The British Journal of Psychiatry (2012)

200, 8991. doi: 10.1192/bjp.bp.111.096727

Editorial

Negative childhood experiences

and mental health: theoretical, clinical
and primary prevention implications{
John Read and Richard P. Bentall
Summary
After decades of ignoring or minimising the prevalence and
effects of negative events in childhood, researchers have
recently established that a broad range of adverse childhood
events are significant risk factors for most mental health
problems, including psychosis. Researchers are now
investigating the biological and psychological mechanisms
involved. In addition to the development of a traumagenic
neurodevelopmental model for psychosis, the exploration of

John Read (pictured) is Editor of the journal Psychosis and was Coordinating
Editor of Models of Madness: Psychological, Social and Biological Approaches
to Schizophrenia (Routledge, 2004). Richard Bentall is Professor of Clinical
Psychology at the University of Liverpool. He is the author of Madness
Explained: Psychosis and Human Nature (Penguin, 2003) and Doctoring the
Mind: Why Psychiatric Treatments Fail (Penguin, 2009)

The study by Keyes et al,1 in this issue, represents an important

contribution to our understanding of the processes by which the
maltreatment of children leads to mental health problems. Just
20 years ago, however, it would have been difficult to get the paper
published. Mental health professions have been slow, even resistant,
to recognise the role of childhood adversities in psychiatric
disorder. The 20th century got off to a poor start when Freud
repudiated his original discovery that many of his clients had been
sexually abused and decided, instead, that these disclosures
represented fantasies. As late as 1975, a leading US psychiatry
textbook insisted that the rate of incest was only one per
million. It was not until the end of the century that epidemiological studies revealed the alarming extent to which adults
neglect and abuse children. Pressure to respond to these findings
came more from the womens movement than from psychiatrists
or psychologists. Our introduction of the post-traumatic stress
disorder (PTSD) diagnosis in 1980 was not in response to abused
children, but to Vietnam veterans. By the time we stopped
dismissing disclosures of abuse as fantasies, we were busy
misinterpreting the effects of childhood trauma as symptoms
of a plethora of mental illnesses with predominantly biological
aetiologies. The decade of the brain at the end of the century was
hardly conducive to understanding the long-term effects of childhood adversity, including ironically on the developing brain.
Childhood adveristy and mental health problems
Following this long period of neglect, however, recent studies have
demonstrated that a wide range of adversities, and not just sexual
abuse, are predictors of many forms of mental ill health, and not
just PTSD. These adversities have been found to include: mothers
ill health, poor nutrition and high stress during pregnancy; being
{

See pp. 107115, this issue.

a range of psychological processes, including attachment and

dissociation, is shedding light on the specific aetiologies of
discrete phenomena such as hallucinations and delusions. It
is argued that the theoretical, clinical and primary prevention
implications of our belated focus on childhood are profound.
Declaration of interest
None.

