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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
J Nerv Ment Dis. Author manuscript; available in PMC 2014 April 23.
Published in final edited form as:
PMCID: PMC3997104
NIHMSID: NIHMS500095

Prevalence of Childhood Physical and Sexual Abuse in Veterans With Psychiatric Diagnoses

Maju Mathew Koola, MD, DPM,* Clifford Qualls, PhD, Deanna L. Kelly, PharmD, BCPP,* Kelly Skelton, MD, Bekh Bradley, PhD, Richard Amar, MD,§ and Erica J. Duncan, PhD

Abstract

We examined the prevalence of childhood (≤18 years) physical and sexual abuse reported among patients admitted to the psychiatric inpatient service and the differential rates of this abuse associated with psychiatric diagnoses. This study consisted of a retrospective chart review of 603 patients admitted to a psychiatric ward during a period of 1 year at Atlanta Veterans Affairs Medical Center who had data on childhood physical and sexual abuse. The prevalence of reported childhood physical or sexual abuse in this inpatient clinical population was 19.4% (117/603). The prevalence of reported physical abuse was 22.6% (19/84) in the women and 12.0% (62/519) in the men (p = 0.008); the prevalence of sexual abuse was 33.3% (28/84) in the women and 7.7% (40/519) in the men (p < 0.0001). More patients with depressive disorders reported sexual abuse than did those without these disorders. More patients with posttraumatic stress disorder (PTSD) reported physical and sexual abuse than did those without these disorders. Stratifying by race, sex, and diagnoses, multivariate analyses showed that the women with PTSD had a greater likelihood to report physical abuse (p = 0.03) and sexual abuse histories (p = 0.008) than did the women without PTSD. The men with substance-induced mood disorder (p = 0.01) were more likely to report physical abuse compared with the men without substance-induced mood disorder. Screening for abuse in patients with depressive disorders and PTSD is warranted to tailor individualized treatments for these patients. More research is needed to better understand the potential implications of childhood abuse on psychiatric diagnoses.

Keywords: Childhood physical and sexual abuse, veterans, adult psychiatric diagnoses, psychiatric inpatients

Early life stress (ELS) includes a broad spectrum of adverse experiences: physical, sexual, and emotional abuse; family instability (marital discord); parental loss; parental rejection (neglect); witnessing domestic violence; parental alcoholism; or living with those who have substance use disorders (SUDs), mental illness, or criminality (Dong et al., 2004; Leitenberg et al., 2004). Increasing evidence supports the hypothesis that different types of ELS may be associated with adult psychopathological consequences (Heim et al., 2000; Pani et al., 2000; Zlotnick et al., 2004).

ELS has been reported in 26% to 32% of individuals diagnosed with mental disorders in a nationally representative sample of 9282 adults (Green et al., 2010). Other retrospective research indicates that ELS is often followed in adulthood by a wide variety of psychopathologies and psychiatric diagnoses that include a range of depressive disorders (Maercker et al., 2004; O’Sullivan, 2004), acute or chronic stress (Heim et al., 2000; Pani et al., 2000), SUDs (Dong et al., 2004; Pani et al., 2000; Zlotnick et al., 2004), posttraumatic stress disorder (PTSD; Maercker et al., 2004), schizophrenia and psychotic disorders (Cutajar et al., 2010; Fisher et al., 2011; Galletly et al., 2011; Read et al., 2005), obesity (Heidbreder et al., 2000), attention deficit hyperactivity disorder (Heidbreder et al., 2000; Heim et al., 2000), fibromyalgia (Bell et al., 1998), somatoform disorders, dissociation disorders (Bell et al., 1998; Maaranen et al., 2004), conversion disorder (Maaranen et al., 2004), and suicide attempts (Dong et al., 2004).

Childhood physical and sexual abuse is prevalent, and the potential psychological and physical harm is great. Psychopathologies, such as the ones listed above, impact the individuals’ physical and emotional health, general functioning, and health care service use (Druss et al., 2000; Greenberg et al., 1999; Wu et al., 2005). PTSD and other anxiety disorders are associated with loss of productivity and absenteeism at work (Greenberg et al., 1999). Depression was associated with a mean of 10 annual sick days, significantly more than many medical conditions (Druss et al., 2000).

