Adverse childhood experiences and prescribed psychotropic medications in adults

Child maltreatment and allostatic load: consequences for physical and mental health in children from low-income families

Child maltreatment and biomarkers of allostatic load were investigated in relation to child health problems and psychological symptomatology. Participants attended a summer research day camp and included 137 maltreated and 110 nonmaltreated low-income children, who were aged 8 to 10 years (M = 9.42) and racially and ethnically diverse; 52% were male. Measurements obtained included salivary cortisol and dehydroepiandosterone, body mass index, waist-hip ratio, and blood pressure; these indicators provided a composite index of allostatic load. Child self-report and camp adult-rater reports of child symptomatology were obtained; mothers provided information on health problems. The results indicated that higher allostatic load and child maltreatment status independently predicted poorer health outcomes and greater behavior problems. Moderation effects indicated that allostatic load was related to somatic complaints, attention problems, and thought problems only among maltreated children. Risks associated with high waist-hip ratio, low morning cortisol, and high morning dehydroepiandosterone also were related to depressive symptoms only for maltreated children. The results support an allostatic load conceptualization of the impact of high environmental stress and child abuse and neglect on child health and behavioral outcomes and have important implications for long-term physical and mental health.

Childhood maltreatment is associated with reduced volume in the hippocampal subfields CA3, dentate gyrus, and subiculum

Childhood maltreatment or abuse is a major risk factor for mood, anxiety, substance abuse, psychotic, and personality disorders, and it is associated with reduced adult hippocampal volume, particularly on the left side. Translational studies show that the key consequences of stress exposure on the hippocampus are suppression of neurogenesis in the dentate gyrus (DG) and dendritic remodeling in the cornu ammonis (CA), particularly the CA3 subfield. The hypothesis that maltreatment is associated with volume reductions in 3-T MRI subfields containing the DG and CA3 was assessed and made practical by newly released automatic segmentation routines for FreeSurfer. The sample consisted of 193 unmedicated right-handed subjects (38% male, 21.9 ± 2.1 y of age) selected from the community. Maltreatment was quantified using the Adverse Childhood Experience study and Childhood Trauma Questionnaire scores. The strongest associations between maltreatment and volume were observed in the left CA2-CA3 and CA4-DG subfields, and were not mediated by histories of major depression or posttraumatic stress disorder. Comparing subjects with high vs. low scores on the Childhood Trauma Questionnaire and Adverse Childhood Experience study showed an average volume reduction of 6.3% and 6.1% in the left CA2-CA3 and CA4-DG, respectively. Volume reductions in the CA1 and fimbria were 44% and 60% smaller than in the CA2-CA3. Interestingly, maltreatment was associated with 4.2% and 4.3% reductions in the left presubiculum and subiculum, respectively. These findings support the hypothesis that exposure to early stress in humans, as in other animals, affects hippocampal subfield development.

Dying to be famous: retrospective cohort study of rock and pop star mortality and its association with adverse childhood experiences

OBJECTIVES

Rock and pop fame is associated with risk taking, substance use and premature mortality. We examine relationships between fame and premature mortality and test how such relationships vary with type of performer (eg, solo or band member) and nationality and whether cause of death is linked with prefame (adverse childhood) experiences.

DESIGN

A retrospective cohort analysis based on biographical data. An actuarial methodology compares postfame mortality to matched general populations. Cox survival and logistic regression techniques examine risk and protective factors for survival and links between adverse childhood experiences and cause of death, respectively.

SETTING

North America and Europe.

PARTICIPANTS

1489 rock and pop stars reaching fame between 1956 and 2006.

OUTCOMES

Stars' postfame mortality relative to age-, sex- and ethnicity-matched populations (USA and UK); variations in survival with performer type, and in cause of mortality with exposure to adverse childhood experiences.

RESULTS

Rock/pop star mortality increases relative to the general population with time since fame. Increases are greater in North American stars and those with solo careers. Relative mortality begins to recover 25 years after fame in European but not North American stars. Those reaching fame from 1980 onwards have better survival rates. For deceased stars, cause of death was more likely to be substance use or risk-related in those with more adverse childhood experiences.

CONCLUSIONS

Relationships between fame and mortality vary with performers' characteristics. Adverse experiences in early life may leave some predisposed to health-damaging behaviours, with fame and extreme wealth providing greater opportunities to engage in risk-taking. Millions of youths wish to emulate their icons. It is important they recognise that substance use and risk-taking may be rooted in childhood adversity rather than seeing them as symbols of success.

