Join Us | Latest Articles | Contact

Journal Home


Editorial Board


Recent Articles


Submit to this journal


Special Issues


Current issue

Trauma Cases and Reviews





DOI: 10.23937/2469-5777/1510003



Childhood Maltreatment Trauma: Relevance for Adult Physical and Emotional Health. A Review

Lindsay Hamilton, Valerie Micol-Foster and Maria Muzik*


Department of Psychiatry, University of Michigan, USA


*Corresponding author: Maria Muzik, Department of Psychiatry, University of Michigan, 4250 Plymouth Rd, Ann Arbor, MI 48109, USA, E-mail: muzik@med.umich.edu
Trauma Cases Rev, TCR-1-003, (Volume 1, Issue 1), Review Article; ISSN: 2469-5777
Received: March 11, 2015 | Accepted: June 02, 2015 | Published: June 04, 2015
Citation: Hamilton L, Micol-Foster V, Muzik M (2015) Childhood Maltreatment Trauma: Relevance for Adult Physical and Emotional Health. A Review. Trauma Cases Rev 1:003. 10.23937/2469-5777/1510003
Copyright: © 2015 Hamilton L, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.



Abstract

Childhood maltreatment (CM) is a widespread public health concern in the U.S. as it affects almost four million children annually. The adverse consequences of CM can be seen across development from attachment disturbances and developmental delays in infancy to an increased risk for conduct and emotional problems in later childhood and adolescence. In addition, the associations between CM and negative outcomes have been traced as far as adulthood to mental and physical wellbeing of adult survivors. This article summarizes current knowledge linking CM exposure to adult functioning, and highlights factors that either buffer or accelerate risk for the individual in the aftermath of childhood trauma. The recognition of distinct factors that shape the relationship between CM and subsequent outcomes may provide a window of opportunity for the development of targeted clinical interventions to adult survivors.


Keywords

Childhood maltreatment, Mental health, Physical health, Resilience


Introduction

Childhood Maltreatment (CM) is prevalent and impacts many children in the United States, with recent national estimates of 3.9 million children being reported to Child Protective Service (CPS) in 2013 and 679,000 substantiated child abuse cases [1]. Childhood maltreatment encompasses multiple different forms of trauma, including physical, sexual, or emotional abuse and also neglect. Neglect is the most widespread type of maltreatment (78% of substantiated reports due to neglect), followed by physical abuse (18.3%) and sexual abuse (9.3%) [1]. The damaging effects of CM can manifest as early as infancy or early school age [2] with negative consequences on memory, attachment, socio-emotional development, or behavioral adjustment [2-6] compared to children who had not experienced early maltreatment. By adolescence, early maltreatment is associated with later depression and suicide attempts [7-10], juvenile delinquency [10-12], conduct disorder [13], substance use disorders [14] and impairments in interpersonal functioning [8] Overall, the devastating consequences of CM on the developmental trajectories of children and adolescents are well documented [15-17]. In this report we focus on effects of CM beyond childhood and adolescence and review published work on CM and adult outcomes, including physical, emotional, and overall functioning. We discuss possible mechanisms underlying the link between CM and adult wellbeing and present several risk and resiliency factors that may be implicated in the relationship between CM and adult outcomes.


Method

In order to identify the most salient research for the current review, the online databases PsycINFO, PubMed, and Google Scholar were searched. The terms for CM included "childhood maltreatment," "childhood abuse" "childhood adversity," while outcome searches were "adult outcomes" "adult health" "adult physical health" and "adult mental health. Factors related to adaptive outcomes included search terms "resilience" "protective factors" "biological factors" "family factors" and "social support." Inclusion criteria for studies included in this review paper were as follows: published studies in English; studies reported on maltreatment participants who had experienced maltreatment before age 18 (i.e., in infancy, childhood, or adolescence); reported study outcome were measured in adulthood (i.e., age 21 and older). There were no exclusions regarding publication year; furthermore all childhood maltreatment types (i.e., childhood physical, sexual and emotional abuse, and physical and emotional neglect) and childhood adversity, a term that encompasses conditions that enhance likelihood for childhood maltreatment (e.g., living with a mentally ill or substance abusing parent, high interpersonal conflict in the home etc.) were included in this report. A total of 200 articles were downloaded and their abstracts reviewed for inclusion by LH and VMF; consensus for appropriate inclusion was reached on 160 papers, which are included in this review.


CM Effects on Adult Physical Health

Adult survivors of CM are more likely to report physical ailments than adults who have not experienced CM including chronic pain [18], headaches and migraine [19-22], gastrointestinal problems [20,23], asthma [21,23], diabetes and heart problems [19,21,23], bronchitis and emphysema [19,24], and finally, cancer [19,25]. These adult survivors utilize medical and emergency services more often for physical health problems [26-29], resulting in increased health care costs [26,29]. Walker and colleagues (1999) reported that annual health care costs were about $97 higher in women with CM exposure compared to women without a history of CM, and victims of childhood sexual abuse (CSA) had the highest cost increase by $245 annually. Childhood maltreatment is also related to higher adult BMI and obesity [19,24,30-32], which is in turn associated with numerous consequences for health and well-being [33-36]. In a sample of over 300 bariatric surgery candidates who presented with extreme obesity (Mean BMI=51.1, SD 9.6kg), over two-thirds (69%) endorsed some form of childhood maltreatment [30]. Another consequence of CM exposure may be greater engagement with risky sexual health behaviors (e.g. younger age of initial sexual activity, greater number of sexual partners, more unplanned pregnancies, greater frequency of sexual intercourse with strangers, etc. [19,24,28,37]. This may lead to increased risk for sexually transmitted infections [19,24]. This relationship between sexual problems and CM has been studied most extensively in survivors of sexual abuse [28,38]. Finally, adult CM survivors also report more sleep problems including problems falling and staying asleep as well as trauma related nightmares [19,24,39-41] compared with adults who have not experienced CM. In summary, exposure to CM is associated with a host of physical problems or problem behavior that increases the likelihood for physical illness and suffering among these adult survivors.


CM Effects on Adult Emotional Health and Overall Functioning

Depression is one of the most common outcome variables of study related to childhood adversity, and the literature widely supports that those who have experienced CM have an increased risk of depression in adulthood [23,28,37,42-48]. Suicidal ideation and attempts, the most severe symptom of depression, is also associated with CM, and this association has been found amongst psychiatric inpatients [49], community health settings [50,51], and large longitudinal studies [19,28,52]. In addition to depression, CM also increases the likelihood for other psychiatric conditions including anxiety disorders [23,28,44] post-traumatic stress disorder [45,47,53], personality disorders [7,54-56] schizophrenia [57,58] and bipolar disorder [59]. There are also markedly higher rates of substance use disorders in CM survivors [60,61].

