127 Captivating Child Abuse Essay Ideas, Research Questions & Essay Examples

Child abuse is one of the crucial problems that has been overlooked for many centuries. At the same time, it is an extremely sensitive issue and should be recognized and reduced as much as possible.

In this article, you will find child abuse research topics and ideas to use in your essay.

Let’s start!

📝 The Child Abuse Essay Structure

🏆 best child abuse topics & essay examples, 👍 good essay topics on child abuse, 📌 simple research topics about child abuse, 💡 interesting topics on child abuse, ❓ child abuse research questions.

Child abuse is one of the most problematic topics in today’s society. Writing child abuse essays may be challenging because it requires analyzing sensitive issues.

The problem refers to physical, psychological, or sexual mistreatment of children. It is vital to discuss this acute issue in studies and essays on child abuse.

Before working on your essay, you should select a topic for discussion. Here are some child abuse essay topics that we can suggest:

  • The problem of child abuse in the US (Canada, the UK)
  • Child abuse: Types and definitions
  • Child neglect crimes and their causes
  • Current solutions to the problem of sexual abuse of children
  • The importance of child maltreatment prevention programs
  • Child abuse: Legal implications
  • Consequences of child abuse and neglect

If you are looking for other possible titles for your paper, you can check out child abuse essays samples online. Remember to only use them as examples to guide your work, and do not copy the information you will find.

One of the most important features of an outstanding essay is its structure. Here are some tips on how you can organize your essay effectively:

  • Do preliminary research before writing your paper. It will help you to understand the issues you will want to discuss and outline which of them you will include in the essay. Remember to keep in mind the type of essay you should write, too.
  • An introductory paragraph is necessary. In this paragraph, you will present background information on the issue and the aspects that you will cover in the paper. Remember to include a thesis statement at the end of this section.
  • Think of the main arguments of your paper. You will present them in the body paragraphs of the essay. What child abuse issues do you want your reader to know about? Dedicate a separate section for each of the arguments. Remember to make smooth transitions between the paragraphs.
  • Remember to dedicate a paragraph to identifying the problem of the essay and explaining the main terms. For example, if you are writing a child labor essay, you can discuss the countries in which this practice is present. You can also reflect on the outcomes of this problem.
  • Include a refutation section if you are writing an argumentative essay. Discuss an alternative perspective on each of your arguments and prove that your opinion is more reliable than the alternative ones.
  • Remember that you should not make paragraphs and sentences too long. It is easier for the reader to comprehend shorter sentences compared to complex ones. You can write between 65 and 190 words per paragraph and include at least 10 words in a sentence. It is a good idea to make all sections of the body paragraphs of similar length.
  • A concluding paragraph or a summary is also very important. In this paragraph, you will discuss the arguments and counter-arguments of your paper.
  • Do not forget to add a reference page in which you will include the sources used in the paper. Ask your professor whether you need a title page and an outline too.
  • If you are not sure that the selected structure is good, check out child abuse essay examples online. Pay attention to how they are organized but do not copy the facts you will find in them.

For extra help, see our free samples and get some ideas for your paper!

  • Educational Program on Child Abuse The report “Initial reliability and validity of a new retrospective measure of child abuse and neglect” by Bernstein, Fink and Handelsman provides the findings of the consistency and validity of some of the conservative measures […]
  • Child Sexual Abuse: Impact and Consequences Due to the adverse consequences of sexual abuse, efforts to have Jody share her ordeal and get immediate help would be my priority.
  • Daniel Valerio Child Abuse In the end, it was an electrician who identified the typical signs of abuse in Daniel that finally led police to investigate, thereby exposing the weakness and ineffectiveness of the Dual Track System; the child […]
  • Randomized Trial of Cognitive-Behavioral Therapy for Chronic Post-Traumatic Stress Disorders in Adult Female Survivors of Childhood Sexual Abuse However, in spite of the fact that there exist a wealth of clinical literature on treatment methodologies of victims of sexual abuse, the evidence base concerning the treatment of victims of childhood sexual abuse exhibiting […]
  • Child Abuse and Neglect Children in Court The objective of this paper was to determine the level of knowledge and nature of attitudes among maltreated children who appeared in court during their detention case hearings.
  • Physical Child Abuse Usually the child is unaware of the abuse due to the na ve state of mind or innocence. Physical abuse also lowers the social-economic status and thus high chances of neglect or abuse due to […]
  • Child Abuse: A Case for Imposing Harsher Punishments to Child Abusers While harsh punishments appear to offer a solution to the problem, this measure may be detrimental to the welfare of the child in the case where the abuser is its guardian.
  • Abuse in Childhood Common Among Alcohol Addicts Dwelling upon the impact of the violence and abuse during childhood, the connection with the further disabilities and disorders is obvious.
  • Cause and Effect of Child Abuse Parental response to the children is also presented in a form of abuse of the rights of the children, as they feel neglected or disowned.
  • Biological Underpinnings Behind Child Abuse The dimension of the baby’s head is also seen to decrease in quantity from on third of the whole body at birth, to a quarter at the age of two years and to an eighth […]
  • Introducing Improvements to Children Abuse Reporting System The paper is connected with the analysis of the quality of the current child abuse report systems because of the serious problems in the sphere of childcare.
  • The Effects of Child Abuse: Capstone Project Time Line The development of a Capstone Project will become a new step in solving the problem and thinking about the possible ways of improvement the situation and creation the most appropriate living conditions for children.
  • Child Abuse and Capstone Project This is why the problem of child abuse remains to be crucial for analysis, as people have to understand its urgency and effects on human behavior.
  • Child Abuse Issues and Its Effects The recognition of child abuse signs is a very important step as it is wrong to believe that child maltreatment takes place because of the presence of a single sing or poor understanding of child […]
  • Effects of Child Abuse and Neglect Antisocial behaviour is one of the outcomes of child abuse and parental neglect that may be disclosed in a variety of forms.
  • Effects of Child Abuse The nature of the effects of child abuse, their consequences in a society, and the most appropriate preventive methods should be considered.
  • Child Abuse Problems and Its Effects on a Future Child’s Life In fact, there were the three main challenges in writing the literature review just completed that were overcome due to the ability to organize the work, follow the suggestions of the experts, and keep in […]
  • A True Nature of the Effects of Child Abuse A society is in need of powerful and effective research that can prove the necessity to introduce the issue of child abuse and its effects as a leading problem the solution of which requires the […]
  • A True Nature of the Effects of Child Abuse and Neglect in a Society The outcomes of child abuse usually depend on a variety of factors like the age of a child, the type of relation between a child and a perpetrator, and, of course, the type of maltreatment.
  • The Causes and Effects of Child Abuse The main problem of the project is the presence of a number of effects of child abuse and parental neglect on children, their development, and communication with the world.
  • Problem of Child Abuse The most common form of child abuse in America and in most parts of the world is child abuse. The cost of child abuse is dire to both the children, healthcare organizations, parents, and the […]
  • Child Abuse Problem The study of the problem of child abuse has begun in the 60s with focusing attention to children problems. In such a case the early recognition of child abuse is of great importance.
  • Child Abuse and Neglect A church/synagogue/mosque retreat activity for parents and they children can be beneficial in strengthening parents to deal with the issues of child abuse and neglect.
  • The Prevention of Child Abuse From the interview conducted with the school administrator of the local elementary school and the director of a local preschool, it is clear that both institutions have some advocacy plans for the prevention of child […]
  • Child Abuse as a Result of Insufficient Policies According to Latzman and Latzman, child abuse may be manifested in the use of excessive physical force when disciplining a child or an adolescent.
  • Child Abuse: History and Causes The purpose of this paper is to explore the history, and causes of child abuse as well as the legislation implemented to address its cases.
  • Child Abuse and Neglect: Drug and Alcohol Problems The families of individuals who have committed a drug related offense should be investigated in order to ensure the practice is acceptable and capable of supporting the needs of more societies.
  • Child Abuse and Protective Act in Idaho Also, abandonment is recognized in Idaho’s definition of child abuse, and, according to the Act, it means the failure of the parent or the guardian to foster a normal relationship with the child.
  • Child Abuse and Neglect and Family Practice Model Also, psychological violence can be either the only form of violence or the consequence of psychological or sexual abuse or neglect. Inadequate evaluation of the child’s capabilities and overstated requirements can also be a form […]
  • Child Abuse in the UAE and Explaining Theories The interest of carrying out the study on child abuse is based on the fact that it is a critical issue in any society, especially due to the actual and possible consequences on the child […]
  • Child Abuse in the Victorian Era in Great Britain This was unacceptable in the eyes of the factory owners resulting in the implementation of the practice of children being sent into the mechanisms of machines while they were still operating since they were supposedly […]
  • New Jersey’s Bill on Child Abuse and Neglect The legislation’s impact is expected to be large because it is targeted at raising awareness of the pervasive issue of child abuse and encouraging the public to stay active and not to disregard any signs […]
  • Child Abuse: Altruistic Behavior Intervention plays a crucial role in the prevention of child abuse, as it helps to eliminate the possibility of the recurrence of events.
  • Child Abuse and Culture: Juan’s Case Analysis The following is the list of reflective insights that I came to while getting myself familiarized with Juan’s case and analyzing this case’s discursive implications: When addressing the issue of children being suspected to have […]
  • Socio-Economic Standing and Propensity for Child Abuse Physicians were the first to notice and report evidence of child abuse and neglect in the 1960s. The UNICEF corroborates the relationship of poverty with child abuse, neglect, and maltreatment.
  • Critical Statistical Data Regarding the Issues Related to Child Abuse Due to acts of abuse children suffer greatly and it will not be wrong to say that these experiences are definitely engraved into the child’s personality.
  • Sociological Perspective on “Punishment” as a Major Contributor to Child Abuse This is done with the aim of ensuring that the child is disciplined and is perceived as a legitimate punishment. This has offered a loophole to parents to abuse the child in the name of […]
  • Discipline and Child Abuse: Motivation and Goals The first proof of the justice and reasonableness of discipline is that it is permitted by law to be considered to be the most authoritative source to consult.
  • Child Abuse: Term Definition However, there is a component that is not so clearly represented in other crimes: a third party, who has observed the abuse or the consequences of abuse has the legal obligation and reasonable cause of […]
  • Protocol for Pre-Testing the Child Abuse and Neglect Public Health Policy Based on the above, it is necessary to identify the conditions of child abuse like the quality of family relations and improper upbringing.
  • Ethical Dilemma of Child Abuse In the above example, a nurse has to apply rational judgment to analyze the extent and threats when making decisions in the best interest of the victim of child abuse.
  • Child Abuse in Singapore The second reason for child abuse in Singapore to continue being one of the most underreported illegal offenses is the country’s collectivist culture.
  • Promoting Child Abuse Prevention Services in Oahu, Hawaii, and the US The primary goal the Hui Hawaii organization is trying to achieve is to improve the well-being of American children by preventing abuse, neglect, and depression.
  • Criminal Justice System: Child Abuse During the consideration of cases as part of a grand jury, citizens perform some functions of the preliminary investigation bodies.
  • Hidden Epidemic of Child Abuse and Neglect Child abuse should be perceived as a form of deviant behavior to which researchers give different explanations: biological, psychological, socio-cultural.
  • Child Abuse Allegations: Multidisciplinary Team Approach In children with allegations of child abuse, what is the effectiveness of the multidisciplinary team approach compared to the non-multidisciplinary team approach on prosecution rates, mental health referrals, and provision of medical examinations?
  • Discussion of Child Abuse: Case of COVID-19 In Cincinnati, 3-year-old Nylo Lattimore was missed in December 2020, and only after 143 days, the child’s body was discovered in the Ohio River.
  • Mandated Reporter Statute in Case of Child Abuse The mandated reporter statute recognizes such steps of reporting child abuse, abandonment, and neglect: The signs of abuse, abandonment, or neglect should be reported immediately to the Florida Department of Children and Families through the […]
  • Child Abuse: Screening Methods and Creating Financial Programs When the reporting is mandatory, it is easy to follow its guidelines which should be carefully elaborated not to be harsh on parents and at the same time offer protection to a child.
  • Domestic Violence, Child Abuse, or Elder Abuse In every health facility, a nurse who notices the signs of abuse and domestic violence must report them to the relevant authorities.
  • Effects of Child Abuse on Adults Second, she was so irrationally averse to the idea of having children that I knew immediately that it would be a contentious point in her future relationships.
  • Child Abuse: Preventive Measures My artifact is an infographic that communicates the various forms of child abuse and how to report them to the necessary authorities.
  • Impact of Child Abuse on Adulthood: An Idea Worth Spreading A frequent argument of those who do not want to recognize the scale of the problem of abuse in the world is “Beating is a sign of love!”.
  • Child Abuse and Maltreatment Discussion Additionally, this may cause a child’s behavior to change, such as making a sad or melancholy face or becoming furious with parents or other adults. When it comes to emotional abuse, a child may feel […]
  • Trafficking Causes Child Abuse and Neglect The dissociation of children from their families and the exposure to intense trauma they are subjected to during and after trafficking may cause the minors to have attachment problems.
  • The Relationship Between Child Abuse and Embitterment Disorder Some emotions, like the dread of tests in school or sibling rivalry and conflicts, are a regular part of growing up.
  • Child Abuse Versus Elder Abuse The second distinction is that older people frequently encounter issues that might lead to abuse or neglect, particularly in nursing homes, such as mental disability, loneliness, and physical limitation.
  • Public Health Media Campaign Proposal for Child Abuse
  • Child Abuse and Lack of Communication in Marriages the Main Factors of Failed Family
  • The Reasons and Three Most Common Factors Contributing to Child Abuse in Our Society
  • Child Abuse and Its Effects on Social and Personality Development
  • Neo-Liberal and Neo-Conservative Perspectives on Child Abuse
  • Physical and Behavioural Indicators of Possible Child Abuse
  • Defining Child Abuse and Its Different Forms in the 21st Century
  • Child Abuse and Neglect: Recognizing the Signs and Symptoms
  • Behind Closed Doors: The Correlation Between Multiple Personality Disorder and Child Abuse
  • Child Abuse and Later Maladjustment in Adulthood
  • Modern Beliefs Regarding the Treatment of Child Abuse Victims
  • Neighborhood Poverty and Child Abuse and Neglect: The Mediating Role of Social Cohesion
  • The Connection Between Child Abuse, Child Discipline, and Adult Behavior
  • State the Possible Types, Signs and Symptoms of Child Abuse and Why It Is Important to Follow the Policies and Procedures of the Work Place
  • Child Abuse and Its Effects on the Physical, Mental, and Emotional State of a Child
  • Child Abuse, and Neglect and Speech and Language Development
  • Social Issue: Child Abuse and How It Affects Early Childhood Development
  • Child Abuse Scandal Publicity and Catholic School Enrollment
  • Physical Abuse: The Different Types of Child Abuse
  • Promoting Help for Victims of Child Abuse: Which Emotions Are Most Appropriate to Motivate Donation Behavior
  • Describing Child Abuse, Its Different Forms, and Solutions to the Problem
  • Child Abuse: The Four Major Types of Abuse, Statistics, Prevention, and Treatment
  • Causes and Risk Factors Behind Child Abuse
  • Child Abuse, Cause, and Effect on the Rest of Their Lives
  • Child Abuse Has Severe Negative Psychological Effects on Children
  • Child Abuse and the Professional Network Working Within the Child Protec
  • Child Abuse Prevention and Control: Can Physical, Sexual or Psychological Abuse Be Controlled Within the Household?
  • Child Abuse and the Effect on Development Into Adulthood
  • Child Abuse: Victim Rights & the Role of Legal Representative
  • Child Abuse and the Legal System – Developmental Forensic Psychology: Unveiling Four Common Misconceptions
  • Parent Stress Factors and Child Abuse: A Tutoring Proposal
  • Approaching Child Abuse From a Multi-Dimensional Perspective
  • Child Abuse, Alcoholism, and Proactive Treatment
  • Adverse Effects and Prevention of Child Abuse
  • Suspected Child Abuse and the Teacher´S Role in Reporting It
  • Child Abuse and Its Correlation to Poverty
  • Sexual Child Abuse Exploring the Mind of the Perpetrator
  • Relationship Between Domestic Violence and Child Abuse and How to Protect the Children From It
  • Child Abuse Saddest and Most Tragic Problem Today
  • Child Abuse and Academic Performance of Children
  • Why Should People Care About Child Abuse?
  • Why Should Child Abuse Be Addressed as a Social Problem?
  • How Child Abuse and Neglect Affect Childhood?
  • How Has Child Abuse Been Conceptualised and Addressed in Policy and Law?
  • How to Protect Children From Abuse and Neglect?
  • What Are the Negative Effects of Child Abuse?
  • How Is the United States Dealing With Child Abuse Problem?
  • How Can Therapy Help Victims of Child Abuse?
  • How Can the Community Stop Child Abuse and Neglect?
  • When Should Teachers Report Child Abuse?
  • What Cause Child Abuse?
  • Does Child Abuse and Neglect Lead To Bullying?
  • How Do the Government and Society Have a Responsibility to Help Child Abuse Victims?
  • Parent Support Groups Can Reduce Child Abuse?
  • When Child Abuse Overlaps With Domestic Violence: The Factors Influencing Child Protection Workers’ Beliefs?
  • How Can Spanking Lead to Child Abuse?
  • How the Government and Society Have a Responsibility to Help Child Abuse Victims
  • What Does Victimology Say About Child Abuse Data?
  • Are There Any Biomarkers for Pedophilia and Sexual Child Abuse?
  • When Does Discipline Cross the Line to Child Abuse?
  • How Child Abuse Affects a Hero, a God, and a Monster in Greek Mythology?
  • Does Child Abuse Create a Psychopath?
  • Does Not Get Noticed Enough Around the World Is Child Abuse?
  • How Can Sexual Child Abuse Affect the Child’s Psychological Development?
  • How Child Abuse Effects Students Education?
  • How Do Abuse and Neglect Impact a Child’s Whole Life?
  • Should Pregnant Drug Abusers Be Charged With Child Abuse?
  • How Children Carry the Weight of Child Abuse?
  • Does Child Abuse Cause Crime?
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Description of the MUSP Cohort

Inclusion criteria for original research publications, quality of supporting literature, predictors: maltreatment types, ethical approval, prevalence and co-occurrence of maltreatment subtypes, cognition and education outcomes, psychological and mental health outcomes, addiction and substance use outcomes, sexual health outcomes, physical health, magnitude of effects, abuse, neglect, and cognitive development, psychological maltreatment: emotional abuse and/or neglect, sexual abuse, physical abuse, limitations, conclusions, long-term cognitive, psychological, and health outcomes associated with child abuse and neglect.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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Lane Strathearn , Michele Giannotti , Ryan Mills , Steve Kisely , Jake Najman , Amanuel Abajobir; Long-term Cognitive, Psychological, and Health Outcomes Associated With Child Abuse and Neglect. Pediatrics October 2020; 146 (4): e20200438. 10.1542/peds.2020-0438

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Video Abstract

Potential long-lasting adverse effects of child maltreatment have been widely reported, although little is known about the distinctive long-term impact of differing types of maltreatment. Our objective for this special article is to integrate findings from the Mater-University of Queensland Study of Pregnancy, a longitudinal prenatal cohort study spanning 2 decades. We compare and contrast the associations of specific types of maltreatment with long-term cognitive, psychological, addiction, sexual health, and physical health outcomes assessed in up to 5200 offspring at 14 and/or 21 years of age. Overall, psychological maltreatment (emotional abuse and/or neglect) was associated with the greatest number of adverse outcomes in almost all areas of assessment. Sexual abuse was associated with early sexual debut and youth pregnancy, attention problems, posttraumatic stress disorder symptoms, and depression, although associations were not specific for sexual abuse. Physical abuse was associated with externalizing behavior problems, delinquency, and drug abuse. Neglect, but not emotional abuse, was associated with having multiple sexual partners, cannabis abuse and/or dependence, and experiencing visual hallucinations. Emotional abuse, but not neglect, revealed increased odds for psychosis, injecting-drug use, experiencing harassment later in life, pregnancy miscarriage, and reporting asthma symptoms. Significant cognitive delays and educational failure were seen for both abuse and neglect during adolescence and adulthood. In conclusion, child maltreatment, particularly emotional abuse and neglect, is associated with a wide range of long-term adverse health and developmental outcomes. A renewed focus on prevention and early intervention strategies, especially related to psychological maltreatment, will be required to address these challenges in the future.

Child maltreatment is a major public health issue worldwide, with serious and often debilitating long-term consequences for psychosocial development as well as physical and mental health. 1   In the United States alone, 3.5 million children are reported for suspected maltreatment each year, with an annual substantiated maltreatment rate of 9.1 per 1000 children. 2   Some of the long-term adverse outcomes associated with maltreatment include cognitive disability, anxiety and depression, psychosis, teen-aged pregnancy, addiction disorders, obesity, and cardiovascular disease. 3   Understanding the distinctive impact of differing types of maltreatment may help medical professionals provide more wholistic care and treatment recommendations as well as identify more specific public health targets for primary prevention.

Unfortunately, however, little is known about the long-term effects of differing types of child maltreatment, which include sexual abuse, physical abuse, emotional abuse, and neglect. 4   According to a meta-analysis review, 5   research on child maltreatment has predominantly been focused on sexual abuse, with far less attention paid to psychological maltreatment (emotional abuse and/or neglect) and the co-occurrence of different types of maltreatment. In addition, most of the current evidence is derived from cross-sectional studies, which may be subject to recall bias, 6 – 8   in which an outcome status (such as depression) may influence recall of the exposure (ie, previous maltreatment). Few previous studies have adequately controlled for confounding variables, such as perinatal risk, socioeconomic adversity, parental psychopathology, and impaired early childhood development, which may predispose to both child maltreatment and later adverse health outcomes.

Longitudinal studies offer evidence that is more robust, but these studies are relatively few in number and have generally been limited to certain sociodemographic groups 9   or to specific types of child maltreatment, such as sexual abuse. 1 , 10   Other longitudinal studies have relied on retrospective recall of maltreatment rather than prospectively collected agency-reported data. 11 – 13   In studies in which prospective data have been collected, 7 , 13 – 17   only a few have compared different types of child maltreatment. 7 , 16 , 17  

In this special article, we review findings from the Mater-University of Queensland Study of Pregnancy (MUSP), a now 40-year longitudinal prenatal cohort study from Brisbane, Australia, involving >7000 women and their children. 18   Unique features of the MUSP include its use of a population-based sample, its use of prospectively substantiated child maltreatment reports, and its consideration of different subtypes of maltreatment. In addition, the study design controlled for a wide range of confounders and covariates, including both maternal and child sociodemographic and mental health variables. This combined body of work, which includes numerous publications over the past decade, has documented a broad range of adverse outcomes associated with child maltreatment, including deficits in cognitive and educational outcomes 19 – 21   ; mental health problems, such as anxiety, depression, posttraumatic stress disorder (PTSD), psychosis, delinquency, and intimate partner violence (IPV) 22 – 25   ; substance abuse and addiction 26 – 30   ; sexual health problems 31   ; physical growth and health deficits 32 – 35   ; and overall decreased quality of life. 36  

Our purpose for this special article is to compare the effects of 4 differing types of maltreatment on long-term cognitive, psychological, addiction, and health outcomes assessed in the offspring at ∼14 and/or 21 years of age. Rather than providing a systematic review or meta-analysis of the current literature, which would include diverse study designs and purposes, we report and compare the findings of individual articles that used a common data set and standard methodology to study a broad array of outcomes. We particularly highlight the long-term impact of emotional abuse and neglect, which has received far less attention in the literature.

Between 1981 and 1983, 8556 consecutive pregnant women who attended their first prenatal clinic visit at the Mater Mothers’ Hospital in Brisbane, Australia, agreed to participate ( Fig 1 ). After excluding mothers who did not deliver a singleton infant at the Mater Mothers’ Hospital or withdrew consent, the MUSP birth cohort consisted of 7223 mother-infant dyads, who were followed over 2 decades: at 3 to 5 days, 6 months, 5 years, 14 years and 21 years. Midway through the study, this rich data set was anonymously linked to state reports of child abuse and neglect, which identified some form of suspected maltreatment in >10% of cases. 37   Notified cases, which had been referred from the community or by general medical practitioners, were investigated by the Queensland government child protection agency. Substantiated maltreatment was determined after a formal investigation when there was “reasonable cause to believe that the child had been, was being, or was likely to be abused or neglected.” 38   Substantiated maltreatment occurred when a notified case was confirmed for (1) sexual abuse, “exposing a child to or involving a child in inappropriate sexual activities”; (2) physical abuse, “any non-accidental physical injury inflicted by a person who had care of the child”; (3) emotional abuse, “any act resulting in a child suffering any kind of emotional deprivation or trauma”; or (4) neglect, “failure to provide conditions that were essential for the healthy physical and emotional development of a child,” which encompassed physical, emotional and medical neglect. 37  

FIGURE 1. Overview of the MUSP enrollment and testing.

Overview of the MUSP enrollment and testing.

