Int J Ment Health Addiction (2017) 15:967–984

DOI 10.1007/s11469-016-9697-8

O R I G I N A L A RT I C L E

Prevalence of Childhood Victimization Experiences

in Psychiatric Patients: a Systematic Review

Cristina dos Santos Mesquita 1 & Miguel Basto-Pereira 1 &

Ângela da Costa Maia 1

Published online: 22 September 2016

# Springer Science+Business Media New York 2016

Abstract Studies have found high prevalence rates of childhood victimization within psychiatric
patients, with a solid association between its occurrence and adult mental disorders. However,
several limitations persist in this field of investigation, leading to a fragmentation of the
knowledge concerning the prevalence of childhood victimization in adult psychiatric patients
and limiting the acting range of the mental health community. In order to better understand the
current status of the investigation in the field, we undertook a systematic review aimed at
identifying studies that assessed the prevalence of childhood victimization experiences in adult
psychiatric patients Our results showed that emotional abuse had the highest prevalence range,
varying from 20.8 % to 94.3 %. Some studies used non validated measures to assess childhood
victimization, while other studies lacked a definition of childhood victimization. We need more
methodologically sound studies, with clear definitions of childhood victimization, in order to
allow comparison across studies and to gain a clear picture of the prevalence rates of childhood
victimization within psychiatric patients.

Keywords Childhood victimization . Prevalence . Psychiatric disorder . Multiple victimization .

Systematic review

Psychiatric patients report high levels of childhood victimization, with several studies establishing
an association between experiences of childhood interpersonal victimization and the later devel-
opment of psychopathology, during adulthood (Goodman et al. 2001; Briggs-Gowan et al. 2010;

* Cristina dos Santos Mesquita

[email protected]

Miguel Basto-Pereira
[email protected]
Ângela da Costa Maia
[email protected]

1
School of Psychology, University of Minho, Campus de Gualtar, 4710-057 Braga, Portugal
968 Int J Ment Health Addiction (2017) 15:967–984

Dinwiddie et al. 2000; Kendall-Tackett 2002; McFarlane et al. 2006; Meade et al. 2009; Mueser,
et al. 2004; Shilvin et al. 2013). We can define interpersonal victimization as actions and
omissions that are consequence of asymmetrical relationships, where power is exerted in an
abusive or neglectful way (Levinson 2002). These victimization experiences may include sexual,
physical and emotional abuse, assault, bullying, physical and emotional neglect and the
witnessing of violence, and may occur within multiple contexts: family, school, community
(D’Andrea et al. 2012).
The study of childhood victimization in psychiatric patients is of extreme importance.
Studies have shown that victimization experiences are more frequent during childhood
(Babchishin and Romano 2014; Finkelhor et al. 2007b; Hochstetler et al. 2014; Menard
2000; Menard and Huizinga 2001; Richmond et al. 2009; Soler et al. 2013; Stevens et al.
2005) and may create vulnerability to the development of psychiatric disorders in adulthood
(Finkelhor et al. 2007a; Ornduff et al. 2001; Read et al. 2007; Read et al. 2005; Schilling et al.
2007; Spertus et al. 2003). The knowledge of the prevalence rates of childhood victimization
within psychiatric patients has crucial implications for intervention and care, highlighting the
need to address emotional issues pertaining to these experiences, in order to promote the
patients’ recovery and psychological adjustment. Failing to address the history of childhood
victimization and its potential consequences for the mental health of the victims may lead to
relapses, symptom maintenance or worsening and successive hospitalizations, increasing the
economic burden for public health. In fact, research has shown that adult psychiatric patients
with childhood victimization have a frequent use of medical emergency services (Silver et al.
2005), exhibit more acute symptoms, require more medical attention and have lower levels of
self-care and reduced threshold from which medical care is sought in response to psycholog-
ical symptoms (Spertus et al. 2003). Read et al. (2007) observed that psychiatric patients with
childhood victimization had earlier first admission to psychiatric services, with longer and
more frequent hospitalizations. They required more medication, presented more severe symp-
toms and were at higher risk of self-mutilating and committing suicide.
A history of victimization may act as a predictor of the success of intervention (Heim et al.
2010). Briere and Jordan (2004) recommend a thorough assessment of this history in psychi-
atric patients, identifying symptoms and problems related, in order to determine
specific targets for intervention, defining areas of potential dysfunction and distress.
Different problems, as fear, feeling of insecurity, guilt, interpersonal problems, and the emo-
tional suffering and psychopathological symptoms, have different intervention needs (Adshead
2000; Banduccia et al. 2014).
Despite the importance of assessing a history of victimization within psychiatric patients,
medical charts of psychiatric patients often lack this assessment (Silver et al. 2005). The failure
to question participants about past experiences can compromise the success of treatments and
interventions, failing identify emotional issues and additional dysfunction pertaining to vic-
timization. This can lead to symptom maintenance/worsening (Silver et al. 2005; McFarlane
et al. 2006) and reduced opportunities for disclosure. According to Read et al. (2007) patients
perceive their mental health to be influenced by their life experiences and expect to be asked
about by mental health professionals; by not fulfilling this expectation, mental health profes-
sionals may be compromising the patients’ recovery, well-being and adjustment.
Although the association between childhood victimization and the later development of
psychiatric disorders in adulthood is well established, , several limitations persist in the
investigation field of victimization, in general, and in the field of victimization within
psychiatric patients specifically. Research in the field of interpersonal victimization has been
Int J Ment Health Addiction (2017) 15:967–984 969

