Dr. Martin H. Teicher

Useful links

Ecophenotype article –

Teicher MH, Samson JA. Childhood maltreatment and psychopathology: A case for ecophenotypic variants as clinically and neurobiologically distinct subtypes.  American Journal of Psychiatry 2013, 170 (10): 1114-1133.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3928064/

Maltreatment and Abuse Chronology of Exposure Scale

Teicher MH, Parigger A. The ‘Maltreatment and Abuse Chronology of Exposure’ (MACE) Scale for the retrospective assessment of abuse and neglect during development. PLoS ONE 2015, 10(2): e0117423

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0117423

Teicher MH, Gordon JB, Nemeroff CB. Recognizing the importance of childhood maltreatment as a critical factor in psychiatric diagnoses, treatment, research, prevention, and education. Mol Psychiatry. 2022; 27: 1331-1338 https://pubmed.ncbi.nlm.nih.gov/34737457/

S2 Recommendations for Researchers: Incorporating Maltreatment into Data Analyses.

Strategies for analyzing or incorporating data on maltreatment range from simple to quite complex. We have laid out a number of strategies and cite publications that can serve as examples.

1. Two group dichotomization. Perhaps the simplest strategy is to use a cutoff criterion to divide participants into an unexposed group (or a no-to-low exposure group) versus a maltreated (or a moderate-to-high exposure group). One good example of this was a study by Nemeroff et al¹ in which they reanalyzed data from a large, multicenter study on treatment responses in chronic depression by dividing participants in those with and without histories of early childhood trauma or loss. They found that psychotherapy alone was superior to antidepressant monotherapy in individuals with childhood trauma but not in those without. Similarly, Teicher et al² reported marked differences in brain connectivity of the anterior cingulate, anterior insula and precuneus in maltreated versus non-maltreated participants.

•  Three group comparison. A similar strategy involves comparing maltreated and non-maltreated individuals with the same primary diagnosis to each other and to a control group without maltreatment or psychopathology. A good example of this is Vythilingam et al³ who compared hippocampal volumes in women with major depression (MDD), with and without maltreatment, to healthy controls. Relative to controls, hippocampal volume was reduced in maltreated individuals with MDD but not in non-maltreated individuals with MDD. A variation on this theme is the comparison of maltreated individuals with psychopathology (susceptible / symptomatic) to comparably maltreated individuals without psychopathology (resilient / asymptomatic) versus unexposed controls. Ohashi et al⁴ found that symptomatic and asymptomatic maltreated groups had the same array of abnormalities in global brain network architecture relative to controls but the asymptomatic group had alteration in the connectivity of 9 specific brain regions that distinguished them from both the control and symptomatic groups.

• Four group comparison. Some studies use a 2 x 2 factorial design that includes participants with and without a specific diagnosis and with and without a history of maltreatment. Heim et al⁵ used this strategy to compare the effects of childhood abuse versus MDD on pituitary- adrenal and autonomic response to stress and found that maltreatment significantly augmented response, particularly in women with concomitant MDD. Another example is a study by Danese et al⁶ who found that the association between MDD and categorical measure of inflammation was no longer significant once maltreatment was taken into account and that maltreatment was the driving factor.

• Larger factorial comparisons. The factorial approach can also be expanded to include maltreated and non-maltreated individuals with multiple psychiatric disorders. Poletti et al⁷ compared individuals with high versus low exposure to maltreatment with diagnoses of schizophrenia, bipolar disorder or no psychopathology. Morphometric differences in orbitofrontal cortex, insula, and thalamus were only apparent in bipolar and schizophrenic participants with high maltreatment scores.

• The ACEs Approach – Maltreatment score as a multilevel categorical variable. A vast array of publications have arisen from the ACEs study which have focused on assessing the relationship between multiplicity of exposure to maltreatment and outcome. In these studies participants were categorized into separate groups by their ACE score (typically 0, 1, 2, 3, 4 and 5 or more ACEs). In most cases the outcome was also categorical and the authors utilized logistic⁸ or binomial⁹ regression to delineate the graded increase in odds ratios of the outcome with higher levels of ACEs. The strategy of using multiple categories to create an “ordinal” variable is standard in epidemiological studies where there can be a large number of participants in each category. 

• Linear regression / ANCOVA – Maltreatment as a continuous variable. While dichotomizing participants into maltreated and non-maltreated groups can lead to convenient interpretations there are substantial costs associated with this procedure, including a loss of statistical power¹⁰. In general, it is preferable to use severity scores as a continuous variable in a regression analysis. A good example of this is Edmiston et al¹¹ who used CTQ scores in adolescents without histories of psychopathology to explore the relationship between overall severity of maltreatment (and severity of exposure to specific types of maltreatment), and measures of cortico-limbic gray matter volume. In this paper each type of exposure was considered independently in a separate analysis using voxel-based morphometry to identify clusters of voxels with significant associations. Similarly, Teicher et al¹² used overall ACE scores and CTQ scores to delineate the association between severity of exposure to maltreatment and hippocampal subfield volumes.

• Linear regression / ANCOVA – Maltreatment as a confounding covariate. We are urging researchers with no intrinsic interest in childhood maltreatment to collect this information as a potential confounding factor. The primary focus of these researchers may be in differences between healthy controls and participants with specific psychiatric disorders, such as MDD, in brain measures or levels of candidate biomarkers. A simple strategy would be to include measures of maltreatment as a covariate and to ascertain the influence of this covariate on the association between diagnostic group and the dependent variable of interest. For these analyses it is much better to use maltreatment as a continuous variable than to dichotomize it, as dichotomizing it will run the risk that a substantial part of the confounding will remain¹³. An example of this approach was a study by Malykhin et al¹⁴ who reported that severity of childhood maltreatment was a significant predictor of anterior cingulate volume while the diagnosis of MDD was not. In contrast, they found that MDD, but not maltreatment, was a significant predictor of amygdala volume.

• Linear regression / ANCOVA – Maltreatment as a moderator – gene x environment interactions. Researchers with no intrinsic interest in childhood abuse or neglect may also benefit from considering maltreatment as a moderator that influences the strength of the relationship between their independent and dependent variables of interest. A moderator effect emerges as a significant interaction term in an ANCOVA analysis. A good example of this approach is a study by Banihashemi et al¹⁵ who reported that childhood maltreatment moderated the effect of combat exposure on cingulum structural integrity. This approach was also used in the pioneering studies by Caspi and colleagues^{16, 17} who demonstrated an interaction between genetic polymorphisms and history of childhood maltreatment (i.e., no, probable, severe) and clinical symptoms, though in these cases the polymorphism is the mediator and maltreatment the independent variable. A caveat in using this approach is that power to detect moderation is low, especially if both the independent variable and the moderator are continuous variables¹⁸.