We searched PubMed from inception to April 2020 for published MUSP articles in which agency-reported child maltreatment was evaluated as the predictor of a range of outcomes. Studies needed to meet the following criteria for inclusion in the review: (1) notified or substantiated abuse and neglect was listed as a main predictor variable and (2) outcomes included standardized measurements of cognitive, psychological, behavioral, or health functioning. From ∼340 published MUSP studies, we identified 24 articles dealing with child maltreatment, of which 21 included state-reported maltreatment versus self-reported maltreatment data ( n = 3). Nineteen of the 21 articles met all inclusion criteria and were evaluated in this review ( Fig 2 ). One study was excluded because it only examined outcomes associated with sexual abuse. 8   Another article was excluded because its outcome measures were similar to another included study. 29  

FIGURE 2. Published studies from the Mater-University of Queensland Study of Pregnancy, linking long-term outcomes with specific maltreatment subtypes (adjusted coefficients or odds ratios ± 95% confidence intervals). CES-D, Center for Epidemiologic Studies–Depression Scale; CI, confidence interval; N, number of offspring in sample; N(Mal), number of offspring who experienced maltreatment. aIn different articles adjusting for co-occurrence of maltreatment subtypes was handled in different ways: (1) statistical adjustment: each maltreatment subtype predictor was statistically adjusted for the other maltreatment subtypes (eg, neglect was adjusted for the occurrence of physical, sexual, and emotional abuse) and is reflected in the table’s odds ratios and coefficients; (2) exclusive categories: different combinations of maltreatment types are included in mutually exclusive groups (eg, physical abuse only, physical abuse and emotional abuse only, physical and emotional abuse and neglect [without sexual abuse], etc; see Table 1); (3) nonexclusive categories: maltreatment categories may overlap with other categories (eg, any substantiated abuse [sexual, physical, or emotional] versus any substantiated neglect); and (4) none: no statistical adjustments or combined categories were presented for co-occurring maltreatment subtypes. bAdjusted coefficients (95% CI) were reported as statistical association measures rather than adjusted odds ratios. cCases of notified (rather than substantiated) maltreatment. In the study by Mills et al,26 a sensitivity analysis was performed after exclusion of unsubstantiated cases of maltreatment. The associations between any maltreatment and substance use were similar to those seen in the original analysis after full adjustment. dMedium effect size, based on magnitude of the adjusted odds ratio (2 ≤ odds ratio ≤ 4). eLarge effect size, based on magnitude of the adjusted odds ratio (odds ratio > 4).

Published studies from the Mater-University of Queensland Study of Pregnancy, linking long-term outcomes with specific maltreatment subtypes (adjusted coefficients or odds ratios ± 95% confidence intervals). CES-D, Center for Epidemiologic Studies–Depression Scale; CI, confidence interval; N , number of offspring in sample; N (Mal) , number of offspring who experienced maltreatment. a In different articles adjusting for co-occurrence of maltreatment subtypes was handled in different ways: (1) statistical adjustment: each maltreatment subtype predictor was statistically adjusted for the other maltreatment subtypes (eg, neglect was adjusted for the occurrence of physical, sexual, and emotional abuse) and is reflected in the table’s odds ratios and coefficients; (2) exclusive categories: different combinations of maltreatment types are included in mutually exclusive groups (eg, physical abuse only, physical abuse and emotional abuse only, physical and emotional abuse and neglect [without sexual abuse], etc; see Table 1 ); (3) nonexclusive categories: maltreatment categories may overlap with other categories (eg, any substantiated abuse [sexual, physical, or emotional] versus any substantiated neglect); and (4) none: no statistical adjustments or combined categories were presented for co-occurring maltreatment subtypes. b Adjusted coefficients (95% CI) were reported as statistical association measures rather than adjusted odds ratios. c Cases of notified (rather than substantiated) maltreatment. In the study by Mills et al, 26   a sensitivity analysis was performed after exclusion of unsubstantiated cases of maltreatment. The associations between any maltreatment and substance use were similar to those seen in the original analysis after full adjustment. d Medium effect size, based on magnitude of the adjusted odds ratio (2 ≤ odds ratio ≤ 4). e Large effect size, based on magnitude of the adjusted odds ratio (odds ratio > 4).

Each of the reviewed articles followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for the conduct of cohort studies. 41   The quality of the studies was also evaluated by using a modified version of the Newcastle-Ottawa Scale, which is used to assess the following domains: sample representativeness and size, comparability between respondents and nonrespondents, ascertainment of outcomes, and statistical quality. 42   On the basis of this assessment, all of the MUSP studies were determined to be of low risk of bias, with a score of 4 out of 5 points ( Supplemental Information ).

In all but 2 studies (which used notified maltreatment 21 , 26   ) events were dichotomized and coded as substantiated maltreatment versus no substantiated maltreatment. According to a validated classification of maltreatment types, 43   specific categories and co-occurring forms of childhood maltreatment 44   were used to predict outcomes. In 2 studies, 19 , 20   all types of abuse were combined into 1 category and compared to neglect, whereas in another study, sexual abuse was compared to any combination of nonsexual maltreatment. 21   In 2 other studies, 26 , 40   emotional abuse and neglect (examples of psychological maltreatment) were combined, partly because of overlapping definitional constructs from the government child protection agency (emotional abuse included “emotional deprivation,” and neglect included the failure to provide for “healthy…emotional development”). In all but 2 of the included articles, 25 , 33   co-occurrence of different types of maltreatment was considered, either by examining specific combinations of maltreatment types (in exclusive or nonexclusive overlapping categories) or by statistically adjusting for all remaining types of maltreatment ( Fig 2 ).

All of the odds ratios, mean differences, or coefficients were adjusted for potential confounding variables ( Fig 3 ). All articles adjusted for a variety of sociodemographic variables, such as age, race, education, income, and marital status. Perinatal and/or childhood factors, such as birth weight, gestational age, and breastfeeding status, were used as covariates, particularly in articles in which cognitive and educational outcomes were examined. Psychological and mental health variables (such as internalizing and externalizing behavior problems, maternal depression, chronic stress, or exposure to violence) were primarily included as covariates in mental health outcome studies, especially for psychosis. Addiction studies adjusted for youth and maternal alcohol or tobacco use, among other covariates, and physical health outcome studies adjusted for relevant covariates (such as BMI in a study of dietary fat intake and parental height when studying offspring height). In selected articles, maltreatment subtypes were also statistically adjusted for the other types of maltreatment to determine independent effects.

FIGURE 3. Covariates used in published articles from the MUSP to adjust for possible confounding. a Race: child’s race, parental race, and maternal or paternal racial origin at pregnancy. b Child age: child age and gestational age. c Maternal age: maternal age at the first visit clinic or at pregnancy. d Maternal education: maternal education (prenatal or at birth). e Family income: annual family income, familial income over the first 5 years or family poverty before birth or over the first 5 years of life, family income before birth, and annual family income. f Maternal marital status and social support: same partner at birth and 14 years and social support at 5 years. g Maternal depression: maternal depression during pregnancy, 3- to 6-month follow-up, or 21-year follow-up; chronic maternal depression. h Maternal alcohol use: maternal alcohol use at 3- to 6-month or 14-year follow-up and binge drinking. i Maternal cigarette use: cigarette use during pregnancy, 6 months postpartum, or at 14-year follow-up. ADHD, attention-deficit/hyperactivity disorder; CES-D, Center for Epidemiologic Studies–Depression Scale; IPV, intimate partner violence. Covariates used in published articles from the MUSP to adjust for possible confounding.

Covariates used in published articles from the MUSP to adjust for possible confounding. a Race: child’s race, parental race, and maternal or paternal racial origin at pregnancy. b Child age: child age and gestational age. c Maternal age: maternal age at the first visit clinic or at pregnancy. d Maternal education: maternal education (prenatal or at birth). e Family income: annual family income, familial income over the first 5 years or family poverty before birth or over the first 5 years of life, family income before birth, and annual family income. f Maternal marital status and social support: same partner at birth and 14 years and social support at 5 years. g Maternal depression: maternal depression during pregnancy, 3- to 6-month follow-up, or 21-year follow-up; chronic maternal depression. h Maternal alcohol use: maternal alcohol use at 3- to 6-month or 14-year follow-up and binge drinking. i Maternal cigarette use: cigarette use during pregnancy, 6 months postpartum, or at 14-year follow-up. ADHD, attention-deficit/hyperactivity disorder; CES-D, Center for Epidemiologic Studies–Depression Scale; IPV, intimate partner violence. Covariates used in published articles from the MUSP to adjust for possible confounding.

A total of 46 outcomes were assessed at 14 years ( n = 5200) and/or 21 years ( n = 3778) ( Fig 1 ) and were grouped into 5 domains ( Fig 2 ):

Cognition and education outcomes included reading ability and perceptual reasoning measured in adolescence, and, at age 21, receptive verbal intelligence and failure to complete high school or be either enrolled in school or employed; attention problems were measured at both time points.

Psychological and mental health outcomes at 21 years included internalizing and externalizing behavior problems (which were also assessed at 14 years), lifetime anxiety disorder, depressive disorder and symptoms, PTSD, lifetime psychosis diagnosis, psychotic symptoms (such as delusional experience or visual and/or auditory hallucinations), delinquency, experience of IPV or harassment, and overall quality of life.

Addiction and substance use, measured at both time points, included alcohol and cigarette use at 14 and 21 years, and cannabis abuse and/or dependence (including early onset) and injecting-drug use at the 21-year follow-up.

Sexual health was investigated at age 21 in terms of early initiation of sexual experience, having multiple sexual partners, youth pregnancy, and miscarriage or termination.

Physical health outcomes measured at 21 years included symptoms of asthma, high dietary fat intake, poor sleep quality, and height deficits.

The 14-year assessments included a youth questionnaire ( n = 5172) and in-person cognitive testing ( n = 3796). The 21-year visit included an in-person assessment of mental health diagnoses in a subset of the cohort ( n = 2531) with the World Health Organization Composite International Diagnostic Interview (CIDI), which is based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria 45   ( Fig 1 ). All of the questionnaire and interview measures were validated, except for reported frequencies of specific events (ie, pregnancy, number of cigarettes, etc).

Associations were described by using either adjusted odds ratios or mean differences and coefficients, along with the corresponding 95% confidence intervals, and were plotted to visualize and compare the statistical significance of each association across specific outcome categories and types of maltreatment ( Figs 4 – 8 ).

FIGURE 4. Child maltreatment and cognition and educational outcomes at 14 and 21 years. A, Adjusted coefficients ± 95% confidence intervals. B, Odds ratios ± 95% confidence intervals. * P < .05.

Child maltreatment and cognition and educational outcomes at 14 and 21 years. A, Adjusted coefficients ± 95% confidence intervals. B, Odds ratios ± 95% confidence intervals. * P < .05.

FIGURE 5. Child maltreatment and psychological and mental health outcomes at 14 and 21 years. A, Adjusted coefficients ± 95% confidence intervals. B, Odds ratios ± 95% confidence intervals. * P < .05.

Child maltreatment and psychological and mental health outcomes at 14 and 21 years. A, Adjusted coefficients ± 95% confidence intervals. B, Odds ratios ± 95% confidence intervals. * P < .05.

FIGURE 6. Child maltreatment and addiction and substance use outcomes at 14 and 21 years (adjusted odds ratio ± 95% confidence interval). * P < .05.

Child maltreatment and addiction and substance use outcomes at 14 and 21 years (adjusted odds ratio ± 95% confidence interval). * P < .05.

FIGURE 7. Child maltreatment and sexual health outcomes at 21 years (adjusted odds ratio ± 95% confidence interval). * P < .05.

Child maltreatment and sexual health outcomes at 21 years (adjusted odds ratio ± 95% confidence interval). * P < .05.

FIGURE 8. Child maltreatment and physical health outcomes at 21 years. A, Adjusted odds ratio ± 95% confidence interval. B, Adjusted coefficients ± 95% confidence interval. * P < .05.

Child maltreatment and physical health outcomes at 21 years. A, Adjusted odds ratio ± 95% confidence interval. B, Adjusted coefficients ± 95% confidence interval. * P < .05.

The MUSP was approved by the Human Ethics Review Committee of The University of Queensland and the Mater Misericordiae Children’s Hospital. Ethical approval was obtained separately from the Human Ethics Review Committee of The University of Queensland for linking substantiated child maltreatment data to the 21-year follow-up data.

In this cohort of 7214 children ( Fig 1 ), 7.1% ( n = 511 children) experienced at least 1 episode of substantiated maltreatment. Substantiated sexual abuse was reported in 2.0% ( n = 147), physical abuse in 4.0% ( n = 287), emotional abuse in 3.7% ( n = 267), and neglect in 3.7% of cases ( n = 269) ( Table 1 ). Almost 60% of the children with substantiated maltreatment had multiple substantiated episodes (293 children; range: 2–14 episodes per child; median: 3 episodes per child 37   ). Of the 3778 young adults included in the 21-year follow-up, 4.5% ( n = 171) had a history of substantiated maltreatment, 39   including sexual abuse ( n = 53), physical abuse ( n = 60), emotional abuse ( n = 71), and neglect ( n = 89).

More than half of the children who experienced substantiated maltreatment were reported for ≥2 co-occurring maltreatment types ( Table 1 ). Of the substantiated sexual abuse cases, 57.1% of the children experienced ≥1 additional maltreatment types (84 of 147); for physical abuse, this proportion was 79.1% (227 of 287); for emotional abuse, 83.5% (223 of 267); and for neglect, 73.6% (198 of 269). In particular, emotional abuse and neglect co-occurred, with or without other types of maltreatment, in ∼59% of cases. 46  

Nonexclusive and Exclusive Categorization of Child Maltreatment Subtypes (Single and in Combination) Within the MUSP Cohort

Abuse (a combined category) and neglect were both associated with significantly lower cognitive scores at both 14 and 21 years, as well as with negative long-term educational and employment outcomes in young adulthood. 19 , 20   This was after adjusting for factors such as the child’s race, sex, birth weight, breastfeeding exposure, and age; family income; and maternal education and alcohol and/or tobacco use ( Fig 3 ). Specifically, proxy measures of IQ, such as reading ability and perceptual reasoning, at age 14 years were adversely associated with both substantiated abuse and neglect. 19   Sexual abuse was associated with attention problems in adolescence, whereas nonsexual maltreatment was associated with attention problems at both time points. 21   Young adults who experienced substantiated child maltreatment had reduced scores on the Peabody Vocabulary Test at 21 years. In terms of educational outcomes in young adulthood, both abuse and neglect manifested a threefold to fourfold increase in odds of failing to complete high school and a twofold to threefold increase in the likelihood of being unemployed at age 21 years 20   ( Figs 2 and 4 ).

During adolescence, physical abuse, emotional abuse, and neglect were all significantly associated with both internalizing and externalizing behavior problems, although this was not the case for physical abuse notifications without co-occurring emotional abuse or neglect. 22   After adjustment for relevant sociodemographic variables, the associations with emotional abuse and neglect remained significant at 21 years. 39   No statistically significant association was found between sexual abuse and these behavior problems at either time point.

Psychological maltreatment in childhood was associated with all of the other 15 psychological and mental health outcomes in young adulthood, except for delinquency in women. This was true after adjustment for sociodemographic variables and psychological and mental health problems (such as attention-deficit/hyperactivity disorder, aggressive behavior problems, and maternal depression or adverse life events, in the case of psychosis and/or IPV exposure outcomes) ( Fig 3 ). Specifically, both emotional abuse and neglect were significantly associated at 21 years with all of the following outcomes: anxiety, depression, PTSD, psychosis (with some exceptions), delinquency in men, and experiencing IPV and harassment (except for neglect). 22 – 25 , 39   Emotional abuse and neglect were the only maltreatment subtypes associated with a significant decrease in quality-of-life scores. 36  

The only mental health outcomes associated with sexual abuse were clinical depression, lifetime PTSD, and experiencing physical IPV. 8 , 25 , 39   Physical abuse was associated with externalizing behavior problems and delinquency (in men), internalizing behavior problems and depressive symptoms, experience of IPV, and PTSD 22 , 24 , 25 , 39   ( Figs 2 and 5 ).

Overall, emotional abuse and/or neglect were associated with all categories of substance use and addiction at both 14 and 21 years, whereas physical and sexual abuse were associated with surprisingly few substance abuse outcomes. Specifically, childhood emotional abuse and neglect were associated with adolescent substance use at age 14, including alcohol use and smoking. 26   This was after adjustment for sociodemographic factors and youth and maternal drug use. The association with cigarette and alcohol use persisted from adolescence to adulthood. The category of "any cigarette use" was the only addiction outcome associated with all 4 types of maltreatment. 40   At 21 years, emotional abuse and neglect were both associated with the early onset of cannabis abuse after adjustment for maternal stress and cigarette use. Additionally, physical abuse, emotional abuse, and neglect all revealed increased odds of cannabis dependence at age 21, with early onset associated with physical abuse and neglect. 28   In contrast, only emotional abuse significantly predicted injecting-drug use in young adult men, after adjustment for maternal alcohol use and depression, whereas all types of substantiated childhood maltreatment were associated with injecting-drug use in women. 27   Sexual abuse was not associated with any addiction or substance use outcome except for cigarette use at 21 years ( Figs 2 and 6 ).

All forms of maltreatment were significantly associated, at 21 years, with early onset of sexual activity and subsequent youth pregnancy. This was after adjustment for factors such as gestational age, youth psychopathology, and drug use. Neglect was the only type of maltreatment associated with having multiple sexual partners and was the maltreatment type most strongly associated with most other sexual health outcomes, especially youth pregnancy. Pregnancy miscarriage was modestly associated with emotional abuse, whereas termination of pregnancy was not associated with any maltreatment subtype 31   ( Figs 2 and 7 ).

Reduced adult height at 21 years, adjusted for parental height, was associated with all maltreatment subtypes except sexual abuse (which was not associated with any of the physical health outcomes). At 21 years, physical abuse was also associated with high dietary fat intake, a risk factor for obesity (adjusted for BMI), and poor sleep quality in men (adjusted for psychopathology and drug use). Asthma at 21 years revealed a modest association with emotional abuse. The combined category of any maltreatment was also associated with high dietary fat intake ( Figs 2 and 8 ).

To estimate the magnitude of potential effects of child maltreatment on long-term outcomes, other studies have used a number of statistical techniques. In one Australian study that used the MUSP and other data sets, the population attributable risk of child maltreatment causing anxiety disorders in men and women, was estimated to be 21% and 31%, respectively, and 16% and 23% for depressive disorders. 46   Similarly, in the MUSP study on cognitive and educational outcomes of maltreated youth, the population attributable risk of child maltreatment leading to “failure to complete high school” was 13%, and 14% for “failure to be in either education or employment at 21 years.” 20  

Based on one published metric of effect size using the magnitude of the adjusted odds ratio, 47   77% of the statistically significant associations in this review were considered to have a medium to large effect size (odds ratio ≥2), including 10% with a large effect size (odds ratio >4) ( Fig 2 ).

In summary, over the past decade, the MUSP has revealed that child maltreatment is associated with a broad array of adverse outcomes during adolescence and young adulthood, including the following:

deficits in cognitive development, attention, educational attainment, and employment;

serious mental health problems, including anxiety, depression, PTSD, and psychosis, as well as delinquency and the experience of IPV;

substance use and addiction problems;

sexual health problems; and

physical health limitations and risk.

These results were seen after adjustment for a broad range of relevant sociodemographic, perinatal, psychological, and other risk factors ( Fig 3 ). Many of the studies also adjusted for the other subtypes of child maltreatment and demonstrated that specific maltreatment types were closely associated with particular outcomes.

Significant cognitive delays and educational failure were seen for both abuse and neglect across adolescence and adulthood. In another study, the authors concluded that preexisting cognitive impairments at 3 or 5 years may explain this association, rather than maltreatment per se. 16   However, other research has revealed that children neglected over the first 4 years of life show a progressive decline in cognitive functioning, which is associated with a significantly reduced head circumference at 2 and 4 years of age. 48   In rodent models, contingent maternal behavior is linked with infant cognitive development, and possible mechanisms include increases in synaptic connections within the hippocampus 49   and reduced apoptotic cell loss. 50   Prolonged maternal separation, in contrast, is associated with impaired cognitive development in rodent and primate models. 51 , 52  

One of the most striking conclusions from this review was the broad association between emotional abuse and/or neglect and adverse outcomes in almost all areas of assessment ( Fig 2 ). In stark contrast, physical abuse and sexual abuse were associated with far fewer adverse outcomes. Overall, quality of life was lower for those who had experienced emotional abuse and neglect but not for those who had experienced physical or sexual abuse. Although emotional abuse and neglect often co-occur with other types of maltreatment, 46   the associated outcomes were generally robust even after statistical adjustment or separation into differing maltreatment categories ( Fig 2 ).

Emotional abuse and neglect in early childhood may lead to psychopathology via insecure attachment, 53 , 54   which has been associated with externalizing behavior problems 55   and impaired social competence. 56 , 57   Emotional neglect, in particular, may lead to deficits in emotion recognition and regulation, as well as insensitivity to reward, 3   potentially influencing social and emotional development. Neglected children are less able to discriminate facial expressions and emotions, 58   whereas youth who have been emotionally neglected show blunted development of the brain’s reward area, the ventral striatum. 59   Reduced reward activation may predict risk for depression, 59   addiction, 60   and other psychopathologies. 61  

Neglect was also associated with the early onset of sexual activity, multiple sexual partners, and youth pregnancy, even after adjustment for other maltreatment subtypes. This suggests that neglect may result in compensatory efforts to obtain sexual intimacy, consistent with other studies revealing higher rates of unprotected sex 62   and adolescent pregnancy in neglected children. 63   In the animal literature, female rodents that experience maternal deprivation tend to have an earlier onset of puberty and increased sexual receptivity, leading to elevated reproductive activity to help offset an environment of higher offspring risk. 64 , 65  

As observed elsewhere, 66   sexual abuse was associated with early sexual experimentation and youth pregnancy as well as symptoms of PTSD and depression. Risky sexual behaviors were independent of other types of maltreatment but were not specific for sexual abuse. An additional MUSP study comparing self-reported and agency-notified child sexual abuse revealed consistent associations with major depressive disorder, anxiety disorders, and PTSD. 8   The absence of associations with other adverse outcomes, however, may be, in part, due to the lower prevalence of substantiated sexual abuse, especially at the 21-year follow-up.

Outcomes associated with physical abuse differed from those associated with sexual abuse, with increased odds of externalizing behavior problems, and delinquency in men. Jaffee 3   suggests that physical abuse, in particular, may lead to a hypervigilance response to threat, including negative attentional bias, disproportionate to relatively mild threat cues. Studies have revealed that physically abused children show selective attention to anger cues, 67   have difficulty disengaging from them, 58 , 68   and are more likely to misinterpret facial cues as being angry or fearful. 69  

Although these studies demonstrated significant associations between maltreatment and a range of long-term outcomes, association does not equal causality. The causal mechanisms proposed above are tentative and may relate to multiple types of maltreatment.

Other limitations should also be considered. Firstly, selective attrition of socioeconomically disadvantaged and maltreated young people was evident in the MUSP cohort ( Supplemental Information ). However, based on multiple imputation calculations and inverse probability weighting of MUSP data, 18 , 70   differences in the rate of loss to follow-up, for both dependent and independent variables, made little difference to either the estimates or their precision, mirroring findings from other longitudinal studies. 71   In addition, the findings were mostly unchanged when using propensity analysis, which is used to assess the effects of nonrandom sampling variation by analyzing the probability of assignment to a particular category within an observational study given the observed covariates. 72   Specifically, the sample was weighted so that it better resembled sociodemographic characteristics at baseline to minimize bias from differential attrition in those with greater socioeconomic disadvantage.

Secondly, differences in the prevalence of specific maltreatment subtypes might have influenced the statistical power to detect true effects, particularly regarding sexual abuse ( Table 1 ).

Finally, the co-occurrence of different types of maltreatment may have impacted the ability to accurately predict the associations between specific types of maltreatment and outcomes. Other studies have revealed that emotional abuse and neglect, in particular, are more likely to co-occur with each other and with other types of maltreatment. 73   However, even in those articles that statistically adjusted for other co-occurring maltreatment subtypes, the associated outcomes linked with emotional abuse and/or neglect were generally robust. In articles that did not adjust for these co-occurrences, some of the strongest associations were still observed for emotional abuse and/or neglect.

Child maltreatment, particularly psychological maltreatment, is associated with a broad range of negative long-term health and developmental outcomes extending into adolescence and young adulthood. Although these data do not establish causality, neurodevelopmental pathways are likely influenced by stress and early social experience through epigenetic mechanisms, which may affect gene expression and regulation and, ultimately, behavior and development. 3 , 74  

Understanding the developmental roots of these adverse outcomes may motivate physicians to more systematically inquire about early-life trauma and refer patients to more appropriate treatment services. 75 , 76   Even more importantly, early intervention and prevention programs, such as prenatal and infancy nurse home visiting, 77   have demonstrated, in randomized clinical trials, diminished rates of child abuse and neglect. 78 , 79   Long-term benefits to the offspring include decreased childhood internalizing problems, 80   reduced antisocial behavior and substance abuse in adolescence, 81   and improved cognitive skills extending into young adulthood. 80 , 82   Supporting at-risk parents and young children should thus be an urgent priority.

Dr Strathearn conceptualized and designed the original study linking the Mater-University of Queensland Study of Pregnancy data set with substantiated reports of child maltreatment, drafted the special article, and reviewed and revised the manuscript; Dr Giannotti assisted in drafting the manuscript and prepared all tables and figures; Drs Mills, Kisely, and Abajobir conceptualized and wrote the original research articles summarized in this article; Dr Najman was the original principal investigator of the Mater-University of Queensland Study of Pregnancy; and all authors critically reviewed the manuscript for important intellectual content and approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Partially supported by the US National Institute on Drug Abuse (R01DA026437). The content is solely the responsibility of the authors and does not necessarily represent the official views of this institute or the National Institutes of Health. Funded by the National Institutes of Health (NIH).

