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Neuropsychology © 2015 American Psychological Association

2016, Vol. 30, No. 2, 143–156 0894-4105/16/$12.00 http://dx.doi.org/10.1037/neu0000228

A Meta-Analysis on the Impact of Psychiatric Disorders


and Maltreatment on Cognition

Marjolaine Masson and Caroline East-Richard Caroline Cellard


Laval University Laval University, and Québec Youth Centre - University
Institute

Objective: Few studies have attempted to describe the range of cognitive impairments in individuals with
psychiatric disorders who experienced maltreatment as children. The aims of this meta-analysis were to
establish the impact of maltreatment and psychiatric disorders on cognition, and to examine the change
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

in impact from childhood to adulthood. Method: Twelve publications from 1970 to 2013 were included,
This document is copyrighted by the American Psychological Association or one of its allied publishers.

with the following inclusion criteria: (a) individuals with a psychiatric disorder who experienced
maltreatment, (b) use of at least 1 standardized neuropsychological measure, and (c) use of a control
group without any psychiatric disorder or mistreatment. The majority of studies (10/12) were about
posttraumatic stress disorder. Several effect sizes were calculated (Hedge’s g) according to the cognitive
domains. Results: The results of the meta-analysis demonstrate that the combination of psychiatric
disorders and childhood maltreatment has a negative impact on global cognitive performance, with a
moderate effect size (g ⫽ ⫺0.59). The most affected cognitive domains for individuals aged 7- to
18-years-old were visual episodic memory (g ⫽ ⫺0.97), executive functioning (g ⫽ ⫺0.90), and
intelligence (g ⫽ ⫺0.68). For individuals over the age of 18-years-old, the most affected cognitive
domains were verbal episodic memory (g ⫽ ⫺0.77), visuospatial/problem solving (g ⫽ ⫺0.73), and
attention (g ⫽ ⫺0.72). The impact of maltreatment and psychiatric disorders was greater in children than
in adults (slope ⫽ 0.008, p ⬍ .002). Conclusion: The results suggest that exposure to maltreatment and
the presence of psychiatric disorders have a broad impact on cognition, with specific neuropsychological
profile.

Keywords: cognition, psychiatric disorders, maltreatment, meta-analysis

Supplemental materials: http://dx.doi.org/10.1037/neu0000228.supp

The United States Child Abuse Prevention and Treatment Act The few studies assessing cognitive domains other than intelli-
(i.e., PL 93–247) defines child maltreatment as “the physical and gence suggest that the effects of maltreatment vary according to
mental injury, sexual abuse, negligence or maltreatment of the age. For example, cognitive deficits in domains such as attention
child, under the age of eighteen by a person who is responsible for (Lovallo et al., 2013; Nolin & Ethier, 2007), executive functions
child’s welfare, which indicates the child health and welfare is (Beers & De Bellis, 2002; DePrince, Weinzierl, & Combs, 2009),
threatened thereby.” Maltreatment has a range of negative effects intelligence, and episodic memory (Goodman, Quas, & Ogle,
on cognition. One major consequence is a decrease in IQ. That is, 2010; Gould et al., 2012) have been observed as early as child-
intellectual disabilities and poor academic performance have been hood. Neuropsychological deficits in executive functions have
reported in neglected (Strathearn, Gray, O’Callaghan, & Wood, been also observed in adults (Perna & Kiefner, 2013; Viola,
2001) and sexually abused children (Jones, Trudinger, & Craw- Tractenberg, Pezzi, Kristensen, & Grassi-Oliveira, 2013). The type
ford, 2004). Lower IQ has also been observed in adults who of maltreatment experienced by children may also have differential
experienced maltreatment during childhood (Perez & Widom,
cognitive impacts; physically abused children demonstrate far
1994).
greater deficits in problem-solving, abstraction, and planning than
do neglected children (Nolin & Ethier, 2007).
Neuroimaging techniques have revealed that the hypothalamic-
This article was published Online First July 20, 2015. pituitary-adrenal (HPA) axis is the primary neurobiological mech-
Marjolaine Masson and Caroline East-Richard, School of Psychology, anism that fails in child victims of maltreatment (Gonzalez, 2013).
Félix-Antoine-Savard Pavillion, Laval University; Caroline Cellard, The three brain regions most likely to be affected by a hyperacti-
School of Psychology, Félix-Antoine-Savard Pavillion, Laval University, vation of the HPA axis are the hippocampus, amygdala, and
and Québec Youth Centre - University Institute. prefrontal cortex (Lupien, McEwen, Gunnar, & Heim, 2009).
Research organism of funding: Richelieu Research Chair on Youth,
Impairments in memory and executive functions are linked to
Childhood, and the Family, which Caroline Cellard is the holder.
Correspondence concerning this article should be addressed to Marjo-
these specific impaired brain regions (Alvarez & Emory, 2006;
laine Masson, School of Psychology, Félix-Antoine-Savard Pavillion, La- Scoville & Milner, 1957; Travis et al., 2014), and impairment in
val University, 2325, rue des Bibliothèques, Québec (Québec), Canada these cognitive processes may therefore be attributable to stress
G1V 0A6. E-mail: marjolaine.masson@gmail.com generated by childhood maltreatment. Disturbances in neurobio-

143
144 MASSON, EAST-RICHARD, AND CELLARD

logical development during the first years of life may also con- analysis suggest that generalized, rather than specific, cognitive
tribute to the emergence of psychiatric disorders. The literature on impairments characterize euthymic bipolar disorder (Mann-
child mistreatment shows a higher prevalence of psychiatric symp- Wrobel et al., 2011). Another meta-analysis revealed moderate
toms and diagnoses in maltreated children than in nonmaltreated cognitive deficits in executive functioning, memory, and atten-
children (Cicchetti & Toth, 2005). tion in depressed patients (Rock et al., 2013). For anxiety, the
Psychological difficulties observed in young victims of mal- cognitive dysfunction profile seems to depend on type of anx-
treatment vary widely. Between 50% and 62% of abused chil- iety disorder; for example, obsessive– compulsive disorder is
dren exhibit clinical internalizing and externalizing problems associated with deficits in executive functioning and visual
(McCrae, 2009). Some studies have shown that victims are memory (Castaneda et al., 2008). Taken together, the evidence
more likely than nonvictims to feel depressed and anxious (De suggests that deficits in three specific cognitive domains—
Bellis, et al., 2001; Éthier, Lemelin, & Lacharité, 2004). In
attention, memory, and executive functioning—are common to
comparison with nonvictims, victims of childhood maltreatment
a range of psychiatric disorders.
are also more likely to meet the diagnostic criteria for reaction
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attachment disorder (Zeanah et al., 2004), attention-deficit/


