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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  

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  

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.

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 ).

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 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 addiction and substance use outcomes at 14 and 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.

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

intimate partner violence

Mater-University of Queensland Study of Pregnancy

posttraumatic stress disorder

Competing Interests

Supplementary data.

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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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• Maltreatment
• Posttraumatic Stress

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• Systematic Review
• Published: 25 September 2020

Social determinants of health and child maltreatment: a systematic review

• Amy A. Hunter 1 , 2 , 3 &
• Glenn Flores 3 , 4  

Pediatric Research volume  89 ,  pages 269–274 ( 2021 ) Cite this article

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Child maltreatment causes substantial numbers of injuries and deaths, but not enough is known about social determinants of health (SDH) as risk factors. The aim of this study was to conduct a systematic review of the association of SDH with child maltreatment.

Five data sources (PubMed, Web of Science Core Collection, SCOPUS, JSTORE, and the Social Intervention Research and Evaluation Network Evidence Library) were searched for studies examining the following SDH: poverty, parental educational attainment, housing instability, food insecurity, uninsurance, access to healthcare, and transportation. Studies were selected and coded using the PICOS statement.

The search identified 3441 studies; 33 were included in the final database. All SDH categories were significantly associated with child maltreatment, except that there were no studies on transportation or healthcare. The greatest number of studies were found for poverty ( n  = 29), followed by housing instability (13), parental educational attainment (8), food insecurity (1), and uninsurance (1).

Conclusions

SDH, including poverty, parental educational attainment, housing instability, food insecurity, and uninsurance, are associated with child maltreatment. These findings suggest an urgent priority should be routinely screening families for SDH, with referrals to appropriate services, a process that could have the potential to prevent both child maltreatment and subsequent recidivism.

SDH, including poverty, parental educational attainment, housing instability, food insecurity, and uninsurance, are associated with child maltreatment.

No prior published systematic review, to our knowledge, has examined the spectrum of SDH with respect to their associations with child maltreatment.

These findings suggest an urgent priority should be routinely screening families for SDH, with referrals to appropriate services, a process that could have the potential to prevent both child maltreatment and subsequent recidivism

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Child maltreatment is a pervasive public health problem in the United States (US). 1 Comprised of acts of commission and omission by a parent or other caregiver (e.g., physical abuse, sexual abuse, and various forms of neglect), 2 child maltreatment is a substantial cause of pediatric injury and death. In 2018, nearly 700,000 childhood victims of nonfatal maltreatment were identified, and an estimated 1770 children died. 1 The combined human and institutional cost attributed to maltreatment morbidity and mortality in the US is estimated to be $124 billion annually. 3

The World Health Organization defines social determinants of health (SDH) as “the conditions in which people are born, grown, work, live, and age, and the wider set of forces and systems shaping the conditions of life.” 4 These conditions are shaped by the distribution of resources, and connect facets of the physical, social, and built environment associated with health outcomes. 5 Among the most commonly recognized SDH (economic stability, education, neighborhood and built environment, health and healthcare, and social and community context), 6 poverty is a major and often overarching factor. Poverty also has been identified as a known risk factor for child maltreatment. 7 Thus, identifying how poverty and other SDH are associated with child maltreatment is a necessary step to develop effective interventions for maltreatment prevention and treatment, and mitigating the risk of associated physical and psychological injury.

Not enough is known about the association of SDH with child maltreatment. Four published systematic reviews have included analyses that examined the relationship between a single or two SDH and maltreatment. Two included socioeconomic status, 8 , 9 one included socioeconomic status and parental educational attainment, 10 and the fourth included immigration status. 11 No published systematic reviews (to our knowledge), however, have examined the spectrum of SDH with respect to their associations with child maltreatment. Therefore, the aim of this study was to conduct a systematic review of the associations of SDH (including poverty, housing insecurity, food insecurity, uninsurance, healthcare access, and transportation) with child maltreatment.

Inclusion criteria

Studies were selected using the PICOS approach for inclusion and exclusion. 12 , 13 The a priori inclusion criteria for studies were as follows: (1) English-language studies, (2) children 0–18 years old living in the US, (3) peer-reviewed, (4) observational and experimental designs, (5) outcome measures reported for at least one form of maltreatment, and 6) exposure measures for at least one SDH. The exclusion criteria were: (1) specific SDH could not be identified, and (2) conference presentations (e.g., abstracts, posters, or oral presentations).

The outcome of interest was child maltreatment, defined by the Child Abuse Prevention and Treatment Reauthorization Act of 2010 as “at a minimum, any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm.” 2 Included studies were assessed for the associations of selected SDH—including poverty, food insecurity, housing instability, parental educational attainment, child uninsurance, transportation barriers, and access barriers to healthcare—with child maltreatment. These SDH were chosen because they are domains hypothesized to be most likely associated with child maltreatment and were addressed in a recently published SDH screening instrument used for testing interventions effective in reducing SDH and improving child and caregiver health. 14 Immigration status was not included because of the recent publication of a systematic review examining the association of this SDH with child maltreatment. 11

Data sources

Five data sources were searched through March 2020: (1) PubMed, (2) Web of Science Core Collection, (3) SCOPUS, (4) JSTORE, and (5) the Social Intervention Research and Evaluation Network Evidence Library. All searches contained the following terms: (“Child Abuse”[Mesh] OR “child abuse”[tw] OR “child maltreatment”[tw] OR “child mistreatment”[tw] OR “child neglect”[tw]) AND (“Social Determinants of Health”[Mesh] OR “social determinants of health”[tw] OR “social class”). Searches for terms related to specific SDH varied. A sample search strategy (SCOPUS) can be found in Supplementary Table S 1 (online) .

An effort-to-yield measure of search precision, number needed to read (NNR) was calculated by taking the inverse of the precision of the searches. Precision was calculated by dividing the number of included studies by the number of screened studies, after removal of duplicates. NNR quantifies the number of articles that would be needed to be read before finding one that meets the established inclusion criteria. Dependent on the subject and inclusion criteria, this number provides insights into the time and resources needed for replication, or to conduct a similar study.

Selection of studies

All studies were stored on a Microsoft Excel document detailing the reasons for inclusion or exclusion.

Data abstraction

A codebook was developed using Microsoft Excel. Variables included study characteristics (year of publication, study design and population size, duration, data sources, and level[s] of analysis), sociodemographic characteristics of the study population (child age, racial composition, and sex), SDH under investigation, child maltreatment type (sexual, physical, psychological, neglect, multiple forms, and other), and measures of study quality.

Study quality

A modified version of the Downs and Black checklist was used to assess study quality (Supplementary Table S 2 ). 15 Each item was scored as no (0) or yes (1). The sum of all items ranged from 1 to 8, with higher scores representing a lower risk of bias.

Data synthesis

The criteria for SDH and definitions of child maltreatment varied by study. Therefore, we were unable to combine endpoints in a meta-analysis. Data synthesis at the level of the individual, family, and community were used to analyze included studies.

Study registration

The study protocol was registered with PROSPERO (CRD42020166969).

Study characteristics

Our initial search yielded 3441 studies. After screening by titles and abstracts, 118 met the initial inclusion criteria. Following a full review of 118 studies, 33 were included in the final analysis. The process for selecting included studies is presented in Fig.  1 . Search precision was 0.0096 and the NNR was 104. The characteristics of included studies are presented in Table  1 . Included studies were published from 1978 to 2020. 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 Nine studies used national data, 16 , 23 , 27 , 30 , 36 , 38 , 42 , 43 , 47 and the remaining studies used data from individual states, including 14 from the Midwest, 17 , 18 , 19 , 20 , 25 , 26 , 28 , 29 , 31 , 33 , 39 , 40 , 41 , 45 four from the South, 21 , 22 , 32 , 37 four from the Northeast, 34 , 35 , 46 , 48 one from the West (California), 24 and one from the Pacific (Alaska). 44 Of these studies, 5 conducted chart reviews, 7 used cohort study designs, 7 used a cross-sectional design, and 14 conducted ecological analyses. Included studies assessed the relationship between SDH and child maltreatment at the levels of the individual, zip code, county, and census tracts.

a Studies may have been excluded for multiple reasons.