Prolonged use of benzodiazepines is associated with childhood trauma in opioid-maintained patients

BACKGROUND

Benzodiazepine (BZD) misuse in opioid-maintained patients is widespread and has been related to poorer treatment success. Associated factors, in particular, traumatic childhood experiences, have not been investigated extensively.

METHODS

Cross-sectional survey including the childhood trauma questionnaire (CTQ) and clinical data among 193 patients prescribed oral opioids or injectable diacetylmorphine for opioid dependence.

RESULTS

BZD use was prevalent (61%) and the burden of childhood traumatic experiences was high with 67% reporting at least one trauma subscore of moderate-to-severe level. In univariate analysis, CTQ-subcategories "emotional abuse" (p<0.05), "emotional neglect" (p<0.01) and "physical neglect" (p<0.001) were significantly associated with prolonged BZD use. In multivariate analysis, prolonged BZD use was associated with categorized overall CTQ-scores (OR 1.5), HCV-seropositivity (OR 4.0), psychiatric family history (OR 2.3), and opioid dose (mg methadone equivalents, OR 1.010).

CONCLUSIONS

Childhood traumatic experiences may be associated with prolonged BZD use in opioid-maintained patients and could pose an important starting-point for prevention.

Application of yoga in residential treatment of traumatized youth

BACKGROUND

The Trauma Center at Justice Resource Institute has adapted a form of Hatha yoga into a trauma-sensitive adjunctive component of intervention for use with complexly traumatized individuals exhibiting chronic affective and somatic dysregulation and associated behavioral, functioning, and health complaints.

OBJECTIVES

This article explores the use of yoga with traumatized youth (aged 12-21 years) in residential treatment.

DESIGN

A review of the literature on the somatic impact of trauma exposure provides a rationale for the use of yoga with this population and highlights an emerging evidence base in support of this practice. Case vignettes illustrate the integration of structured, gentle yoga practices into residential programming for youth with severe emotional and behavioral problems.

RESULTS

Anecdotal data and clinical observation underscore the promise of yoga as a viable approach to build self-regulatory capacity of traumatized youth.

CONCLUSIONS

Future directions in the development and evaluation of trauma-informed yoga practices for youth are discussed.

Adverse childhood experiences and smoking status in five states

OBJECTIVE

Our objective was to examine the associations between adverse childhood experiences (ACEs) and smoking behavior among a random sample of adults living in five U.S. states.

METHODS

We used data from 25,809 participants of the 2009 Behavioral Risk Factor Surveillance System to assess the relationship of each of the 8 adverse childhood experiences and the adverse childhood experience score to smoking status.

RESULTS AND CONCLUSIONS

Some 59.4% of men and women reported at least one adverse childhood experience. Each of the eight adverse childhood experiences measures was significantly associated with smoking status after adjustment for demographic variables. The prevalence ratios for current and ever smoking increased in a positive graded fashion as the adverse childhood experience score increased. Among adults who reported no adverse childhood experiences, 13.0% were currently smoking and 38.3% had ever smoked. Compared to participants with an adverse childhood experience score of 0, those with an adverse childhood experience score of 5 or more were more likely to be a current smoker (adjusted prevalence ratio (aPR): 2.22, 95% confidence interval [CI]: 1.92-2.57) and to have ever smoked (aPR: 1.80, 95% CI: 1.67-1.93). Further research is warranted to determine whether the prevention of and interventions for adverse childhood experiences might reduce the burden of smoking-related illness in the general population.

Trauma in early childhood: Empirical evidence and clinical implications

Children in the birth to 5 age range are disproportionately exposed to traumatic events relative to older children, but they are underrepresented in the trauma research literature as well as in the development and implementation of effective clinical treatments and in public policy initiatives to protect maltreated children. Children from ethnic minority groups and those living in poverty are particularly affected. This paper discusses the urgent need to address the needs of traumatized young children and their families through systematic research, clinical, and public policy initiatives, with specific attention to underserved groups. The paper reviews research findings on early childhood maltreatment and trauma, including the role of parental functioning, the intergenerational transmission of trauma and psychopathology, and protective contextual factors in young children's response to trauma exposure. We describe the therapeutic usefulness of a simultaneous treatment focus on current traumatic experiences and on the intergenerational transmission of relational patterns from parent to child. We conclude with a discussion of the implications of current knowledge about trauma exposure for clinical practice and public policy and with recommendations for future research.