characterized by the focus on single experiences of victimization and the consequences for the
adjustment and mental health of these single categories (Álvarez-Lister et al. 2014; Ellonen
and Salmi 2011; Grych and Swan 2012; Hamby and Grych 2013; Higgins and McCabe 2001;
Pereda and Gallardo-Pujol 2014a; Pereda et al. 2014b), neglecting the study of co-occurring
categories of victimization. However, recent studies have shown that victimization tend to co-
occur, with one experience increasing the risk of additional victimization (Álvarez-Lister et al.
2014; Ellonen and Salmi 2011; Grych and Swan 2012; Higgins and McCabe 2001; Kirchner
et al. 2014; Pereda et al. 2014b). This fragmentation in the study of victimization prevents the
scientific community from acquiring a deeper understanding of the phenomenon of victimi-
zation, impeding the delineation of victimization profiles of individuals exposed to multiple
categories of victimization (Pereda and Gallardo-Pujol 2014a). Moreover, some categories of
victimization have received increased attention from the scientific community: according to
the results of a meta-analysis, the investigation has focused on exploring the occurrence of
childhood sexual abuse (Stoltenborgh et al. 2015). Concerning the study of victimization in
psychiatric patients, studies tend to favor the study of specific diagnoses of mental disorder, as
depression and posttraumatic stress disorder (Álvarez-Lister et al. 2014; Bouffard and Koeppel
2014; Green et al. 2000; Horwitz et al. 2001), thus limiting the understanding and knowledge
of the victimizations’ role in the mental health of the victims.
These limitations have lead to a serious fragmentation of the knowledge concerning the
prevalence of childhood victimization in adult psychiatric patients and to a lack of integration
of the results of studies from different areas of expertise, as psychology, psychiatry, social
service and epidemiology. Ultimately, this resulted in a narrowing of the acting range of the
mental health community, compromising the success of treatments and the definition
of more targeted interventions and political actions aimed at promoting the adjustment
of psychiatric patients and ultimately preventing relapses, additional hospitalizations, and
revictimization experiences (D’Andrea et al. 2012). As a result, there is a need of a systema-
tization of the information, increasing the knowledge of childhood victimization experiences in
psychiatric patients.
We conducted a systematic review that aimed know the history of childhood victimization
reported by adult psychiatric patients. We wanted to identify studies that assessed the preva-
lence of childhood victimization experiences, in order to establish the relevance of a routine
assessment in psychiatric context, worth to be considered when defining interventions.
Additionally, we also addressed a methodological concern in studies assessing the prevalence
of childhood victimization, namely with the use of validated measures to assess childhood
victimization, and the definition of victimization.
This systematic review goes beyond previous studies as it includes all experiences of
childhood interpersonal victimization, with no restriction as to specific categories, describing
studies that addressed single and multiple victimization. We focus on self-reported experi-
ences, thought to provide more accurate estimates of prevalence, with no restriction to
diagnoses of mental disorder. Additionally, we also attended to methodological con-
cerns with the measures used to assess victimization, and the definition of victimiza-
tion. The knowledge of the prevalence of childhood victimization within psychiatric
patients may help clarifying their impact in the later psychological functioning, explaining the
maintenance/worsening of psychopathological symptoms, and informing about the design of
more targeted interventions and treatments, resulting in more effective interventions, a
decrease in the number and length of hospitalizations, and in the social and economic
burden of mental disorder.
970 Int J Ment Health Addiction (2017) 15:967–984

