Pharmacology, Biochemistry and Behavior 206 (2021) 173195
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Pharmacology, Biochemistry and Behavior
journal homepage: www.elsevier.com/locate/pharmbiochembeh
Effect of child abuse and neglect on schizophrenia and other
psychotic disorders
Barbara H. Chaiyachati a, b, c, d, *, Raquel E. Gur a, b
a
The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
The University of Pennsylvania, Lifespan Brain Institute of Penn-Medicine and CHOP, Philadelphia, PA, United States of America
c
The Center for Pediatric Clinical Effectiveness and Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
d
The Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, United States of America
b
A R T I C L E I N F O
A B S T R A C T
Keywords:
Schizophrenia
Psychosis
Child abuse
Child neglect
Adverse childhood experiences
Child maltreatment
Childhood experiences impact long-term physical and behavioral health outcomes including potential risk for
schizophrenia and psychosis. Negative experiences, such as child abuse and neglect, have been specifically
associated with risk for schizophrenia and psychosis. This review provides a brief overview of child abuse and
neglect, including its position within the larger field of trauma and adversity and its long term consequences. The
link to schizophrenia is then explored. Principles of treatment and outcomes for schizophrenia with antecedent
child abuse and neglect are then reviewed. Finally, next steps and points of prevention are highlighted.
That childhood experiences of abuse and neglect can impact health is
widely accepted. The scope of these impacts, both direct and indirect,
immediate and long-term, continues to be clarified through interdisci­
plinary assessment.
1. Child maltreatment
1.1. Scale of the issue
Child maltreatment including all forms of physical, sexual, and
emotional abuse as well as neglect is a persistent and significant risk to
the health and well-being of children. Child welfare numbers indicate
that more than 3 million children had an investigation or response
related to concerns for maltreatment in each recent year in the U.S. (US
DHHA AFC, 2021). Of these reports, more than 600,000 children were
substantiated as victims of maltreatment with a population-wide
maltreatment fatality rate of 2.5 per 100,000 in 2019 (US DHHA AFC,
2021). Child welfare involvement, including removal from a care
environment, does not immediately abate impacts on health and wellbeing as children in foster care in the U.S. experience much higher
risk of all-cause mortality than children in the general population
(Chaiyachati et al., 2020).
Risks of childhood maltreatment are not isolated to the U.S. Litera­
ture converges on the global struggle for uniformly safe experiences in
childhood. Data from the World Health Organization world mental
health survey document a global population report rate by adults of
8.0% for physical abuse, 1.6% for sexual abuse, and 4.4% for neglect
(Kessler et al., 2010). Yet, precise estimates of global burden of
maltreatment may be limited given cultural influences on specific def­
initions of maltreatment and wide variance in reporting mandates across
international jurisdictions (Daro, 2008). For example, when separated
by continent, international estimates based on self-report place median
prevalence of sexual abuse among girls between 9.0% in Asia and 28.8%
in Australia while self-reported experiences of neglect range in median
prevalence from 14.8% in Europe to 56.7% in South America for boys
and 13.9% in Europe to 54.8% in South America for girls (Moody et al.,
2018).
1.2. Exposure definitions
Beyond the cultural and jurisdictional variations that impact the
counting of child maltreatment, clinical and research definitions of child
maltreatment vary widely and are sometimes used interchangeably with
umbrella terms such as trauma or adversity. While examples of trauma
and adversity have definite overlap, they also hold unique positions in
clinical and research realms – and in relation to child abuse and neglect.
Trauma results “from an event, series of events, or set of circum­
stances that is experienced by an individual as physically or emotionally
* Corresponding author at: The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America.
E-mail address: chaiyachab@chop.edu (B.H. Chaiyachati).
https://doi.org/10.1016/j.pbb.2021.173195
Received 9 March 2021; Received in revised form 20 April 2021; Accepted 29 April 2021
Available online 5 May 2021
0091-3057/© 2021 Published by Elsevier Inc.
