The Lifetime Effects of Child Maltreatment

Written by Dr Rob Thomson, PhD, Brainwave Trust Researcher/Kaiako

This replaces the article “Why Should We Care? The Abuse and Neglect of Children in New Zealand” by Hilary Nobilo in 2016.

Children are influenced by their experiences, and what happens to them can either help or get in the way of their healthy development. Children need to feel loved and safe, and if they experience maltreatment the effects can last not only for their lifetime but may impact future generations. Child maltreatment is a global issue which can have serious life-long physical, psychological and social consequences.

This article addresses the potential impacts of child maltreatment on the development of children, and the factors that have been associated with increased risk of maltreatment. By understanding these we can all play a role in prevention, early intervention, and support. This will help our children and society overcome the intergenerational effects of maltreatment. 

What is child maltreatment?

Child maltreatment is generally considered both actions or inactions by a parent or other caregiver that result in harm, potential for harm, or a threat of harm to a child.¹ This includes ill-treatment, abuse, neglect, or deprivation of any child or young person. Oranga Tamariki consider harm as physical, sexual, or emotional abuse, neglect or exposure to family violence, which interrupts, or damages the physical and/or psychological development of the child.²

The harm to the child may be intentional or unintentional. For example, a caregiver might use harsh punishment because they wanted to change the child’s behaviour rather than to cause harm, but this is still child maltreatment.³

In considering child maltreatment we tend to focus on the child’s primary caregivers; however, some children are maltreated by a substitute caregiver such as a teacher, coach, babysitter, or in state care. The extent of abuse in state care has recently been highlighted in Aotearoa New Zealand;⁴ especially for tamariki Māori. ⁵ Although abuse in state care is outside the scope of this article, it is important to recognise the long-term effects of institutional abuse; especially for children with a history of maltreatment before they came into state care.⁶ Efforts to protect tamariki from maltreatment in their own families have often led to them experiencing additional maltreatment by subsequent caregivers.

There are four main forms of child maltreatment that are generally recognised⁷ (1) physical abuse, (2) emotional or psychological maltreatment, (3) sexual abuse, and (4) neglect. Increasingly, witnessing adult intimate-partner violence is also seen as a separate type of maltreatment.⁸ Unfortunately, children who are maltreated are often exposed to more than one type of maltreatment⁹, which can increase the negative effects exponentially.

1. Physical abuse

Definitions vary from very broad, such as a nonaccidental physical injury to a child, to more specific by defining acts of abuse such as shaking, throwing, hitting, pushing, grabbing, dragging or kicking. However, the consensus is that physical abuse includes acts that either:

• cause physical harm, or 
• create substantial risk of physical harm to a child.¹⁰  

Physical discipline, such as smacking, that may have been socially acceptable or commonplace in the past, or in some countries, is also considered physical abuse,¹¹and it is estimated that globally nearly 400 million young children experience violent discipline at home.¹²

2. Emotional or psychological maltreatment

Emotional or psychological maltreatment is a regular pattern of behaviour by the caregiver that can lead to the child feeling unwanted or unloved and may impair their healthy development.¹³ It is important to note that it is the regular pattern of behaviour or relationship between the caregiver and child that is the issue, given that no parent will be available and responsive all the time.

Emotional maltreatment may involve:

• psychological abuse, which are behaviours that actively harm the child’s mental health, and/or, 
• psychological neglect, where a parent fails to meet the emotional needs of the child.  

Some researchers have defined psychological maltreatment as a failure to meet the child’s needs to be recognised and respected by their caregivers.¹⁴ This can include frequent emotional unavailability or unresponsiveness, inappropriate or inconsistent interactions, failure to realise the child’s capabilities, and blaming the child for not doing things they are not capable of. An example of this is where caregivers punish children for not being able to use the toilet, when they are not yet capable of (or are still learning about) using the toilet consistently.

Psychological maltreatment may be the most common form of maltreatment, and more damaging than other forms of maltreatment¹⁵, as this can convey to a child that they are worthless, flawed, unloved, unwanted, endangered, or valued only in meeting another’s needs.