1. Mediation. As childhood maltreatment is the most important preventable risk factor for a host of psychiatric disorders there is a pressing need to understand how exposure to maltreatment becomes embedded into our biology, and our psychological processes, to enhance risk. Correspondingly, a number of studies have sought to identify factors that mediate these associations. A good example of this approach was a study by Weissman et al¹⁹ who reported that reduced hippocampal and amygdala volumes mediated the association between history of childhood maltreatment, stressful life events and symptoms of depression. On a simpler level, Teicher et al²⁰ reported that impaired sleep mediated almost 50% of the association between maltreatment and reduced hippocampal volume. Another good example of mediation is the study by Kim et al²¹ who delineated how various types of impulsivity may mediate the association between childhood maltreatment and alcohol dependence.

• Multiple regression / ANCOVA – Comparative influence of different types of maltreatment. Childhood maltreatment is multifaceted and there is often considerable interest in identifying whether a dependent variable, such as a symptom score or neurobiological measure, is associated with exposure to a specific type of maltreatment. Theoretically, a multiple regression analysis can include severity scores for multiple type of maltreatment as independent variables. This approach assumes that there is an additive relationship between exposure to different types of adversity, which is a reasonable assumption as the Adverse Childhood Experience Study has shown a graded ‘dose-related’ effect between exposure to multiple forms of early adversity and outcome measures. A problem arises however, as these measures are not independent predictors but are correlated, which can lead to problems with collinearity. A strategy Teicher et al²² adopted in this instance was to gauge the relative importance of these various types of exposure in a multiple regression analysis. Assessment of relative importance in linear models is simple in the special case where all regressors are uncorrelated. Each regressor’s contribution then is their univariate r², and all univariate r²-values add up to the full r². This does not apply with exposure to different types of maltreatment as they are intercorrelated so that it is no longer straightforward to break down model r² into shares from the individual regressors²³. Hence, we used a technique for variance decomposition developed by Lindeman, Merenda, and Gold²⁴ and recommended by Johnson and Lebreton²⁵ and Gro¨mping²³ to gauge their relative importance. Briefly this technique decomposes r² by calculating the sequential contribution of each regressor (in which the contribution of a regressor depends on the regressors that come before) by averaging over all possible sequential orderings (R package relaimpo). Because there are limits to the degree of collinearity that this approach can effectively manage, we recommend assessing the degree of cross-correlation and calculating the variance inflation factor (VIF) for each predictor variable. Typically, VIFs exceeding 4 warrant further investigation, while VIFs exceeding 10 are signs of serious multicollinearity. Hence, we recommend using this approach only if VIFs are below 4. Alternative statistical approach for analyzing collinear predictors is regularized or penalized regression using elastic net or lasso techniques²⁶ as Teicher and colleagues^{22, 27, 28}, have used in some maltreatment studies as well as least angle regression as used in a series of maltreatment studies by Dunn and colleagues^29-32.

• Path analyses and structural equation models (SEMs). A wide range of maltreatment-related studies examine the interrelationships between an array of independent (endogenous) and dependent (exogenous) variables that can include mediation, moderation, mediated moderation and longitudinal relationships. SEMs are particularly valuable when a researcher is interested in testing a specific theoretical model or in comparing alternative theoretical models. Path models are a simpler subset of models that only include observed variables. Teicher and colleagues have used path models to test and reject the hypothesis that history or symptoms of depression or post-traumatic stress disorder mediated the association between maltreatment and hippocampal volume¹². Structural equation models stand apart by including latent constructs that are not directly measured but are reflected by an array of observable variables and are comparable to factors in a factor analysis. Interesting studies that have employed this approach have shown, for example that: (i) deficits in emotional regulation mediate the relationship between childhood abuse and later eating disorder symptoms³³; (ii) that callous / unemotional traits and conscientiousness mediate and moderate the relationship between maltreatment and risky behaviors³⁴; (iii) that urgency plays an important intervening role in the association between childhood maltreatment, PTSD, and substance-related problems³⁵; (iv) that the longitudinal effects of childhood sexual abuse on co-occurring substance misuse and mental health problems in adulthood were fully mediated by adolescent alcohol abuse while childhood emotional abuse had a direct effect on these adult outcomes³⁶; and (v) that parental verbal affection did not effectively attenuate the influence of parental verbal abuse on psychiatric symptomatology in early adulthood³⁷.

• Longitudinal methodologies. SEMs provide one strategy for assessing effects of endogenous variables on longitudinal exogenous measures. Mixed effects models provide a powerful alternative. An excellent example is a study by Doom et al³⁸ who delineated, using multiple-group growth curves, that maltreated and non-maltreated children differed in their developmental pattern of cortisol regulation.

• Machine learning / artificial intelligence – approaches / delineation of sensitive periods. The Maltreatment and Abuse Chronology of Exposure (MACE) scale³⁹ was designed to retrospectively identify sensitive periods by identifying the specific type and timing of maltreatment most strongly associated with a particular outcome such as the size or functional response of a brain region or the risk for developing a psychiatric disorder such as MDD. The critical problem in identifying the most important risk factors is the very high degree of collinearity between type-time measures such as severity of exposure to a particular type of maltreatment at adjacent ages. Collinearity is a common problem in data mining that can be addressed using certain machine-learning strategies. Random forest regression (RFR) predicts outcome by creating a forest of decision trees with each tree generated from a different subset of the data and constrained in the number of ‘predictors’ it can consider at each decision point⁴⁰. This “wisdom of the crowd” strategy provides superior predictions and is highly resistant to collinearity⁴¹. The tree structure can also model interactions and does not assume a linear relationship between exposure and response. Variable importance is assessed by permuting each variable, and determining how much this degrades model fit (increase in mean square error)⁴⁰. Permuting unimportant predictors has minimal effect on mean square error whereas permuting important predictors has a much larger effect. We use a variant of Brieman’s approach with conditional inference trees⁴² that rectifies a problem in the estimation of importance of predictors with many versus few levels or categories⁴², and selected this algorithm following Monte-Carlo comparisons across a large number of simulations of varying complexity evaluating all AI algorithms in the R caret package that could handle both categorical and continuous outcomes. Importance in RFR-CIT is not determined by prevalence of exposure. Teicher and colleagues^43-49 have published several studies using this approach that provide additional details. Researchers interested in using this approach with the MACE can request specific R software from MHT.

A final request. Searching the childhood maltreatment literature is challenging as some authors use the terms ‘abuse’ or ‘neglect’, or specifically ‘sexual abuse’ or ‘physical abuse’. More recently, the terms ‘threat’ and ‘deprivation’ are being promulgated. Other authors prefer ‘early life stress’,  ‘childhood adversity’, ‘childhood trauma’ ‘complex trauma’ and ‘toxic stress’. We would like to request that you include ‘maltreatment’, as an umbrella term, in either the title or the abstract to make it easier for us to find each other’s work.