B.H. Chaiyachati and R.E. Gur
Pharmacology, Biochemistry and Behavior 206 (2021) 173195
harmful or life threatening and that has lasting adverse effects on the
individual's functioning and mental, physical, social, emotional, or
spiritual well-being” (SAMHSA, 2014). The modern conception of
trauma in behavioral health began when Post-Traumatic Stress Disorder
(PTSD) was formally entered the Diagnostic and Statistical Manual of
Mental Disorders, 3rd edition, in 1980 (Kawa and Giordano, 2012). The
official diagnostic advent of PTSD recognized the indirect or persistent
impacts of trauma as had been described after experiences of severe
trauma, mostly war, throughout historical texts and previous diagnostic
manuals (Benedek and Ursano, 2009). In subsequent years, the defini­
tion of the requisite inciting trauma evolved rapidly in both research and
clinical venues with movement toward broader definition, encompass­
ing more remote experiences, such as child maltreatment, as sufficient
for PTSD trigger (Andreasen, 2010).
The concept of adversity became routine within the medical lexicon
after the landmark study of adverse childhood experiences (ACEs) in
1998 (Felitti et al., 1998). Adversities tabulated by Felitti included
psychologic, physical and sexual abuse, household dysfunction through
mental illness, substance use, intimate partner violence, and incarcera­
tion. Their key finding, a dose-response association between ACE count
and poor adult health outcomes, underscored an association between
adverse exposures and physical health relevant to public health inquiries
and interventions. Subsequent decades of work have continued to put
into relief the significant, multifaceted, and varied impacts of adversity
on long-term well-being and physical health (Hughes et al., 2017).
Consistent with the initial survey, many studies of adversity include
direct recount of experiences of child abuse and neglect though varia­
tions have also arisen, including methods to assess ACEs in children and
adolescents that do not include direct measures of maltreatment (Bethell
et al., 2017).
Overall, child abuse and neglect are adverse experiences and are
predominantly viewed as trauma across clinical and research realms.
However, there are traumatic and adverse experiences that do not, in
isolation, comprise child abuse and neglect. Thus, care should be taken
when describing the impacts of child abuse and neglect based upon
broader trauma and adversity literature to clarify composite versus
specific associations. For example, one widely used questionnaire to
assess childhood experiences of abuse and neglect, the Childhood
Trauma Questionnaire (CTQ), is exclusively comprised of domains of
abuse and neglect while other broadly used, similarly named question­
naires such as the Trauma History Questionnaire, include questions
across domains of trauma including crime and natural disasters (Bern­
stein et al., 1998; Hooper et al., 2011). Yet, as above, the themes hold
true across many measures of adversity, trauma, and maltreatment –
when we fail to keep children safe and support their well-being, they are
at risk for both immediate and long-term harm.
missed medical care, inadequate or inconsistent well care may result in
missed opportunities for early detection and prevention of disease, such
as within the premorbid or prodromal phases of psychosis (Seidman and
Nordentoft, 2015). Third, by meta-analysis and systematic review, a
causal relationship has been suggested between experiences of child
maltreatment and some behavior changes that may impact physical
health such as high risk sexual behaviors (Norman et al., 2012). Finally,
as measured within ACE questionnaires, child abuse and neglect have
been shown to be associated with a broad range of long-term poor
physical health associations (Felitti et al., 1998; Hughes et al., 2017;
Zarse et al., 2019). Moreover, chronic ACEs associate with cumulative
derailment of health trajectory, consistent with dose-response effect
(Thompson et al., 2015).
1.3.2. Non-psychotic psychopathology
There are widely cited connections between experiences of child­
hood abuse and neglect and psychopathology (Norman et al., 2012;
Gardner et al., 2019; Carr et al., 2020; Humphreys et al., 2020). With
regard to affective disorders, single study estimates support that a his­
tory of reported abuse or neglect may increase risk of depression by
three- to four-fold and meta-analysis affirms connection between
childhood maltreatment as measured by CTQ and depression diagnosis
(Brown et al., 1999; Humphreys et al., 2020). Child maltreatment is also
associated with severe course of depression including treatment resis­
tance (Nelson et al., 2017). Similarly, several forms of child maltreat­
ment have been found to be associated with anxiety by meta-analysis
(Gardner et al., 2019). Finally, as penultimate marker of emotional
health, experiences of physical or sexual abuse are significantly associ­
ated with increased risk of suicidality in adolescents and adults (Evans
et al., 2005; Angelakis et al., 2019).
1.3.3. Environmental risks
Any individual or family outcome happens within an environmental
milieu of risk and protection. Many studies have attempted to assess
predictors to child abuse and neglect in efforts to target prevention.
