Adverse childhood experiences and prescribed psychotropic medications in adults

The Complex Interplay of Adverse Childhood Experiences, Race, and Income

An extensive research base shows evidence of racial disparities in health outcomes, and a growing body of evidence points to associations between adverse childhood experiences (ACEs) and poor health. This study uses data from the 2011 and 2012 Wisconsin Behavioral Risk Factor Surveillance System surveys to identify the relative contributions of ACEs, race, and adult income to predicting three sets of adverse adult health outcomes. The authors found that controlling for demographic factors, ACEs strongly predict health risk behaviors, indicators of poor general health, and chronic health conditions. Adult low-income status is associated with poor general health and chronic health conditions, but not health risk behaviors. African American race is marginally associated only with indicators of poor general health, and this association is attenuated when ACEs and adult income are controlled. These findings suggest a complex interplay among ACEs, race, and income.

Diagnoses of sexual abuse and their common registered comorbidities in the total population of Stockholm

BACKGROUND

Prior research based on self-reports has proven sexual abuse to be a risk factor for pain and psychiatric disorders. However, less is known about how this is reflected within the healthcare system. The aim of this study was to study the 2-year prevalence of diagnosis of sexual abuse and concomitant conditions.

METHODS

Using data from VAL, the study population included all living persons in Stockholm County, Sweden, between 1 January 2008 and 31 December 2014 (N=2 549 496). Diagnoses of sexual abuse were identified during 2013-2014, with information on the concomitant conditions somatic pain, depression, anxiety, psychotic disorders and bipolar disorders, stress disorders and alcohol and substance abuse. All diagnoses were prospectively registered. Age and neighbourhood socioeconomic status-adjusted ORs with 95% CIs for individuals with a diagnosis of sexual abuse, using individuals without sexual abuse as referents, were calculated.

RESULTS

Girls at the ages 13-17 years had the highest 2-year prevalence (0.69%) of sexual abuse followed by girls 5-12 years (0.11%), and girls 0-4 years (0.04%). For women 45 years and older the 2-year prevalence rates were substantially lower (0.008-0.004%). The highest 2-year prevalence of sexual abuse in men was seen in boys 5-12 (0.03%) years. The total 2-year prevalence of diagnoses of sexual abuse among the population in the material was 0.04%. The highest ORs of comorbidities for girls (ages 0-17 years) with sexual abuse versus those without sexual abuse were: Stress disorder; 15.7 (13.1 to 18.9), drug abuse; 10.0 (7.7 to 13.0), and alcohol abuse; 9.7(7.8 to 12.0). For boys (ages 0-17 years), the highest ORs of comorbidities were: Stress disorder 12.4 (6.0 to 25.7), anxiety disorders; 5.5 (2.6 to 11.5), and alcohol abuse; 3.9 (1.4 to 11.3). The highest ORs of comorbidities for women (18-) with sexual abuse versus those without sexual abuse were: alcohol abuse; 19.3 (12.6 to 29.6), drug abuse; 16.7 (10.7 to 26.1) and psychotic disorders; 15.3 (8.0 to 29.4). For men (18-) the highest ORs of comorbidities were: alcohol abuse; 25.8 (15.2 to 43.9), anxiety disorders; 14.3 (8.5 to 24.2) stress disorder; 12.9 (7.5 to 22.1) and drug abuse; 12.9 (6.9 to 24.1).

CONCLUSIONS

Diagnoses of drug and alcohol abuse, psychotic, bipolar, stress anxiety disorders, depression and somatic pain are more common among individuals with a diagnosis of sexual abuse than among individuals without a diagnosis of sexual abuse.

Impact of Perpetrator Type on Attributions of Mother Fault in Child Sexual Abuse

Blaming nonoffending mothers for child sexual abuse has substantial negative consequences for both the mother and child victim. Although perpetrator type has been shown to influence how much blame and responsibility is placed on nonoffending mothers in child sexual abuse cases, research to date has focused primarily on perpetrators who are strangers to the child or the child's biological father, ignoring the effect of other father-figure perpetrators. The current study examined how differences in perpetrator's relationship to the mother impacted blame, responsibility, cause, and prevention as separate constructs. One hundred and eight participants from an online community sample were randomly assigned to read a vignette describing a child sexual abuse situation with a female victim and one of two perpetrators: the victim's biological father or the mother's boyfriend. Participants assigned significantly higher levels of fault for CSA to the mother when the perpetrator was the mother's boyfriend. Implications and future directions are discussed.

Are mental health services getting better at responding to abuse, assault and neglect?

OBJECTIVE

To determine whether staff responses to abuse disclosures had improved since the introduction of a trauma policy and training programme.

METHOD

The files of 250 clients attending four New Zealand mental health centres were audited.

RESULTS

There was a significant improvement, compared to an audit prior to the introduction of the policy and training, in the proportion of abuse cases included in formulations, and, to a lesser extent, in treatment plans. There was no significant improvement in the proportion referred for relevant treatment, which remained at less than 25% across abuse categories. The proportion of neglect disclosures responded to was significantly lower than for abuse cases. Fifty percent of the files in which abuse/neglect was recorded noted whether the client had been asked about previous disclosure, and 22% noted whether the client thought there was any connection between the abuse/neglect and their current problems. Less than 1% of cases were reported to legal authorities. People diagnosed with a psychotic disorder were significantly less likely to be responded to appropriately.

CONCLUSION

Future training may need to focus on responding well to neglect and people diagnosed with psychosis, on making treatment referrals, and on initiating discussions about reporting to authorities.

Childhood adversity and subsequent mental health status in adulthood: screening for associations using two linked surveys

AIMS

Accumulating evidence links childhood adversity to negative health outcomes in adulthood. However, most of the available evidence is retrospective and subject to recall bias. Published reports have sometimes focused on specific childhood exposures (e.g. abuse) and/or specific outcomes (e.g. major depression). Other studies have linked childhood adversity to a large and diverse number of adult risk factors and health outcomes such as cardiovascular disease. To advance this literature, we undertook a broad examination of data from two linked surveys. The goal was to avoid retrospective distortion and to provide a descriptive overview of patterns of association.

METHODS

A baseline interview for the Canadian National Longitudinal Study of Children and Youth collected information about childhood adversities affecting children aged 0-11 in 1994. The sampling procedures employed in a subsequent study called the National Population Health Survey (NPHS) made it possible to link n = 1977 of these respondents to follow-up data collected later when respondents were between the ages of 14 and 27. Outcomes included major depressive episodes (MDE), some risk factors and educational attainment. Cross-tabulations were used to examine these associations and adjusted estimates were made using the regression models. As the NPHS was a longitudinal study with multiple interviews, for most analyses generalized estimating equations (GEE) were used. As there were multiple exposures and outcomes, a statistical procedure to control the false discovery rate (Benjamini-Hochberg) was employed.