3. Sexual abuse

Child sexual abuse is any sexual activity between an adult and a child, or between two youths where one exerts power over the other. This can include contact abuse from touching, or masturbation to penetrative acts, and non-contact abuse such as threats of sexual abuse, harassment, or exposure to pornography or inappropriate sexual material.¹⁶ 

In Aotearoa New Zealand, sexual abuse is considered any action where a child or a young person is used for a sexual purpose including contact abuse (e.g. contact with breasts or genitals, encouraging the child to perform sexual acts) and non-contact abuse (e.g. exhibitionism, exposure to pornography, suggestive behaviours, sexting or grooming).¹⁷ Another disturbing aspect of abuse is child sexual exploitation, where the abuse occurs for financial benefit through prostitution, trafficking or pornography, often through the internet.¹⁸

Despite concern about stranger danger, most perpetrators are known and trusted by the child as a friend or acquaintance, family member, or someone in authority such as a teacher or coach.¹⁹ Research has shown that most perpetrators are male (up to 95%), however it is believed that the prevalence of child sexual abuse by women is under reported.²⁰ There is also evidence that many perpetrators are adolescents or young adults, and this may be becoming more common.²¹

Unlike other forms of abuse there is often a process of grooming by the perpetrator where they become trusted, develop an exclusive relationship with the child, distance the child from other people, and desensitise the child to sexual behaviours.²² Perpetrators who do not have an existing relationship with the family are more easily able to do this online, especially if the child’s online access is unmonitored.²³
This highlights the importance of adult supervision and ensuring that children and young people are taught online safety.

4. Neglect

Neglect is a pattern of behaviour where the child’s needs are not being met which can be just as damaging as other forms of child maltreatment. Unlike other forms of maltreatment, neglect is an act of omission, or failure in the duty of care.²⁴ Neglect is a failure to meet a child’s basic physical, emotional, medical/dental, or educational needs; failure to provide adequate nutrition, hygiene, or shelter; or failure to ensure a child’s safety. This could be leaving the child alone or without appropriate supervision, not providing adequate food or clothing, or not seeking medical treatment when needed. It is important to note that neglect can include both specific incidents as well as a pattern of behaviour where the child’s needs are not being met.²⁵  

Neglect also needs to be considered in the wider cultural context and societal issues such as poverty and social exclusion. Many parents in our society despite their best efforts, do not have sufficient resources to meet their child’s needs.²⁶ Furthermore, in many communities, child neglect may be seen as a failure of the community rather than the individual caregivers.²⁷ Tamariki can also experience neglect in wealthier families (affluent neglect), where although there may be adequate or ample financial resources, the children are not receiving the emotional and psychological support they need.²⁸

Although neglect is often not recognised by other people (compared to other forms of child maltreatment),²⁹ neglect may be the most common form of maltreatment,³⁰ and is linked with a wide range of negative health outcomes.³¹

5.  Witnessing intimate-partner violence

Researchers have also considered witnessing intimate partner violence (IPV) as a separate type of child maltreatment.³² This can be any incident of threatening behaviour, violence, or abuse (psychological, physical, sexual, financial, or emotional) between adults who are, or have been, intimate partners or family members. It has also been argued that IPV and child maltreatment must be addressed together,³³ as children may be physically caught up in the violence, and/or harmed psychologically.

How common is child maltreatment?

Unfortunately, child maltreatment is very common. It is difficult to accurately determine how many children experience maltreatment, as studies differ in definitions, and methodology³⁴ (e.g., police data, child self-report, or adult self-report), and many victims do not talk about their maltreatment, however, it has been estimated that:

• One in four children have experienced child abuse and/or neglect; especially emotional/psychological abuse and neglect (which are less likely to be reported).³⁵  
• Globally up to one billion children experience physical, emotional or sexual violence and neglect each year.³⁶  
• Six in ten children experience violent discipline at home.³⁷
• The Center for Disease Control (CDC) and the World Health Organisation (WHO) report that one in four girls and one in seven boys experience sexual abuse.³⁸  

In Aotearoa New Zealand we have one of the highest rates of child homicide in the OECD, as at least 20 children are killed every year.³⁹ Violence against children, and the number of children admitted to hospitals with injuries due to abuse or neglect appears to  be increasing.⁴⁰ Rates of sexual abuse are also high with one in five children reporting or known to be experiencing sexual abuse.⁴¹  

This high rate of violence experienced by young people is reflected by adolescents in the National Youth Health & Wellbeing Survey (2021) in Aotearoa New Zealand.⁴² Fifty-nine percent of young people reported that adults had yelled or sworn at them or another person, and 17% physically hurt them or another person at home in the last 12 months.

