Child Abuse & Neglect 35 (2011) 937945

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Child Abuse & Neglect
The disease burden of childhood adversities in adults:
A population-based study

Pim Cuijpers
a,b,
, Filip Smit
a,b,c
, Froukje Unger
c
, Yvonne Stikkelbroek
d
,
Margreet ten Have
c
, Ron de Graaf
c
a
EMGO Institute for Health and Care Research, VU University and VU University Medical Center, Amsterdam, The Netherlands
b
Department of Clinical Psychology, VU University Amsterdam, Amsterdam, The Netherlands
c
Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
d
Research Center Psychosocial Problems in Context, Utrecht University, Utrecht, The Netherlands
a r t i c l e i n f o
Article history:
Received 19 May 2010
Received in revised form7 June 2011
Accepted 9 June 2011
Available online 17 November 2011
Keywords:
Disease burden
Disability adjusted life years
Childhood adversities
Mental disorders
a b s t r a c t
Objectives: There is much evidence showing that childhood adversities have considerable
effects on the mental and physical health of adults. It could be assumed therefore, that the
disease burden of childhood adversities is high. It has not yet been examined, however,
whether this is true.
Method: We used data of alarge representative sample (N =7,076) of the general population
in the Netherlands. We calculated the disability weight (DW) for each respondent. The DW
is a weight factor that reects the severity of a disease or condition ona scale from 0 (perfect
health) to 1 (equivalent to death). We used an algorithm based on the SF-6D to estimate DW.
Because the DW indicates the proportion of a healthy life year that is reduced by the specic
health state of the individual, it also possible to calculate the total number of years lost due
to disability (YLD) in the population. We calculated the years lived with disability (YLD)
for 9 different childhood adversities (in the areas of parental psychopathology; abuse and
neglect; major life events), as well as for major categories of mental disorders and general
medical disorders.
Results: All 9 adversities resulted in a signicantly increased DW, except death of a par-
ent before the age of 16. Adversities in the category of abuse and neglect are associated
with the highest DWs (0.057), followed by parental psychopathology (0.031) and life events
during childhood (0.012). All adversities (46.4% of the population reports one or more adver-
sity) are associated with 20.7 YLD/1,000, which is more than all mental disorders together
(12.9 YLD/1,000). The category of abuse/neglect has the highest YLD/1,000 (15.8), which is
also higher than all mental disorders together. Adjustment for the presence of mental and
general medical disorders resulted in comparable outcomes.
Conclusions: Childhood adversities are more important from a public health point of view
than all common mental disorders together, and should be a priority for public health
interventions.
2011 Elsevier Ltd. All rights reserved.

NEMESIS was supported by the Netherlands Ministry of Health, Welfare and Sport (VWS).