the product of an unwanted pregnancy; early loss of parents via

death or abandonment; witnessing interparental violence;
dysfunctional parenting (particularly affectionless overcontrol);
parental substance misuse, mental health problems and criminal
behaviour; childhood sexual, physical and emotional abuse; childhood emotional or physical neglect; bullying; childhood medical
illness; and war trauma.2,3 Of course, it is very likely that these
types of events have their impact in interaction with other factors
such as heavy cannabis consumption, genetic predisposition and
epigenetic processes.3
Some of these adversities have been shown to be intergenerational, so that parents who themselves suffered in childhood
struggle to provide an optimum environment for their own
children. This finding can be used to counter the argument that
research into intrafamilial causes of mental health problems is
undesirable because it is family blaming. On the contrary, the
findings should encourage us to identify the needs not only of
the identified patient but of parents and other family members,
whose problems often originating in their own childhoods
tend to go unnoticed.
Some of these adversities have also been found to be related to
another powerfully intergenerational phenomenon, poverty,
which has been characterised as the cause of the causes. In their
2009 book, The Spirit Level,4 epidemiologists Richard Wilkinson
and Kate Pickett present convincing evidence that relative poverty
may be an even stronger predictor of mental health than poverty
per se. Countries with the worst disparities between richest and
poorest have the worst outcomes, not only in mental health and
drug misuse but also in physical health, violence, teenage pregnancies
and, importantly for the topic at hand, child well-being.
The range of mental health outcomes for which childhood
adversities are risk factors is equally broad. It might be quicker
to list those not predicted by childhood adversity. Those that are
include: in childhood conduct disorder, attention-deficit
hyperactivity disorder and oppositional defiant disorder; and, in
adulthood depression, anxiety disorders (including generalised
anxiety disorder, phobias and PTSD), eating disorders, sexual
dysfunction, personality disorder, dissociative disorder and
substance misuse.2 Moreover, childhood abuse is related to
severity of disturbance whichever way one defines severity. People
subjected to childhood physical or sexual abuse are more likely to
be admitted to a psychiatric hospital; have earlier, longer and more

89

Read & Bentall

frequent admissions; receive more psychiatric medication; are

more likely to self-harm and to try to kill themselves; and have
higher global symptom severity.3
In another valuable contribution to this literature, in a recent
issue of the Journal, Kessler et al analysed data from 21 countries.2
They concluded that childhood adversities were highly prevalent
and interrelated. They also found that childhood adversities
associated with maladaptive family functioning (e.g. parental
mental illness, child abuse, neglect) were the strongest predictors
of disorders. Of equal importance is their confirmation that
childhood adversities have strong associations with all classes of
disorders and that there is little specificity across disorders. They
acknowledge, however, that the World Mental Health Surveys on
which they based their analyses (as did Wilkinson & Pickett4)
excluded psychosis. Many other studies relating to psychosocial
aetiology exclude psychosis. Nevertheless, it is in this area that
we find the most surprising findings.

supports this general framework, showing, for example, that

victimisation can lead to sensitisation of the dopamine system,
which has long been thought to play a role in psychosis.
At a psychological level, researchers have focused on
mechanisms that might mediate between childhood adversity
and later mental health problems, including attachment,
dissociation, psychodynamic defences, coping responses, impaired
access to social support, and revictimisation.3,8,9 This research has
the potential to uncover specificities in the effects of adversity
which may be difficult to see when only broad diagnoses are considered. For example, childhood sexual trauma appears to have a
specific effect on the risk of hallucinations, which may reflect a
long-term impact on the processes underlying source monitoring
(the ability to differentiate internal and external stimuli); whereas
attachment difficulties and more chronic victimisation, for
example bullying, may increase the risk of paranoid delusions
by affecting the way that individuals appraise unpleasant
experiences.10