Method

Data Sources and Search Strategy

We searched through Scopus, Web of Knowledge, PubMed and PsycArticles, from January of
2000 to January of 2013. Searches were conducted using both medical subject headings
(MeSH) and keywords. Table 1 illustrates our search strategy.
The first two authors reviewed independently titles and abstracts to select eligible studies.
After seeking for agreement, selected studies were fully read. Disagreements were solved with
the intervention of the third author.

Inclusion and Exclusion Criteria

Articles were selected if they met the following inclusion criteria: quantitative studies in
English, Portuguese, Spanish and French, fully published in peer-review journal.
Participants had to be adult psychiatric patients; we only selected studies where all participants
had the same diagnosis of mental disorder, according to the Diagnostic and Statistical Manual
of Mental Disorders (DSM). We intended to use a common nomenclature for the establishment
of a diagnosis of mental disorder, evidence-based, allowing the comparison across studies.
Childhood victimization had to be assessed through self-reports, as it has been suggested that
official records may underestimate the real prevalence rates (Shaffer et al. 2008), with
reference to the instrument/measures used. We excluded literature reviews, systematic reviews,
meta-analysis, qualitative studies, studies assessing symptoms of mental disorder with no clear
diagnosis and studies assessing adult and/or lifetime victimization.

Data Extraction

We extracted the following data: design, country where the study was conducted, sample size,
sex of the participants, psychiatric disorder, use of validated measures of victimization,
categories of victimization and their prevalence. The methodological quality of the studies
was assessed on the basis of the following criteria: description of the sampling process,
response rate information and definition of victimization. Each criterion received a qualitative
classification of YES/NO, depending on the presence/absence of the concerning information.

Results

Figure 1 shows our search results. The search in Scopus held 791 records, Web of Knowledge
held 736 records, PubMed held 390 records and PsycInfo/PsycArticles held 16 records. After
revision, a total of 24 studies were included in the systematic review.
Table 2 displays the descriptive data for the 24 studies included in the review. Table 3
summarizes the main results from the data extracted. Only one study presented a longitudinal
design. Thirteen studies were conducted in the United States of America (USA). , with eight
studies carried in Europe. The sample size per study varied from 30 to 648. Psychiatric
disorders focused included schizophrenic disorder, major depressive disorder, borderline
personality disorder , bipolar disorder substance-related disorders (, alcohol dependence
disorder, personality disorders, panic disorder (and posttraumatic stress disorder. . Categories
Int J Ment Health Addiction (2017) 15:967–984 971

Table 1 Keywords used in search strategy

Search strategy

Victim Mental disorder Child

Multiple victimization Mental illness Childhood
Child abuse Psychological disorder Children
Child sexual abuse Psychopathology
Child maltreatment Personality disorders
Victimization Patient
Child neglect Inpatient
Family violence Outpatient
Physical abuse Psychiatric patients
Psychological trauma Clinical population
Violence Clinical sample
Emotional abuse
Domestic violence
Rape
Combined with OR #1 Combined with OR #2 Combined with OR #3
#1 AND #2 AND #3

of victimization assessed included sexual abuse, physical abuse, emotional abuse, physical
neglect, emotional neglect, verbal abuse, witnessing to family violence and any type of
childhood victimization. Sexual abuse was the most studied category of victimization, targeted
in nineteen studies, followed by physical abuse with thirteen studies. Ten studies investigated
single victimization experiences, while the remaining explored the prevalence of multiple