RESULTS

Childhood adversities were consistently associated with a cluster of potentially related outcomes: MDE, psychotropic medication use and smoking. These outcomes may be related to one another since psychotropic medications are used in the treatment of major depression, and smoking is strongly associated with major depression. However, no consistent associations were observed for other outcomes examined: physical inactivity, excessive alcohol consumption, binge drinking or educational attainment.

CONCLUSIONS

The conditions found to be the most strongly associated with childhood adversities were a cluster of outcomes that potentially share pathophysiological connections. Although prior literature has suggested that a very large number of adult outcomes, including physical inactivity and alcohol-related outcomes follow childhood adversity, this analysis suggests a degree of specificity with outcomes potentially related to depression. Some of the other reported adverse outcomes (e.g. those related to alcohol use, physical inactivity or more distal outcomes such as obesity and cardiovascular disease) may emerge later in life and in some cases may be secondary to depression, psychotropic medication use and smoking.

Relationships between adverse childhood experiences and adult mental well-being: results from an English national household survey

Background

Individuals’ childhood experiences can strongly influence their future health and well-being. Adverse childhood experiences (ACEs) such as abuse and dysfunctional home environments show strong cumulative relationships with physical and mental illness yet less is known about their effects on mental well-being in the general population.

Methods

A nationally representative household survey of English adults (n = 3,885) measuring current mental well-being (Short Edinburgh-Warwick Mental Well-being Scale SWEMWBS) and life satisfaction and retrospective exposure to nine ACEs.

Results

Almost half of participants (46.4 %) had suffered at least one ACE and 8.3 % had suffered four or more. Adjusted odds ratios (AORs) for low life satisfaction and low mental well-being increased with the number of ACEs. AORs for low ratings of all individual SWEMWBS components also increased with ACE count, particularly never or rarely feeling close to others. Of individual ACEs, growing up in a household affected by mental illness and suffering sexual abuse had the most relationships with markers of mental well-being.

Conclusions

Childhood adversity has a strong cumulative relationship with adult mental well-being. Comprehensive mental health strategies should incorporate interventions to prevent ACEs and moderate their impacts from the very earliest stages of life.

Adverse Experiences in Early Childhood and Kindergarten Outcomes

OBJECTIVE

To examine associations between adverse childhood experiences (ACEs) in early childhood and teacher-reported academic and behavioral problems in kindergarten.

METHODS

We conducted a secondary analysis of data from the Fragile Families and Child Wellbeing Study, a national urban birth cohort. Subjects with primary caregiver-reported information on ACE exposures ascertained at 5 years and teacher-reported outcomes at the end of the child's kindergarten year were included. Outcomes included teacher ratings of academic skills, emergent literacy skills, and behavior. We included 8 ACE exposures on the basis of the original Centers for Disease Control and Prevention Kaiser study and created an ACE score by summing individual adversities. We examined the associations between teacher-reported academic and behavioral outcomes and ACE scores by using logistic regression.

RESULTS

In the study sample, 1007 children were included. Fifty-five percent had experienced 1 ACE and 12% had experienced ≥ 3. Adjusting for potential confounders, experiencing ≥ 3 ACEs was associated with below-average language and literacy skills (adjusted odds ratio [AORs]: 1.8; 95% confidence interval [CI]: 1.1-2.9) and math skills (AOR: 1.8, 95% CI: 1.1-2.9), poor emergent literacy skills, attention problems (AOR: 3.5, 95% CI: 1.8-6.5), social problems (AOR: 2.7, 95% CI: 1.4-5.0), and aggression (AOR: 2.3, 95% CI: 1.2-4.6).

CONCLUSIONS

In this study of urban children, experiencing ACEs in early childhood was associated with below-average, teacher-reported academic and literacy skills and behavior problems in kindergarten. These findings underscore the importance of integrated approaches that promote optimal development among vulnerable children.

The CASA Trauma and Attachment Group (TAG) Program for Children who have Attachment Issues Following Early Developmental Trauma

OBJECTIVE

There is relatively little research about effective therapeutic approaches for children in middle childhood who have attachment related diagnoses as a result of experiencing significant, early developmental trauma. This study describes findings from an intensive, dyad-based intervention, aimed at stabilizing attachment relationships with primary caregivers, increasing caregiver reflective function skills, and reducing children's trauma-related behavioural sequelae.

METHOD

We analyzed retrospective data from 51 caregiver/child dyads who participated in the Trauma and Attachment Group (TAG) Program from September 2011-December 2014. This data included pre- and post-intervention scores retrieved from the Parenting Relationship Questionnaire (PRQ), the Parent Report of Post-Traumatic Stress Symptoms (PROPS), and the Parental Reflective Functioning Questionnaire (PRFQ-1).

RESULTS

The preliminary findings show statistically significant improvements in attachment, communication, discipline practices, involvement, and relational frustration. Additionally there were statistically significant improvements in parental reflective functioning, and a trend towards a reduction in symptoms typical of post-traumatic stress disorder.

CONCLUSION

Poor quality or inconsistent interactions with early caregivers can lead to life-long impairments in physical and mental health. This intensive program shows potential as a way to improve longer-term outcomes for children exposed to early developmental trauma. Longer-term research is required to further substantiate outcomes, appraise cost analysis, as well as to consider evaluation with appropriate comparison groups.

Changing Medicine and Building Community: Maine's Adverse Childhood Experiences Momentum

Physicians are instrumental in community education, prevention, and intervention for adverse childhood experiences. In Maine, a statewide effort is focusing on education about adverse childhood experiences and ways that communities and physicians can approach childhood adversity. This article describes how education about adversity and resilience can positively change the practice of medicine and related fields. It exemplifies the collective impact model by increasing community knowledge, affecting medical practice, and improving lives.

Mood dysregulation and affective instability in emerging adults with childhood maltreatment: An ecological momentary assessment study

Childhood maltreatment increases risk for mood, anxiety, substance use and personality disorders and is associated with alterations in structure, function and connectivity of brain regions involved in emotional regulation. We sought to assess whether maltreatment was specifically associated with disturbances in positive or negative mood regulation. Ecological momentary ratings were collected with a wristwatch-like device with joy-stick (Seiko ecolog) approximately six times per day over a week in 60 unmedicated participants (22 control, 38 maltreated, 18-25 years old). Forty-five percent of maltreated subjects had a history of major depression but all were currently euthymic. Principal component analysis with varimax rotation was used to provide orthogonal measures of positive and negative valence, which were analyzed for indices of variability, circadian rhythmicity and persistence, using linear and non-linear hierarchical modeling and Hurst analysis. Groups did not differ in mean levels of positive or negative affect. Maltreated subjects had increased variability and circadian and hemicircadian abnormalities in ratings of positive but not negative affect. Conversely, they had higher estimated Hurst exponents for negative but not positive affect ratings indicating a greater degree of persistence. Abnormalities in variability, rhythmicity and persistence were present in both maltreated subjects with and without histories of major depression. These findings suggest that both positive and negative valence systems may be dysregulated in individuals with childhood maltreatment. However the nature of the dysregulation appears to differ fundamentally in these domains, as positive mood ratings were more variable and negative ratings more persistent.