Effects of early life stress on cognitive and affective function: an integrated review of human literature

RATIONALE

The investigation of putative effects of early life stress (ELS) in humans on later behavior and neurobiology is a fast developing field. While epidemiological and neurobiological studies paint a somber picture of negative outcomes, relatively little attention has been devoted to integrating the breadth of findings concerning possible cognitive and emotional deficits associated with ELS. Emerging findings from longitudinal studies examining developmental trajectories of the brain in healthy samples may provide a new framework to understand mechanisms underlying ELS sequelae.

OBJECTIVE

The goal of this review was twofold. The first was to summarize findings from longitudinal data on normative brain development. The second was to utilize this framework of normative brain development to interpret changes in developmental trajectories associated with deficits in cognitive and affective function following ELS.

RESULTS

Five principles of normative brain development were identified and used to discuss behavioral and neural sequelae of ELS. Early adversity was found to be associated with deficits in a range of cognitive (cognitive performance, memory, and executive functioning) and affective (reward processing, processing of social and affective stimuli, and emotion regulation) functions.

CONCLUSION

Three general conclusions emerge: (1) higher-order, complex cognitive and affective functions associated with brain regions undergoing protracted postnatal development are particularly vulnerable to the deleterious effects of ELS; (2) the amygdala is particularly sensitive to early ELS; and (3) several deficits, particularly those in the affective domain, appear to persist years after ELS has ceased and may increase risk for later psychopathology.

Behavioral vaccines and evidence-based kernels: nonpharmaceutical approaches for the prevention of mental, emotional, and behavioral disorders

In the United States the rates for some mental, emotional, and behavioral problems (MEBs) have objectively increased over the past 20 to 50 years. The attributes of a public health approach to the treatment of MEBs are defined in this article. Multiple examples of how public health approaches might reduce or prevent MEBs using low-cost evidence-based kernels, which are fundamental units of behavior, are discussed. Such kernels can be used repeatedly, which then act as "behavioral vaccines" to reduce morbidity or mortality and/or improve human wellbeing. The author calls for 6 key policy actions to improve MEBs in young people.

Child maltreatment and the transition to adult-based medical and mental health care

BACKGROUND

Child maltreatment is a public health problem with lifelong health consequences for survivors. Each year, >29 000 adolescents leave foster care via emancipation without achieving family permanency. The previous 30 years of research has revealed the significant physical and mental health consequences of child maltreatment, yet health and well-being have not been a priority for the child welfare system.

OBJECTIVES

To describe the health outcomes of maltreated children and those in foster care and barriers to transitioning these adolescents to adult systems of care.

METHODS

We reviewed the literature about pediatric and adult health outcomes for maltreated children, barriers to transition, and recent efforts to improve health and well-being for this population.

RESULTS

The health of child and adult survivors of child maltreatment is poor. Both physical and mental health problems are significant, and many maltreated children have special health care needs. Barriers to care include medical, child welfare, and social issues. Although children often have complex medical problems, they infrequently have a medical home, their complex health care needs are poorly understood by the child welfare system that is responsible for them, and they lack the family supports that most young adults require for success. Recent federal legislation requires states and local child welfare agencies to assess and improve health and well-being for foster children.

CONCLUSIONS

Few successful transition data are available for maltreated children and those in foster care, but opportunities for improvement have been highlighted by recent federal legislation.

Assessment for and response to adverse childhood experiences

Literature strongly suggests that early exposure to adverse childhood experiences (ACEs) disrupts crucial normal stages of childhood development and predisposes these individuals to subsequent psychiatric sequelae. Even with these data, little is found in nursing literature that discusses ACEs and their impact on adult mental health. Therefore, the purpose of this article is to address how nurses approach communication with clients about and assess for traumatic life experiences. In addition, screening measures for ACEs will be presented, along with discussion about ethical responsibilities of health professionals and researchers in asking about abuse.

Making room for mental health in the medical home

Discussions of health care reform emphasize the need for coordinated care, and evidence supports the effectiveness of medical home and integrated delivery system models. However, mental health often is left out of the discussion. Early intervention approaches for children and adolescents in primary care are important given the increased rates of detection of mental illness in youth. Most adults also receive treatment for mental illness from nonspecialists, underscoring the role for mental health in medical home models. Flexible models for coordinated care are needed for people with serious mental illness, who have high rates of comorbid medical problems. Programs implemented in the New York State public mental health system are examples of efforts to better coordinate medical and mental health services.

Youth self-report of physical and sexual abuse: a latent class analysis

OBJECTIVE

To determine if meaningful groups of at-risk pre-adolescent youth could be identified based on their self-report of physical and sexual abuse histories.