Records identified through database Additional records identified through other

searching sources
(n = 1933 ) (n = 23)

Records after duplicates removed

(n = 1130)

Records screened Records excluded

(n = 1130) (n =842)

Full-text articles excluded

Full-text articles assessed for eligibility (n = 264 )
(n = 288 )
Reasons for exclusion:
122 – Participants had different diagnosis of mental disorder
53 - No data/inadequate data about victimization prevalence
52 - Psychiatric diagnosis not according to DSM
16 - Data for childhood victimization not separated from adulthood
Studies included in qualitative synthesis victimization
(n = 24 ) 8 - Method of assessment was not self-report
4 - Participants were the same from other studies
3 - Data from control group not separated from experimental group
3 - Adult victimization
3 -Studies not retrieved

Fig. 1 Flow diagram

Table 2 Descriptive data
972

Authors, Year Design Country Sample Sex (%) Psyhciatric Disorder Cathegory of Victimization, Prevalence (%)
Size
Male Female

Andover et al. 2007 Cross sectional USA 93 26.9 73.1 Major Depression Physical abuse Sexual abuse
Disorder 60.2 26.9
Assion et al. 2009 Cross sectional Germany 74 41 59 Bipolar Disorder Any type of abuse
50
Bandelow et al. 2005 Cross sectional Germany 66 28.8 71.2 Borderline Mother beats child Sexual abuse Father beats child Witnessing
Personality family
Disorder violence
63.6 % 60.3 % 57.6 % 27.3 %
Calhoun et al. 2007 Cross sectional USA 399 100 Schizophrenic Physical abuse Sexual abuse
Disorders 61 % 31 %
Evren and Evren 2006 Cross sectional Turkey 154 100 Substance-related Emotional Neglect Physical abuse Emotional abuse Sexual abuse
Disorders 42.9 % 31.8 % 20.8 % 8.4 %
Evren et al. 2008 Cross sectional Turkey 176 100 Alcohol Dependence Any type of abuse
Disorder 52.3 %
Fernando et al. 2011 Cross sectional New Zealand 372 35.8 64.2 Major Depression Emotional Neglect Threaten N/contact Contact
Disorder with abuse sexual abuse sexual abuse
42.5 % 33.8 % 12.1 % 5.3 %
Garno et al. 2005 Cross sectional USA 100 50 50 Borderline Emotional abuse Physical abuse Emotional neglect Sexual abuse
Personality 37 % 24 % 24 % 21 %
Disorder
Gaudiano and Cross sectional USA 623 36.3 63.7 Major Depression Emotional abuse Physical abuse Physical neglect Sexual abuse
Zimmerman 2010 Disorder 40 % 38.5 % 38,4 % 36 %
Golier et al. 2003 Cross sectional USA 180 65 35 Personality Disorders Physical abuse Sexual abuse
41.7 % 23.3 %
Int J Ment Health Addiction (2017) 15:967–984
Table 2 (continued)

Authors, Year Design Country Sample Sex (%) Psyhciatric Disorder Cathegory of Victimization, Prevalence (%)
Size
Male Female

Gratz and Tull 2010 Cross sectional USA 61 54 46 Substance-related Any type of abuse
Disorders 23 %
Hagenaars et al. 2011 Cross sectional The Netherlands 110 22 78 Posttraumatic Stress Any type of abuse
Disorder 34,5 %
Laporte et al. 2012 Cross sectional Canada 53 100 Borderline Emotional abuse Physical abuse Physical neglect Sexual abuse
Personality 94,3 % 77,4 % 52,8 % 26,4 %
Disorder
Leverich et al. 2003 Longitudinal USA 648 46.5 53.5 Bipolar Disorder Sexual abuse Physical abuse
Int J Ment Health Addiction (2017) 15:967–984