This document is copyrighted by the American Psychological Association or one of its allied publishers.

hyperactivity disorder (ADHD), opposition disorder, and con- Impact of Maltreatment and Psychiatric Disorders
duct disorder (Garland et al., 2001). Finally, higher rates of on Cognition
posttraumatic stress disorder (PTSD; McLeer, Callaghan,
Henry, & Wallen, 1994), personality disorders, substance Many studies have examined either the impact of maltreat-
abuse, somatization, and dissociation (Jones et al., 2013; ment or psychiatric diagnosis on cognition, but few studies have
Macfie, Cicchetti, & Toth, 2001; Ryan, Kilmer, Cauce, Wa- assessed the relationships between cognitive deficits, maltreat-
tanabe, & Hoyt, 2000) have been observed in abused children. ment, and the development of psychiatric disorders. Given that
In adulthood, the primary diagnoses reported in this population both maltreatment and psychiatric disorders negatively impact
are mood disorders (Widom, DuMont, & Czaja, 2007), anxiety cognition, it is plausible that their combination would produce
disorders (Fergusson, Boden, & Horwood, 2008) such as PTSD even greater cognitive deficits. This hypothesis has been sub-
(Breslau et al., 2014), alcohol and drug abuse and dependence stantiated by studies indicating that children who have experi-
(Clark, Lesnick, & Hegedus, 1997; Kendler et al., 2000; Widom, enced maltreatment and who were diagnosed with psychiatric
Marmorstein, & White, 2006), behavioral disorders (Green et al., disorders demonstrated greater cognitive deficits than did chil-
2010), antisocial personality disorder (Johnson, Cohen, Brown, dren who had been maltreated but had no psychiatric disorder.
Smailes, & Bernstein, 1999), and psychotic disorders (Arseneault
It has been suggested that the HPA axis becomes permanently
et al., 2011). The strong relationship between maltreatment in
deregulated in patients with PTSD, altering cognitive function-
childhood and diverse psychiatric disorders in children and adults
ing (Shea, Walsh, Macmillan, & Steiner, 2005). For example,
suggests that maltreatment is a common nonspecific risk factor for
adults with PTSD and maltreatment showed lower IQ in com-
the development of psychiatric disorders, rather than a specific risk
factor for a given disorder (Keyes et al., 2012). parison with individuals reporting maltreatment only (Wilson,
The risk of developing a psychiatric disorder varies with the Hansen, & Li, 2011). Moreover, children who suffered from
type of maltreatment experienced. For example, childhood sexual maltreatment and PTSD have been found to have difficulties in
abuse has been demonstrated to lead to rates of mental health executive functioning when performing the Wisconsin Card
problems 2.4 times higher than those associated with other types of Sorting Test (WCST; Beers & De Bellis, 2002); in contrast,
maltreatment (i.e., physical abuse or neglect; Fergusson et al., executive functioning impairments were not observed in chil-
2008). The same study demonstrated that children exposed to dren who suffered from maltreatment without PTSD (Perna &
physical abuse had rates that were 1.5 times higher than those for Kiefner, 2013; Viola et al., 2013). Together, these findings
children not exposed to physical punishment (i.e., neglect; Fergus- highlight the additional negative impact of psychiatric disorders
son et al., 2008). associated with maltreatment on victims’ cognitive profile.

Impact of Psychiatric Diagnosis on Cognition Study Objectives


Psychiatric disorders alone—without childhood maltreat- The present meta-analysis assesses cognitive functioning in
ment— generate clinical symptoms, but also generate cognitive
individuals who suffered from any kind of maltreatment and
impairments. Indeed, cognitive deficits are a core feature of
several disorders, including schizophrenia (Schaefer, Gian- who subsequently developed psychiatric disorders (maltreat-
grande, Weinberger, & Dickinson, 2013), bipolar disorder ment ⫹ psychiatric disorder ⫽ M ⫹ PD). The first objective
(Mann-Wrobel, Carreno, & Dickinson, 2011), major depressive was to determine whether the combination of maltreatment and
disorder (Rock, Roiser, Riedel, & Blackwell, 2013), and several psychiatric disorders has a negative impact on every cognitive
anxiety disorders (Castaneda, Tuulio-Henriksson, Marttunen, domain of interest (intelligence, verbal episodic memory, visual
Suvisaari, & Lonnqvist, 2008). Each of these psychiatric dis- episodic memory, working memory, attention, executive func-
orders can lead to a wide range of cognitive impairments. For tioning, visuospatial/problem solving, and processing speed), or
example, patients with schizophrenia demonstrate significant if some domains are unaffected. The second objective was to
impairments in the domains of processing speed and episodic examine whether or not neuropsychological profile varies ac-
memory (Schaefer et al., 2013). Results from a recent meta- cording to age and type of maltreatment.
NEUROPSYCHOLOGY, PSYCHIATRIC DISORDERS AND MALTREATMENT 145

Method Neurocognitive Domains


Two of the coauthors with expertise in neuropsychology (MM
Literature Search and CC, PhDs) independently categorized the neuropsychological
measures examined in the selected articles. Neuropsychological
The literature review described here was conducted in the con-
measures were defined by objectively assessing a cognitive
text of a wider systematic review on maltreatment and cognition.
domain. Consensus was achieved through discussion and theoret-
This review allowed us to conduct two meta-analyses with differ-
ical models (Strauss et al., 2006). Eight categories of cognitive
ent experimental designs: the first (Masson, Bussières, East-
domains were identified: intelligence, verbal episodic memory,
Richard, R-Mercier, & Cellard, 2015) compared groups that suf-
visual episodic memory, working memory, attention, executive
fered maltreatment to a group without maltreatment (exclusion:
functioning, visuospatial/problem solving, and processing speed.
psychiatric disorders) and the second (the present meta-analysis)
Executive functions are intrinsic to the ability to respond in an
compared groups with M ⫹ PD to a group with neither maltreat-
adaptive manner to novel situations (Lezak, Howieson, & Loring,
ment or psychiatric disorders. MEDLINE, PsycInfo and Embase
2004). Executive functioning is a shorthand description for a
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

databases were searched for articles published between 1970 and


complex set of processes that have been broadly and variously
This document is copyrighted by the American Psychological Association or one of its allied publishers.