Study outcomes

Twenty-nine studies explored the association of poverty with child maltreatment. 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 47 Poverty was found to be consistently and strongly associated with maltreatment, with all but three studies identifying a significant association between either familial or community-level poverty and child maltreatment. 16 , 18 , 21 Across studies, poverty was defined by county, 45 neighborhood, 41 familial/household income, 17 , 18 , 19 , 20 , 23 , 28 , 41 , 42 , 43 socioeconomic status, 44 poverty rate, 21 , 27 , 35 , 40 unemployment, 16 , 17 , 21 , 31 , 32 , 34 , 36 , 40 percentage of families living below the federal poverty level, 24 , 28 , 31 , 32 , 33 , 36 , 37 , 38 , 39 children living in poverty, 17 , 47 receipt of public assistance, 19 , 25 , 31 , 40 composite impoverishment scores, 26 and self-reported acute financial challenges. 22

In some studies, the relationship between poverty and maltreatment differed by abuse type. For example, one study found that neighborhood poverty was associated with all three forms of child maltreatment, but to different degrees. 38 Another study indicated that financial problems were strongly associated with neglect and abandonment, but the association was less pronounced for sexual abuse. 21

Associations between poverty and maltreatment varied by race/ethnicity. A study comparing predominantly white and black neighborhoods found that the association between poverty and child maltreatment was strongest in whites. 25 Research linking multiple sources of data showed that black children living in poverty were twice as likely to be reported for needs-based neglect than their white counterparts. 26 A recent study showed that when income was held constant, white race was strongly associated with both sexual abuse and neglect, and black race was associated with physical abuse. 27

Housing instability

Thirteen studies examined the relationship between housing instability and child maltreatment. 16 , 18 , 20 , 21 , 23 , 26 , 28 , 29 , 32 , 33 , 34 , 40 , 46 Most studies revealed that housing instability is associated with child maltreatment. Among these studies, the definition of housing stability varied, and included percent vacancy, 21 , 26 , 32 , 33 , 40 rates of foreclosure and delinquency, 16 , 18 , 34 hazardous living conditions, 29 and instability/mobility (>1 move per year). 20 , 23 , 28 Only one study examined homelessness, performing an analysis of hospital and pediatric ambulatory records of children <18 years old. 46 After matching families on income, homeless children were found to have higher rates of maltreatment-related emergency-department (ED) visits and child maltreatment than their nonhomeless counterparts. One study found that displacement due to foreclosure, eviction, or mortgage delinquency was associated with maltreatment investigations. 34 Two studies documented that housing instability/mobility (>1 move per year) was associated with child protective service (CPS) reports and maltreatment risk. 20 , 23

Two studies found no association between housing insecurity and child maltreatment. 18 , 28 In the first, housing instability consisted of an aggregate measure of material hardship, including difficulty paying rent, eviction, or having experienced any utility shutoff in the previous year. 18 In the second, housing instability was measured by residential mobility. 28

Several studies reported differences in the association between housing stability and child maltreatment type. Two identified an association between the percent of vacant housing in communities and sexual abuse. 21 , 32 Another study found that hazardous housing conditions were associated with neglect, but not physical abuse; a history of housing instability increased the strength of this association. 29 One study found that mortgage delinquency was associated with traumatic brain injury and other forms of physical abuse. 20

Food insecurity

Just one study examined the relationship between food insecurity and child maltreatment. 30 An analysis of a national sample from the Fragile Families and Childhood Wellbeing Study revealed that, compared with food-secure households, food-insecure households experienced increased rates of total parental aggression (7% vs. 20%, respectively). Controlling for maternal characteristics did not attenuate this association.

Parental educational attainment

Eight studies considered the relationship between parental educational attainment and child maltreatment. 17 , 18 , 20 , 24 , 25 , 32 , 41 , 42 The results of most studies indicate that low parental educational attainment is associated with child maltreatment. Parental educational attainment was defined as high-school completion in six studies, 17 , 18 , 20 , 32 , 41 , 42 maternal education level in one, 25 and completion of postsecondary education in the last. 24 Two studies found no association. 18 , 24 Notably, one of these studied failed to report victim and perpetrator demographic characteristics (age, sex, or race/ethnicity), 18 and the other relied on self-reported data. 24

Uninsurance

One study was identified that examined the association of the child lacking health insurance with child maltreatment. 48 This study reported that a higher proportion of preadolescent children seen in the ED with suspected sexual child abuse were uninsured, compared with a control group of children seen in the ED with upper-limb fractures, at 52% vs. 1%, respectively. No statistical analyses, however, were conducted, nor is it clear whether there was matching of cases and controls by age, sex, or other relevant characteristics.

The search did not reveal any studies that examined the associations of transportation or access to healthcare with child maltreatment.

Multiple studies document that SDH, including poverty, housing instability, food insecurity, low parental educational attainment, and child uninsurance, are significantly associated with child maltreatment. A recent systematic review also concluded that although the immigrant parental status is associated with a lower likelihood of overall child maltreatment, it may be associated with a higher risk of child neglect and neglectful supervision. 11 Taken together, these findings suggest that an urgent priority, therefore, should be to routinely screen families for SDH in inpatient and outpatient settings and in CPS, and to address identified SDH with referrals to appropriate services. This screening and referral process could have the potential to not only prevent child maltreatment by reducing or eliminating the SDH before they result in maltreatment, but might also decrease the risk of maltreatment recidivism in families in which maltreatment already has occurred. The American Academy of Pediatrics, American Academy of Family Physicians, and the National Academy of Sciences, Engineering, and Medicine all have endorsed SDH screening and service referral. 49 , 50 , 51 Several studies document that patients and caregivers are comfortable with completing SDH screening. 52 , 53 , 54 , 55 , 56 Addressing SDH by referral to such services as case managers, social workers, housing vouchers, medical–legal partnerships, and parent mentors, already has been shown to reduce hospitalizations, improve housing quality and stability, enhance economic security, improve healthcare outcomes, insure more uninsured children, increase the quality of care, empower parents, and save money for society, 57 thereby holding great promise as interventions that may prove effective in ultimately reducing or preventing child maltreatment.

Poverty was the SDH for which the greatest number of studies documented an association with child maltreatment. Although few studies have investigated the temporal relationship between poverty and child maltreatment, 8 there is evidence that families living in poverty are more likely to be reported to CPS for neglect. 58 Poverty sequelae, such as inability to feed, clothe, or house a child, overlap with the definition of child neglect, so it is important to distinguish intentional neglect from family challenges related to living in poverty. Differential or alternative response is one CPS approach that addresses maltreatment reports by attending to unmet family needs. 59 An analysis of the effectiveness of this form of intervention has shown that families living in poverty benefit most from this approach. 60 To date, this response has been implemented at the individual and family levels. Extending differential or alternative response to the community level may be an effective strategy for families living in impoverished neighborhoods, where racial biases in child maltreatment reports and investigations have been identified.

The study results underscore several unanswered questions regarding the association between SDH and child maltreatment. First, it is unclear whether transportation barriers or impaired access to healthcare are associated with child maltreatment, given that no studies were identified on these SDH. Second, because the definitions for each SDH varied considerably within and across studies (especially for poverty), it is unclear whether more consistent SDH definitions would yield different findings. Third, because males as caregivers and heads of household were under-represented and often excluded from some study populations, 20 , 23 , 25 , 33 an unanswered question is whether there are associations of paternal educational attainment and other male-caregiver SDHs with child maltreatment. Although single mothers have been identified as an at-risk population for maltreatment perpetration, it is equally important to examine the role that men play in maltreatment. In a previous analysis, the first author identified men as the predominant perpetrator in 58% of cases of fatal maltreatment in the US. 61 Results of our study emphasize the need for research inclusive of male caregivers, to identify and mitigate risk factors before they escalate to maltreatment fatalities. Fourth, most studies focusing on sexual abuse were primarily limited to female populations, 32 despite evidence that male children also are victims of sexual abuse. There is an urgent need to investigate how SDH perpetuate or protect against sexual abuse in male children, so that prevention efforts can be tailored by sex. Finally, because most studies combined maltreatment into one aggregate category, an unanswered question is what are the associations of SDH with specific maltreatment categories. It has been posited that each maltreatment type has a unique etiology, and lumping these types into one category likely attenuates the ability to identify meaningful associations. Although few studies in this systematic review disaggregated by maltreatment categories, those that did found significant differences in maltreatment risk according to the SDH examined.

Based on the study findings, a research agenda is proposed to address key issues regarding the association of SDH with child maltreatment. Research is needed to address the aforementioned identified research gaps, including studies on transportation barriers, impaired access to healthcare, consistently defined SDH, SDH for male caregivers, and the associations of SDH with specific maltreatment categories and male victims of sexual abuse. Studies are needed to determine whether there is a direct association between the number of SDH and the risk of maltreatment, and whether the presence of multiple SDH can synergistically increase maltreatment risk. Research is urgently needed to determine whether SDH screening and referral to appropriate services result in SDH reduction and elimination as well as decreases in or the prevention of child maltreatment and maltreatment recidivism.