References

1.         Nemeroff CB, Heim CM, Thase ME, Klein DN, Rush AJ, Schatzberg AF et al. Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma. Proc Natl Acad Sci U S A 2003; 100(24): 14293-14296.

2.         Teicher MH, Anderson CM, Ohashi K, Polcari A. Childhood Maltreatment: Altered Network Centrality of Cingulate, Precuneus, Temporal Pole and Insula. Biol Psychiatry 2013.

3.         Vythilingam M, Heim C, Newport J, Miller AH, Anderson E, Bronen R et al. Childhood trauma associated with smaller hippocampal volume in women with major depression. Am J Psychiatry 2002; 159(12): 2072-2080.

4.         Ohashi K, Anderson CM, Bolger EA, Khan A, McGreenery CE, Teicher MH. Susceptibility or Resilience to Maltreatment Can Be Explained by Specific Differences in Brain Network Architecture. Biol Psychiatry 2019; 85(8): 690-702.

5.         Heim C, Newport DJ, Heit S, Graham YP, Wilcox M, Bonsall R et al. Pituitary-adrenal and autonomic responses to stress in women after sexual and physical abuse in childhood. JAMA 2000; 284(5): 592-597.

6.         Danese A, Moffitt TE, Pariante CM, Ambler A, Poulton R, Caspi A. Elevated inflammation levels in depressed adults with a history of childhood maltreatment. Arch Gen Psychiatry 2008; 65(4): 409-415.

7.         Poletti S, Vai B, Smeraldi E, Cavallaro R, Colombo C, Benedetti F. Adverse childhood experiences influence the detrimental effect of bipolar disorder and schizophrenia on cortico-limbic grey matter volumes. J Affect Disord 2016; 189: 290-297.

8.         Dube SR, Anda RF, Felitti VJ, Chapman DP, Williamson DF, Giles WH. Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. JAMA 2001; 286(24): 3089-3096.

9.         Anda RF, Brown DW, Felitti VJ, Bremner JD, Dube SR, Giles WH. Adverse childhood experiences and prescribed psychotropic medications in adults. Am J Prev Med 2007; 32(5): 389-394.

10.       Altman DG, Royston P. The cost of dichotomising continuous variables. Bmj 2006; 332(7549): 1080.

11.       Edmiston EE, Wang F, Mazure CM, Guiney J, Sinha R, Mayes LC et al. Corticostriatal-limbic gray matter morphology in adolescents with self-reported exposure to childhood maltreatment. Arch Pediatr Adolesc Med 2011; 165(12): 1069-1077.

12.       Teicher MH, Anderson CM, Polcari A. Childhood maltreatment is associated with reduced volume in the hippocampal subfields CA3, dentate gyrus, and subiculum. Proc Natl Acad Sci U S A 2012; 109(9): E563-572.

13.       Royston P, Altman DG, Sauerbrei W. Dichotomizing continuous predictors in multiple regression: a bad idea. Stat Med 2006; 25(1): 127-141.

14.       Malykhin NV, Carter R, Hegadoren KM, Seres P, Coupland NJ. Fronto-limbic volumetric changes in major depressive disorder. J Affect Disord 2012; 136(3): 1104-1113.

15.       Banihashemi L, Wallace ML, Sheu LK, Lee MC, Gianaros PJ, Mackenzie RP et al. Childhood maltreatment moderates the effect of combat exposure on cingulum structural integrity. Dev Psychopathol 2017; 29(5): 1735-1747.

16.       Caspi A, Sugden K, Moffitt TE, Taylor A, Craig IW, Harrington H et al. Influence of life stress on depression: moderation by a polymorphism in the 5-HTT gene. Science 2003; 301(5631): 386-389.

17.       Caspi A, McClay J, Moffitt TE, Mill J, Martin J, Craig IW et al. Role of genotype in the cycle of violence in maltreated children. Science 2002; 297(5582): 851-854.

18.       McClelland GH, Judd CM. Statistical difficulties of detecting interactions and moderator effects. Psychol Bull 1993; 114(2): 376-390.

19.       Weissman DG, Lambert HK, Rodman AM, Peverill M, Sheridan MA, McLaughlin KA. Reduced hippocampal and amygdala volume as a mechanism underlying stress sensitization to depression following childhood trauma. Depress Anxiety 2020; 37(9): 916-925.

20.       Teicher MH, Ohashi K, Khan A, Hernandez Garcia LC, Klengel T, Anderson CM et al. Does sleep disruption mediate the effects of childhood maltreatment on brain structure? Eur J Psychotraumatol 2017; 8(Suppl 7): 1450594.

21.       Kim ST, Hwang SS, Kim HW, Hwang EH, Cho J, Kang JI et al. Multidimensional impulsivity as a mediator of early life stress and alcohol dependence. Sci Rep 2018; 8(1): 4104.

22.       Teicher MH, Vitaliano GD. Witnessing violence toward siblings: an understudied but potent form of early adversity. PLoS One 2011; 6(12): e28852.

23.       Grömping U. Estimators of relative importance in linear regression based on variance decomposition. The American Statistician 2007; 61: 139–147.

24.       Lindeman RH, Merenda PF, Gold RZ. Introduction to Bivariate and Multivariate Analysis. Scott, Foresman: Glenview, IL, 1980.

25.       Johnson JW, Lebreton JM. History and use of relative importance indices in organizational research. Organizational Research Methods 2004; 7: 238–257.

26.       Tomaschek F, Hendrix P, Baayen RH. Strategies for addressing collinearity in multivariate linguistic data. Journal of Phonetics 2018; 71: 249-267.

27.       Schalinski I, Breinlinger S, Hirt V, Teicher MH, Odenwald M, Rockstroh B. Environmental adversities and psychotic symptoms: The impact of timing of trauma, abuse, and neglect. Schizophr Res 2019; 205: 4-9.

28.       Schalinski I, Teicher MH, Carolus AM, Rockstroh B. Defining the impact of childhood adversities on cognitive deficits in psychosis: An exploratory analysis. Schizophr Res 2018; 192: 351-356.

29.       Crawford KM, Choi K, Davis KA, Zhu Y, Soare TW, Smith A et al. Exposure to early childhood maltreatment and its effect over time on social cognition. Dev Psychopathol 2020: 1-11.

30.       Dunn EC, Crawford KM, Soare TW, Button KS, Raffeld MR, Smith A et al. Exposure to childhood adversity and deficits in emotion recognition: results from a large, population-based sample. J Child Psychol Psychiatry 2018; 59(8): 845-854.