June 2013 to identify all studies reporting neuropsychological data


defined. A literature review identified 18 subcomponents of exec-
of individuals that suffered from maltreatment. A combination of
utive function (Packwood, Hodgetts, & Tremblay, 2011). The
the following Medical Subject Headings (Mesh) and search terms
present meta-analysis followed the Miyake’s model (Miyake et al.,
was used: “childⴱ” OR “adolescentⴱ” OR “adult” – AND “cognitⴱ”
2000) which included three executive functions: updating, inhibi-
OR “neuropsychoⴱ” OR “memory” OR “executive function” OR
tion, and shifting. As a consequence, working memory and prob-
“attention deficit” OR “IQ” OR “cognitive disorders” - AND
lem solving were considered separately according to another the-
“maltreatment” OR “childⴱ abuseⴱ” OR “childⴱ neglectⴱ” OR
oretical model (Baddeley & Hitch, 1974). Classification of
“sexual abuse” OR “physical abuse” OR “childhood trauma.” This
neuropsychological tests by cognitive domain can be seen in Table
meta-analysis targeted individuals who experienced maltreatment
1S in the supplementary data.
and who had a psychiatric diagnosis. The meta-analysis was per-
formed according to the preferred reporting items for systematic
reviews and meta-analyses (PRISMA) standards, including evalu- Statistical Analysis
ation of bias (confounding, overlapping data, publication bias;
All analyses were performed using the comprehensive meta-
Moher, Liberati, Tetzlaff, & Altman, 2009). Screening of article
analysis software package (Borenstein, Hedges, Higgens, & Roth-
titles and abstracts was performed by two independent investiga-
stein, 2000). It is recommended that Cohen’s d or Hedge’s g be
tors (CC and MM). In the event of disagreement or uncertainty, the
used when original studies have compared two groups and the
full text was read and discussed until agreement was achieved.
differences between their means are available (Borenstein,
After data extraction, the next phase of the search strategy in-
Hedges, Higgins, & Rothstein, 2009). Hedge’s g was used as a
volved a manual search for studies potentially overlooked by
measure of effect size (Hedges, 1981). We calculated the mean
screening the references of all retrieved articles (reference list
difference between M ⫹ PD and healthy control groups’ perfor-
searching). To ensure that all relevant studies were included in the
mance divided by the pooled standard deviation and adjusted for
meta-analysis, we also contacted 27 experts in the field of mal-
small sample size bias (Hedges & Olkin, 1985). Hedges’s g was
treatment and cognition.
appropriated for the current meta-analysis because it further al-
lowed us to correct for the small sample size bias (Hedges &
Inclusion/Exclusion Criteria Olkin, 1985). Negative effect sizes indicate poorer performance by
the maltreatment group. Interpretation of effect sizes was done
Inclusion criteria for the studies in the current meta-analysis
according to Cohen’s guidelines (d ⫽ 0.20 is small; d ⫽ 0.50 is
were the following: (a) to be published in English or French; (b) to
moderate; d ⫽ 0.80 is large; Cohen, 1988).
include participants less than 60-years-old; (c) to have a group
Effect sizes were computed for each cognitive domain.
with a psychiatric disorder included in the Diagnostic and Statis-
Within each cognitive domain, mean effect size, standard error,
tical Manual of Mental Disorders - DSM–III–R, DSM–IV or DSM–
95% confidence interval and corresponding z-value and signif-
IV–TR (American Psychiatric Association, 1987, 1994, 2000) that
icance level were reported. All calculations were performed
also suffered from maltreatment during childhood or adolescence
under the assumptions of a conservative random effect model.
(sexual abuse, physical abuse, neglect or emotional/psychological
In addition, the Q-statistic was computed to evaluate the ho-
abuse); (d) to have a control group having neither psychopathology
mogeneity of the study results within each domain (fixed
or maltreatment; (e) to report data from an assessment of cognitive
model).
functioning using standardized neuropsychological tests listed in a
compendium of Neuropsychological Tests-3rd edition (Strauss,
Sherman, & Spreen, 2006); and (f) to have sufficient statistical Results
data to compute an effect size.
Exclusion criteria were the following: (a) presence of a neuro- Search
logical disease (e.g., traumatic brain injury, stroke, neurodegen-
erative disease); and (b) presence of any disease— except psychi- Results of the literature search and reasons for excluding articles
atric disorder—that could affect cognitive processes (e.g., HIV, are shown in a flowchart diagram according to PRISMA guide-
diabetes). lines (see Figure 1). After the initial screening procedures, 1,196
146 MASSON, EAST-RICHARD, AND CELLARD
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This document is copyrighted by the American Psychological Association or one of its allied publishers.

Figure 1. Flowchart literature search and data extraction according to the PRISMA guidelines.

articles were excluded for the following reasons: case study, no were evaluated in the eligibility step. In the case of missing data or
maltreatment (e.g., an absence of maltreatment in the entire group possible overlap, the authors were contacted. Because no addi-
or just for some people in the group), no population of interest tional information could be obtained or if the overlapping was
(e.g., people older than 60 years, patients with neurological dis- confirmed by authors, these articles (Bremner et al., 1997; De
ease, assessment of parent abuser, etc.), no data on cognition (e.g., Bellis & Keshavan, 2003; De Bellis, et al., 2002; Tupler & De
study without neuropsychological assessment or study which used Bellis, 2006; Weniger, Lange, Sachsse, & Irle, 2008) were ex-
an experimental assessment or tests not listed in the compendium), cluded from further analysis. Ultimately, 12 studies were included
no clinical group with psychiatric diagnoses, no control group in the present meta-analysis and their characteristics are available
without maltreatment or prevalence study. A total of 33 full texts in Table 1S in the supplementary data. It is important to note that
NEUROPSYCHOLOGY, PSYCHIATRIC DISORDERS AND MALTREATMENT 147

the goal was to study a range of psychiatric disorders but the end

n/a

n/a
12
12
7
5
12
6
5
k
result was that the majority of studies (10/12) were about PTSD.

7.77–36.70
7.77–14.60
23.80–36.70

9.00–17.00
Range

15–98

0–80
31.1–85
Demographics

n/a

n/a
The complete dataset included 734 participants, of which 313
(42.64%) had M ⫹ PD while the remaining 421 (57.36%) did not.
The sample-weighted mean age for the M ⫹ PD group was

35.08 (26.80)
20.25 (11.28)

31.09 (30.46)
70.09 (19.73)
Control
Mean (SD)

11.57 (2.04)
32.39 (5.23)

13.28 (3.25)
20.77 ⫾ 12.14 years (range of study means: 8.30 to 39.70) years,

n/a

n/a
compared with 20.25 ⫾ 11.28 years for controls (range: 7.77 to
36.70 years). In all studies reporting participant sex, 30.78% of the
M ⫹ PD group and 31.09% of control participants were males.