Corresponding author address: Department of Clinical Psychology and EMGO Institute for Health and Care Research, VU University Amsterdam, Van
der Boechorststraat 1, 1081 BT Amsterdam, The Netherlands.
0145-2134/$ see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.chiabu.2011.06.005
938 P. Cuijpers et al. / Child Abuse & Neglect 35 (2011) 937945
Introduction
There is much evidence showing that the long-term effects of childhood adversities on mental and physical health are
considerable. The increased risk of developing a mental disorder in adults with an adversity during childhood has been
conrmed in many studies, and includes an increased risk for mood disorders (Collishaw et al., 2007; Comijs, Beekman,
Smit, Bremmer, van Tilburg, & Deeg, 2007; Kessler, Davis, & Kendler, 1997), anxiety disorders (Phillips, Hammen, Brennan,
Najman, & Bor, 2005; Springer, Sheridan, Kuo, & Carnes, 2007), alcohol problems (Kessler et al., 1997; Kestil et al., 2008),
eating disorders (Johnson, Cohen, Gould, Kasen, et al., 2002), and psychotic symptoms (De Graaf, Bijl, ten Have, Beekman,
& Vollebergh, 2004; Janssen et al., 2004). Furthermore, childhood adversities have been found to be signicantly associated
with an increased risk for suicidal ideation and suicide attempts (Enns et al., 2006), with increased rates of comorbidity in
mental disorders (De Graaf, Bijl, ten Have, Beekman, & Vollebergh, 2004), with severe interpersonal difculties (Johnson,
Cohen, Kasen, & Brook, 2002), weight problems (Johnson, Cohen, Gould, et al., 2002), and early retirement because of dis-
ability (Harkonmki et al., 2007). Other evidence shows that childhood adversities may be associated with general medical
disorders, suchas migraine (Juang, Wang, &Fuh, 2004; Sumanen, Rantala, Sillanmki, &Mattila, 2007), peptic ulcers (Markku,
Koskenvuo, Sillanmki, &Mattila, 2009), arthritis (Scott et al., 2008; Von Korff et al., 2009), coronary heart disease (Sumanen,
Koskenvuo, Sillanmki, & Mattila, 2005), and diabetes (Thomas, Hyppnen, & Power, 2008).
Because childhood adversities seem to cut across many different disorders and problems, it may be very well possible
that the quality of life in adults having one or more childhood adversities is considerably reduced. Whether or not childhood
adversities are associated with an increased disease burden in adults has not been examined yet. In the current study, we
will try to estimate the disease burden of childhood adversities using data from a large representative population-based
study.
The relationship between childhood adversities on the one hand and health during adulthood on the other hand, can be
explained using different models. Several studies showthat life stress, addiction or depression could function as a direct or
an indirect effect on the relationship between childhood adversities and decreased health in adulthood. For example, the
experience of childhood adversities may result in coping or regulation strategies that have a negative impact on health, such
as smoking, high alcohol consumption or over-eating. These might lead to health problems, which might in turn lead to
disease burden (Felitti et al., 1998; Sachs-Ericsson, Cromer, Hernandez, & Kendall-Tackett, 2009; Wegman & Stetler, 2009).
There are indications that abuse-related alterations in brain function are possible mediators in etiology, which may reduce
immune systemor increase the vulnerability to stress (Sachs-Ericsson et al., 2009).
In addition, in many cases, other family problems than parental psychopathology or child maltreatment may co-occur,
further affecting both mental and general medical disorders. Family characteristics like family conict, neglectful relation-
ships or social emotional status could put children at risk for traumatic experiences and are often found in families where
childmaltreatment is prevalent (Sachs-Ericssonet al., 2009; Wegman&Stetler, 2009). This poses the questionof howexactly
negative health outcomes are linked to childhood adversities. A more complete understanding of these issues is likely to
lead to a better understanding of the relationship between childhood adversities and disease burden.
In most research, disease burden is expressed in terms of disability-adjusted life years (DALY). One DALY is equivalent
to one lost year of healthy life. It represents an estimation of the gap between current health status and an ideal situation
of the whole population living into old age in full health. The DALY has its origins in an assessment of the Global Burden
of Disease study, which was conducted under auspices of the World Bank and WHO (Murray & Lopez, 1996). The DALY
combines years of life lost (YLL) due to premature mortality and years lost due to disability (YLD). If a disease results in
premature death it can be calculated how many years of life are lost in a given population because of that disease. In the
same way, it is possible to calculate howmany years are lost in terms of quality of life, because of years lived with a certain
disease. For example, it is estimated that of each year lived with a major depressive disorder, 46% of the quality of life in this
year is missed because of the depressive disorder (Kruijshaar, Hoeymans, Spijker, Stouthard, & Essink-Bot, 2005). This 46%
is also called the disability weight (DW). If in a population of 1,000, 50 people have a major depression during a full year, the
YLD in that population is 23 (500.46). That means that of a total of 1,000 lived years, 23 years are lost because of major
depression.
In the current study, we will only focus on the YLD which can be attributed to childhood adversities. There is much
research showing that childhood adversities are associated with health outcomes in adulthood (Corso, Edwards, Fang, &
Mercy, 2008; Felitti et al., 1998; Sachs-Ericsson, Kendall-Tackett, & Hernandez, 2007; Sachs-Ericsson et al., 2009). However,
the overall impact of childhood adversities on disease burden on a population level has not been examined well.
In the current study, we will focus on non-fatal disease burden (expressed in YLD) that can be attributed to childhood