The Complex Trauma Questionnaire (ComplexTQ): development and preliminary psychometric properties of an instrument for measuring early relational trauma

Research on the etiology of adult psychopathology and its relationship with childhood trauma has focused primarily on specific forms of maltreatment. This study developed an instrument for the assessment of childhood and adolescence trauma that would aid in identifying the role of co-occurring childhood stressors and chronic adverse conditions. The Complex Trauma Questionnaire (ComplexTQ), in both clinician and self-report versions, is a measure for the assessment of multi-type maltreatment: physical, psychological, and sexual abuse; physical and emotional neglect as well as other traumatic experiences, such rejection, role reversal, witnessing domestic violence, separations, and losses. The four-point Likert scale allows to specifically indicate with which caregiver the traumatic experience has occurred. A total of 229 participants, a sample of 79 nonclinical and that of 150 high-risk and clinical participants, were assessed with the ComplexTQ clinician version applied to Adult Attachment Interview (AAI) transcripts. Initial analyses indicate acceptable inter-rater reliability. A good fit to a 6-factor model regarding the experience with the mother and to a 5-factor model with the experience with the father was obtained; the internal consistency of factors derived was good. Convergent validity was provided with the AAI scales. ComplexTQ factors discriminated normative from high-risk and clinical samples. The findings suggest a promising, reliable, and valid measurement of early relational trauma that is reported; furthermore, it is easy to complete and is useful for both research and clinical practice.

Childhood adversity and behavioral health outcomes for youth: An investigation using state administrative data

This study aimed to measure the relative contribution of adverse experiences to adolescent behavioral health problems using administrative data. Specifically, we sought to understand the predictive value of adverse experiences on the presence of mental health and substance abuse problems for youth receiving publicly funded social and health services. Medicaid claims and other service records were analyzed for 125,123 youth age 12-17 and their biological parents. Measures from administrative records reflected presence of parental domestic violence, mental illness, substance abuse, criminal justice involvement, child abuse and/or neglect, homelessness, and death of a biological parent. Mental health and substance abuse status of adolescents were analyzed as functions of adverse experiences and other youth characteristics using logistic regression. In multivariate analyses, all predictors except parental domestic violence were statistically significant for substance abuse; parental death, parental mental illness, child abuse or neglect and homelessness were statistically significant for mental illness. Odds ratios for child abuse/neglect were particularly high in both models. The ability to identify risks during childhood using administrative data suggests the potential to target prevention and early intervention efforts for children with specific family risk factors who are at increased risk for developing behavioral health problems during adolescence. This study illustrates the utility of administrative data in understanding adverse experiences on children and the advantages and disadvantages of this approach.

Do adverse childhood experiences affect surgical weight loss outcomes?

Bariatric surgery is an effective and enduring treatment for obesity; however, variation in weight loss may occur following surgery. Many factors beyond technical considerations may influence postoperative outcomes. A better understanding of the influence of adverse childhood experiences (ACE) on surgical weight loss may improve preoperative care. Demographic and preoperative and postoperative data were prospectively obtained for 223 patients undergoing bariatric surgery. All cases were completed laparoscopically without serious complication. Patients completed the ACE questionnaire, which assesses childhood maltreatment. Patients had an average age of 48 years and 77 % were female. There was a significant reduction from preoperative to 12-month postoperative BMI (45 to 31 kg/m(2), p ≤ 0.01). The average ACE score was 2.9 and these patients were more likely than population norms to have an ACE score ≥4 (35.9 vs. 12.5 %, p < 0.001). There was a positive correlation between the number of preoperative comorbidities and preoperative ACE score (R = 0.112, p = 0.09). Patients with a high ACE score (≥6) vs. patients low ACE scores had a higher postoperative BMI at 6-months (36.9 vs. 33.4 kg/m(2), p = 0.03) and 12-months postoperatively (34.5 vs. 30.5 kg/m(2), p = 0.07). High ACE patients had higher total cholesterol (191 vs. 169 mg/dL, p = 0.02) and LDL cholesterol (116 vs. 94 mg/dL, p = 0.02) than low ACE patients 12-months postoperatively. A high preoperative ACE score decreases weight loss following bariatric surgery and may warrant an increased preoperative counseling.

Verbal abuse, like physical and sexual abuse, in childhood is associated with an earlier onset and more difficult course of bipolar disorder

OBJECTIVES

Physical or sexual abuse in childhood is known to have an adverse effect on the course of bipolar disorder, but the impact of verbal abuse has not been well elucidated.

METHODS

We examined the occurrence and frequency (never to frequently) of each type of abuse in childhood in 634 US adult outpatients (average age 40 years). Patients gave informed consent and provided information about their age of onset and course of illness prior to study entry.

RESULTS

Verbal abuse alone occurred in 24% of the patients. Similar to a history of physical or sexual abuse, a history of verbal abuse was related to an earlier age of onset of bipolar disorder and other poor prognosis characteristics, including anxiety and substance abuse comorbidity, rapid cycling, and a deteriorating illness course as reflected in ratings of increasing frequency or severity of mania and depression.

CONCLUSIONS

A lasting adverse impact of the experience of verbal abuse in childhood is suggested by its relationship to an earlier age of onset of bipolar disorder, other poor prognosis factors, and a deteriorating course of illness. Verbal abuse is a common confound in comparison groups defined by a lack of physical or sexual abuse. Ameliorating the impact of verbal abuse on the unfolding course of bipolar disorder appears to be an important target of therapeutics and worthy of attempts at primary and secondary prophylaxis. Family-based treatments that focus on psychoeducation, enhancing intra-family communication, and coping skills may be particularly helpful.

The 'Maltreatment and Abuse Chronology of Exposure' (MACE) scale for the retrospective assessment of abuse and neglect during development

There is increasing interest in childhood maltreatment as a potent stimulus that may alter trajectories of brain development, induce epigenetic modifications and enhance risk for medical and psychiatric disorders. Although a number of useful scales exist for retrospective assessment of abuse and neglect they have significant limitations. Moreover, they fail to provide detailed information on timing of exposure, which is critical for delineation of sensitive periods. The Maltreatment and Abuse Chronology of Exposure (MACE) scale was developed in a sample of 1051 participants using item response theory to gauge severity of exposure to ten types of maltreatment (emotional neglect, non-verbal emotional abuse, parental physical maltreatment, parental verbal abuse, peer emotional abuse, peer physical bullying, physical neglect, sexual abuse, witnessing interparental violence and witnessing violence to siblings) during each year of childhood. Items included in the subscales had acceptable psychometric properties based on infit and outfit mean square statistics, and each subscale passed Andersen's Likelihood ratio test. The MACE provides an overall severity score and multiplicity score (number of types of maltreatment experienced) with excellent test-retest reliability. Each type of maltreatment showed good reliability as did severity of exposure across each year of childhood. MACE Severity correlated 0.738 with Childhood Trauma Questionnaire (CTQ) score and MACE Multiplicity correlated 0.698 with the Adverse Childhood Experiences scale (ACE). However, MACE accounted for 2.00- and 2.07-fold more of the variance, on average, in psychiatric symptom ratings than CTQ or ACE, respectively, based on variance decomposition. Different types of maltreatment had distinct and often unique developmental patterns. The 52-item MACE, a simpler Maltreatment Abuse and Exposure Scale (MAES) that only assesses overall exposure and the original test instrument (MACE-X) with several additional items plus spreadsheets and R code for scoring are provided to facilitate use and to spur further development.