Composite International Diagnostic Interview

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posttraumatic stress disorder

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Psychiatry Online

  • February 01, 2024 | VOL. 181, NO. 2 CURRENT ISSUE pp.83-170
  • January 01, 2024 | VOL. 181, NO. 1 pp.1-82

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The Devastating Clinical Consequences of Child Abuse and Neglect: Increased Disease Vulnerability and Poor Treatment Response in Mood Disorders

  • Elizabeth T.C. Lippard , Ph.D. ,
  • Charles B. Nemeroff , M.D., Ph.D.

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A large body of evidence has demonstrated that exposure to childhood maltreatment at any stage of development can have long-lasting consequences. It is associated with a marked increase in risk for psychiatric and medical disorders. This review summarizes the literature investigating the effects of childhood maltreatment on disease vulnerability for mood disorders, specifically summarizing cross-sectional and more recent longitudinal studies demonstrating that childhood maltreatment is more prevalent and is associated with increased risk for first mood episode, episode recurrence, greater comorbidities, and increased risk for suicidal ideation and attempts in individuals with mood disorders. It summarizes the persistent alterations associated with childhood maltreatment, including alterations in the hypothalamic-pituitary-adrenal axis and inflammatory cytokines, which may contribute to disease vulnerability and a more pernicious disease course. The authors discuss several candidate genes and environmental factors (for example, substance use) that may alter disease vulnerability and illness course and neurobiological associations that may mediate these relationships following childhood maltreatment. Studies provide insight into modifiable mechanisms and provide direction to improve both treatment and prevention strategies.

“It is not the bruises on the body that hurt. It is the wounds of the heart and the scars on the mind.” —Aisha Mirza

“We can deny our experience but our body remembers.” —Jeanne McElvaney, Spirit Unbroken: Abby’s Story

It is now well established that childhood maltreatment, or exposure to abuse and neglect in children under the age of 18, has devastating consequences. Over the past two decades, research has begun not only to define the consequences in the context of health and disease but also to elucidate mechanisms underlying the link between childhood maltreatment and medical, including psychiatric, outcomes. Research has begun to shed light on how childhood maltreatment mediates disease risk and course. Childhood maltreatment increases risk for developing psychiatric disorders (e.g., mood and anxiety disorders, posttraumatic stress disorder [PTSD], antisocial and borderline personality disorders, and substance use disorders). It is associated with an earlier age at onset and a more severe clinical course (i.e., greater symptom severity) and poorer treatment response to pharmacotherapy or psychotherapy. Early-life adversity is also associated with increased vulnerability to several major medical disorders, including coronary artery disease and myocardial infarction, cerebrovascular disease and stroke, type 2 diabetes, asthma, and certain forms of cancer. The net effect is a significant reduction in life expectancy in victims of child abuse and neglect. The focus of this review is to expand on previous reviews by synthesizing the literature and integrating much recent data, with a focus on investigating childhood maltreatment interactions with risk for mood disorders, disease onset, and early disease heterogeneity, as well as emerging data suggesting modifiable mechanisms that could be targeted for early intervention and prevention strategies. A major emphasis of this review is to provide a clinically relevant update to practicing mental health practitioners.

Prevalence and Consequences of Childhood Maltreatment

It is estimated that one in four children will experience child abuse or neglect at some point in their lifetime, and one in seven children have experienced abuse over the past year. In 2016, 676,000 children were reported to child protective services in the United States and identified as victims of child abuse or neglect ( 1 ). However, it is widely accepted that statistics on such reports represent a significant underestimate of the prevalence of childhood maltreatment, because the majority of abuse and neglect goes unreported. This is especially true for certain types of childhood maltreatment (notably emotional abuse and neglect), which may never come to clinical attention but have devastating consequences on health independently of physical abuse and neglect or sexual abuse. Although rates of children being reported to child protective services have remained relatively consistent over recent decades ( Figure 1 ), our understanding of the devastating medical and clinical consequences of childhood maltreatment has grown, and childhood maltreatment is now well established as a major risk factor for adult psychopathology. In this review, we seek to summarize the burgeoning literature on childhood maltreatment, specifically focusing on the link between childhood maltreatment and mood disorders (depression and bipolar disorder). The data converge to point toward future directions for education, prevention, and treatment to decrease the consequences of childhood maltreatment, especially in regard to mood disorders.

FIGURE 1. National estimates of childhood maltreatment in the United States a

a Panel A graphs the prevalence of maltreatment (calculated national estimate/rounded number of victims by year, and panel B graphs rates of victimization per 1,000 children, between 1999 and 2016, as reported by the Children’s Bureau, which produces an annual Child Maltreatment report including data provided by the United States to the National Child Abuse and Neglect Data Systems. Estimated rates of maltreatment have remained high over the past two decades. The asterisk calls attention to the fact that before 2007, the national estimates were based on counting a child each time he or she was the subject of a child protective services investigation. In 2007, unique counts started to be reported. The unique estimates are based on counting a child only once regardless of the number of times he or she is found to be a victim during a reporting year. (Information obtained from https://www.acf.hhs.gov/cb/research-data-technology/statistics-research/child-maltreatment .)

Childhood Maltreatment Increases Risk for Illness Severity and Poor Treatment Response in Mood Disorders

The link between childhood maltreatment and risk for mood disorders and differences in disease course following illness onset has been well documented ( 2 – 8 ). Multiple studies have demonstrated greater rates of childhood maltreatment in patients with major depression and bipolar disorder ( 9 – 11 ). Indeed, a recent meta-analysis revealed that 46% of individuals with depression report childhood maltreatment ( 12 ). Patients with bipolar disorder also report high levels of childhood maltreatment ( 13 , 14 ), with estimates as high as 57% ( 15 ). Childhood maltreatment is associated with an increased risk and earlier onset of unipolar depression, with syndromal depression occurring on average 4 years earlier in individuals with a history of childhood maltreatment compared with those without such a history ( 12 ). Childhood maltreatment is also associated with a more pernicious disease course, including a greater number of lifetime depressive episodes and greater depression severity, with the majority of studies showing more recurrence and greater persistence of depressive episodes ( 16 – 18 ). For example, Wiersma et al. ( 19 ), in an analysis of 1,230 adults with major depressive disorder drawn from the Netherlands Study of Depression and Anxiety, found that childhood maltreatment (measured with the Childhood Trauma Interview) was associated with chronicity of depression, defined as being depressed for ≥24 months over the past 4 years, independent of comorbid anxiety disorders, severity of depressive symptoms, or age at onset. Increased risk for suicide attempts and comorbidities, including increased rates of anxiety disorders, PTSD, and substance use disorders, are reported in individuals with depression who experience childhood maltreatment. Individuals with major depressive disorder and atypical features report significantly more traumatic life events (including physical abuse, sexual abuse, and other forms of trauma) both before and after their first depressive episode, independently of sex, age at onset, or duration of depression ( 20 ). Additionally, childhood maltreatment has consistently been shown to be associated with poor treatment outcome (after psychotherapy, pharmacotherapy, and combined treatment) in depression, as assessed by lack of remission or response or longer time to remission ( 12 , 18 , 21 , 22 ).

Although the studies cited above describe a link between childhood maltreatment and a more pernicious depression course, most studies have been cross-sectional, and the possibility of recall bias and mood effects (owing to the retrospective investigation of childhood maltreatment in individuals who are currently depressed) cannot be ruled out. However, studies over the past few years comparing retrospective and prospective measurement of childhood maltreatment suggest consistency between retrospective reports and prospective designs ( 23 , 24 ), although a recent meta-analysis ( 25 ) suggested poor agreement between these measures, with better agreement observed when retrospective measures were based on interviews and in studies with smaller samples. Longitudinal and prospective studies are emerging that have further confirmed and extended our understanding of the devastating consequences of childhood maltreatment on illness course ( 5 , 7 ). Ellis et al. ( 26 ) recently reported that childhood maltreatment increased risk for more severe trajectories of depressive symptoms during a 7-year longitudinal study in 243 adolescents in the Orygen Adolescent Development Study. Gilman et al. ( 27 ) reported that childhood maltreatment increased the risk for recurrent depressive episodes and suicidal ideation by 20%−30% during a 3-year follow-up of 2,497 participants diagnosed with major depressive disorder in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Additionally, Widom et al. ( 7 ), in a study that followed a cohort of 676 children with documented childhood maltreatment and compared risk for major depression in adulthood between them and a cohort of 520 children matched on age, race, sex, and family social class who were not exposed to childhood maltreatment, found a clear association between childhood maltreatment and both increased risk for depression and earlier onset of the disorder.

Although more research has been reported investigating the link between childhood maltreatment and disease onset and course in unipolar depression, more recent evidence supports the link between childhood maltreatment and disease onset and course in bipolar disorder ( 28 ). Childhood maltreatment is associated with increased disease vulnerability and earlier age at onset of bipolar disorder ( 29 ). Jansen et al. ( 30 ) sought to determine whether childhood maltreatment mediated the effect of family history on diagnosis of a mood disorder. The findings indicated that one-third of the effect of family history on risk for mood disorders was mediated by childhood maltreatment. As with depression, studies on bipolar disorder with a prospective or longitudinal approach are few, but they are informative. Using data from the NESARC (N=33,375), Gilman et al. ( 31 ) found that childhood physical and sexual abuse were associated with increased risk for first-onset and recurrent mania independently of recent life stress. An association between childhood maltreatment and prodromal symptoms has also been reported in bipolar disorder ( 32 ), suggesting that childhood maltreatment may contribute to disease vulnerability before onset of the first manic episode. Childhood maltreatment in the context of bipolar disorder is also associated with a more pernicious disease course, including greater frequency and severity of mood episodes (both depressive and manic), greater severity of psychosis symptoms, and greater risk for comorbidities (i.e., anxiety disorders, PTSD, substance use disorders), rapid cycling, inpatient hospitalizations, and suicide attempts ( 28 , 33 – 41 ). Studies are beginning to emerge investigating treatment response in bipolar disorder following childhood maltreatment. Such studies remain few, but they suggest that childhood maltreatment is associated with a poor response to benzodiazepines ( 42 ) and anticonvulsants ( 41 ) in bipolar disorder. The concatenation of findings in depression and bipolar disorder are concordant in that childhood maltreatment increases risk for, and early onset of, first mood episode and episode recurrence. Childhood maltreatment affects disease trajectories, including in its association with more insidious mood episodes, poor treatment response, a greater risk for comorbidities, and a greater risk for suicide ideation, attempts, and completion. The link between childhood maltreatment and increased prevalence of suicide-related behaviors is of particular importance given the high rate of suicide ideation, attempts, and completion in depression and bipolar disorder. Despite many prevention strategies (e.g., education and outreach and clinical studies to identify risk factors for impending suicide attempts in individuals with mood disorders), suicide rates have not decreased but in fact have increased in the United States. The link between childhood maltreatment and suicide-related behavior has been reviewed by several groups ( 21 , 33 , 43 – 47 ). Dube et al. ( 48 ) reported that adverse childhood experiences, including childhood maltreatment, increased the risk for suicide attempts twofold to fivefold in 17,337 adults in the now classic Adverse Childhood Experiences Study. Gomez et al. ( 49 ) reported that physical or sexual abuse increased the odds of suicide ideation, planning, and attempts among the 9,272 adolescents in the U.S. National Comorbidity Survey Adolescent Supplement. Miller et al. ( 50 ) examined the relationship between childhood maltreatment and prospective suicidal ideation in a cohort of 682 youths followed over a 3-year period. Emotional maltreatment predicted suicidal ideation, independently of previous suicidal ideation and depressive symptom severity. Childhood maltreatment is also associated with earlier age at first suicide attempt ( 51 ). Additionally, an association between childhood maltreatment and suicide risk in 449 individuals age 60 or older was recently reported from the Multidimensional Study of the Elderly, in the Family Health Strategy in Porto Alegre, Brazil ( 52 ). The effect was independent of depressive symptom severity. These findings suggest that childhood maltreatment increases risk for suicide-related behavior across the lifespan. More work is warranted in investigating the biological mechanisms that may mediate the association between childhood maltreatment and suicide-related behaviors.

Timing of Childhood Maltreatment: Are There Periods of Heightened Sensitivity?

Although childhood maltreatment at any age can result in long-lasting consequences ( 53 ), there is evidence that the timing, duration, and severity of maltreatment mediate the risk for later psychopathology ( 54 ). Childhood maltreatment that occurs earlier in life and continues for a longer duration is associated with the worst outcomes ( 55 ). This is supported by preclinical models (rodent and nonhuman primate) that investigated maternal separation ( 56 , 57 ), a paradigm more similar to neglect in humans. One study in rodents found that maternal separation during the early postnatal period (days 2–15) but not the later postnatal period (days 7–20) is associated with anxious and depressive-like behaviors in adulthood ( 57 ). Although this postnatal period coincides with in utero development in humans, there is evidence that in utero insults in the form of stress can have consequences similar to early-life trauma ( 58 , 59 ), supporting the translational validity of these models. Clinical studies also support the importance of timing of childhood maltreatment in moderating risk for psychopathology. Cowell et al. ( 60 ) investigated the timing and duration of childhood maltreatment in 223 maltreated children between the ages of 3 and 9 and found that children who were maltreated during infancy and those who experienced chronic maltreatment had poorer inhibitory control and working memory. Dunn et al. ( 61 ) investigated the relationship between timing of childhood maltreatment and depression and suicidal ideation in early adulthood among 15,701 participants in the National Longitudinal Study of Adolescent Health, and found that exposure to early maltreatment, especially during the preschool years (between ages 3 and 5), was most strongly associated with depression. Additionally, sexual abuse occurring during early childhood, compared with adolescence, was reported to be more strongly associated with suicidal ideation ( 61 ). While these studies suggest that childhood maltreatment that occurs earlier in development may further increase risk for developing mood disorders and associated behaviors in adulthood, it is important to emphasize that evidence suggests that exposure to maltreatment during later childhood and adolescence also independently increases risk for mood disorders. Emotional abuse and neglect, especially if it occurs between ages 8 and 9, increases depressive symptoms ( 62 ). Emotional abuse during adolescence also increases risk for depression ( 63 ).

More work is emerging investigating the negative consequences of bullying. A study of 1,420 participants (ages 9–16) revealed that victims of bullying showed an increased prevalence of generalized anxiety disorder, depression, and suicide-related behavior ( 64 ). A recent study of more than 5,000 children that comprised a longitudinal data set (the Avon Longitudinal Study of Parents and Children in England and the Great Smoky Mountains Study in the United States) ( 65 ) found an increased risk for mental health problems, including anxiety, depression, and self-harm, in individuals who experienced bullying, but not other maltreatment. Additionally, an association between childhood bullying by peers and risk for suicide-related behaviors (ideation, planning, attempting, and onset of plan among ideators), independent of childhood maltreatment by adults, was reported in a sample of U.S. Army soldiers ( 66 ).

Some studies suggest that differential periods of sensitivity to different subtypes of maltreatment are distinctly associated with an increased risk for mood disorders. Recently, a stronger relationship was reported between adult depression and early childhood sexual abuse (occurring at age 5 or earlier) and later childhood physical abuse (occurring at age 13 or later), compared with maltreatment that occurred during other developmental periods ( 67 ). Harpur et al. ( 68 ) reported that early childhood maltreatment (between birth and age 4) predicted more anxiety symptoms, and maltreatment that occurred in late childhood or early adolescence (between ages 10 and 12) predicted more depressive symptoms in adolescence. Taken together, these studies suggest that maltreatment at any age and across different contexts (physical and emotional, familial- and peer-induced) often result in long-lasting and severe consequences and that there may be specific sensitive periods in development when exposure to distinct types of maltreatment may differentially increase risk for affective disorders in adulthood. To date, the majority of research investigating the impact of childhood maltreatment timing on illness risk and course in mood disorders has focused on depression. One study ( 69 ) reported that early sexual or physical abuse (before age 11) in 225 early psychosis patients (6.7% with a bipolar disorder diagnosis) coincided with lower scores on the Global Assessment of Functioning Scale and the Social and Occupational Functioning Assessment Scale during a 3-year follow-up period, whereas late sexual or physical abuse (between ages 12 and 15) did not. More work investigating timing of maltreatment and associated clinical outcomes is warranted.

Experiencing Single Subtypes of Abuse and Neglect Versus Experiencing Multiple Types

Several groups have sought to determine the impact of single types of childhood maltreatment on mood disorders. Although all types of childhood maltreatment (physical, emotional, and sexual) increase disease vulnerability and risk for more severe illness course in mood disorders, including increased risk for suicide ( 52 ), there may be some distinctions between individual subtypes and associated outcomes ( 70 ). An association between sexual abuse and lifetime risk for anxiety disorders, depression, and suicide attempts independent of other types of maltreatment has been reported ( 2 , 71 , 72 ). In bipolar disorder, physical abuse and sexual abuse independently increase risk for illness vulnerability and more severe course ( 13 ). One study of 446 youths (ages 7 to 17) found that physical abuse was independently associated with a longer duration of illness in bipolar disorder, a greater prevalence of comorbid PTSD and psychosis, and a greater prevalence of family history of a mood disorder when compared with sexual abuse, which was only associated with a greater prevalence of PTSD ( 13 ). Recent life stress in adulthood was found to increase risk for first-onset mania in individuals with a history of childhood physical maltreatment, but not individuals with a history of sexual maltreatment ( 31 ). However, it should be noted that early-life sexual abuse in the study was a strong risk factor for mania even in the absence of recent life stress.

Neglect is the least studied form of early-life adversity, and emerging data suggest differential consequences following neglect as compared with abuse ( 73 ). Similarly, long-lasting consequences following emotional maltreatment, independently of other forms of maltreatment, have also been reported ( 47 , 74 , 75 ). In a 2015 meta-analysis, emotional abuse showed the strongest association with depression, followed by neglect and sexual abuse ( 76 ), a finding supported by another recent meta-analysis ( 77 ). Spertus et al. ( 78 ) reported that emotional abuse and neglect predicted depressive symptoms even after controlling for physical and sexual abuse, further suggesting emotional abuse and neglect to be independently related to illness severity in depression. Parental “verbal aggression” was found to increase risk for depression and anxiety in adolescents, with risk suggested to be greater following verbal aggression compared with physical abuse ( 79 ). Khan et al. ( 63 ) recently reported that nonverbal emotional abuse in males and peer emotional abuse in females are important predictors of lifetime history of major depression and are more predictive than number of types of maltreatment experienced. Another recent meta-analysis ( 12 ) reported that in individuals with depression, emotional neglect was the most common reported form of childhood maltreatment, and emotional abuse was most closely related to symptom severity. High prevalence of emotional maltreatment is also reported in bipolar disorder (approximately 40%), with emotional maltreatment associated with disease vulnerability and more severe illness course, including rapid cycling, comorbid anxiety or stress disorders, suicide attempts or ideation, and cannabis use ( 80 ).

Although studies on subtypes of maltreatment are only now burgeoning, they are concordant in implicating emotional maltreatment, in addition to physical and sexual maltreatment, in increasing risk for, and differences in disease course of, mood disorders. Emotional maltreatment and neglect are clearly the least studied of all forms of childhood adversity. This is in part because they are often overlooked and least likely to come to clinical attention, as compared with physical and sexual abuse, which can, of course, result in physical injury. Because emotional maltreatment and neglect are likely the most prevalent forms of childhood maltreatment in psychiatric populations ( 81 ), and given findings suggesting that independent of other forms of maltreatment, emotional maltreatment has long-lasting consequences that increase risk for mood disorders and illness outcome ( 74 , 75 ), more research on the role of emotional maltreatment and neglect are urgently needed.

Although the findings described above suggest the hypothesis that different subtypes of early-life adversity may independently increase risk for mood disorders and that some subtypes may be more closely related to specific differences in illness course and severity, it is clear that subtypes of abuse and neglect, as a rule, do not occur in isolation but instead occur together in the same individuals. For example, individuals experiencing physical or sexual abuse likely also experience emotional maltreatment. Some studies have investigated the impact of multiple types of childhood maltreatment. A recent meta-analysis reported that 19% of individuals with major depression report more than one form of childhood maltreatment and, while all childhood maltreatment subtypes have been shown to increase the risk of depression, experiencing multiple forms of childhood maltreatment further elevates this risk ( 12 ). The Adverse Childhood Experiences study provided evidence of an additive effect of eight early-life stress events (including abuse but also other early-life stressors, such as divorce, domestic violence, household substance abuse, and parental loss) on adult psychopathology. Specifically, individuals with four or more early-life stress events had significantly increased risk for depression, anxiety, suicide attempts, substance use disorders, and other detrimental outcomes ( 82 , 83 ). An additive or cumulative effect of early-life stress on increased risk for mood, anxiety, and substance use disorders has also been reported by others ( 5 , 6 ). Multiple adverse childhood experiences (maltreatment plus other forms of stressful events) also result in higher rates of comorbidities ( 7 , 82 ). Likewise, a dose-response relationship between number of types of childhood maltreatment and illness severity in bipolar disorder has been suggested, including increased risk for comorbid anxiety disorders and substance use disorders ( 84 ).

Underlying Mechanisms by Which Childhood Maltreatment Increases Risk for Mood Disorders and Contributes to Disease Course

As depicted in Figure 2 , several putative biological mechanisms by which childhood maltreatment may increase the risk for mood disorders and disease progression have been described ( 21 , 85 ). These include, but are not limited to, inflammation and other immune system perturbations, alterations in the hypothalamic-pituitary-adrenal (HPA) axis, and genetic and epigenetic processes as well as structural and functional brain imaging changes. These studies provide insight into modifiable targets and provide direction to improve both treatment and prevention strategies.

FIGURE 2. Child maltreatment, its consequences, and windows for intervention across development a

a The gray arrow represents the development of disease vulnerability, disease onset, and variations in disease course and treatment. Exposure to childhood maltreatment at any point during development (red bar) can result in long-lasting consequences, including increasing disease vulnerability and illness severity in mood disorders. There may be optimal windows (black arrows) across development when interventions could decrease disease burden by decreasing disease vulnerability and improving illness course; these include before and after birth (parenting classes and parenting support groups), at the time of maltreatment, when prodromal symptoms begin to emerge, immediately following disease onset, and during disease course (e.g., improving treatment response). Modifiable targets are beginning to emerge (green arrows and text) and point to behavioral and environmental factors, as well as genetic and other molecular factors, that could be focused on for interventions.

Biological Abnormalities Associated With Childhood Maltreatment

Several persistent biological alterations associated with childhood maltreatment may mediate the increased risk for development of mood and other disorders. Childhood maltreatment is associated with systemic inflammation ( 86 , 87 ) as assessed by measurements of C-reactive protein (CRP) and inflammatory cytokines including tumor necrosis factor-alpha and interleukin-6. Childhood maltreatment was found to be associated with increased plasma CRP levels and increased body mass index in 483 participants identified as being on the psychosis spectrum ( 88 ). Patients with depression and bipolar disorder have also been reported to exhibit increased levels of inflammatory markers ( 89 – 92 ). It is unclear whether childhood maltreatment–associated inflammation is responsible for the observations in patients with mood disorders. Anti-inflammatory drugs are a promising novel therapeutic strategy in the subgroup of depressed patients with elevated inflammation ( 93 ), although the findings thus far are preliminary, and further study on inflammation as a modifiable target is warranted.

Another mechanism through which childhood maltreatment may increase risk for mood disorders is through alterations of the HPA axis and corticotropin-releasing factor (CRF) circuits that regulate endocrine, behavioral, immune, and autonomic responses to stress. Research documenting how childhood maltreatment contributes to altered HPA axis and CRF circuit activity in preclinical and clinical studies has been reviewed in detail elsewhere ( 21 ). Childhood adversity likely increases sensitivity to the effects of recent life stress on the course of both unipolar and bipolar disorder. Soldiers exposed to childhood maltreatment have a greater risk for depression or anxiety following recent life stressors ( 94 ). Likewise, individuals exposed to childhood maltreatment have a greater risk of mania following recent life stressors compared with individuals without childhood maltreatment ( 31 , 34 ). Individuals with depression or bipolar disorder and early-life stress report lower levels of stress prior to recurrence of a mood episode compared with individuals with depression or bipolar disorder without early-life stress ( 34 , 95 ); this suggests that less stress is required to induce a mood episode in individuals who were exposed to childhood maltreatment. These findings support theoretical sensitization frameworks on the role of stress in unipolar depression and bipolar disorder ( 96 – 99 ). Alterations in the HPA axis and CRF circuits following childhood maltreatment are mechanisms that likely contribute to increased risk for mood episodes following stressful life events and may be modifiable targets. Indeed, Abercrombie et al. ( 100 ) recently reported that therapeutics targeting cortisol signaling may show promise in the treatment of depression in adults with a history of emotional abuse.

In addition to the biological mechanisms noted above, genetic predisposition undoubtedly also plays a role in the pathogenesis of mood disorders following early-life stress. As previously reviewed ( 21 ), studies support the interaction of genetic predisposition and childhood maltreatment in increasing risk for mood disorders and affecting disease course. Indeed, this is now considered a prototype of how gene-by-environment interactions influence disease vulnerability. Polymorphisms in genes comprising components of the HPA axis and CRF circuits increase the risk for adult mood disorders in adults exposed to childhood maltreatment. For example, polymorphisms in the FK506 binding protein 5 (FKBP5) gene interact with childhood maltreatment to increase risk for major depression, suicide attempts, and PTSD ( 101 – 105 ). Caspi et al. ( 106 ) found that adults exposed to childhood maltreatment who carried the short arm allele of the serotonin transporter promoter polymorphism (heterozygotes and homozygotes) exhibited an increased risk for a depressed episode, greater depressive symptoms, and greater risk for suicidal ideation and attempts compared with homozygotes with two long arm alleles. A large number of studies now support the interaction between early-life stress, the serotonin transporter promoter, and other serotonergic gene polymorphisms and disease vulnerability and illness course in depression and bipolar disorder ( 107 – 111 ), although conflicting findings have also been reported ( 112 ). Childhood maltreatment has also been reported to interact with corticotropin-releasing hormone receptor 1 gene (CRHR1) polymorphisms to predict syndromal depression and increase risk for suicide attempts in adults ( 113 – 115 ). Early-life stress interactions with other genetic polymorphisms to influence risk for mood disorders and illness course include, but are not limited to, brain-derived neurotrophic factor (BDNF) Val66Met polymorphism ( 116 , 117 ), toll-like receptors ( 118 ), the oxytocin receptor ( 119 ), inflammation pathway genes ( 120 ), and methylenetetrahydrofolate reductase ( 121 ), although negative findings have also been reported ( 122 ). Studies employing polygenic risk score (PRS) analyses, an approach assessing the combined impact of multiple genotyped single-nucleotide polymorphisms, have reported that PRS is differentially related to risk for depression in individuals with a history of childhood maltreatment compared with those without maltreatment ( 123 , 124 ), although negative findings have also been reported ( 125 ).