Family risk factors that have been shown to be associated with abuse and
neglect include poverty and dysfunctional parent-child attachment
(Stith et al., 2009; Pelton, 2015). These environmental disruptions have
also been found to be associated with schizophrenia (Cannon et al.,
2002; Faust and Stewart, 2008; Hakulinen et al., 2019).
Individual experiences of abuse and neglect have also been associ­
ated with multiple behavioral and social risks, some of which have been
separately associated with psychosis. Literature has repeatedly demon­
strated an association between child abuse and neglect with a range of
risk behavior uptake including substance use, even suggesting causality
by meta-analysis and systematic review (Norman et al., 2012; Carliner
et al., 2016). History of childhood abuse has also been expressly asso­
ciated with younger age of onset of alcohol use disorder (Schuckher
et al., 2018). Among adolescents with child welfare involvement, history
of physical abuse and out-of-home placement has been found to be
associated with polysubstance use (Snyder and Smith, 2015).
1.3. General outcomes associated with child maltreatment
While the focus of this review is upon the associations between
psychosis and experiences of child maltreatment, this must be placed in
context of other known, concurrently conveyed risks from experiences of
child abuse and neglect including physical health and non-psychotic
impacts within behavioral health.
2. Psychosis spectrum after child abuse and neglect
2.1. Schizophrenia after child abuse and neglect
1.3.1. Physical health
The connections between experiences of abuse and neglect and
physical health are multifaceted. There are at least four general areas of
connection to consider. First, physical health impacts from child abuse
and neglect can include immediate and direct injuries. For example,
approximately one-quarter of bone fractures in the first year of life are
related to child abuse (Flaherty et al., 2014). Second, physical health
may additionally be compromised by insufficient access to routine
medical care or well-child care. Evaluation of physical health of children
at entrance to child welfare system demonstrates high rates of unmet
health needs (Szilagyi et al., 2015). Compounding the direct risks of
Studies have long supported associations between adverse childhood
experiences and schizophrenia. A systematic review completed in 2012
synthesized the association between schizophrenia and childhood ex­
periences of abuse and adversities and posited that sum risk associated
with adversity accounted for 33% overall population likelihood for
schizophrenia (Varese et al., 2012). That analysis documented signifi­
cantly increased odds of schizophrenia for each category of child
maltreatment assessed: sexual abuse OR 2.38 (1.98–2.87), physical
abuse OR 2.95 (2.25–3.88), emotional abuse OR 3.40 (2.06–5.62). A
subsequent review assessing self-report of childhood experiences among
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Pharmacology, Biochemistry and Behavior 206 (2021) 173195
those with schizophrenia demonstrated 26% with childhood sexual
abuse, 39% with childhood physical abuse, and 34% with childhood
emotional abuse (Bonoldi et al., 2013). Further work has shown that
interviewer and self-report of child abuse have high rate of agreement,
an important point of confirmation in triangulating the assessment of
objectively conferred risk versus experience as coded within individual
schema (Negriff et al., 2017).
Antecedent trauma may impact the presentation of schizophrenia in
multiple ways. Generally, across populations, history of child abuse may
impact overall health, well-being, and co-morbid diagnoses (see Section
1.3). Inconsistent caregiver relationships related to disrupted family
dynamics or placement instability of foster care may lend particular risk
to delayed recognition of premorbid phenotypes and early behavior
changes. Moreover, disrupted family relationships may lead to only
partial or completely unknown family history, which may otherwise
support clinical diagnosis.
In addition to the association of childhood maltreatment with risk for
and diagnosis of schizophrenia, it has also been shown that history of
child maltreatment may be associated with overall worse outcomes after
diagnosis (Thomas et al., 2019). Studies have documented increased
likelihood of early establishment of treatment-resistant schizophrenia
(TRS) as well as worsened trajectory during chronic disease (Davidson
et al., 2009; Misiak and Frydecka, 2016). Age at exposure to trauma has
also been shown to differentiate course of symptoms after diagnosis of
schizophrenia, with earlier trauma associated with more negative out­
comes (Alameda et al., 2016).
the “exposome”, in mental health, including psychosis, is paramount.
Fig. 1 provides a schematic presentation of the pathway to psychosis.