421 (57.36%)

329 (78.15%)
92 (21.85%)
The sample-weighted average of years of education across the five
studies that provided this information was 12.53 ⫾ 2.24 years for
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421
n/a

n/a

n/a
n/a
n/a
N
the M ⫹ PD group (range: 9.47 to 15) and 13.28 ⫾ 3.25 for
This document is copyrighted by the American Psychological Association or one of its allied publishers.

controls (range: 9 to 17). The demographic characteristics of both


groups in the included studies are summarized in Table 1.

n/a

n/a
12
12
7
5
12
6
5
k
Main Meta-Analysis

8.30–39.70
8.30–14.10
24.80–39.70

9.47–15.00
0–71.4
31.80–85.7
Table 2 and Figure 2 display the results of the meta-analysis of

Range

14–58
M ⫹ PD and control group differences on general cognitive

n/a

n/a
performance. Negative effect sizes indicate impairment in the M ⫹
PD group relative to healthy controls, with a grand mean weighted
effect size of g ⫽ ⫺0.59 (k ⫽ 12, 95% CI [⫺0.72, ⫺0.46]). A

26.08 (12.86)
20.77 (12.14)

30.78 (29.55)
66.93 (19.49)
significant Q statistic (Q11 ⫽ 47.36, p ⬍ .000) indicated hetero-

Mean (SD)

11.48 (1.74)
33.77 (6.21)

12.53 (2.24)
M ⫹ PD
geneity among the studies beyond what would be expected on the

n/a

n/a
basis of sampling variation. The forest plot (see Figure 2) shows
Hedge’s g for each study and the g global in the last line.

313 (42.64%)

210 (67.09%)
103 (32.91%)
Publication Bias

313
n/a

n/a

n/a
n/a
n/a
N

Publication bias can be examined graphically with a funnel plot


(Egger, Davey Smith, Schneider, & Minder, 1997). In Figure 3,
effect sizes of each study are plotted. Funnel plots show studies
distributed symmetrically about the mean effect size if there is no
12

12
12
12
7
5
12
6
5
k

publication bias (Borenstein et al., 2009). However, in the current


study, the funnel plot (see Figure 3) shows little asymmetry at the
7.77–39.70
7.77–14.60
23.80–39.70

31.10–85.70
9.00–17.00
1995–2009

top and at the bottom with studies missing at the right. This led us
Range

14–98

0–80
n/a

to assume that there was a publication bias. In order to control


for this bias, a “Trim-and-Fill” procedure was used (Duval &
Tweedie, 2000) yielding an unbiased estimate of the effect size.
This procedure allowed us to create a funnel plot that included
30.58 (21.06)
20.51 (11.70)

30.97 (30.00)
68.45 (18.29)
2003.25 (3.93)

11.52 (1.88)
33.08 (5.65)

12.91 (2.74)
Mean (SD)

both the observed studies and the imputed studies. Thus, the
83.33

adjusted effect size was reported in Table 3. The effect sizes are
Total

similar and are of moderate effect (g ⫽ 0.53, k ⫽ 12, 95% CI


[⫺0.67, ⫺0.40]).
539 (73.43%)
195 (26.57%)

Results by Cognitive Domain or Age


N (%)
Demographic Data per Group

734
734
n/a

n/a

n/a
n/a
n/a

The results of the meta-analysis of M ⫹ PD and control group


differences in eight cognitive domains are shown in Table 2.
Cognitive performance was significantly impaired in the M ⫹ PD
group across all domains. A large effect size was observed for
Country where study

Race (% Caucasian)

executive functioning (g ⫽ ⫺0.90, 95% CI [⫺1.19, ⫺0.61]).


conducted (% in

Education (years)
Characteristic

Publication year

Moderate effect sizes were observed for verbal episodic memory


18 and older

(g ⫽ ⫺0.71, 95% CI [⫺0.87, ⫺0.55]), visuospatial/problem solv-


Sample size
Age (years)

ing (g ⫽ ⫺0.66, 95% CI [⫺1.00, ⫺0.33]), intelligence


Table 1

U.S.)

% male
7–18

(g ⫽ ⫺0.65, 95% CI [⫺0.75, ⫺0.54), and attention (g ⫽ ⫺0.61,


95% CI [⫺0.92, ⫺0.30]). There was a significant effect of cogni-
148 MASSON, EAST-RICHARD, AND CELLARD

Table 2
Meta-Analytic Results Based on Cognitive Domains or Age (k ⫽ 12)

Total Heterogeneity test


Number of sample Effect Standard 95% confidence
Cognitive domains/Age studies (k) size (N) size (g) error Variance interval Z-value p-value Q-statistic Df (Q) p-value

Global g 12 734 ⫺0.592 0.067 0.005 [⫺0.724, ⫺0.460] ⫺8.791 0.000 47.364 11 0.000
Adjusted g (publication bias) 12 734 ⫺0.532 [⫺0.669, ⫺0.395] 66.110
Cognitive domains
Intelligence 26 1,805 ⫺0.646 0.053 0.003 [⫺0.750, ⫺0.543] ⫺12.257 0.000 27.817 25 0.316
Verbal episodic memory 23 858 ⫺0.712 0.082 0.007 [⫺0.873, ⫺0.550] ⫺8.628 0.000 30.284 22 0.112
Visual episodic memory 17 713 ⫺0.196 0.130 0.017 [⫺0.452, 0.059] ⫺1.506 0.132 46.995 16 0.000
Working memory 4 173 ⫺0.357 0.151 0.023 [⫺0.653, ⫺0.062] ⫺2.368 0.018 0.314 3 0.957
Attention 7 433 ⫺0.610 0.159 0.025 [⫺0.922, ⫺0.298] ⫺3.836 0.000 14.660 6 0.023
Executive function 8 270 ⫺0.897 0.147 0.022 [⫺1.186, ⫺0.609] ⫺6.099 0.000 9.139 7 0.243
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Visuo-spatial/problem solving 4 142 ⫺0.662 0.170 0.029 [⫺0.995, ⫺0.329] ⫺3.900 0.000 2.563 3 0.464
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Processing speed 4 116 ⫺0.191 0.181 0.033 [⫺0.547, 0.165] ⫺1.053 0.292 1.092 3 0.779
Total between 24.056 7 0.001
Age
7–17 years 7 539 ⫺0.668 0.072 0.005 [⫺0.810, ⫺0.526] ⫺9.227 0.000 16.270 6 0.012
18 and older 5 195 ⫺0.487 0.114 0.013 [⫺0.710, 0.263] ⫺4.263 0.000 20.646 4 0.000
Total between 1.800 1 0.180