Studies investigating the role of epigenetics (e.g., the modification of gene expression through DNA methylation and acetylation) in mediating detrimental outcomes following early-life stress have recently appeared ( 126 ). For example, a recent study reported that hypermethylation of the first exon of a monoamine oxidase A (MAOA) gene region of interest mediated the association between sexual abuse and depression ( 127 ). Childhood maltreatment is also associated with epigenetic modifications of the glucocorticoid receptor ( 128 ), the FKBP5 gene ( 101 ), and the serotonin 3A receptor ( 129 ), with these modifications associated with suicide completion, altered stress hormone systems, and illness severity, respectively. Childhood maltreatment–associated epigenetic changes in individuals who died by suicide have been identified in human postmortem studies ( 130 ). These studies, and others not cited here, support gene–by–childhood maltreatment interactions, including epigenetic modifications, in risk for mood disorders and in illness course.

Epigenetics may also be one mechanism that contributes to the intergenerational transmission of trauma ( 131 – 133 ), although it is important to note that nongenomic mechanisms are also implicated in the intergenerational transmission of behavior ( 134 ). There is a robust literature in rodent models supporting the intergenerational transmission of maternal behavior—maternal traits being passed to offspring—including abuse-related phenotypes ( 132 , 135 ). Intergenerational transmission of behavior is also implicated in humans. Yehuda et al. ( 136 , 137 ) investigated risk for psychopathology in offspring of Holocaust survivors. These pivotal studies identified increased risk for PTSD, mood disorders, and substance use disorders in offspring. These offspring also reported having higher levels of emotional abuse and neglect, which correlated with severity of PTSD in the parent ( 136 , 137 ), implicating early-life stress in transmission of psychopathology. While there is evidence that children with developmental disabilities are at a higher risk for neglect ( 138 – 140 ), there is a paucity of studies investigating whether offspring of individuals with mental illness are more liable to abuse. However, as discussed above, higher rates of maltreatment are reported in individuals with mood disorders, but whether and what familial factors may drive these elevated rates, or whether these interactions contribute to the intergenerational transmission of psychopathology, are not known. In light of the emerging data on intergenerational transmission of trauma, this is an important, complex area in need of further study. There have not been many genetic studies in this area. In a study investigating early-life maltreatment in a rodent model, early-life abuse (defined as stepping on, dropping, or dragging offspring, and active avoidance) was associated with altered BDNF expression and methylation in the prefrontal cortex in adult offspring, with adult offspring also showing poorer maternal care patterns when rearing their own offspring ( 135 ). Altered expression and methylation of BDNF is reported in individuals with mood disorders ( 141 , 142 ). These studies highlight the importance of understanding the intergenerational transmission of trauma and psychopathology to identify modifiable targets to improve outcomes, for example, the family unit and interpersonal relationships. It is noteworthy that while the majority of research has focused on intergenerational transmission of maternal traits, research is also emerging that supports the important role of paternal care on intergenerational transmission of behavior ( 131 ). More study on intergenerational transmission of trauma is needed.

Pathways to Mood Disorder Outcomes

More work on mechanisms and pathways by which childhood maltreatment increases risk for and ultimately results in adult mood disorders is essential for early intervention. Childhood maltreatment is associated with a marked increase in medical morbidities and an array of physical symptoms, and in general it predicts poor health and a shorter lifespan ( 143 , 144 ). Higher rates of comorbid substance use disorders in individuals with mood disorders who report experiencing childhood maltreatment is of particular interest. Childhood maltreatment has consistently been associated with a number of high-risk health behaviors, including smoking and alcohol and drug use—behaviors thought to contribute to the association between childhood maltreatment and poor health ( 145 – 148 ). These behaviors on their own increase risk for, and alter disease course in, mood disorders ( 149 – 153 ). More study on the relationship between early-life adversity, substance use disorders, and mood disorders is therefore warranted. For example, childhood maltreatment is associated with increased risky alcohol use, alcohol-related problems, and alcohol use disorders ( 154 , 155 ), and alcohol use disorders are an established risk factor for both depression and bipolar disorder ( 149 – 151 ) in addition to increasing risk for a more severe clinical course, such as further increasing risk for suicide ( 152 , 153 ). A recent study reported that depression mediates the relationship between childhood maltreatment and alcohol abuse ( 156 ). Another study recently reported that sexual abuse increased risk of alcohol use and depression in adolescence, which then influenced risk for adult depression, anxiety, and substance abuse ( 157 ). In a longitudinal study investigating changes in patterns of substance use over time in 937 adolescents, childhood maltreatment was associated with an increased progression toward heavy polysubstance use ( 158 ). More research is needed looking at the interactions between childhood maltreatment and other drugs of abuse. This is especially true in light of the current opioid epidemic, as increased rates of childhood maltreatment are also reported in individuals with opioid use disorders ( 159 – 161 ), and greater reported childhood maltreatment is associated with faster transmission from use to dependence ( 162 ) and with higher rates of suicide attempts in this population ( 163 ).

Interestingly, certain genes described above that exhibit gene–by–childhood maltreatment interactions on risk for mood disorders, including FKBP5 and the serotonin transporter promoter polymorphisms, also exhibit gene-by-childhood maltreatment interactions on risk for alcohol use disorders ( 164 – 168 ). Alterations in the stress hormone system are also associated with an increased risk for alcohol use disorders in individuals with a history of childhood maltreatment ( 169 ), and past-year negative life events have been reported to increase drinking and drug use, an effect that is dependent on genetic variation in the serotonin transporter gene ( 170 ). Childhood maltreatment has been found to be associated with an earlier age at initiation of alcohol and marijuana use, with this association mediated by externalizing behaviors ( 171 ). Impulsivity may mediate the relationship between childhood maltreatment and increased risk for developing alcohol or cannabis abuse ( 172 ). Etain et al. ( 173 ) conducted a path analysis in 485 euthymic patients with bipolar disorder and uncovered a significant association between impulsivity and emotional abuse, and impulsivity was associated with an increased risk for substance use disorders. These studies suggest that in some individuals with a history of childhood maltreatment, although not all, interventions that focus on alcohol or drug use problems, and specifically externalizing behaviors that may mediate the link between childhood maltreatment and alcohol or drug use problems (e.g., impulsivity), could decrease disease burden by decreasing risk for developing mood disorders or by improving illness course (e.g., decreasing symptom severity and risk for suicide).

Substance use disorders are also associated with increases in inflammatory markers ( 174 , 175 ). Inflammation is suggested to contribute to comorbid alcohol use disorders and mood disorders ( 176 ), and it contributes to a variety of medical morbidities ( 177 ), and these in turn are associated with an increased risk for mood disorders ( 177 ). Speculatively, inflammation may be one mechanism by which childhood maltreatment increases risk for medical morbidity and through that pathway increases risk for mood disorders. While there is a paucity of studies on the pathways described above, the associations between childhood maltreatment, risky health behaviors, inflammation, and medical morbidities warrant more study, as identifying pathways (mediators and moderators) to illness outcomes could foster the development of more effective interventions and treatment strategies.

It should be noted that not all individuals who experience childhood maltreatment develop mood disorders. This may be related in part to genetics. However, other resiliency factors are likely of importance. In a recent meta-analysis, Braithwaite et al. ( 178 ) identified interpersonal relationships, cognitive vulnerabilities, and behavioral difficulties as modifiable predictors of depression following childhood maltreatment. Specifically, social support and secure attachments were reported to exert a buffering effect on risk for depression, brooding was suggested to be a cognitive marker of risk, and externalizing behavior was suggested to be a behavioral marker of risk. Other researchers have also reported that social support may be protective and that interventions directed toward enhancing social support may decrease disease vulnerability and improve illness course ( 179 ). Metacognitive beliefs, or beliefs about one’s own cognition, are suggested to mediate the relationship between childhood maltreatment and mood-related and positive symptoms in individuals with psychotic or bipolar disorders ( 180 ). Specifically, beliefs about thoughts being uncontrollable or dangerous mediated the relationship between emotional abuse and depression or anxiety and positive symptom subscale score on the Positive and Negative Syndrome Scale. Affective lability was found to mediate the relationship between childhood maltreatment and several clinical features in bipolar disorder, including suicide attempts, anxiety, and mixed episodes ( 181 ), and social cognition was suggested to moderate the relationship between physical abuse and clinical outcome in an inpatient psychiatric rehabilitation program ( 182 ).

Childhood Maltreatment and Associated Alterations in Neural Structure and Function

Research on neurobiological consequences that may mediate the relationship between childhood maltreatment and risk for, and affect disease course in, mood disorders is clearly integral to addressing the question of whether the consequences of early-life stress are reversible. Although a comprehensive review of neuroimaging findings is beyond the scope of this review, over the past 5 years, review articles summarizing the neurobiological associations with childhood maltreatment have emphasized the long-lasting neurobiological structural and functional changes in the brain following maltreatment ( 21 , 83 , 183 , 184 ). In brief, while null and conflicting findings have been reported, data are converging to suggest that childhood maltreatment is associated with lower gray matter volumes and thickness in the ventral and dorsal prefrontal cortex, including the orbitofrontal and anterior cingulate cortices, hippocampus, insula, and striatum, with more recent studies also suggesting an association with decreased white matter structural integrity within and between these regions ( 185 – 194 ). Smaller hippocampal and prefrontal cortical volumes following childhood maltreatment are consistently reported in unipolar depression and other psychiatric disorders ( 189 , 195 – 199 ), with gene-by-environment interactions suggested ( 200 – 202 ). These studies suggest mechanisms that may cross diagnostic boundaries in conferring risk for psychopathology and genetic variation that may link neurobiology, childhood maltreatment, and vulnerability for detrimental outcomes.

Studies investigating differences in function within, and functional connectivity between, these regions following childhood maltreatment are emerging, with more recent results suggesting that these changes may relate to risk for psychopathology. It was recently reported that decreased prefrontal responses during a verbal working memory task mediated the relationship between childhood maltreatment and trait impulsivity in young adult women ( 203 ). In a study investigating functional responses to emotional faces in 182 adults with a range of anxiety symptoms ( 204 ), the authors found that increased amygdala and decreased dorsolateral prefrontal activity to fearful and angry faces—as well as increased insula activity to fearful and increased ventral but decreased dorsal and anterior cingulate activity to angry faces—mediated the relationship between childhood maltreatment and anxiety symptoms. Differences in functional connectivity, measured with multivariate network-based approaches, within the dorsal attention network and between task-positive networks and sensory systems have been reported in unipolar depression following childhood maltreatment ( 205 ). Altered reward-related functional connectivity between the striatum and the medial prefrontal cortex has also been reported in individuals with greater recent life stress and higher levels of childhood maltreatment, with increased connectivity associated with greater depressive symptom severity ( 206 ). Childhood maltreatment–associated changes in functional connectivity between the amygdala and the dorsolateral and rostral prefrontal cortex have been suggested to contribute to altered stress response and mood in adults ( 207 ). Additionally, childhood maltreatment has been reported to moderate the association between inhibitory control, measured with a Stroop color-word task, and activation in the anterior cingulate cortex while listening to personalized stress cues, an individual’s recounting of his or her own stressful events ( 208 ). As discussed above, it has been hypothesized that childhood maltreatment may increase risk for mood disorders through alterations of the HPA axis and CRF circuits in the brain. Therefore, research aimed at identifying neurobiological changes in function of CRF circuits in the brain that may mediate the relationship between childhood maltreatment and risk for mood disorders and affect disease course, including interactions with recent life stress, is a promising area of investigation.

Recent studies investigating altered function could suggest neurobiological mechanisms of risk but may also suggest possible mechanisms underlying resilience ( 183 ). Functional studies, such as those discussed above, that link functional changes in the brain following childhood maltreatment to mood-related symptoms can provide some clues to help identify mechanisms underlying risk. However, in the absence of longitudinal study of outcomes, these results must still be interpreted with caution. While the majority of studies have been cross-sectional, longitudinal studies are beginning to emerge. Opel et al. ( 209 ) recently reported that reduced insula surface area mediated the association between childhood maltreatment and relapse of depression among 110 patients with unipolar depression followed prospectively. A longitudinal study incorporating structural MRI in 51 adolescents (37% of whom had a history of childhood maltreatment) found that reduced cortical thickness in prefrontal and temporal cortices was associated with psychiatric symptoms at follow-up ( 210 ). Swartz et al. ( 211 ) followed 157 adolescents over a 2-year period and reported results suggesting that early-life stress is associated with amygdala hyperactivity during threat processing, with this finding preceding syndromal mood or anxiety. Longitudinal study of outcomes following childhood maltreatment and underlying neurobiology (predictors and trajectories) is critically needed to identify modifiable targets that confer risk and disentangle mechanisms of risk and resilience.

Only recently have studies investigating childhood maltreatment in bipolar disorder and neurobiological associations begun to emerge. Similar to unipolar depression and other psychiatric disorders, decreased ventral and dorsolateral prefrontal, insula, and hippocampal gray matter volume are reported in individuals with bipolar disorder with a history of childhood maltreatment compared with individuals with bipolar disorder without childhood maltreatment ( 202 , 212 , 213 ). Decreased white matter structural integrity across the whole brain, including lower structural integrity in the corpus callosum and uncinate fasciculus, have been reported in individuals with bipolar disorder who reported having experienced child abuse compared with those who did not and a healthy comparison group ( 214 , 215 ). Interestingly, one study ( 214 ) found that the effects of childhood maltreatment on white matter structural integrity were specific to individuals with bipolar disorder; decreased structural integrity was not observed in healthy comparison individuals with a history of childhood maltreatment compared with healthy individuals without maltreatment. In light of this finding, along with recently published data from other groups ( 216 – 218 ), it is possible that some consequences following childhood maltreatment may be more robust or distinct in some individuals—or that perhaps individuals with a genetic predisposition for mood disorders may be more vulnerable to the detrimental effects of childhood maltreatment.

Altered amygdala and hippocampal volumes are suggested to be differentially modulated following childhood maltreatment in patients with bipolar disorder compared with a healthy comparison group ( 216 ), although interactions with history of treatment (e.g., duration of lithium exposure) cannot be ruled out, as this was not investigated. Souza-Queiroz et al. ( 217 ) found that childhood maltreatment was associated with decreased amygdala volume, decreased ventromedial prefrontal connectivity with the amygdala and hippocampus, and decreased structural integrity in the uncinate fasciculus—the main white matter fiber tract connecting these regions. The bipolar group primarily drove these effects, with only smaller amygdala volume associated with childhood maltreatment in the healthy comparison group. While these findings could be driven by higher rates of maltreatment reported in the bipolar disorder group, or other clinical factors such as medication exposure and history of depressed or manic episodes, they could also suggest interactions between genetic vulnerability to bipolar disorder (or other environmental factors) and neurobiological consequences following childhood maltreatment.

More research is needed to identify genes that may influence neurobiological vulnerability following childhood maltreatment. An example of a potential gene that may mediate this relationship is the serotonin transporter promoter. Genetic variation in the serotonin transporter promoter is associated with differences in structural integrity of white matter in bipolar disorder ( 219 ). Because a large number of studies support the interaction between early-life stress, the serotonin transporter promoter, and disease vulnerability and illness course in depression and bipolar disorder ( 106 – 111 ), this example highlights the potential of genes to contribute to long-lasting structural consequences in the brain following childhood maltreatment in mood disorders. Genetic imaging studies are emerging and suggest gene-by-environment interactions on structural and functional alterations following childhood maltreatment. For example, one study found that hippocampal volume differences following childhood maltreatment are mediated by genetic variation in bipolar disorder ( 202 ). Additionally, polymorphisms in stress system genes, including FKBP5 and NR3C1, are suggested to moderate the effects of childhood maltreatment on amygdala reactivity ( 220 – 222 ) and hippocampal volumes ( 223 ). Studies investigating interactions between familial risk for mood disorders and childhood maltreatment and associated structural and functional changes in the brain would be useful to test whether familial factors (genetic and environmental vulnerability) may interact with childhood maltreatment to alter brain structure and function while avoiding confounders such as medication exposure.

Limitations and Future Directions

A sizable percentage of patients with mood disorders have a history of childhood maltreatment. While the devastating consequences of childhood maltreatment cannot be disavowed, several limitations in research should be noted. Research groups often assess childhood maltreatment differently, and this can result in a measurement bias. Demographic characteristics and differences in assessments (age and sex ratio of participants; clinical versus nonclinical populations being studied; observer-rated versus self-rated depression measures) are all suggested to contribute to differences in prevalence of childhood maltreatment and relation with illness severity ( 12 ). For example, studies using the Childhood Trauma Questionnaire report higher rates of emotional abuse compared with studies using other measures to investigate childhood maltreatment ( 12 ). Further study is warranted investigating the neurobiological mechanisms, underlying genetics, familial factors, and modifiable targets that may drive development of mood disorders following childhood maltreatment. A promising area is network-based approaches to understand this link ( 224 ). Additionally, consequences following different types of maltreatment require further investigation, as different forms of childhood maltreatment may be associated with distinct neural consequences, and a better understanding of these relations is critical for the development of more effective interventions and prevention strategies. For example, Heim et al. ( 225 ) reported that victims of sexual abuse exhibit more alterations in the somatosensory area, whereas victims of emotional abuse exhibit differences in areas mediating emotional processing and self-awareness, including the anterior cingulate and parahippocampal gyrus. More work is needed to investigate whether there are sensitive periods in development when maltreatment has more robust consequences on neurobiology. Humphreys et al. ( 226 ) recently reported that hippocampal volume differences were associated with stress severity during early childhood (≤5 years of age), but there was no association between hippocampal volumes and stress occurring during later childhood. Studies investigating interactions between childhood maltreatment and genetic variation or familial risk for mood disorders could identify mechanisms underlying risk and resiliency in the absence of some study-related confounders (e.g., medication).

Longitudinal studies are critically needed to distinguish what behaviors and mechanisms (genetic and neurobiological) may contribute to risk and whether alterations in behaviors or neurobiology are secondary to mood disorder onset. It is important to emphasize that sex differences likely contribute to outcomes following childhood maltreatment ( 227 ). These include females, compared with males, having a higher risk for internalizing disorders (depression and anxiety) ( 228 , 229 ), greater deficits in neural systems underlying emotional regulation ( 187 , 230 ), and being more susceptible to stress-induced changes in the HPA axis ( 231 ) following maltreatment. Males, compared with females, may be more vulnerable to developing externalizing disorders (conduct disorders and substance use disorders) ( 232 ). However, few studies have investigated sex differences following childhood maltreatment. More research on sex differences is critically needed, including on the underlying neurobiology. As previously reviewed ( 21 ), early-life adversity is associated with increased vulnerability to several major medical disorders, including coronary artery disease and myocardial infarction, cerebrovascular disease and stroke, type 2 diabetes, asthma, and certain forms of cancer. More work is needed on medical morbidities that may increase risk for early mortality following early-life adversity. Additionally, more research is needed on disparities that contribute to, and minority communities that show, elevated rates of early-life adversity. As discussed above, rates of early-life adversity are higher among individuals with developmental disabilities ( 138 – 140 ). Rates of trauma are also higher in youths in the lesbian, gay, bisexual, transgender, and questioning (LGBTQ) community ( 233 ). Few studies have been published in this area. Youths in the LGBTQ community show higher rates of mood disorders, anxiety, suicide, and alcohol and drug use ( 234 ). In a recent study, Rhoades et al. ( 235 ) investigated the relationship between parental rejection, homelessness, and mental health outcomes in LGBTQ youths. Parental rejection was associated with higher rates of homelessness, with experience of homelessness associated with greater feelings of hopelessness, PTSD and depressive symptoms, and greater prevalence of past suicide attempts and more individuals saying they are likely to attempt suicide in the future. More work is critically needed in vulnerable populations, including work focused on interventions that may improve mental health outcomes, for example, interventions that focus on the family unit and interpersonal relationships to foster support and educational interventions, which may decrease peer victimization and cyberbullying ( 236 , 237 ).

In summary, studies converge on and consistently support the finding that childhood maltreatment increases disease vulnerability for mood disorders, as well as a more pernicious disease course. A reduction in the prevalence of childhood maltreatment would have a substantial impact on decreasing disease burden ( 238 ). Studies suggesting modifiable targets are only just beginning to emerge and point to behavioral and environmental factors that could be focused on for early interventions.

Dr. Nemeroff has served as a consultant for Bracket (Clintara), Fortress Biotech, EMA Wellness, Gerson Lehrman Group, Intra-Cellular Therapies, Janssen Research and Development, Magstim, Navitor Pharmaceuticals, Sunovion Pharmaceuticals, Taisho Pharmaceutical, Takeda, TC MSO, and Xhale; he holds stock in AbbVie, Antares, BI Gen Holdings, Celgene, Corcept Therapeutics Pharmaceuticals Company, EMA Wellness, OPKO Health, Seattle Genetics, TC MSO, Trends in Pharma Development, and Xhale; he is a member of the scientific advisory boards of the Anxiety Disorder Association of America (ADAA), the American Foundation for Suicide Prevention (AFSP), Bracket (Clintara), the Brain and Behavior Research Foundation, the Laureate Institute for Brain Research, Skyland Trail, and Xhale and on the boards of directors of ADAA, AFSP, Gratitude America, and Xhale Smart; he has had income sources or equity of $10,000 or more from American Psychiatric Publishing, Bracket (Clintara), CME Outfitters, EMA Wellness, Intra-Cellular Therapies, Magstim, Takeda, TC-MSO, and Xhale; he holds patents on a method and devices for transdermal delivery of lithium (US 6,375,990B1), a method of assessing antidepressant drug therapy via transport inhibition of monoamine neurotransmitter by ex vivo assay (US 7,148,027B2), and compounds, compositions, methods of synthesis, and methods of treatment (CRF receptor binding ligand) (US 8,551,996 B2). Dr. Lippard reports no financial relationships with commercial interests.

Dr. Lippard’s research is supported by NIH grant K01AA027573. Dr. Nemeroff’s research is supported by NIH grants MH117293 and AA-024933.

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Research Article

Improving measurement of child abuse and neglect: A systematic review and analysis of national prevalence studies

Roles Conceptualization, Formal analysis, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Director, Childhood Adversity Research Program, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia, Adjunct Professor, Johns Hopkins University, Bloomberg School of Public Health, Baltimore MD, United States of America

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Roles Conceptualization, Formal analysis, Methodology, Writing – review & editing

Affiliation Institute for Lifecourse Development, University of Greenwich, Greenwich, London, United Kingdom

Affiliation School of Public Health, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia

Roles Data curation, Formal analysis, Project administration, Writing – review & editing

Affiliation Institute for Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia

Affiliation Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom

  • Ben Mathews, 
  • Rosana Pacella, 
  • Michael P. Dunne, 
  • Marko Simunovic, 
  • Cicely Marston

PLOS

  • Published: January 28, 2020
  • https://doi.org/10.1371/journal.pone.0227884
  • Reader Comments

Fig 1

Child maltreatment through physical abuse, sexual abuse, emotional abuse, neglect, and exposure to domestic violence, causes substantial adverse health, educational and behavioural consequences through the lifespan. The generation of reliable data on the prevalence and characteristics of child maltreatment in nationwide populations is essential to plan and evaluate public health interventions to reduce maltreatment. Measurement of child maltreatment must overcome numerous methodological challenges. Little is known to date about the extent, nature and methodological quality of these national studies. This study aimed to systematically review the most comprehensive national studies of the prevalence of child maltreatment, and critically appraise their methodologies to help inform the design of future studies.

Guided by PRISMA and following a published protocol, we searched 22 databases from inception to 31 May 2019 to identify nationwide studies of the prevalence of either all five or at least four forms of child maltreatment. We conducted a formal quality assessment and critical analysis of study design.

This review identified 30 national prevalence studies of all five or at least four forms of child maltreatment, in 22 countries. While sound approaches are available for different settings, methodologies varied widely in nature and robustness. Some instruments are more reliable and obtain more detailed and useful information about the characteristics of the maltreatment, including its nature, frequency, and the relationship between the child and the person who inflicted the maltreatment. Almost all studies had limitations, especially in the level of detail captured about maltreatment, and the adequacy of constructs of maltreatment types.

Conclusions

Countries must invest in rigorous national studies of the prevalence of child maltreatment. Studies should use a sound instrument containing appropriate maltreatment constructs, and obtain nuanced information about its nature.