adversities. We will also compare these results with the YLD that are associated with mental and general medical disorders.
Methods
Subjects and procedure
We used the data of the Netherlands Mental Health Survey and Incidence Study (NEMESIS) which have been described
in detail elsewhere (Bijl, Van Zessen, & Ravelli, 1998). In brief, a random, stratied, multistage sample was obtained in
three steps at baseline. First, municipalities were stratied by urbanization, and 90 municipalities were drawn randomly
P. Cuijpers et al. / Child Abuse & Neglect 35 (2011) 937945 939
and proportionately fromthese strata. Second, within each municipality, households were randomly drawn fromthe postal
register. Finally, within each household the person with the most recent birthday was selected on condition that he or
she was aged between 18 and 65 years and sufciently uent in Dutch to be interviewed. Eligible persons who were not
immediately available were contacted later in the year. The response rate was 69.7% resulting in a sample of 7,076 people
at baseline. Of the included sample 49.1% was female, 80.8% was married or lived with a partner, and 67.6% had a paid
job. The mean age was 41.2 years (SD=11.9). Survey participants were very similar to the Dutch population with regard to
gender, marital status and urbanicity (Bijl et al., 1998). Participants had to be uent in Dutch to be interviewed. Therefore,
minority groups were underrepresented in the study (De Graaf et al., 2005). All data were collected in structured face-to-face
interviews. Although the Nemesis study has 2 follow-up measurements, in the current study we only use the data of the
baseline, which was conducted in 1996 (nal sample size: 7,076). Each interviewlasted about 1hours.
The ethics committee of the Netherlands Institute of Mental Health and Addiction approved these procedures.
Measures
Childhoodadversities. Atotal of ninechildhoodadversities wereexamined, includingfour types of abuseandneglect (physical,
psychological and sexual abuse, and emotional neglect), three types of parental psychopathology (depression, anxiety, and
problemdrinking), and two life events before the age of 16 (death of a parent, and divorce).
To assess childhood abuse and neglect, respondents were asked whether they had experienced, before the age of 16,
emotional neglect, psychological abuse, physical abuse or sexual abuse. Respondents were prompted to report each of these
adversities with questions such as Before you reached the age of 16, were you ever psychologically abused?physically
abused?sexually abused? Responses to these enquiries were recorded as: never, one time, sometimes, regularly, often, or
very often. For the present study, these responses were dichrotomized to reect the occurrence (at least sometimes, coded
1) or absence (never or one time, coded 0) of each form of abuse. Emotional neglect was described to participants
as follows: People at home didnt listen to you, your problems were ignored, you had the feeling of not being able to nd
any attention or support fromthe people in your house. Psychological abuse was described to participants as follows: You
were cursed, unjustly punished, your brothers and sisters were favoredbut no bodily harmwas done. Physical abuse was
dened as follows: You were kicked, hit with or without an object, or you were physically maltreated in any other way.
Sexual abuse was dened as follows: You were touched sexually by anyone against your will, or you were forced to touch
anyone sexually, or pressured into sexual contact against your will.
Parental mental illness
Parental mental illness was assessed by asking respondents whether their biological parents (mother, father, or both)
had ever suffered fromdepression, anxiety disorders or phobias, or problemdrinking. For the present analyses, dichotomous
variables reecting a mental illness in mother, father, or both parents were used.
Childhood life events
Childhood life events were assessed by asking respondents whether 1 or both parents had died before they were 16 or
whether their parents had divorced before the age of 16.
Disability weights (DWs)
The DWis the inverse of the health related quality of life. For example, if the quality of life in an individual is 0.87 on a
scale of 0 (health state equivalent to death) to 1 (perfect health), the DWis the inverse, 0.13.
We estimated DWs according to the methods described by Brazier, Roberts, and Deverill (2002). In this method the DWs
are calculated using the MOS-SF-36. The MOS-SF-36 (Medical Outcomes Study Short Form-36 Health Survey) is a much
used instrument to assess functional impairment (Ware & Sherbourne, 1992). It measures 8 health concepts, including
physical functioning, role limitations caused by physical health problems, role limitations caused by emotional problems,
social functioning, emotional well-being, energy/fatigue, pain, and general health perceptions. In our sample we found good
reliability coefcients (Cronbachs alpha) for each of the 8 subscales of the MOS-SF-36, ranging from 0.77 to 0.90. Several
studies have indicated that the MOS-SF-36 is a well-validated instrument to assess functional impairment (Hays & Morales,
2001; McHorney, Ware, & Raczek, 1993; Schlenk et al., 1998; Stewart, Hays, & Ware, 1998).
In order to allow the DWs to be calculated from the SF-36, 3 steps were taken by Brazier and colleagues (2002). First,
they reduced the size and complexity of the SF-36. This reduction was realized by a reduction of the number of dimensions,
and by selecting the items that contributed most to the longer versions of the dimension scores. This process resulted in a
6-itemversion, the SF-6D, which was used in the current study. In the second step, a representative sample of the general
public fromthe UK (N=836) valued a sample of 249 health states dened by the SF-6D. Each respondent was asked to rank,
and then value, 6 of these states in a personal interview, using a modication of a method developed by a teamat McMaster
(Furlong, Feeny, & Torrance, 1990). In the third step, the results of the survey were used in a model to predict values for
all possible health states that can be described by the reduced version of the SF-36, via various alternative econometric