The specific role of childhood adversity as an “Environmental Hit” is
central in our efforts at early identification of factors that increase risk
for psychosis as well as for early intervention in disease course.
3.1. Embedding of trauma
Overall, the broad impacts of child abuse and neglect on psychotic
and non-psychotic behavioral health outcomes imply the presence of
transdiagnostic risk mechanisms connecting experiences of abuse and
neglect with behavioral health disruptions. One such proposed
connection is the development of altered threat processing as a trans­
diagnostic vulnerability after experiences of child abuse and neglect
(McLaughlin and Lambert, 2017).
Studies of neurocognition and neuroimaging specifically connecting
schizophrenia and clinical risk for psychosis with adversity, trauma, and
child abuse have expanded over the past decade. The general approach
has been to compare individuals with a history of childhood adversity to
those without such a history, as well as to healthy controls. With regard
to neurocognition, while sample sizes vary, overall results suggest that
individuals with schizophrenia and risk for psychosis with a history of
childhood adversity, including child abuse, show more cognitive
impairment than healthy comparators as well as affected individuals
without reported childhood adversity (Wells et al., 2020). Interestingly,
impacts on social cognition domain, including emotion processing, have
been shown to be more strongly associated with experiences of
maltreatment than with schizophrenia diagnoses (Kilian et al., 2018;
Tognin et al., 2020).
Reported burden of childhood adversity has been found to be asso­
ciated with brain structure and function, including measures of psy­
chosis symptoms (Gur et al., 2019). Brain regions related to social
cognition have been specifically examined, suggesting that reduced
anterior cingulate cortex volume is associated with poorer performance
in a social cognition measure across the sample of healthy participants
and individuals with schizophrenia (Rokita et al., 2020).
Underpinning differences in neurocognition and neuroimaging and
changes in basic biologic functions have also been seen connecting
schizophrenia with abuse and neglect. For example, child abuse and
neglect is a moderating factor in the pattern of cortisol reactivity in those
with schizophrenia (Quide et al., 2020). Additional hypotheses such as
altered expression of brain-derived neurotrophic factor (BDNF) have
arisen from animal models (Popovic et al., 2019). While the overall
trends are promising, results connecting disease measures and brainbehavior parameters with childhood adversity are heterogeneous and
additional work is needed to clarify the emerging findings.
2.2. Schizophrenia comorbidities
Schizophrenia has a shared clinical presentation and broad range of
comorbidity with other diagnoses. For example, estimates of comor­
bidity for schizophrenia and PTSD range from 0 to 57% (Seow et al.,
2016). The known comorbid trends, overlapping history, predisposing
factors, and clinical features complicate disentangling separate di­
agnoses. The clinical intersection has been particularly elucidated in
persons returning from war (OConghaile and DeLisi, 2015). Such com­
mon comorbidities contribute to the complexities of elucidating the
specificity of findings to schizophrenia.
The growing focus on a dimensional approach to psychopathology
further supports the commonalities of psychotic symptoms across
diagnostic categories. Of relevance, experiences of trauma, including
child abuse and neglect, have been shown to be predictive of the broader
category of psychotic experiences, beyond schizophrenia. For example,
international work has demonstrated associations between trauma ex­
posures, including child abuse and neglect, and psychotic experiences
(McGrath et al., 2017a; McGrath et al., 2017b).
Relatedly, the psychosis spectrum includes a range of subthreshold
experiences and symptoms that may, or may not, be prodromal to
schizophrenia. Early identification of subthreshold symptoms including
clinical high or ultra-high risk may facilitate early intervention and
abatement of symptom progression. A meta-analysis highlighted that
individuals at clinical high risk for schizophrenia reported significantly
more episodes of all types of abuse and neglect than controls (Peh et al.,
2019). Notably, within the populations of clinical high risk patients,
childhood abuse and neglect was not significantly associated with
transition to psychosis within the captured follow-up periods (6 months
to 15 years).
3.2. Genetic predisposition
Genetically conveyed predispositions to schizophrenia may also
impact the associations between childhood experiences and schizo­
phrenia in many ways.