Adverse childhood experiences are associated with adult sleep disorders: a systematic review

Adverse childhood experiences (ACEs) represent substantial threats to public health and affect about 58% of youth in the US. In addition to their acute effects such as injury and physical trauma, ACEs are associated with an increased risk of several negative health outcomes throughout the life course. Emerging evidence suggests that sleep disorders may be one such outcome, but existing studies have not been systematically reviewed and summarized. We conducted a systematic review to summarize the evidence concerning the relationship between ACEs and sleep disorders and disturbances, with a focus on adult women. Original publications were identified through searches of the electronic databases MEDLINE, Embase, and Web of Science using the keywords "childhood," "adversity," "abuse," and "sleep" as well as searches of the reference lists of eligible studies. Studies evaluating ACEs that occurred before 18 years of age and sleep outcomes that were assessed at 18 years or older were adjudicated and included. A total of 30 publications were identified. Of the 30 studies, 28 were retrospective analyses and there was vast heterogeneity in the types of ACEs and sleep outcomes measured. The majority of retrospective studies (N = 25 of 28) documented statistically significant associations between sleep disorders including sleep apnea, narcolepsy, nightmare distress, sleep paralysis, and psychiatric sleep disorders with a history of childhood adversity. In many studies, the strengths of associations increased with the number and severity of adverse experiences. These associations were corroborated by the two prospective studies published to date. Notably, investigators have documented statistically significant associations between family conflict at 7-15 years of age and insomnia at 18 years of age (odds ratio, OR = 1.4; 95% confidence interval, CI = 1.2-1.7) and between childhood sexual abuse and sleep disturbances 10 years later in adult women (β = 0.24, p <0.05). There is a growing scientific body of knowledge suggesting an association between ACEs and multiple sleep disorders in adulthood. The available evidence indicates the need to develop treatment strategies such as trauma-informed care for survivors of abuse who suffer from sleep disorders and disturbances. Further, longitudinal studies among diverse populations are needed to improve the overall understanding of this association and to investigate potential gender and racial/ethnic disparities in the strength of the association.

Cost-effectiveness of Legacy for Children™ for Reducing Behavioral Problems and Risk for ADHD among Children Living in Poverty

This paper describes the programmatic costs required for implementation of the Legacy for Children™ (Legacy) program at two sites (Miami and Los Angeles) and enumerate the cost-effectiveness of the program. Legacy provided group-based parenting intervention for mothers and children living in poverty. This cost-effectiveness analysis included two behavioral outcomes, behavioral problems, and attention-deficit/hyperactivity disorder (ADHD), and programmatic costs collected prospectively (2008 US$). Incremental costs, effects, the incremental cost-effectiveness ratio (ICER), and cost-effectiveness acceptability curves were estimated for the intervention groups relative to a comparison group with a 5 year analytic horizon. The intervention costs per family for Miami and Los Angeles were $16,900 and $14,100, respectively. For behavioral problems, the incremental effects were marginally significant (p=0.11) for Miami with an ICER of $178,000 per child at high risk for severe behavioral problems avoided. For ADHD, the incremental effects were significant (p=0.03) for Los Angeles with an ICER of $91,100 per child at high risk for ADHD avoided. Legacy was related to improvements in behavioral outcomes within two community-drawn sites and the costs and effects are reasonable considering the associated economic costs.

Presurgical Psychological and Neuroendocrine Predictors of Psychiatric Morbidity After Major Vascular Surgery: A Prospective Longitudinal Study

OBJECTIVES

Major life stressors, including major surgeries, are often followed by psychiatric symptoms and disorders. Prior retrospective work found abdominal aortic aneurysm (AAA) repair is followed by increased psychiatric morbidity, which may adversely influence physical and functional recovery. Identifying risk factors before surgery, such as dysregulation in stress response systems, might be useful in improving preventative intervention.

METHODS

Two hundred sixteen patients receiving open AAA or aortofemoral bypass surgeries, endovascular AAA repair, or nonsurgical AAA treatment were recruited from two vascular surgery services. Psychiatric symptoms and salivary cortisol measures (waking, 4 PM, and 11 PM, before and after low-dose dexamethasone) were obtained at intake and 3- and 9-month follow-ups.

RESULTS

After open surgeries, 18% of patients had new psychiatric disorders, compared with 4% of patients receiving endovascular AAA repair or nonsurgical treatment (odds ratio = 6.0, 95% confidence interval = 1.6-22.1, p = .007). Having a history of major depression predicted the onset of new disorders in surgical patients. Presurgical cortisol levels were associated with both baseline (r = 0.23, p < .05) and 9-month (r = 0.32, p < .01) psychiatric symptoms (cortisol B = 1.0, standard error = 0.48, p < .05, in repeated-measures mixed model).

CONCLUSIONS

Open AAA repair surgery is prospectively linked to the development of psychiatric morbidity, and history of depression elevates risk. Cortisol measures before surgery are associated with current and future psychological functioning, suggesting potential neurobiological mechanisms that may contribute to vulnerability. These results can help identify surgical patients at risk and point to potential targets for risk reduction interventions.

Cumulative Effects of Stressful Childhood Experiences on Delusions and Hallucinations

The association between stressful childhood experiences (SCE) and psychotic symptoms is still not clearly understood, and different causal pathways have been proposed. Generalized estimating equation modeling was used to test the dose-response relationship between SCE and delusions and hallucinations at baseline and follow-up periods and the possible confounding effects of dissociation on this relationship. The prevalence of SCE in individuals with psychotic disorders was high, with more co-occurring SCE categories being positively associated with more types of delusions and hallucinations. Each additional SCE was associated with a 1.20 increase in the incidence rate ratio (95% confidence interval [CI; 1.09, 1.32]) for hallucinations and a 1.19 increase (CI [1.09, 1.29]) for delusions, supporting a dose-response association. After we controlled for the mediating effects of dissociative symptoms at follow-up, SCE remained independently associated with delusions. We propose that cumulative SCE can result in complex trauma reactions that present with a broad range of symptomatology, including dissociative, posttraumatic stress disorder, and psychotic symptoms.