METHODS

Youth participating in a consortium of ongoing longitudinal studies were interviewed using an audio-computer assisted self-interview (A-CASI) when they were approximately 12 years of age to obtain information about their perceived experiences of physical (18 items) and sexual (12 items) abuse. In addition, Child Protective Service records were reviewed and the taxonomy developed for defining maltreatment characteristics (Barnett, Manly, & Cicchetti, 1993) was applied. A total of 795 youth completed the age 12 interview and had their records reviewed during the period from birth to the time of their age 12 interview. A latent variable modeling approach, specifically latent class analysis (LCA), was used to generate profiles of youth based on their endorsements of the physical and sexual abuse items. These profiles were then compared to CPS reports of physical or sexual abuse to determine their validity.

RESULTS

The LCA identified 4 interpretable classes or groups of pre-adolescent youth. Based on the pattern of responses to specific items the classes were identified as follows: (1) no physical or sexual abuse; (2) high physical abuse/low sexual abuse; (3) no physical abuse/moderate sexual abuse; and (4) high physical and sexual abuse. Follow-up analyses indicated that the odds of a CPS report for Classes 2, 3, and 4 compared to Class 1 were significantly greater (2.21, 2.55, and 5.10, respectively).

CONCLUSION

The latent variable modeling approach allowed for the identification of meaningful groups of youth that accounted for both the occurrence of multiple types of abuse as well as differing severities associated with each type. It is suggested that this methodological approach may be most useful in future efforts to identify the antecedents and consequences of maltreatment.

PRACTICE IMPLICATIONS

The results of the present study not only have implications for future research efforts, but also suggest that in practice, youth at-risk for maltreatment may be reliable and valid reporters of their physical and sexual abuse experiences.

[Chronic psychotropic drugs use in the Canadian labor force: what are the contributions of occupation and work organization conditions?]

BACKGROUND

This study aims to better understand the contributions of occupation and work organization conditions to the development of chronic psychotropic drugs use among workers in Canada.

METHODS

The study is based on a secondary analysis of the longitudinal data of the National Population Health Survey (NPHS) of Statistics Canada which includes five cycles from 1994-1995 to 2002-2003. A panel of 6585 people from 15 to 55 years old and employed at cycle 1 and nested in 1413 neighbourhoods was selected. Multilevel models of regression were estimated on three levels: repeated measures (level 1=24,785 observations) were nested in the individuals (level 2=6585 individuals) and the individuals nested in the local communities (level 3=1413 neighborhoods).

RESULTS

The prevalence of multiple episodes (two episodes and more between cycle 1 and cycle 5) of psychotropic drugs use was 6.7% (95%CI=6.0-7.4%). Only occupation and the number of working hours showed a significant contribution. Family and individual variables like marital status and personality traits (locus of control and sense of coherence) had a significant contribution, in addition to time, gender, age, physical health, number of cigarettes and stressful childhood events.

CONCLUSION

Work contributes weakly to the risk of chronic psychotropic drugs use, whereas individual characteristics make a much more important contribution to the phenomenon.

The prevalence of childhood adversity among healthcare workers and its relationship to adult life events, distress and impairment

OBJECTIVE

We investigated the prevalence of childhood adversity among healthcare workers and if such experiences affect responses to adult life stress.

METHODS

A secondary analysis was conducted of a 2003 study of 176 hospital-based healthcare workers, which surveyed lifetime traumatic events, recent life events, psychological distress, coping, social support, and days off work due to stress or illness.

RESULTS

Sixty eight percent (95% CI 61.1-74.9) of healthcare workers had one or more experience of violence, abuse or neglect, 33% (95% CI 26.1-40.0) before the age of 13. Compared to healthcare workers who did not experience childhood adversity, those who did reported more recent life events (median 11 vs. 5 over the previous 6 months, p<.001) and greater psychological distress (median score 17 vs. 13, p<.001). The relationship between life events and psychological distress was not linear. Most healthcare workers without childhood adversity (73%) reported a low number of life events which were not associated with psychological distress. Most healthcare workers with childhood adversity (81%) reported a higher number of life events, for which the correlation between events and distress was moderately strong (Spearman's rho=.50, p<.001). Childhood adversity was also associated with more missed work days. Each of these outcomes was higher in 22 healthcare workers (13%) who had experienced more than one type of childhood adversity.

CONCLUSIONS

Childhood adversity is common among healthcare workers and is associated with a greater number of life events, more psychological distress and impairment.