Unfortunately, children who experience maltreatment often do not talk about it and suffer in silence. There are a range of factors such as cultural norms, type of abuse, family dynamics and previous history that can help or hinder disclosure.⁴³ The response of the person to whom the abuse is disclosed is
essential. Supportive responses from non-offending caregivers can help disclosure and promote adjustment, whereas negative or dismissive responses, especially by caregivers, can be more harmful than delayed or nondisclosure itself.⁴⁴ In other words, children can be discouraged from further reporting if the response they receive is not helpful, or they have been made to feel that it is their fault.

What are the consequences of child maltreatment?

We are constantly learning more about the possible short-term, long-term and intergenerational effects of maltreatment, with a large body of evidence indicating potential physical, mental, and social consequences of child maltreatment through into adulthood. There is a clear link between maltreatment, brain development and behaviour, and we need to look past the presenting behaviours of the child to consider what challenges the child is facing. Too often children are seen as “naughty” or “difficult” rather than maltreated, so we need to look beyond the behaviour to understand what may be going on for the child.

We now understand that the physical and psychological effects of maltreatment are adaptive changes in the brain for children trying to survive in an unsafe world, however these changes can be harmful over time. These brain changes are associated with emotional dysregulation, increased reward-seeking or substance use and attachment challenges.⁴⁵  

Every tamaiti is unique, and the effects of maltreatment can have widely different impacts. Furthermore, children who appear to show minimal effects of maltreatment during childhood (or the ‘silent period’) may show latent vulnerability. This is where the effects are seen later in life, with an elevated risk of health problems in adolescence and adulthood.⁴⁶ As such, there is a need for support for all children who have experienced maltreatment to prevent or reduce future harms arising from their experiences. Even where children seem to be doing well after maltreatment, they still need continued support.

Although it is difficult to attribute specific health issues to types of maltreatment and other adverse experiences, some of the common poor outcomes associated with maltreatment are discussed below:

1. Physical effects

Child maltreatment may result in a range of immediate physical injuries, which may require medical treatment, and potentially death. The effects of maltreatment can also last for much longer. It is challenging for researchers to determine the precise long-term effects of maltreatment, given that it frequently occurs alongside other forms of adversity. Nonetheless, there is considerable evidence of long-term physical effects of child maltreatment in several areas. Maltreatment has been associated with increased mortality risk in adulthood as well as a shorter life expectancy. Adults who experienced child maltreatment are at increased risk of physical illnesses such as cardiovascular disease, obesity & diabetes, asthma, cancer and other disease.⁴⁸  Maltreatment can also lead to earlier onset of illness, more frequent or serious episodes, and higher comorbidity (experience of two or more medical conditions).⁴⁹  

2. Psychological impacts

Maltreatment may have both immediate and long-term psychological effects through into adulthood. Children who have experienced maltreatment are more likely to have mental health issues including internalising (e.g., depression & anxiety) and externalising behaviours (e.g., aggression) deficits in cognitive functioning,⁵⁰ and developmental delays.⁵¹ This is often when these children come to the attention of adults, as the adult finds the child’s behaviours challenging or concerning. Furthermore, for children and young people with a history of maltreatment, especially sexual abuse, available mental health services may be less effective compared to those who have not been maltreated.⁵² 

Child maltreatment is also associated with an increased likelihood of mental illness in adolescence and adulthood,⁵³ including depression, anxiety, post-traumatic stress disorder (PTSD), and substance use disorders.⁵⁴ The effects of child maltreatment can last a lifetime.

3. Brain development

The effects of child maltreatment on the developing brain can be widespread. Predicting the effects of maltreatment on brain development is complicated, due to individual differences, the specific type/s of maltreatment, relationship with the perpetrator, the child’s stage of development, and protective factors such as support from non-maltreating adults. 