Childhood adversities predict strongly the use of psychotropic drugs in adulthood: a population-based cohort study of 24,284 Finns

BACKGROUND

Exposure to adverse childhood experiences has been shown to be associated with negative health outcomes including mental health problems, but only a few studies with register-based data have used psychotropic drugs as an outcome variable. The purpose of this study is to examine whether adverse emotional childhood experiences, such as serious conflicts in the family and frequent fear of a family member, predict the use of psychotropic drugs in adulthood. In addition, the association of a child-parent relationship during childhood with the use of psychotropic drugs is studied.

METHODS

The participants of the population-based Health and Social Support Study (24,284 working aged Finns) were followed up for 9 years. The information on childhood experiences and child-parent relationships was obtained from the questionnaires in 1998 and 2003. The number of psychotropic purchases (antipsychotics, drugs for bipolar disorder, antidepressants, anxiolytics, hypnotics and sedatives) was obtained from the National-Drug-Prescription-Register. Logistic and multinomial regression models were used.

RESULTS

A graded association between childhood adversities and the use of psychotropic drugs was found, even after adjustments for occupational training, work status, recent life events and health behaviour. Frequent fear of a family member showed the strongest association: the OR for multiple use of antidepressants was 3.08 (95% CI 2.72 to 3.49) and 2.69 (2.27 to 3.20) for multiple use of anxiolytics. Use of psychotropic drugs was clearly increased among those with poor child-parent relationship and multiple childhood adversities.

CONCLUSIONS

The results highlight the effect of environmental factors during childhood on mental health and the need for early recognition of families at risk.

Childhood adversities and traumata in Lebanon: a national study

BACKGROUND

The goal of this paper is to map the total occurrence and evaluate the risk of co-occurrence of childhood adversities (CA) and a wide variety of childhood traumatic events (including war) in a national sample.

METHOD

The nationally representative sample included 2,857 respondents and the instrument used was the Composite International Diagnostic Interview which screened for all CAs and traumatic events.

RESULTS

27.9% experienced CAs; the most common were parental death and parental mental/substance use disorder. 70.6% experienced a war-related traumatic event during their lifetime, and around half of them (38.1%) experienced it below the age of 18 years. 51.3% of the subjects experienced a traumatic event not related to war during their lifetime, and 19.2% experienced it before the age of 18 years. Sexual abuse, being a refugee during war, and experiencing a natural disaster were associated with female gender. Having any CA was associated with active war exposure (OR: 4.2, CI: 2.0-8.6); war-related direct personal trauma (OR: 3.9, CI: 1.5-10.0); war-related trauma to others (OR: 2.4, CI: 1.3-4.4); non-war direct personal trauma (OR: 3.8, CI: 2.0-7.4); and any non-war childhood traumatic event (OR: 1.9, CI: 1.1-3.1).

CONCLUSION

Childhood is awash with adversities and traumatic events that co-occur and should be measured simultaneously; otherwise, the effects of a subset of traumata or adversities could be wrongly thought to be the contributor to negative outcomes under study.

Unexpected adverse childhood experiences and subsequent drug use disorder: a Swedish population study (1995-2011)

AIMS

Exposure to extraordinary traumatic experience is one acknowledged risk factor for drug use. We aim to analyse the influence of potentially life-changing childhood stressors, experienced second-hand, on later drug use disorder in a national population of Swedish adolescent and young adults (aged 15-26 years).

DESIGN

We performed Cox proportional hazard regression analyses, complemented with co-relative pair comparisons.

SETTING

Sweden.

PARTICIPANTS

All individuals in the Swedish population born 1984-95, who were registered in Sweden at the end of the calendar year that they turned 14 years of age. Our follow-up time (mean 6.2 years; range 11 years) started at the year they turned 15 and continued to December 2011 (n = 1,409,218).

MEASUREMENTS

Our outcome variable was drug use disorder, identified from medical, legal and pharmacy registry records. Childhood stressors, as per DSM-IV stressor criteria, include death of an immediate family member and second-hand experience of diagnoses of malignant cancer, serious accidental injury and victim of assault. Other covariates include parental divorce, familial psychological wellbeing and familial drug and alcohol use disorders.

FINDINGS

After adjustment for all considered confounders, individuals exposed to childhood stressors 'parental death' or 'parental assault' had more than twice the risk of drug use disorder than those who were not [hazard ratio (HR) = 2.63 (2.23-3.09) and 2.39 (2.06-2.79), respectively].

CONCLUSIONS

Children aged under 15 years who experience second-hand an extraordinary traumatic event (such as a parent or sibling being assaulted, diagnosed with cancer or dying) appear to have approximately twice the risk of developing a drug use disorder than those who do not.

Adverse childhood experiences among Hawai'i adults: Findings from the 2010 Behavioral Risk Factor Survey

The prevalence of adverse childhood experiences (ACEs) among Hawai'i adults and their impact on the health of affected individuals are unknown. Aiming to provide Hawai'i State baseline information on ACEs and their associations with health conditions and risk behaviors, the 2010 Hawai'i Behavioral Risk Factor Surveillance System (BRFSS) included the ACE module. Using 5,928 survey respondents who completed the module, demographic attributes were estimated and multivariate logistic regression analysis was performed to examine the association between ACEs and sixteen selected health indicators. In 2010, approximately 57.8% of Hawai'i adults reported experiencing at least one ACE. Native Hawaiians had the highest prevalence followed by Whites. Adults aged ≥ 65 years had the lowest prevalence on all ACEs. The prevalence of ACEs was inversely related to education and household income levels. Compared to those without ACEs, adults with ACEs had higher odds for a number of health conditions and risk behaviors. Moreover, as the number of ACEs increased, the odds for these health conditions and risk behaviors increased. Hawai'i adults with ACEs were more likely to report dissatisfaction with life compared to those without ACEs. Men were more likely to report having a family member in prison, while women were more likely to report experiencing sexual abuse. Recommendations include further research on the unbiased contributions of ACEs to diseases and risk behaviors, and the development of culturally-appropriate interventions to reduce the prevalence of ACEs in Hawai'i.

Complex trauma

Complex trauma refers to traumatic events that are chronic, interpersonal, and occur within the context of caregiving relationships; the term also describes the pattern of symptoms associated with such experiences. This article explores the prevalence, causes, and phenomenology of complex trauma in children and adolescents. The investigators also describe family-related and system-related issues, assessment strategies, diagnostic challenges, and clinical intervention options.

Childhood adversity and asthma prevalence: evidence from 10 US states (2009-2011)

Background

Existing evidence on stress and asthma prevalence has disproportionately focused on pregnancy and postpregnancy early life stressors, largely ignoring the role of childhood adversity as a risk factor. Childhood adversity (neglect, stressful living conditions and maltreatment) may influence asthma prevalence through mechanisms on the hypothalamic-pituitary axis.

