PUN106 Mental Health and early life adversity Dunne.pdf

Its inpopulation health unit

1. 12/05/2012
1
MentalHealthand Mental
 Health
 and
 
early life adversity 
Prof Michael Dunne PUN106 Population Health
May 14
th
, 2012 
Key readings
•Anda, R.F., Butchart, A., Felitti, V.J., Brown, D.W. (2010) 
Building a Framework for Global Surveillance of the Public 
Health Implications of Adverse Childhood Experiences. 
A
merican Journal of Preventive Medicine, 39(1), 93
–
98
•US CDC ACE study website: http://www.cdc.gov/ace/
•WHO ACE‐International Questionnaire website:  •http://www.who.int/violence_injury_preventio n/violence/activities/adverse_childhood_expe
riences/en/index.html
•Shonkoff, Boyce & McEwan (2009) Neuroscience, molecular biology and the 
childhood roots of health disparities. Journal of the American Medical Association, 
301, 2252‐2259
•Afifi et l (2008)  Population attributable fractions of psychiatric disorders and 
suicide ideation and attempts associated with adverse childhood experiences. 
American Journal of Public Health, 98, 946‐952
The global burden of non‐communicable diseases
Impacts on Disability Adjusted Life Years
Prince M et al (2007): No health without mental health, Lancet, 370:859 ‐77
Time Trends in Global Mortality from Chronic Diseases
The well-known epidemiological transition
Yach, D. et al. JAMA 2004;291:2616-2622
Source derived from data in the World Health Report 20031 and Murray and Lopez.3 *The 2020 projections were estimated by Murray and Lopez.3.

2. 12/05/2012
2
Which types of mental health problems 
contribute most to morbidity?
•10 leading causes of disability among people aged 15‐44years, 
global estimates
•HIV/AIDS 13.0%
•Unipolar depression8.6
•Road traffic accidents 4.9
•Tuberculosis 3.9
•Alcohol use disorders3.0
•Self‐inflicted injuries2.7
Idfiiii
26
•
I
ron 
d
e
fi
c
ic
iency anem
ia
2
.
6
•Schizophrenia2.6
•Bipolar disorder2.5
•Violence 2.3
–Data from Patel et al, 2006
The total
burden of mental disorders is 
difficult to measure
Mtldi dINTERACTith
bid
•
M
en
t
a
l di
sor
d
ers 
INTERACT
 w
ith
 many co‐mor
bid
  
health conditions
•Consider diabetes and/or morbid obesity
•HIV/AIDS and other chronic viral infections
•Injuries
•The CAUSES of mental disorder are difficult to 
understand, and to control
Focus of my research in recent years 
•What are the important proximal and distal 
influences on the health of young people?
–Particular focus on the effects of childhood 
adversity such as violence, emotional 
maltreatment, educational stress, social and 
family connectedness, poverty etc 
•How can research findingsbe directed toward 
mental health promotion? 
A Lifecourse Approach to Health
In-utero
Home
Genetic &
Social
Inheritance
Educational Success
Parental SEP
Chains of
Social
Causation
Home
School
Neighborhood
Day Care
Lipid Metabolism
Glucose
Regulation
Immune Function
Background
Infection
Diet - Physical Activity - Smoking
Role Models - Peer Groups
Beliefs - Dispositions
Adult
Disease
Work
Hypertension
Atherosclerosis
Obesity
Chains of
Biological
Causation
Stress
Lynch, 2000;  Kaplan, 2007

3. 12/05/2012
3
The science base supporting the 
im
p
act of earl
y
 life adversit
y
 on 
pyy physical and mental health CONCEPTUAL MODEL
See also Gilbert R, Widom CS, Browne K, et al (2009) The Lancet,
Shonkoff et al (2009) JAMA and Anda et al (2010)Am J Preventive Medicine.
CAUSAL PATHWAY
HOW ADVERSITY IS BUILT INTO THE BODY
“Weathering” of the body under 
persistent stress
•Persistent stressful experiences overuse and 
dltlthlld d
ysregu
la
t
e neura
l pa
th
ways norma
ll
y use
d
 
for adaptation to threat. 
•This is believed to accelerate the normal 
ageing process.  
•
Thereisagrowingbodyofpatho
‐
There
 is
 a
 growing
 body
 of
 patho
‐
physiological research to support this idea.
•See Shonkoff et al, JAMA(2009)
Toxic Stress Damages Brain 
Architecture
•Excessive and repeated stress
causes the release of chemicals that
impair cell growth and interfere with
the formation of healthy neural
circuits in the brain
•Toxic stress can damage the brain's
Healthy brain
stress response system and
contribute to premature ageing of the
body
Abused brain