29.2 % 28,4 %
Lysaker et al. 2001 Cross sectional USA 54 96.3 3.7 Schizophrenic Sexual abuse
Disorders 35 %
Lysaker et al. 2004 Cross sectional USA 30 100 Schizophrenic Sexual abuse
Disorders 40 %
Oquendo et al. 2007 Cross sectional USA 314 41.4 58.6 Major Depression Any type of abuse
Disorder 36 %
Ozkan and Altindag 2005 Cross sectional Turkey 112 36.6 63.4 Panic Disorder Sexual abuse
12.5 %
Resnick et al. 2003 Cross sectional USA 47 36.2 63.8 Schizophrenic Sexual abuse
Disorders 38.3 %
Schäfer et al. 2010 Cross sectional Germany 38 58 42 Alcohol Dependence Emotional neglect Emotional abuse Sexual abuse Physical neglect
Disorder 40 % 32 % 26.9 % 26 %
Shannon et al. 2011 Cross sectional UK 85 78.8 21.2 Schizophrenic Emotional neglect Physical neglect Emotional abuse Physical abuse
Disorders 54.1 % 32.9 % 32.9 % 24.7 %
Spence et al. 2008 Cross sectional Ireland 40 62.5 37.5 Schizophrenic Physical abuse Sexual abuse
Disorders 45 % 30 %
973
Table 2 (continued)
974

Authors, Year Design Country Sample Sex (%) Psyhciatric Disorder Cathegory of Victimization, Prevalence (%)
Size
Male Female

Zanarini et al. 2000 Cross sectional USA 358 22.9 77.1 Borderline Verbal abuse Emotional abuse Physical abuse Emotional
Personality neglect
Disorder 34.4 % 33 % 24 % 24 %
Zlotnick et al. 2001 Cross sectional USA 235 35 65 Major Depression Sexual abuse
Disorder 25 %
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Int J Ment Health Addiction (2017) 15:967–984 975

Table 3 Summary of the data extracted

Data extracted Description

Sample size Minimum 30

Maximum 648
Number of studies
Design Cross sectional 23
Longitudinal 1
Country where studies were conducted USA 13
Germany 3
Turkey 3
Canada 1
New Zealand 1
The Netherlands 1
United Kingdom 1
Ireland 1
Sex of the participants Only male 4
Only female 2
Male and female 18
Psychiatric disorder Schizophrenic disorder 6
Major depressive disorder 5
Borderline personality disorder 4
Bipolar disorder 2
Substance related disorder 2
Alcohol dependence disorder 2
Posttraumatic stress disorder 1
Panic disorder 1
Personality disorders 1
Categories of victimization Sexual abuse 19
Physical abuse 13
Emotional abuse 7
Physical neglect 6
Emotional neglect 6
Verbal abuse 1
Witnessing to family violence 1
Threaten of abuse 1
Any type of victimization 5
Number of categories of victimization Single victimization 10
Multiple victimization 14

victimization. Data from prevalence are described reporting minimum and maximum ranges
for each category of victimization. In cases where there was only one value as reference, that
value was reported. Sexual abuse ranged from 4.5 % to 60.3 %. Physical abuse varied between
24 % and 77.4 %. Estimates of emotional abuse ranged from 20.8 % to 94.3 %. Physical
neglect varied between 12 % (and 52.8 %. Emotional neglect ranged from 24 % to 54.1 %.
The prevalence of witnessing to family violence was found to be 27.3 %; for threaten of abuse
976 Int J Ment Health Addiction (2017) 15:967–984

Table 4 Assessment of the methodological quality of the studies

Authors, year Validated measures Description Response rate Definition of

to assess victimization of sampling information victimization
methods (Y/N) (Y/N) (Y/N)