Limitations and strengths

Certain study limitations should be noted. First, as with all systematic reviews, the quality of this analysis is limited by the scientific rigor of included studies. Second, studies were selected based on the search criteria. It is possible that relevant literature was missed because of the heterogeneity of terms used to describe the various SDH and child maltreatment. Third, many included studies were cross-sectional or ecological, preventing the ability to draw conclusions about the temporal relationship between SDH and child maltreatment. Fourth, many data sources for the included studies used administrative data derived from CPS. In most instances, these records only included reports of maltreatment that were screened in and accepted for either an investigation or alternative response. As a result, these data sources likely exclude many cases of maltreatment, given evidence demonstrating equivalent risk of incidence and recurrence between maltreatment reports and substantiations. 28 , 38

SDH, including poverty, parental educational attainment, housing instability, food insecurity, and uninsurance, are associated with child maltreatment. These findings suggest that an urgent priority should be routinely screening families for SDH, with referrals to appropriate services, a process that could have the potential to prevent both child maltreatment and subsequent recidivism. Unanswered questions include whether SDH are associated with specific maltreatment categories and male victims of sexual abuse, and whether transportation barriers, impaired access to healthcare, consistently defined SDH, and SDH for male caregivers are associated with child maltreatment. A proposed research agenda includes addressing these unanswered questions; determining whether there is a direct association between the number of SDH and the risk of maltreatment, and whether the presence of multiple SDH can synergistically increase maltreatment risk; and investigations on whether SDH screening and referral to appropriate services result in SDH reduction and elimination, as well as decreases in or the prevention of child maltreatment and maltreatment recidivism.

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Current research on child maltreatment epidemiology

• Andreas Jud   ORCID: orcid.org/0000-0003-0135-4196 1 , 2  

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Child protection research in general should inform parents and other caregivers on how to best provide a violence-free upbringing for their children. It should furthermore inform professionals on how to best protect and support victimized children and their families. Research on child maltreatment epidemiology has yet another, specific goal: it should inform policy-makers and administrators on how to best manage child protection systems, on how to improve early detection of child maltreatment and accessibility for high-risk groups, particularize and scale-up prevention programs, etc. Unfortunately, research on child maltreatment epidemiology still has many gaps: population surveys have so far primarily focused on the prevalence of child sexual abuse and only a handful of countries can build their child protection strategies and policies on evidence of nationally representative data of reported child maltreatment incidents. This special issue aims at contributing to bridge the gap on lacking child maltreatment epidemiological research. It provides an overview on current studies in this area, both on the prevalence of child maltreatment and reported incidents:

Witt et al. [ 1 ] report the most recent findings on the prevalence of child maltreatment in Germany. Surveying a representative sample of 2510 participants between the ages of 14 and 94 years in 2016, they corroborate previous studies in highlighting that having experienced an incident of child maltreatment, particularly neglect, is still rather common for residents in Germany: over 10% of participants reported at least moderate emotional neglect and even more than 20% at least moderate physical neglect. The decline of this most prevalent form for younger ages is, however, promising. For other forms of child maltreatment, the prevalence has not decreased with younger age of the participants. Many efforts are still needed to tackle child maltreatment in this high-income country.

In an unprecedented effort, Nikolaidis et al. [ 2 ] not only collected data on child maltreatment prevalence for a single country, but for a majority of countries in the Balkan region—Albania, Bosnia and Herzegovina, Bulgaria, Croatia, the Former Yugoslavian Republic of Macedonia, Greece, Romania, Serbia, and Turkey. The shared methodology of the Balkan Epidemiological Study on Child Abuse and Neglect (BECAN) allows for a reliable comparison of findings in these different countries. A total of 42,194 children at the ages of 11, 13 and 16 years participated and self-reported high rates of lifetime and past-year prevalence of child maltreatment. For all countries, beyond 50% of the sample reported a lifetime prevalence for both experiencing psychological and physical violence. In contrast to the majority of literature on child sexual abuse, several countries have higher rates of male sexual abuse compared to females.

Canadian researchers had a pioneering role in collecting incidence data on reported child maltreatment. For two decades, the Ontario Incidence Study on Reported Child Abuse and Neglect (OIS) surveyed a representative sample of child maltreatment investigations every 5 years. This exceptional source of child maltreatment incidence data is one of the few worldwide that is able to identify trends in child protection practice. The findings of Fallon et al. [ 3 ] show a substantial decrease in rates of reported child sexual abuse across waves which may indicate a “real” decline. Policy changes had an obvious impact on incidence rates. By introducing the new category “risk of future maltreatment”, reported incidents have almost doubled. If this approach helps to identify and support more families before violence happens and offer them the necessary support to address their problems, we should ultimately be able to reduce prevalence of child maltreatment.

Finally, Jud et al. [ 4 ] present lessons learned from the first nationwide study on agency response to all forms of child maltreatment in Switzerland. To reach a remarkably high participation rate of 76% of the contacted agencies, the researchers intensely collaborated with child protection practitioners: they listened to their input in designing the survey, worked together in creating a set of variables, and continued to exchange both formally and informally during the survey and beyond. Researchers who are planning a representative study on reported child maltreatment will likely be able to transfer some of these “good practice” examples to their own context.

Taken together, findings of these studies might help to trigger and inspire urgently needed future research on child maltreatment epidemiology. Furthermore, establishing university institutes and positions focusing on child protection research will also advance the field. At the University of Ulm, Germany, the state of Baden-Württemberg provides both resources for the Competence Center Child Abuse and Neglect and the first chair in German-speaking Europe on Child Maltreatment Epidemiology and Trends in Child Protection. I feel honored to have been selected for this position. Hopefully, other universities will follow and formally implement child protection research as a part of their portfolio—a field of research that has the potential to contribute to children’s lives free of violence.

Witt A, Brown RC, Plener PL, Brähler E, Fegert JM. Child maltreatment in Germany: prevalence rates in the general population. Child Adolesc Psychiatry Ment Health. 2017;11:47. https://doi.org/10.1186/s13034-017-0185-0 .

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Nikolaidis G, Petroulaki K, Zarokosta F, Tsirigoti A, Hazizaj A, Cenko E, et al. Lifetime and past-year prevalence of children’s exposure to violence in 9 Balkan countries: the BECAN study. Child Adolesc Psychiatry Ment Health. 2018;12:1. https://doi.org/10.1186/s13034-017-0208-x .

Fallon B, Trocmé N, Filippelli J, Black T, Joh-Carnella N. Responding to safety concerns and chronic needs: trends over time. Child Adolesc Psychiatry Ment Health. 2017;11:60. https://doi.org/10.1186/s13034-017-0200-5 .

Jud A, Kosirnik C, Mitrovic T, Ben Salah H, Fux E, Koehler J, et al. Mobilizing agencies for incidence surveys on child maltreatment: successful participation in Switzerland and lessons learned. Child Adolesc Psychiatry Ment Health. 2018;12:3. https://doi.org/10.1186/s13034-017-0211-2 .

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Jud, A. Current research on child maltreatment epidemiology. Child Adolesc Psychiatry Ment Health 12 , 21 (2018). https://doi.org/10.1186/s13034-018-0228-1

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Study unpicks why childhood maltreatment continues to impact on mental and physical health into adulthood

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Childhood maltreatment can continue to have an impact long into adulthood because of how it effects an individual’s risk of poor physical health and traumatic experiences many years later, a new study has found.

We’ve known for some time that people who experience abuse or neglect as a child can continue to experience mental health problems long into adulthood Sofia Orellana

Individuals who experienced maltreatment in childhood – such as emotional, physical and sexual abuse, or emotional and physical neglect – are more likely to develop mental illness throughout their entire life, but it is not yet well understood why this risk persists many decades after maltreatment first took place.

In a study published in Proceedings of the National Academy of Sciences, scientists from the University of Cambridge and Leiden University found that adult brains continue to be affected by childhood maltreatment in adulthood because these experiences make individuals more likely to experience obesity, inflammation and traumatic events, all of which are risk factors for poor health and wellbeing, which in turn also affect brain structure and therefore brain health.

The researchers examined MRI brain scans from approximately 21,000 adult participants aged 40 to 70 years in UK Biobank, as well as information on body mass index (an indicator of metabolic health), CRP (a blood marker of inflammation) and experiences of childhood maltreatment and adult trauma.