CM may also interfere with domains in a person's life course that are the foundations for overall achievement and life satisfaction. CM survivors may experience problems in interpersonal functioning, relationship difficulties, and marital and family problems [37,54]. Their educational achievement is impaired [54,62,63], most likely based on the fact that CM survivors show lower scores on standardized tests, more school absenteeism and grade repetitions, and are more often school dropouts [64]. Subsequently, adult CM survivors are also more likely dependent on welfare, and have difficulties in finding and maintaining employment [54,62,63,65]. Additionally, rates of CM are also reported higher in homeless populations than in the general population [66].

In summary, abundant literature supports that CM has detrimental effects on adult physical and psychological functioning, and the effects appears to be dose-dependent, such that greater severity of CM (i.e., longer abuse exposure, or multiple types of abuse) is associated with increased prevalence of poor outcomes [19,67,68], more complex symptom presentations [45], and more severe problems [69].


Possible Pathways Linking CM and Adult Functioning

In a seminal paper based on a review of the literature, Kendell-Tackett and colleagues (2002) proposed four possible pathways of how CM exposure may translate to poor adult functioning. This section expands upon this framework with the inclusion of more recent findings in the literature supporting its merit. In addition, we will also elaborate on how CM may be affecting a person's capacity for emotion regulation, ultimately laying the ground for adult psychopathology.

As a first pathway, Kendell-Tackett et al. (2002) proposed that CM may predispose an individual to engage in unhealthy life-style behaviors and habits that subsequently interfere with one's health [70]. Research supports the relationship of CM to increased smoking [19,71,56] sedentary lifestyle [19], alcohol and substance abuse [19,28,47,54,71] and poor eating habits [72]. These behaviors over time may increase the risk for cardiovascular disease, cancer, and overall increased mortality [73-76]. Knowledge about this link is highly relevant for clinicians as they have access to this patient population, and can educate about and motivate towards healthy life style changes.

As a second pathway, the research group proposed the phenomenon of re-victimization, that is, the observation that survivors of CM are more likely to again encounter abuse later in their life, often through a romantic partner [27,66,77,78]. It has been hypothesized that victims of CM are more likely to mate with abusive romantic partners later in life because a critical psychological sequel from their childhood abuse was the establishment of low self-esteem and the failure to learn appropriate assertiveness and self-protection skills [77,79]. Over time, CM survivors may experience learned helplessness, expecting maltreatment to be a normative part of interpersonal relationships, and failing to see possibilities for escape or alternatives [80].

As a third pathway, CM may lead to changes in cognitive processing that ultimately shapes their overall functioning [70,81]. Survivors of CM are less accurate in processing stimuli designed to elicit different emotions and seem to have a "bias towards more negative perceptions" [82]. For example, when exposed to standard pictures that are known to elicit positive, neutral, or negative emotions, CM survivors failed to recognize the positive and neutral pictures more often than controls did, while their recall for negative pictures was equally accurate [81]. Young & Widom (2014) suggest that this may be because CM survivors develop a negative world view from their childhood experiences, which as such, makes positive emotions more difficult to recall [81]. Others have supported that negative cognitive styles mediate the relationship between CM and subsequent psychopathology [55,83-85]. As a result of this altered emotion processing in CM survivors, these individuals may develop negative internalized beliefs about themselves and their world including feelings of shame, mistrust [83], pessimistic and rigid beliefs about the self and world, hopelessness [84,85], and persistent feeling of the world being dangerous [86]. These negative cognitions are thought to underlie vulnerability for depression [87,88], PTSD [89,90] and personality disorders [91,92].

Finally, as a fourth pathway, Kendell-Tackett et al (2002) propose that the CM may lead to poor outcomes through greater vulnerability for negative emotions, which then predispose to greater risk for psychopathology [70]. The capacity to regulate one's emotions and tolerate and recover from distress is a critical component for emotional wellbeing across the life span [93-95]. Managing arousal and regulate one's emotions is established already in infancy and early childhood through parental modeling and coaching [96]. In abusive circumstances, the abusive caregiver fails to respond to the emotional needs of the young child and thus jeopardizes the child's developmental competencies in acknowledging and managing emotions [97]. This child grows up to be a parent and adult with impaired ability to regulate emotions when faced with life circumstances (e.g., stress, loss, relationship challenges…) that demand coping and affective regulation [97]. This inability, in turn, may make this person more vulnerable to experience psychopathology, such as depression [83], borderline personality disorder [97], or PTSD [98,99].


Protective Factors that may Buffer CM Effects

A review by Heller and colleagues [100] outlined three main factors that may promote a person's resilience following childhood maltreatment: 1) Biology, 2) Family support, and 3) Social support. In the remainder of this paper we will elaborate on these three factors. This section expands upon Heller's original findings on temperamental and dispositional features associated with resilience to include other biological constructs as well including gender differences, genetics and neuroendocrine functioning which all are reported to modify vulnerability and resilience. Moreover, we also expand in this review on additional family and social support factors that have been published since the original Heller paper.


Biology

A person's biological make-up (e.g. gender or trait markers,) may enhance or reduce resilience. Women who have experienced CM are more vulnerable than men to develop negative consequences including higher rates of depression [101] and PTSD [102,103]. Several factors may make women more vulnerable to effects of trauma. Reproductive hormones (e.g. estrogen, progesterone) have been found to alter the functionality of the biological stress systems (e.g., the hypothalamic-pituitary adrenal (HPA-) stress axis) and also the processing of emotional experiences [104,105]. Specifically, reproductive hormones influence emotional memory processing: during the luteal phase (high levels of progesterone and estradiol) women have more intense emotional memory acquisition/consolidation and recall, and have more intrusive and intense memories in response to trauma experiences (e.g., flashbacks; [106,107] when compared with women in the follicular phase or compared to men. Thus, women who are CM survivors and in relationships with ongoing abuse exposure may be at a greater risk for psychopathology because of their reproductive hormones. In addition, women may also be at an increased risk for sleep difficulties because of reproduction. Sleep disturbances are more common around times of reproductive changes such as pregnancy [108] and in the postpartum [109,110]. A review by Soares and Murray (2008) describes the numerous hormonal disruptions implicated in the postpartum period which may explain impacts to sleep outside of newborn care, such as the decline in progesterone after delivery as well as changes in melatonin, both of which are implicated in sleep [111]. In summary, reproductive hormones may make women with CM histories particularly vulnerable for psychopathology and sleep disorders.