4. 12/05/2012
4
Latent effects of adversity during 
sensitive periods
•Adult disease and risk factors for poor health can be 
embedded durin
g
 p
eriods of child develo
p
ment 
gpp
where the brain is sensitive to a variety of 
environmental stimuli, both positive and negative   (Shonkoff et al, 2009).
•Biological pathways
: Inadequate nutrition, low 
birthweight and recurrent infections are linked to 
diabetesandrespiratoryandcardiovasculardisease diabetes
 and
 respiratory
 and
 cardiovascular
 disease
•Bio‐Behavioural pathways
: Maternal drug use during 
pregnancy leads to child’s high tolerance for 
stimulants or depressants and drug‐seeking 
behaviour in adolescence
This model is interesting....
but is it clinically meaningful?
Evidence regarding links between ACEs and adult 
chronic diseases, and common risk factors in the 
biological pathways to disease onset 
.....
but

is

it

clinically

meaningful?
Straightforward method: Count the amount of serious
adverse experiences reported by people who develop
a disease or who have health-risk behaviours
•The largest study of its kind – more than 17000 adult 
membersofahealthmaintenance
organisation
intheUSA
The ADVERSE CHILDHOOD EXPERIENCES 
(ACE) study 
members
 of
 a
 health
 maintenance
 organisation
in
 the
 USA
  
•All were interviewed about many aspects of their health 
and early life adverse experiences 
•These people were followed up over more than 10 years, 
through health checks and search of death registers
•Excellent resource
:
•US CDC ACE study website: http://www.cdc.gov/ace/
ACE model –the maintypes of 
CHILDHOOD ADVERSITY
CHILD ABUSE/NEGLECT HOUSEHOLD dysfunction
Psychological (by parents) Substance abuse in close relatives
Physical (by parents) Living with a mentally ill person
Sexual (anyone) Parental Separation / Divorce
Emotional ne
g
lect Mother treated violentl
y
g
y
Physical neglect Imprisoned family member
CDC
Also - Exposure to trauma in the community (war and interpersonal violence)
that induces sustained periods of fear, distress and confusion

5. 12/05/2012
5
ADVERSE CHILDHOOD EVENTS & ISCHEMIC HEART DISEASE
(Dong et al, 2004)
Dong et al found a dose‐response relation of ACEs to IHD and a relation between 
almost all individual ACEs and IHD. Nine of 10 categories of ACE significantly 
increased the risk of IHD by 1.3‐to 1.7‐fold compared to persons with no ACEs
ADVERSE CHILDHOOD EVENTS & COPD
(Anda et al, 2008)
2
2.5
Association between ACE score and IHD (Adjusted 
OR)
The age of first
hospitalisation for
COPD was stron
g
l
y

0
0.5
1
1.5
2
012345+
OR
ACE SCORE
gy
related to ACEs
The ACE Score had a graded relationship to the 
occurrence of COPD. 
). 
ACEs AND LUNG CANCER  
(Anda et al, 2010)
3
3.5
0.5
1
1.5
2
2.5
RR for lung cancer
0
01234,56,7,8
•Compared to persons without ACEs, the risk of lung cancer for those with 
>or= 6 ACEs was increased approximately 3‐fold. Persons with 6 or more 
ACEs were hospitalized 13 years earlier on average than those without ACEs
ACEs & LIVER DISEASE
(Dong et al, 2004)
Each of 10 ACEs increased the risk of liver disease 1.2 to 1.6 times (P<.001). 
ACE SCORE

6. 12/05/2012
6
USA adults
Childhood adversity and adult SMOKING 
% smoker
, 
Felitti et al, 1998
ACE SCORE
Childhood adversity and adult ALCOHOL abuse
4
USA adults with alcohol disorder
2
3
0
Adverse Childhood Experiences and attempted suicide, USA
4
2025
2
1
3
2
3
4
% attempting suicide
5
10
15
20
Felitti et al, 1998
0
0
0
1
0
ACE score
0
0
04+ 123
Number of Adverse Childhood Experiences
and Teen Sexual Behaviors, USA
35
40
45
m (%)
0
1
2
3
4 or more
Number of adverse factors:
1015
20
25
30
ent With Health Problem
0
5
10
Perce
Intercourse by
a
g
e 15
Teen
pregnancy
Teen
p
aternit
y
For more information, see the CDC (2012) ACE study reports