Sofia Orellana, a PhD student at the Department of Psychiatry and Darwin College, University of Cambridge, said: “We’ve known for some time that people who experience abuse or neglect as a child can continue to experience mental health problems long into adulthood and that their experiences can also cause long term problems for the brain, the immune system and the metabolic system, which ultimately controls the health of your heart or your propensity to diabetes for instance. What hasn’t been clear is how all these effects interact or reinforce each other.”

Using a type of statistical modelling that allowed them to determine how these interactions work, the researchers confirmed that experiencing childhood maltreatment made individuals more likely to have an increased body mass index (or obesity) and experience greater rates of trauma in adulthood. Individuals with a history of maltreatment tended to show signs of dysfunction in their immune systems, and the researchers showed that this dysfunction is the product of obesity and repeated exposure to traumatic events.

Next, the researchers expanded their models to include MRI measures of the adult’s brains and were able to show that widespread increases and decreases in brain thickness and volume associated with greater body mass index, inflammation and trauma were attributable to childhood maltreatment having made these factors more likely in the first place. These changes in brain structure likely mean that some form of physical damage is occurring to brain cells, affecting how they work and function.

Although there is more to do to understand how these effects operate at a cellular level in the brain, the researchers believe that their findings advance our understanding of how adverse events in childhood can contribute to life-long increased risk of brain and mind health disorders.

Professor Ed Bullmore from the Department of Psychiatry and an Honorary Fellow at Downing College, Cambridge, said: “Now that we have a better understanding of why childhood maltreatment has long term effects, we can potentially look for biomarkers – biological red flags – that indicate whether an individual is at increased risk of continuing problems. This could help us target early on those who most need help, and hopefully aid them in breaking this chain of ill health.”

The research was supported by MQ: Transforming Mental Health, the Royal Society, Medical Research Council, National Institute for Health and Care Research (NIHR) Cambridge Biomedical Research Centre, the NIHR Applied Research Collaboration East of England, Girton College and Darwin College.

Reference Orellana, SC et al. Childhood maltreatment influences adult brain structure through its effects on immune, metabolic and psychosocial factors. PNAS; 9 Apr 2024 ; DOI: 10.1073/pnas.230470412

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Study helps explain why childhood maltreatment continues to impact on mental and physical health into adulthood

Childhood maltreatment can continue to have an impact long into adulthood because of how it effects an individual's risk of poor physical health and traumatic experiences many years later, a new study has found.

Individuals who experienced maltreatment in childhood -- such as emotional, physical and sexual abuse, or emotional and physical neglect -- are more likely to develop mental illness throughout their entire life, but it is not yet well understood why this risk persists many decades after maltreatment first took place.

In a study published in Proceedings of the National Academy of Sciences , scientists from the University of Cambridge and Leiden University found that adult brains continue to be affected by childhood maltreatment in adulthood because these experiences make individuals more likely to experience obesity, inflammation and traumatic events, all of which are risk factors for poor health and wellbeing, which in turn also affect brain structure and therefore brain health.

The researchers examined MRI brain scans from approximately 21,000 adult participants aged 40 to 70 years in UK Biobank, as well as information on body mass index (an indicator of metabolic health), CRP (a blood marker of inflammation) and experiences of childhood maltreatment and adult trauma.

Sofia Orellana, a PhD student at the Department of Psychiatry and Darwin College, University of Cambridge, said: "We've known for some time that people who experience abuse or neglect as a child can continue to experience mental health problems long into adulthood and that their experiences can also cause long term problems for the brain, the immune system and the metabolic system, which ultimately controls the health of your heart or your propensity to diabetes for instance. What hasn't been clear is how all these effects interact or reinforce each other."

Using a type of statistical modelling that allowed them to determine how these interactions work, the researchers confirmed that experiencing childhood maltreatment made individuals more likely to have an increased body mass index (or obesity) and experience greater rates of trauma in adulthood. Individuals with a history of maltreatment tended to show signs of dysfunction in their immune systems, and the researchers showed that this dysfunction is the product of obesity and repeated exposure to traumatic events.

Next, the researchers expanded their models to include MRI measures of the adult's brains and were able to show that widespread increases and decreases in brain thickness and volume associated with greater body mass index, inflammation and trauma were attributable to childhood maltreatment having made these factors more likely in the first place. These changes in brain structure likely mean that some form of physical damage is occurring to brain cells, affecting how they work and function.

Although there is more to do to understand how these effects operate at a cellular level in the brain, the researchers believe that their findings advance our understanding of how adverse events in childhood can contribute to life-long increased risk of brain and mind health disorders.

Professor Ed Bullmore from the Department of Psychiatry and an Honorary Fellow at Downing College, Cambridge, said: "Now that we have a better understanding of why childhood maltreatment has long term effects, we can potentially look for biomarkers -- biological red flags -- that indicate whether an individual is at increased risk of continuing problems. This could help us target early on those who most need help, and hopefully aid them in breaking this chain of ill health."

The research was supported by MQ: Transforming Mental Health, the Royal Society, Medical Research Council, National Institute for Health and Care Research (NIHR) Cambridge Biomedical Research Centre, the NIHR Applied Research Collaboration East of England, Girton College and Darwin College.

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Materials provided by University of Cambridge . The original text of this story is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License . Note: Content may be edited for style and length.

Journal Reference :

• Orellana, SC et al. Childhood maltreatment influences adult brain structure through its effects on immune, metabolic and psychosocial factors. . PNAS , 2024 DOI: 10.1073/pnas.230470412

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Fast Facts: Preventing Child Abuse & Neglect

Child abuse and neglect are serious public health problems and adverse childhood experiences (ACEs) . They can have long-term impacts on health, opportunity, and wellbeing. This issue includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (such as a religious leader, a coach, a teacher) that results in harm, the potential for harm, or threat of harm to a child. There are four common types of abuse and neglect:

• Physical abuse is the intentional use of physical force that can result in physical injury. Examples include hitting, kicking, shaking, burning, or other shows of force against a child.
• Sexual abuse involves pressuring or forcing a child to engage in sexual acts. It includes behaviors such as fondling, penetration, and exposing a child to other sexual activities. Please see CDC’s Preventing Child Sexual Abuse webpage for more information.
• Emotional abuse refers to behaviors that harm a child’s self-worth or emotional well-being. Examples include name-calling, shaming, rejecting, withholding love, and threatening.
• Neglect is the failure to meet a child’s basic physical and emotional needs. These needs include housing, food, clothing, education, access to medical care, and having feelings validated and appropriately responded to.

For more information about preventing child abuse and neglect definitions please see Child Maltreatment Surveillance: Uniform Definitions for Public Health and Recommended Data Elements [4.12 MB, 148 Pages, 508] .

Child abuse and neglect are common. At least 1 in 7 children have experienced child abuse or neglect in the past year in the United States. This is likely an underestimate because many cases are unreported. In 2020, 1,750 children died of abuse and neglect in the United States.

Children living in poverty experience more abuse and neglect. Experiencing poverty can place a lot of stress on families, which may increase the risk for child abuse and neglect. Rates of child abuse and neglect are 5 times higher for children in families with low socioeconomic status.

Child maltreatment is costly. In the United States, the total lifetime economic burden associated with child abuse and neglect was about $592 billion in 2018. This economic burden rivals the cost of other high-profile public health problems, such as heart disease and diabetes.

Children who are abused and neglected may suffer immediate physical injuries such as cuts, bruises, or broken bones. They may also have emotional and psychological problems, such as anxiety or posttraumatic stress.

Over the long term, children who are abused or neglected are also at increased risk for experiencing future violence victimization and perpetration, substance abuse, sexually transmitted infections, delayed brain development, lower educational attainment, and limited employment opportunities.

Chronic abuse may result in toxic stress, which can change brain development and increase the risk for problems like posttraumatic stress disorder and learning, attention, and memory difficulties.

Child abuse and neglect are preventable. Certain factors may increase or decrease the risk of perpetrating or experiencing child abuse and neglect. To prevent child abuse and neglect violence, we must understand and address the factors that put people at risk for or protect them from violence. Everyone benefits when children have safe, stable, nurturing relationships and environments. CDC developed Child Abuse and Neglect Prevention Resource for Action [4 MB, 50 Pages]  to help communities use the best available evidence to prevent child abuse and neglect. This resource is available in English and Spanish [21MB, 52 Pages, 508] and can impact individual behaviors and relationships, family, community, and societal factors that influence risk and protective factors for child abuse and neglect.

Different types of violence are connected and often share root causes. Child abuse and neglect are linked to other forms of violence through  shared risk and protective factors . Addressing and preventing one form of violence may have an impact on preventing other forms of violence.

See Child Abuse and Neglect Resources   for publications, data sources, and prevention resources for preventing child abuse and neglect.