Multiple studies support gene by environment relevance at the
intersection of child abuse and predisposition to schizophrenia. The
polygenic risk score for schizophrenia (PRS-S), based on the Psychiatric
Genetics Consortium schizophrenia meta-analysis, in the study of
childhood adversity in schizophrenia supported specific impact of sexual
abuse, emotional abuse, and emotional neglect, but not physical abuse
or physical neglect, on additive risk for schizophrenia in those with
genetic susceptibility (Guloksuz et al., 2019). Additional work has
demonstrated that, at the population level, recent stressful life events as
well as previous traumas and genetic risk for schizophrenia by PRS were
associated with poor mental health – demonstrating the pleitotropic
impacts of both trauma and genetic risk to poor mental health (Pries
et al., 2020b).
Gene by environment interaction assessment does not, however,
3. Mechanisms
Multiple complex and interacting factors contribute to the presen­
tation of schizophrenia in late adolescence and early adulthood. Prog­
ress in genomics and other omics, quantitation of environmental
measures across early development, and methods for the study of brain behavior offer critical tools for dissecting the complexities. Under­
standing the importance and interrelatedness of the total exposures, or
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Pharmacology, Biochemistry and Behavior 206 (2021) 173195
Fig. 1. Schematic presentation of the pathway to psychosis. CHR: clinical high risk.
fully clarify role of gene-environment correlation. For example, deri­
vation of polygenic scores may not have been powered to separate ex­
periences of trauma that were associated with passive genetic correlates
(Jaffee and Price, 2008). Importantly, several studies have continued to
support direct, causal association of trauma with psychosis, above and
beyond genetic predisposition or gene-environment correlation. For
example, a general population twin cohort of 593 adolescents and young
adults supported association of experiences of child abuse and neglect
with increased negative affect, decreased positive affect, and increased
subtle psychosis expression, without concordant association for PRS-S
(Pries et al., 2020a). This study concluded that childhood adversities
in individuals with high PRS-S may be pleiotropically associated with
emotion dysregulation and risk for psychosis. A study of two interna­
tional cohorts that accounted for both parental and child PRS similarly
concluded that trauma, including child abuse and neglect, association
with psychosis was likely multifactorial with a direct causal role of
trauma in addition to gene-environment correlation (Sallis et al., 2020).
comorbidity with PTSD, intrusive thoughts, and hallucinations. Second,
concurrent depression may be a mediating factor in associations be­
tween exposures to child abuse and neglect and worse functioning over
time after diagnosis with schizophrenia (Alameda et al., 2017).
Evidence-based treatment of comorbid depression should be attended to
in this particular risk population.
4.2. Treatment resistant schizophrenia
Treatment-resistant schizophrenia may be more common among
those with history of child maltreatment (see Section 2.1). Overall
optimized outcomes for TRS include active and recurrent awareness to
risks of TRS and differentiation from pseudo-resistance (Potkin et al.,
2020). Modifiable risk factors predictive of TRS include delay in treat­
ment at initial psychosis, nonadherence to antipsychotics, inadequately
addressed comorbidities such as substance-use disorders, and lack of
early antipsychotic response (Carbon and Correll, 2014). Connections
between pharmaco-resistant psychosis and history of maltreatment are
poorly understood and represent a critical area of future research.
However, a first step in consideration of targeted therapy in
schizophrenia informed by history of trauma is the identification of
trauma. Literature suggests that there is inconsistent inquiry regarding
child abuse and neglect in clinical care (Read et al., 2018). At present,
integration of trauma-informed practices continues to be standard of
care and should be adhered to within treatment for patients with
schizophrenia with or without specific disclosure of history of abuse.
Moreover, as clinicians consider active solicitation of history of abuse
and neglect, they should be aware of jurisdictional policies regarding
mandatory reporting. For example, several states in the U.S. include
disclosures of child abuse regardless of age at disclosure (e.g., by adult
patients) within mandatory reporting statutes (Child Welfare Gateway,
2019). Practically, this may require additional informed consent and
disclosures at outset of therapeutic relationship to ensure foundational
trust.
3.3. Substance use
As outlined above (see Section 1.3.3), experiences of child abuse and
neglect are associated with increased risk of substance use, as well as
earlier age of substance use disorder (Carliner et al., 2016; Schuckher
et al., 2018). Relatedly, significant bodies of work support the high rate
of comorbid substance use and psychosis and include bidirectional
connections between substance use and diagnosis (Degenhardt et al.,
2018). In particular, cannabis use has been associated with increased
risk of schizophrenia as well as earlier age of onset and worse clinical
course (Hasan et al., 2020). Further elucidation of relationships among
these three forces, child abuse and neglect, substance use, and schizo­
phrenia, is warranted.