tive domain (Qbetween ⫽ 24.06, p ⬍ .001), with small effect sizes each cognitive domain by age strata (see Table 3). Results showed
for processing speed (g ⫽ ⫺0.19, 95% CI [⫺0.55, ⫺0.17]) and that cognitive domains were differentially affected according to
visual episodic memory (g ⫽ ⫺0.20, 95% CI [⫺0.45, 0.06]) age.
differing significantly from the large and moderate effect sizes For people below the age of 18 (range: 7.77 to 14.60 years),
listed above. strong effect sizes were observed for visual episodic memory
The data were also analyzed according to age. Metaregressions (g ⫽ ⫺0.97, 95% CI [⫺1.30, ⫺0.63]) and executive functions
showed a significantly different impact of age on the effect size (g ⫽ ⫺0.90, 95% CI [⫺1.19, ⫺0.61]). Moderate effect sizes were
(slope ⫽ 0.008, SE ⫽ 0.003, p ⫽ .002), so as age increases, so too observed for intelligence (g ⫽ ⫺0.68, 95% CI [⫺0.80, ⫺0.57]),
does the g value increase. It is important to note here that the g visuospatial/problem solving (g ⫽ ⫺0.63, 95% CI [⫺1.10, ⫺0.16]),
scale is negative, such that when g value increases in the scale it verbal episodic memory (g ⫽ ⫺0.55, 95% CI [⫺0.82, ⫺0.27]),
moves closer to a value of 0. Thus, effect sizes decrease as age attention (g ⫽ ⫺0.53, 95% CI [⫺1.04, ⫺0.02]) and working memory
increases. The scatter plot shows that there are mainly two age
(g ⫽ ⫺0.52, 95% CI [⫺1.12, 0.20]). There was a significant effect of
groups merged among the 12 studies (see Figure 1S in the sup-
cognitive domain (Qbetween ⫽ 13.64, p ⫽ .058), with a smaller effect
plementary data for scatterplot of age). Thus, participants from
size for processing speed (g ⫽ ⫺0.19, 95% CI [⫺0.55, ⫺0.17])
each study were classified as belonging to one of these two age
compared with all of other cognitive domains.
strata: less or more than 18-years-old.
Regarding adults over the age of 18 (range: 24.80 to 39.70
years), only six out of eight cognitive domains were assessed, with
Results by Cognitive Domain and Age
executive functioning and processing speed not being assessed. A
After analyzing variations in cognitive performance by cogni- strong effect size was observed for verbal episodic memory
tive domain and age separately, we then examined effect sizes for (g ⫽ ⫺0.77, 95% CI [⫺0.98, ⫺0.56]). Moderate effect sizes were

Study name Statistics for each study Hedges's g and 95% CI


Hedges's Lower Upper Relativ e
g limit limit weight
Bremner et al., 1995 -0,337 -0,478 -0,196 10,38
De Bellis et al., 1999 -0,961 -1,195 -0,726 8,59
Freeman & Beck, 2000 -0,584 -0,942 -0,225 6,30
De Bellis et al., 2002 -0,309 -0,564 -0,055 8,19
Beers & De Bellis, 2002 -0,595 -0,748 -0,443 10,18
Bremner et al., 2004 -0,554 -0,785 -0,323 8,66
Pederson et al., 2004 -0,058 -0,352 0,237 7,43
Porter et al., 2005 -0,914 -1,329 -0,499 5,45
Irle et al., 2005 -0,633 -0,795 -0,470 10,00
De Bellis et al., 2006 -0,675 -0,866 -0,483 9,44
Grassi-Oliveira et al., 2008 -0,961 -1,376 -0,546 5,44
De Bellis et al., 2009 -0,709 -0,874 -0,544 9,95
-0,592 -0,724 -0,460
-1,50 -0,75 0,00 0,75 1,50

Fav ours A Fav ours B

Figure 2. Forest plot of global cognition among studies in maltreatment.


NEUROPSYCHOLOGY, PSYCHIATRIC DISORDERS AND MALTREATMENT 149

Funnel Plot of Standard Error by Hedges's g


0,0

0,1

Standard Error
0,2

0,3

0,4
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-2,0 -1,5 -1,0 -0,5 0,0 0,5 1,0 1,5 2,0

Hedges's g

Figure 3. Funnel plot of cognitive disorders in M ⫹ PD.

observed for visuospatial/problem solving (g ⫽ ⫺0.73, 95% CI type of maltreatment, diagnosis, and socioeconomic status
[⫺1.27, ⫺0.19]), attention (g ⫽ ⫺0.72, 95% CI [⫺1.04, ⫺0.41]), and (SES)— on effect size variability within the total sample.
intelligence (g ⫽ ⫺0.52, 95% CI [⫺0.74, ⫺0.30]). There was a For the type of maltreatment, four categories were established in
significant difference between cognitive domains (Qbetween ⫽ 26.96, order to see if each category’s impact on cognition was the same:
p ⬍ .001), with a smaller effect size for visual episodic memory maltreatment (includes all type of abuse), abuse (includes sexual
(g ⫽ ⫺0.04, 95% CI [⫺0.26, ⫺0.19]) compared with verbal episodic and/or physical abuse, and/or emotional abuse), sexual abuse and
memory (g ⫽ ⫺0.77), attention (g ⫽ ⫺0.72), and intelligence neglect (physical and/or emotional). Because some studies focused
(g ⫽ ⫺0.52). Finally, the difference between means in visual episodic on maltreatment in general, their design only included one group
memory was not significant. of children who suffered from any kind of maltreatment. There-
fore, all types of maltreatment are mixed in this category (physical
Moderator Variable Analyses abuse, emotional abuse, sexual abuse, neglect, etc.). Some studies
Regarding the current analysis, a significant Q-value in Table 2 were interested in the impact of abuse—regardless of the type of
(Q11 ⫽ 47.36, p ⬍ .001) signified great variation in cognitive abuse—and did not specify if it was sexual, physical, emotional, or
performance from study to study. Therefore, a series of analyses all. Those studies were classified in the “abuse” category. When
was performed to examine the influence of moderator variables— the study specified the type of abuse, therefore the study was

Table 3
Meta-Analytic Results Based on Cognitive Domain by Age

Total Heterogeneity test


Number of sample Effect Standard 95% confidence
Cognitive domains studies (k) size (N) size (g) error Variance interval Z-value p-value Q-statistic Df (Q) p-value