Citation: Mathews B, Pacella R, Dunne MP, Simunovic M, Marston C (2020) Improving measurement of child abuse and neglect: A systematic review and analysis of national prevalence studies. PLoS ONE 15(1): e0227884. https://doi.org/10.1371/journal.pone.0227884

Editor: Abraham Salinas-Miranda, University of South Florida, UNITED STATES

Received: September 10, 2019; Accepted: December 31, 2019; Published: January 28, 2020

Copyright: © 2020 Mathews 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.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Child maltreatment is common and causes substantial adverse health, educational and behavioural consequences [ 1 ]. Understanding its prevalence and characteristics in nationwide populations is essential to plan and evaluate interventions to reduce maltreatment. However, measurement of child maltreatment is known to be far from universal, and when performed must confront methodological challenges. This study systematically reviews the most comprehensive national studies of the prevalence of child maltreatment, and critically appraises their methodologies to help inform future measurement.

Child maltreatment in its five recognised forms is a major public health issue [ 2 ]. Physical and mental diseases are caused through proximal and distal pathways. Immediate physical injuries and conditions include brain injury and failure to thrive, and a panoply of psychological disorders include anxiety, depression, and suicidality. Studies have found serious effects of physical abuse [ 3 , 4 , 5 ], sexual abuse [ 6 , 7 ], emotional abuse [ 5 , 8 – 10 ], neglect [ 5 , 9 , 11 ], and exposure to domestic violence [ 12 – 14 ]. Experiencing multiple forms of maltreatment is common [ 12 ], and is associated with more severe outcomes [ 14 , 15 ], including alcohol and drug abuse, mental illness, interpersonal violence, and sexual risk taking [ 16 ].

The adoption of coping mechanisms such as smoking, alcohol and drug use can compound the damage by causing diseases in the medium to long term; and chronic stress can cause coronary artery disease, pulmonary fibrosis, and inflammation [ 17 – 22 ]. Potent mediators include prolonged psychological distress, risky behaviours, social withdrawal and dysfunction, impaired cognitive development, low educational and occupational attainment, and interpersonal relationship difficulties. A growing body of evidence is showing child maltreatment affects brain development, shortens telomeres, and produces epigenetic neurobiological changes [ 23 – 26 ]. The disease and economic burdens are substantial: a recent estimate of the cost of disability-adjusted life years (DALYs) lost across East Asia and the Pacific was 1.88% of the region’s GDP, equating to $194 billion in 2012 dollars [ 27 ].

As a global policy imperative, the United Nations recognises the gravity of child maltreatment and its consequences. The United Nations Agenda for Sustainable Development includes a target of ending abuse of children [ 28 ]. Reliable scientific data on national prevalence is essential to measure progress against this goal, and to inform policy efforts aimed at prevention, early identification and response [ 29 – 30 ].

Nationwide studies of the experience of childhood maltreatment can identify baseline prevalence stratified by maltreatment type, as well as important contextual features including the child’s sex, age, and relationship with the abusive person. Without good measurement techniques and repeated measures over time, we lack understandings of baseline measures, of whether maltreatment is increasing or declining, of changes in maltreatment types over time, and of the efficacy of policy and practice interventions designed to reduce child maltreatment for the whole population and for key sub-populations.

Despite the necessity for good data in public health generally and in child maltreatment in particular, approximately half of all countries have failed to report any kind of robust prevalence estimates [ 2 ], and extant studies are often limited to measuring one or few maltreatment types [ 31 ]. Accordingly, prevalence estimates are often inadequately specified, and are almost certainly underestimated. In addition, existing studies vary widely in design, sample and methods, and often use non-standardized instruments [ 5 , 32 ]. Where an instrument is non-standardized and untested, the risk may be heightened that the study will fail to capture experiences that constitute maltreatment, and may capture experiences that do not constitute maltreatment, hence producing unreliable results. Importantly, the use of unsound maltreatment constructs and operational definitions also compromises the reliability of recorded measures [ 33 – 34 ]. As an example of this, studies of sexual abuse that do not include non-contact sexual abuse will underestimate prevalence; conversely, studies that include as sexual abuse genuinely consensual acts between peers will overestimate prevalence. Similarly, studies of neglect that do not consider medical neglect will underestimate prevalence. Studies of emotional abuse that include non-abusive yelling will overestimate prevalence.

Optimal methodologies for measuring population characteristics of child maltreatment can ensure adequate detail is captured to yield reliable, detailed, useful data. For best quality estimates, prevalence studies should adopt robust conceptual understandings of maltreatment types and their operational definitions [ 33 ]. In addition, prevalence studies need to ask a series of items to obtain accurate data, rather than a single question which will tend to underestimate prevalence [ 35 ]. Similarly, to avoid underestimates, items should be behaviourally specific, rather than vague, ambiguous or non-specific [ 36 ]. All national prevalence studies face methodological and practical challenges, and studies take different approaches [ 2 , 12 , 14 , 30 ]. Ideally, however, all five forms of child maltreatment should be measured simultaneously, since many children experience such poly-victimization and its heightened consequences [ 1 , 14 , 16 ]. To provide nuanced, useful information, studies should ask about prevalence, and about the specific nature of the acts, their severity, frequency, and timing, and the relationship of the child to the person inflicting the abuse [ 33 ]. These factors influence health outcomes and provide evidence about specific risk and protective factors and how these may best be targeted. Rigorous measurement of child maltreatment is complex, but is essential to inform prevention efforts and drive nationwide social change [ 2 , 14 , 29 , 36 , 37 ].

Recent research has reviewed global prevalence estimates [ 2 , 31 ], the nature of population health surveys exploring consequences of child maltreatment [ 37 ], and approaches in studies of youth [ 38 ]. However, to date, there has not been a systematic review and methodological appraisal of high quality national population prevalence studies of child maltreatment to provide a baseline for future measurement efforts.

This study aimed to investigate three questions. First, what national studies have been conducted of the prevalence and nature of all five, or at least four, major forms of child maltreatment? Second, what methodologies were used in these studies? Third, what does a critical analysis of these studies indicate about the methodological rigour, quality, and practical viability of different approaches? The results of our investigation can inform future efforts to generate baseline prevalence estimates, design policy responses, and chart trends over time, as more societies confront the challenge of childhood maltreatment.

Search strategy

Our systematic review was guided by PRISMA [ 39 ] ( S1 Fig ). We developed a protocol, registered at PROSPERO [ 40 ]. #CRD42017068120, https://www.crd.york.ac.uk/PROSPERO ). Adopting our search strategy ( S1 File ), we searched 22 databases from their inception to 31 May 2019.

Eligibility criteria

We searched for quantitative studies of the prevalence of child maltreatment. Included studies met four criteria: (1) primary empirical studies of the prevalence of four or five types of child maltreatment: ((i) physical abuse; (ii) emotional or psychological abuse; (iii) neglect; (iv) exposure to domestic violence; and (v) sexual abuse; (2) studies conducted nationwide using a representative sample of the population; (3) studies involving adult or child participants providing self-reported information about their experience, or studies where adults provided information about their child’s experience; (4) peer-reviewed studies or substantial grey literature.

As detailed in our search strategy ( S1 File ), in Phase 1, MS, JD and ED screened records by title. We removed duplicates using electronic software (Endnote), and removed remaining duplicates about the same study, selecting the publication providing the most detailed account. In Phase 2, BM and RP independently screened records by title and abstract. Disagreements were discussed between BM and RP to achieve consensus. To identify any further potential eligible studies at this stage that may not have been captured in the search, all co-authors considered if there were any further known studies requiring inclusion that were not in the Phase 2 shortlist. In Phase 3, BM and RP independently assessed full text of screened in articles. Disagreements were discussed between BM and RP to achieve consensus, with reasons recorded. We screened reference lists of included studies to identify any further potential eligible studies. We used a translator to assist in screening non-English studies. This process resulted in 23 eligible studies ( Fig 1 ).

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Data extraction and analysis

We developed a template to extract 60 data items from each study considering design, procedure, sample, instrument, ethics, and subpopulation analysis ( S2 File ). We extracted 45 items about the instrument, including: name, psychometric data, definitions of maltreatment constructs, number of questions asked about each type, and whether questions explored: (a) the relationship between the child and the person inflicting maltreatment; (b) nature of the acts; (c) severity (e.g., if they caused injuries); (d) frequency. MS and BM extracted these data. We separately tabulated the extracted items each study asked about maltreatment, with BM conducting a final double-check regarding these ( S3 File ).

Our critical analysis included an appraisal of the construct validity of study items and the soundness of their operational definition. To inform this analysis, we identified robust conceptual understandings of each maltreatment type as established in the scholarly literature, and adopted these as an evaluative standard. Physical abuse involves intentional acts of physical force by a parent or caregiver, excluding lawful corporal punishment [ 41 ]. Sexual abuse involves contact and non-contact sexual acts, inflicted by any adult or child in a position of power over the victim, to seek or obtain physical or mental sexual gratification, when the child does not have capacity to provide consent, or has capacity but does not provide consent [ 42 ]. Emotional or psychological abuse is inflicted by a parent or caregiver, and includes emotional unavailability, hostile interaction, developmentally inappropriate interaction, failure to acknowledge the child’s individuality, and failure to integrate the child into the social world [ 43 ]. Neglect involves parental or caregiver omissions to provide the basic necessities of life suited to the child’s developmental stage, as recognised by the child’s cultural context, including physical, emotional, medical, environmental, supervisory, and educational neglect [ 44 ]. Exposure to domestic violence involves the child witnessing a parent or other family member being subjected to assaults, threats or property damage by another adult or teenager normally resident in the household [ 12 ].

Our critical analysis was also informed by an understanding that prevalence studies must be conducted with low risk of bias to obtain reliable findings. In our analysis, we assessed study rigour, quality and practicability, and used a quality assessment tool designed to assess risk of bias in population-based prevalence studies [45, S4 File ]. Using our quality assessment tool, we created an overall risk of bias score for each study which summed scores for individual items (maximum score 10). RP and CM independently assessed each study considering four external validity items and five internal validity items. Disputes were resolved through an independent third assessor (MD, BM). Our critical analysis further considered suitability of approach, considering: methodology to recruit the sample and accommodate high-risk sub-samples; administration method; instrument; soundness of conceptual constructs; ethics; and practical viability.

Systematic review

This review identified 23 articles reporting the results of national studies of the prevalence of all five or four of the recognized forms of child maltreatment. One of these articles reported the results of a study conducted simultaneously in nine countries in the Balkan Peninsula, and eight of these national studies met our eligibility criteria [ 46 ]. Accordingly, in total, our review identified 30 national studies, conducted in 22 countries. Studies were published between 2005 and 2019. Extracted data revealed study location, scope, participants, data collection method, and instrument. Table 1 presents the extracted information from included studies. The supporting information details the prevalence rates reported by each study ( S5 File ).

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There were four studies in the USA [ 47 – 50 ], three in the UK [ 51 – 53 ], two in Hong Kong [ 54 – 55 ] two in Taiwan [ 56 – 57 ], and two in Germany [ 58 , 59 ]. There was one study in Denmark [ 60 ], the Netherlands [ 61 ], Switzerland [ 62 ], Japan [ 63 ], Suriname [ 64 ], Saudi Arabia [ 65 ], Israel [ 66 ], South Africa [ 67 ], and Hungary [ 68 ]. In the Balkans study [ 46 ], eight met eligibility criteria based on the number of types of maltreatment studied: Albania, Bosnia & Herzegovina, Bulgaria, Croatia, the Former Yugoslavian Republic of Macedonia, Greece, Romania, and Serbia; in general for our purposes, we treat these as one study. The Turkish study involved three forms of maltreatment, so was excluded from our analyses.

Fourteen studies measured all five maltreatment types [ 47 – 51 , 53 , 56 – 57 , 61 , 64 – 68 ]. Of nine studies measuring four maltreatment types, seven omitted EDV [ 46 , 52 , 58 – 60 , 62 – 63 ], and two omitted sexual abuse [ 54 – 55 ]. Eleven studies measured prevalence throughout childhood and in the past year; nine measured prevalence through childhood only, and three measured past year incidence only.

Only nine studies explored all five types of maltreatment across childhood, defined as aged under 18 [ 48 – 50 , 53 , 64 – 68 ]. These studies occurred in seven countries (USA, UK, Suriname, Saudi Arabia, Israel, South Africa and Hungary), and only three involved a sample of adults providing data about experiences over their entire childhood [ 53 , 65 , 68 ]. Four studies in Germany, the UK and Japan obtained information from adults about all maltreatment across childhood except EDV [ 52 , 58 – 59 , 63 ].

Eight studies involved only child participants aged under 18 providing self-report data. Three studies included child and adult participants each providing self-report data. Five studies involved a household’s child participant aged under 18 providing self-report data (four involved children aged 10–17 and one involved children aged 11–17) and the household’s parents providing proxy data about a child aged under the cut-off. Five studies involved only adults providing self-report data (24 year olds; 18–24 year olds; 20–49 year olds; 18 and over). Sample sizes ranged from 1094 to 12,035 participants. Five studies adopted measures to recruit high-risk sub-populations [ 48 , 56 , 60 , 62 , 64 ].

Seven studies were conducted in schools: Taiwan [ 56 – 57 ], the Netherlands [ 61 ]. Switzerland [ 62 ], Suriname [ 64 ], and the Balkans study [ 46 ]. Eleven studies were conducted in households by interviews, in Hong Kong [ 54 – 55 ], Hungary [ 68 ], the UK [ 51 – 53 ], Germany [ 58 – 59 ], Japan [ 63 ], Saudi Arabia [ 65 ], and South Africa [ 67 ]. Five studies used remote computer assisted telephone interviews (CATI), with four in the USA [ 47 – 50 ], and one in Denmark [ 60 ]. Data collection time ranged from 1 month to 2 years.

Methodologies to recruit the sample and accommodate high-risk subpopulations also varied. In most studies, the target population was a close representation of the national population. Studies in schools were done in countries with high school attendance. All studies used random selection. However, few studies used strategies to capture participants from culturally and linguistically diverse groups, or from high-risk groups such as those in out of home care.

Response rates for household studies generally ranged from 56% to 78%, with one reporting a participation rate of 94.8% [ 67 ]. Rates in school-based studies showed schools’ participation rate ranging from 49%-79%, and then with almost 100% response rates from children in participating schools. Response rates in CATI studies ranged from 60% to 79.5%, with more recent studies having lower rates [ 47 – 49 ].

Regarding consent to participate, 18 of the studies involved child participants exclusively or with adult participants. Nine studies involved only child participants; in these, two required only the child’s consent [ 56 , 62 ], one required the child’s consent and parental passive consent [ 64 ], one required the child’s consent and either passive or active parental consent [ 46 ], and five required parental active consent and the child’s consent [ 54 – 55 , 57 , 61 , 66 – 67 ].

Of the studies involving child participants, seven reported the measures used by research teams when a child was suspected to have been harmed or at risk [ 46 – 50 , 53 , 67 ]. Nine studies reported other measures to assist any distressed participants [ 46 , 48 , 52 , 54 , 56 , 60 , 62 , 64 ].

Studies used a range of instruments and approaches to measuring each maltreatment type. Table 2 presents key data extracted from the instrument used in each study. Comprehensive details about the maltreatment items are detailed in the supporting information ( S3 File ).

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Eight studies used the Juvenile Victimization Questionnaire (JVQ). These studies used different versions of the JVQ, either using its original form [ 72 ], an enhanced form [ 48 – 50 ], or an adapted version [ 53 , 62 , 66 – 67 ]. Two studies used the Conflict Tactics Scale Parent-Child version (measuring physical abuse, emotional abuse, and neglect), and the CTS2 (EDV) [ 54 – 55 ]. Two studies used the ICAST-C, in either its original form [ 56 ] or an adapted version [ 46 ]. Two studies used the Childhood Trauma Questionnaire [ 58 – 59 ]. Single studies used the Adverse Childhood Experiences International Questionnaire [ 65 ], the Adverse Childhood Experiences questionnaire [ 68 ], and the Lifestyle and Attitudes Towards Sexual Behavior instrument [ 63 ]. Four studies used a blend of instruments [ 51 , 57 , 61 , 64 ]. Two studies used self-developed instruments [ 52 , 60 ].

Six studies did not report psychometric data on instrument validity and reliability. Six studies reported psychometric data on the instrument as used [ 46 , 54 – 56 , 58 , 72 ]. Studies using enhanced or adapted versions of instruments generally cited the original instrument’s data but did not report further psychometric tests.

Most studies did not define overarching concepts of each form of maltreatment, instead operationalising these concepts into questions about the participant’s experiences. Approaches to some but not all forms of maltreatment broadly aligned with the nature of maltreatment concepts as established by the scholarly literature. Approaches to physical abuse and sexual abuse were generally sound. Approaches to the construct and operationalisation of emotional abuse were generally sub-optimal, with some exceptions (e.g., [ 46 , 52 ]). Neglect was also rarely well-operationalised, with some exceptions (e.g., [ 49 , 52 – 53 , 58 – 59 , 66 ].

Studies explored maltreatment experiences in varying depth, reflected by the number and nature of questions asked ( Table 2 ). For sexual abuse, 12 studies asked between five and eight questions. Most studies asked about the relationship with the person inflicting the abuse, and the nature of the acts; more than half asked about frequency; but few asked about severity. Other notable differences included: two studies being limited to sexual abuse by a parent/guardian [ 51 , 60 ]; most studies including contact and non-contact acts, but three studies included contact abuse only [ 62 , 65 , 68 ]; four studies asking only one question [ 51 , 62 – 63 , 68 ].

For physical abuse, eight studies asked only one question, although these included multiple distinct concepts [ 47 – 51 , 62 , 63 , 68 ]. Six studies asked between five and nine questions. Most asked about relationship and nature; more than half asked about frequency; but few asked about severity. A notable difference was in the treatment of spanking on a child’s bottom: seven studies excluded “spanking on your bottom” from the definition of physical abuse [ 47 – 50 , 53 , 62 , 66 ]; four studies included spanking with a bare hand as physical abuse [ 46 , 54 – 56 ]; and four studies included as physical abuse being hit or spanked on the bottom but only when done with an implement or hard object [ 51 , 52 , 57 , 64 ].

For emotional or psychological abuse, eight studies asked between five and eight questions. Most asked about relationship and nature; more than half asked about frequency; but few asked about severity. Other notable differences included: three studies being limited to a single generic question [ 51 , 61 , 64 ]; seven studies using a single compound question [ 47 – 51 , 62 , 67 ]; and only two studies using a detailed scale of items closely aligned with a sound conceptual model [ 46 , 52 ].

For neglect, 12 studies asked between five and 11 questions. Five studies asked one question [ 47 – 48 , 62 , 63 , 68 ]. Most asked about relationship and nature; more than half asked about frequency; but few asked about severity. Six studies asked detailed questions about multiple dimensions of neglect, and their severity [ 49 – 50 , 52 , 58 – 59 , 66 ]. Other notable differences included: some studies operationalising neglect very broadly, including a parent having low aspirations [ 51 ], or not helping with homework [ 64 ]; only one study asking about educational neglect [ 64 ]; and one study omitting physical and nutritional neglect [ 46 ].

For exposure to domestic violence, six studies asked between six and eight questions. Most asked about relationship and nature; more than half asked about frequency; but few asked about severity. Notable differences were: two studies used the comprehensive CTS2 scale of 39 items originally devised for use with adult couples [ 54 – 55 ]; and the original JVQ had two physical assault items [ 72 ], and later added six items about threats or property damage by other family members [ 48 – 50 ].

Risk of bias

Table 3 sets out the quality assessment and scoring results for each study. Scores ranged from 6 to 10. Most studies had relatively high internal and external validity. We concluded that studies scoring 9.5 or 10 had minimal bias. Five studies achieved scores of 10: two in Hong Kong [ 54 – 55 ], and one each in Taiwan [ 56 ], Israel [ 66 ] and South Africa [ 67 ]. Five studies achieved scores of 9.5: three in the USA [ 48 – 50 ], one in the UK [ 53 ], and the Balkans study [ 46 ]. Five other studies achieved scores of 9, from Saudi Arabia [ 65 ], the UK [ 52 ], Germany [ 62 ], Hungary [ 68 ], and Taiwan [ 57 ]. Four studies scored 7, and two scored 6; here we concluded risk of bias was high, particularly regarding selection bias and non-response bias.

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This systematic review identified 30 studies of the prevalence of either four or five forms of child maltreatment, conducted in 22 nations. In addition, many other studies have been conducted of three or fewer maltreatment types, such as studies of sexual, physical and emotional abuse. These have been conducted on a stand-alone basis [ 76 ], or as part of a systematic campaign supported by a global public private partnership [ 77 ]. By 2019, the Violence Against Children Surveys (VACS), which also measure the prevalence of physical, sexual and emotional abuse, had been conducted in 16 countries and were being planned in a further eight countries in Africa, Asia and the Caribbean [ 30 , 77 – 78 ]. Other studies have considered the prevalence of a mixture of peer violence and maltreatment by parents or caregivers [ 79 – 80 ]. Accordingly, a good deal of evidence has been generated about the prevalence of child maltreatment in several dozen nations, representing substantial progress in the international understanding of the epidemiology of child maltreatment. However, this review has highlighted the fact that the vast majority of nations lack reliable benchmark national prevalence data on a comprehensive assessment of maltreatment, including measurement of four or five of the recognised five types of maltreatment, and almost all lack follow-up studies to establish trends over time. This study demonstrates the urgent need to conduct more rigorous prevalence studies, particularly those by measuring all relevant types of maltreatment, to generate more accurate understandings of the extent of maltreatment, and to enable progress in reducing child maltreatment against the SDG target.

Our review also shows that there is substantial variation in study participants across the different studies, limiting comparability and introducing certain strengths and limitations which are important to consider in designing future work. Several studies obtained data using parents as proxies for children under 10, and reported reliable responses. This approach may capture data about very young children’s experiences that is otherwise unattainable, although accurate estimates rely on parents being both knowledgeable and truthful in their responses [ 47 ]. Yet, the literature reports no evidence of reporter bias in comparisons of adult proxy and youth self-report data [ 47 , 48 ].

Arguably, from a public health perspective, studies provide most comprehensive and reliable estimates when capturing prevalence data over the entire span of childhood up to age 18. Furthermore, where a study’s participants are children and or young adolescents, past year incidence data is useful. Over half of the studies in this review included children as respondents. In these studies, responses benefitted from being direct and proximate to the experience as well as capturing useful stratified data about single year incidence in a closely contemporaneous time period. Developmental evidence suggests children’s and adolescents’ participation is entirely appropriate. While adolescents may generally differ from adults in the attainment of psychosocial capacities to understand long-term consequences, regulate conduct, and withstand social and emotional pressures, their cognitive capacity is not substantially different from that of adults [ 81 – 84 ]. Similarly, apart from those still in early developmental stages, children’s cognition and reliable episodic memory is sufficiently developed to enable participation in survey research [ 85 – 86 ]. This justifies the design of instruments for child and adolescent participants, including the careful approach of the developers of the Juvenile Victimization Questionnaire in designing an instrument suitable for participants as young as eight [ 72 ].

Ethically, there is no impediment to involving child and adolescent participants [ 87 ]. Adolescents and children are cognitively capable of providing their own consent, and are ethically entitled to do so as autonomous individuals. Moreover, adolescents and children have rights to freedom of expression, and bear the right of participation in matters affecting them. While there remains no consensus on the most justifiable approach to confidentiality and welfare [ 87 – 90 ], we assert that studies can adopt robust measures to balance imperatives of attaining sufficient study participation, while ensuring participant welfare and confidentiality. While confidentiality is a foundational principle in these studies, the exception to this, conveyed to youth participants at the outset, that cases of current or imminent significant risk of danger may be referred to welfare authorities, has been found not to affect response rates [ 38 , 53 ]. Alongside this, studies can adopt stepwise approaches drawing on multiple psychological and legal resources to support participants who disclose severe incidents or who experience distress [ 87 ]. However, it is important not overstate the frequency of distress. Several studies have found low rates of distress among youth participants in studies of maltreatment, and the level of youth distress does not differ significantly from that of adults. Furthermore, even distressed participants mostly maintain their involvement was worthwhile [ 38 , 91 ]. A recent US study, for example, found only 0.8% of participants aged 10–17 reported being “pretty or a lot” upset by answering the questions, and even this did not unduly affect their reported willingness to participate [ 91 ]. An associated finding is that children in high-risk sub-populations, such as those in out-of-home care, have not been well represented, leading to likely underestimates of prevalence and scarce evidence about specific risk profiles.

Studies that rely on adults’ retrospective accounts offer the substantial benefit of capturing data about experiences across childhood. One limitation of such studies is that they will not obtain recent proximal data of single year incidence. An additional potential limitation, yet to be fully analysed, may be that retrospective accounts are affected by various kinds of recall bias. We acknowledge that some have argued that retrospective studies do not provide data about child abuse experiences that is as accurate as prospective studies [ 92 – 93 ] and have cautioned against sole reliance on retrospective accounts, especially where prevalence estimates are used to draw causal inferences about the effect of maltreatment on biomedical diseases. A recent systematic review and meta-analysis concluded that prospective and retrospective measures of childhood maltreatment identify different groups of individuals [ 94 ]. However, it was also recognised that prospective measures may have lower sensitivity than retrospective measures of the experience of maltreatment, and concluded that “the low agreement between prospective and retrospective measures cannot be interpreted to directly indicate poor validity of retrospective measures” and that retrospective measures could have greater ability to identify true cases [ 94 ]. The well-known discrepancies between true maltreatment rates and those recorded in many data sources used for prospective studies is attributable to the low correlation between actual experiences and their representation in official data such as crime statistics and child protection service records. Few maltreatment experiences are ever brought to the attention of criminal justice agencies or child protection services. The caution urged regarding retrospective reports appropriately appears more directed towards studies considering causation of disease than estimation of population prevalence. It is also accepted that lack of validity tends to underreport the experience of abuse [ 95 – 97 ], and studies of test-retest reliability regarding retrospective accounts have indicated general stability over time [ 98 ]. We acknowledge that retrospective reports may have compromised validity for various reasons, including motivational factors and memory biases, and measurement features including poorly worded questions [ 92 , 94 ]. Overall, however, our view is that retrospective studies of child maltreatment, especially when well-designed with behaviourally-specific questions grounded in sound constructs of maltreatment, with representative samples of the population, offer the opportunity to obtain sufficiently accurate estimates of the prevalence of child maltreatment experiences.

