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INVITED EDITORIAL
CHILDHOOD ADVERSITIES AND MENTAL ILL HEALTH
RAIMO K. R. SALOKANGAS
In 1896, Viennese neurologist Sigmund Freud, basing on his experience of treating 18 patients, proposed a hypothesis that 
sexual abuse was responsible for his patients’ neuroses and other mental problems. The following year Freud started to doubt 
his theory, concluding that the memories of sexual abuse might in fact be the result of imagination, i.e. fantasies. Although 
Freud abandoned the (seduction) theory, he still believed that sexuality played an important role in manifestation of neuroses 
(1). In clinical practice, we may face Freud’s dilemma: when are patient reports on childhood adverse experiences real, when 
are they the product of imagination or even sometimes of (unskilful?) therapeutic intervention. Specifically, this difficulty 
concerns sexual abuse but may also relate to other types of childhood adversities.
However, there is no doubt that childhood adverse and trauma (CAT) experiences are common in the general population and 
very common among people seeking help (2,3), and frequently associated with physical illness, mental problems and disturbed 
behaviour in adulthood (4-9). CAT experiences tend to be frequent and accumulate for some individuals. In a random sample 
of 692 citizens aged 18 years or more, drawn from the general population of the Varsinais-Suomi Health District of South-West 
Finland, 72% of participants reported at least one and 48% two or more CAT experiences. In primary care, the corresponding 
figures were 77% and 58%, and in psychiatric outpatient care as high as 94% and 81% (10). 
There are several ways to assess and classify CAT experiences. In the literature, emotional and physical abuse, emotional 
and physical neglect, and sexual abuse are generally regarded as five core childhood adversity domains (11,12), and can be 
retrospectively obtained with standardized measurements, such as the Childhood Trauma Questionnaire CTQ (13), the Early 
Trauma Inventory-Self Report ETI-SR (14) and the Trauma and Distress Scale TADS (15). Another way is to record severe 
objective life events and investigate their prospective associations with ill-health indicators. However, this measurement type 
loses the individual’s subjective experiences and their effect on outcome indicators.
The majority of research on CAT experiences has dealt with sexual abuse, as well as physical and emotional abuse, and to 
a lesser extent physical and emotional neglect. Contrary to this scientific interest, emotional neglect has been the most frequent, 
and sexual abuse the least, reported domain of CAT experiences. For example, in our population sample 51% of the participants 
reported emotional neglect, 50% physical neglect, 37% emotional abuse, 23% physical abuse and only 5.5% sexual abuse (10). 
It is remarkable that emotional neglect has received so little interest among researchers and media, although its detrimental 
effects on children’s early development has been known for long time. In 1973, Bowlby (16) proposed that in the context of the 
attachment relationship, a child internalizes a sense of care as reliable or unreliable, protective or threatening, and a complementary 
perception of the self as deserving or undeserving of care, as effective or inept at eliciting adequate nurturance, support and 
protection. According to this attachment theory, these internalized representations form the basis of the working models of the self, 
of others, and of the self-with-others that guide future behaviour and shape subsequent experiences in the interpersonal milieu. 
Negative representational models of attachment figures originating from childhood and adolescence tend to persist relatively 
unchanged into and throughout adult life, and can manifest in neurotic symptoms and personality disorders (17). Parental emotional 
rejection, as a part of the acceptance-rejection syndrome, may specifically lead to psychological maladjustment, including a 
KEY WORDS: CHILDHOOD TRAUMA, CHILDHOOD ADVERSE EXPERIENCES, CAT EXPERIENCES, 
MENTAL DISORDERS
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Salokangas R.Invited Editorial
Childhood adversities and mental ill health
PSYCHIATRIA FENNICA 
2021;52:10-13
negative worldview (18). We tested the attachment theory in our population sample and found that all CAT domains associated 
with quality of perceived attitude of others. However, from all CAT domains, only emotional neglect had a specific effect: 
participants, who had faced emotional neglect in their childhood, perceived that other people had a negative attitude towards 
them (19). That finding indicates that emotional neglect in early childhood may persist into adulthood, have a negative impact 
on interpersonal relationships and may even manifest as an untrustworthy attitude towards other people and the whole of society. 