Temperamental differences may also increase vulnerability or act as buffer following CM exposure. Temperament can be defined as biologically based individual differences influenced by heredity, maturation, and experience [112]. Genes code for the biological substrate, and inherited variations of one's genetic code may increase or decrease one's resilience [113]. For example, of the several genes which may contribute to temperamental differentiation, the dopamine D4 receptor (DRD4) gene has been studied more extensively. Having the DRD4 long allele (L-DRD4 or also called 7-repaet polymorphism, 7R) is implicated in greater attention difficulties and higher activity levels [114,115] and has been associated with ADHD in children [116]. In adulthood, Bakermans-Kranenburg and colleagues (2011) found that having the DRD4-7R moderated the relationship between childhood parental problems and unresolved trauma and loss, such that parenting problems only mattered in 7R carriers [117]. Findings like these and many similar published in recent years, document the importance of both genetic and environmental processes which may increase risk and resilience following CM.

Other individual characteristics may also be related to differential resilience following CM [118] including intellectual ability, self-esteem, locus of control, attribution of blame, and spirituality [100]. Some research supports that greater intelligence fosters more successful coping [119,120]; however operational definitions of intellectual functioning vary in the literature, and measures of intelligence tend to be indirect and global than direct measures of IQ [100]. Additionally, positive beliefs about the self, such as high self-esteem and internal locus of control are associated with lower rates of psychopathology and lower rates of re-victimization following CM and thus may also be important factors in resilience [119,121-123]. Results on locus of control are heterogeneous, however, as much research has found that the tendency to blame external sources (external locus of control) for the traumatic event (e.g. blaming the perpetrator for the event) is more common in resilient samples [24-126]. Finally, higher levels of spirituality or religiosity are associated with resilient outcomes [121,126] despite the fact that CM in general is often associated with lower religiosity [127-129].

CM may change the functioning of one's neuroendocrine systems (i.e., HPA axis) and alter the structure or functioning of brain neurocircuits related to stress coping. Some research suggests that survivors of CM have a decrease in the size of the hippocampus, amygdala, and neocortex which alters the HPA axis functioning [105,130] leaving survivors of CM more vulnerable to stress [131]. Genetic variants in the axis' functioning (e.g., variations in the gene coding for the corticotrophin-releasing hormone receptor CRHR1) may be related to more dysfunctional coping following environmental stress [132]. For example, in survivors of CM, one variant in the CRHR1 gene has been associated with a protective effect against adult depression [133,134], indicating that a person's biological make-up interacts with the environmental exposure (i.e., the CM) to create risk or resilience.


Family factors

Several studies support findings that family factors may moderate risk for adult psychopathology following CM. Negative family functioning (e.g. conflict) contributes to worse adult outcomes and positive family functioning (e.g. expressiveness, and family cohesion) contributes to better outcomes [135-138]. Perceived social support, defined as perception of availability and support (e.g. emotional, social, practical, financial) from family sources are also protective and buffer against depression and anxiety [139], or suicide attempts [140] in CM samples. Within the context of the family, parental support as well as secure attachment with a parent or care giver who have also been implicated in adaptive outcomes following CM. The adaptive effects of caregiver support include higher self-esteem, lower internalizing symptoms (anxiety, depression) and externalizing symptoms (aggression, delinquency), as well as decreased cigarette smoking compared to CM survivors with lower caregiver support [56,141-144]. In fact, Fromuth (1986) found that correlations between childhood sexual abuse and later psychological adjustment largely disappeared once controlling for parental support, indicating the critical role of parental support in the aftermath of CM. However, other studies do not confirm the role of family in mitigating adult outcomes. Howell & Miller-Graff (2014) found that only friends' social support was associated with resiliency to adult psychopathology [145], and other research has found that parental support did not have a mediating effect on adult psychological adjustment following CM [146]. Variation in methodology for defining family functioning and support may contribute to differential outcomes [100]; as well as the fact that some studies do not separate social support into family versus other forms of support [48,147]. In addition, the perpetrator of maltreatment is not usually controlled for in analyses with social support, and thus, it likely follows that support from a parent or caregiver may not be protective in cases where he or she was the source of maltreatment [145,146].


Social support

Finally, non-familial forms of social support may be also highly relevant for adaptation following CM. Heller et al. (1999) emphasizes the role of school and community involvement [100] in providing a buffer for CM [148,149]. In addition, social support from friends has shown a protective effect against adult psychopathology in CM survivors [145,150]. Research has also demonstrated the effect of romantic attachment relationships in adulthood following CM; secure romantic attachment orientation appears to be protective, while insecure attachment is associated with greater psychopathology [85,138,151,152]. Thus, a relationship with a supportive partner appears to be a critical factor for resiliency following CM exposure [144].

Social support in the context of abuse disclosure may be important for survivors as well [48,126]. Some research has found that in the case of sexual abuse disclosure, subsequent adulthood functioning was mediated by negative reactions of caregivers or family to the disclosure as a child [153,154] highlighting the importance of social support following the immediate aftermath of childhood maltreatment.


Conclusion and Clinical Implications

CM is not uncommon and has been shown in multiple studies to potentially have a devastating impact on the lives of many adult survivors. In this paper we have discussed the many ways how CM may shape adults' physical and emotional functioning, and proposed, based on the literature, several mechanisms for the long term poor adult outcomes. For clinicians this knowledge is highly relevant, as it may shed light on some of their "difficult" patients' maladaptive behaviors and help shape their understanding for why these patients may have a difficult time modifying their life styles. Recent work on Motivational Interviewing [155] strategies, specifically use of reflective listening and emotional validation, had demonstrated good results to engage individuals with trauma backgrounds [156]. It is apparent that CM may impact well-being in adulthood through profound effects on physical and emotional health as well as other aspects of functioning, including education, romantic relationships, and world view. Finally, we also outlined risk and protective factors that may modify the risk. Women and individuals with low family and social support seem to be particularly at risk for poor outcomes in the face of CM. The recognition of factors that may modify the relationship between CM and subsequent outcomes may provide a window of opportunity for the development of targeted clinical interventions to hopefully change life trajectories of individuals touched by childhood maltreatment.


Acknowledgements

Support for this research or manuscript preparation was provided by grants from the National Institute of Mental Health and Eunice Kennedy Shriver National Institute of Child Health and Human Development (NIMH K23 MH080147; PI: Muzik) and the Michigan Institute for Clinical and Health Research (MICHR) at the University of Michigan (UL1RR024986; PI: Muzik).


References
  1. Child Maltreatment 2012 (2012) U.S. Department of Health & Human Services Administration for Children and Families, Administration on Children, Youth, & Families, Children's Bureau. Washington, DC, USA.