31.       Dunn EC, Soare TW, Raffeld MR, Busso DS, Crawford KM, Davis KA et al. What life course theoretical models best explain the relationship between exposure to childhood adversity and psychopathology symptoms: recency, accumulation, or sensitive periods? Psychol Med 2018; 48(15): 2562-2572.

32.       Marini S, Davis KA, Soare TW, Zhu Y, Suderman MJ, Simpkin AJ et al. Adversity exposure during sensitive periods predicts accelerated epigenetic aging in children. Psychoneuroendocrinology 2020; 113: 104484.

33.       Burns EE, Fischer S, Jackson JL, Harding HG. Deficits in emotion regulation mediate the relationship between childhood abuse and later eating disorder symptoms. Child Abuse Negl 2012; 36(1): 32-39.

34.       Carlson M, Oshri A, Kwon J. Child maltreatment and risk behaviors: The roles of callous/unemotional traits and conscientiousness. Child Abuse Negl 2015; 50: 234-243.

35.       Mirhashem R, Allen HC, Adams ZW, van Stolk-Cooke K, Legrand A, Price M. The intervening role of urgency on the association between childhood maltreatment, PTSD, and substance-related problems. Addict Behav 2017; 69: 98-103.

36.       Skinner ML, Hong S, Herrenkohl TI, Brown EC, Lee JO, Jung H. Longitudinal Effects of Early Childhood Maltreatment on Co-Occurring Substance Misuse and Mental Health Problems in Adulthood: The Role of Adolescent Alcohol Use and Depression. J Stud Alcohol Drugs 2016; 77(3): 464-472.

37.       Polcari A, Rabi K, Bolger E, Teicher MH. Parental verbal affection and verbal aggression in childhood differentially influence psychiatric symptoms and wellbeing in young adulthood. Child Abuse Negl 2014; 38(1): 91-102.

38.       Doom JR, Cicchetti D, Rogosch FA. Longitudinal patterns of cortisol regulation differ in maltreated and nonmaltreated children. J Am Acad Child Adolesc Psychiatry 2014; 53(11): 1206-1215.

39.       Teicher MH, Parigger A. The ‘Maltreatment and Abuse Chronology of Exposure’ (MACE) scale for the retrospective assessment of abuse and neglect during development. PLoS One 2015; 10(2): e0117423.

40.       Breiman L. Random Forests. Machine Learning 2001; 45: 5-32.

41.       Liaw A, Wiener M. Classification and Regression by randomForest. R News 2002; 2/3: 18-22.

42.       Strobl C, Boulesteix AL, Zeileis A, Hothorn T. Bias in random forest variable importance measures: illustrations, sources and a solution. BMC Bioinformatics 2007; 8: 25.

43.       Zhu J, Lowen SB, Anderson CM, Ohashi K, Khan A, Teicher MH. Association of Prepubertal and Postpubertal Exposure to Childhood Maltreatment With Adult Amygdala Function. JAMA Psychiatry 2019.

44.       Teicher MH, Anderson CM, Ohashi K, Khan A, McGreenery CE, Bolger EA et al. Differential effects of childhood neglect and abuse during sensitive exposure periods on male and female hippocampus. Neuroimage 2018; 169: 443-452.

45.       Teicher MH, Ohashi K, Khan A. Additional insights into the relationship between brain network architecture and susceptibility and resilience to the psychiatric sequelae of childhood maltreatment. Adversity and Resilience Science 2020; 1(1): (In press).

46.       Khan A, McCormack HC, Bolger EA, McGreenery CE, Vitaliano G, Polcari A et al. Childhood Maltreatment, Depression, and Suicidal Ideation: Critical Importance of Parental and Peer Emotional Abuse during Developmental Sensitive Periods in Males and Females. Front Psychiatry 2015; 6: 42.

47.       Schalinski I, Teicher MH. Type and timing of childhood maltreatment and severity of shutdown dissociation in patients with schizophrenia spectrum disorder. PLoS One 2015; 10(5): e0127151.

48.       Schalinski I, Teicher MH, Nischk D, Hinderer E, Muller O, Rockstroh B. Type and timing of adverse childhood experiences differentially affect severity of PTSD, dissociative and depressive symptoms in adult inpatients. BMC Psychiatry 2016; 16: 295.

49.       Schalinski I, Teicher MH, Rockstroh B. Early neglect is a key determinant of adult hair cortisol concentration and is associated with increased vulnerability to trauma in a transdiagnostic sample. Psychoneuroendocrinology 2019; 108: 35-42.

Teicher MH, Gordon JB, Nemeroff CB. Recognizing the importance of childhood maltreatment as a critical factor in psychiatric diagnoses, treatment, research, prevention, and education. Mol Psychiatry. 2022; 27: 1331-1338 https://pubmed.ncbi.nlm.nih.gov/34737457/

S1 Recommendations for Researchers: Collecting Information on Exposure to Childhood Maltreatment

We can provide some guidance for researchers interested in assessing exposure to CM. In adults a good starting point is to use a retrospective self-report scale. This is usually sufficient for publications and grant proposals though a more rigorous approach would be to combine this with a structured trauma interview¹. Two of the most frequently used self-report scales for adults are the Adverse Childhood Experiences (ACEs) Checklist² and the Childhood Trauma Questionnaire short form (CTQ-SF)³. The ACEs Checklist consists of 10 two-part questions that access exposure, before age 18, to physical abuse, psychological abuse, sexual abuse, physical neglect, emotional neglect, and aspects of household dysfunction including a parent who’s an alcoholic or drug user, a mother who’s a victim of domestic violence, a family member going to jail, a family member with a mental illness or who attempted suicide, and parental separation or divorce. The ACEs score (0 – 10) is the number of types of exposure recollected. This instrument has been used in a large number of epidemiological studies showing the graded relationship between number of types of self-reported exposure to childhood maltreatment and risk for a host of psychiatric and medical disorders or symptoms^4-31 and it has also been used in some neuroimaging studies^32-35. Several studies were cited to illustrate the range of topics explored as well as the journal that have published studies using the ACEs checklist as a primary measure. Detailed data on the test-retest reliability of the ACEs checklist have been published by Dube et al². This instrument is readily available online (https://acestoohigh.com/got-your-ace-score/) and is free to use.

The CTQ-SF consists of 28 questions and provides indices of severity (range 5 – 25) of exposure to five types of CM: physical abuse, sexual abuse, emotional abuse, emotional neglect and physical neglect. The CTQ-SF, or the 70-item full scale CTQ, have been used primarily in clinical research studies and has been helpful in delineating possible consequences of exposure to specific types of CM^36-117. Many studies were cited to illustrate the range of topics explored as well as the journal that have published studies using the CTQ as a primary measure. The CTQ has been validated in adolescents¹¹⁸ as well as adults. Detailed information on the psychometric properties of the CTQ^{119, 120} and CTQ-SF^121-124 have been reported including translations into multiple languages. These scales are available from Pearson for a modest fee.