• Fortson, B. L., Klevens, J., Merrick, M. T., Gilbert, L. K., & Alexander, S. P. (2016). Child Abuse and Neglect Prevention Resource for Action: A Compilation of the Best Available Evidence. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Note: The title of this document was changed in July 2023 to align with other Prevention Resources being developed by CDC’s Injury Center. The document was previously cited as “Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities”.
• Leeb RT, Paulozzi L, Melanson C, Simon T, Arias I. Child Maltreatment Surveillance: Uniform Definitions for Public Health and Recommended Data Elements, Version 1.0. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2008.
• Finkelhor D, Turner HA, Shattuck A, Hamby SL. Prevalence of Childhood Exposure to Violence, Crime, and Abuse: Results from the National Survey of Children’s Exposure to Violence. JAMA Pediatr. 2015;169(8):746–754. doi:10.1001/jamapediatrics.2015.0676
• U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2022). Child Maltreatment 2020. Available from https://www.acf.hhs.gov/cb/researchdata technology/statistics-research/childmaltreatment .
• Klika JB, Rosenzweig J, Merrick M. Economic burden of known cases of child maltreatment from 2018 in each state. Child and adolescent social work journal. 2020 Jun;37(3):227-34.
• Centers for Disease Control and Prevention.(2022). Health and Economic Costs of Chronic Diseases. Available from https://www.cdc.gov/chronicdisease/about/costs/index.htm
• Shonkoff J, Garner A, & Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, and Section on Developmental and Behavioral Pediatrics. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232-e246.
• Preventing Multiple Forms of Violence: A Strategic Vision for Connecting the Dots. (2016). Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

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Childhood maltreatment influences adult brain structure through its effects on immune, metabolic, and psychosocial factors

Affiliations.

• 1 Department of Psychiatry, University of Cambridge, Cambridge CB2 0SZ, United Kingdom.
• 2 Department of Psychology, University of Cambridge, Cambridge CB2 3EB, United Kingdom.
• 3 Institute of Psychology, Leiden University, Leiden 2333 AK, The Netherlands.
• 4 Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge CB2 7EF, United Kingdom.
• 5 Department of Psychology, University of Pennsylvania, Philadelphia, PA 19104-6241.
• 6 Institute of Education and Child Studies, Leiden University, Leiden 2333 AK, The Netherlands.
• 7 Cambridgeshire & Peterborough NHS Foundation Trust, Cambridge CB21 5EF, United Kingdom.
• PMID: 38593073
• DOI: 10.1073/pnas.2304704121

Childhood maltreatment (CM) leads to a lifelong susceptibility to mental ill-health which might be reflected by its effects on adult brain structure, perhaps indirectly mediated by its effects on adult metabolic, immune, and psychosocial systems. Indexing these systemic factors via body mass index (BMI), C-reactive protein (CRP), and rates of adult trauma (AT), respectively, we tested three hypotheses: (H1) CM has direct or indirect effects on adult trauma, BMI, and CRP; (H2) adult trauma, BMI, and CRP are all independently related to adult brain structure; and (H3) childhood maltreatment has indirect effects on adult brain structure mediated in parallel by BMI, CRP, and AT. Using path analysis and data from N = 116,887 participants in UK Biobank, we find that CM is related to greater BMI and AT levels, and that these two variables mediate CM's effects on CRP [H1]. Regression analyses on the UKB MRI subsample ( N = 21,738) revealed that greater CRP and BMI were both independently related to a spatially convergent pattern of cortical effects (Spearman's ρ = 0.87) characterized by fronto-occipital increases and temporo-parietal reductions in thickness. Subcortically, BMI was associated with greater volume, AT with lower volume and CPR with effects in both directions [H2]. Finally, path models indicated that CM has indirect effects in a subset of brain regions mediated through its direct effects on BMI and AT and indirect effects on CRP [H3]. Results provide evidence that childhood maltreatment can influence brain structure decades after exposure by increasing individual risk toward adult trauma, obesity, and inflammation.

Keywords: MRI; childhood maltreatment; gray matter; inflammation; metabolic.

• Brain* / diagnostic imaging
• Brain* / metabolism
• C-Reactive Protein / metabolism
• Child Abuse* / psychology
• Inflammation / metabolism
• Obesity / complications
• C-Reactive Protein

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• MQF17_24/MQ Mental Health Research (MQ)
• NIHR203312/NIHR | NIHR Cambridge Biomedical Research Centre (NIHR Cambridge BRC)

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Child abuse reports by medical staff linked to children’s race, Stanford Medicine study finds

Over-reporting of Black children and under-reporting of white children as suspected abuse victims suggests systemic bias from medical providers, Stanford Medicine research shows.

February 6, 2023 - By Erin Digitale

Stanford researchers have found that medical professionals are less likely to report suspected abuse when an injured child is white. wavebreakmedia/Shutterstock

Black children are over-reported as suspected victims of child abuse when they have traumatic injuries, even after accounting for poverty, according to new research from the Stanford School of Medicine .

The study , which drew on a national database of nearly 800,000 traumatic injuries in children, appears in the February issue of the Journal of Pediatric Surgery . It also found evidence that injuries in white children are under-reported as suspected abuse.

The study highlights the potential for bias in doctors’ and nurses’ decisions about which injuries should be reported to Child Protective Services, according to the researchers. Medical caregivers are mandated reporters, obligated to report to CPS any situations in which they think children may be victims of abuse. Because caregivers rarely admit to injuring their children, such reports rely in part on providers’ gut feelings, making them susceptible to unconscious, systemic bias.

Bias can harm both Black and white children, said senior study author Stephanie Chao , MD, assistant professor of surgery at Stanford Medicine. The study’s lead author is Modupeola Diyaolu, MD, a resident in general surgery at Stanford Medicine.

“If you over-identify cases of suspected child abuse, you’re separating children unnecessarily from their families and creating stress that lasts a lifetime,” Chao said. “But child abuse is extremely deadly, and if you miss one event — maybe a well-to-do Caucasian child where you think ‘No way’ — you may send that child back unprotected to a very dangerous environment. The consequences are really sad and devastating on both sides.”

Distinguishing race and poverty

Racial disparities in reporting child abuse have been documented before, but prior studies have not controlled well for poverty, which is a risk factor for abuse. Some experts argue that disproportionate reporting of injured Black children as possible abuse victims reflects only that their families tend to have lower incomes, not that medical professionals are subject to bias. Chao’s team wanted to clarify the debate.

The new study drew on data from the National Trauma Data Bank, which is maintained by the American College of Surgeons. The researchers studied records of nearly 800,000 traumatic injuries that occurred in children ages 1 to 17 from 2010 to 2014 and from 2016 to 2017. Of these injuries, 1% were suspected to be caused by abuse, based on medical codes used to report different types of abuse. The researchers controlled their findings for whether children had public or private insurance as a marker for family income.

Suspected victims of child abuse were younger (a median age of 2 versus 10 years), more likely to have public insurance (77% versus 43%) and more likely to be admitted to the intensive care unit (68% versus 48%) than the general population of children with traumatic injuries. Suspected child abuse victims also were 10 times as likely as the general population of children with traumatic injuries to die of their injuries in the hospital, with 8.2% of suspected abuse victims versus 0.84% of all children with traumatic injuries dying during hospitalization.

Stephanie Chao

Similar proportions of children in the suspected child abuse group and in the general population of injured children were of Asian, Native Hawaiian/Pacific Islander, American Indian and “other” races, and similar proportions of both groups were of Hispanic or Latino ethnicity.

However, Black patients were over-represented among suspected child abuse victims, comprising 33% of suspected child abuse victims and 18% of the general population of injured children. White children comprised 51% of suspected child abuse victims and 66% of the general population of injured children.

“Even when we control for income — in this case, via insurance type — African American children are still significantly over-represented as suspected victims of child abuse,” said Chao. “In addition, they were reported with lower injury severity scores, meaning there was more suspicion for children with less-severe injuries in one particular racial group.”

In general, the researchers found medical professionals had a higher threshold for suspecting white families of abuse and a lower threshold for suspecting Black families. For example, white children in the suspected abuse group were more likely than Black children to have worse injuries, and they were more likely to have been admitted to the intensive care unit.

Implementing universal screening

Chao and her colleagues are designing more equitable ways to screen injured children for possible abuse. An important element, she said, is to make the screening universal so evaluation for possible abuse is not initiated primarily by medical providers’ gut feelings.