  2. Kotch JB, Lewis T, Hussey JM, English D, Thompson R, et al. (2008) Importance of early neglect for childhood aggression. Pediatrics 121: 725-731.

  3. Ainsworth MDS, Eichberg C (1991) Effects on infant-mother attachment of mother's unresolved loss of an attachment figure, or other traumatic experience. Attachment Across the Life Cycle 3: 160-183.

  4. Gaensbauer TJ (2002) Representations of trauma in infancy: Clinical and theoretical implications for the understanding of early memory. Infant Mental Health Journal 23: 259-277.

  5. Schore AN (2001) The effects of early relational trauma on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal 22: 201-269.

  6. Zeanah CH, Scheeringa MS (1997) The experience and effects of violence in infancy. Children in a Violent Society: 97-123.

  7. Brown J, Cohen P, Johnson JG and Smailes EM (1999) Childhood Abuse and Neglect: Specificity of Effects on Adolescent and Young Adult Depression and Suicidality. J Am Acad Child Adolesc Psychiatry 38: 1490-1496.

  8. Johnson JG, Cohen P, Gould MS, Kasen S, Brown J, et al. (2002). Childhood adversities, interpersonal difficulties, and risk for suicide attempts during late adolescence and early adulthood. Archives of General Psychiatry 59: 741-749.

  9. Jonson-Reid M, Kohl PL, Drake B (2012) Child and adult outcomes of chronic child maltreatment. Pediatrics 129: 839-845.

  10. Smith C, Thornberry TP (1995) The relationship between childhood maltreatment and adolescent involvement in delinquency. Criminology 33: 451-481.

  11. Fergusson DM, Lynskey MT (1997) Physical punishment/maltreatment during childhood and adjustment in young adulthood. Child Abuse Negl 21: 617-630.

  12. Ryan JP, Testa MF (2005) Child maltreatment and juvenile delinquency: Investigating the role of placement and placement instability. Children and Youth Services Review 27: 227-249.

  13. Huizinga D, Haberstick BC, Smolen A, Menard S, Young SE, et al. (2006). Childhood maltreatment, subsequent antisocial behavior, and the role of monoamine oxidase A genotype. Biol Psychiatry 60: 677-683.

  14. De Sanctis VA, Trampush JW, Harty SC, Marks DJ, Newcorn JH, et al. (2008). Childhood maltreatment and conduct disorder: independent predictors of adolescent substance use disorders in youth with attention deficit/hyperactivity disorder. J Clin Child Adolesc Psychol 37: 785-793.

  15. Glaser D (2012) Effects of child maltreatment on the developing brain Brain, mind, and developmental psychopathology in childhood: 199-218.

  16. Kendall-Tackett KA, Williams LM, Finkelhor D (1993) Impact of sexual abuse on children: a review and synthesis of recent empirical studies. Psychol Bull 113: 164-180.

  17. Tonmyr L, Thornton T, Draca J, Wekerle C (2010) A review of childhood maltreatment and adolescent substance use relationship. Current Psychiatry Reviews 6: 223-234.

  18. Davis DA, Luecken LJ, Zautra AJ (2005) Are reports of childhood abuse related to the experience of chronic pain in adulthood? A meta-analytic review of the literature. Clin J Pain 21: 398-405.

  19. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, et al. (1998) Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 14: 245-258.

  20. Goodwin RD, Hoven CW, Murison R, Hotopf M (2003) Association between childhood physical abuse and gastrointestinal disorders and migraine in adulthood. Am J Public Health 93: 1065-1067.

  21. Romans S, Belaise C, Martin J, Morris E, Raffi A (2002) Childhood abuse and later medical disorders in women. An epidemiological study. Psychother Psychosom 71: 141-150.

  22. Tietjen GE, Brandes JL, Peterlin BL, Eloff A, Dafer RM, et al. (2010) Childhood maltreatment and migraine (part II). Emotional abuse as a risk factor for headache chronification. Headache 50: 32-41.

  23. Springer KW, Sheridan J, Kuo D, Carnes M (2007) Long-term physical and mental health consequences of childhood physical abuse: Results from a large population-based sample of men and women. Child Abuse Negl 31: 517-530.

  24. Anda RF, Felitti VJ, Bremner JD, Walker JD, Whitfield C, et al. (2006) The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci 256: 174-186.

  25. Fuller-Thomson E, Brennenstuhl S (2009) Making a link between childhood physical abuse and cancer: results from a regional representative survey. Cancer 115: 3341-3350.

  26. Arnow BA (2004) Relationships between childhood maltreatment, adult health and psychiatric outcomes, and medical utilization. J Clin Psychiatry 65: 10-15.

  27. Cannon EA, Bonomi AE, Anderson ML, Rivara FP, Thompson RS (2010) Adult health and relationship outcomes among women with abuse experiences during childhood. Violence Vict 25: 291-305.

  28. Fergusson DM, McLeod GF, Horwood LJ (2013) Childhood sexual abuse and adult developmental outcomes: findings from a 30-year longitudinal study in New Zealand. Child Abuse Negl 37: 664-674.

  29. Walker EA, Unutzer J, Rutter C, Gelfand A, Saunders K, et al. (1999) Costs of health care use by women HMO members with a history of childhood abuse and neglect. Arch Gen Psychiatry 56: 609-613.

  30. Grilo CM, Masheb RM, Brody M, Toth C, Burke-Martindale CH, et al. (2005) Childhood maltreatment in extremely obese male and female bariatric surgery candidates. Obes Res 13: 123-130.

  31. Gunstad J, Paul RH, Spitznagel MB, Cohen RA, Williams LM, et al. (2006) Exposure to early life trauma is associated with adult obesity. Psychiatry Res 142: 31-37.

  32. Walker EA, Gelfand A, Katon WJ, Koss MP, Von Korff M, et al. (1999) Adult health status of women with histories of childhood abuse and neglect. Am J Med 107: 332-339.

  33. Calle EE (2007) Obesity and cancer. BMJ 335: 1107-1108.

  34. Flegal KM, Kit BK, Orpana H, Graubard BI (2013) Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA 309: 71-82.

  35. Fontaine KR, Barofsky I (2001) Obesity and health-related quality of life. Obes Rev 2: 173-182.

  36. Norman RJ, Clark AM (1998) Obesity and reproductive disorders: a review. Reprod Fertil Dev 10: 55-63.

  37. Mullen PE, Martin JL, Anderson JC, Romans SE, Herbison GP (1996) The long-term impact of the physical, emotional, and sexual abuse of children: a community study. Child Abuse Negl 20: 7-21.