The pathophysiological link between ELS and adverse adult sequelae is the subject of a growing body of recent research. There is increasing appreciation in the literature that early adverse experiences can leave a lasting signature on the genetic predispositions that affect emerging brain architecture and long-term health (Shonkoff and Garner, 2012). These authors argue that many of the adult diseases are developmental disorders that begin early in life and that disruptive impacts of toxic stress link early adversity to later impairments in learning, behavior, and both physical and mental well-being. Ongoing areas of research link early stress specifically to perturbations in function of the hypothalamic-adrenocorticoid-pituitary axis (Heidbreder et al., 2000; Heim et al., 2000), other neuroendocrine measures (Heidbreder et al., 2000; Heim et al., 2000, 1997; Macri and Laviola, 2004), alterations in the immune cytokine interleukin 6 (Carpenter et al., 2010), and dopaminergic changes (Pani et al., 2000).

Little is known about the extent of childhood physical and sexual abuse in the clinical population in the Veterans Affairs (VA) system. This is an important clinical question because concomitant childhood physical and sexual abuse in veteran populations may contribute to poorer outcomes, treatment resistance, and greater severity of mental illness, which, in turn, may increase the need for VA health care services by these patients (Kendall-Tackett and Becker-Blease, 2004). Childhood physical and sexual abuse in this population may be associated with considerable economic burden not only for the patients affected but also for the VA health care system and other mental health care systems.

Because of the aforementioned link between ELS and adult sequelae and the potential impact an ELS history may be exerting on health care needs of adult psychiatric patients, this study was undertaken to ascertain the prevalence of reported childhood (≤18 years) physical and sexual abuse among psychiatric inpatients with a wide range of diagnoses in a VA Medical Center (VAMC). The working hypotheses were that the prevalence would be substantial in the patients as a whole but highest in inpatients with mood, anxiety, and SUDs.

METHODS

Participants and Study Design

The patients were all psychiatric inpatients at Atlanta VAMC during the period of August 1, 2004, to July 31, 2005. The study consisted of a retrospective chart review to ascertain the prevalence of childhood physical and sexual abuse among psychiatric inpatients and to compare the prevalence among psychiatric diagnoses.

Data Sets

The admission history and physical (H&P) note contains information about childhood (<18 years) physical and sexual abuse that was completed by the admitting psychiatry attending or resident. These data were read directly from the patients’ charts using the electronic clinician interface and the information entered into investigator-created databases. When present, a note documenting the Addiction Severity Index (ASI) also contains information on childhood physical and sexual abuse that was included in the study databases. Admissions data were extracted from the Veterans Integrated Service Network (VISN7) Corporate Database. Dates of admission and discharge, treating specialty for the admission, and discharge diagnoses were included, along with identifying information, to permit linkage to other tables of data. These data were extracted and imported into customized databases in FilemakerPro for Macintosh (version 8.0; Filemaker, Inc, Santa Clara, CA), in which the length of each admission was computed and readmissions for individual patients were compiled. Demographic information included race, sex, age, era of service (period in which the veteran served in the military), VA service–connected status (whether the patient receives disability payment from the VA), and other economic variables that categorize the patients’ financial and employment status and marital status.

The Emory University Institutional Review Board approved this study and granted it exempt from obtaining informed consent documents from the patients. The Atlanta VA Research and Development Committee and the VISN7 Corporate Database Committee also approved this study.

Statistical Analysis

The demographic and admission data were computed as mean ± standard deviation for continuous variables or as number (percentage) of binary for categorical variables. Comparisons of the prevalence (percentage) of childhood physical and sexual abuse between those patients with a given diagnosis and those without that diagnosis (the complement) were done using chi-square tests. The patients with missing data on physical or sexual abuse (n = 52) were not included in the analyses. Univariate analyses of all demographic and diagnostic variables were performed. Next, multivariate analyses were performed that incorporated all univariate models with a p-value of 0.05 or less. The “best” multivariate models were determined by stepwise (variable selection) logistic regression and verified by backward selection logistic regression; here, the odds ratios (ORs) with their 95% confidence intervals (CIs) reported for each variable were adjusted for the other variables in the model (if any). The candidate variables considered and listed for the multivariate analyses were those that had a p-value of less than 0.05 in the univariate models. The statistical package used was SAS 9.2 (SAS Institute Inc, Cary, NC). A p-value of 0.05 or less was considered statistically significant.

RESULTS

During the period of study, there were a total of 857 inpatient psychiatric admissions of 655 unique patients and a final sample of 603 patients with abuse history data available. Overall, the population was typical of VA patients at Atlanta VAMC. The mean age was about 50 years, 56% were African-American, and 86% were men. The mean ± SD length of hospital stay for this population was 11.7 ± 11.77 days. In this VA-based study, there were 69 individuals (13%) with combat experience. The demographic variables for the sample of 603 individual patients are summarized in Table 1.