Methods

Data from the Center for Disease Control's (CDC's) Behavioral Risk Factor Surveillance System (BRFSS) surveys were used to examine cross-sectional associations of adverse childhood experiences (ACE) with lifetime and current asthma prevalence. Information on childhood adversity was available from 84 786 adult respondents in 10 US states. Poisson regression models (with robust SE) were used to estimate prevalence ratios (PRs) relating overall ACE score and dimensions of exposure ACE to asthma prevalence, adjusting for socioeconomic status.

Results

Greater ACE was associated with a higher prevalence of asthma (adjusted PR_{cat 4}=1.78 (95% CI 1.69 to 1.87), adjusted PR_{cat 1}=1.21 (95% CI 1.16 to 1.27)). Reported experiences of sexual abuse (adjusted PR=1.48* (1.42 to 1.55)) and physical abuse (adjusted PR=1.38* (1.33 to 1.43)) were associated with a higher asthma prevalence. No clear socioeconomic gradient was noted, but those reporting lowest education and income levels reported high rates of asthma and adversity. Sensitivity analyses indicated that ACE exposures were interrelated.

Conclusions

Report of childhood adversity predicts asthma prevalence among US adults. Frameworks for asthma prevention need to recognise and integrate aspects related to childhood adversity. Further investigation into specific time periods of exposure would provide meaningful inferences for interventions.

Hospitalized youth and child abuse: a systematic examination of psychiatric morbidity and clinical severity

Many children and adolescents who require psychiatric hospitalization have been physically or sexually abused, yet the association between reported histories of abuse and the complexity and severity of mental illness among psychiatrically hospitalized youth is poorly described with regard to current inpatient psychiatric practice. We sought to determine the association between histories of abuse and psychiatric complexity and severity in psychiatrically hospitalized youth including comorbidity patterns, psychotropic medication use, reason for admission and length of hospitalization. A systematic chart review was performed on 1433 consecutive psychiatric hospitalizations of children and adolescents that occurred over a 10-month period. Children with a history of abuse were more likely to be diagnosed with multiple DSM-IV-TR disorders than non-traumatized children. A history of sexual abuse was associated with more medication use than in their non-traumatized peers and a higher likelihood of treatment with antipsychotic medications, both at admission and discharge. Physical and sexual abuse were independently associated with increased length of stays, with exposure to both physical and sexual abuse associated with a 2-day increase in duration of hospitalization compared to non-traumatized patients. The findings from this study draw attention to the adverse impact of abuse on psychiatric morbidity and complexity and suggest the need for trauma-informed treatment in psychiatric hospital settings.

Use of psychotropic medication groups in people with severe mental illness and stressful childhood experiences

Stressful childhood experiences (SCE) are associated with a variety of health and social problems. In people with severe mental illness (SMI) traumatic childhood experiences have been linked to more severe and treatment refractory forms of psychiatric symptoms, including psychotic symptoms. This study evaluates the use of psychotropic medication groups in a population of people with SMI and SCE, testing the association between SCE and prescription medication in an SMI population. A sample of 183 participants with SMI was divided into 2 exposure groups: high SCE (4 to 7 categories of SCE) and low SCE (0 to 3 categories of SCE). Both groups were compared in regard to prescribed dosing of psychotropic medications (antipsychotics, mood stabilizers, antidepressants, and anxiolytics/hypnotics). Participants who endorsed high SCE received higher doses of antipsychotic medications and mood stabilizers than those with low exposure. The results demonstrate that people with higher SCE categories received a higher dosing of psychotropic medication, specifically antipsychotic medication and mood stabilizers.

Social work and adverse childhood experiences research: implications for practice and health policy

Medical research on "adverse childhood experiences" (ACEs) reveals a compelling relationship between the extent of childhood adversity, adult health risk behaviors, and principal causes of death in the United States. This article provides a selective review of the ACE Study and related social science research to describe how effective social work practice that prevents ACEs and mobilizes resilience and recovery from childhood adversity could support the achievement of national health policy goals. This article applies a biopsychosocial perspective, with an emphasis on mind-body coping processes to demonstrate that social work responses to adverse childhood experiences may contribute to improvement in overall health. Consistent with this framework, the article sets forth prevention and intervention response strategies with individuals, families, communities, and the larger society. Economic research on human capital development is reviewed that suggests significant cost savings may result from effective implementation of these strategies.

Notes from the field: planting, nurturing, and watching things grow

Editors' Note: We invited a sample of AJPM's Editorial Board, supplement guest editors, and longtime colleagues and contributors to share their experiences and impressions of the impact of AJPM on their respective domains. We were particularly fond of Ken Powell's analogy to being "tenders of the planted seed"--as planters, weeders, and harvesters--watching and nurturing the growth of AJPM, and have elected to lead with his commentary.

Relationship among adverse childhood experiences, history of active military service, and adult outcomes: homelessness, mental health, and physical health

OBJECTIVES

We determined whether a report of adverse childhood experiences predicts adult outcomes related to homelessness, mental health, and physical health and whether participation in active military service influences the relationship between childhood and adult adversity.

METHODS

Using data from the 2010 Washington State Behavioral Risk Factor Surveillance System, we tested by means of logistic regression the relationship between adverse childhood experiences and 3 adult outcomes--homelessness, mental health, and physical health--as well as differences among those with a history of active military service.

RESULTS

Adverse childhood experiences separately predicted increased odds of experiencing homelessness as an adult and mental health and physical health problems. Childhood adversity increased the likelihood of adult homelessness and poor physical health among individuals with no history of active military service and the likelihood of mental health problems among individuals with a history of active military service.

CONCLUSIONS

The relationship between childhood adversity and adult adversity changes in degree when history of active military service is controlled, which has implications for Armed Forces recruitment strategies and postmilitary service risk assessment.

Childhood maltreatment and psychopathology: A case for ecophenotypic variants as clinically and neurobiologically distinct subtypes

OBJECTIVE

Childhood maltreatment increases risk for psychopathology. For some highly prevalent disorders (major depression, substance abuse, anxiety disorders, and posttraumatic stress disorder) a substantial subset of individuals have a history of maltreatment and a substantial subset do not. The authors examined the evidence to assess whether those with a history of maltreatment represent a clinically and biologically distinct subtype.

METHOD

The authors reviewed the literature on maltreatment as a risk factor for these disorders and on the clinical differences between individuals with and without a history of maltreatment who share the same diagnoses. Neurobiological findings in maltreated individuals were reviewed and compared with findings reported for these disorders.

RESULTS

Maltreated individuals with depressive, anxiety, and substance use disorders have an earlier age at onset, greater symptom severity, more comorbidity, a greater risk for suicide, and poorer treatment response than nonmaltreated individuals with the same diagnoses. Imaging findings associated with these disorders, such as reduced hippocampal volume and amygdala hyperreactivity, are more consistently observed in maltreated individuals and may represent a maltreatment-related risk factor. Maltreated individuals also differ from others as a result of epigenetic modifications and genetic polymorphisms that interact with experience to increase risk for psychopathology.