940 P. Cuijpers et al. / Child Abuse & Neglect 35 (2011) 937945
techniques. This procedure resulted in a health related quality of life valuation for each of the 18,000 health states of the
SF-6D (the 6 items each had 5 or 6 possible answers, resulting in these 18,000 possible combinations).
We employed Braziers econometric algorithmto calculate the DWfor each of the respondents fromthe relevant SF-36
items. The DWindicates the proportion of a healthy life year that is reduced by the specic health state of the individual.
Thus the DWs are on a scale of 01, where 0 (not disabled) indicates perfect health and 1 refers to a health state equivalent
to death. For specic health states, the corresponding DWs can be placed somewhere on this scale.
DSM-III-R axis-I disorders. DSM-III-R axis-I disorders were assessed with the Composite International Diagnostic Interview
(CIDI; World Health Organization, 1997), Dutch 1.1 version (Ter Smitten, Smeets, & van den Brink, 1998). The CIDI is a
fully computerized psychiatric interview and can be used by trained interviewers who are not clinicians. The CIDI is used
worldwide, and WHO eld trials have documented acceptable reliability and validity (Wittchen, 1994).
In the current study, we assessed the presence of three major categories of common mental disorders DSM-III-R dis-
orders in the past month: mood disorders, anxiety disorders, and substance-related disorders. In some analyses, we also
examined all mental disorders, which include the three categories of common mental disorders, as well as eating disorders
and schizophrenia (although the prevalence rates of these disorders were very lowin this study (<0.3%)).
General medical disorders. From a list of 31 chronic general medical disorders, subjects self-reported the presence of 1 or
more conditions being treated or monitored by a physician in the 12 months before baseline. Examples included asthma,
emphysema, osteoarthritis, heart disease, peptic ulcer, and diabetes.
Statistical analyses
First, we examined the associations between each of the nine childhood adversities and demographic variables, as well as
the associations between the childhood adversities and the presence of common mental disorders, and between childhood
adversities and general medical disorders. These associations were examined with Chi-square tests. In the same way we
examined groups of childhood adversities (abuse and neglect; parental psychopathology; life events).
Second, we calculated the (unadjusted) mean Disability Weight (DW) for the different childhood adversities, as well as
for general medical disorders and major categories of common mental disorders. We calculated these DWs in a series of
bivariate regression analyses in which the DWwas the dependent variable, and each adversity was the predictor. We also
conducted bivariate regression analyses with somatic and each of the major categories of mental disorders as predictors.
In these regression analyses, the resulting regression coefcients can be interpreted as the excess DW over the base rate
(constant). The base rate is the average DWof the total population.
In order to estimate the (unadjusted) disease burden of childhood adversities and somatic and mental disorders in terms
of YLD, we calculated the 1-month prevalence rates of each of the mental disorders and multiplied this with the (excess) DW
and the number of life-years (prevalence DW1,000). This resulted in the total number of YLD in a population of 1,000
people. The population number 1,000 could be replaced by any other number (if the number of YLDwould be calculated in a
populationof 1,000,000 the same formula would be used (prevalence DW1,000,000). We used 1-monthprevalence rates
as an estimate of the point-prevalence of the disorders. The point-prevalence is the prevalence of a disorder at 1 moment in
time. For the general medical disorders we used the 12 month prevalence, and because these were chronic conditions we
assumed that these approached the point-prevalence.
Third, we calculated the adjusted DWs and the adjusted YLD, by conducting a multiple regression analysis with the DW
as the dependent variable, and childhood adversities, somatic and the major categories of mental disorders as predictors.
Because childhood adversities are often found to be associated with mental and somatic disorders, we adjusted for the
presence of mental and somatic disorders in these analyses. This allowed us to examine the unique contribution of childhood
adversities to the DW. Again, the resulting regression coefcients can be interpreted as the excess DWover the base rate
(constant). This allowedus tocalculate the overall adjustedYLDby multiplying the adjusted(excess) DWwiththe prevalence
rate and the number of life-years.
To account for initial non-response, corrective weights were used in all analyses. After weighting, the sample followed
exactly the same multivariate distribution over age, sex, marital status and urbanization as the population according to
Statistics Netherlands (downloadable fromhttp://www.cbs.nl/).
The Brazier algorithmwas conducted in SPSS, version 16.0. All other analyses were conducted with STATA version 8.2/SE
for Windows.
Results
Childhood adversities in the general population
Table 1 presents the percentages of people in the general population with each of the childhood adversities, according to
different categories of demographic and clinical characteristics. We also present the demographic and clinical data for the
group of people who had any childhood adversity, and who had any adversity in one of the three major groups (parental
psychopathology; abuse/neglect; life events).
P. Cuijpers et al. / Child Abuse & Neglect 35 (2011) 937945 941
Table 1
Childhood adversities (before the age of 16) in the general population: demographic characteristics, somatic and mental disorders.
a
Total (%) Demographics Mental disorders Somatic
disorder
% women % living
alone
% paid
job
Mood
disorder
Anxiety
disorder
Substance
related
Any mental
disorder
Total population 100 49.7 17.7 69.4 3.9 9.0 5.8 16.5 39.3
Parental psychopathology
Depression 22.4 54.2