Chao created a universal screening system, in use at Stanford Medicine Children’s Health since 2019, in which every time a child younger than 6 years old is evaluated for an injury sustained in a private home, the electronic medical record automatically sends an alert to the organization’s child abuse team. Composed of pediatricians and social workers with specialized training in abuse detection, the team checks the medical record for other indications of abuse. In most cases, no such signals are found, and the entire process occurs behind the scenes. However, if the medical record shows any red flags, the medical staff who admitted the patient to the emergency department or hospital can be alerted for further consideration of whether further work-up or a CPS report is warranted.

Chao is also now working with Epic, the nation’s largest electronic medical record company, to include an automated child abuse screening tool in its system. The screening tool will be tested at several medical institutions later this year.

Chao hopes the work will improve the accuracy of CPS reports, especially when it comes to reducing the impact of medical providers’ unconscious bias.

“Everyone means well here, but the consequences of getting these reports wrong are pretty dire in either direction,” she said. “If we don’t recognize bias and always chalk it up to something else, we can’t fix the problem in a thoughtful way. Now, I hope we can recognize it and work toward a solution.”

The study was funded by the National Center for Advancing Translational Sciences (grant KL2TR003143).

About Stanford Medicine

Stanford Medicine is an integrated academic health system comprising the Stanford School of Medicine and adult and pediatric health care delivery systems. Together, they harness the full potential of biomedicine through collaborative research, education and clinical care for patients. For more information, please visit med.stanford.edu .

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Fact Sheet: How DHS is Combating Child Exploitation and Abuse

Every day, the Department of Homeland Security (DHS) leads the fight against child exploitation and abuse. As part of the Department’s mission to combat crimes of exploitation and protect victims, we investigate these abhorrent crimes, spread awareness, collaborate with interagency and international partners, and expand our reach to ensure children are safe and protected.

DHS battles child exploitation and abuse using all available tools and resources department-wide, emphasizing its commitment in April 2023 by adding “Combat Crimes of Exploitation and Protect Victims” as its sixth core mission.

As part of the Department’s ongoing work on this mission, today DHS is announcing Know2Protect, the U.S. government’s first prevention and awareness campaign to combat online child sexual exploitation and abuse. In recognition of April’s Child Abuse Prevention Month, DHS is committed to raising awareness, preventing child exploitation and abuse, and bringing perpetrators to justice.

Between October 2022 and April 2024, DHS:

• Expanded and unified the Department’s focus on combating cybercrimes by redesignating the HSI Cyber Crimes Center as the DHS Cyber Crimes Center to enhance coordination across all DHS agencies and offices to combat cyber-related crimes and further the Department’s mission to combat online child sexual exploitation and abuse (CSEA).
• The Blue Campaign, now part of the DHS Center for Countering Human Trafficking, increased national partnerships from 43 in FY22 to 64 in FY23. The campaign hosted 194 national trainings on the indicators of human trafficking and how to report these crimes with over 19,000 participants from the federal government, non-governmental organizations, law enforcement, and the general public. In April 2024, Blue Campaign announced a partnership with rideshare company Lyft to train their drivers, who interact with millions of riders per year, on how to recognize and report human trafficking. Read more accomplishments in the DHS Center for Countering Human Trafficking’s FY 2023 Annual Report .
• Identified and/or assisted 2,621 child victims of exploitation through the work of Homeland Security Investigations and made more than 6,100 arrests for crimes involving the sexual exploitation of children. Learn more in Immigration and Customs Enforcement (ICE) ’s FY2023 Annual Report .
• Joined the Biden-Harris Administration and interagency partners to collaborate on actions to keep children and teens safe as part of the Kids Online Health and Safety Task Force and the White House Online Harassment and Abuse Task Force.
• Tasked the Department’s external advisory bodies, including the Homeland Security Advisory Council , the Homeland Security Academic Partnership Council , and the Faith-Based Security Advisory Council , to each form a subcommittee to review DHS efforts to combat online child sexual exploitation and abuse. In the coming months, they will share their findings, which will help inform the Department’s future efforts to tackle these issues.
• Began implementing a trauma-informed and victim and survivor-centered multidisciplinary workplan through the Joint Council on Combating Child Sexual Exploitation, established by President Biden and Australian Prime Minister Albanese. The Council, co-chaired by Secretary Alejandro N. Mayorkas, is focused on building the capacity of countries in the Indo-Pacific region to combat this crime; jointly developing policy recommendations to tackle the issue; conducting joint investigations and operations; sharing research and development efforts; preventing victimization through education and awareness campaigns; and safety-by-design.

To accomplish this work, DHS coordinates with law enforcement at home and abroad to enforce and uphold our laws, protects victims with a victim-centered approach that prioritizes respect and understanding, and works to stop this heinous crime through public education and outreach.

Enforcing Our Laws

DHS works with domestic and international partners to enforce and uphold the laws that protect children from abuse. The Department works collaboratively with the Department of Justice, the FBI, U.S Marshals, Interpol, Europol, and international law enforcement partners to arrest and prosecute perpetrators.

• Increased U.S. government and law enforcement efforts to combat financial sextortion – a crime targeting children and teens by coercing them into sending explicit images online and extorting them for money. In the past two years HSI received 4500 sextortion tips from Cote d’Ivoire and 665 children have been identified and supported by HSI. Learn more about the crime of sextortion .
• Helped deny more than 1,400 convicted, registered U.S. child sex offenders entry to foreign countries through travel notifications sent by the HSI Angel Watch Center. These efforts build international cooperation to ensure all countries are safe from predators.
• Partnered with 61 regional Internet Crimes Against Children Task Forces to investigate people involved in the online victimization of children, including those who produce, receive, distribute and/or possess child sexual abuse material, or who engage in online sexual enticement of children.
• Researched and developed modern tools and technologies that equip domestic and international law enforcement partners with advanced forensic capabilities to accomplish their mission to identify victims and apprehend child sexual abusers. For example, DHS’s Science and Technology Directorate developed the StreamView application to help law enforcement more efficiently address child exploitation cases by helping investigators aggregate, organize, and analyze investigative leads to identify the location of a crime, the victim, and bring the perpetrator to justice. Since May 2023, StreamView has led to the rescue of 68 victims, 47 arrests, eight life sentences, and dismantled eight trafficking networks having up to one million registered users.
• The U.S. Secret Service provides forensic and technical assistance to the National Center for Missing and Exploited Children (NCMEC) and state/local law enforcement in cases involving missing and exploited children. 
• U.S. Customs and Border Protection screens all unaccompanied children and other arriving minors for indicators of abuse or exploitation, human trafficking, and other crimes, and all suspected criminal cases are referred to HSI.

Protecting and Supporting Victims

DHS incorporates a victim-centered approach into all Department programs, policies, and operations that involve victims of crime. This effort seeks to minimize additional trauma, mitigate undue penalization, and provide needed stability and support to victims.

HSI’s “ Operation Renewed Hope ” mission in July 2023 resulted in the generation of 311 probable identifications of previously unknown victims, including 94 positive contacts and several confirmed victim rescues from active abuse due to their locations being discovered through materials uncovered during the investigations. The investigation also led to the identification of perpetrators of child sexual abuse material. HSI completed “ Operation Renewed Hope II ” in Spring 2024, which resulted in the generation of 414 probable identifications of previously unknown victims, and positive identification of 30 previously unknown child sexual abuse victims, which included 8 victims rescued from active abuse.

• Once victims of child exploitation are identified and/or rescued, the HSI Victim Assistance Program (VAP) supports them and their non-offending caretaker(s) by using highly trained forensic interview specialists to conduct victim-centered and trauma-informed forensic interviews. In addition, VAP’s victim assistance specialists provide other resources to victims such as crisis intervention, referrals for short and long term medical and/or mental health care, and contact information for local social service programs for young victims, and agencies to assist in the healing process.
• The Center for Countering Human Trafficking hosted its second annual virtual DHS Human Trafficking Seminar for DHS employees who are part of the Department’s mission to end human trafficking or are interested in this work. Over 900 employees from across the Department attended to learn more about DHS’s work and victim-centered approach to combating this crime.
• HSI provides  short-term immigration protections to human trafficking victims , including victims of child sex trafficking. U.S. Citizen and Immigration Services (USCIS) provides victim-based or humanitarian-related immigration benefits to child victims of human trafficking, abuse, and neglect, including Special Immigration Juvenile (SIJ) classification, T visa, U visa, and VAWA immigrant classification.

Educating and Increasing Public Awareness

An integral part of this work is educating and expanding public awareness to help prevent this crime and hold perpetrators accountable. DHS does this important work every day.