  38. Aaron M (2012) The pathways of problematic sexual behavior: A literature review of factors affecting adult sexual behavior in survivors of childhood sexual abuse. Sexual Addiction & Compulsivity 19: 199-218.

  39. Greenfield EA, Lee C, Friedman EL, Springer KW (2011) Childhood abuse as a risk factor for sleep problems in adulthood: evidence from a U.S. national study. Ann Behav Med 42: 245-256.

  40. Schäfer V and Bader K (2009) The impact of early-life maltreatment on dreams of patients with insomnia. International Journal of Dream Research 2: 20-28.

  41. Swanson LM, Hamilton L, Muzik M (2014) The role of childhood trauma and PTSD in postpartum sleep disturbance. J Trauma Stress 27: 689-694.

  42. Afifi TO, Boman J, Fleisher W, Sareen J (2009) The relationship between child abuse, parental divorce, and lifetime mental disorders and suicidality in a nationally representative adult sample. Child Abuse Negl 33: 139-147.

  43. Johnson JG, Cohen P, Brown J, Smailes EM, Bernstein DP (1999) Childhood maltreatment increases risk for personality disorders during early adulthood. Arch Gen Psychiatry 56: 600-606.

  44. Buist A, Janson H (2001) Childhood sexual abuse, parenting and postpartum depression--a 3-year follow-up study. Child Abuse Negl 25: 909-921.

  45. Cloitre M, Stolbach BC, Herman JL, van der Kolk B, Pynoos R, et al. (2009) A developmental approach to complex PTSD: childhood and adult cumulative trauma as predictors of symptom complexity. J Trauma Stress 22: 399-408.

  46. Dias A, Sales L, Hessen DJ, Kleber RJ (2014) Child maltreatment and psychological symptoms in a Portuguese adult community sample: the harmful effects of emotional abuse. Eur Child Adolesc Psychiatry: 1-12.

  47. Duncan RD, Saunders BE, Kilpatrick DG, Hanson RF, Resnick HS (1996) Childhood physical assault as a risk factor for PTSD, depression, and substance abuse: findings from a national survey. Am J Orthopsychiatry 66: 437-448.

  48. Runtz MG, Schallow JR (1997) Social support and coping strategies as mediators of adult adjustment following childhood maltreatment. Child Abuse Negl 21: 211-226.

  49. Bryer JB, Nelson BA, Miller JB, Krol PA (1987) Childhood sexual and physical abuse as factors in adult psychiatric illness. Am J Psychiatry 144: 1426-1430.

  50. Briere J, Runtz M (1986) Suicidal thoughts and behaviours in former sexual abuse victims. Canadian Journal of Behavioural Science/Revue Canadienne Des Sciences Du Comportement 18: 413-423.

  51. Kaslow NJ, Thompson MP, Okun A, Price A, Young S, et al. (2002) Risk and protective factors for suicidal behavior in abused African American women. J Consult Clin Psychol 70: 311-319.

  52. Silverman AB, Reinherz HZ, Giaconia RM (1996) The long-term sequelae of child and adolescent abuse: a longitudinal community study. Child Abuse Negl 20: 709-723.

  53. Yehuda R, Halligan SL, Grossman R (2001) Childhood trauma and risk for PTSD: relationship to intergenerational effects of trauma, parental PTSD, and cortisol excretion. Dev Psychopathol 13: 733-753.

  54. Dolan M, Whitworth H (2013) Childhood sexual abuse, adult psychiatric morbidity, and criminal outcomes in women assessed by medium secure forensic service. J Child Sex Abus 22: 191-208.

  55. Hengartner MP, Müller M, Rodgers S, Rössler W, Ajdacic-Gross V (2013) Can protective factors moderate the detrimental effects of child maltreatment on personality functioning? J Psychiatr Res 47: 1180-1186.

  56. Topitzes J, Mersky JP, Reynolds AJ (2010) Child maltreatment and adult cigarette smoking: a long-term developmental model. J Pediatr Psychol 35: 484-498.

  57. Schenkel LS, Spaulding WD, DiLillo D, Silverstein SM (2005) Histories of childhood maltreatment in schizophrenia: relationships with premorbid functioning, symptomatology, and cognitive deficits. Schizophr Res 76: 273-286.

  58. Read J, van Os J, Morrison AP, Ross CA (2005) Childhood trauma, psychosis and schizophrenia: a literature review with theoretical and clinical implications. Acta Psychiatr Scand 112: 330-350.

  59. Garno JL, Goldberg JF, Ramirez PM, Ritzler BA (2005) Impact of childhood abuse on the clinical course of bipolar disorder. Br J Psychiatry 186: 121-125.

  60. Kendler KS, Bulik CM, Silberg J, Hettema JM, Myers J, et al. (2000) Childhood sexual abuse and adult psychiatric and substance use disorders in women: an epidemiological and cotwin control analysis. Arch Gen Psychiatry 57: 953-959.

  61. Lo CC, Cheng TC (2007) The impact of childhood maltreatment on young adults' substance abuse. Am J Drug Alcohol Abuse 33: 139-146.

  62. Currie J, Widom CS (2010) Long-term consequences of child abuse and neglect on adult economic well-being. Child Maltreat 15: 111-120.

  63. Mersky JP, Topitzes J (2010) Comparing early adult outcomes of maltreated and non-maltreated children: A prospective longitudinal investigation. Children and Youth Services Review 32: 1086-1096.

  64. Stone S (2007) Child maltreatment, out-of-home placement and academic vulnerability: A fifteen-year review of evidence and future directions. Children and Youth Services Review 29: 139-161.

  65. Tanaka M, Jamieson E, Georgiades K, Duku EK, Boyle MH, et al. (2011) The association between childhood abuse and labor force outcomes in young adults: Results from the Ontario child health study. Journal of Aggression, Maltreatment & Trauma 20: 821-844.

  66. Stein JA, Leslie MB, Nyamathi A (2002) Relative contributions of parent substance use and childhood maltreatment to chronic homelessness, depression, and substance abuse problems among homeless women: Mediating roles of self-esteem and abuse in adulthood. Child Abuse Negl 26: 1011-1027.

  67. Chartier MJ, Walker JR, Naimark B (2010) Separate and cumulative effects of adverse childhood experiences in predicting adult health and health care utilization. Child Abuse Negl 34: 454-464.

  68. Messina N, Grella C (2006) Childhood trauma and women's health outcomes in a California prison population. Am J Public Health 96: 1842-1848.

  69. Edwards VJ, Holden GW, Felitti VJ, Anda RF (2003) Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: Results from the Adverse Childhood Experiences study. Am J Psychiatry 160: 1453-1460.