7. 12/05/2012
7
Other disorders linked to ACEs •Clinical depression •Anxiety disorders
•Diabetes
•Morbid obesity
•Chronic, medically unexplained  
pain disorders
•(www.cdc.gov/ace/index.htm
)
Adversity is also inked with unresponsiveness to 
pharmacotherapy for mental disorder 
(clinical trial by Klein et al, 2009)
A longer duration of illness; earlier onset; greater number of episodes, 
symptomseverity,self
‐
ratedfunctionalimpairment,
suicidality
,and
symptom
 severity,
 self
rated
 functional
 impairment,
 suicidality
,
 and
 
comorbid anxiety disorder; and higher levels of dysfunctional attitudes 
and self‐criticism were each associated with multiple forms of 
childhood adversity
A history of maternal overcontrol, paternal abuse, paternal indifference, 
sexual abuse, and an index of clinically significant abuse each predicted 
a lower probability of remission. Among patients completing a 12‐week
 
trial, 32% with a history of clinically significant abuse, compared to 44% 
without such a history, achieved remission of symptoms. 
These findings indicate that a history of childhood adversity is 
associated with an especially chronic form of Depression that is less 
responsive to medication 
The end result?
Potential years of life lost  due to ACEs 
(Brown et al, 2009)
Brown et al (2009) carried out a remarkable longitudinal analysis
as part of the ACE study. People were followed up 9 to 10 years
ft i t i th h h f d th d Of th i iti l
a
ft
er
in
t
erv
iew
th
roug
h
searc
h
o
f

d
ea
th
recor
d
s.
Of

th
e
in
iti
a
l
sample, 1,539 had died. People with six or more ACEs died
nearly 20 years earlieron average than those with no ACEs (60.6
years compared to 79.1 years).
The magnitude of that effect is truly extraordinary and demands
closer analysis in much further research.
Brown et al (2009) found that some of the effect, but certainly not all, was mediated by an effect of ACEs on health-risk behaviours and low socio-economic position
QUT
’s
EastAsian
research
QUT s
East
 Asian
 research
 
into the health consequences of 
childhood adversity

8. 12/05/2012
8
To date, there has been little relevant research 
in most of Asia
•There has been some qualitative research with 
highriskgroups(mainlydonebyNGOs) high
 risk
 groups
 (mainly
 done
 by
 NGOs)
•Several surveys of adolescents/young adults 
early experiences of physical, emotional and 
sexual abuse and neglect (mainly in Hong 
Kong & mainland China)
Ntti
litdiltdi
•
N
o re
t
rospec
ti
ve or 
long
it
u
di
na
l s
t
u
di
es 
involving adults in this region
•Our work has included studies in China, 
Malaysia and Vietnam
Child maltreatment and mental health of 
adolescents in Viet Nam  Nguyen, Dunne, Le (2010) Bulletin of the WHO, 88, 22‐3
[Collaboration between QUT and Hanoi School of Public Health]
•Self‐report anonymous survey of 2,591 students in 
secondary and high schools in Hai Duong (rural) and 
Ha Noi (urban)
•Assessed emotionalabuse (7), neglect(7), physical
abuse (6) and sexualabuse (8) items 
•Adolescents were classified as positive for 
maltreatment if their sub‐type score was at or 
above the mean
Vietnamese adolescents’ reports of
multiple type maltreatment, by gender
Multiple adversity and Depression
15
20
25
30
n score
Females
0 5
10
no abuse 1 f orm 2 f orms 3 f orms 4 f orms
Mea
n
Males

9. 12/05/2012
9
Multiple adversity and anxiety
30 10
15
20
25
Mean score
Females Males
0
5
no
abuse
1 form 2 form s 3 form s 4 form s
Adversity & suicidal thinking (past year)
ADVERSE CHILDHOOD EXPERIENCES,
MENTAL HEALTH and RISK BEHAVIOURS AMONG
2,300 ADOLESCENTS IN VIETNAM
Researchers: Thai Thanh Truc
1,2
, Kim Xuan Loan
1,2
,
Nguyen Do Nguyen
1
and Michael Dunne
2
1. Faculty of Public Health, HCMC UMP
2. School of Public Health, Queensland University of Technology
1
ACE International Questionnaire,
World Health Organisation
Technical advisory meeting WHO Geneva 4-5 April 2011
We integrated the ACE-IQ into a
broad survey of health and well-being
•
In a collaboration between
Ho Chi Minh
•
In

a

collaboration

between

Ho

Chi

Minh

City UMP Faculty of Public Health and
QUT, and recently the Hue UMP, we have
completed qualitative work in Hue and
surveys of 2,300 adolescents in HCMC and
A
Long
A
n