Through neuroimaging techniques, it has been demonstrated that child maltreatment is associated with changes in brain structure, function, and systems that may affect the attachment process, stress management systems, epigenetic regulation and long-term psychological and social issues.⁵⁵ These effects are influenced by the nature of the abuse, the severity and duration, and the timing of the maltreatment which can be greater during sensitive developmental periods such as early childhood and adolescence.⁵⁶ The neurobiological changes associated with child maltreatment may also create latent vulnerability, where the risk for future psychological issues is increased.⁵⁷  

Child maltreatment is associated with reduced volume of specific parts of the brain such as the prefrontal cortex, which is responsible for executive functioning and emotional regulation, the hippocampus, which is important for memory and learning and reduced integrity of the corpus collosum that connects the brain’s hemispheres.⁵⁸ It is also found that the amygdala is often overactive in children who have been maltreated which can result in hypervigilance, increased fear and emotional dysregulation.⁵⁹  

These changes can affect how the child responds to stress as the hypothalamic-pituitary-adrenal (HPA) axis can become dysregulated, leading to elevated or blunted cortisol levels. This may lead to increased long-term risk for depression, anxiety and other mental health disorders.⁶⁰ There is also evidence of disrupted development of areas important for bonding and attachment⁶¹ such as the anterior
cingulate cortex (ACC), which is important for the development of empathy and emotional awareness, and the superior temporal sulcus (STS), which is important for social perception.   

A current area of research is the study of epigenetics, which is how the environment and experiences of a person affect how their genes are both expressed and passed on to future generations. Child maltreatment may affect gene expression through epigenetic modification of DNA, in particular the
glucocorticoid receptor gene (NR3C1), which is related to stress response systems,⁶² and the Oxytocin Receptor Gene (OXTR), which influences emotional regulation and social bonding.⁶³ This research demonstrates the long-term effects of child maltreatment not only through into adulthood, but potentially for future generations.

The good news

The positive news is that the brain and neural pathways can be changed. Emerging evidence indicates that recovery is possible through neuroplasticity, where the brain can reorganise itself by forming, or reforming neural connections. Targeted interventions such trauma-focused therapies, and supportive caregiving⁶⁴ can make a difference. The more protective factors tamariki have in their lives, and strategies to reduce risk factors increases the chance of positive outcomes.

Risk factors for child maltreatment

In trying to understand why child maltreatment occurs, and develop prevention strategies, we need to move from just blaming caregivers to understand the factors that are associated with increased risk. Maltreatment results from complex interaction between multiple risk factors.⁶⁵ These risk factors interact at different levels including the child, the family and societal levels. 

1. Child factors 

Unfortunately, some children are at greater risk of maltreatment than others. Young children (especially in their first year) are at the greatest risk of maltreatment, and this risk decreases as they get older.⁶⁶ Children with additional health and developmental needs and other health conditions are also at higher risk of maltreatment.⁶⁷

There also appear to be some gender differences, as girls have a higher risk of sexual abuse than boys, and boys are at higher risk for harsh verbal and physical discipline than girls.⁶⁸ Recent research has also demonstrated the high incidence of maltreatment in childhood reported by young adults with diverse gender or diverse sexualities.⁶⁹

2. Parental and caregiver factors 

It takes a village to raise a family, and raising tamariki in a safe and loving environment is the responsibility of the whole community. Parenting can be challenging at times for all parents, but some parents face additional challenges which may affect their ability to care for their children in healthy ways.⁷⁰ Many of these are related to their own childhood experiences, and systematic factors such as poverty and social exclusion.  These parents may need additional support from the wider community. 

Most adults that experienced maltreatment as a child do not maltreat their own children, but a significant minority do,⁷¹ so it is important to understand the key risk factors to identify when parents and caregivers are more likely to need support.

There are several caregiver risk factors that have been identified⁷² including:

• parental mental illness,⁷³ 
• hazardous use of alcohol and other substances,⁷⁴
• family violence and history of childhood maltreatment,⁷⁵  
• social isolation,⁷⁶ 
• stressors such as single parenting and large households.⁷⁷

It’s important to note that while these factors have been associated with an increased risk of maltreatment, many parents in these situations raise their children in positive ways. Although there has been a tendency to target interventions to caregivers, the wider societal context must be considered in interpreting these factors.

3. Societal and environmental factors

There is considerable evidence of an association between poverty and child maltreatment. Although child maltreatment occurs across all socioeconomic groups, economic hardship of the family and community is a significant risk factor, especially when multiple deprivations occur.⁷⁸ In Aotearoa, most deaths resulting from child maltreatment occurred within the most socioeconomically deprived communities.⁷⁹

Although there may be higher rates of reported child maltreatment in marginalised communities or specific ethnic groups, birth cohort and self-report studies show no significant cultural differences.⁸⁰ This suggests ongoing structural and systematic inequities are the cause rather than cultural differences.⁸¹ Consequently, care must be taken in interpreting research using data on reported child maltreatment rates as these may mask important risk factors.