20.1

71.5 7.0

15.2

8.8

25.0

41.3
Anxiety 11.0 56.5

18.6 69.3 8.3

15.9

6.4 23.3

43.8

Problemdrinking 8.3 58.7

20.6 65.4

8.1

15.7

8.1

24.3

44.2

Abuse and neglect

Physical abuse 7.0 44.4 25.1

63.4

9.8

20.0

8.7

29.5

43.8

Psychological abuse 11.6 59.7

24.5

62.4

10.9

23.4

8.1

31.1

48.5

Sexual abuse 3.7 73.2

22.5

53.1

15.1

25.8

4.6 33.0

54.3

Emotional neglect 23.1 52.9

25.2

68.3 8.7

18.4

8.1

27.3

44.9

Life events
Death of a parent 7.5 52.4 18.5 66.5 3.4 10.2 4.4 16.2 40.7
Divorce 6.6 55.3 23.6

62.4

5.6 13.9

12.7

25.8

38.5
Any adversity 46.4 52.3

20.8

68.8 6.3

14.2

7.7

22.9

42.0

Any parental psychopathology 28.6 54.8

19.7

70.4 6.8

14.6

8.4

23.9

42.2

Any abuse/neglect 27.9 52.5

23.4

67.3

8.4

17.7

7.5

26.1

44.7

Any life event 14.3 53.7

21.1

64.2

4.2 11.9

8.1

20.5

39.8
a
We tested whether each group differed fromthe rest of the population with Chi-square analyses and with t-tests for continuous variables.

p<0.05.

p<0.01.