Andover et al. 2007 Yes No No Yes

Assion et al. 2009 Yes No Yes No
Bandelow et al. 2005 No No Yes Yes
Calhoun et al. 2007 Yes Yes Yes Yes
Evren and Evren 2006 Yes Yes Yes Yes
Evren et al. 2008 No Yes Yes Yes
Fernando et al. 2011 No Yes Yes Yes
Garno et al. 2005 Yes Yes Yes Yes
Gaudiano and Zimmerman 2010 Yes Yes No Yes
Golier et al. 2003 Yes Yes No Yes
Gratz and Tull 2010 Yes Yes No Yes
Hagenaars et al. 2011 No Yes No No
Laporte et al. 2012 Yes Yes Yes Yes
Leverich et al. 2003 No No No No
Lysaker et al. 2001 Yes Yes Yes Yes
Lysaker et al. 2004 Yes No No Yes
Oquendo et al. 2007 No No No No
Ozkan and Altindag 2005 Yes Yes No Yes
Resnick et al. 2003 Yes Yes No Yes
Schäfer et al. 2010 Yes Yes Yes Yes
Shannon et al. 2011 Yes Yes Yes Yes
Spence et al. 2008 Yes Yes Yes Yes
Zanarini et al. 2000 Yes Yes Yes Yes
Zlotnick et al. 2001 Yes Yes Yes Yes

it was 33.8 % (and verbal abuse was 34.4 %. The category of any type of childhood
victimization ranged from 23 % to 52.3 %.

Quality Assessment of the Studies

Table 4 presents the results from the quality assessment of the included studies. Six studies
assessed the prevalence of reported victimization with non validated measures. Six studies
lacked information concerning sampling methods; In the remaining studies, the researchers
used convenience samples. Ten studies had no information concerning response rates.

Discussion

Our systematic review aimed to identify studies that assessed the prevalence of childhood
interpersonal victimization in adult psychiatric patients, focusing on some methodological
Int J Ment Health Addiction (2017) 15:967–984 977

concerns within these studies. To our knowledge, no previous systematic reviews explored the
prevalence of childhood interpersonal victimization in adult psychiatric patients with no
restrictions to the categories of victimization included nor to the diagnosis of mental disorder.

Study Characteristics

A summary of the descriptive characteristics of the included studies allowed us to verify that
most of the studies were cross-sectional and used convenience samples and validated measures
to assess childhood victimization. Studies were conducted mostly in North America. The use
of convenience samples may fail to provide representative participants and limits the gener-
alization of the data. Most studies used validated measures of victimization, allowing
a higher confidence in the results found and easing comparison across studies.
However, definitions of victimization were not always consensual, demanding for
caution across comparisons. The use of non validated measures raises the question
of what is being measured. This is especially relevant in studies where the presence
of victimization was assessed through a single question. Our search did not retrieve
studies exploring the prevalence of childhood victimization in psychiatric patients from South
America, Africa and Asia. This can be due to a combination of a general lack of studies
conducted in these continents with our inclusion and exclusion criteria, that may have prevent
studies from these regions to be retrieved.

Diagnoses of Mental Disorder

The diagnoses of mental disorders from the studies included in our systematic review reflect
the trend in this field of investigation to focus on specific categories, with a lack of studies
concerning dissociative disorders, sexual disorders, sleep disorders and eating disorders. In the
group of personality disorders, four studies focused on borderline personality disorder and one
study explored the group of personality disorders in general, with no studies
concerning other diagnoses from Axis II. This may be explained by the higher
prevalence of the targeted psychiatric disorders, making it easier to access participants through
their availability on mental health institutions. Additionally, these patients might have been
more willing to participate.

Prevalence of Childhood Victimization

Childhood sexual abuse was the category of victimization most explored within the studies of
our systematic review, followed by physical abuse. These are the categories most targeted by
childhood protective services and to which more financial resources are channeled, due to the
fact that their consequences are more immediately visible and identifiable (Finkelhor et al.
2007a; Higgins and McCabe 2001; Scher et al. 2004; Widom et al. 2008). However, the main
focus given to the study of childhood sexual and physical abuse may overrate the impact of
these experiences in the negative consequences experienced, which could be better explained
as a result of the co-occurrence of multiple categories of victimization (Álvarez-Lister et al.
2014; Liu et al. 2012; Pereda and Gallardo-Pujol 2014a), overestimating the role and impact of
single experiences and underestimating the prevalence rates, and limiting the knowledge on
the prevalence of additional categories of victimization, thus failing to reach the full experience
of the child, (Grych and Swan 2012).
978 Int J Ment Health Addiction (2017) 15:967–984