Specific environmental events such as Covid and other natural disasters have also been associated with child maltreatment due to increased risk factors such as isolation, mental and financial stress, and lack of access to support services.⁸¹ Unfortunately, due to isolation from schools, medical and social services, child maltreatment may not be identified. 

Individual differences

Despite child maltreatment being associated with many serious negative outcomes, there are significant individual differences in the way children and adults respond to the maltreatment. Some children may be more resilient,⁸³ due to both internal characteristics of the child (e.g., temperament) and external factors (e.g., positive relationships and community support).⁸⁴ For example, genetic predispositions and environmental factors such as parental responsiveness, and social support may reduce the effects of maltreatment on HPA dysregulation.⁸⁵ 

How can we help?

To break the cycle of child maltreatment in Aotearoa, we need to address the risk factors, develop policy and practices to prevent maltreatment, and all take responsibility to provide tamariki with safe and loving environments. To create change, we all have a role to play:

1. There are clear links between child maltreatment, brain development and behaviour. We need to look past the presenting behaviours, and to take a trauma-informed approach to supporting children (and adults) who have experienced child maltreatment.⁸⁶ In understanding the effects of child maltreatment, we need to consider not “what’s wrong with you?” but “what has happened to you?”.
   
   
2. Children who experience maltreatment often do not talk about their situation, or delay reporting it, and are only identified when their behaviour is of concern. For boys this is often becoming challenging and aggressive, whereas girls are more likely to be subdued and/or compliant⁸⁷ which may mean they are overlooked.
   
   
3. Children who are being maltreated at home need other adults in their world to notice and respond. The response of caregivers and other supportive adults is important. Tamariki only receive help when adults are proactive on their behalf. It is essential to recognise who children are likely to turn to (i.e., other trusted adults) and ensure that those people know how to best respond.⁸⁸
   
   
4. Ensure that families can access culturally appropriate and led services that best meet the needs of their tamariki and whānau.
   
   
5. There is a need to shift away from blaming parents and caregivers and towards addressing community and structural inequities such as poverty,⁸⁹ and lack of social support.⁹⁰ Rather than focusing on “why would a caregiver maltreat their child?”, we should shift to “how can I help a caregiver better meet their child’s needs?”. Policies and practices that support families are needed as shame and stigma from parents and caregivers experiencing poverty may hinder engagement with social services and support.⁹¹
   
   
6. Community protective factors such as connectedness with school and positive teacher relationships, safe communities, and access to community activities to supportive prosocial friendships need to be improved.⁹²
   
   
7. We need more primary prevention through positive parenting education programmes to improve parental knowledge and positive parenting skills.⁹³
   
   
8. Schools and communities need abuse prevention programmes for children and adolescents, to help them recognise abuse and develop skills to keep themselves safe⁹⁴ (especially online).
   
   
9. Children who have experienced maltreatment and their caregivers need trauma-focussed therapeutic support.⁹⁵ Caregivers also need education and resources so that they can effectively support their child.⁹⁶
   
   
10. Improved data and monitoring of risk factors, especially in times of increased stress such as a pandemic.⁹⁷
    

Conclusions

Child maltreatment is very common in Aotearoa New Zealand, and there are links between maltreatment, brain development and behaviour. We are constantly learning more about the effects of maltreatment, with a large body of evidence demonstrating potential physical, mental, and social consequences of child maltreatment through into adulthood, and potentially into future generations.

Although people may focus on physical and sexual abuse, psychological maltreatment and neglect are much more common, and potentially more damaging than other forms of maltreatment as children do not receive the emotional and psychological support they need to thrive.

To prevent child maltreatment, we need to understand the potential risk factors and address structural and social issues such as poverty and social exclusion. We also need to understand the short-term and long-term effects of trauma and increase those factors which are protective such a community connections and social support.  

We need to shift our thinking from focusing on the challenging behaviours of the child to addressing the underlying maltreatment, and from blaming caregivers to looking at ways to support them. Child maltreatment in Aotearoa New Zealand is a community problem, and we all have a role to play to help our tamariki achieve their potential.