p<0.001.
As can be seen, childhood adversities were signicantly associated with increased levels of mental disorders, as well
as with general medical disorders: two of the three major categories of childhood adversities (parental psychopathology;
abuse/neglect) were strongly associated with mental and general medical disorders.
We also found that people who had suffered one or more childhood adversities were more often women, lived alone,
and in some cases had a paid job less often. Parental death did not seemto be associated with mental or somatic disorder.
Unadjusted disability weights and years lived with disability per 1,000 inhabitants
The unadjusted (excess) disability weights and years lived with disability per 1,000 inhabitants for different childhood
adversities, and disorders are presented in Table 2. As can be seen, the mean overall DWin the general population is 0.177,
which results in a total of 176.8 YLD per 1,000 inhabitants. The DWs were signicantly higher than the base rate in all
childhood adversities, except parental death before the age of 16 (p>0.05). The excess DWs ranged from0.019 for divorce of
Table 2
Prevalence (%), disability weights (DWs) and years lived with disability per 1,000 inhabitants (YLD/1,000), in childhood adversities, mental and general
medical disorders.
Prevalence DW (SE) YLD/1,000
Parental psychopathology
Depression 21.7 0.026 (0.003) 5.7
Anxiety 10.6 0.041 (0.005) 4.4
Problemdrinking 8.3 0.031 (0.005) 2.6
Abuse and neglect
Physical abuse 7.3 0.051 (0.006) 3.7
Psychological abuse 11.8 0.070 (0.005) 8.3
Sexual abuse 3.8 0.067 (0.009) 2.5
Emotional neglect 22.8 0.056 (0.003) 12.7
Life events
Death of a parent 7.6 NS
Divorce 7.2 0.019 (0.006) 1.4
Any adversity 46.4 0.044 (0.003) 20.7
Any parental psychopathology 29.6 0.031 (0.003) 9.0
Any abuse and neglect 27.9 0.057 (0.003) 15.8
Any life event 14.3 0.012 (0.004) 1.8
Somatic disorder 39.3 0.072 (0.003) 28.2
Mental disorders 16.5 0.078 (0.004) 12.9
Mood disorder 3.9 0.174 (0.008) 6.8
Anxiety disorder 9.7 0.094 (0.005) 9.0
Substance-related disorder 5.8 0.024 (0.006) 1.4
Total population 1.00 0.177 (0.001) 176.8
942 P. Cuijpers et al. / Child Abuse & Neglect 35 (2011) 937945
Table 3
Adjusted disability weights (DWs) and years lived with disability per 1,000 inhabitants (YLD/1,000), in different childhood adversities, mental and general
medical disorders.
a,b,c
DW SE YLD/1,000
d
Childhood adversities
Parental anxiety 0.023 (0.004) 2.4
Psychological abuse 0.028 (0.005) 3.3
Emotional neglect 0.025 (0.003) 5.8
Any adversity 0.031
e
(0.003) 14.5
Somatic disorder 0.062 (0.003) 24.5
Mental disorders 0.061
f
(0.004) 10.0
Mood disorder 0.124 (0.008) 4.9
Anxiety disorder 0.048 (0.005) 4.6
Base rate (constant) 0.131 (0.002) 130.6
a
Analyses were conducted with multiple regression analyses.
b
The disability weights for childhood adversities, mental and general medical disorders should be interpreted as the excess DWover the base rate; the
YLD/1000 were calculated as: excess DWprevalence 1,000.
c
All DWs were signicant at the p<0.001 level.
d
YLD/1,000 are calculated as DWprevalence 1,000.
e
This is the result of a separate multivariate regression analysis with DWas dependent variable, and any childhood adversities, somatic disorder and
the three categories of mental disorders as predictor.
f
This is the result of a separate multivariate regression analysis with DWas dependent variable, and childhood adversities, somatic disorder and any
mental disorder as predictor.
the parents to 0.070 for psychological abuse. Adversities in the category of abuse and neglect are associated with the highest
DWs (0.057), followed by parental psychopathology (0.031) and life events during childhood (0.012). The DWs associated
with childhood adversities are lower than the DWs associated with somatic and the major categories of mental disorders.
The YLD per 1,000 inhabitants do not only depend on the mean DW, but also on the prevalence of the condition. Because
the prevalence rates of several childhood adversities are relatively high (Table 2), the YLD/1,000 is also high. All adversities
(46.4% of the population reports one or more adversity) are associated with 20.7 YLD/1,000, which is more than all mental
disorders together (12.9 YLD/1,000). The category of abuse/neglect has the highest YLD/1,000 (15.8), which is also higher
than all mental disorders together.
Individual adversities which are associated with high disease burden are emotional neglect (12.7 YLD/1,000, which is
almost the same as the disease burden of all mental disorders together), and psychological abuse (8.3 YLD/1,000; which is
higher than all mood disorders together).
Disability weights and years lived with disability per 1,000 inhabitants, adjusted for mental and general medical disorders
We entered the 9 childhood adversities together with the 3 categories of mental disorders and general medical disorders
as predictors into a multivariate regression model, with DWas the dependent variable. The results are presented in Table 3
(only variables that remained signicant in the multivariate analyses are presented in the Table). We removed the non-