The fourth finding is that while considerable investment is required for all kinds of approach, viable approaches to survey administration are available for diverse geographical settings to accommodate large and small nations, and attain sufficient participation. The implications of this are clear for future study design. School-based studies appeared most often in small nations, which may more readily facilitate centralised educational sector endorsement for the research, or which may have a high commitment to social research. When school leaders agree for their school to participate, children generally participate at a very high rate. Similarly, household studies identified in this review generally occurred in small nations. Both school-based and household studies require substantial numbers of staff, but may be most feasible where labour costs are manageable and where the social ecology is of sufficient strength to support and perhaps even require direct personal involvement in such research. In larger nations, for reasons of practicability and cost, studies used CATI and achieved satisfactory response rates. Perhaps for reasons of cost, and practical difficulty, a challenge remains to capture the experience of culturally and linguistically diverse sub-populations, and hard to reach groups such as children who are not in school, or who are in out of home care. Future research could consider optimal local strategies to respond to this challenge.

Our fifth finding is that selection, design and testing of an appropriate instrument appears an enduring challenge. In this regard, two coexisting needs must be balanced by any study: first, to be practicable in terms of the time and cost required to design, test and administer an instrument and minimise missing data; and second, to achieve sufficient comprehensiveness and ensure construct validity by describing maltreatment types in a way congruent with conceptual understandings [ 33 ]. Our review showed that a wide variety of instruments have been used, with psychometric data often not reported. The JVQ was the instrument most often used in either full-form or short-form; moreover, several studies adapted the original JVQ, sometimes adding a considerable number of items. These adapted versions did not appear to have been subjected to testing. While inconsequential modification of a proven instrument obviates the need for re-testing, substantial modification may be further supported by cognitive testing and test-retest reliability. What is relatively clear is that a proven, sound instrument offers both practicable and methodological benefits over a blended tool, or a new unproven instrument.

Our sixth finding is that instruments must soundly operationalise constructs of each maltreatment type by describing them in a way congruent with sound conceptual understandings. This review and critical appraisal found that instruments most often adopted unsound constructs and operationalisation of neglect, and emotional abuse. In particular, many studies did not consider sufficient operational categories of these maltreatment types as required by sound conceptual models, which will lead to under-estimates of prevalence, and will miss the opportunity to capture important information about the nature of specific experiences. Other studies used broad or vague conceptual expressions, which will have the opposite effect of over-estimating prevalence. This finding provides a contextual demonstration of the problem of unsound constructs compromising reliability and validity in general [ 33 , 34 ], and of the ongoing challenge to this field to adopt sound constructs of maltreatment and sound behaviourally-specific examples of these constructs [ 99 ]. Additionally in this regard, many studies asked only one question about a maltreatment type, which leads to underestimates of prevalence [ 36 ]. Single-item assessment, even through a compound question involving multiple elements of a construct, cannot capture accurate or nuanced data and should be avoided wherever possible. Finally, we found few questions about educational neglect. Arguably, since education is a human right recognised by the United Nations Convention on the Rights of the Child article 28, and is a condition for human flourishing [ 100 ] and a protective factor against multiple adversities such as child marriage [ 101 ], this is a significant dimension of neglect warranting greater priority. We recommend particularly close attention to how future studies conceptualise and operationalise these forms of maltreatment.

A seventh finding is that few studies asked detailed follow-up questions about the child’s relationship with the person inflicting the acts, and the severity and frequency of the acts. Generally, studies using the JVQ asked the most detailed follow-up questions. Obtaining information about the severity, frequency, timing, and relational setting of abuse and neglect is important, since the closeness of the relationship between the person maltreating the child and the child can have significant effects [ 102 – 103 ], and the timing of maltreatment is also important, with studies finding effects for both sex and age [ 104 ]. From a public health perspective, the measurement of maltreatment should ideally move beyond raw prevalence, and yield sufficiently sensitive and nuanced information about these key contextual features of the maltreatment to inform future public health policy and prevention efforts, including the indication of priority areas for responses. The addition of such questions presents challenges for instrument design and implementation, including the time to administer additional questions. However, we recommend such questions wherever possible.

Limitations

We reviewed studies measuring the traditional forms of child maltreatment, and excluded studies of adverse childhood experiences conceptualised more broadly, such as peer bullying and community violence. Some researchers recommend that studies include both maltreatment and these other adversities [ 37 ] on the basis that chronic exposure to multiple adversities influences developmental trajectories through the lifespan. However, we applied rigorous eligibility criteria of four or five of the recognized maltreatment categories, all clearly associated with adverse sequelae, and which most closely reflect specific SDG targets of caregiver abuse and any sexual violence. Recent outcomes of the ACE study itself have only focused on these five types and three classes of household dysfunction [ 18 ]. Additionally, our data extraction method for the quality assessment was not formally validated, but we adopted an approach similar to that used elsewhere [ 32 , 35 , 45 ] considering key variables in detail. Similarly, while there were no previously validated risk of bias measures for this specific type of prevalence study, we used a method with high interrater agreement that has been used elsewhere [ 45 ], including in prevalence studies of abuse and interpersonal violence [ 105 – 106 ]. Our approach to risk of bias adopted a conservative approach, and reasonably concluded that studies scoring 9.5 or 10 had minimal bias.

This systematic review and analysis has shown nationwide studies of the prevalence of child maltreatment have been conducted, using methods of administration suited to the setting, and involving child participants, adult participants, or both. However, there are few such nationwide studies of all five or even four maltreatment types, leaving substantial gaps in knowledge about the experience of childhood maltreatment in nearly all countries. Overall, our review and analysis indicates many of the completed studies are generally sound, but some take a more comprehensive and conceptually robust approach to provide nuanced, useful data for researchers and policymakers. To enable measurement of progress against the United Nations Agenda for Sustainable Development Goal 16 of reduction of child abuse, many countries need to invest in robust national prevalence studies. Such studies should measure exposure to domestic violence in addition to physical abuse, sexual abuse, emotional abuse, and neglect. Studies should use an instrument with demonstrated validity and reliability, and must ensure maltreatment types are operationalised appropriately in the questions asked. If participants are children or adolescents under age 18, studies should capture past year incidence, as well as childhood prevalence. Information should be captured about the specific nature, severity and frequency of the maltreatment, and the relationship of the child to the person who inflicted the acts. Such data can best inform the development and monitoring of nationwide prevention efforts.

Supporting information

S1 fig. prisma checklist..

https://doi.org/10.1371/journal.pone.0227884.s001

S1 File. Search strategy.

https://doi.org/10.1371/journal.pone.0227884.s002

S2 File. Data extraction template.

https://doi.org/10.1371/journal.pone.0227884.s003

S3 File. Extracted survey items.

https://doi.org/10.1371/journal.pone.0227884.s004

S4 File. Quality assessment tool.

https://doi.org/10.1371/journal.pone.0227884.s005

S5 File. Prevalence rates of included studies.

https://doi.org/10.1371/journal.pone.0227884.s006

Acknowledgments

We acknowledge Juliet Davis, Elizabeth Dallaston, and Andrea Boskovic for providing research assistance. We also thank the journal reviewers for their helpful comments.

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  • Published: 12 August 2021

The impact of childhood psychological maltreatment on mental health outcomes in adulthood: a protocol for a systematic review and meta-analysis

  • Zhuoni Xiao   ORCID: orcid.org/0000-0002-9715-174X 1 ,
  • Mina Murat Baldwin 1 ,
  • Franziska Meinck 2 , 3 ,
  • Ingrid Obsuth 4 &
  • Aja Louise Murray 1  

Systematic Reviews volume  10 , Article number:  224 ( 2021 ) Cite this article

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Research suggests that childhood psychological maltreatment (i.e., emotional abuse and emotional neglect) is associated with mental health problems that persist into adulthood, for example anxiety, depression, post-traumatic stress disorder (PTSD), suicidal ideation, and aggression; however, a systematic review and meta-analysis of the existing literature would help clarify the magnitude and moderators of these associations, and the extent to which they may be affected by publication bias, as well as the methodological strengths and weakness of studies in this area.

The reporting of this protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) Statement. Searches will be carried out via several databases, including Web of Science, Medline, PubMed, PsycINFO, Applied Social Science Index and Abstract, ERIC and EMBASE. Empirical peer-reviewed research articles that fit pre-specified eligibility criteria will be included in the review. Studies will be eligible if they include participants age 18 or over at time of mental health assessment, include information on childhood psychological maltreatment (emotional abuse and/or neglect) perpetrated by a primary caregiver or adult in the same household, and provide quantitative information on the association between these factors. Studies using prospective and retrospective designs and written in either English or Chinese will be eligible. Two independent reviewers will screen and assess studies for inclusion in the review as well as extract the data, with consensus reached through discussion in cases of discrepancy. A third reviewer will be consulted to resolve any discrepancies that remain. The relevant Newcastle–Ottawa scales will be used for assessing the quality of studies. If a sufficient number of comparable studies are retrieved, a meta-analysis will be conducted using a random effects model. Study-level moderators (i.e., year of publication, quality of the study and study geographical location) will be examined in the meta-analyses.

This systematic review will provide an understanding of the long-term effects of childhood psychological maltreatment on adult mental health, which adds to previous reviews focusing primarily on the effects of physical and sexual abuse. The results of the review will help inform clinical practice in approaches to treating those with a history of psychological maltreatment in childhood. The gaps and weaknesses in the evidence identified will also inform recommendations for future research.

Peer Review reports

Childhood abuse is significantly associated with adverse emotional, cognitive, behavioural and social outcomes for children [ 16 , 19 , 22 ], with difficulties frequently continuing into adulthood [ 7 ]. According to the World Health Organization (WHO) (2020), childhood abuse refers to all forms of abuse (e.g. physical, sexual, emotional, psychological and neglect) that result in potential or actual harm to a child’s physical or psychological health.

Childhood emotional abuse is the type of abuse least well-studied [ 1 ]. There has been one systematic review on the association between childhood emotional abuse and neglect in school-aged children [ 19 ],however, there has been no systematic review or meta-analysis on the long-term mental health effects of childhood psychological maltreatment on adults.

There are different definitions of psychological maltreatment, for example, Vega Castelo (2012) stated that psychological maltreatment refers to affective and cognitive aspects of child maltreatment. For the purpose of this review, psychological maltreatment is defined as including two specific concepts: childhood emotional abuse and childhood emotional neglect. Forms of psychological maltreatment may include rejecting, isolating, neglecting, exploiting, and terrorizing [ 12 ]. Emotional abuse in childhood refers to continual deliberate mistreatment of a child, which may include deliberately trying to scare, humiliate, ignore, and isolate the child. Emotional abuse is often a part of other forms of abuse,however, it can also happen on its own [ 4 ]. In contrast to emotional abuse, emotional neglect may be unintentional, and caregivers are sometimes unaware that they are emotionally neglecting their child. Emotional neglect in childhood refers to caregivers’ failure to recognize, understand or provide what a child really needs, and may sometimes refer to lack of attention to a child [ 4 ]. The primary distinction between childhood emotional neglect and childhood emotional abuse is that the former reflects indifferent parenting while the latter reflects hostile parenting [ 17 ].

This review will focus on psychological maltreatment perpetrated by primary caregivers or another adult in household specifically. This focus is motivated by the fact that in the traditional family model, primary caregivers and cohabiting adults are often the most important figures for a child. This is also reflected in commonly used measures of maltreatment. For example, in measures such as the Childhood Traumatic Questionnaire [ 5 ], Adverse Childhood Experience, etc., the items ask whether primary caregivers or adults living in the same household committed maltreatment. The focus on psychological maltreatment is motivated by the fact that it is currently the least-well studied form of abuse in terms of its effects on adult mental health. Part of the reason may be the challenges inherent in measuring psychological maltreatment. Compared with physical and sexual abuse, the assessment and identification of psychological maltreatment can be more difficult [ 2 ], since there is no physical evidence of its occurrence. However, the negative outcomes of it may manifest in numerous ways such as impaired emotional, cognitive, or social development, including outcomes such as depression [ 13 ], helplessness (Black, SlepAM, & Heyman, 2001), aggression (Diza, Simantov, & Rickert, 2002), emotional dysregulation (Burns, Jacksons, & Harding, 2010) delinquency, substance abuse, PTSD, anxiety, and low self-esteem (Kilpatrict, Saunders, & Smith, 2003).

Rationale for the current review

There are numerous systematic reviews on the associations between physical or sexual abuse and adult mental health [ 3 , 15 ],however—to the best of the authors’ knowledge—to date, no research has been carried out to synthesize current evidence on the relationships between childhood psychological maltreatment by primary caregivers (or adults living in the same household) and adult mental health. A systematic review on this topic can provide an understanding of the consistency and strength of the link between early childhood maltreatment and adult mental health outcomes at both the clinical and sub-clinical level. A systematic review and meta-analysis can help provide a more precise estimate of the association than has been provided by primary studies to date. It will also allow us to examine the factors that moderate the magnitude of this association, and to evaluate whether the field is affected by publication bias. Further, it will provide a characterization of the quality of empirical studies in this field and identify gaps in the literature.

The primary review questions will be:

What are the long-term effects of childhood psychological maltreatment on adult mental health?

What are the unique effects of childhood psychological maltreatment by caregivers on adult mental health after adjusting for other forms of abuse?

How do study-level moderators such as year of publication, quality of study and location of study affect these associations?

The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) recommendations have been used to guide the reporting in this systematic review protocol and will be used to guide the reporting of the review itself [ 21 ]. This systematic review protocol has been registered in the International Prospective Register of Systematic Reviews (PROSPERO) with registration number CRD42020197833.

Search strategy

To search the existing literature on childhood psychological maltreatment, the following keywords will be used: ‘child abuse’, ‘childhood psychological maltreatment’, ‘childhood emotional abuse’, ‘child neglect’, ‘childhood emotional neglect’, ‘psychological aggression’, ‘psychological violence’, ‘psychological domestic violence’ and ‘childhood psychological victimisation’. The Boolean operator ‘OR’ will be used to combine the search terms and with specific syntax be adapted to the different databases.

To capture the concept of mental health, these key search terms will be used: ‘mental health’, ‘generalised anxiety disorder’, ‘depression’, ‘major depression disorder’, ‘PTSD’, ‘personality disorder’, ‘eating disorder’, ‘bipolar disorder’, ‘schizophrenia’, ‘panic disorder’, ‘psychosis’, ‘social anxiety disorder’, ‘suicide ideation’, ‘suicide attempt’, ‘non-suicidal self-injury’ and ‘substance abuse’. The Boolean operator ‘OR’ will be used to combine these search terms, adapted to the syntax of different databases.

The Boolean operator (‘AND’) will be used to combine keywords from psychological maltreatment and mental health. In addition, the maltreatment terms will be combined with child* and the mental health terms with adult* using the AND operator in order to link the concepts to the relevant developmental stages.

Several databases will be used searching for relevant papers: Web of Science, Medline, PubMed, PsycINFO, Applied Social Science Index and Abstract, ERIC and EMBASE. For grey literature, several databases will be used: WHO database, PhD thesis/dissertation databases, and Open Grey.

For literature written in Chinese, ZhiWang which is a well-known database in China, and covers various journals written in Chinese, will be used for searching the literature.

Inclusion criteria

Participants aged over 18 at assessment of the mental health problems.

Measurement of abuse: studies that measured childhood psychological maltreatment using retrospective self-report, questionnaires, interviews, or police or social work records will be included.

Measurement of mental health: studies that measured mental health problems (standard diagnoses as listed in the DSM-V or ICD-10 or using mental health scores based on validated measures) using self-report, questionnaires or clinical interviews will be included.

Types of maltreatment: studies that only assessed childhood psychological maltreatment, childhood emotional neglect, childhood emotional abuse, or studies that assessed both childhood emotional abuse and childhood emotional neglect and other types of abuse (e.g., physical, or sexual) will be included. The abuse must have been committed by the primary caregivers, or the adult living in the same household.

Comparison: adults who experienced only childhood psychological maltreatment versus adults who experienced different forms of abuse during childhood, with or without psychological maltreatment versus adults who experienced no abuse during childhood will be compared.

Ascertainment of exposure to childhood psychological maltreatment by primary caregivers (or adults living in the same household): Studies using either retrospective or prospective data will be included.

Studies that reported odds ratio or other effect size: If the studies do not report the relevant effect size, they will be eligible for inclusion only if they provide the raw information such that the effect size could be calculated. When the raw information not available in the text, authors will contact the authors to request such data.

Additional inclusion criteria include:

Articles written in either English or Chinese will be included reflecting the language capabilities of the team.

Exclusion criteria

Any book chapters, case studies, letter, opinions, and editorials that do not present new data will be excluded.

Qualitative investigations will be excluded.

Studies that do not provide an analysis of childhood psychological maltreatment will be excluded.

Studies that focus on psychological maltreatment perpetrated by non-parental others or where data for primary caregivers or another adult in household cannot be disaggregated from data on abuse perpetrated by others will not be included.

Studies where different types of abuse are combined and not separately reported so that it is not possible to obtain an effect for childhood psychological maltreatment will be excluded.

Studies where the outcome is physical rather than mental illness will be excluded.

Review papers (narrative reviews, systematic reviews, and meta-analyses) will be excluded.

Study selection

The bibliographic software program Zotero will be used to manage and store relevant studies. Duplicate studies will be removed via this software. Two independent reviewers will scrutinise the electronic searches for eligibility and inclusion of studies into the systematic review based on their title and abstract. Full texts of potentially relevant papers will be retrieved and reviewed independently by two reviewers. A final determination of whether an article meets inclusion criteria will be made on examination of the full article, the reason for each excluded study will be documented. A third reviewer will be consulted to resolve any discrepancies that cannot be resolved through discussion between the original reviewers. Figure  1 presents the flow diagram to be adopted in the systematic review for study selection [ 20 ].

figure 1

PRISMA flow diagram

Methodological appraisal of study

Classification of risk of bias as recommended by the Newcastle–Ottawa Quality Assessment Scale will be used to assess the quality of selected case–control for retrospective study or cohort studies for longitudinal studies [ 25 ]. Main domains of this assessment are selection (adequateness of case definition, representativeness of the cases, selection of controls and definition of controls), comparability (comparability of cases and controls based on the design or analysis) and exposure (ascertainment of exposure, same method of ascertainment for cases and control and non-response rate). A study can be awarded a maximum of four stars for selection, two stars for comparability and three stars for exposure. More stars represent lower risk of bias. Two reviewers will independently assess the studies for methodological quality with discrepancies being resolved through discussion and a third reviewer will be consulted where consensus cannot be reached through discussion.

Data extraction

Study findings will be extracted using a structured database. It will include pertinent information such as author name and date of publication, sample size, sample population, study geographical location, sample population demographic, study setting, study methodology, types of abuse, measurement of childhood psychological maltreatment, duration of abuse, measurement of various mental health outcomes, perpetrator of the maltreatment, age at exposure to maltreatment, the relation between childhood psychological maltreatment and mental health outcomes (as an odds ratio or risk ratio), and covariates adjusted for. When available, both adjusted and unadjusted statistics will be extracted. Two reviewers will independently conduct the data extraction with consensus reached through discussion in case of discrepancies. Where consensus is not reached through discussion, a third reviewer will be consulted. If any new categories are identified during the course of the review, they will be added, and the extraction database will be modified as needed. If there are any missing data or relevant information, authors will be contacted to supply the information. To detect the unique effects of childhood psychological maltreatment by caregivers on adult mental health after adjusting for other forms of abuse, researchers will extract the statistical information of the studies exploring the associations between childhood psychological maltreatment and adult mental health when adjusting for other types of abuse.

Data analysis

A narrative synthesis of the findings from the included studies will be presented. The narrative synthesis will focus on socio-demographic characteristics of the samples (duration of abuse, who the maltreatment was inflicted by, age at exposure to maltreatment), characteristic of the studies (study setting, sample size, study design), methodology (questionnaire, self-report, experimental design, clinical interview, police or social work records), types of mental health issues, effect size and odd/risk ratios.

A meta-analysis will be conducted if there are enough studies with information related to both childhood psychological maltreatment and mental health. Results will be summarized using a forest plot. Results from different study designs will not be pooled together (e.g., studies that assessed only childhood psychological maltreatment and studies that assessed different types of abuse) to prevent a misleading summary of the study effect; rather, they will be analysed separately. If possible, meta-analyses of both adjusted and unadjusted effects will be conducted and results compared. A random effects model will be utilized for the meta-analysis as it is likely that studies will not be homogeneous. Studies are expected to represent fairly substantial differences in method (i.e. types of participants, measurements) and are thus not anticipated to reflect a single underlying effect size. The ‘Metafor’ package for R statistical software will be used for meta-analysis [ 24 ].

The GRADE criteria will be used to assess the quality of the evidence provided by the observational studies in relation to the outcome (Higgins & Green, 2011). The quality of the evidence will be rated as very low, low, moderate, and high; and factors that may decrease the quality are risk of bias, imprecision, inconsistency and indirectness (Higgins & Green, 2011).

Assessment of heterogeneity and moderator analysis

Study heterogeneity will be assessed by examining the characteristics of studies and similarities between childhood psychological maltreatment and mental health outcomes. Statistical heterogeneity will be assessed by calculating Q and I 2 . Where there are sufficient numbers of studies in the meta-analysis, study-level moderators will be tested. These may include study quality (based on the quality assessment described above), study geographical location, year of publication, and sample size. Moderator analysis will be using the ‘Metafor’ package.

Assessment of reporting bias

In case of an appropriate number of studies ( n  ≥ 10), publication bias will be assessed using a funnel plot for each outcome by plotting the effect size against study size (Higgins & Green, 2011). An Egger test [ 11 ] and the trim and fill method [ 10 ] will be used to statistically test for publication bias and its potential impact.

This protocol outlines the plan for a systematic review and, if applicable, a meta-analysis on the effects of childhood emotional abuse and childhood emotional neglect (collectively ‘psychological maltreatment’) perpetrated by primary caregivers or adults living in the same household in childhood on adult mental health outcomes. There is currently no systematic review and meta-analysis focusing specifically on the long-term effects of childhood psychological maltreatment on adult mental health outcomes, therefore, the review will help fill this important gap. The findings from this review could help illuminate the long-term impact of psychological maltreatment, in combination with and net of other forms of abuse. This can help inform prevention and intervention strategies to help target resources and minimise the impact of psychological maltreatment. It will also potentially provide insights into whether the impact of psychological maltreatment varies across contexts; which mental health outcomes it is most strongly related to; and whether its impact has changed over time. This review will also explore where the major gaps are in current evidence in other to make recommendations for future research. Finally, it will help provide an assessment of the quality of the work on the field and identify areas for improvement in future research to strengthen the evidence in the field.

Availability of data and materials

Not applicable.

Abbreviations

The Diagnostic and Statistical Manual of Mental Disorders (5th edition)

International Classification of Diseases, tenth revision

Preferred Reporting Items for Systematic Review and Meta-Analysis

Post-traumatic stress disorder

World Health Organization

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FM received support from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme [Grant Agreement Number 852787] and the UK Research and Innovation Global Challenges Research Fund [ES/S008101/1].

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Xiao, Z., Baldwin, M.M., Meinck, F. et al. The impact of childhood psychological maltreatment on mental health outcomes in adulthood: a protocol for a systematic review and meta-analysis. Syst Rev 10 , 224 (2021). https://doi.org/10.1186/s13643-021-01777-4

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Understanding Child Abuse and Neglect (1993)

Chapter: 1 introduction, 1 introduction.

Child maltreatment is a devastating social problem in American society. In 1990, over 2 million cases of child abuse and neglect were reported to social service agencies. In the period 1979 through 1988, about 2,000 child deaths (ages 0-17) were recorded annually as a result of abuse and neglect (McClain et al., 1993), and an additional 160,000 cases resulted in serious injuries in 1990 alone (Daro and McCurdy, 1991). However tragic and sensational, the counts of deaths and serious injuries provide limited insight into the pervasive long-term social, behavioral, and cognitive consequences of child abuse and neglect. Reports of child maltreatment alone also reveal little about the interactions among individuals, families, communities, and society that lead to such incidents.

American society has not yet recognized the complex origins or the profound consequences of child victimization. The services required for children who have been abused or neglected, including medical care, family counseling, foster care, and specialized education, are expensive and are often subsidized by governmental funds. The General Accounting Office (1991) has estimated that these services cost more than $500 million annually. Equally disturbing, research suggests that child maltreatment cases are highly related to social problems such as juvenile delinquency, substance abuse, and violence, which require additional services and severely affect the quality of life for many American families.

The Importance Of Child Maltreatment Research

The challenges of conducting research in the field of child maltreatment are enormous. Although we understand comparatively little about the causes, definitions, treatment, and prevention of child abuse and neglect, we do know enough to recognize that the origins and consequences of child victimization are not confined to the months or years in which reported incidents actually occurred. For those who survive, the long-term consequences of child maltreatment appear to be more damaging to victims and their families, and more costly for society, than the immediate or acute injuries themselves. Yet little is invested in understanding the factors that predispose, mitigate, or prevent the behavioral and social consequences of child maltreatment.