CONCLUSIONS

Phenotypic expression of psychopathology may be strongly influenced by exposure to maltreatment, leading to a constellation of ecophenotypes. While these ecophenotypes fit within conventional diagnostic boundaries, they likely represent distinct subtypes. Recognition of this distinction may be essential in determining the biological bases of these disorders. Treatment guidelines and algorithms may be enhanced if maltreated and nonmaltreated individuals with the same diagnostic labels are differentiated.

Synergistic childhood adversities and complex adult psychopathology

Numerous studies find a cumulative effect of different types of childhood adversities on increasing risk for serious adult mental and medical outcomes. This study uses the National Comorbidity Survey-Replication sample to investigate the cumulative impact of 8 childhood adversities on complex adult psychopathology as indexed by (a) number of lifetime diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV; American Psychiatric Association, 1994); (b) number of 4 DSM-IV disorder categories (mood, anxiety, impulse control, and substance abuse disorders); and (c) coexistence of internalizing and externalizing disorders. Seven of the 8 childhood adversities were significantly associated with complex adult psychopathology. Individuals with 4 or more childhood adversities had an odds ratio of 7.3, 95% confidence interval [4.7, 11.7] for 4 disorder categories. Additive and multiplicative synergistic effects increasing adult psychopathology were found for specific pairwise combinations of childhood adversities. Synergistic patterns differed by gender suggesting that women are more impacted by sexual abuse and men by economic hardship. The absence of childhood adversities was protective, in that it significantly decreased an individual's risk for subsequent adult mental illness. The results support the clinical impression that increased childhood adversity is associated with more complex adult psychopathology.

Childhood determinants of adult psychiatric disorder

The aim of this project was to assess the current evidence from longitudinal studies for childhood determinants of adult mental illness. Because of the variable and often prolonged period between factors in childhood and the identification of mental illness in adults, prospective studies, particularly birth cohorts, offer the best chance of demonstrating associations in individuals.

A review was undertaken in 2006 of the published literature from longitudinal studies, together with some large-scale retrospective studies and relevant reviews which provided supplementary evidence. The main focus was upon potentially ameliorable characteristics, experiences or situations of childhood; however, other factors, not determinants but pre-cursors, associated with later mental illness could not be left out.

Seven major electronic data-bases of published research were interrogated with a range of key-words and the results supplemented from personal searches, enquiries and reference trails. In excess of 1,500 abstracts were read to select 250 papers for full review. The material was assessed in relation to ten factors:

Psychological disturbance; Genetic Influences; Neurological Deviance; Neuroticism; Behaviour; School Performance; Adversity; Child Abuse or Neglect; Parenting and parent-child relationships; Disrupted and Disfunctional Families.

In 2011 the search was repeated for the period 2006 to mid-2011, using the same search terms and supplemented in the same manner. Over 1,800 abstracts emerged and almost 200 papers selected for more detailed review. These were then integrated into the original text with modifications where necessary. The whole text was then revised and edited in January / February 2012.

There is continuing evidence for the association with later mental ill-health for each of these ten factors, but with different degrees of conviction. The evidence for each is discussed in detail and weighed both separately and in relation to others. These are then summarised, and the research implications are considered. Finally, the implications for prevention are discussed together with the practical potential for preventive and health-promoting programmes.

The health and social consequences of adverse childhood experiences (ACE) across the lifespan: an introduction to prevention and intervention in the community

This introduction to the themed issue overviews of the Adverse Childhood Experiences (ACE) Study and discusses prevention and intervention with ACE and their consequences in communities. A commentary by Dr. Robert Anda, an ACE Study Co-Principal Investigator, is incorporated within this introduction. Implications of articles within the issue are addressed, and next steps are explored.

Multi-exposure and clustering of adverse childhood experiences, socioeconomic differences and psychotropic medication in young adults

Purpose

Stressful childhood experiences have negative long-term health consequences. The present study examines the association between adverse childhood experiences, socioeconomic position, and risk of psychotropic medication in young adulthood.

Methods

This register-based cohort study comprises the birth cohorts between 1985 and 1988 in Sweden. We followed 362 663 individuals for use of psychotropic medication from January 2006 until December 2008. Adverse childhood experiences were severe criminality among parents, parental alcohol or drug abuse, social assistance recipiency, parental separation or single household, child welfare intervention before the age of 12, mentally ill or suicidal parents, familial death, and number of changes in place of residency. Estimates of risk of psychotropic medication were calculated as odds ratio (OR) with 95% confidence intervals (CIs) using logistic regression analysis.

Results

Adverse childhood experiences were associated with increased risks of psychotropic medication. The OR for more than three adverse childhood experiences and risk of psychotropic medication was for women 2.4 (95% CI 2.3–2.5) and for men 3.1 (95% CI 2.9–3.2). The risk of psychotropic medication increased with a higher rate of adverse childhood experiences, a relationship similar in all socioeconomic groups.

Conclusions

Accumulation of adverse childhood experiences increases the risk of psychotropic medication in young adults. Parental educational level is of less importance when adjusting for adverse childhood experiences. The higher risk for future mental health problems among children from lower socioeconomic groups, compared to peers from more advantaged backgrounds, seems to be linked to a higher rate of exposure to adverse childhood experiences.

Adverse childhood experiences and frequent insufficient sleep in 5 U.S. States, 2009: a retrospective cohort study

Background

Although adverse childhood experiences (ACEs) have previously been demonstrated to be adversely associated with a variety of health outcomes in adulthood, their specific association with sleep among adults has not been examined. To better address this issue, this study examines the relationship between eight self-reported ACEs and frequent insufficient sleep among community-dwelling adults residing in 5 U.S. states in 2009.

Methods

To assess whether ACEs were associated with frequent insufficient sleep (respondent did not get sufficient rest or sleep ≥14 days in past 30 days) in adulthood, we analyzed ACE data collected in the 2009 Behavioral Risk Factor Surveillance System, a random-digit-dialed telephone survey in Arkansas, Louisiana, New Mexico, Tennessee, and Washington. ACEs included physical abuse, sexual abuse, verbal abuse, household mental illness, incarcerated household members, household substance abuse, parental separation/divorce, and witnessing domestic violence before age 18. Smoking status and frequent mental distress (FMD) (≥14 days in past 30 days when self-perceived mental health was not good) were assessed as potential mediators in multivariate logistic regression analyses of frequent insufficient sleep by ACEs adjusted for race/ethnicity, gender, education, and body mass index.

Results

Overall, 28.8% of 25,810 respondents reported frequent insufficient sleep, 18.8% were current smokers, 10.8% reported frequent mental distress, 59.5% percent reported ≥1 ACE, and 8.7% reported ≥ 5 ACEs. Each ACE was associated with frequent insufficient sleep in multivariate analyses. Odds of frequent insufficient sleep were 2.5 (95% CI, 2.1-3.1) times higher in persons with ≥5 ACEs compared to those with no ACEs. Most relationships were modestly attenuated by smoking and FMD, but remained significant.