  70. Kendall-Tackett K (2002) The health effects of childhood abuse: four pathways by which abuse can influence health. Child Abuse Negl 26: 715-729.

  71. Rodgers CS, Lang AJ, Laffaye C, Satz LE, Dresselhaus TR, et al. (2004) The impact of individual forms of childhood maltreatment on health behavior. Child Abuse Negl 28: 575-586.

  72. Greenfield EA, Marks NF (2009) Violence from parents in childhood and obesity in adulthood: using food in response to stress as a mediator of risk. Soc Sci Med 68: 791-798.

  73. Biswas A, Oh PI, Faulkner GE, Bajaj RR, Silver MA, et al. (2015) Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis. Ann Intern Med 162: 123-132.

  74. Micha R, Mozaffarian D (2010) Saturated fat and cardiometabolic risk factors, coronary heart disease, stroke, and diabetes: a fresh look at the evidence. Lipids 45: 893-905.

  75. Schane RE, Ling PM, Glantz SA (2010) Health effects of light and intermittent smoking: a review. Circulation 121: 1518-1522.

  76. Yamori Y, Liu L, Mizushima S, Ikeda K, Nara Y; CARDIAC Study Group (2006) Male cardiovascular mortality and dietary markers in 25 population samples of 16 countries. J Hypertens 24: 1499-1505.

  77. . Messman T L, Long PJ (1996). Child sexual abuse and its relationship to revictimization in adult women: A review. Clinical Psychology Review 16: 397-420.

  78. Noll JG, Horowitz LA, Bonanno GA, Trickett PK, Putnam FW (2003) Revictimization and self-harm in females who experienced childhood sexual abuse: results from a prospective study. J Interpers Violence 18: 1452-1471.

  79. Jehu D, Gazan M (2009) Psychosocial adjustment of women who were sexually victimized in childhood or adolescence. Can J Commun Ment Health 2: 71-82.

  80. Walker LE, Browne A (1985) Gender and victimization by intimates. J Pers 53: 179-195.

  81. Young JC, Widom CS (2014) Long-term effects of child abuse and neglect on emotion processing in adulthood. Child Abuse Negl 38: 1369-1381.

  82. Rosebrock L, Hoxha D, Gollan J (2015) Affective reactivity differences in pregnant and postpartum women. Psychiatry Res 227: 179-184.

  83. Coates A, Messman-Moore TL (2014) A structural model of mechanisms predicting depressive symptoms in women following childhood psychological maltreatment. Child Abuse & Neglect 38: 103-113.

  84. Gibb BE, Alloy LB, Abramson LY, Rose DT, Whitehouse WG, et al. (2001) History of childhood maltreatment, negative cognitive styles, and episodes of depression in adulthood. Cognitive Therapy and Research 25: 425-446.

  85. Hankin BL (2005) Childhood maltreatment and psychopathology: Prospective tests of attachment, cognitive vulnerability, and stress as mediating processes. Cognit Ther Res 29: 645-671.

  86. Foa EB, Ehlers A, Clark DM, Tolin DF, Orsillo SM (1999) The Posttraumatic Cognitions Inventory (PTCI): Development and validation. Psychological Assessment 11: 303-314.

  87. Abramson LY, Metalsky GI, Alloy LB (1989) Hopelessness depression: A theory-based subtype of depression. Psychol Rev 96: 358-372.

  88. Alloy LB, Abramson LY, Whitehouse WG, Hogan ME, Tashman NA, et al. (1999) Depressogenic cognitive styles: predictive validity, information processing and personality characteristics, and developmental origins. Behav Res Ther 37: 503-531.

  89. Norris AE, Aroian KJ (2008) Assessing reliability and validity of the Arabic language version of the Post-traumatic Diagnostic Scale (PDS) symptom items. Psychiatry Res 160: 327-334.

  90. Moser JS, Hajcak G, Simons RF, Foa EB (2007) Posttraumatic stress disorder symptoms in trauma-exposed college students: The role of trauma-related cognitions, gender, and negative affect. J Anxiety Disord 21: 1039-1049.

  91. Domes G, Schulze L, Herpertz SC (2009) Emotion recognition in borderline personality disorder-a review of the literature. J Pers Disord 23: 6-19.

  92. Levine D, Marziali E, Hood J (1997) Emotion processing in borderline personality disorders. J Nerv Ment Dis 185: 240-246.

  93. Gross JJ (1998) The emerging field of emotion regulation: an integrative review. Rev Gen Psychol 2: 271-299.

  94. Gross JJ, Thompson RA (2007) Emotion regulation: Conceptual foundations. In: Handbook of Emotion Regulation, Guilford Press 3-24.

  95. Quoidbach J, Berry EV, Hansenne M, Mikolajczak M (2010) Positive emotion regulation and well-being: Comparing the impact of eight savoring and dampening strategies. Pers Individ Dif 49: 368-373.

  96. Thompson RA, Meyer S (2007) Socialization of emotion regulation in the family. Handbook of Emotion Regulation, Guilford Press 249.

  97. Carvalho Fernando S, Beblo T, Schlosser N, Terfehr K, Otte C, et al. (2014) The impact of self-reported childhood trauma on emotion regulation in borderline personality disorder and major depression. J Trauma Dissociation 15: 384-401.

  98. Burns EE, Jackson JL, Harding HG (2010) Child maltreatment, emotion regulation, and posttraumatic stress: The impact of emotional abuse. J Aggress Maltreat Trauma 19: 801-819.

  99. Stevens NR, Gerhart J, Goldsmith RE, Heath NM, Chesney SA, et al. (2013) Emotion regulation difficulties, low social support, and interpersonal violence mediate the link between childhood abuse and posttraumatic stress symptoms. Behav Ther 44: 152-161.

  100. Heller SS, Larrieu JA, D'Imperio R, Boris NW (1999) Research on resilience to child maltreatment: empirical considerations. Child Abuse Negl 23: 321-338.

  101. Weiss EL, Longhurst JG, Mazure CM (1999) Childhood sexual abuse as a risk factor for depression in women: psychosocial and neurobiological correlates. Am J Psychiatry 156: 816-828.

  102. Breslau N, Davis GC, Andreski P, Peterson EL, Schultz LR (1997) Sex differences in posttraumatic stress disorder. Arch Gen Psychiatry 54: 1044-1048.

  103. Zoladz PR, Diamond DM (2013) Current status on behavioral and biological markers of PTSD: a search for clarity in a conflicting literature. Neurosci Biobehav Rev 37: 860-895.