The Maltreatment and Abuse Exposure Scale (MAES)¹²⁵ and the Maltreatment and Abuse Chronology of Exposure (MACE) scale¹²⁵ are newer self-report inventories developed by Teicher and Parigger¹²⁵ to address deficiencies in previous scales and to provide a more comprehensive picture. For example, the CTQ does not inquire about witnessing domestic violence and the ACE checklist only inquiries about witnessing violence to mothers, but interfamilial violence can also occur to fathers and to siblings and violence to siblings may be more consequential than violence to mothers in terms of risk for psychiatric symptomatology¹²⁶. The MAES and MACE collect information on witnessing interparental violence and witnessing violence to siblings. The ACE checklist also contains items on mental illness/suicide and drug abuse in family members, which may confound genetic risk with exposure. The MACE and MAES rectify these deficiencies and also include items on exposure to peer emotional and peer physical bullying, which fit the definition of childhood maltreatment, but are not incorporated into other scales. In addition, all previous instruments were developed using Classical Test Theory. The MACE and MAES were developed using Item Response Theory which offers many advantages in terms of selection of test items. Further, the MACE and MAES consists of 10 scales with Rasch scoring properties, which means that they produce a ‘fundamental measure’ with at least interval scaling properties which cannot be claimed by scales developed through classical test theory.

The MACE and MAES consists of 52-item for assessing severity of exposure to each of 10 type of CM (i.e., parental physical abuse, parental verbal abuse, parental non-verbal emotional abuse, sexual abuse, witnessing interparental violence, witnessing violence to siblings, emotional neglect, physical neglect, peer emotional bullying and peer physical bullying) during the first 18 years. The MACE adds age scales to each item so that severity of exposure is delineated during each year of childhood. It was designed in this manner to delineate sensitive periods when exposure to a specific type of maltreatment may emerge as the most important risk factor for neurobiological alterations^{127, 128} or psychiatric disorders¹²⁹. The observation that abuse between ages 4-7 was associated with an especially poor response to antidepressants¹³⁰ and that prepubertal (particularly ages 3-6) versus post-pubertal exposure (particularly ages 13-15) to CM were associated with opposite effects on amygdala response to threat in adulthood¹²⁷ suggest that more granular information on type and timing of exposure may be necessary to fully understand the consequences of CM and to prescribe effective treatments.

The MACE has been used primarily to delineate sensitive periods or overall associations between maltreatment and aspects of brain development^{34, 127, 128, 131-134}, psychiatric symptomatology^{129, 135-142} or endocrine response¹⁴³.  Detailed psychometrics have been published for the English version¹²⁵ and for translations^144-146. These instruments have been placed into the public domain and REDcap and Qualtrics scripts are freely available from MHT for its incorporation into research studies.

Overall, contemporary instruments for retrospectively rating severity of exposure to maltreatment in adults have excellent test-retest reliability (e.g., CTQ r = .88¹⁴⁷, The Childhood Abuse and Trauma Scale r = .89¹⁴⁸, MACE r = .91¹²⁵). This high reliability also applies to individuals with significant psychopathology. Fisher et al¹⁴⁹ reported that self-report ratings of exposure were stable in individuals with psychotic disorders and did not fluctuate with either their levels of psychosis or depression.

There are also a number of structured or semi-structured interviews available for assessing maltreatment including the Traumatic Antecedents Interview¹, Interview for Traumatic Events in Childhood¹⁵⁰, Childhood Experiences of Care and Abuse Interview¹⁵¹ and the Early Trauma Inventory¹⁵². Results of interviews may correspond somewhat more closely to prospective measures¹⁵³. A comprehensive approach that we have adopted in research studies has been to use multiple self-report measures along with a detailed semi-structured interview.

Many other scales for assessing exposure have been developed. Saini et al¹⁵⁴ have recently published a review of available instruments for assessing maltreatment with a comparison of their psychometric properties.

Assessing maltreatment in children is more complex. Many studies on the potential effects of maltreatment on children have used inpatient samples in which this material was collected as part of the assessment and with the clinical service responsible for reporting children with ongoing abuse or neglect to child protective services^{155, 156}. Other studies have used child protective service records, or foster care placements, as a starting point for enrolling participants^157-160. The evaluation of cases in which child abuse and neglect are suspected clinically but denied by parents can become quite complex and best performed by individuals or teams with special expertise. Comprehensive guidelines have been published for pediatricians¹⁶¹ and family physicians¹⁶². The Stanford Medicine website provides useful information for the more general screening of infants, children and adolescents for various types of abuse or neglect https://childabuse.stanford.edu/screening/children.html.

The Juvenile Victimization Questionnaire (revised) is a comprehensive structured interview that has been used in research studies to obtain lifetime and one-year prevalence rates for exposure to maltreatment, peer and sibling victimization, sexual victimization, witnessing and other forms of indirect exposure to violence and conventional crime^163-165. The ISPCAN Child Abuse Screening Tool Children’s Version is a multi-national, multi-lingual, consensus-based survey instrument designed to detect exposure to violence, physical, psychological and sexual victimization as well as neglect in their homes during the last year¹⁶⁶. The Traumatic Events Screening Inventory (TESI)^167-169 has both parent and child versions and is available through the National Center for PTSD. TESI inquiries about potentially traumatic events including current and previous injuries, hospitalizations, domestic violence, community violence, disasters, accidents, physical, and sexual abuse and whether these events meet DSM Criterion A of PTSD. Stover and Berkowitz¹⁷⁰ review methods of assessing violence exposure in very young children.

There are also a number of self-report measures for children and adolescents. The CTQ has been validated in children age 12 or older¹¹⁸, and is a good choice to provide continuity with studies in adults. The Multidimensional Neglectful Behavior Scale is a self-report instrument for children that assesses exposure to both violence and neglect and provides a particularly in depth assessment of exposure to multiple types of neglect¹⁷¹. Additional scales for children and adolescents are reviewed by Strand et al¹⁷² and included in the recent review by Saini et al¹⁵⁴.

In short, there is a wide range of tools available for assessing abuse and neglect that can be readily employed by researchers. Although maltreatment is multifaceted it can be adequately assessed about as readily as researchers assess symptoms of depression using self-report instruments such as the Center for Epidemiologic Studies Depression Scale (CES-D)¹⁷³, or via interview such as the Structured Interview Guide for the Hamilton Depression Rating Scale¹⁷⁴. Hence, clinical researchers in the mental health area should have no difficulty adding measures of maltreatment into their research protocols. We should also emphasize that asking these questions does not distress participants who are often grateful for being asked.

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131.     Pechtel P, Lyons-Ruth K, Anderson CM, Teicher MH. Sensitive periods of amygdala development: the role of maltreatment in preadolescence. Neuroimage 2014; 97: 236-244.