Several studies have shown that CAT experiences associate with mood and anxiety disorders, psychoses, substance abuse 
and suicidal behaviour, and an accumulation of several CAT experiences for individuals with psychiatric disorders is typical 
(10). Therefore, the question on specific associations is not only interesting but also important from a practical point of view. In 
a study on patients attending primary and psychiatric outpatient care, all CAT domains and their sum had significant associations 
with psychiatric disorders. However, CAT domains and psychiatric diagnoses correlated extensively with each other. When all 
these intercorrelations were taken into account, only physical abuse and emotional neglect had significant associations with 
clinical disorders: physical abuse associated specifically with depression, mania, anxiety and psychoses, while emotional neglect 
associated specifically with depression, anxiety and substance abuse (20). 
The association between emotional neglect and substance abuse deserves special attention. Young substance abusers have, 
among other childhood adversities, experienced emotional neglect and may therefore perceive that other people, including 
help-providers, have a negative and rejecting attitude towards them. These emotionally neglected youths are in many ways 
marginalized and they have great difficulties in accepting institutional help. Instead, a group of youths with similar experiences 
may offer emotional acceptance to the neglected youths and support their unstable and fragile self-esteem resulting in a greater 
marginalization outside organized society. 
Gender and depression seem to have an important role in the association between CAT experiences and alcohol abuse. In 
both gender groups, all CAT domains associate with alcohol problems and a major part of the CAT experiences on alcohol abuse 
is mediated via depression. Additionally, in females sexual abuse and physical abuse seem to have a direct effect on alcohol 
problems (21). These notions have important indications. The typical practice of requiring alcohol abstinence before treating 
depression patients with alcohol problems may not be reasonable. Concurrent treatment of both depression and alcohol abuse 
may be more successful and more human.
It is interesting to note that there are some similarities in the effect of CAT experiences on alcohol abuse and on suicidality. 
In a follow-up study of patients with clinical high risk to psychosis, suicidal thoughts during follow-up period were predicted 
by baseline clinical depression in females, while in males, concurrent depressive symptoms were major indicators for suicidal 
thoughts (22). In males, alcohol abuse, depressiveness and suicidal thoughts often coexist, indicating that although active treatment 
of depressive mood is important in both genders, it may be life-saving particularly in alcohol-abusing males.
In clinical practice, examination of CAT experiences is an important but sometimes challenging job. It is good to remember 
that although CAT experiences may have some aetiological significance with regard to patient disorders or problems, they always 
represent only one factor among many others, such as genetic predisposition, personality, later life events etc. Empathic and 
understanding processing of childhood experiences may increase the patient’s understanding of his/her own history, and help 
acknowledge these experiences and incidents as part of his/her life. Painful experiences have often become apparent in a patient’s 
childhood and may relate to family members. In a successful therapeutic intervention, a patient is able to understand the difficulties 
and limitations of the family member who has been responsible for his/her adversities, even maltreatment. Understanding does 
not necessarily mean acceptance of the maltreatment, rather it often results in forgiveness. Therapy cannot change the past but it 
can increase understanding and as a result improve the psychological resources and future life of the patient. 
From a prevention point of view, it would be important to arrange long-term counselling and guiding to parents who are 
expecting their first child. Young couples need support and guidance in their changing mutual relationship and childcare. It is 
reasonable to assume that modern parents are aware of the importance of a child’s cognitive development and the detrimental 
effects of abusive treatment. However, children’s need for emotional interaction and lack thereof, i.e. emotional neglect, are 
not recognized to the same extent. Maternity clinics could emphasize more parental attention to their child’s emotional needs. 
In addition to guiding parents in childcare, maternity clinics could offer marital counselling and crisis support to families, thus 
preventively helping them over challenging situations.
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Salokangas R. Invited Editorial
Childhood adversities and mental ill health
PSYCHIATRIA FENNICA 
2021;52:10-13
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Author:
Raimo K. R. Salokangas, MD, PhD, MSc, PsD
Professor of Psychiatry, emeritus
Department of Psychiatry, University of Turku
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Invited Editorial
Childhood adversities and mental ill health