The panel has identified five key reasons why child maltreatment research should be viewed as a central nexus of more comprehensive research activity.

Research On Child Maltreatment Is Currently Undervalued And Undeveloped

Research in the field of child maltreatment studies is relatively undeveloped when compared with related fields such as child development, so-

cial welfare, and criminal violence. Although no specific theory about the causes of child abuse and neglect has been substantially replicated across studies, significant progress has been gained in the past few decades in identifying the dimensions of complex phenomena that contribute to the origins of child maltreatment.

Efforts to improve the quality of research on any group of children are dependent on the value that society assigns to the potential inherent in young lives. Although more adults are available in American society today as service providers to care for children than was the case in 1960, a disturbing number of recent reports have concluded that American children are in trouble (Fuchs and Reklis, 1992; National Commission on Children, 1991; Children's Defense Fund, 1991).

Efforts to encourage greater investments in research on children will be futile unless broader structural and social issues can be addressed within our society. Research on general problems of violence, substance addiction, social inequality, unemployment, poor education, and the treatment of children in the social services system is incomplete without attention to child maltreatment issues. Research on child maltreatment can play a key role in informing major social policy decisions concerning the services that should be made available to children, especially children in families or neighborhoods that experience significant stress and violence.

As a nation, we already have developed laws and regulatory approaches to reduce and prevent childhood injuries and deaths through actions such as restricting hot water temperatures and requiring mandatory child restraints in automobiles. These important precedents suggest how research on risk factors can provide informed guidance for social efforts to protect all of America's children in both familial and other settings.

Not only has our society invested relatively little in research on children, but we also have invested even less in research on children whose families are characterized by multiple problems, such as poverty, substance abuse, violence, welfare dependency, and child maltreatment. In part, this slower development is influenced by the complexities of research on major social problems. But the state of research on this topic could be advanced more rapidly with increased investment of funds. In the competition for scarce research funds, the underinvestment in child maltreatment research needs to be understood in the context of bias, prejudice, and the lack of a clear political constituency for children in general and disadvantaged children in particular (Children's Defense Fund, 1991; National Commission on Children, 1991). Factors such as racism, ethnic discrimination, sexism, class bias, institutional and professional jealousies, and social inequities influence the development of our national research agenda (Bell, 1992, Huston, 1991).

The evolving research agenda has also struggled with limitations im-

posed by attempting to transfer the results of sample-specific studies to diverse groups of individuals. The roles of culture, ethnic values, and economic factors pervade the development of parenting practices and family dynamics. In setting a research agenda for this field, ethnic diversity and multiple cultural perspectives are essential to improve the quality of the research program and to overcome systematic biases that have restricted its development.

Researchers must address ethical and legal issues that present unique obligations and dilemmas regarding selection of subjects, provision of services, and disclosure of data. For example, researchers who discover an undetected incident of child abuse in the course of an interview are required by state laws to disclose the identities of the victim and offender(s), if known, to appropriate child welfare officials. These mandatory reporting requirements, adopted in the interests of protecting children, may actually cause long-term damage to children by restricting the scope of research studies and discouraging scientists from developing the knowledge base necessary to guide social interventions.

Substantial efforts are now required to reach beyond the limitations of current knowledge and to gain new insights that can improve the quality of social service efforts and public policy decisions affecting the health and welfare of abused and neglected children and their families. Most important, collaborative long-term research ventures are necessary to diminish social, professional, and institutional prejudices that have restricted the development of a comprehensive knowledge base that can improve understanding of, and response to, child maltreatment.

Dimensions Of Child Abuse And Neglect

The human dimensions of child maltreatment are enormous and tragic. The U.S. Advisory Board on Child Abuse and Neglect has called the problem of child maltreatment ''an epidemic" in American society, one that requires a critical national emergency response.

The scale and severity of child abuse and neglect has caused various public and private organizations to mobilize efforts to raise public awareness of individual cases and societal trends, to improve the reporting and tracking of child maltreatment cases, to strengthen the responses of social service systems, and to develop an effective and fair system for protecting and offering services to victims while also punishing adults who deliberately harm children or place them in danger. Over the past several decades, a growing number of state and federal funding programs, governmental reports, specialized journals, and research centers, as well as national and international societies and conferences, have examined various dimensions of the problem of child maltreatment.

The results of these efforts have been inconsistent and uneven. In addressing aspects of each new revelation of abuse or each promising new intervention, research efforts often have become diffuse, fragmented, specific, and narrow. What is lacking is a coordinated approach and a general conceptual framework that can add new depth to our understanding of child maltreatment. A coordinated approach can accommodate diverse perspectives while providing direction and guidance in establishing research priorities and synthesizing research knowledge. Organizational mechanisms are also needed to facilitate the application and integration of research on child maltreatment in related areas such as child development, family violence, substance abuse, and juvenile delinquency.

Child maltreatment is not a new problem, yet concerted service, research, and policy attention toward it is just beginning. Although isolated studies of child maltreatment appeared in the medical and sociological literature in the first half of the twentieth century, the publication of "The Battered Child Syndrome" by C. Henry Kempe and associates (1962) is generally considered the first definitive paper in the field in the United States. The efforts of Kempe and others to publicize disturbing medical experience with child abuse and neglect led to the passage of the first Child Abuse Prevention and Treatment Act in 1974 (P.L. 93-247). The act, which has been amended several times (most recently in 1992), established a governmental program designed to guide and consolidate national and state data collection efforts regarding reports of child abuse and neglect, conduct national surveys of household violence, and sponsor research and demonstration programs to prevent, identify, and treat child abuse and neglect.

However, the federal government's leadership role in building a research base in this area has been complicated by changes and inconsistencies in research plans and priorities, limited funding, politicized peer review, fragmentation of effort among various federal agencies, poorly scheduled proposal review deadlines, and bias introduced by competing institutional objectives. 1 The lack of comprehensive, long-term planning for a research base has resulted in a field characterized by contradictions, conflict, and fragmentation. The role of the National Center for Child Abuse and Neglect as the lead federal agency in supporting research in this field has been sharply criticized (U.S. Advisory Board, 1991). Many observers believe that the federal government lacks leadership, funding, and an effective research program for studies on child maltreatment.

The Complexity Of Child Maltreatment

Child maltreatment was originally seen in the form of "the battered child," often portrayed in terms of physical abuse. Today, four general categories of child maltreatment are generally recognized: (1) physical

abuse, (2) sexual abuse, (3) neglect, and (4) emotional maltreatment. Each category covers a range of behaviors, as discussed in Chapter 2.

These four categories have become the focus of separate studies of incidence and prevalence, etiology, prevention, consequences, and treatment, with uneven development of research within each area and poor integration of knowledge across areas. Each category has developed its own typology and framework of reference terms, revealing certain similarities (such as the importance of developmental perspectives in considering the consequences of maltreatment) but also important differences (such as the predatory behavior associated with some forms of sexual abuse that do not appear in the etiology of other forms of child maltreatment).

In addition to the category of child maltreatment, the duration, source, intensity, timing, and situational context of incidents of child victimization are now recognized as important factors in studying the origin and consequences of child maltreatment. Yet information about these factors is rarely requested or recorded by social agencies or health professionals in the process of identifying or documenting reports of child maltreatment. Furthermore, research is often weakened by variation in research definitions of child maltreatment, bias in the recruitment of research subjects, the absence of information regarding circumstances surrounding maltreatment reports, the absence of measures to assess selected variables under study, and the absence of a developmental perspective in many research studies.

The co-occurrence of different forms of child maltreatment has been examined only to a limited extent. Relatively little is known about areas of similarity and differences in terms of causes, consequences, prevention, and treatment of selected types of child abuse and neglect. Inconsistencies in definitions often preclude comparative analyses of clinical studies. For example, studies of sexual abuse have indicated wide variations in its prevalence, often as a result of differences in the types of behavior that might be included in the definition adopted by each research investigator. Emotional abuse is also a matter of controversy in some quarters, primarily because of broad variations in its definition.

Research on child maltreatment is also complicated by the fragmentation of services and responses by which our society addresses specific reports of child maltreatment. Cases may involve children who are victims or witnesses to single or repeated incidents of child abuse and neglect. Sadly, child maltreatment often involves various family members, relatives, or other individuals who reside in the homes or neighborhoods of the affected children. Adult figures may be perpetrators of offensive incidents or mediators in intervention or prevention efforts.

The importance of the social ecological framework of the child has only recently been recognized in studies of maltreatment. Responses to child abuse and neglect involve a variety of social institutions, including commu-

nities, schools, hospitals, churches, youth associations, the media, and other social structures that provide services for children. Such groups and organizations present special intervention opportunities to reduce the scale and scope of the problem of child maltreatment, but their activities are often poorly documented and uncoordinated. Finally, governmental offices at the local, state, and federal levels have legal and social obligations to develop programs and resources to address child maltreatment, and their role is critical in developing a research agenda for this field.

In the past, the research agenda has been determined predominantly by pragmatic needs in the development and delivery of treatment and prevention services rather than by theoretical paradigms, a process that facilitates short-term studies of specialized research priorities but impedes the development of a well-organized, coherent body of scientific knowledge that can contribute over time to understanding fundamental principles and issues. As a result, the research in this field has been generally viewed by the scientific community as fragmented, diffuse, decentralized, and of poor quality.

Selection of Research Studies

The research literature in the field of child maltreatment is immense—over 2000 items are included in the panel's research bibliography, a portion of which is referenced in this report. Despite this quantity of literature, researchers generally agree that the quality of research on child maltreatment is relatively weak in comparison to health and social science research studies in areas such as family systems and child development. Only a few prospective studies of child maltreatment have been undertaken, and most studies rely on the use of clinical samples (which may exclude important segments of the research population) or adult memories. Both types of samples are problematic and can produce biased results. Clinical samples may not be representative of all cases of child maltreatment. For example, we know from epidemiologic studies of disease of cases that were derived from hospital records that, unless the phenomenon of interest always comes to a service provider for treatment, there exist undetected and untreated cases in the general population that are often quite different from those who have sought treatment. Similarly, when studies rely on adult memories of childhood experiences, recall bias is always an issue. Longitudinal studies are quite rare, and some studies that are described as longitudinal actually consist of hybrid designs followed over time.

To ensure some measure of quality, the panel relied largely on studies that had been published in the peer-reviewed scientific literature. More rigorous scientific criteria (such as the use of appropriate theory and methodology in the conduct of the study) were considered by the panel, but were not adopted because little of the existing work would meet such selection

criteria. Given the early stage of development of this field of research, the panel believes that even weak studies contain some useful information, especially when they suggest clinical insights, a new perspective, or a point of departure from commonly held assumptions. Thus, the report draws out issues based on clinical studies or studies that lack sufficient control samples, but the panel refrains from drawing inferences based on this literature.

The panel believes that future research reviews of the child maltreatment literature would benefit from the identification of explicit criteria that could guide the selection of exemplary research studies, such as the following:

For the most part, only a few studies will score well in each of the above categories. It becomes problematic, therefore, to rate the value of studies which may score high in one category but not in others.

The panel has relied primarily on studies conducted in the past decade, since earlier research work may not meet contemporary standards of methodological rigor. However, citations to earlier studies are included in this report where they are thought to be particularly useful and when research investigators provided careful assessments and analysis of issues such as definition, interrelationships of various types of abuse, and the social context of child maltreatment.

A Comparison With Other Fields of Family and Child Research

A comparison with the field of studies on family functioning may illustrate another point about the status of the studies on child maltreatment. The literature on normal family functioning or socialization effects differs in many respects from the literature on child abuse and neglect. Family sociology research has a coherent body of literature and reasonable consensus about what constitutes high-quality parenting in middle-class, predominantly White populations. Family functioning studies have focused predominantly on large, nonclinical populations, exploring styles of parenting and parenting practices that generate different kinds and levels of competence, mental health, and character in children. Studies of family functioning have tended to follow cohorts of subjects over long periods to identify the effects of variations in childrearing practices and patterns on children's

competence and adjustment that are not a function of social class and circumstances.

By contrast, the vast and burgeoning literature on child abuse and neglect is applied research concerned largely with the adverse effects of personal and social pathology on children. The research is often derived from very small samples selected by clinicians and case workers. Research is generally cross-sectional, and almost without exception the samples use impoverished families characterized by multiple problems, including substance abuse, unemployment, transient housing, and so forth. Until recently, researchers demonstrated little regard for incorporating appropriate ethnic and cultural variables in comparison and control groups. In the past decade, significant improvements have occurred in the development of child maltreatment research, but key problems remain in the area of definitions, study designs, and the use of instrumentation.

As the nature of research on child abuse and neglect has evolved over time, scientists and practitioners have likewise changed. The psychopathologic model of child maltreatment has been expanded to include models that stress the interactions of individual, family, neighborhood, and larger social systems. The role of ethnic and cultural issues are acquiring an emerging importance in formulating parent-child and family-community relationships. Earlier simplistic conceptionalizations of perpetrator-victim relationships are evolving into multiple-focus research projects that examine antecedents in family histories, current situational relationships, ecological and neighborhood issues, and interactional qualities of relationships between parent-child and offender-victim. In addition, emphases in treatment, social service, and legal programs combine aspects of both law enforcement and therapy, reflecting an international trend away from punishment, toward assistance, for families in trouble.

Charge To The Panel

The commissioner of the Administration for Children, Youth, and Families in the U.S. Department of Health and Human Services requested that the National Academy of Sciences convene a study panel to undertake a comprehensive examination of the theoretical and pragmatic research needs in the area of child maltreatment. The Panel on Research on Child Abuse and Neglect was asked specifically to:

The report resulting from this study provides recommendations for allocating existing research funds and also suggests funding mechanisms and topic areas to which new resources could be allocated or enhanced resources could be redirected. By focusing this report on research priorities and the needs of the research community, the panel's efforts were distinguished from related activities, such as the reports of the U.S. Advisory Board on Child Abuse and Neglect, which concentrate on the policy issues in the field of child maltreatment.

The request for recommendations for research priorities recognizes that existing studies on child maltreatment require careful evaluation to improve the evolution of the field and to build appropriate levels of human and financial resources for these complex research problems. Through this review, the panel has examined the strengths and weaknesses of past research and identified areas of knowledge that represent the greatest promise for advancing understanding of, and dealing more effectively with, the problem of child maltreatment.

In conducting this review, the panel has recognized the special status of studies of child maltreatment. The experience of child abuse or neglect from any perspective, including victim, perpetrator, professional, or witness, elicits strong emotions that may distort the design, interpretation, or support of empirical studies. The role of the media in dramatizing selected cases of child maltreatment has increased public awareness, but it has also produced a climate in which scientific objectivity may be sacrificed in the name of urgency or humane service. Many concerned citizens, legislators, child advocates, and others think we already know enough to address the root causes of child maltreatment. Critical evaluations of treatment and prevention services are not supported due to both a lack of funding and a lack of appreciation for the role that scientific analysis can play in improving the quality of existing services and identifying new opportunities for interventions. The existing research base is small in volume and spread over a wide variety of topics. The contrast between the importance of the problem and the difficulty of approaching it has encouraged the panel to proceed carefully, thoroughly distinguishing suppositions from facts when they appear.

Research on child maltreatment is at a crossroads—we are now in a position to merge this research field with others to incorporate multiple perspectives, broaden research samples, and focus on fundamental issues that have the potential to strengthen, reform, or replace existing public policy and social programs. We have arrived at a point where we can

recognize the complex interplay of forces in the origins and consequences of child abuse and neglect. We also recognize the limitations of our knowledge about the effects of different forms of social interventions (e.g., home visitations, foster care, family treatment programs) for changing the developmental pathways of abuse victims and their families.

The Importance Of A Child-Oriented Framework

The field of child maltreatment studies has often divided research into the types of child maltreatment under consideration (such as physical and sexual abuse, child neglect, and emotional maltreatment). Within each category, researchers and practitioners have examined underlying causes or etiology, consequences, forms of treatment or other interventions, and prevention programs. Each category has developed its own typology and framework of reference terms, and researchers within each category often publish in separate journals and attend separate professional meetings.

Over a decade ago, the National Research Council Committee on Child Development Research and Public Policy published a report titled Services for Children: An Agenda for Research (1981). Commenting on the development of various government services for children, the report noted that observations of children's needs were increasingly distorted by the "unmanageably complex, expensive, and confusing" categorical service structure that had produced fragmented and sometimes contradictory programs to address child health and nutrition requirements (p. 15-16). The committee concluded that the actual experiences of children and their families in different segments of society and the conditions of their homes, neighborhoods, and communities needed more systematic study. The report further noted that we need to learn more about who are the important people in children's lives, including parents, siblings, extended family, friends, and caretakers outside the family, and what these people do for children, when, and where.

These same conclusions can be applied to studies of child maltreatment. Our panel considered, but did not endorse, a framework that would emphasize differences in the categories of child abuse or neglect. We also considered a framework that would highlight differences in the current system of detecting, investigating, or responding to child maltreatment. In contrast to conceptualizing this report in terms of categories of maltreatment or responses of the social system to child maltreatment, the panel presents a child-oriented research agenda that emphasizes the importance of knowing more about the backgrounds and experiences of developing children and their families, within a broader social context that includes their friends, neighborhoods, and communities. This framework stresses the importance of knowing more about the qualitative differences between children who suffer episodic experiences of abuse or neglect and those for whom mal-

treatment is a chronic part of their lives. And this approach highlights the need to know more about circumstances that affect the consequences, and therefore the treatment, of child maltreatment, especially circumstances that may be affected by family, cultural, or ethnic factors that often remain hidden in small, isolated studies.

An Ecological Developmental Perspective

The panel has adopted an ecological developmental perspective to examine factors in the child, family, or society that can exacerbate or mitigate the incidence and destructive consequences of child maltreatment. In the panel's view, this perspective reflects the understanding that development is a process involving transactions between the growing child and the social environment or ecology in which development takes place. Positive and negative factors merit attention in shaping a research agenda on child maltreatment. We have adopted a perspective that recognizes that dysfunctional families are often part of a dysfunctional environment.

The relevance of child maltreatment research to child development studies and other research fields is only now being examined. New methodologies and new theories of child maltreatment that incorporate a developmental perspective can provide opportunities for researchers to consider the interaction of multiple factors, rather than focusing on single causes or short-term effects. What is required is the mobilization of new structures of support and resources to concentrate research efforts on significant areas that offer the greatest promise of improving our understanding of, and our responses to, child abuse and neglect.

Our report extends beyond what is, to what could be, in a society that fosters healthy development in children and families. We cannot simply build a research agenda for the existing social system; we need to develop one that independently challenges the system to adapt to new perspectives, new insights, and new discoveries.

The fundamental theme of the report is the recognition that research efforts to address child maltreatment should be enhanced and incorporated into a long-term plan to improve the quality of children's lives and the lives of their families. By placing maltreatment within the framework of healthy development, for example, we can identify unique sources of intervention for infants, preschool children, school-age children, and adolescents.

Each stage of development presents challenges that must be resolved in order for a child to achieve productive forms of thinking, perceiving, and behaving as an adult. The special needs of a newborn infant significantly differ from those of a toddler or preschool child. Children in the early years of elementary school have different skills and distinct experiential levels from those of preadolescent years. Adolescent boys and girls demon-

strate a range of awkward and exploratory behaviors as they acquire basic social skills necessary to move forward into adult life. Most important, developmental research has identified the significant influences of family, schools, peers, neighborhoods, and the broader society in supporting or constricting child development.

Understanding the phenomenon of child abuse and neglect within a developmental perspective poses special challenges. As noted earlier, research literature on child abuse and neglect is generally organized by the category or type of maltreatment; integrated efforts have not yet been achieved. For example, research has not yet compared and contrasted the causes of physical and sexual abuse of a preschool child or the differences between emotional maltreatment of toddlers and adolescents, although all these examples fall within the domain of child maltreatment. A broader conceptual framework for research will elicit data that can facilitate such comparative analyses.

By placing research in the framework of factors that foster healthy development, the ecological developmental perspective can enhance understanding of the research agenda for child abuse and neglect. The developmental perspective can improve the quality of treatment and prevention programs, which often focus on particular groups, such as young mothers who demonstrate risk factors for abuse of newborns, or sexual offenders who molest children. There has been little effort to cut across the categorical lines established within these studies to understand points of convergence or divergence in studies on child abuse and neglect.

The ecological developmental perspective can also improve our understanding of the consequences of child abuse and neglect, which may occur with increased or diminished intensity over a developmental cycle, or in different settings such as the family or the school. Initial effects may be easily identified and addressed if the abuse is detected early in the child's development, and medical and psychological services are available for the victim and the family. Undetected incidents, or childhood experiences discovered later in adult life, require different forms of treatment and intervention. In many cases, incidents of abuse and neglect may go undetected and unreported, yet the child victim may display aggression, delinquency, substance addiction, or other problem behaviors that stimulate responses within the social system.

Finally, an ecological developmental perspective can enhance intervention and prevention programs by identifying different requirements and potential effects for different age groups. Children at separate stages of their developmental cycle have special coping mechanisms that present barriers to—and opportunities for—the treatment and prevention of child abuse and neglect. Intervention programs need to consider the extent to which children may have already experienced some form of maltreatment in order to

evaluate successful outcomes. In addition, the perspective facilitates evaluation of which settings are the most promising locus for interventions.

Previous Reports

A series of national reports associated with the health and welfare of children have been published in the past decade, many of which have identified the issue of child abuse and neglect as one that deserves sustained attention and creative programmatic solutions. In their 1991 report, Beyond Rhetoric , the National Commission on Children noted that the fragmentation of social services has resulted in the nation's children being served on the basis of their most obvious condition or problem rather than being served on the basis of multiple needs. Although the needs of these children are often the same and are often broader than the mission of any single agency emotionally disturbed children are often served by the mental health system, delinquent children by the juvenile justice system, and abused or neglected children by the protective services system (National Commission on Children, 1991). In their report, the commission called for the protection of abused and neglected children through more comprehensive child protective services, with a strong emphasis on efforts to keep children with their families or to provide permanent placement for those removed from their homes.

In setting health goals for the year 2000, the Public Health Service recognized the problem of child maltreatment and recommended improvements in reporting and diagnostic services, and prevention and educational interventions (U.S. Public Health Service, 1990). For example, the report, Health People 2000 , described the four types of child maltreatment and recommended that the rising incidence (identified as 25.2 per 1,000 in 1986) should be reversed to less than 25.2 in the year 2000. These public health targets are stated as reversing increasing trends rather than achieving specific reductions because of difficulties in obtaining valid and reliable measures of child maltreatment. The report also included recommendations to expand the implementation of state level review systems for unexplained child deaths, and to increase the number of states in which at least 50 percent of children who are victims of physical or sexual abuse receive appropriate treatment and follow-up evaluations as a means of breaking the intergenerational cycle of abuse.

The U.S. Advisory Board on Child Abuse and Neglect issued reports in 1990 and 1991 which include national policy and research recommendations. The 1991 report presented a range of research options for action, highlighting the following priorities (U.S. Advisory Board on Child Abuse and Neglect, 1991:110-113):

This report differs from those described above because its primary focus is on establishing a research agenda for the field of studies on child abuse and neglect. In contrast to the mandate of the U.S. Advisory Board on Child Abuse and Neglect, the panel was not asked to prepare policy recommendations for federal and state governments in developing child maltreatment legislation and programs. The panel is clearly aware of the need for services for abused and neglected children and of the difficult policy issues that must be considered by the Congress, the federal government, the states, and municipal governments in responding to the distress of children and families in crisis. The charge to this panel was to design a research agenda that would foster the development of scientific knowledge that would provide fundamental insights into the causes, identification, incidence, consequences, treatment, and prevention of child maltreatment. This knowledge can enable public and private officials to execute their responsibilities more effectively, more equitably, and more compassionately and empower families and communities to resolve their problems and conflicts in a manner that strengthens their internal resources and reduces the need for external interventions.

Report Overview

Early studies on child abuse and neglect evolved from a medical or pathogenic model, and research focused on specific contributing factors or causal sources within the individual offender to be discovered, addressed, and prevented. With the development of research on child maltreatment over the past several decades, however, the complexity of the phenomena encompassed by the terms child abuse and neglect or child maltreatment has become apparent. Clinical studies that began with small sample sizes and weak methodological designs have gradually evolved into larger and longer-term projects with hundreds of research subjects and sound instrumentation.

Although the pathogenic model remains popular among the general public in explaining the sources of child maltreatment, it is limited by its primary focus on risk and protective factors within the individual. Research investigators now recognize that individual behaviors are often influenced by factors in the family, community, and society as a whole. Elements from these systems are now being integrated into more complex theories that analyze the roles of interacting risk and protective factors to explain and understand the phenomena associated with child maltreatment.

In the past, research on child abuse and neglect has developed within a categorical framework that classifies the research by the type of maltreatment typically as reported in administrative records. Although the quality of research within different categories of child abuse and neglect is uneven and problems of definitions, data collection, and study design continue to characterize much research in this field, the panel concluded that enough progress has been achieved to integrate the four categories of maltreatment into a child-oriented framework that could analyze the similarities and differences of research findings. Rather than encouraging the continuation of a categorical approach that would separate research on physical or sexual abuse, for example, the panel sought to develop for research sponsors and the research community a set of priorities that would foster the integration of scientific findings, encourage the development of comparative analyses, and also distinguish key research themes in such areas as identification, incidence, etiology, prevention, consequences, and treatment. This approach recognizes the need for the construction of collaborative, long-term efforts between public and private research sponsors and research investigators to strengthen the knowledge base, to integrate studies that have evolved for different types of child maltreatment, and eventually to reduce the problem of child maltreatment. This approach also highlights the connections that need to be made between research on the causes and the prevention of child maltreatment, for the more we learn about the origins of child abuse and neglect, the more effective we can be in seeking to prevent it. In the same manner, the report emphasises the connections that need to be made between research on the consequences and treatment of child maltreatment, for knowledge about the effects of child abuse and neglect can guide the development of interventions to address these effects.