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133.     Ohashi K, Anderson CM, Bolger EA, Khan A, McGreenery CE, Teicher MH. Susceptibility or Resilience to Maltreatment Can Be Explained by Specific Differences in Brain Network Architecture. Biol Psychiatry 2019; 85(8): 690-702.

134.     Teicher MH, Ohashi K, Khan A. Additional insights into the relationship between brain network architecture and susceptibility and resilience to the psychiatric sequelae of childhood maltreatment. Adversity and Resilience Science 2020; 1(1): (In press).

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137.     Schalinski I, Teicher MH. Type and timing of childhood maltreatment and severity of shutdown dissociation in patients with schizophrenia spectrum disorder. PLoS One 2015; 10(5): e0127151.

138.     Schalinski I, Teicher MH, Nischk D, Hinderer E, Muller O, Rockstroh B. Type and timing of adverse childhood experiences differentially affect severity of PTSD, dissociative and depressive symptoms in adult inpatients. BMC Psychiatry 2016; 16: 295.

139.     Teicher MH, Ohashi K, Khan A, Hernandez Garcia LC, Klengel T, Anderson CM et al. Does sleep disruption mediate the effects of childhood maltreatment on brain structure? Eur J Psychotraumatol 2017; 8(Suppl 7): 1450594.

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142.     Hecker T, Hermenau K, Salmen C, Teicher M, Elbert T. Harsh discipline relates to internalizing problems and cognitive functioning: findings from a cross-sectional study with school children in Tanzania. BMC Psychiatry 2016; 16: 118.

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144.     Isele D, Teicher MH, Ruf-Leuschner M, Elbert T, Kolassa I-T, Schury K et al. KERF – Ein Instrument zur umfassenden Ermittlung belastender Kindheitserfahrungen: Erstellung und psychometrische Beurteilung der deutschsprachigen MACE (Maltreatment and Abuse Chronology of Exposure) Scale. Zeitschrift fu¨r Klinische Psychologie und Psychotherapie 2014; 43(2): 121–130.

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S1 Recommendations for Researchers: Collecting Information on Exposure to Childhood Maltreatment

We can provide some guidance for researchers interested in assessing exposure to CM. In adults a good starting point is to use a retrospective self-report scale. This is usually sufficient for publications and grant proposals though a more rigorous approach would be to combine this with a structured trauma interview¹. Two of the most frequently used self-report scales for adults are the Adverse Childhood Experiences (ACEs) Checklist² and the Childhood Trauma Questionnaire short form (CTQ-SF)³. The ACEs Checklist consists of 10 two-part questions that access exposure, before age 18, to physical abuse, psychological abuse, sexual abuse, physical neglect, emotional neglect, and aspects of household dysfunction including a parent who’s an alcoholic or drug user, a mother who’s a victim of domestic violence, a family member going to jail, a family member with a mental illness or who attempted suicide, and parental separation or divorce. The ACEs score (0 – 10) is the number of types of exposure recollected. This instrument has been used in a large number of epidemiological studies showing the graded relationship between number of types of self-reported exposure to childhood maltreatment and risk for a host of psychiatric and medical disorders or symptoms^4-31 and it has also been used in some neuroimaging studies^32-35. Several studies were cited to illustrate the range of topics explored as well as the journal that have published studies using the ACEs checklist as a primary measure. Detailed data on the test-retest reliability of the ACEs checklist have been published by Dube et al². This instrument is readily available online (https://acestoohigh.com/got-your-ace-score/) and is free to use.

The CTQ-SF consists of 28 questions and provides indices of severity (range 5 – 25) of exposure to five types of CM: physical abuse, sexual abuse, emotional abuse, emotional neglect and physical neglect. The CTQ-SF, or the 70-item full scale CTQ, have been used primarily in clinical research studies and has been helpful in delineating possible consequences of exposure to specific types of CM^36-117. Many studies were cited to illustrate the range of topics explored as well as the journal that have published studies using the CTQ as a primary measure. The CTQ has been validated in adolescents¹¹⁸ as well as adults. Detailed information on the psychometric properties of the CTQ^{119, 120} and CTQ-SF^121-124 have been reported including translations into multiple languages. These scales are available from Pearson for a modest fee.

The Maltreatment and Abuse Exposure Scale (MAES)¹²⁵ and the Maltreatment and Abuse Chronology of Exposure (MACE) scale¹²⁵ are newer self-report inventories developed by Teicher and Parigger¹²⁵ to address deficiencies in previous scales and to provide a more comprehensive picture. For example, the CTQ does not inquire about witnessing domestic violence and the ACE checklist only inquiries about witnessing violence to mothers, but interfamilial violence can also occur to fathers and to siblings and violence to siblings may be more consequential than violence to mothers in terms of risk for psychiatric symptomatology¹²⁶. The MAES and MACE collect information on witnessing interparental violence and witnessing violence to siblings. The ACE checklist also contains items on mental illness/suicide and drug abuse in family members, which may confound genetic risk with exposure. The MACE and MAES rectify these deficiencies and also include items on exposure to peer emotional and peer physical bullying, which fit the definition of childhood maltreatment, but are not incorporated into other scales. In addition, all previous instruments were developed using Classical Test Theory. The MACE and MAES were developed using Item Response Theory which offers many advantages in terms of selection of test items. Further, the MACE and MAES consists of 10 scales with Rasch scoring properties, which means that they produce a ‘fundamental measure’ with at least interval scaling properties which cannot be claimed by scales developed through classical test theory.

The MACE and MAES consists of 52-item for assessing severity of exposure to each of 10 type of CM (i.e., parental physical abuse, parental verbal abuse, parental non-verbal emotional abuse, sexual abuse, witnessing interparental violence, witnessing violence to siblings, emotional neglect, physical neglect, peer emotional bullying and peer physical bullying) during the first 18 years. The MACE adds age scales to each item so that severity of exposure is delineated during each year of childhood. It was designed in this manner to delineate sensitive periods when exposure to a specific type of maltreatment may emerge as the most important risk factor for neurobiological alterations^{127, 128} or psychiatric disorders¹²⁹. The observation that abuse between ages 4-7 was associated with an especially poor response to antidepressants¹³⁰ and that prepubertal (particularly ages 3-6) versus post-pubertal exposure (particularly ages 13-15) to CM were associated with opposite effects on amygdala response to threat in adulthood¹²⁷ suggest that more granular information on type and timing of exposure may be necessary to fully understand the consequences of CM and to prescribe effective treatments.

The MACE has been used primarily to delineate sensitive periods or overall associations between maltreatment and aspects of brain development^{34, 127, 128, 131-134}, psychiatric symptomatology^{129, 135-142} or endocrine response¹⁴³.  Detailed psychometrics have been published for the English version¹²⁵ and for translations^144-146. These instruments have been placed into the public domain and REDcap and Qualtrics scripts are freely available from MHT for its incorporation into research studies.