7–17 years
Intelligence 18 1,473 ⫺0.680 0.059 0.003 [⫺0.795, ⫺0.566] ⫺11.612 0.000 18.773 17 0.342
Verbal episodic memory 6 212 ⫺0.545 0.140 0.019 [⫺0.818, ⫺0.271] ⫺3.903 0.000 0.849 5 0.974
Visual episodic memory 3 163 ⫺0.965 0.171 0.029 [⫺1.300, ⫺0.629] ⫺5.639 0.000 0.658 2 0.720
Working memory 1 29 ⫺0.521 0.368 0.135 [⫺1.241, 0.200] ⫺1.417 0.157 0.000 1.000 0.000
Attention 4 268 ⫺0.529 0.262 0.069 [⫺1.043, ⫺0.016] ⫺2.019 0.043 11.819 3 0.008
Executive function 8 270 ⫺0.897 0.147 0.022 [⫺1.186, ⫺0.609] ⫺6.099 0.000 9.139 7 0.243
Visuo-spatial/problem solving 3 87 ⫺0.626 0.240 0.058 [⫺1.096, ⫺0.156] ⫺2.612 0.009 2.478 2 0.290
Processing speed 4 116 ⫺0.191 0.181 0.033 [⫺0.547, 0.165] ⫺1.053 0.292 1.092 3 0.779
Total between 13.643 7 0.058
18 and older
Intelligence 8 332 ⫺0.520 0.113 0.013 [⫺0.742, ⫺0.298] ⫺4.590 0.000 7.362 7 0.392
Verbal episodic memory 17 646 ⫺0.773 0.107 0.011 [⫺0.983, ⫺0.563] ⫺7.226 0.000 27.785 16 0.034
Visual episodic memory 14 550 ⫺0.037 0.113 0.013 [⫺0.259, 0.185] ⫺0.326 0.745 23.204 13 0.039
Working memory 3 144 ⫺0.324 0.166 0.027 [⫺0.649, 0.000] ⫺1.959 0.050 0.077 2 0.962
Attention 3 165 ⫺0.724 0.160 0.025 [⫺1.037, ⫺0.411] ⫺4.535 0.000 1.757 2 0.415
Visuo-spatial/problem solving 1 55 ⫺0.725 0.276 0.076 [⫺1.266, ⫺0.185] ⫺2.630 0.009 0.000 1.000 0.000
Total between 26.962 5 0.000
150 MASSON, EAST-RICHARD, AND CELLARD

classified in a more precise category such as physical abuse, sexual meta-analysis, the average effect size of the global cognitive
abuse, or neglect. It is important to note that “maltreatment” and performance implied more than 50% distribution overlap. There-
“abuse” categories could include persons who experienced multi- fore, most participants with histories of maltreatment and PTSD
ple types of maltreatment or a single type. Results showed that share similar neuropsychological functioning with controls.
type of maltreatment had a significant effect (Qbetween ⫽ 10.18,
p ⫽ .017) and influenced the effect size (see Table 4). The abuse Impact of Maltreatment and Psychiatric Disorder
category had a small effect size (g ⫽ ⫺0.23, 95% CI Across Age
[⫺0.50, ⫺0.04]), which significantly differed from the large effect
Results also showed that the impact of psychiatric disorders
size of the neglect category (g ⫽ ⫺0.76, 95% CI [⫺0.96, ⫺0.56]).
(especially PTSD) and maltreatment differed according to age.
Concerning psychiatric diagnosis and SES, analyses could not
Indeed, this negative impact was of lesser importance as age
be computed because of a lack of studies in each category: diag-
increased. Therefore, it could be that some compensatory pro-
nosis (k ⫽ 1 in borderline personality disorders-BPD, k ⫽ 1 in
cesses occur in adulthood that helped to decrease the negative
major depressive disorder-MDD, k ⫽ 10 in PTSD categories) and
impact of M ⫹ PD that lasted since childhood. Moreover, neuro-
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SES (k ⫽ 1 in low SES, k ⫽ 7 for middle-upper SES). Although


psychological profiles differed considerably between people
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the analysis could not be conducted, it is worth noting that the


younger than 18-years-old (range: 7.77 to 14.60) and people 18
corpus of studies is characterized by patients with PTSD (10 out of
years and older (range: 24.80 to 39.70). However, it is difficult to
12) with middle-upper SES level (seven out of 12).
compare all cognitive domains between the two age strata because
executive functioning and processing speed were not assessed in
Discussion those aged 18 and older.
The aims of the current meta-analysis were to determine the Regarding people below the age of 18, intelligence was the
impact of maltreatment and psychiatric disorders on cognition and cognitive domain most often assessed (19 variables across the 12
to examine whether such impact varied across age groups and studies). Visual episodic memory and executive functioning (in-
types of maltreatment. Overall, 734 participants in 12 studies cluding verbal fluency, mental flexibility, inhibition, and switch-
published between 1970 and 2013 were included in the meta- ing) had very large effect sizes for this stratum. Moreover, in
analysis. Although the goal was to study a range of psychiatric young people, intelligence, visuospatial/problem solving, verbal
disorders, the majority of studies included participants with PTSD. memory, attention, and working memory had moderate effect
sizes. Consequently, all cognitive domains were moderately or
Impact of Maltreatment and Psychiatric Disorder on severely affected, with the exception of processing speed, which
had a small effect size.
Neuropsychological Functioning
With respect to people 18 years and older, the neuropsycholog-
Results showed that people that suffered from psychiatric dis- ical profile differed considerably and especially for the more
orders (BPD: k ⫽ 1, MDD: k ⫽ 1, and PTSD: k ⫽ 10) and affected cognitive domains. A large effect size was observed in
maltreatment had worse global cognitive performance than people verbal episodic memory whereas for young people it was in visual
of similar ages in the general population (moderate effect size, episodic memory. In adults, visual episodic memory was consid-
g ⫽ ⫺0.59). The global impact of maltreatment and psychiatric ered unaffected because there was no significant difference be-
disorder (especially PTSD) on cognitive functioning is of moder- tween M ⫹ PD and control groups. Our findings are consistent
ate effect size. The combination of childhood maltreatment and with the literature for PTSD, which has shown verbal memory
psychiatric disorder has greater impact than maltreatment alone. impairments to be the most consistent cognitive deficits in PTSD
Effectively, another meta-analysis examined the impact of mal- (Horner & Hamner, 2002; Johnsen & Asbjørnsen, 2008; Vaster-
treatment on cognition in people without psychiatric disorder and ling & Brailey, 2005) whereas visual memory seems affected in
showed a moderate effect size (g ⫽ 0.50) lower than the present children/adolescents but does not remain impaired during adult-
meta-analysis (g ⫽ 0.59; Masson et al., 2015). hood. In addition, the visuospatial/problem solving, attention, and
It is worth pointing out that effect sizes can also be interpreted intelligence domains had moderate effect sizes. Finally, a small
in terms of the percent of overlap of the maltreated group’s scores effect size was observed for working memory. Taken together, the
with those of the control group (Cohen, 1988). In the current impact of maltreatment and psychiatric disorder (especially PTSD)