10. 12/05/2012
10
Three risk behaviour indicators
•
Youth health risk behaviors (%) Youth

health

risk

behaviors

(%)
M F Total
– Smoking during the past 30 days 5.7 2.1 3.7
– Drinking during the past 30 days 30.6 31.4 31.1
Ud dii ( t bik )
12 6
48 83
–
U
n
d
erage
d
r
iv
ing ever
(
mo
t
or
bik
es
)

12
.
6

4
.
8

8
.
3
Sex AgeTo t a l
N %
ANY endorsement of an item on 
MaleFemale≤15 > 15
Neglect
Emotional neglect
350 (63.2) 412 (61.3)
**
419 (63.2) 343 (60.9) 762 (62.2)
Physical neglect
63
(
11.4
)
45
(
6.7
)
47
(
7.1
)
61
(
10.8
)
*
108
(
8.8
)
ACE SUMMARY (HCMC survey in 6 schools
Physical

neglect
()
()
()
()
()
Household dysfunction
Household substance abuse
60 (10.8) 59 (8.8)54 (8.1) 65 (11.6)
*
119 (9.7)
Household mental illness
24 (4.3) 38 (5.7) 34 (5.1) 28 (5.0) 62 (5.1)
Household member treated
violently
107 (19.3) 131 (19.5) 119 (18.0) 119 (21.1) 238 (19.4)
Incarcerated household member
16 (2.9) 18 (2.7) 16 (2.4) 18 (3.2) 34 (2.8)
Parental separation or divorce
66 (11.9) 136 (20.2)
***
100 (15.1) 102 (18.1) 202 (16.5)
Childhood abuse
Emotional abuse
57 (10.3) 91 (13.5) 72 (10.9) 76 (13.5) 148 (12.1)
Physical abuse
29 (5.2) 37 (5.5) 35 (5.3) 31 (5.5) 66 (5.4)
Sexual abuse
47 (8.5) 57 (8.5)41 (6.2) 63 (11.2)
**
104 (8.5)
Exposure to community violence
163 (29.4) 158 (23.5)
*
169 (25.5) 152 (27.0)321 (26.2)
Multiple adversity (all events before age 18)
By Gender and Age
(N and %)
Multiple
occurrence of
Sex Age
ACETo t a l
MaleFemale≤15 > 15
0
92 (16.6) 109 (16.2) 120 (18.1) 81 (14.4) 201 (16.4)
1
195 (35.2) 262 (39.0) 257 (38.8) 200 (35.5) 457 (37.3)
2
133 (24.0) 133 (19.8) 130 (19.6) 136 (24.2) 266 (21.7)
3
73 (13.2) 86 (12.8) 87 (13.1) 72 (12.8) 159 (13.0)
≥ 4
61 (11.0) 82 (12.2) 69 (10.4) 74 (13.1) 143 (11.7)
*
4050
e
Multiple adversity and Depression
102030
CES-D score
0
0
1
2
3
4+
Multiple Adverse Childhood Experiences
Male Female Overall

11. 12/05/2012
11
Multiple adversity and suicidal thoughts
4050 02030
Suicidal thought (%)
01
0
1
2
3
4+
Multiple Adverse Childhood Experiences
Male Female Overall
Multiple adversity and smoking
20
25
%)
5
10
15
Male Female Total
Smoking (%
0
01234+
Multiple ACE
Multiple adversity and drinking
%)
50
60
Drinking (%
10 20 30
40
Male Female Total
Multiple ACE
0
01234+
Multiple adversity and underage driving
g (%)
3035
40
Underage driving
5
10 15 20 2530
Male Female Total
Multiple ACE
05
01234+