Emotional abuse was the category of victimization with the widest prevalence range.
Recent studies have shown that emotional abuse may be more prevalent that sexual and
physical abuse, with more detrimental consequences for the mental health of the victim
(Coates and Messman-Moore 2014; Foran et al. 2012; Gagné et al. 2005; Hammock et al.
2015; Kerley et al. 2010; Liu et al. 2012; Paul and Eckenrode 2015; Shepherd-McMullen et al.
2015; Spertus et al. 2003).
We found considerable differences in the prevalence rates that may be explained by
methodological differences between studies. Sexual abuse ranged from 4.5 % to 60.3 %.
Both studies had cross sectional designs, with samples composed mostly by female partici-
pants in patients with borderline personality disorder. Differences across studies concern the
country where the studies were conducted (USA vs Germany, respectively), size of the sample
(higher in the first study), and the fact that the second study used a non validated measure to
assess the prevalence of childhood victimization.
Physical abuse varied between 24 % and 77.4 %. Both studies were conducted in North
America, using cross-sectional designs in psychiatric patients with borderline personality disor-
der, using validated measures to assess childhood victimization. They differed in the size of the
sample, higher in the first study, and in the sex distribution of the participants: the first study had
equal number of male and female participants and the second had only female participants.
Emotional abuse ranged from 20.8 % to 94.3 %. Studies had in common a cross-sectional
design and the use of validated measures. Differences concerned the country where studies
were carried (Turkey vs Canada), the sample size, higher in the first study, the sex distribution
in the sample (only males vs only females) and the psychiatric disorders focused (substance
related disorders vs borderline personality disorder).
The prevalence for physical neglect varied between 12 % and 52.8 %. Both studied were
cross-sectional, carried in North America with patients with borderline personality disorders,
using validated measures to assess victimization. Differences concerned the size of the sample,
smaller in the second study, and the sex distribution, with the first study presenting an equal
number of male and female participants while the second had only female participants.
As for emotional neglect, the lower end of the prevalence range, 24 %, came from two cross-
sectional studies, both conducted in the USA in participants with borderline personality disorders,
assessing victimization using validated measures. These two studies differed in the size of the
sample and the sex distribution: one had an equal number of male and female participants and the
other had more female participants. Both studies differed from the study presenting the upper end
of the prevalence range, 54.1 %, in respect to the country (UK), sex distribution (only male
participants) and the targeted psychiatric disorder: schizophrenic disorder.
The study of any type of abuse presented prevalence rates ranging from 23 % to 52.3 %.
Both studies were cross-sectional, carried with participants with substance related disorders
using validated measures to assess childhood victimization. These studies differed in the
country they were conducted (USA vs Turkey), the sample size (higher in the first study)
and sex distribution (balanced distribution vs only male participants). The remaining catego-
ries of victimization were focused on a single study and did not allowed comparisons across
different studies.

Limitations

This systematic review has some limitations. Our criteria concerning the inclusion of studies
where all participants had the same diagnosis of mental disorder according to DSM may have
Int J Ment Health Addiction (2017) 15:967–984 979

biased our results, excluding several studies. Studies have shown sex differences in the
prevalence of childhood victimization. Although some of the studies included in our system-
atic review separated prevalence rates for male and female, it was beyond the scope of this
review to investigate this issue. Likewise, the comparison of contrasting groups (eg.: healthy
adults, adults with only adulthood victimization, adults with childhood and adulthood victim-
ization, with random samples) was also beyond the scope of this review, despite additional
contributions that could be provided.