  104. Heim C, Newport DJ, Mletzko T, Miller AH, Nemeroff CB (2008) The link between childhood trauma and depression: insights from HPA axis studies in humans. Psychoneuroendocrinology 33: 693-710.

  105. Teicher MH, Andersen SL, Polcari A, Anderson CM, Navalta CP, et al. (2003) The neurobiological consequences of early stress and childhood maltreatment. Neurosci Biobehav Rev 27: 33-44.

  106. Felmingham KL, Bryant RA (2012) Gender differences in the maintenance of response to cognitive behavior therapy for posttraumatic stress disorder. J Consult Clin Psychol 80: 196-200.

  107. Ferree NK, Kamat R, Cahill L (2011) Influences of menstrual cycle position and sex hormone levels on spontaneous intrusive recollections following emotional stimuli. Conscious Cogn 20: 1154-1162.

  108. Hedman C, Pohjasvaara T, Tolonen U, Suhonen-Malm AS, Myllylä VV (2002) Effects of pregnancy on mothers' sleep. Sleep Med 3: 37-42.

  109. Matsumoto K, Shinkoda H, Kang M, Seo Y (2003) Longitudinal Study of Mothers' Sleep-Wake Behaviors and Circadian Time Patterns from Late Pregnancy to Postpartum-Monitoring of Wrist Actigraphy and Sleep Logs. Biol Rhythm Res 34: 265-278.

  110. Swain AM, O'Hara MW, Starr KR, Gorman LL (1997) A prospective study of sleep, mood, and cognitive function in postpartum and nonpostpartum women. Obstet Gynecol 90: 381-386.

  111. Moline ML, Broch L, Zak R, Gross V (2003) Sleep in women across the life cycle from adulthood through menopause. Sleep Med Rev 7: 155-177.

  112. Rothbart MK, Ahadi SA, Evans DE (2000) Temperament and personality: origins and outcomes. J Pers Soc Psychol 78: 122-135.

  113. Bowes L, Jaffee SR (2013) Biology, genes, and resilience: toward a multidisciplinary approach. Trauma Violence Abuse 14: 195-208.

  114. Auerbach JG, Faroy M, Ebstein R, Kahana M, Levine J (2001) The association of the dopamine D4 receptor gene (DRD4) and the serotonin transporter promoter gene (5-HTTLPR) with temperament in 12-month-old infants. J Child Psychol Psychiatry 42: 777-783.

  115. Schmidt LA, Fox NA, Perez-Edgar K, Hamer DH (2009) Linking gene, brain, and behavior: DRD4, frontal asymmetry, and temperament. Psychol Sci 20: 831-837.

  116. Lynn DE, Lubke G, Yang M, McCracken JT, McGough JJ, et al. (2005) Temperament and character profiles and the dopamine D4 receptor gene in ADHD. Am J Psychiatry 162: 906-913.

  117. Bakermans-Kranenburg MJ, van IJzendoorn MH, Caspers K, Philibert R (2011) DRD4 genotype moderates the impact of parental problems on unresolved loss or trauma. Attach Hum Dev 13: 253-269.

  118. Werner EE (1989) High-risk children in young adulthood: a longitudinal study from birth to 32 years. Am J Orthopsychiatry 59: 72-81.

  119. Fergusson DM, Horwood LJ (2003) Resilience to childhood adversity: Results of a 21-year study. In: Resilience and vulnerability: Adaptation in the context of childhood adversities, Suniya S Luthar, (ed) Cambridge University Press 130-155.

  120. Masten AS, Best KM, Garmezy N (1990) Resilience and development: Contributions from the study of children who overcome adversity. Dev Psychopathol 2: 425-444.

  121. Bogar CB, Hulse-Killacky D (2006) Resiliency determinants and resiliency processes among female adult survivors of childhood sexual abuse. J Couns Dev 84: 318-327.

  122. Moran PB, Eckenrode J (1992) Protective personality characteristics among adolescent victims of maltreatment. Child Abuse Negl 16: 743-754.

  123. Walsh K, Blaustein M, Knight WG, Spinazzola J, van der Kolk BA (2007) Resiliency factors in the relation between childhood sexual abuse and adulthood sexual assault in college-age women. J Child Sex Abus 16: 1-17.

  124. Feinauer LL, Stuart DA (1996) Blame and resilience in women sexually abused as children. Am J Fam Ther 24: 31-40.

  125. Liem JH, James JB, O'Toole JG, Boudewyn AC (1997) Assessing resilience in adults with histories of childhood sexual abuse. Am J Orthopsychiatry 67: 594-606.

  126. Valentine L, Feinauer LL (1993) Resilience factors associated with female survivors of childhood sexual abuse. Am J Fam Ther 21: 216-224.

  127. Bierman A (2005) The Effects of Childhood Maltreatment on Adult Religiosity and Spirituality: Rejecting God the Father Because of Abusive Fathers? J Sci Study Relig 44: 349-359.

  128. Finkelhor D, Hotaling GT, Lewis I, Smith C (1989) Sexual abuse and its relationship to later sexual satisfaction, marital status, religion, and attitudes. J Interpers Violence 4: 379-399.

  129. Hall TA (1995) Spiritual effects of childhood sexual abuse in adult Christian women. J Psychol Theol 23: 129-134.

  130. Grassi-Oliveira R, Ashy M, Stein LM (2008) Psychobiology of childhood maltreatment: effects of allostatic load? Rev Bras Psiquiatr 30: 60-68.

  131. McCrory E, De Brito SA, Viding E (2011) The impact of childhood maltreatment: a review of neurobiological and genetic factors. Front Psychiatry 2: 48.

  132. Blomeyer D, Treutlein J, Esser G, Schmidt MH, Schumann G, et al. (2008) Interaction between CRHR1 gene and stressful life events predicts adolescent heavy alcohol use. Biol Psychiatry 63: 146-151.

  133. Grabe HJ, Schwahn C, Appel K, Mahler J, Schulz A, et al. (2010) Childhood maltreatment, the corticotropin-releasing hormone receptor gene and adult depression in the general population. Am J Med Genet B Neuropsychiatr Genet 153: 1483-1493.

  134. Polanczyk G, Caspi A, Williams B, Price TS, Danese A, et al. (2009) Protective effect of CRHR1 gene variants on the development of adult depression following childhood maltreatment: Replication and extension. Arch Gen Psychiatry 66: 978-985.

  135. Fassler IR, Amodeo M, Griffin ML, Clay CM, Ellis MA (2005) Predicting long-term outcomes for women sexually abused in childhood: contribution of abuse severity versus family environment. Child Abuse Negl 29: 269-284.