Adverse childhood experiences are associated with the risk of lung cancer: a prospective cohort study

Background

Strong relationships between exposure to childhood traumatic stressors and smoking behaviours inspire the question whether these adverse childhood experiences (ACEs) are associated with an increased risk of lung cancer during adulthood.

Methods

Baseline survey data on health behaviours, health status and exposure to adverse childhood experiences (ACEs) were collected from 17,337 adults during 1995-1997. ACEs included abuse (emotional, physical, sexual), witnessing domestic violence, parental separation or divorce, or growing up in a household where members with mentally ill, substance abusers, or sent to prison. We used the ACE score (an integer count of the 8 categories of ACEs) as a measure of cumulative exposure to traumatic stress during childhood. Two methods of case ascertainment were used to identify incident lung cancer through 2005 follow-up: 1) hospital discharge records and 2) mortality records obtained from the National Death Index.

Results

The ACE score showed a graded relationship to smoking behaviors. We identified 64 cases of lung cancer through hospital discharge records (age-standardized risk = 201 × 100,000^-1 population) and 111 cases of lung cancer through mortality records (age-standardized mortality rate = 31.1 × 100,000^-1 person-years). The ACE score also showed a graded relationship to the incidence of lung cancer for cases identified through hospital discharge (P = 0.0004), mortality (P = 0.025), and both methods combined (P = 0.001). Compared to persons without ACEs, the risk of lung cancer for those with ≥ 6 ACEs was increased approximately 3-fold (hospital records: RR = 3.18, 95%CI = 0.71-14.15; mortality records: RR = 3.55, 95%CI = 1.25-10.09; hospital or mortality records: RR = 2.70, 95%CI = 0.94-7.72). After a priori consideration of a causal pathway (i.e., ACEs → smoking → lung cancer), risk ratios were attenuated toward the null, although not completely. For lung cancer identified through hospital or mortality records, persons with ≥ 6 ACEs were roughly 13 years younger on average at presentation than those without ACEs.

Conclusions

Adverse childhood experiences may be associated with an increased risk of lung cancer, particularly premature death from lung cancer. The increase in risk may only be partly explained by smoking suggesting other possible mechanisms by which ACEs may contribute to the occurrence of lung cancer.

Correlations among self-esteem, aggression, adverse childhood experiences and depression in inmates of a female juvenile correctional facility in Japan

AIM

The purpose of this study was to examine the following hypothesis: (i) Self-esteem and aggressiveness, adverse childhood experiences (ACE), and a depressive tendency interact with each other. (ii) The subjects show a strong depressive tendency, and each of the other factors exerts a main effect on, and interacts with, the depressive tendency.

METHOD

The subjects were 91 juveniles (all female) admitted to a female juvenile correctional facility between November 2005 and December 2006. They were aged 15-19 years, with a mean age of 17.0 (SD = 1.18) years. Self-esteem scale, aggression scale, ACE questionnaire, and depression scale were conducted.

RESULTS

Significant main effects (R(2) = 0.50, P < 0.001) on the depression score were observed in self-esteem (beta = -0.41, P < 0.001) and aggression (beta = 0.21, P < 0.05). Self-esteem, aggression, ACE, and depression were found to be interrelated.

CONCLUSION

Low self-esteem was also shown to exert marked effects on various factors. About half of the inmates of the facility were depressed, and the main effects of self-esteem, aggression, and the ACE score were shown to influence the depression score.

Policy statement--The future of pediatrics: mental health competencies for pediatric primary care

Pediatric primary care clinicians have unique opportunities and a growing sense of responsibility to prevent and address mental health and substance abuse problems in the medical home. In this report, the American Academy of Pediatrics proposes competencies requisite for providing mental health and substance abuse services in pediatric primary care settings and recommends steps toward achieving them. Achievement of the competencies proposed in this statement is a goal, not a current expectation. It will require innovations in residency training and continuing medical education, as well as a commitment by the individual clinician to pursue, over time, educational strategies suited to his or her learning style and skill level. System enhancements, such as collaborative relationships with mental health specialists and changes in the financing of mental health care, must precede enhancements in clinical practice. For this reason, the proposed competencies begin with knowledge and skills for systems-based practice. The proposed competencies overlap those of mental health specialists in some areas; for example, they include the knowledge and skills to care for children with attention-deficit/hyperactivity disorder, anxiety, depression, and substance abuse and to recognize psychiatric and social emergencies. In other areas, the competencies reflect the uniqueness of the primary care clinician's role: building resilience in all children; promoting healthy lifestyles; preventing or mitigating mental health and substance abuse problems; identifying risk factors and emerging mental health problems in children and their families; and partnering with families, schools, agencies, and mental health specialists to plan assessment and care. Proposed interpersonal and communication skills reflect the primary care clinician's critical role in overcoming barriers (perceived and/or experienced by children and families) to seeking help for mental health and substance abuse concerns.