12. 12/05/2012
12
Influenceofchildabuseonpatternofexpenditures
Worldwide, these and many other effects 
lead to increased health care expenditure
Influence
 of
 child
 abuse
 on
 pattern
 of
 expenditures
in women's adult health service utilization 
in Ontario, Canada
Tang et al (2006)
Ta n g B, et. al. (2006). The influence of child abuse on the pattern of expenditures in women's 
adult health services utilization in Ontario, Canada. Social Science and Medicine, 63, 1711‐1719. 
Tang et al methods
Probability based sample of women aged 15‐
6464
Child Maltreatment History Self‐Report 
Questionnaire
Self‐reported health service utilization X unit 
cost cost
Ta n g B, et. al. (2006). The influence of child abuse on the pattern of expenditures in women's 
adult health services utilization in Ontario, Canada. Social Science and Medicine, 63, 1711‐1719. 
Overallhowmuchofthepoor Overall
, 
how
 much
 of
 the
 poor
 
health can be attributed directly to 
adversity?
This is a very complex question

13. 12/05/2012
13
Fraction of mental disorders and suicidal behaviour 
attributable to child sexual abuse
Female
%
Male %
Depression 7-8% 4-5%
Alcohol use/dependence 7-8% 4-5%
Drug use/dependence 7-8% 4-5%
Panic disorder 13% 7%
PTSD 33% 21%
Suicide 11% 6%
Andrews et al., Child sexual abuse, WHO, 2004
ACEs and Population Attributable Fractions for 
Psychiatric disorders 
(Afifi et al, American Journal of Public Health, 2008)
•
APAFistheestimatedproportionofanoutcomein
•
A
 PAF
 is
 the
 estimated
 proportion
 of
 an
 outcome
 in
 
a population that would be prevented if the 
exposure was eliminated
•Afifi et al (2008) analysed US National 
Comorbidity Survey of Mental Health (N=5,692 
adults interviewed)
•Risk of disorder was strongly associated with 
ACEs. PAFs ranged from small to substantial, for 
both men and women
PAFs of ACEs in the USA
•Afifi et al focused on common mental disorders
()()
•
Women 
(
%
)
              Men 
(
%
)
•Any mood disorder: 17.2 10.9
•Anxiety Disorder 16.4 9.2
•Substance use disorder 7.6 19.0
•Suicidal ideation 10.3 8.7
•Suicide attempts 4.7 2.6
PAFs (%) of ACEs in the USA
(Any mood disorder)
•AdversityFemale Male
•Physical abuse 3.8 4.7
•Sexual abuse 13.2 4.8
•Witness D. Violence     11.8 12.2

14. 12/05/2012
14
PAFs (%) of ACEs in the USA
(Suicidal thinking and actions)
•AdversityFemale Male •
S
uicidal thinkin
g
 (
ever
)
g()
•Physical abuse 3.2 5.8
•Sexual abuse 8.9 n.s.
•Witness D. Violence                     n.s. 8.5
•Suicide attempt (ever)
•Physical abuse 7.8 11.2
•
Sexualabuse
30
0
5
9
•
Sexual
 abuse
30
.
0
5
.
9
•Witness D. Violence                   10.0 n.s.
•Source: Afifi et al (2008) AJPH, 98(5), 946‐952
Questions
•What is the relevance of this type of research 
fblihlth? f
or pu
bli
c 
h
ea
lth?
•Remember to think about both sides of the 
PAF
•In August 2012 –UNICEF/WHO Think Tank 
meeting on the economic costs of violence 
against children in the Asia‐Pacific region 
Why are some people severely affected by 
difficulties in childhood, and others not?
•Some people who suffer extreme adversity in 
childhood have social 
p
roblems later in life
,
 but 
p,
many others do not
•A fascinating studyin New Zealand by Caspi et al 
(2002) stimulated considerable interest in biological 
factors that might promote resilience. 
•Monoamine ox
y
dase
(
Enz
y
me
)
 activit
y
 was 
y
(y)y
measured in violent  and non‐violent young adults 
who were victims of child abuse
New Zealand Longitudinal study findings
•Longitudinal study of relationship between child maltreatment of 
males, MAOA activity and later proclivity for violence (Dunedin NZ 
study)