Endnotes

1.   Massullo et al., 2023
2.   Oranga Tamariki Practice Centre, 2019
3.   McCoy & Keen, 2022
4.   Duncan, 2020
5.   MacDonald, 2023
6.   Ozanne, et al., 2024
7.   Massullo, et al., 2023
8.   Gardner, et al., 2019
9.   McCoy & Keen, 2022
10.   Massullo, et al., 2023; McCoy & Keen, 2022
11.   Backhaus, et al., 2023
12.   Unicef, 2024a
13.   Hayashi, 2022; Xiao, et al., 2022
14.   Gama, et al., 2021
15.   Xiao, et al.. 2022
16.   Dai & Kissoon, 2025
17.   Oranga Tamariki practice centre, 2019
18.   Ali, Haykal & Youssef, 2023
19.   Dai & Kissoon, 2025; UNICEF, 2024b
20.   Reingold & Goldner, 2023
21.   Mathews, et al., 2024
22.   Jeglic, et al., 2023
23.   Ringenberg, et al., 2022
24.   Massullo, et al., 2023; McCoy & Keen, 2022
25.   World Health Organisation, 2022
26.   Skinner, Bywaters & Kennedy, 2023
27.   Abdullah & Thattengat, 2025
28.   Bernard, 2019
29.   Xiao, et al., 2024
30.   Avdibegović, & Brkić, 2020
31.   Simon, et al., 2024
32.   Brownell, 2024; Higgins, et al., 2023
33.   Fanslow, et al., 2019
34.   Massullo, et al., 2023
35.   Lippard & Nemeroff, 2023
36.   UNICEF, 2024a
37.   UNICEF, 2024a
38.   Dai & Kissoon, 2025; UNICEF, 2024b
39.   Family Violence Death Review Committee, 2022
40.   Salvation Army, 2025
41.   Child Matters, 2021
42.   Malatest International, 2021
43.   Augusti, & Myhre, 2024; Latiff, et al., 2024
44.   Manay & Collin-Vézina, 2021
45.   Samson, et al., 2024
46.   Samson, et al., 2024
47.   Gordon (2021)
48.   D’arcy-Bewick, et al., 2022; Gordon, 2021
49.   Lippard & Nemeroff, 2023
50.   Lynch & Widom, 2022
51.   Winter, et al., 2022
52.   Stewart, et al., 2023
53.   Hogg, et al., 2023; Lippard & Nemeroff, 2023; Telfar, et al., 2023
54.   Capusan, et al., 2021
55.   Samson, et al., 2024
56.   Tomoda, et al., 2024
57.   Samson, et al., 2024
58.   Samson, et al., 2024; Tomoda, et al., 2024
59.   Tomoda, et al., 2024
60.   Ferrara, et al., 2025
61.   Tomoda, et al., 2024
62.   Wadji, et al., 2021
63.   Ríos, et al., 2023
64.   Teicher, et al., 2024
65.   Avdibegović & Brkić, 2020; Young & Tandon, 2024
66.   McCoy & Keen, 2022
67.   Nyberg, et al., 2023; Young & Tandon, 2024
68.   McCoy & Keen, 2022
69.   Higgins, et al., 2025
70.   Younas & Gutman, 2023
71.   Langevin, et al., 2021
72.   Young & Tandon, 2024
73.   Langevin, et al., 2021
74.   Huckle & Romeo, 2023
75.   Younas & Gutman, 2023
76.   Langevin, et al., 2021
77.   Young & Tandon, 2024
78.   Skinner, et al., 2023
79.   Family Violence Death Review Committee, 2022
80.   Telfar et al., 2023
81.   Rouland, et al., 2019
82.   Carsley, et al., 2024; Letourneau, et al., 2022
83.   McCoy & Keen, 2022
84.   Ungar, Collin-Vézina & Perry, 2022
85.   Ferrara, et al., 2025
86.   Thompson, et al., 2024
87.   Gautam, et al., 2024
88.   Manay & Collin-Vézina, 2021
89.   Skinner, et al., 2023
90.   Younas & Gutman, 2023
91.   Letourneau, et al., 2022
92.   Jean-Thorn, et al., 2022
93.   Young, & Tandon, 2024
94.   Gubbels, et al., 2023
95.   Young, & Tandon, 2024
96.   Wallis & Woodworth, 2021
97.   Huang, et al., 2023

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