Childhood adversity and psychosis

Until very recently the hypothesis that abuse in childhood has a
causal role in psychosis was regarded by many biologically
oriented psychiatrists as heresy. Although the public all over the
world (including patients and their families) place more emphasis
on adverse life events than on genetics or brain abnormalities
when asked about the causes of schizophrenia, David Kingdon
found, in 2004, that for every British psychiatrist who agreed with
the public, 115 thought psychosis is caused primarily by biological
factors.5 Nonetheless, the evidence on the association between
childhood adversity and psychosis has accumulated at a staggering
pace. The first large-scale general population studies did not
appear until 2004.3,6 By 2009 a review3 had identified 11. Ten of
these found that childhood maltreatment is significantly related
to psychosis. The authors of the one exception corrected a flaw
in their original study and found the same as the other ten.7 Nine
of the 11 tested for, and found, a doseresponse relationship.3 For
example, a prospective study in The Netherlands6 found, after
controlling for history of hallucinations or delusions in firstdegree relatives, that people who had been abused as children were
nine times more likely than non-abused people to experience
pathology-level psychosis. The odds ratio for mild abuse was
2.0, but 48.4 for severe abuse.
The 2009 review3 also reported a relationship between
childhood abuse and the actual content of hallucinations and
delusions, as well as research demonstrating that abuse
disclosures by people diagnosed with schizophrenia are reliable.
It cites seven studies of first-episode psychosis that confirm the
relationship between adverse childhood events and negative outcomes. Another review8 concluded: There is now considerable
evidence of an association between child sexual abuse and
psychosis. This relationship is at least as strong as, and may be
stronger than, that with other mental disorders.
Many researchers, such as Keyes and colleagues,1 are now
exploring the mechanisms and processes by which events in
childhood can lead to mental health problems years later. For
example, in an attempt to generate a genuinely integrated
psycho-socio-biological approach,3 the traumagenic neurodevelopmental model9 of psychosis (proposed by J.R. and
colleagues) draws on the evidence that the biochemical and
structural abnormalities found in people diagnosed with
schizophrenia, which have often been portrayed as evidence of a
brain disease, are also found in the brains of traumatised
children. Animal research, in which it has been possible to
examine the effects of adversity in precisely controlled conditions,

90

Implications
The implications of our having finally taken seriously the causal
role of childhood adversity are profound. Clinically, the first step
is to ask about childhood events in order to facilitate meaningful
formulations and comprehensive treatment plans. This is still not
happening routinely in many services.11 The impact of the
introduction of National Health Service guidelines in 2008
remains to be seen.12
The most important implication is in the domain of primary
prevention. George Albee13 put it succinctly:
Primary prevention research inevitably will make clear the relationship between
social pathology and psychopathology and then will work to change social and
political structures in the interests of social justice. It is as simple and as difficult as
that!

John Read, PhD, Department of Psychology, University of Auckland, New Zealand;

Richard P. Bentall, PhD, School of Psychology, University of Liverpool, UK
Correspondence: Professor John Read, Department of Psychology, Private Bag
92019, Auckland, New Zealand. Email: j.read@auckland.ac.nz
First received 14 Jul 2011, accepted 26 Oct 2011

References
1

Keyes KM, Eaton NR, Krueger RF, McLaughlin KA, Wall MM, Grant BF, et al.
Child maltreatment and the structure of common psychiatric disorders.
Br J Psychiatry 2012; 200: 10715.

Kessler RC, McLaughlin KA, Greif Green J, Gruber MJ, Sampson NA, Zaslavsky
AM, et al. Childhood adversities and adult psychopathology in the WHO
World Mental Health Surveys. Br J Psychiatry 2010; 197: 37885.

Read J, Bentall RP, Fosse R. Time to abandon the bio-bio-bio model of

psychosis: exploring the epigenetic and psychological mechanisms by which
adverse life events lead to psychotic symptoms. Epidemiol Psichiatr Soc
2009; 18: 299310.

Wilkinson R, Pickett K. The Spirit Level: Why Equality is Better for Everyone.
Penguin Books, 2010.

Read J, Haslam N, Sayce L, Davies E. Prejudice and schizophrenia: a review

of the Mental illness is an Illness like any other approach. Acta Psychiatr
Scand 2006; 114: 30318.

Janssen I, Krabbendam L, Bak M, Hanssen M, Vollebergh W, De Graaf R, et al.

Childhood abuse as a risk factor for psychotic experiences. Acta Psychiatr
Scand 2004; 109: 3845.

Cutajar M, Mullen P, Ogloff J, Thomas S, Wells D, Spataro J. Schizophrenia

and other psychotic disorders in a cohort of sexually abused children. Arch
Gen Psychiatry 2010; 67: 11149.

Negative childhood experiences and mental health

8 Bebbington P. Childhood sexual abuse and psychosis: aetiology and

mechanism. Epidemiol Psichiatr Soc 2009; 18: 28493.