Conclusions

Childhood exposures to eight indicators of child maltreatment and household dysfunction were significantly associated with frequent insufficient sleep during adulthood in this population. ACEs could be potential indicators promoting further investigation of sleep insufficiency, along with consideration of FMD and smoking.

Caudate gray matter volume in obsessive-compulsive disorder is influenced by adverse childhood experiences and ongoing drug treatment

BACKGROUND

Exposure to adverse childhood experiences (ACE) increases the risk of adult physical and mental health disorders, including obsessive-compulsive disorder (OCD), and influences adult cortical neural responses and gray matter (GM) volumes. Robust neuroimaging findings associated OCD with corticostriatal dysfunction and with abnormal morphology and metabolism of cortical areas and basal ganglia.

METHODS

We explored the GM correlates of ACE in 40 patients with OCD (15 drug-naive and 25 drug-treated patients) with magnetic resonance imaging voxel-based morphometry at 3.0 T. Regional GM volumes were the dependent variable, and drug treatment (naive vs treated) and breadth of exposure to ACE (high vs low) were the factors of interest. Sex, duration of illness, and handedness were considered as nuisance covariates. Whole brain statistical threshold was P < 0.05 familywise error corrected for multiple comparisons.

RESULTS

Patients with higher levels of exposure to ACE showed increased GM volume in the head of the left caudate nucleus. Ongoing drug treatment was associated with reduced GM volume in the same area. Earlier age at onset of OCD, need for medication treatment, and mixed handedness were correlated with higher levels of ACE.

CONCLUSIONS

Exposure to ACE increased, and ongoing drug treatment decreased, caudate GM in OCD. Increased volume and metabolism of the caudate nucleus have been consistently associated with OCD. Our findings suggest a detrimental effect of ACE on the brain underpinnings of OCD, with an opposite effect of medications.

Predictors of mental health service utilisation in a non-treatment seeking epidemiological sample of Australian adults

This study sought to replicate Parslow and Jorm's (Aust N Z J Psychiatry 34(6): 997-1008, 2000) research on need, enabling and predisposing factors as predictors of mental health service use, with the addition of childhood trauma as a predisposing factor. It utilised a non-treatment seeking epidemiological sample of Australian adults (N = 822) to examine 25 variables covering psychiatric disorder, socio-demographics, physical health problems, and childhood trauma as predictors of mental health visits to general practitioners (GP's), mental health specialists and non-mental health specialists. A consistent multivariate predictor of mental health visits to all types of professionals was psychological distress. Presence of an affective disorder, age, and number of health problems were additional predictors of visiting a GP. Being female, divorced, and exposure to childhood trauma predicted use of a mental health specialist, while rural living was associated with lower use of these services. Results highlight the importance of general psychological distress and need factors in seeking help for mental health, and reinforce the lifelong disadvantage arising from adverse childhood experiences and the need to address these issues in adult mental health services.

Long-term cognitive sequelae: abused children without PTSD

Many lines of research suggest that childhood abuse and neglect are associated with later developing psychiatric diagnoses, academic problems, cognitive difficulty, and possible brain changes as measured through brain imaging. Data were collected on children (N = 41) who completed a neuropsychological evaluation. Of those evaluated, 18 had a documented history of physical and/or emotional abuse or significant neglect and 23 had no history of abuse/neglect. When controlling for Full-Scale IQ (FSIQ), the abused children had significantly lower scores on measures of executive functioning (Wisconsin Card-Sorting Test-Categories, Maintenance of Set, and Perseveration and Wechsler Intelligence Scale for Children-Fourth Edition Working Memory), and effect sizes were large for these variables. Neither group had any test scores significantly lower than their FSIQ. Cross-tabulation analyses showed that the abused children were more likely to subsequently be diagnosed with a behavioral or emotional disorder. Consistent with psychobiological theories and imaging studies, our data are suggestive that childhood abuse and neglect are associated with later development of behavioral and emotional disorders and areas of cognitive weakness and possible impairment. Future research may be conducted to clarify these effects, the possibility of a dose-effect relationship, and timing of possible critical periods of brain vulnerability.

PTSD'S mediation of the relationships between trauma, depression, substance abuse, mental health, and physical health in individuals with severe mental illness: evaluating a comprehensive model

OBJECTIVE

Following trauma exposure and PTSD, individuals with severe mental illness (SMI) frequently suffer a complex course of recovery complicated by reduced mental and physical health and increased substance abuse. The authors evaluated a theoretical PTSD-SMI model which theorizes that trauma, PTSD, depression, substance abuse, mental health, and physical health are interrelated and that PTSD mediates these relationships.

METHOD

Participants were ethnoracially diverse individuals diagnosed with SMI (N=175) who were assessed for trauma exposure, severity of PTSD and depression, substance abuse, and overall mental and physical health functioning. Pearson's correlations were utilized to examine the relationships between study domains. The mediating effects of PTSD were assessed using regression coefficients and the Sobel test for mediation.

RESULTS

A majority of participants with SMI (89%) reported trauma exposure and 41% reported meeting diagnostic criteria for PTSD. On average, participants were exposed to over four types of traumatic events. Trauma, severity of PTSD and depression, substance abuse, and overall mental and physical health functioning were significantly interrelated. PTSD partially mediated the relationships between trauma and severity of depression and between trauma and overall mental health; PTSD fully mediated the trauma and overall physical health relationship.

DISCUSSION

Within an ethnoracially diverse SMI sample, trauma exposure and PTSD comorbidity were high and associated with severity of depression, substance abuse, overall mental health and physical health functioning. Supporting our theoretical PTSD-SMI model, PTSD mediated the adverse effects of trauma exposure on participants' current severity of depression and overall mental and physical health functioning.

Understanding interpersonal trauma in children: why we need a developmentally appropriate trauma diagnosis

Childhood exposure to victimization is prevalent and has been shown to contribute to significant immediate and long-term psychological distress and functional impairment. Children exposed to interpersonal victimization often meet criteria for psychiatric disorders other than posttraumatic stress disorder (PTSD). Therefore, this article summarizes research that suggests directions for broadening current diagnostic conceptualizations for victimized children, focusing on findings regarding victimization, the prevalence of a variety of psychiatric symptoms related to affect and behavior dysregulation, disturbances of consciousness and cognition, alterations in attribution and schema, and interpersonal impairment. A wide range of symptoms is common in victimized children. As a result, in the current psychiatric nosology, multiple comorbid diagnoses are necessary-but not necessarily accurate-to describe many victimized children, potentially leading to both undertreatment and overtreatment. Related findings regarding biological correlates of childhood victimization and the treatment outcome literature are also reviewed. Recommendations for future research aimed at enhancing diagnosis and treatment of victimized children are provided.