signicant variables stepwise (the variable with the highest p-value in the rst step, the second with the highest p-value
in the second step, until all non-signicant predictors were removed). As can be seen in Table 3, only 3 adversities were
found to have a signicant association with the DW after controlling for somatic and mental disorders: parental anxiety,
psychological abuse, and emotional neglect. The YLD/1,000 in 3 signicant adversities was considerable. Emotional neglect
had the highest YLD/1,000 (5.8), which was higher than the YLD/1,000 for mood disorders (4.9).
Because we wanted to assess the overall DW of all adversities together, we conducted a separate regression analysis
with a dummy variable indicating whether the subject had experienced any childhood adversity (yes/no) as well somatic
and mental disorders as predictor. This indicated that the overall DWof any adversity was 0.031 (SE=0.003), and that the
YLD/1,000 was 14.5, which was 45% higher than all mental disorders together.
In the same way, we examined the overall DWof all categories of mental disorders together. We conducted a separate
regression analysis with the 9 adversities, somatic disorders and one category of mental disorders (any mental disorder) as
predictor. After backward removal of non-signicant variables, the DWfor any mental disorder was 0.061 (SE=0.004), and
the YLD/1,000 was 10.0.
Discussion
In this study, we examined the disability weights (DWs) of childhood adversities. A DWindicates the amount of quality
of life that is lost in a certain health state, because of a disorder or risk factor. A DWindicates the percentage of quality of
life that is lost because of the disorder or health state on a scale of 01, where 0 (not disabled) indicates perfect health and
1 refers to a health state equivalent to death. With the DWit is also possible to examine the impact of a certain disease or
risk factor on a population. The years lived with disability (YLD) indicate howmany years in good health are lost because of
a disorder or risk factor in a population.
P. Cuijpers et al. / Child Abuse & Neglect 35 (2011) 937945 943
We found strong indications that the disease burden of childhood adversities in adults is very high. On an individual level,
each of the adversities had a lower DWthan mood and anxiety disorders. This should be interpreted with caution because
our method to measure childhood adversities was not optimal (see below). However, the prevalence of childhood adversities
we found in the population was high. Because these prevalence rates were high, however, the total disease burden in terms
of YLD on the population level was also high, despite the low DWon an individual level. When all adversities were taken
together theYLDwas considerablyhigher thantheYLDassociatedwithmental disorders. This remainedtrueafter adjustment
for the presence of mental and general medical disorders. The fact that the DWremained signicant after adjusting for the
presence of mental disorders also suggests that childhood adversities have an independent effect on disease burden, apart
from their effect on mental and general medical disorders. This should be interpreted with caution, however, because we
did not measure all mental disorders in this study. Among the nine childhood adversities we examined, psychological
abuse, emotional neglect and parental anxiety were the ones that remained signicant in multivariate analyses in which
we adjusted for other adversities, mental and general medical disorders. So, it seems that especially these three adversities
have an independent effect on DW. These ndings are in line with other research showing that childhood adversities are
associated with health outcomes in adulthood (Corso et al., 2008; Felitti et al., 1998; Sachs-Ericsson et al., 2007, 2009). Our
study adds to this by showing that childhood adversities have a strong impact on disease burden, through increasing the
risk of mental and general medical disorders, but also by an effect which is independent fromthese disorders.
This study has several strengths andlimitations. Strengths include the relatively large, representative community sample,
andtheuseof well-validateddiagnostic instruments toassess thepresenceof mental disorders. Thereare, however, alsosome
limitations. First, the assessment of childhood adversities relied on retrospective recall at the time of the baseline interview.
However, there is evidence that supports the validity of accurate recall of adverse childhood events, although retrospective
research may introduce some sampling error (Hardt & Rutter, 2004). If anything, this design of using retrospective reports,
might lead to underreporting of childhood adversities (Oosterlee, Vink, & Smit, 2009). In the rst place, it has been shown
that maltreated people are not always able to remember being maltreated, for example due to dissociation (Corso et al.,
2008). Secondly, older people tend to report less childhood adversities. This may for example be due to memory reasons,
or to premature mortality in people that have experienced childhood adversities (Felitti et al., 1998). Underestimating the