Overall, contemporary instruments for retrospectively rating severity of exposure to maltreatment in adults have excellent test-retest reliability (e.g., CTQ r = .88¹⁴⁷, The Childhood Abuse and Trauma Scale r = .89¹⁴⁸, MACE r = .91¹²⁵). This high reliability also applies to individuals with significant psychopathology. Fisher et al¹⁴⁹ reported that self-report ratings of exposure were stable in individuals with psychotic disorders and did not fluctuate with either their levels of psychosis or depression.

There are also a number of structured or semi-structured interviews available for assessing maltreatment including the Traumatic Antecedents Interview¹, Interview for Traumatic Events in Childhood¹⁵⁰, Childhood Experiences of Care and Abuse Interview¹⁵¹ and the Early Trauma Inventory¹⁵². Results of interviews may correspond somewhat more closely to prospective measures¹⁵³. A comprehensive approach that we have adopted in research studies has been to use multiple self-report measures along with a detailed semi-structured interview.

Many other scales for assessing exposure have been developed. Saini et al¹⁵⁴ have recently published a review of available instruments for assessing maltreatment with a comparison of their psychometric properties.

Assessing maltreatment in children is more complex. Many studies on the potential effects of maltreatment on children have used inpatient samples in which this material was collected as part of the assessment and with the clinical service responsible for reporting children with ongoing abuse or neglect to child protective services^{155, 156}. Other studies have used child protective service records, or foster care placements, as a starting point for enrolling participants^157-160. The evaluation of cases in which child abuse and neglect are suspected clinically but denied by parents can become quite complex and best performed by individuals or teams with special expertise. Comprehensive guidelines have been published for pediatricians¹⁶¹ and family physicians¹⁶². The Stanford Medicine website provides useful information for the more general screening of infants, children and adolescents for various types of abuse or neglect https://childabuse.stanford.edu/screening/children.html.

The Juvenile Victimization Questionnaire (revised) is a comprehensive structured interview that has been used in research studies to obtain lifetime and one-year prevalence rates for exposure to maltreatment, peer and sibling victimization, sexual victimization, witnessing and other forms of indirect exposure to violence and conventional crime^163-165. The ISPCAN Child Abuse Screening Tool Children’s Version is a multi-national, multi-lingual, consensus-based survey instrument designed to detect exposure to violence, physical, psychological and sexual victimization as well as neglect in their homes during the last year¹⁶⁶. The Traumatic Events Screening Inventory (TESI)^167-169 has both parent and child versions and is available through the National Center for PTSD. TESI inquiries about potentially traumatic events including current and previous injuries, hospitalizations, domestic violence, community violence, disasters, accidents, physical, and sexual abuse and whether these events meet DSM Criterion A of PTSD. Stover and Berkowitz¹⁷⁰ review methods of assessing violence exposure in very young children.

There are also a number of self-report measures for children and adolescents. The CTQ has been validated in children age 12 or older¹¹⁸, and is a good choice to provide continuity with studies in adults. The Multidimensional Neglectful Behavior Scale is a self-report instrument for children that assesses exposure to both violence and neglect and provides a particularly in depth assessment of exposure to multiple types of neglect¹⁷¹. Additional scales for children and adolescents are reviewed by Strand et al¹⁷² and included in the recent review by Saini et al¹⁵⁴.

In short, there is a wide range of tools available for assessing abuse and neglect that can be readily employed by researchers. Although maltreatment is multifaceted it can be adequately assessed about as readily as researchers assess symptoms of depression using self-report instruments such as the Center for Epidemiologic Studies Depression Scale (CES-D)¹⁷³, or via interview such as the Structured Interview Guide for the Hamilton Depression Rating Scale¹⁷⁴. Hence, clinical researchers in the mental health area should have no difficulty adding measures of maltreatment into their research protocols. We should also emphasize that asking these questions does not distress participants who are often grateful for being asked.

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Recommendations for Researchers: Collecting Information on Exposure to Childhood Maltreatment

S1 Recommendations for Researchers: Collecting Information on Exposure to Childhood Maltreatment

We can provide some guidance for researchers interested in assessing exposure to CM. In adults a good starting point is to use a retrospective self-report scale. This is usually sufficient for publications and grant proposals though a more rigorous approach would be to combine this with a structured trauma interview¹. Two of the most frequently used self-report scales for adults are the Adverse Childhood Experiences (ACEs) Checklist² and the Childhood Trauma Questionnaire short form (CTQ-SF)³. The ACEs Checklist consists of 10 two-part questions that access exposure, before age 18, to physical abuse, psychological abuse, sexual abuse, physical neglect, emotional neglect, and aspects of household dysfunction including a parent who’s an alcoholic or drug user, a mother who’s a victim of domestic violence, a family member going to jail, a family member with a mental illness or who attempted suicide, and parental separation or divorce. The ACEs score (0 – 10) is the number of types of exposure recollected. This instrument has been used in a large number of epidemiological studies showing the graded relationship between number of types of self-reported exposure to childhood maltreatment and risk for a host of psychiatric and medical disorders or symptoms^4-31 and it has also been used in some neuroimaging studies^32-35. Several studies were cited to illustrate the range of topics explored as well as the journal that have published studies using the ACEs checklist as a primary measure. Detailed data on the test-retest reliability of the ACEs checklist have been published by Dube et al². This instrument is readily available online (https://acestoohigh.com/got-your-ace-score/) and is free to use.

The CTQ-SF consists of 28 questions and provides indices of severity (range 5 – 25) of exposure to five types of CM: physical abuse, sexual abuse, emotional abuse, emotional neglect and physical neglect. The CTQ-SF, or the 70-item full scale CTQ, have been used primarily in clinical research studies and has been helpful in delineating possible consequences of exposure to specific types of CM^36-117. Many studies were cited to illustrate the range of topics explored as well as the journal that have published studies using the CTQ as a primary measure. The CTQ has been validated in adolescents¹¹⁸ as well as adults. Detailed information on the psychometric properties of the CTQ^{119, 120} and CTQ-SF^121-124 have been reported including translations into multiple languages. These scales are available from Pearson for a modest fee.