TABLE 1
Demographic and Clinical Data on 603 Subjects

The prevalence of childhood physical or sexual abuse reported in this clinic population was 19.4% (117/603). There were 81 patients (13.4%) reporting childhood physical abuse and 68 patients (11.3%) reporting childhood sexual abuse. Thirty-two patients (5.3%) reported both childhood physical and sexual abuse.

A total of 22.6% of the women (19 of 84) reported physical abuse as opposed to 12.0% of the men (62 of 519; χ21 = 7.1; p = 0.008). Similarly, 33.3% of the women as opposed to 7.7% of the men reported sexual abuse (χ21 = 47.5; p < 0.0001). Among 243 patients with depressive disorders, 14.4% reported sexual abuse in contrast to 9.2% of 360 patients without depressive disorders (χ21 = 4.0; p = 0.05). Among 176 patients with PTSD, 17.6% reported physical abuse in contrast to 11.7% of 427 patients without PTSD (χ21 = 3.7, p = 0.05). Similarly, in 176 patients with PTSD, 15.9% reported sexual abuse in contrast to 9.4% of 427 patients without PTSD (χ21 = 5.3; p = 0.02). The prevalence of reported physical and sexual abuse for the patients with each major diagnostic group is summarized in Table 2.

TABLE 2
Prevalence of Childhood Physical and Sexual Abuse by Demographic and Diagnostic Categories (N = 603)

The results of the multivariate analyses using significant demographic (race) and diagnosis candidate variables stratified by sex are listed in Table 3. The prevalence of reported physical abuse was greater in the women with PTSD than in the women without PTSD (OR, 3.3; 95% CI, 1.2–9.7; p = 0.03). Similarly, the prevalence of reported sexual abuse was greater in the women with PTSD compared with the women without PTSD (OR, 3.8; CI, 1.4–10.3; p = 0.008). In the men, the pattern was different. The prevalence of reported physical abuse was greater in the men with substance-induced mood disorder compared with the men without substance-induced mood disorder (OR, 2.3; CI, 1.2–4.3; p = 0.01). In addition, in the men, African-American race was a predictor of lower rates of reported physical abuse than in those who were not African-American (OR, 0.4; CI, 0.2–0.7; p = 0.002). The prevalence of reported physical abuse in the men with or without opiate use disorder failed to reach significance in the multivariate model although it was significant in the univariate model.

TABLE 3
Multivariate Analysis of the Prevalence of Childhood Physical and Sexual Abuse by Sex

DISCUSSION

In this retrospective study of the prevalence of reported childhood abuse in adult psychiatric inpatients, there were several predictors of reported abuse. The women were more likely to report abuse than were the men. African-American race was a predictor of lesser rates of reported physical and sexual abuse than in those not of this race. The patients with PTSD were more likely to report childhood physical and sexual abuse than were the patients without PTSD. The patients with depressive disorders were more likely to report sexual abuse than were the patients without depressive disorders. This latter finding in the sample as a whole may be partially driven by sex-specific findings, in that reported sexual abuse was higher at a trend level in the men with depression than without depression, whereas this pattern was not seen in the women. Although 64% of the entire sample used illicit drugs or alcohol, those with SUDs did not have significantly higher reported physical or sexual abuse than those without SUDs. Surprisingly, the patients with cocaine use disorder were less likely to report physical abuse than were the patients without cocaine use disorder. Sex-specific effects may have driven some findings in the group as a whole. Stratifying by race, sex, and diagnostic candidate variables, the multivariate analyses showed that the women with PTSD were more likely to report physical and sexual abuse compared with the women without PTSD. In the men, reported physical abuse was less likely in African-Americans than in those of other races. In those with substance-induced mood disorder, physical abuse in men was more likely to be seen. A greater percentage of the inpatients reporting a childhood physical or sexual abuse history had three or more admissions during the index year of the study than did those without a reported abuse history.

Two negative findings carry special significance for the VA health care system. The patients who served in the Vietnam era and those with direct combat experience did not have significantly increased rates of reported childhood abuse than those patients not in those categories. The Vietnam cohort is the largest group of VA patients, and patients with combat exposure comprise a large and important portion of the VA clinical population.

