiaume C, St-Georges M (1998) Diagnostic interview schedule for children (DISC–2.25) in Quebec: reliability findings in light of the MECA study. J Am Acad Child Adolesc Psychiatry 37: 1167–1174. doi: 10.1097/00004583-199811000-00016
- 194. Robins LN, Helzer JE, Cottler L, Goldring E (1989) National Institute of Mental Health Diagnostic Interview Schedule Version III Revised (DIS-III-R). St Louis (Missouri): Washington University.
- 195. Cooper Z, Fairburn CG (1987) The Eating Disorder Examination: a semi-structured interview for the assessment of the specific psychopathology of eating disorders. Int J Eat Disord 8: 1–8. doi: 10.1002/1098-108x(198701)6:1<1::aid-eat2260060102>3.0.co;2-9
- 196. Bremner J, Bolus R, Mayer E (2007) Psychometric properties of the Early Trauma Inventory-Self Report. J Nerv Ment Dis 195: 211–218. doi: 10.1097/01.nmd.0000243824.84651.6c
- 197. Rey J, Singh M, Hung S, Dossetor D, Newman L, et al. (1997) A global scale to measure the quality of the family environment. Arch Gen Psychiatry 54: 817–822. doi: 10.1001/archpsyc.1997.01830210061006
- 198. Kilpatrick DG, Saunders BE, Amick-McMullan A, Best CL, Veronen LJ, et al. (1989) Victim and crime factors associated with the development of crime-related post-traumatic stress disorder. Behav Ther 20: 199–214. doi: 10.1016/s0005-7894(89)80069-3
- 199. Puig-Antich J, Chambers W (1978) The schedule of affective disorders and schizophrenia for school-aged children. New York: New York Psychiatric Institute.
- 200. Seltzer ML (1971) The Michigan Alcoholism Screening Test: the quest for a new diagnostic instrument. Am J Psychiatry 127: 89–94.
- 201. Lecrubier Y, Sheehan DV, Weiller E, Amorim P, Bonora I, et al. (1997) The Mini International Neuropsychiatric Interview (MINI). A short diagnostic structured interview: reliability and validity according to the CIDI. Eur Psychiatry 12: 224–231. doi: 10.1016/s0924-9338(97)83296-8
- 202. Parker G, Tupling H, Brown LB (1979) A parental bonding instrument. Br J Med Psychol 52: 1–10. doi: 10.1111/j.2044-8341.1979.tb02487.x
- 203. Prins A, Ouimette PC, Kimerling R, Thrailkill A, Cameron R, et al. (2004) The Primary Care PTSD Screen (PC-PTSD): development, operating characteristics and clinical utility. Primary Care Psychiatry 9: 9–14. doi: 10.1185/135525703125002360
- 204. Dohrenwend BS, Kranoff L, Askenasy AR, Dohrenwend BP (1978) Exemplification of a method for scaling life events: the PERI Life Events Scale. J Health Soc Behav 19: 205–229. doi: 10.2307/2136536
- 205. Newmann JP (1984) Sex differences in symptoms of depression: clinical disorder or normal distress. J Health Soc Behav 25: 136–159. doi: 10.2307/2136665
- 206. Wing JK, Cooper JE, Sartorius N (1974) The measurement and classification of psychiatric symptoms. London: Cambridge University Press.
- 207. Beck A, Kovacs M, Weissman A (1979) Assessment of suicidal intention: the Scale for Suicide Ideation. J Consult Clin Psychol 47: 343–352. doi: 10.1037//0022-006x.47.2.343
- 208. Yates TM, Carlson EA (2003) Self-Injurious Behavior Questionnaire. Minneapolis (Minnesota): University of Minnesota.
- 209. Silberstein S, Lipton R, Sliwinski M (1996) Classification of daily and near-daily headaches: field trial of revised IHS criteria. Neurology 47: 871–875. doi: 10.1212/wnl.47.4.871
- 210. Spitzer RL, Williams JB, Gibbon M, First M (1990) Structured Clinical Interview for DSM-III-R (nonpatient edition). Washington (District of Columbia): American Psychiatric Press.
- 211. First M, Spitzer R, Williams J, Gibbon M (1995) Structured Clinical Interview for DSM-IV–Patient Edition (SCID-P). Washington (District of Columbia): American Psychiatric Press.
- 212. Norris FH (1990) Screening for traumatic stress: a scale for use in the general population. J Appl Soc Psychol 20: 1704–1718. doi: 10.1111/j.1559-1816.1990.tb01505.x
- 213. Achenbach TM (1991) Manual of the Youth Self-Report and 1991 profile. Burlington (Vermont): Department of Psychiatry, University of Vermont.