occurrence of childhood adversities might lead to an even higher disease burden than found in the current study. There
is also evidence that a condential self-reported survey format for questioning childhood abuse is more likely to elicit
reports of childhood abuse histories than a standard psychiatric intake interview(Dill, Chu, Grob, &Eisen, 1991). There were
several other problems with the questions assessing childhood adversities, apart fromthe retrospective nature. The question
measuring child abuse does not make clear who was responsible for the abuse. Furthermore, the childhood adversities were
assessedwithonly one question, while more questions or more detailedquestions couldhave resultedinless underreporting
of the adversities. If the assessment of childhood adversities would have been better and higher prevalence rates would have
been found, this would have led to an even higher impact on the disease burden of childhood adversities.
A second limitation is that we also assessed general medical disorders using self-report. We did, however, ask whether
the patient was treated for it by a doctor. Furthermore, several studies have shown that there is good agreement between
medical records and self-reported chronic conditions, including diabetes, heart disease, and asthma (Kehoe, Wu, Leske, &
Chylack, 1994; Kriegsman, Penninx, Van Eijk, Boeke, & Deeg, 1996). Third, we have to realize that the YLD are only one part
of the disease burden, and we did not examine the other part (years of life lost due to premature mortality). This results in
a clear underestimation of the overall disease burden of general medical disorders we examined in this study. Fourth, we
used the Brazier algorithm to calculate DWs and YLD, which was developed using the assessments of the British general
population, while our sample was fromThe Netherlands. This may have inuenced our outcomes somewhat. Fifth, we used
the 12-month prevalence rates of general medical disorders, while we estimated the 1-month prevalence rates of mental
disorders. However, as the general medical disorders were all chronic, this probably did not change the overall results
considerably. Sixth, in the data collection used in this study people were not asked whether they adopted treatment or not.
It can be expected that being in treatment or not may inuence the ndings. On the one hand, the DWand YLD might be
higher for people who never received treatment, assuming that people that received well tailored care are more capable of
processing the adversities that has been experienced in childhood. On the other hand, it is also possible that persons with
more severe childhood maltreatment and symptoms would be more likely to seek treatment. Even with treatment, their
residual symptoms could be more severe than those who did not seek treatment. Seventh, respondents are probably not
accurate reporters of their parents mental health disorders, because the assessment of these disorders requires a diagnostic
interview by a experienced and well-trained clinician. Despite these limitations, the results of our study clearly show that
the impact of childhood adversities on public health is very large.
The ndings of this study conrm the importance of preventive interventions. For example, prevention would require
increased recognition of the occurrence of childhood adversities and the recognition that childhood adversities in many
cases lead to coping and regulation strategies that often have a negative impact on health outcomes. Increased recognition
is a rst step towards taking preventive measures (Felitti et al., 1998).
In health care recognition is a problem, because the relationship between childhood adversities and health problems is
overlooked (Sachs-Ericsson et al., 2009). A possible reason could be the time delay between the adversity and the health
problems. Many physicians do not start conversation or do not ask questions about the possibility of childhood adversities
because those are considered sensitive issues and too personal matters. Research has shown that physicians fears are often
unfounded (Felitti et al., 1998). If screening for psychological problems or health issues would include screening for the
944 P. Cuijpers et al. / Child Abuse & Neglect 35 (2011) 937945
occurrence of childhood adversities, childhood adversities could be detected in an earlier stage and treatment could have a
more integrative approach in which the symptoms are addressed as well as the causes of these symptoms.
When researching the relationships between child maltreatment and adult health outcomes, most studies examine the
long term consequences caused by sexual abuse. Less research is done on the effect of neglect, whereas the results in this
study indicate that neglect accounts for a higher disease burden than sexual abuse and is far more prevalent. This indicates
that future research is needed on the long termconsequences of neglect, since the prevalence of neglect is the highest among
all types of child maltreatment.
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