The results of the current study regarding the association of reported childhood abuse and diagnosis of mood and anxiety disorders are in accord with several previous studies. The National Comorbidity Survey was a nationally representative survey of the US population (N = 5877), in which data on childhood abuse histories and lifetime diagnoses were gathered (Molnar et al., 2001). In that study, the overall rate of reported childhood sexual abuse was 13.5% in women and 2.5% in men. These rates are considerably lower than our observed rates of 33.3% for women and 7.7% for men. In that study, the diagnoses associated with reported childhood sexual abuse were clustered in the anxiety and mood disorder spectrum, in accord with our findings, but also included several substance disorders. In the current study, in the multivariate model, substance-induced mood disorder was significantly associated with reported physical abuse in men.

Other studies have seen similar associations between reported childhood abuse and mood and anxiety disorders. Stein et al. (1996) found higher rates of childhood physical and sexual abuse histories in patients with anxiety disorders than in those without these diagnoses. However, in this study, the patients were limited to those with anxiety spectrum disorders, so data were not analyzed on other diagnoses. A large study of 1931 subjects (Hovens et al., 2010) found that reported childhood trauma was associated with diagnoses of anxiety and depression, but this study also restricted the diagnoses in their patient sample to anxiety and depression. In the current study, although there was a high prevalence of reported childhood sexual abuse in patients with depressive disorders and PTSD, there was not a significantly elevated prevalence in other anxiety disorders. This could be explained by the small sample size (n = 45) of anxiety disorders other than PTSD in the current sample.

Our finding of lower rates of physical abuse in African-American men is not consistent with higher rates of child maltreatment in African-American families reported in another study (Sedlak et al., 2012). However, the extant data on this issue is inconsistent, with much research suggesting that low income rather than race is associated with increased risk for child maltreatment (Drake et al., 2011).

Strengths and Limitations

The major strength of this study is the large sample size (N = 603). There are many published studies on the association of abuse with psychiatric diagnoses (Coverdale and Turbott, 2000; Mueser et al., 1998). However, there is little literature documenting the prevalence of childhood physical and sexual abuse compared across psychiatric diagnoses. To our knowledge, this is the first study to report the prevalence of reported childhood physical and sexual abuse in patients with psychiatric diagnoses in an inpatient VA health care setting.

This study has several limitations. First, this was a retrospective chart review study. The subjects may have underreported their abuse experiences (Williams, 1994). Because this was a retrospective study, we cannot be sure exactly how the admitting clinician asked the questions to gather information for the prompt in the template for the admission write-up. Hence, the possibility of reporting bias with clinicians asking these questions cannot be ruled out. Approximately 8% of 655 subjects were missing abuse information from the H&P notes in up to seven admissions and in the ASI notes. In the large epidemiological Adverse Childhood Experiences study (N = 658), retrospective findings were found to be trustworthy and stable over time (Dube et al., 2004). Furthermore, prospective studies are also not ideal because a substantial number of cases may be missed and unreported abuse may be more severe. In a prospective study, 82% of 365 survivors of sexual abuse had never reported their abuse to law enforcement or state agencies. For all these reasons, prospective findings cannot be solely relied upon (Kendall-Tackett, 1991).

A second limitation is that childhood physical and sexual abuse history was gathered from the psychiatric history provided at admission and from the ASI. Abuse history was not documented using a validated research rating scale. However, there was convergent validity for childhood abuse documented in clinical case notes versus self-report on a questionnaire (Fisher et al., 2011). Another limitation is that specific information about the perpetrator of the abuse was not available, nor was there information on the severity and the frequency of the traumas. For this reason, the effects of cumulative trauma could not be evaluated. ELS is a broad term that comprises of physical, sexual, and emotional abuse; witnessing domestic violence; having an alcoholic parent; parental rejection, and others. In this study, we focused only on childhood physical and sexual abuse because data on emotional abuse were not available. In addition, we did not consider the effect of multiple diagnoses in our analyses. A final limitation is that we did not look at adult physical and sexual abuse because it would be difficult to separate its effects from the veterans’ combat experience.

CONCLUSIONS AND FUTURE DIRECTIONS

In summary, there was an overall prevalence of reported childhood physical or sexual abuse of 18% among veterans admitted to a VA psychiatric ward. This is a clinically relevant finding from a relapse prevention and health care cost perspective. Psychiatric inpatients with depressive disorders and PTSD may be particularly likely to have histories of childhood physical and sexual abuse, and a special screening for abuse is warranted in patients with these diagnoses for personalized management, which is a National Institute of Mental Health mission. More research is needed on how to best treat psychiatric patients with histories of abuse to prevent symptom relapse and to further our understanding of the potential effects of childhood abuse on the clinical course of psychiatric illnesses.