Table 4
Moderator Variables Analyses

Total Heterogeneity test


Number of sample Effect Standard 95% confidence
Moderator variables studies (k) size (N) size (g) error Variance interval Z-value p-value Q-statistic Df (Q) p-value

Type of maltreatment
Maltreatment 5 439 ⫺0.637 0.083 0.007 [⫺0.799, ⫺0.475] ⫺7.692 0.000 14.119 4 0.007
Abuse 2 75 ⫺0.229 0.136 0.019 [⫺0.496, 0.038] ⫺1.678 0.093 2.819 1 0.093
Sexual abuse 3 121 ⫺0.633 0.098 0.010 [⫺0.826, ⫺0.440] ⫺6.439 0.000 2.279 2 0.320
Neglect 2 99 ⫺0.760 0.101 0.010 [⫺0.958, ⫺0.562] ⫺7.509 0.000 1.221 1 0.269
Total between 10.180 3 0.017
NEUROPSYCHOLOGY, PSYCHIATRIC DISORDERS AND MALTREATMENT 151

on neuropsychological profile appears to be of lesser magnitude in One hypothesis could be that psychiatric disorders did not lead
adults. to even more cognitive disorders in abused children, because their
neuropsychological profile was already highly impaired. In con-
Impact of Maltreatment and Psychiatric Disorder trast, as neglected children initially have less cognitive disorders
Across Type of Diagnosis than abused children, the addition of a psychiatric disorder (espe-
cially PTSD) leads to important changes in their neuropsycholog-
In the current meta-analysis, the majority of studies (10 out of
ical profile. For example, given that childhood abuse and PTSD
12) examined relationships between cognition, maltreatment, and
both lead to memory deficits, an abused child with PTSD is likely
PTSD. The two remaining studies examined MDD and BPD. We
to have memory disorders. Negligence does not appear to be
identified no studies examining the relationships between cogni-
associated with memory disorders and so a neglected child would
tion, maltreatment, and other anxiety disorder subtypes. Previous
not necessarily have memory disorders but a neglected child with
studies showed that the profile and nature of cognitive dysfunction
PTSD might have such deficits. Consequently, the difference
varies across anxiety disorder subtypes (Castaneda et al., 2008).
between controls and M ⫹ PD groups was greater when it con-
Several reviews on cognitive deficits in PTSD have been published
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cerned people that were neglected. However, this result should be


though the results may not be generalizable because the majority
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interpreted carefully specifically because of the small number of


of studies have focused on specific populations, such as combat
studies for some categories (k ⫽ 2 for neglect). Moreover, even if
veterans or prisoners of war (for a review see Horner & Hamner,
the effect size was larger for neglect, it was substantial for “mal-
2002). Among young adults with PTSD, impairments have been
treatment” and “sexual abuse” alone too.
observed in attention (Jenkins, Langlais, Delis, & Cohen, 2000),
A second hypothesis could be the fact that Nolin and Ethier’s
short- and long-term verbal and visual memory (Vasterling, Brai-
(2007)study, who demonstrated better results for neglected people
ley, Constans, & Sutker, 1998) and executive functioning (Stein,
compared with abused, comprised children only. The present
Kennedy, & Twamley, 2002). This is congruent with the current
meta-analysis is about children and adults. This argument is sup-
meta-analysis, which highlights the larger effect sizes in visual
ported by a prospective study (Nikulina & Widom, 2013) which
memory and executive functioning in young people and verbal
examined whether childhood abuse and neglect predicts compo-
memory in adults.
nents of executive functioning and nonverbal reasoning ability in
The fact that individuals had suffered from maltreatment in
middle adulthood and whether PTSD moderates this relationship.
addition to PTSD did not seem to lead to a different neuropsycho-
Their results showed that childhood neglect predicted poorer ex-
logical profile than individuals who had suffered from PTSD
ecutive functioning and nonverbal reasoning in adulthood, whereas
without maltreatment. Moreover, an interesting study (De Bellis,
physical and sexual abuse did not. As a consequence, there is some
Woolley, & Hooper, 2013) comparing maltreated individuals with
evidence that neglect may have longer lasting effects than physi-
or without PTSD did not reveal distinct neuropsychological pro-
cal/sexual abuse. Moreover, authors showed that a past history of
files between the two groups. According to authors, these results
PTSD did not mediate or moderate these relations (Nikulina &
support a dynamic developmental traumatology model (De Bellis,
Widom, 2013). Therefore, in the present meta-analysis, if the
2001) where an early trauma causes global and multiple neuro-
impact of maltreatment and psychiatric disorder on neuropsycho-
psychological deficits that are not related to current PTSD symp-
logical profile appears to be of lesser magnitude in adults, it is
toms or psychopathology. These findings may indicate that mal-
rather related to compensative mechanisms than related to evolu-
treatment or PTSD could lead to the same cognitive impairments
tion of psychiatric disorder.
independently; therefore the association of both of them does not
change the neuropsychological profile but can increase the
strength of the impairments. Research Implications and Limitations

Impact of Maltreatment and Psychiatric Disorder The aim of the meta-analysis was to study the effects of mal-
treatment across a range of psychiatric disorders but ultimately
Across Type of Maltreatment
most studies focused solely on PTSD; this represents the main
Regarding the effect of the type of maltreatment on cognition, limit of the meta-analysis. All but two studies (MDD and BPD) in
the effect size for people with psychiatric disorder who suffered the review were conducted with people with PTSD, revealing a
from neglect was more important than the effect size of people lack of studies evaluating the impact of maltreatment on neuro-
with psychiatric disorder and abuse (sexual, physical, and/or emo- psychological functioning when combined with diverse psychiatric
tional). This result was unexpected because people that are ne- disorders (e.g., mood disorders, anxiety disorders, disruptive be-
glected (without psychiatric disorder) often have fewer cognitive havior disorders, antisocial behavior, or psychosis). The reasons
disorders than people that are abused. For example, Nolin and for this are unclear but may relate to the fact that PTSD is
Ethier (2007) found that children that were neglected differed from frequently observed after exposure to maltreatment (Breslau et al.,
control group in that they obtained lower scores in auditory atten- 2014) and thus it is sensible to explore associations between
tion and response set, as well as visual-motor integration. More- maltreatment and this disorder. At the same time, childhood mal-
over, these same children demonstrated a greater capacity for treatment is strongly associated with a wide range of psychiatric
problem solving, abstraction and planning than physically abused outcomes, suggesting that maltreatment is a nonspecific risk for
and control children (Nolin & Ethier, 2007). Consequently, the psychopathology (Keyes et al., 2012) and not especially associated
addition of psychiatric disorder (especially PTSD) to maltreatment with any one disorder.
would have a higher negative impact for children who suffer from One key question is whether the results of the current meta-
neglect. analysis would be the same if there were other psychiatric diag-
152 MASSON, EAST-RICHARD, AND CELLARD