• Trained more than 2,000 law enforcement officials and child advocacy personnel throughout the country to enhance their counter-child exploitation tactics.
• Educated over 186,000 kids, teens, parents, and teachers about internet safety and how to stay safe from sexual predators through the iGuardian program. DHS recently revamped Project iGuardian materials and using those materials, HSI has trained 419 special agents and completed presentations across 32 states and 8 countries. Presentations target kids aged 10 and up and their trusted guardians and focus on sharing information about the dangers of online environments, how to stay safe online, and how to report abuse and suspicious activity.
• USSS Childhood Smart Program Ambassadors educated more than 112,000 children, parents, and teachers across 31 states and the District of Columbia about how to prevent online sexual exploitation and child abduction. The Childhood Smart Program provides age-appropriate presentations to children as young as five as well as to adults. Presentations focus on internet and personal safety as well as other topics such as social media etiquette and cyber bullying.
• The HSI Human Rights Violations and War Crimes Center trained over 955 individuals across the interagency on female genital mutilation or cutting, a severe form of child abuse under federal law when done to individuals under the age of 18.
• The DHS Blue Campaign Blue Lighting Initiative, part of the Center for Countering Human Trafficking, trained over 260,000 aviation personnel to identify potential traffickers and human trafficking victims and report their suspicions to law enforcement in FY 2023. The Initiative added 31 new partners this past year, raising its total partners to 136 aviation industry organizations, including its first two official international partners.
• The Cybersecurity and Infrastructure Security Agency administers SchoolSafety.gov, an interagency website that includes information, guidance and resources on a range of school safety topics. SchoolSafety.gov houses a child exploitation section and corresponding resources to help school communities identify, prevent and respond to child exploitation. Since its launch in January 2023, the SchoolSafety.gov child exploitation section has been viewed more than 17,380 times.

What You Can Do and Resources Available

• Project iGuardians™: Combating Child Predators
• Childhood Smart Program
• Visit SchoolSafety.gov for resources to help educators, school leaders, parents, and school personnel identify, prevent, and respond to child exploitation. 
• Learn more about sextortion : it is more common than you think. 
• Learn more from the National Center for Missing and Exploited Children .

How to report suspected online child sexual exploitation and abuse in the United States:

• Contact your local, state, campus, or tribal law enforcement officials directly. Call 911 in an emergency.
• If you suspect a child has been abducted or faces imminent danger, contact your local police and the NCMEC tip line at 1-800-THE-LOST (1-800-843-5678) .
• If you suspect a child might be a victim of online sexual exploitation, call the HSI Tip Line at 1-866-347-2423 and report it to NCMEC’s CyberTipline .
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‘This isn’t how good scientific debate happens’: academics on culture of fear in gender medicine research

Cass review found professionals in the field are scared to discuss views amid risk of reputational damage and online abuse

C ritical thinking and open debate are pillars of scientific and medical research. Yet experienced professionals are increasingly scared to openly discuss their views on the treatment of children questioning their gender identity.

This was the conclusion drawn by Hilary Cass in her review of gender identity services for children this week, which warned that a toxic debate had resulted in a culture of fear.

Her conclusion was echoed by doctors, academic researchers and scientists, who have said this climate has had a chilling effect on research in an area that is in desperate need of better evidence .

Some said they had been deterred from pursuing what they believed to be crucial studies, saying that merely entering the arena would put their reputation at risk. Others spoke of abuse on social media, academic conferences being shut down, biases in publishing and the personal cost of speaking out.

“In most areas of health, medical researchers have freedom to answer questions to problems without fear of judgment,” said Dr Channa Jayasena, a consultant in reproductive endocrinology at Imperial College London. “I’ve never quite known a field where the risks are also in how you’re seen and your beliefs. You have to be careful about what you say both in and out of the workplace.”

Sallie Baxendale, a professor of clinical neuropsychology at UCL’s Institute of Neurology, received abuse after publishing a systematic review of studies that investigated the impact of puberty blockers on brain development. Her review found that “critical questions” remained around the nature, extent and permanence of any arrested development of cognitive function linked to the treatment.

The paper, which summarised the state of relevant research, was met with an immediate backlash. “I’ve been accused of being an anti-trans activist, and that now comes up on Google and is never going to go away,” Baxendale said. “Imagine what it’s like if that is the first thing that comes up when people Google you? Anyone who publishes in this field has got to be prepared for that.”

The lack of high-quality research, highlighted by Cass, has been a subject of growing unease among doctors, according to Dr Juliet Singer, a consultant child and adolescent psychiatrist and former governor of the Tavistock and Portman NHS foundation trust.

In 2020, Singer conducted a survey of specialist child psychiatry trainees, which highlighted concerns about the lack of explanation for the exponential growth in referrals to adolescent gender services, the lack of long-term outcome studies on treatments, and insufficient evidence on the long-term effects of hormone blockers.

She said raising questions such as what was driving the unprecedented rise in birth-registered girls presenting with gender-related distress in puberty appeared to be deemed “unacceptable” by some senior leaders at Tavistock.

“There’s been a shutting down of anybody who has suggested we need to think about a deeper understanding of why these young people are in such distress,” she said. “It’s been remarkable the difference from other ordinary clinical practice.”

Others have found that commenting publicly on the scientific merits of work by other academics – normally a routine part of media coverage of science and health – has put scientists in the firing line when it comes to trans-related issues.

Jayasena described receiving hate mail after welcoming a US study in which a trans woman was given hormones to be able to have the experience of breastfeeding and, separately, being accused of transphobia after commenting on research about athletic performance in trans women .

“I felt concerns for my safety,” he said. “I find my quotes are weaponised. That is very worrying and most colleagues would never go near this type of topic for that reason.”

Another senior researcher in endocrinology, who wished to remain anonymous, said medical professionals had resorted to sharing concerns and views on anonymous WhatsApp groups.

“The bad-mouthing and the social media destruction of people’s reputation and careers is so damning,” the academic said. “Professional people are worried about how they will be characterised on social media and cannot express dissent without it resulting in very aggressive, inappropriate behaviours. It’s causing people to stop talking and just move away from it and not get involved.”

She added: “This isn’t how good scientific debate happens – it happens when people can talk honestly and without fear.”

The risk of being attacked is enough to deter younger researchers from entering the field, Baxendale believes. “It’s tough, I think most people would just walk away. Why risk your reputation? There are many people early in their careers, and I do not blame them one bit, who would not be prepared to accept that,” she said.

The situation hampers efforts to establish a firm medical basis for treatments, Baxendale believes. If the best researchers avoid the field, there is a danger it will become dominated by less rigorous scientists and those who have an interest in their results supporting particular beliefs.

After publishing her review, Baxendale was contacted by a senior expert outside the UK who said they had walked away from a study after being told the team would only publish “positive” findings.

Jayasena says there has been a perception of research being dominated by “a self-selected cohort of people who will be on either side of the fence and perhaps not so interested in advancing the field”. And in the absence of a robust evidence base, there has been greater scope for ideology to fill the knowledge gap.

“Ultimately, I’ve seen completely unhelpful views on both sides,” Jayasena said. “There’s an overly affirming view of let’s just do everything. This results in what I’d call bro-science. We’re getting that disconnect between evidence and assumed knowledge because the internet is an echo chamber. Then there’s the other side of things – a more rightwing, moralistic view. Unfortunately, some members of the medical community are immersed in these views.”

This can act as a disincentive for learned societies, NHS bodies and scientific journals to become involved at any level.

In an effort to find common ground among academics, doctors, patient groups and campaigners that might serve as a springboard for objective research, Singer attempted to organise a conference at Great Ormond Street hospital in 2022.

The meeting was an invite-only academic conference for specialist child psychiatry trainees and consultant child psychiatrists in London, and Cass was due to present her interim findings, alongside speakers with a diverse range of perspectives, including former gender identity development services clinicians.

“What I wanted to do with the conference was just bring together people with different perspectives,” she said. “So clinicians working with children and adolescents can hear different perspectives and, with an open mind, come to appropriate clinical and research questions to ask.”

However, after fielding significant numbers of complaints and making concessions aimed at achieving a balanced programme, the conference was cancelled by Health Education England the day before it was due to take place after a “protected whistleblower’s report” was sent in from someone describing themselves as a researcher on anti-trans conspiracy theories. Despite reassurances that the conference would be reorganised by HEE and the Royal College of Psychiatrists, it is yet to happen.

Others spoke of the challenge of getting studies published in high-profile journals, raising concerns that some journal editors may prefer to reject studies rather than face potential criticism. As a consequence, papers that flag knowledge gaps in gender medicine can become ghettoised in particular journals, making those publications appear overly critical.