15. 12/05/2012
15
Those with a genotype conferring high MAOA activity were less 
likely to develop psychosocial 
problems and to perpetrate violence themselves. Similar results reported by Widom & Brzustowicz, 
2006, in the USA, but only 
among white males. 
Genes, gender, and culture interact in complex ways.
•
Keep a sense of perspective
Mental and 
p
h
y
sical ill health and disorders are caused 
py
by numerous
factors. Health promotion and 
preventive  Interventions must not be focused too 
much on single causes.
Lifecourse development research is very active 
internationally and is making progress in identifying 
those physical diseases and mental disorders which 
are NOT linked to  childhood adversity
Let’s agree that not all adversity 
has bad effects
•Positive stress: 
–Short lived (eg. New school, favourite toy is stolen, pet is lost)
–Minor physiological changes, such as elevated stress hormones
–
Children
 learn
 to
 cope
 and
 this
 aids
 their
 personal
 development
Childrenlearntocopeandthisaidstheirpersonaldevelopment
•Tolerable Stress
–Much more intense, but usually short‐term duration (death of loved one, 
surviving a natural disaster, witnessing an accident)
–With good support from parents and others, the child can overcome the stress 
and may become stronger and more resilient
–With no support the child may have long term difficulty in 
coping
•Tox i c Stress
–
Intenseadverseexperiencesoverlongperiodsoftime(severechildabuseand Intense
 adverse
 experiences
 over
 long
 periods
 of
 time
 (severe
 child
 abuse
 and
 
neglect; exposure to war or long‐term social unrest and community violence etc)
–The child’s physiological stress response system is highly active for prolonged 
periods. Leads to permanent changes in development of the brain. This in turn 
increases risk of drug dependence, self‐harm, relationship problems, poor 
educational achievement etc)
–
Positive support can help, but sometimes the damage is too severe
(Middlebrooks & Audage, 2010 - See summary in Dunne & Askari, 2012)
Society‐level preventive 
public health  interventions

16. 12/05/2012
16
Early investment in
preventive programs for
disadvantaged youth
See Doyle et al (2009)
Theearlychildhoodinvestmentcan The
 early
 childhood
 investment
 can
 
start prior to and be sustained 
during pregnancy
SDll(2009)Iiilh S
ee 
D
oy
le et a
l (2009)
 I
nvest
ing 
in ear
ly 
h
uman 
development: Timing and economic efficiency
Economics and Human Biology, 7, 106.
(Doyle et al, 2009)
Academic, economic and social outcomes of pre‐
school based interventions (two decade follow‐up)
Perry Preschool Abecedarian program
Source: Knudsen et al (2006) PNAS, 201, 10155‐62

17. 12/05/2012
17
Final comments
Of course, not all adverse experience can be prevented and in many
circumstances, very few people know the experiences occurred, and
tifill d
so canno
t
spec
ifi
ca
ll
y respon
d
.
However, much can be done and there are many success stories.
One of the most impressive is the decline in bullying and associated
violence in schools over the past 20 years. Another is the
substantial reduction in murder, rape and assault of adolescents in
the past 15 years (especially in the USA).
Much needs to be done and prevention of childhood adversity is becoming quite a strong focus of WHO Violence Prevention Division, the US CDC Injury Prevention Division, UNICEF and other global public health agencies.
Further references
•Ben‐Shlomo Y & Kuh D (2002) A life course approach to chronic disease epidemiology: 
conceptual models, empirical challenges and interdisciplinary  perspectives  International 
Journal of Epidemiology2002;31:285‐293
•Braveman P and Barclay C (2009) Health Disparities Beginning in Childhood: A Life‐Course 
Perspective
Pediatrics
124
;S
163
S
175
Perspective
. 
Pediatrics
,
124
;S
163
‐
S
175
•Dunne MP & Askari S (2012) Adverse childhood experiences and chronic diseases among 
adults. Hue University Journal of Medicine and Pharmacy, 2(1),22‐27.
•Dunne MP, Chen JQ & Choo WY (2008) The evolving evidence base for child protection in 
Chinese societies. Asia Pacific Journal of Public Health, 20, 267‐76. 
•Doyle 
O et al (2009) Investing in early development: Timing and economic efficiency. 
EconomicsandHumanBiology
7
1
6
Economics
 and
 Human
 Biology
, 
7
, 
1
‐
6
.
•Nguyen HT, Dunne MP, Le VA. (2010). Multiple types of child maltreatment and adolescent 
mental health in Vietnam. Bulletin of the World Health Organisation, 88, 22‐30
•Tang B, et. al. (2006). The influence of child abuse on the pattern of expenditures in 
women's adult health services utilization in
 Ontario, Canada. Social Science and Medicine, 
63, 1711‐1719.