4. Treatment
4.1. Comorbidities
5. Prevention
In situations of trauma history and schizophrenia or psychosis,
actionable targets worth specific treatment consideration have been
identified. First, transdiagnostic mechanisms of trauma with clinical
overlap of PTSD psychosis and schizophrenia warrant consideration of
role for evidence-based PTSD treatment in settings of schizophrenia with
history of trauma. Integrated treatment of PTSD in psychosis has been
documented as safe and efficacious by randomized control trial (van den
Berg et al., 2015; van den Berg et al., 2016). Thus, recommendations
stand to consider history of trauma with attention to potential
5.1. Prevention of childhood trauma
While it continues to be important to quantify and understand the
physical and behavioral health impacts of child abuse and neglect,
adequate literature has created foundational justification to support
prevention efforts. For example, epidemiologic studies of ACE associa­
tions with physical health have demonstrated lower impact of isolated
early ACEs versus chronic ACEs, emphasizing the potential for
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Pharmacology, Biochemistry and Behavior 206 (2021) 173195
meaningful intervention to abate the risk trajectory (Thompson et al.,
2015).
The multi-layer ecologic context in which child abuse and neglect
originates supports multiple potential levels of prevention (Belsky,
1980; Sidebotham, 2001). Unfortunately, there are no uniformly rec­
ommended prevention interventions identified within healthcare per
the U.S. Preventive Services Task Force (Moyer, 2013). Reassuringly,
evidence supports that some forms of childhood adversity – namely
physical and sexual abuse - are decreasing in the U.S. (Finkelhor, 2020).
Incidence of neglect, however, may require larger, societal interventions
to impact population rates (Feely et al., 2020). Moreover, it is important
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EUGEI study." World Psychiatry 18(2): 173–182.
Gur, R.E., Moore, T.M., Rosen, A.F.G., Barzilay, R., Roalf, D.R., Calkins, M.E.,
Ruparel, K., Scott, J.C., Almasy, L., Satterthwaite, T.D., Shinohara, R.T., Gur, R.C.,
2019. Burden of environmental adversity associated with psychopathology,
maturation, and brain behavior parameters in youths. JAMA Psychiatry 76 (9),
966–975.
Hakulinen, C., McGrath, J.J., Timmerman, A., Skipper, N., Mortensen, P.B., Pedersen, C.
B., Agerbo, E., 2019. The association between early-onset schizophrenia with
employment, income, education, and cohabitation status: nationwide study with 35
years of follow-up. Soc. Psychiatry Psychiatr. Epidemiol. 54 (11), 1343–1351.
5.2. Early recognition of and intervention in substance use
As outlined above (Sections 1.3.3 and 3.3), substance use has been
established as increased subsequent to child abuse and also with po­
tential causative role in subsequent development with schizophrenia.
Thus, focused attention to clinical interventions to abate substance use
as sequalae to trauma and antecedent to schizophrenia are warranted.
Early screening and intervention for substance use should be
considered starting in childhood. The American Academy of Pediatrics
has affirmed recommendations to screen for substance use including
alcohol from adolescence (Levy et al., 2016). Data supports utility of
some tools for substance use initiation screening as early as age 9
(Ridenour et al., 2015). Meta-analysis also provides evidence for treat­
ment in adolescence though additional work is needed (Steele et al.,
2020).
6. Conclusion
Childhood experiences impact long-term physical and behavioral
health outcomes including conveying risk for schizophrenia and psy­
chosis. Multiple mechanisms may connect child abuse and neglect with
schizophrenia including both direct and indirect forces. After diagnosis,
schizophrenia with antecedent trauma may have more severe clinical
course and, when trauma is reported, providers should heed risk of
treatment resistance. Additionally, childhood trauma may convey
transdiagnostic risks that compounds clinical care by multiple comor­
bidities. Early prevention of child abuse and neglect holds promise
though will require systems coordination. Finally, regardless of presence
or absence of child abuse and neglect disclosure, we should strive as
clinicians and researchers to conduct ourselves in trauma-informed
ways.
Funding
T32 MH019112 (BHC)
R01-MH119219 (REG).
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