ACKNOWLEDGMENTS

The authors thank the Atlanta Veterans Affairs Medical Center, Decatur, GA, for the support with resources and the use of facilities. The authors thank Cantrina Hayslett for her assistance in the collection of data.

Footnotes

DISCLOSURES

This study was supported by the University of New Mexico Clinical and Translational Science Center grant 1UL1RR031977-01. The first author’s work on the analyses and dissemination of data was supported by the NIMH-funded T32 grant MH067533-07 (PI: William Carpenter, MD) and an American Psychiatric Association/Kempf Fund Award for Research Development in Psychobiological Psychiatry (M. M. K.). Erica Duncan, MD, and Deanna L. Kelly, PharmD, BCCP, have received investigator-initiated grant funding from Janssen Pharmaceutica, Ortho-McNeil Janssen Scientific Affairs, and Bristol-Myers Squibb and Company. The other authors declare no conflict of interest.

REFERENCES

  • Bell IR, Baldwin CM, Russek LG, Schwartz GE, Hardin EE. Early life stress, negative paternal relationships, and chemical intolerance in middle-aged women: Support for a neural sensitization model. J Womens Health. 1998;7:1135–1147. [PubMed]
  • Carpenter LL, Gawuga CE, Tyrka AR, Lee JK, Anderson GM, Price LH. Association between plasma IL-6 response to acute stress and early-life adversity in healthy adults. Neuropsychopharmacology. 2010;35:2617–2623. [PMC free article] [PubMed]
  • Coverdale JH, Turbott SH. Sexual and physical abuse of chronically ill psychiatric outpatients compared with a matched sample of medical outpatients. J Nerv Ment Dis. 2000;188:440–445. [PubMed]
  • Cutajar MC, Mullen PE, Ogloff JR, Thomas SD, Wells DL, Spataro J. Schizophrenia and other psychotic disorders in a cohort of sexually abused children. Arch Gen Psychiatry. 2010;67:1114–1119. [PubMed]
  • Dong M, Anda RF, Felitti VJ, Dube SR, Williamson DF, Thompson TJ, Loo CM, Giles WH. The interrelatedness of multiple forms of childhood abuse, neglect, and household dysfunction. Child Abuse Negl. 2004;28:771–784. [PubMed]
  • Drake B, Jolly JM, Lanier P, Fluke J, Barth RP, Jonson-Reid M. Racial bias in child protection? A comparison of competing explanations using national data. Pediatrics. 2011;127:471–478. [PubMed]
  • Druss BG, Rosenheck RA, Sledge WH. Health and disability costs of depressive illness in a major U.S. corporation. Am J Psychiatry. 2000;157:1274–1278. [PubMed]
  • Dube SR, Williamson DF, Thompson T, Felitti VJ, Anda RF. Assessing the reliability of retrospective reports of adverse childhood experiences among adult HMO members attending a primary care clinic. Child Abuse Negl. 2004;28:729–737. [PubMed]
  • Fisher HL, Craig TK, Fearon P, Morgan K, Dazzan P, Lappin J, Hutchinson G, Doody GA, Jones PB, McGuffin P, Murray RM, Leff J, Morgan C. Reliability and comparability of psychosis patients’ retrospective reports of childhood abuse. Schizophr Bull. 2011;37:546–553. [PMC free article] [PubMed]
  • Galletly C, Van Hooff M, McFarlane A. Psychotic symptoms in young adults exposed to childhood trauma—A 20 year follow-up study. Schizophr Res. 2011;127:76–82. [PubMed]
  • Green JG, McLaughlin KA, Berglund PA, Gruber MJ, Sampson NA, Zaslavsky AM, Kessler RC. Childhood adversities and adult psychiatric disorders in the National Comorbidity Survey Replication I: Associations with first onset of DSM-IV disorders. Arch Gen Psychiatry. 2010;67:113–123. [PMC free article] [PubMed]
  • Greenberg PE, Sisitsky T, Kessler RC, Finkelstein SN, Berndt ER, Davidson JR, Ballenger JC, Fyer AJ. The economic burden of anxiety disorders in the 1990s. J Clin Psychiatry. 1999;60:427–435. [PubMed]
  • Heidbreder CA, Weiss IC, Domeney AM, Pryce C, Homberg J, Hedou G, Feldon J, Moran MC, Nelson P. Behavioral, neurochemical and endocrinological characterization of the early social isolation syndrome. Neuroscience. 2000;100:749–768. [PubMed]