The Maltreatment and Abuse Exposure Scale (MAES)¹²⁵ and the Maltreatment and Abuse Chronology of Exposure (MACE) scale¹²⁵ are newer self-report inventories developed by Teicher and Parigger¹²⁵ to address deficiencies in previous scales and to provide a more comprehensive picture. For example, the CTQ does not inquire about witnessing domestic violence and the ACE checklist only inquiries about witnessing violence to mothers, but interfamilial violence can also occur to fathers and to siblings and violence to siblings may be more consequential than violence to mothers in terms of risk for psychiatric symptomatology¹²⁶. The MAES and MACE collect information on witnessing interparental violence and witnessing violence to siblings. The ACE checklist also contains items on mental illness/suicide and drug abuse in family members, which may confound genetic risk with exposure. The MACE and MAES rectify these deficiencies and also include items on exposure to peer emotional and peer physical bullying, which fit the definition of childhood maltreatment, but are not incorporated into other scales. In addition, all previous instruments were developed using Classical Test Theory. The MACE and MAES were developed using Item Response Theory which offers many advantages in terms of selection of test items. Further, the MACE and MAES consists of 10 scales with Rasch scoring properties, which means that they produce a ‘fundamental measure’ with at least interval scaling properties which cannot be claimed by scales developed through classical test theory.

The MACE and MAES consists of 52-item for assessing severity of exposure to each of 10 type of CM (i.e., parental physical abuse, parental verbal abuse, parental non-verbal emotional abuse, sexual abuse, witnessing interparental violence, witnessing violence to siblings, emotional neglect, physical neglect, peer emotional bullying and peer physical bullying) during the first 18 years. The MACE adds age scales to each item so that severity of exposure is delineated during each year of childhood. It was designed in this manner to delineate sensitive periods when exposure to a specific type of maltreatment may emerge as the most important risk factor for neurobiological alterations^{127, 128} or psychiatric disorders¹²⁹. The observation that abuse between ages 4-7 was associated with an especially poor response to antidepressants¹³⁰ and that prepubertal (particularly ages 3-6) versus post-pubertal exposure (particularly ages 13-15) to CM were associated with opposite effects on amygdala response to threat in adulthood¹²⁷ suggest that more granular information on type and timing of exposure may be necessary to fully understand the consequences of CM and to prescribe effective treatments.

The MACE has been used primarily to delineate sensitive periods or overall associations between maltreatment and aspects of brain development^{34, 127, 128, 131-134}, psychiatric symptomatology^{129, 135-142} or endocrine response¹⁴³.  Detailed psychometrics have been published for the English version¹²⁵ and for translations^144-146. These instruments have been placed into the public domain and REDcap and Qualtrics scripts are freely available from MHT for its incorporation into research studies.

Overall, contemporary instruments for retrospectively rating severity of exposure to maltreatment in adults have excellent test-retest reliability (e.g., CTQ r = .88¹⁴⁷, The Childhood Abuse and Trauma Scale r = .89¹⁴⁸, MACE r = .91¹²⁵). This high reliability also applies to individuals with significant psychopathology. Fisher et al¹⁴⁹ reported that self-report ratings of exposure were stable in individuals with psychotic disorders and did not fluctuate with either their levels of psychosis or depression.

There are also a number of structured or semi-structured interviews available for assessing maltreatment including the Traumatic Antecedents Interview¹, Interview for Traumatic Events in Childhood¹⁵⁰, Childhood Experiences of Care and Abuse Interview¹⁵¹ and the Early Trauma Inventory¹⁵². Results of interviews may correspond somewhat more closely to prospective measures¹⁵³. A comprehensive approach that we have adopted in research studies has been to use multiple self-report measures along with a detailed semi-structured interview.

Many other scales for assessing exposure have been developed. Saini et al¹⁵⁴ have recently published a review of available instruments for assessing maltreatment with a comparison of their psychometric properties.

Assessing maltreatment in children is more complex. Many studies on the potential effects of maltreatment on children have used inpatient samples in which this material was collected as part of the assessment and with the clinical service responsible for reporting children with ongoing abuse or neglect to child protective services^{155, 156}. Other studies have used child protective service records, or foster care placements, as a starting point for enrolling participants^157-160. The evaluation of cases in which child abuse and neglect are suspected clinically but denied by parents can become quite complex and best performed by individuals or teams with special expertise. Comprehensive guidelines have been published for pediatricians¹⁶¹ and family physicians¹⁶². The Stanford Medicine website provides useful information for the more general screening of infants, children and adolescents for various types of abuse or neglect https://childabuse.stanford.edu/screening/children.html.

The Juvenile Victimization Questionnaire (revised) is a comprehensive structured interview that has been used in research studies to obtain lifetime and one-year prevalence rates for exposure to maltreatment, peer and sibling victimization, sexual victimization, witnessing and other forms of indirect exposure to violence and conventional crime^163-165. The ISPCAN Child Abuse Screening Tool Children’s Version is a multi-national, multi-lingual, consensus-based survey instrument designed to detect exposure to violence, physical, psychological and sexual victimization as well as neglect in their homes during the last year¹⁶⁶. The Traumatic Events Screening Inventory (TESI)^167-169 has both parent and child versions and is available through the National Center for PTSD. TESI inquiries about potentially traumatic events including current and previous injuries, hospitalizations, domestic violence, community violence, disasters, accidents, physical, and sexual abuse and whether these events meet DSM Criterion A of PTSD. Stover and Berkowitz¹⁷⁰ review methods of assessing violence exposure in very young children.

There are also a number of self-report measures for children and adolescents. The CTQ has been validated in children age 12 or older¹¹⁸, and is a good choice to provide continuity with studies in adults. The Multidimensional Neglectful Behavior Scale is a self-report instrument for children that assesses exposure to both violence and neglect and provides a particularly in depth assessment of exposure to multiple types of neglect¹⁷¹. Additional scales for children and adolescents are reviewed by Strand et al¹⁷² and included in the recent review by Saini et al¹⁵⁴.

In short, there is a wide range of tools available for assessing abuse and neglect that can be readily employed by researchers. Although maltreatment is multifaceted it can be adequately assessed about as readily as researchers assess symptoms of depression using self-report instruments such as the Center for Epidemiologic Studies Depression Scale (CES-D)¹⁷³, or via interview such as the Structured Interview Guide for the Hamilton Depression Rating Scale¹⁷⁴. Hence, clinical researchers in the mental health area should have no difficulty adding measures of maltreatment into their research protocols. We should also emphasize that asking these questions does not distress participants who are often grateful for being asked.

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Child Maltreatment, Brain Imaging and Mental IllnessRoyal_Society_Mal_2017_standard

Impact of Childhood Maltreatment on Brain Development and the Critical Importance of Distinguishing Between Maltreated and Non-Maltreated Diagnostic SubtypesISNR_2017_Keynote_Teicher

Childhood Abuse, Brain Development and Psychopathology – Lecture

Child_Abuse_brain_psychopath_Amsterdam_2017

Childhood Abuse, Brain Development and Psychopathology – Keynote

Child_Abuse_brain_psychopath_ESTSS_2017

The Neurobiological Impact of Childhood Maltreatment and Substance Abuse

Albatros_talk_2017_Paris_revised2