  136. Griffin ML, Amodeo M (2010) Predicting long-term outcomes for women physically abused in childhood: Contribution of abuse severity versus family environment. Child Abuse Negl 34: 724-733.

  137. Harter S, Alexander PC, Neimeyer RA (1988) Long-term effects of incestuous child abuse in college women: Social adjustment, social cognition, and family characteristics J Consult Clin Psychol 56: 5-8.

  138. Riggs SA, Sahl G, Greenwald E, Atkison H, Paulson A, et al. (2007) Family environment and adult attachment as predictors of psychopathology and personality dysfunction among inpatient abuse survivors. Violence Vict 22: 577-600.

  139. Folger SF, Wright MOD (2013) Altering risk following child maltreatment: Family and friend support as protective factors. J Fam Violence 28: 325-337.

  140. Thompson MP, Kaslow NJ, Lane DB, Kingree J (2000) Childhood maltreatment, PTSD, and suicidal behavior among African American females. J Interpers Violence 15: 3-15.

  141. Fromuth ME (1986) The relationship of childhood sexual abuse with later psychological and sexual adjustment in a sample of college women. Child Abuse Negl 10: 5-15.

  142. Lowell A, Renk K, Adgate AH1 (2014) The role of attachment in the relationship between child maltreatment and later emotional and behavioral functioning. Child Abuse Negl 38: 1436-1449.

  143. Muller RT, Thornback,K, Bedi R (2012) Attachment as a mediator between childhood maltreatment and adult symptomatology. J Fam Violence 27: 243-255.

  144. Romans SE, Martin JL, Anderson JC, O'Shea ML, Mullen PE (1995) Factors that mediate between child sexual abuse and adult psychological outcome. Psychol Med 25: 127-142.

  145. Howell KH, Miller-Graff LE (2014) Protective factors associated with resilient functioning in young adulthood after childhood exposure to violence. Child Abuse Negl 38: 1985-1994.

  146. Merrill LL, Thomsen CJ, Sinclair BB, Gold SR, Milner JS (2001) Predicting the impact of child sexual abuse on women: The role of abuse severity, parental support, and coping strategies. J Consult Clin Psychol 69: 992-1006.

  147. Vranceanu AM, Hobfoll SE, Johnson RJ (2007) Child multi-type maltreatment and associated depression and PTSD symptoms: the role of social support and stress. Child Abuse Negl 31: 71-84.

  148. Egeland B, Carlson E, Sroufe LA (1993) Resilience as process. Dev Psychopathol 5: 517-528.

  149. Herrenkohl EC, Herrenkohl RC, Egolf B (1994) Resilient early school-age children from maltreating homes: outcomes in late adolescence. Am J Orthopsychiatry 64: 301-309.

  150. Powers A, Ressler KJ, Bradley RG (2009) The protective role of friendship on the effects of childhood abuse and depression. Depress Anxiety 26: 46-53.

  151. Busuito A, Huth-Bocks A, Puro E (2014) Romantic Attachment as a Moderator of the Association Between Childhood Abuse and Posttraumatic Stress Disorder Symptoms. J Fam Violence 29: 567-577.

  152. Roche DN, Runtz MG, Hunter MA (1999) Adult Attachment A Mediator between Child Sexual Abuse and Later Psychological Adjustment. J Interpers Violence 14: 184-207.

  153. Hopson HE (2010) Disclosure, Social Reactions to Disclosure, and Mental Health Outcomes among Adult Child Sexual Abuse Victims. Electronic Theses and Dissertations. Paper 1685.

  154. Roesler TA (1994) Reactions to disclosure of childhood sexual abuse. The effect on adult symptoms. J Nerv Ment Dis 182: 618-624.

  155. Miller WR, Rollnick S (1991) Motivational Interviewing: preparing people to change addictive behavior. New York: Guilford Press 348.

  156. Wahab S, Burke P, Chapman C, Hohman M, Manthey T, et al. (2010) Guiding as practice: Motivational interviewing and trauma-informed work with survivors of intimate partner violence. Partner Abuse 1: 92-103.

International Journal of Anesthetics and Anesthesiology (ISSN: 2377-4630)
International Journal of Blood Research and Disorders   (ISSN: 2469-5696)
International Journal of Brain Disorders and Treatment (ISSN: 2469-5866)
International Journal of Cancer and Clinical Research (ISSN: 2378-3419)
International Journal of Clinical Cardiology (ISSN: 2469-5696)
Journal of Clinical Gastroenterology and Treatment (ISSN: 2469-584X)
Clinical Medical Reviews and Case Reports (ISSN: 2378-3656)
Journal of Dermatology Research and Therapy (ISSN: 2469-5750)
International Journal of Diabetes and Clinical Research (ISSN: 2377-3634)
Journal of Family Medicine and Disease Prevention (ISSN: 2469-5793)
Journal of Genetics and Genome Research (ISSN: 2378-3648)
Journal of Geriatric Medicine and Gerontology (ISSN: 2469-5858)
International Journal of Immunology and Immunotherapy (ISSN: 2378-3672)
International Journal of Medical Nano Research (ISSN: 2378-3664)
International Journal of Neurology and Neurotherapy (ISSN: 2378-3001)
International Archives of Nursing and Health Care (ISSN: 2469-5823)
International Journal of Ophthalmology and Clinical Research (ISSN: 2378-346X)
International Journal of Oral and Dental Health (ISSN: 2469-5734)
International Journal of Pathology and Clinical Research (ISSN: 2469-5807)
International Journal of Pediatric Research (ISSN: 2469-5769)
International Journal of Respiratory and Pulmonary Medicine (ISSN: 2378-3516)
Journal of Rheumatic Diseases and Treatment (ISSN: 2469-5726)
International Journal of Sports and Exercise Medicine (ISSN: 2469-5718)
International Journal of Stem Cell Research & Therapy (ISSN: 2469-570X)
International Journal of Surgery Research and Practice (ISSN: 2378-3397)
Trauma Cases and Reviews (ISSN: 2469-5777)
International Archives of Urology and Complications (ISSN: 2469-5742)
International Journal of Virology and AIDS (ISSN: 2469-567X)
More Journals

Contact Us

ClinMed International Library | Science Resource Online LLC
3511 Silverside Road, Suite 105, Wilmington, DE 19810, USA
Email: contact@clinmedlib.org
 

Feedback

Get Email alerts
 
Creative Commons License
Open Access
by ClinMed International Library is licensed under a Creative Commons Attribution 4.0 International License based on a work at https://clinmedjournals.org/.
Copyright © 2017 ClinMed International Library. All Rights Reserved.