Predicting functional resilience among young-adult children of opiate-dependent parents

PURPOSE

This study describes the adversities experienced by a sample of children of opiate-dependent parents, examines criteria for young adulthood functional resilience, and tests parent, child, and school predictors of resilience.

METHODS

The Focus on Families (FOF) project was a randomized trial of a family-focused intervention with opiate-dependent individuals in methadone treatment and their children. Analyses were conducted on data from the children in treatment and control families during the original study (1991-1995) and a long-term follow-up interview (2005-2006).

RESULTS

Although all participants had an opiate-dependent parent, 70% experienced two or more additional types of childhood adversity and 20% experienced four or more types. A total of 24% met the following three criteria for functional resilience at the time of their young-adult interview: (1) working or being enrolled in school, (2) no history of substance abuse or dependence, and (3) no adult criminal charges in the prior 5 years. The FOF intervention did not significantly predict functional resilience. Girls were approximately four times more likely to exhibit resilience than boys. Experiencing a wider range of adversities in addition to having an opiate-dependent parent did not reduce the likelihood of functional resilience. Of the five child, family, and school predictors tested, only externalizing or internalizing problems in childhood were significantly associated with the likelihood of functional resilience (odds ratio = .30, p = .04) as a young adult.

CONCLUSIONS

These findings suggest that early intervention with families with opiate-dependent parents to prevent and reduce internalizing and externalizing problems in their children holds the most promise of supporting resilient adaptation in early adulthood.

Cumulative violence exposure and self-rated health: longitudinal study of adolescents in the United States

OBJECTIVE

The goal was to determine whether cumulative exposure to violence in childhood and adolescence contributes to disparities in self-rated health among a nationally representative sample of US adolescents.

METHODS

The National Longitudinal Survey of Youth 1997 is an ongoing, 8-year (1997-2004), longitudinal, cohort study of youths who were 12 to 18 years of age at baseline (N = 8224). Generalized estimating equations were constructed to investigate the relationship between cumulative exposure to violence and risk for poor health.

RESULTS

At baseline, 75% of subjects reported excellent or very good health, 21.5% reported good health, and 4.5% reported fair or poor health. Cumulative violence exposures (witnessed gun violence, threat of violence, repeated bullying, perceived safety, and criminal victimization) were associated with a graded increase in risk for poor health and reduced the strength of the relationship between household income and poor health. In comparison with subjects with no violence exposure, risk for poor self-rated health was 4.6 times greater among subjects who reported >or=5 forms of cumulative exposure to violence, controlling for demographic features and household income. Trend analysis revealed that, for each additional violence exposure, the risk of poor health increased by 38%. Adjustment for alcohol use, drug use, smoking, depressive symptoms, and family and neighborhood environment reduced the strength of the relationships between household income and cumulative exposure to violence scores and poor self-rated health, which suggests partial mediation of the effects of socioeconomic status and cumulative exposure to violence by these factors.

CONCLUSIONS

In this nationally representative sample, social inequality in risk for poor self-rated health during the transition from adolescence to adulthood was partially attributable to disparities in cumulative exposure to violence. A strong graded association was noted between cumulative exposure to violence and poor self-rated health in adolescence and young adulthood.

Childhood Abuse Related to Nicotine, Illicit and Prescription Drug use by Women: Pilot Study

A sample of 811 women ages 18 to 59 ( M = 26.0, SD=6.5) responded to an advertisement by telephone. Inquiries were made about childhood abuse status and adult use of alcohol, nicotine, and prescription and illicit drugs. Significant associations were noted for reported sexual, physical, and emotional childhood abuse with use of nicotine, marijuana, and antidepressants in adulthood. Reported childhood physical and emotional abuses were also significantly associated with use of cocaine and anxiolytics, and sexual abuse with antipsychotic use in adulthood. Only childhood emotional abuse was associated with the use of sleeping pills. Number of types of abuse was significantly related with use of nicotine, marijuana, cocaine, antidepressants, antipsychotics, and anxiolytics. Alcohol use was not related to any type of abuse. The long-term effects of childhood emotional abuse may be just as severe as physical or sexual abuse.