  • Heim C, Newport DJ, Heit S, Graham YP, Wilcox M, Bonsall R, Miller AH, Nemeroff CB. Pituitary-adrenal and autonomic responses to stress in women after sexual and physical abuse in childhood. JAMA. 2000;284:592–597. [PubMed]
  • Heim C, Owens MJ, Plotsky PM, Nemeroff CB. Persistent changes in corticotropin-releasing factor systems due to early life stress: Relationship to the pathophysiology of major depression and post-traumatic stress disorder. Psychopharmacol Bull. 1997;33:185–192. [PubMed]
  • Hovens JG, Wiersma JE, Giltay EJ, van Oppen P, Spinhoven P, Penninx BW, Zitman FG. Childhood life events and childhood trauma in adult patients with depressive, anxiety and comorbid disorders vs. Acta Psychiatr Scand. 2010;122:66–74. [PubMed]
  • Kendall-Tackett K. Characteristics of abuse that influence when adults molested as children seek treatment. J Interpers Violence. 1991;6:486–493.
  • Kendall-Tackett K, Becker-Blease K. The importance of retrospective findings in child maltreatment research. Child Abuse Negl. 2004;28:723–727. [PubMed]
  • Leitenberg H, Gibson LE, Novy PL. Individual differences among undergraduate women in methods of coping with stressful events: The impact of cumulative childhood stressors and abuse. Child Abuse Negl. 2004;28:181–192. [PubMed]
  • Maaranen P, Tanskanen A, Haatainen K, Koivumaa-Honkanen H, Hintikka J, Viinamaki H. Somatoform dissociation and adverse childhood experiences in the general population. J Nerv Ment Dis. 2004;192:337–342. [PubMed]
  • Macri S, Laviola G. Single episode of maternal deprivation and adult depressive profile in mice: Interaction with cannabinoid exposure during adolescence. Behav Brain Res. 2004;154:231–238. [PubMed]
  • Maercker A, Michael T, Fehm L, Becker ES, Margraf J. Age of traumatisation as a predictor of post-traumatic stress disorder or major depression in young women. Br J Psychiatry. 2004;184:482–487. [PubMed]
  • Molnar BE, Buka SL, Kessler RC. Child sexual abuse and subsequent psychopathology: Results from the National Comorbidity Survey. Am J Public Health. 2001;91:753–760. [PubMed]
  • Mueser KT, Goodman LB, Trumbetta SL, Rosenberg SD, Osher C, Vidaver R, Auciello P, Foy DW. Trauma and posttraumatic stress disorder in severe mental illness. J Consult Clin Psychol. 1998;66:493–499. [PubMed]
  • O’Sullivan C. The psychosocial determinants of depression: A lifespan perspective. J Nerv Ment Dis. 2004;192:585–594. [PubMed]
  • Pani L, Porcella A, Gessa GL. The role of stress in the pathophysiology of the dopaminergic system. Mol Psychiatry. 2000;5:14–21. [PubMed]
  • Read J, van Os J, Morrison AP, Ross CA. Childhood trauma, psychosis and schizophrenia: A literature review with theoretical and clinical implications. Acta Psychiatr Scand. 2005;112:330–350. [PubMed]
  • Sedlak AJ, Mettenburg J, Basena M, Petta I, McPherson K, Green A, Li S. Fourth National Incidence Study of Child Abuse and Neglect (NIS-4) (2009–2010) 2012 Available at: http://www.law.harvard.edu/programs/about/cap/cap-conferences/rd-conference/rd-conference-papers/sedlaknis.pdf.
  • Shonkoff JP, Garner AS. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129:232–246. [PubMed]
  • Stein MB, Walker JR, Anderson G, Hazen AL, Ross CA, Eldridge G, Forde DR. Childhood physical and sexual abuse in patients with anxiety disorders and in a community sample. Am J Psychiatry. 1996;153:275–277. [PubMed]
  • Williams LM. Recall of childhood trauma: A prospective study of women’s memories of child sexual abuse. J Consult Clin Psychol. 1994;62:1167–1176. [PubMed]
  • Wu EQ, Birnbaum HG, Shi L, Ball DE, Kessler RC, Moulis M, Aggarwal J. The economic burden of schizophrenia in the United States in 2002. J Clin Psychiatry. 2005;66:1122–1129. [PubMed]
  • Zlotnick C, Tam T, Robertson MJ. Adverse childhood events, substance abuse, and measures of affiliation. Addict Behav. 2004;29:1177–1181. [PubMed]