Recommendations

The results of our systematic review allow us to assess the current state of the investigation in
the field of prevalence of childhood victimization in psychiatric patients, stressing the main
findings and identifying gaps that need to be addressed. Our major findings concern the fact
that most studies were cross-sectional, carried in the USA, with a restricted set of diagnoses of
mental disorder included, a major focus on sexual abuse, and methodological differences that
hamper the real estimate of childhood victimization prevalence.
Researchers should focus on conducting more longitudinal studies, needed to ascertain
causation between childhood victimization and adult mental disorder, following children with
victimization experiences throughout until adulthood, assessing their mental health and psy-
chosocial adjustment.
Our search did not retrieve studies from South America, Africa and Asia, signalizing a need
of addressing the prevalence of childhood victimization within these populations. The rele-
vance of this fact is wide. The definition of what constitutes victimization is influenced by
cultural factors. Migratory flows may lead communities of foreign individuals to establish
themselves in contexts where their cultural traditions are not accepted or understood.
The knowledge of what is considered victimization in these cultures can translate in
more effective intervention with social minorities. Also, this knowledge allows establishing
comparisons for successful social, political and economic strategies to intervene and prevent
childhood victimization within these communities (Cohen et al. 2001; Futa et al. 2001; Elliott
and Urquiza 2006).
The studies included in our systematic review assessed the prevalence of childhood
victimization considering a restricted set of diagnoses of mental disorder, a limitation fre-
quently pointed in the literature of this field of investigation (Álvarez-Lister et al. 2014;
Bouffard and Koeppel 2014; Green et al. 2000; Horwitz et al. 2001). The knowledge
concerning victimization prevalence rates across all diagnoses of mental disorders would
provide with a clearer frame of the distribution of these prevalence rates, providing clues for
additional research, that could allow to assess causation between childhood victimization and
specific diagnoses of mental disorder. Furthermore, this knowledge would have a central role
in delineating victimization profiles in their association with later mental disorders.
Sexual abuse was the most studied category of victimization; our results also illustrate that
childhood victimization tend to co-occur. The implications of these findings are remarkable,
emphasizing the need to adjust not only the research in this field, by developing investigations
that focus on all categories of childhood victimization, but also actions and interventions to
address emotional issues pertaining to victimization, in order to increase their effectiveness by
delineating a more detailed history of the patients’ past victimization experiences.
Prevalence ranges of childhood victimization were very wide, rising concerns about the
reasons behind the discrepancies. Methodological issues may help explain this, namely, the use
980 Int J Ment Health Addiction (2017) 15:967–984

of non validated measures to assess victimization, and the lack of consensus on the definition
of victimization across studies. There is a need for the scientific community to reach a
consensus in the definition of childhood victimization, with clear operationalization of what
constitutes each category of interpersonal victimization. This would translate in the elaboration
of consensual validated measures to assess childhood victimization, allowing comparisons
across studies.

Conclusions

Our findings sustain the position of Finkelhor et al. (2007a) who found that childhood
victimizations tend to co-occur. Victimized children experience multiple categories of victim-
ization, with more detrimental outcomes for mental and physical health and quality of life. The
considerable prevalence rates found in the studies included in our systematic review suggest
the need for a thorough assessment of victimization in clinical settings, considering a
wide range of victimization experiences in order to develop more targeted
interventions and preventive measures to reduce the costs associated with
unsuccessful treatments, non compliance and relapses, and promote recovery and
adjustment. These assessments would deepen the knowledge of victimization
profiles, allowing to design programs aimed at reducing risk factors that may create
vulnerability to further victimization and revictimization. In their review, Heim et al.
(2004) studied the physiological implications of early adverse experiences in depres-
sion. The physiological changes in the stress response led depressed patients to respond
differently to treatment and to have more relapses after initial remission, compared to depressed
patients with no history of childhood victimization. This has serious implications for interven-
tion and recovery and emphasizes the need to ask about childhood victimization.
We expect that our findings, identifying the existing gaps in this field of investigations, and our
recommendations for future studies, add to the knowledge of childhood victimization in adult
psychiatric patients and help reducing the fragmentation featuring this field of investigation.

Compliance with Ethical Standards

Conflict of Interest Authors Cristina dos Santos Mesquita, Miguel Basto-Pereira and Ângela da Costa Maia
declare that they have no conflict of interest.
Authors Cristina dos Santos Mesquita, Miguel Basto-Pereira and Ângela da Costa Maia declare that there
were no sources of grant or financial support.

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