11 Read J, Hammersley P, Rudegeair T. Why, when and how to ask about child
abuse. Adv Psychiatr Treat 2007; 13: 10110.

9 Read J, Perry B, Moskowitz A, Connolly J. The contribution of early traumatic

events to schizophrenia in some patients: a traumagenic
neurodevelopmental model. Psychiatry 2001; 64: 31945.

12 NHS Confederation. Briefing 162: Implementing National Policy on Violence

and Abuse. Ministry of Health, 2008.

10 Bentall RP, Fernyhough C. Social predictors of psychotic experiences:

specificity and psychological mechanisms. Schizophr Bull 2008; 34: 101220.

13 Albee GW. Revolutions and counter-revolutions in prevention. Am Psychol

1996; 51: 11303.

psychiatry
in pictures

Ashanti fertility dolls (Akuaba)

Malcolm P. Weller
Belief in myths allows the comfort of opinion without the discomfort of thought.
John F. Kennedy
In superstitions, intuitive concepts and spurious attribution coexist with acquired rational
knowledge. In animals superstitious learning based on intermittent rewards, unlike the
withdrawal of predictable reward, is difficult to extinguish.
It might be thought that increasing environmental control would reduce reliance on
unverified beliefs. Nevertheless, despite the conflict with religious prohibitions, in
American society approximately one quarter believe in astrology, clairvoyance, ghosts
and communication with the dead. Such beliefs, and good-luck charms, are often
important parts of peoples lives.
Akuaba (from Akua, a day-name for a female born on a Wednesday, and ba, child;
hence, Akuas child) refers to the fertility doll carved from wood by the Ashanti (more
correctly, Asante), a major ethnic group of the Ashanti Region of Ghana. At their height
they dominated most of Ghana, as well as parts of Togo and the Ivory Coast.
Fertility dolls are recommended by a herbalist, or generally a priest, and the woodcarver
has high status, reinforcing prevailing belief. Like normal children, they are dressed and
tied to the back, or form part of a home shrine when not being carried.
The line of descent in Ashanti culture is matrilineal. Dolls are thought to represent an ideal of feminine beauty, the likelihood of
having a beautiful female child being increased in those who carry the doll. Accordingly, the dolls were also carried by pregnant
women, but more often by infertile women. Apart from the normal desire for motherhood, infertility could raise suspicions of
witchcraft. Because of the premium on fertility and the stress of infertility, associated physiological perturbations might be
thought to aggravate infertility.
Anecdotal evidence suggests that womens fertility is lower in stressful circumstances and that conception is more frequent
during or after a holiday, or after adoption, following a protracted period of infertility. The idea that stress limits fertility would
be a natural barrier to population expansion at times of drought and famine and would be a mechanism for balancing population
to resources. In support of these ideas, extreme weight loss, as in anorexia nervosa, leads to amenorrhea. Ovulation in the Kung!
of the Northern Kalahari desert area of Botswana, a non-contraceptive using population with a low fertility and a birth space
interval of greater than 3 years, is linked to the rains, but otherwise there is no evidence to support these suppositions in
humans when objective data are rigorously analysed, even in artificial fertility treatment.
It is estimated that one in three or four Ashanti women possessed a doll. Ironically, fertility in Ghana is low compared with most
other African countries. The elevation of anecdote over evidence might be summarised in the present example by saying that the
wish to mother is the thought.
With grateful thanks to Adrian Bird for valuable input and helpful discussion.
References available on request to Professor Malcolm P. Weller, School of Health and Social Sciences, Middlesex University,
email: psychiatry@weller.tv. Image s Skeptiseum. Reproduced with permission.
The British Journal of Psychiatry (2012)
200, 91. doi: 10.1192/bjp.bp.111.096073

91

Negative childhood experiences and mental health: theoretical,

clinical and primary prevention implications

John Read and Richard P. Bentall

BJP 2012, 200:89-91.
Access the most recent version at DOI: 10.1192/bjp.bp.111.096727

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