In constructing this report, the panel has considered eight broad areas: Identification and definitions of child abuse and neglect (Chapter 2) Incidence: The scope of the problem (Chapter 3) Etiology of child maltreatment (Chapter 4) Prevention of child maltreatment (Chapter 5) Consequences of child maltreatment (Chapter 6) Treatment of child maltreatment (Chapter 7)

Human resources, instrumentation, and research infrastructure (Chapter 8) Ethical and legal issue in child maltreatment research (Chapter 9)

Each chapter includes key research recommendations within the topic under review. The final chapter of the report (Chapter 10) establishes a framework of research priorities derived by the panel from these recommendations. The four main categories identified within this framework—research on the nature and scope of child maltreatment; research on the origins and consequences of child maltreatment; research on the strengths and limitations of existing interventions; and the need for a science policy for child maltreatment research—provide the priorities that the panel has selected as the most important to address in the decade ahead.

1. The panel received an anecdotal report, for example, that one federal research agency systematically changed titles of its research awards over a decade ago, replacing phrases such as child abuse with references to maternal and child health care, after political sensitivities developed regarding the appropriateness of its research program in this area.

Bell, D.A. 1992 Faces at the Bottom of the Well: The Permanence of Racism . New York: Basic Books.

Children's Defense Fund 1991 The State of America's Children . Washington, DC: The Children's Defense Fund.

Daro, D. 1988 Confronting Child Abuse: Research for Effective Program Design . New York: The Free Press, Macmillan. Cited in the General Accounting Office, 1992. Child Abuse: Prevention Programs Need Greater Emphasis. GAO/HRD-92-99.

Daro, D., and K. McCurdy 1991 Current Trends in Child Abuse Reporting and Fatalities: The Results of the 1990 Annual Fifty State Survey . Chicago: National Committee for Prevention of Child Abuse.

Fuchs, V.R., and D.M. Reklis 1992 America's children: Economic perspectives and policy options. Science 255:41-46.

General Accounting Office 1991 Child Abuse Prevention: Status of the Challenge Grant Program . May. GAO:HRD91-95. Washington, DC.

Huston, A.C., ed. 1991 Children in Poverty: Child Development and Public Policy . New York: Cambridge University Press.

Kempe, C.H., F.N. Silverman, B. Steele, W. Droegemueller, and H.R. Silver 1962 The battered child syndrome. Journal of the American Medical Association 181(1): 17-24.

McClain, P.W., J.J. Sacks, R.G. Froehlke, and B.G. Ewigman 1993 Estimates of fatal child abuse and neglect, United States, 1979 through 1988. Pediatrics 91(2):338-343.

National Commission on Children 1991 Beyond Rhetoric: A New American Agenda for Children and Families . Washington, DC: U.S. Government Printing Office.

National Research Council 1981 Services for Children: An Agenda for Research . Commission on Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.

U.S. Advisory Board on Child Abuse and Neglect 1990 Child Abuse and Neglect: Critical First Steps in Response to a National Emergency . August. Washington, DC: U.S. Department of Health and Human Services. August. 1991 Creating Caring Communities . September. Washington, DC: U.S. Department of Health and Human Services.

U.S. Public Health Service 1990 Violent and abusive behavior. Pp. 226-247 (Chapter 7) in Healthy People 2000 Report . Washington, DC: U.S. Department of Health and Human Services.

The tragedy of child abuse and neglect is in the forefront of public attention. Yet, without a conceptual framework, research in this area has been highly fragmented. Understanding the broad dimensions of this crisis has suffered as a result.

This new volume provides a comprehensive, integrated, child-oriented research agenda for the nation. The committee presents an overview of three major areas:

  • Definitions and scope —exploring standardized classifications, analysis of incidence and prevalence trends, and more.
  • Etiology, consequences, treatment, and prevention —analyzing relationships between cause and effect, reviewing prevention research with a unique systems approach, looking at short- and long-term consequences of abuse, and evaluating interventions.
  • Infrastructure and ethics —including a review of current research efforts, ways to strengthen human resources and research tools, and guidance on sensitive ethical and legal issues.

This volume will be useful to organizations involved in research, social service agencies, child advocacy groups, and researchers.

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Top 80 Child Abuse Topics For Your Essay

Child abuse is one of the most burning problems in the modern society. To raise awareness about this issue, many professors assign academic papers on child abuse topics to their students. In case you’ve got the task to compose an essay on any of the child abuse research topics, you might need some expert advice for creating a top-notch paper.

Top Hints On Creating A Paper On Maltreatment, Violence, and Neglect

Child abuse topics for a research paper might be covered from different angles. The first thing you need to know to succeed in crafting an essay of this kind is the discipline related to the chosen topic. For example, you can describe the facts and arguments from psychological, medical, sociological, and biological viewpoints, as well as from the human rights perspective.

The basic structure of the essay that covers the research topic on violence or child abuse should contain these elements:

  • Introduction. Rocket launch your paper with a nice hook. Moreover, it is important to come up with the basic concepts about child abuse and describe its main reasons.
  • Main part. This part of your essay should have several paragraphs, where each part should be dedicated for one strong argument. Pick up only the most important facts and ideas, use a proper tone and voice to describe this sensitive topic.
  • Conclusion. It might be a good idea to offer some solutions to the problem of child abuse, as well as make a summary of the entire academic paper.

You can find tons of child abuse and neglect facts and concepts for the research paper online. However, when it comes to choosing a research topic on child abuse, many students are feeling lost and confused. Below you will find the best topics for your essay related to this area divided into different groups.

Best Topics For Child Abuse And Neglect Research Paper

Neglect is a combination of both mental and physical abuse. It is likely to appear when a kid can’t get access to healthcare, adequate nutrition, clothing, schooling, and having a shelter. Child abuse topics of this kind include:

  • The Problem Of Child Neglect
  • Indicators Of Neglect
  • General Neglect And Its Consequences
  • Severe Neglect And Its Impact On Human Health
  • Psycho-social Failure To Thrive
  • The Dangerous Numbers: Child Abuse Statistics
  • The Behaviors Indicating Child Abuse
  • Infancy Traumas
  • Effects Of Neglect In Early Childhood
  • The Cause Of Childhood Neglect
  • How To Prevent Childhood Neglect
  • Toxic Social Behaviors Among Parents
  • Children Growing In A Neglecting Families
  • Poor Supervision And Its Impact On Children’s Health
  • The Later Influences Of Child Neglect
  • The Problem Of Medical Mistreatment Of The Young Children

Physical Child Abuse Research Topics

Hitting, shaking, burning, and other types of physical injury that lead to bruises, scratches, and broken bones are all about physical abuse. Moreover, being murdered is one of the effects of physical abuse. Unfortunately, physical abuse continues to be one of the most serious issues in the modern society.

  • Most Common Child Maltreatment Scenarios
  • Taking Care Of Child Abuse Victims
  • Ways To Stop Child Abuse Cycles
  • Maltreatment And Serious Diseases
  • Family Violence
  • Bullying And Threatening
  • Types Of Child Abuse
  • The Problem Of Child Maltreatment In The U.S.
  • Is Punishment At Schools Is A Type Of Child Abuse?
  • The History Of Child Maltreatment
  • Punishment Vs Child Abuse

Emotional Child Abuse Topics

This type of abuse appears in unhealthy environments and includes verbal assault and humiliation. Ignoring and threatening the child is one of the most important features of emotional abuse. Not only this type of abuse might occur in the family, but it can also be present at school and online. Emotional abuse is the same as serious as physical one since it might cause serious diseases and conditions among young adults.

  • Critical Analysis Reflection Of Child Maltreatment
  • Abusive Mothers
  • Definitions Of Child Abuse
  • The Social Problem Of Child Abuse
  • Behavioral Indicators Of Child Abuse: Parents
  • Behavioral Indicators Of Child Abuse: Children
  • Verbal Abuse
  • Emotional Deprivation: The Basic Concepts
  • Indication Of Emotional Deprivation
  • Toxic Interaction Between Children And Parents

Sexual Child Abuse

This type of abuse is about any type of sexual contact between kids and adults, as well as between younger and older children. Being one of the most disputable problems in modern world, sexual child abuse is also one of the most popular topics for college essays.

  • Current Solutions To Sexual Abuse
  • The Factors That Cause Child Sexual Abuse
  • The Long-term Effects Of Sexual Child Abuse
  • Child Sexual Abuse Prevention Programs
  • Treating Sexually Abused Children
  • Sexual Abuse Statistics
  • The Concepts Of Sexual Abuse
  • Healing Children After Sexual Abuse
  • The Problem Of Child Sexual Exploitation

Domestic Violence Subtopics For Your Essay

Domestic violence has been a common issue for millions of families throughout the world. This type of abuse has a negative impact on children and teens, as well as might have serious consequences for kids’ health and well-being. Domestic violence is a serious issue everyone should definitely know about.

  • Children And Domestic Violence
  • The Effects Of Maltreatment On Kids And Families
  • Domestic Violence In The Modern World
  • Domestic Violence In Black Families
  • Prevalence Of Domestic Violence
  • Consequences Of Domestic Violence
  • Preventive Child Maltreatment Programs
  • Taking Care Of Children Removed From Homes Due To Maltreatment
  • Child Visiting And Domestic Abuse

Child And Baby Abuse Topics For A Research Paper

Baby abuse and prenatal neglect are also among the posers for millions of families all over the world. The issue can be described from different angles and requires more global publicity.

  • Prenatal Neglect
  • Neonatal Babies And Drug Addiction
  • Shaken Baby Syndrome
  • Social Support Of The Victims Of Baby Abuse
  • Baby Neglect And Maltreatment Problems
  • Levels Of Baby And Child Abuse In Different Countries
  • Baby Abuse: A Global View
  • Parent Training For Preventing Child Abuse
  • Parent-child Aggression
  • Is Obesity One Of The Forms Of Child Abuse?
  • Stepchildren Abuse

Trafficking Of Minors

Labor and sex trafficking are common issues for lots of countries, including the United States. Each year, thousands of children and teens are being kidnapped throughout the country for trafficking. Although the government structures are trying to fight this problem, lots of questions remain to be answered.

  • Children’s Rights
  • Child Protection In Court
  • Child Abuse Prevention
  • The Problem Of Missing Children
  • Labor Trafficking Of Kids And Teenagers
  • Sex Trafficking Of Children
  • Child Trafficking Statistics
  • International Children Trafficking
  • The Risks Of Child Trafficking
  • Preventing Child And Teenage Trafficking
  • Ways Of Children’s Trafficking
  • Trafficking Children In Numbers

How to Compose Essays On Child Abuse Topics

Creating an academic paper requires doing lots of research, analyzing various ideas and concepts, as well as choosing the most powerful arguments for an essay. In most cases, your paper should meet the basic requirements of academic writing:

  • It should be 100% original and have no plagiarism
  • The content of the essay should correspond to its topic
  • The paper should be written with the proper voice and tone
  • The paper should be well-structured and contain proper formatting
  • It should be error-free and doesn’t contain any typos
  • The descriptions should be concise and top-notch
  • The paper should have a traditional essay structure with an introduction, main part, and conclusion
  • The facts described in the essay should be chosen wisely
  • The paper shouldn’t contain too many arguments
  • Introduction and the conclusion should be logically connected
  • The information described in the paper needs to be fresh and up-to-date
  • Using only reliable sources is obligatory

Meeting all these requirements might appear to be extremely challenging for many young learners. Unfortunately, spending days and hours writing an essay is a common practice for lots of students. That is why many learners are looking for professional writing assistance. Our education experts are ready to give you a helping hand and create an astonishing essay on any topic, including child abuse and neglection for you. This way, you will get a brilliant academic paper, have lots of free time for personal needs, and improve your academic performance with excellent grades.

REFERENCES:

  • Books on child abuse
  • Statistics on child sexual abuse
  • Examples of child abuse cases
  • Impact of child abuse on health
  • Frequently asked questions about child sexual abuse
  • Child abuse prevention
  • Child abuse and neglect

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  • v.5(2); Apr-Jun 2014

Child abuse: A classic case report with literature review

Arthur m. kemoli.

Department of Paediatric Dentistry and Orthodontics, University of Nairobi, Kenya

Mildred Mavindu

Child abuse and neglect are serious global problems and can be in the form of physical, sexual, emotional or just neglect in providing for the child's needs. These factors can leave the child with serious, long-lasting psychological damage. In the present case report, a 12-year-old orphaned boy was physically abused by a close relative who caused actual bodily and emotional trauma to the boy. After satisfactorily managing the trauma and emotional effects to the patient, in addition to the counseling services provided to the caregiver, the patient made a steady recovery. He was also referred to a child support group for social support, and prepare him together with his siblings for placement in a children's home in view of the hostile environment in which they were living.

Introduction

For a long time, child protection in general has been perceived as a matter for the professionals specializing in social service, health, mental health, and justice systems. However, this problem remains a duty to all, and more so a concern for other social scientists such as anthropologists, economists, historians, planners, political scientists, sociologists, and humanists (e.g., ethicists, legal scholars, political theorists, and theologians) who contribute to the understanding of the concepts of and strategies in child protection and the responsibility for adults and institutions with roles in ensuring the safety and the humane care of children under their care. Child abuse, therefore, is when harm or threat of harm is made to a child by someone acting in the role of caretaker.[ 1 , 2 ] It is a worldwide problem with no social, ethnic, and racial bounds.[ 3 ] Child abuse can be in the form of physical abuse, when the child suffers bodily harm as a result of a deliberate attempt to hurt the child, or severe discipline or physical punishment inappropriate to the child's age. It can be sexual abuse arising from subjecting the child to inappropriate exposure to sexual acts or materials or passive use of the child as sexual stimuli and/or actual sexual contacts. Child abuse can also be in the form of emotional abuse involving coercive, constant belittling, shaming, humiliating a child, making negative comparisons to others, frequent yelling, threatening, or bullying of the child, rejecting and ignoring the child as punishment, having limited physical contact with the child (e.g., no hugs, kisses, or other signs of affection), exposing the child to violence or abuse of others or any other demeaning acts. All these factors can lead to interference with the child's normal social or psychological development leaving the child with lifelong psychological scars. Lastly, child abuse can be in the form of child neglect, when an able caregiver fails to provide basic needs, adequate food, clothing, hygiene, supervision shelter, supervision, medical care, or support to the child.[ 4 ]

It is usually difficult to detect child abuse, unless one creates an atmosphere that would encourage disclosure by the child being abused.[ 5 ] Nonetheless, a good medical and social history may help to unravel the problem. Signs and symptoms of child abuse commonly include subnormal growth of the child, unexplained head and dental injuries, soft-tissue injuries like bruises and bite marks, burns and bony injuries like broken ribs, in the absence of a history pointing to the cause or causes of the trauma. The present case report describes a child who was abuse by a very close relative, and who caused physical and psychological trauma to the young lad.

Case Report

Peter, a 12-year-old boy, accompanied by his maternal aunt, presented at the local university Dental Hospital (Pediatric Dental Clinic) in Kenya in October 2012, with a complaint of a large, painful left facial swelling related to the left upper incisors. He had been referred from a local rural hospital where he had been taken by the same aunt, for treatment of the swelling. The swelling had occurred only 2 days prior to visiting the local hospital, and 4 days before presenting himself at the University Dental Hospital. Enquiry about the causes of the swelling provided unclear answers. Family history indicated that the young boy was a first-born among three siblings (9-year-old girl, 5-year-old boy), and that their single parent (mother) had been deceased for 6 years due to HIV-related complications. The three children had moved to live with their maternal grandparents and their seven sons. The patient had no adverse past medical history and had never consulted a dentist previous to the present problem. The boy was in grade seven in a local primary school and had the aspiration of becoming a medical doctor in future. It was not possible to establish from the aunt or the boy the situation of the patient's other siblings.

An extra-oral examination showed a young boy with a normal gait, sickly, unkempt, rather withdrawn, and small for his age. He had asymmetrical face due to the swelling involving his left submandibular region and spreading upwards to the inferior orbital margin, febrile (39.1°C), a marked submandibular lymphadenopathy on the left side, the skin overlying the swelling was warm, shiny and fluctuant, and the lips were dry and incompetent (2 cm) and as shown in [Figures ​ [Figures1a 1a – c ]. However, the temporomandibular joint movements were normal. The patient was also found to have a big, healing scar on the dorsal surface of the left foot, the cause of which was also unclear [ Figure 1 ].

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(a) Frontal and (b) lateral (c) profiles of the patient showing the facial asymmetry with the left submandibular to infra-orbital and the healing scar on the foot

Intra-oral examination revealed a young boy in the permanent dentition with un-erupted third permanent molars, poor oral hygiene with heavy plaque deposits on the tongue and a generalized but moderate inflammation of the gingiva. There was a grade three mobility in relation to 11, 12, 21, 22 and a grade two mobility in relation to 23, 24, 25 (Miller mobility index). There was intramucosal swelling in relation to 21-24 extending labially/buccally (measuring 4 cm × 3 cm) and palatally (measuring 3 cm × 2 cm). On elevation of the upper lip, active discharge of pus mixed with blood and some black granules could be seen emanating from the abscess. There were no alveolar/bone fractures elicited, but carious lesions were present on 46 (occlusal), 47 and 37 (buccal). Orthodontic evaluation showed Angles class I molar relation on the left and edge to edge tending to class II on the right side. The canines were in class I relationship bilaterally. There was an anterior over-jet of 3 mm (11/21), an overbite of 20%, coincidental dental/facial midline and crowding on the upper right arch with 15 palatally displaced as can be seen in Figure ​ Figure2a 2a – c .

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(a) Intra-oral photographs of the patient showing the labial and (b) palatial swelling in relation to displaced 21 and 22 (c), generalized marginal gingival inflammation, palatally displaced 15, moderate dental plaque deposits and a moderate anterior dental crowding in the lower dental arch

For investigations, orthopantogram, intra-oral periapical 11, 12, upper and lower standard occlusal and bite wing radiographs were taken and examined. In addition, clinical photographs, study models, and vitality tests for the traumatized teeth were undertaken. A diet and nutrition assessment, full blood count, stool microscopic analysis for ova and cyst and bacterial culture and sensitivity were also undertaken.

The results of the radiographs showed un-erupted with potential impaction of 48 and 38, an upper midline radioluscence, widened periodontal space in relation to 11, 21 (with a mesial tilt), 22, occlusal caries on 46 and buccal caries on 47 and 37. There was the presence of root fractures involving the apical one-third of 21, 22. Vitality tests conducted on the traumatized incisors showed false positive (may be due to the presence of infection). The blood analysis showed the presence of neutrophilia (suggestive of bacterial infection), mild iron deficiency, but he was sero-negative. From the diet chart, the boy was generally on a noncariogenic diet that lacked the intake of fruits and animal proteins. Nutritional assessment revealed a boy with a height of 144 cm, a weight of 28 kg, and a body mass index (BMI) of 13.5 Kg/m 2 (below 5 th percentile (given the ideal BMI should be 17.8 Kg/m 2 in the 50 th percentile).

From the history adduced and the results of the investigations, a diagnosis of child abuse and neglect was reached, with the boy having suffered traumatic injuries resulting in facial cellulitis, Ellis class VI fracture involving 21, 22 associated dentoalveolar abscess and subluxation of 11, 12. In addition, there were dental carious lesions on 46 (occlusally), 47 and 37 (buccally) and a relatively severe malnutrition. The patient had also moderate plaque induced gingivitis, mild anemia (microcytic and iron deficiency), mild dental fluorosis, potentially impacted 48 and 38 and crowding in the upper right and lower anterior arches.

The objective of treating the boy was to eliminate the pain, infection, improve the general and oral health, restore carious teeth, improve esthetic and report the child abuse and neglect to the relevant authorities. In the initial phase of treatment, the patient was admitted for 4 days and placed on dexamethasone 8 mg stat, cefuroxime 750 mg 3 times a day, metronidazole 500 mg 3 times a day, diclofenac 50 mg tablets alternating 4 hourly with oral paracetamol 1000 mg 3 times a day, to run for 5 days. Patient was also placed on chlorhexidine mouthwash 10 ml twice daily for 7 days and ranferon (hematinics) 10 ml to be used twice a day for 1 month. The second phase of treatment included incision and drainage of the abscess, followed by the splinting of the mobile teeth in the upper dental arch using semi-rigid splint of 0.6 mm stainless steel round wire for 4 weeks while. Root canal treatment of 11, 21, 12, and 22 followed thereafter.[ 6 ] A referral of the patient was made the child support center in the main referral hospital, plus the patient was placed on future recalls to determine whether the patient would have overcome the problem and the oral health was maintained in good condition.

The third phase of treatment involved interceptive orthodontics with the extraction of 15 to relieve the crowding in the area. Oral hygiene instructions were availed to the patient and the guardian, placement of fissure sealants was done for the premolars and molars to help reduce plaque retention on these teeth, preventive resin restorations were placed on 37, 46, and 47. The root fractures involving the apical one-third of 21 and 22 meant that the two teeth were to be initially dressed using non setting calcium hydroxide, and after healing, root canals are filled in the usual manner [ Figure 3 ].

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Postobturation intraoral periapial radiograph showing the restoration on 12, 11, 21, and 22

Nutrition evaluation had initially been done and when the patient was re-evaluated after 1 month, he had gained bodyweight up to 1 kg. The child support center continued to carry out psychotherapy, and during one of the sessions, the patient confessed to having undergone physical abuse and threatened not to divulge any information by one of the uncles. The center considered placing the boy into a children's home, probably together with his siblings. Radiographic examinations evaluation after 3 months indicated some external apical root resorption taking place on 21 and 22. Further follows-ups were to continue.[ 7 ] After 10 months, the oral health and general heath of the patient had remarkably improved as shown in Figure 4 .

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Posttreatment photographs taken after 10 months showing improved oral health of the patient and the glimmer of confidence in the patient as shown in a-d respectively

All types of child abuse and neglect leave the affected child with long-lasting scars that may be physical or psychological, but they are the emotional scars that leave the child with life-long effects, damage to the child's sense of self, the ability to build healthy relationships and function at home, work or school. This situation can in turn result in the child turning to alcohol or drugs to numb the painful feelings. On the other hand, the exposure by the child to violence during childhood can increase vulnerability of that child to mental and physical health problems like anxiety disorder, depression, etc.,[ 8 , 9 ] and make victims more likely to become perpetrators of violence later in life.[ 10 ] The oral cavity can be a central focus for physical abuse due to its significance in communication and nutrition.[ 3 , 11 ]

A neglected and abused child like the one described here, can become helpless and passive, displaying less affect to anything whether positive or negative in his or her encounters.[ 12 ] The patient described was vulnerable to abuse as he already lacked the parental protection in his early life, and was living in a poor, but large family where competition for available resources must have been stiff. The abuser, therefore, his own uncle, probably did not like their presence gave him the assumption that the children would grow up to take away what he probably thought would be his dues from the family.

In Kenya and even in many other countries, data on the prevalence of child abuse is still scarce. A Kenyan study undertaken in 2013 showed that violence against children was very high, with 31.9% and 17.5% female and male, respectively reporting having been exposed to sexual violence, 65.8% and 72.9% female and male respectively to physical violence. In the same study, 18.2% and 24.5% female and male, respectively had been abused prior to attaining 18 years of age, and only 23.8% female and 20.6% male reported not having experienced any form of violence during childhood.[ 13 ] Child abuse in Kenya, therefore, appears to be a rampant problem within the society. In all cases of abuse reported in the literature, the perpetrators were most often well-known to the children. The motive of child abuse has not always clear, just as it was the case with the patient described here. The patient under study here hailed from a family with low socio-economic background where providing for extra needs in the family could have been a problem. Even during treatment of the patient the family found the cost of treatment to be very high and unaffordable to them, and a waiver of the cost had to be sought and obtained from the University Dental Hospital. Further, the child having been orphaned with the death of their single parent (mother) left these children unprotected and vulnerable to such abuse from uncles who may have been competing for same needs in an already crowded family. It is possible that factors as poverty, social isolation, and familial disruption could have contributed to the abuse meted by this boy.[ 1 ] The fact that the problem was established at this stage, it probably provided the patient and his siblings with the opportunity to get early support and avert serious health problems for them. The referral to the local child protection authority was done to attain this goal and also to have the children monitored consistently for their safety from further child abuse. The child protection agency was indeed considering placing them in the custody of a children's home, though sadly, according to a report by the Kenyan Government, the utilization of these support services had not been very high,[ 13 ] for reasons unknown.

The treatment of the patient was carried out in a humane manner, and assistance provided whenever possible to have the full treatment completed. The problem of nutrition was still a difficult one for this large family with a poor background. Nonetheless, the guardian was still briefed on the issue, and informed about the importance of a balanced diet for optimal growth and immunity boosting for such young child, and suggestions for alternative cost-effective foods for the child. It was hoped that the support services of giving the patient and probably his siblings a new home would help the young child to grow and develop normally without fear of abuse.

The management of child abuse can be complicated, and often require a multidisciplinary approach, encompass professionals who will identifying the cause of the abuse or neglect, treatment of the immediate problems and referral of the child to the relevant child protection authority for action. Counseling services for the child and the caregivers should form part of the management regime. In the present case, the objectives were met and the patient got full benefits of this approach.

Source of Support: Nil

Conflict of Interest: None declared.

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