noses included. As the present meta-analysis has revealed that the Inventory-ETI (Bremner, Vermetten, & Mazure, 2000), Childhood
neuropsychological profile of individuals suffering from maltreat- Trauma Questionnaire-CTQ (Bernstein & Fink, 1998), Trauma
ment and PTSD is close to those suffering from PTSD without Symptom Inventory-TSI (Briere, 1995), Traumatic Antecedent
maltreatment, we can assume that additional cognitive impair- Questionnaire-TAQ (Herman, Perry, & van der Kolk, 1989), or
ments would be observed in association with each specific psy- detailed trauma interviews. Third, some children who suffer from
chiatric disorder. For example, processing speed is the most im- maltreatment experience multiple types, not a single type. For
paired cognitive domain in patients with schizophrenia (Schaefer example, in the abuse group, there were children who suffered
et al., 2013); therefore, individuals suffering from maltreatment from one type of abuse (e.g., emotional abuse) and children who
and schizophrenia would have a similar pattern. Furthermore, suffered from several types of abuse (e.g., sexual and physical
MDD is characterized by verbal memory, executive functions, and abuse). This could have affected our results but could not be
processing speed impairments (Bora, Harrison, Yücel, & Pantelis, controlled for in the present meta-analysis because of studies’
2013); BPD is associated with generalized cognitive impairments design. No study compared a group of participants with multimal-
(Mann-Wrobel et al., 2011); and obsessive– compulsive disorder is treatment to a group that experienced only a single type of mal-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

characterized by deficits in executive functioning and visual mem- treatment. The impact on cognition may be cumulative: The more
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ory (Castaneda et al., 2008). As a result, had all of these psychi- types of maltreatment children suffer from, the greater the risk of
atric disorders been included in the meta-analysis, additional im- developing cognitive disorders.
pairments would likely have been observed in processing speed Our analysis also highlights a lack in crucial moderator vari-
and executive functions in adults. ables linked to maltreatment: age, duration, and severity of mal-
The study of cognition can lead to some limitations. First, a treatment. We were interested by these specific variables because
neuropsychological test involves multiple cognitive processes; and they could change the impact of maltreatment on cognition. Un-
similar multiple demand cortex can underlie many neuropsycho- fortunately, those variables were reported in very few articles only.
logical tasks (Duncan, 2010). Nevertheless, the categorization into Age and duration of maltreatment were almost never reported
several cognitive domains is more convenient to interpret results probably because they are difficult to assess and self-reports could
and can guide the clinician to build his neuropsychological battery. be contested because of autobiographical memory impairment
Second, the cognitive domains examined in a meta-analysis are (memory of trauma; Goodman et al., 2010). Finally, severity of
those addressed in the studies reviewed and not selected by the maltreatment is an important question but nearly impossible to
authors. As a consequence, executive functioning and processing assess. Effectively, it is difficult to attest that a type of maltreat-
speed were not assessed in adults aged 18 and older. Third, some ment is more severe than another. For this reason, researchers
studies did not report the information concerning the use of a never address this notion of severity. As the onset of maltreatment
minimum cut-off for IQ in their inclusion criteria. Hence, seven is rarely documented and it is not clear about the origins of PTSD
out of 12 studies applied a cut-off by excluding people who have (or others psychiatric disorders), it may be mixed. Indeed, there is
a full-scale IQ lower than 70 or 80. Regarding the five remaining a possibility that cognitive impairments may have occurred prior to
studies (Bremner et al., 1995; Bremner, Vermetten, Afzal, & the maltreatment or to the diagnoses. For example, people with
Vythilingam, 2004; Grassi-Oliveira, Stein, Lopes, Teixeira, & intellectual disabilities are more likely to experience maltreatment
Bauer, 2008; Irle, Lange, & Sachsse, 2005; Pederson et al., 2004), than people without disabilities and then a lot of others types of
it seems that no participants had an intellectual deficiency (because disabilities (Horner-Johnson & Drum, 2006). Additionally, cogni-
of standard IQ means) whereas this was not listed as an exclusion tive impairments could contribute to the development of psychi-
criteria. For future research, it will be essential that authors specify atric disorders or symptoms, this is the concept of cognitive
if they apply a cut-off because this might artificially skew the psychopathology (Van der Linden & Ceschi, 2008). In these
results when studies that do and do not apply this cut-off are specific cases, cognitive impairments may represent the initiating
pooled together. cause of the maltreatment or may underlie the diagnosis.
The study of maltreatment is difficult for several reasons. First, With regards to the moderator analysis we have performed
the definition of maltreatment often changes from one study to the (SES, type of diagnosis, and type of maltreatment), only one
next. For this reason, we decided to refer to the definition of The moderator variable (type of maltreatment) has been useful because
United States’ Child Abuse Prevention and Treatment Act (i.e., PL of lack of studies in each category. First, only eight of 12 studies
93–247). It is important to distinguish childhood maltreatment to reported the SES information and only one study reported data for
childhood adversities. Indeed, maltreatment is a kind of adversity participants with low SES. Second, as mentioned above, the type
but it is not the only one. Twelve childhood adversities were of diagnosis was essentially focused on PTSD.
identified including three types of interpersonal loss (parental In the current meta-analysis, the effects of maltreatment and
death, parental divorce, and other loss of contact with parents or psychiatric disorders (especially PTSD) may be confounded and
caregivers), four types of parental maladjustment (mental illness, yet sparse research has attempted to disentangle the effects of
substance abuse, criminality, and family violence), four types of maltreatment and PTSD on cognitive functioning. Because not
maltreatment (physical abuse, sexual abuse, emotional abuse, and everyone who experiences trauma develops PTSD, studies that
neglect), and family economic adversity (McLaughlin et al., 2012). compare samples with maltreatment and PTSD with controls who
Therefore, studies examining childhood adversities were not in- do not have a trauma history cannot differentiate the effects of
cluded in the meta-analysis because groups always mixed different trauma from PTSD (Gunnar & Quevedo, 2007). Alternatively,
kinds of adversities and data specific to maltreatment could not be studies comparing traumatized children with PTSD with trauma-
extracted. Second, the measures used to assess maltreatment across tized children without PTSD are able to address the effects of
the various studies are not always consistent: Early Trauma PTSD but not the traumatic experience (Schoeman, Carey, &
NEUROPSYCHOLOGY, PSYCHIATRIC DISORDERS AND MALTREATMENT 153

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