Fuelled by concerns about the poor quality of research, the Cass report has set the stage for a major NHS trial that should start this year. It will look at the safety and efficacy of puberty blockers, but also cross-sex hormones that are used to masculinise or feminise people, and psychosocial interventions, with the aim of establishing a robust evidence base.

Many are hopeful that the Cass report, and the NHS trial it recommends, are an opportunity to draw a line under the infighting and abuse and establish a more constructive field of gender medicine.

“It will take time, but it’s allowed people to breathe and feel confident in questioning treatments,” said Singer. “People work in this field because they want to help young people and that drive will still be there. It’s important and valuable work. Cass has now given us permission to do it.”

Baxendale is acutely aware that many patients and their families, reading coverage of the Cass report this week, will be left wondering whether help will be available, whether treatments work and whether they can trust their doctors.

“It must be so distressing for them,” she said. “But I think there is hope. The NHS research will be rigorous, it’s balanced to look at benefits and harms, and I think once we’ve got the results we will have a proper service for these kids.”

• Transgender
• Medical research
• Young people

More on this story

Scottish gender clinic pauses prescribing puberty blockers to under-18s

No case for closing Scotland’s only NHS gender services clinic, says first minister

Veteran trans campaigner: ‘Cass review has potential for positive change’

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Handbook of Child Maltreatment pp 35–64 Cite as

Recent Research on Child Neglect

• Howard Dubowitz 5 ,
• Julia M. Kobulsky 6 &
• Laura J. Proctor 7  
• First Online: 22 February 2022

1783 Accesses

2 Citations

Part of the book series: Child Maltreatment ((MALT,volume 14))

Neglect is the most common form of child maltreatment, adversely affecting multiple domains of functioning throughout the lifespan. Repeated calls have implored the scientific community to remedy the “neglect of neglect,” which refers to the paucity of research on neglect relative to abuse, particularly regarding prevention and intervention. Barriers to the advancement of scientific knowledge and to tackling this intractable public health problem include the difficulties defining neglect and inadequate concern regarding its relative harm. Despite these challenges, numerous studies on the nature and consequences of child neglect have been conducted. This review focuses on recent advances in research regarding child neglect’s nature, measurement, prevalence, etiology, consequences, prevention, and intervention. It is guided by the question: What is new about neglect? Although much work remains to be done, noteworthy advances have been made.

With permission, this chapter builds upon what we wrote for R. Geffner, et al. (Eds) (2021). Handbook of interpersonal violence and abuse across the lifespan . New York: Springer Nature.

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Dubowitz, H., Kobulsky, J.M., Proctor, L.J. (2022). Recent Research on Child Neglect. In: Krugman, R.D., Korbin, J.E. (eds) Handbook of Child Maltreatment. Child Maltreatment, vol 14. Springer, Cham. https://doi.org/10.1007/978-3-030-82479-2_2

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New Directions in Child Abuse and Neglect Research

Editors: Anne C. Petersen , Joshua Joseph , and Monica Feit . Authors: Committee on Child Maltreatment Research, Policy, and Practice for the Next Decade: Phase II ; Board on Children, Youth, and Families ; Committee on Law and Justice ; Institute of Medicine ; National Research Council .

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Each year, child protective services receive reports of child abuse and neglect involving six million children, and many more go unreported. The long-term human and fiscal consequences of child abuse and neglect are not relegated to the victims themselves -- they also impact their families, future relationships, and society. In 1993, the National Research Council (NRC) issued the report, Under-standing Child Abuse and Neglect , which provided an overview of the research on child abuse and neglect. New Directions in Child Abuse and Neglect Research updates the 1993 report and provides new recommendations to respond to this public health challenge. According to this report, while there has been great progress in child abuse and neglect research, a coordinated, national research infrastructure with high-level federal support needs to be established and implemented immediately.

New Directions in Child Abuse and Neglect Research recommends an actionable framework to guide and support future child abuse and neglect research. This report calls for a comprehensive, multidisciplinary approach to child abuse and neglect research that examines factors related to both children and adults across physical, mental, and behavioral health domains--including those in child welfare, economic support, criminal justice, education, and health care systems--and assesses the needs of a variety of subpopulations. It should also clarify the causal pathways related to child abuse and neglect and, more importantly, assess efforts to interrupt these pathways. New Directions in Child Abuse and Neglect Research identifies four areas to look to in developing a coordinated research enterprise: a national strategic plan, a national surveillance system, a new generation of researchers, and changes in the federal and state programmatic and policy response.

• Collapse All
• THE NATIONAL ACADEMIES
• COMMITTEE ON CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE FOR THE NEXT DECADE: PHASE II
• Acknowledgments
• DESCRIBING THE PROBLEM
• CONSEQUENCES
• THE CHILD WELFARE SYSTEM
• EFFECTIVE INTERVENTIONS AND SERVICE DELIVERY SYSTEMS
• RESEARCH INFRASTRUCTURE
• RECOMMENDATIONS
• THE 1993 REPORT
• TRENDS SINCE 1993
• THE CURRENT STUDY
• STUDY APPROACH
• RESEARCH ADVANCES IN CHILD ABUSE AND NEGLECT
• A SYSTEMS FRAMEWORK FOR CHILD ABUSE AND NEGLECT
• THE UNIQUE ROLE OF SOCIAL AND ECONOMIC STRATIFICATION
• ORGANIZATION OF THE REPORT
• DEFINITIONS
• INCIDENCE RATES AND THE PROBLEM OF UNDERREPORTING
• INCIDENCE TRENDS
• DETERMINATION OF CHILD ABUSE AND NEGLECT
• CONCLUSIONS
• ESTABLISHING A CAUSAL CONNECTION
• CANDIDATE EXPLANATORY FACTORS FOR CHILD ABUSE AND NEGLECT
• PROTECTIVE FACTORS
• METHODOLOGICAL CHALLENGES
• CASCADING CONSEQUENCES
• NEUROBIOLOGICAL OUTCOMES
• COGNITIVE, PSYCHOSOCIAL, AND BEHAVIORAL OUTCOMES
• HEALTH OUTCOMES
• ADOLESCENT AND ADULT OUTCOMES
• INDIVIDUAL DIFFERENCES IN OUTCOMES
• ECONOMIC BURDEN
• OVERVIEW OF THE CHILD WELFARE SYSTEM
• MAJOR POLICY SHIFTS IN CHILD WELFARE SINCE 1993
• SYSTEM-LEVEL REFORMS INTENDED TO IMPROVE PRACTICE AND OUTCOMES
• RESEARCH ON KEY POLICY AND PRACTICE REFORMS
• FOCUS ON WELL-BEING OUTCOMES
• ISSUES THAT REMAIN TO BE ADDRESSED
• TREATMENT PROGRAMS
• PREVENTION STRATEGIES
• COMMON ISSUES IN IMPROVING PROGRAM IMPACTS
• BUILDING AN INTEGRATED SYSTEM OF CARE
• COMPONENTS OF THE CHILD ABUSE AND NEGLECT RESEARCH INFRASTRUCTURE
• Multidisciplinary and Multimethod Perspectives
• The Role of Cultural Factors
• Longitudinal Studies, Surveillance, and Registries
• Research Funding
• CHALLENGES IN CHILD ABUSE AND NEGLECT RESEARCH
• EXISTING OPPORTUNITIES TO CREATE AN INTEGRATED CHILD ABUSE AND NEGLECT RESEARCH INFRASTRUCTURE
• THE POLICY LANDSCAPE
• FEDERAL LAWS AND POLICIES
• STATE LAWS AND POLICIES
• GUIDING PRINCIPLES
• FINAL THOUGHTS
• Appendix A Workshop Open Session Agendas
• Appendix B Research Recommendations and Priorities from the 1993 National Research Council Report Understanding Child Abuse and Neglect
• Appendix C Biosketches of Committee Members

This study was supported by Contract/Grant No. HHSP23320110010YC between the National Academy of Sciences and the Administration for Children and Families, U.S. Department of Health and Human Services. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project.

Suggested citation:

IOM (Institute of Medicine) and NRC (National Research Council). 2014. New directions in child abuse and neglect research. Washington, DC: The National Academies Press.

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

• Cite this Page Committee on Child Maltreatment Research, Policy, and Practice for the Next Decade: Phase II; Board on Children, Youth, and Families; Committee on Law and Justice; Institute of Medicine; National Research Council; Petersen AC, Joseph J, Feit M, editors. New Directions in Child Abuse and Neglect Research. Washington (DC): National Academies Press (US); 2014 Mar 25. doi: 10.17226/18331
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