Health-related quality of life among adults who experienced maltreatment during childhood

Ranking the Ten Adverse Childhood Experiences: Long-Term Consequences to Health-Related Quality of Life

INTRODUCTION

This study compared the long-term harmful consequences of individual adverse childhood experiences (ACEs) to subsequent health-related quality of life (HRQOL) among U.S. adults.

METHODS

Respondents were from the eleven U.S. states that included the optional ACE module questionnaire in the 2021 Behavioral Risk Factor Surveillance Systems (BRFSS). Relative importance (RI) was estimated for ten ACEs to respondents' self-rated general health (SRGH), physically unhealthy days (PUD), mentally unhealthy days (MUD), and activity limitation days (ALD). A variable's importance was measured as the average gains in R-squared after adding the variable to all sub-models. Statistical analysis was performed in 2023.

RESULTS

After controlling for demographics, household mental illness was the most important ACE for SRGH, MUD, and ALD, with RIs of 16.4, 28.4 and 23.4, respectively. This ACE was ranked second for PUD (RI=17.8). Sexual abuse was ranked first for PUD (18.7), second for MUD (16.6) and ALD (20.9), and fifth for SRGH (10.4). Parental separation (RI ≤2.4) and incarcerated household member (2.8-5.4) were the least important ACEs for all 4 outcomes. Sexual abuse, parental separation, emotional abuse, and basic needs were not met were considerably more important among females while household mental illness and household substance abuse were more important among males.

CONCLUSIONS

This study highlight that certain ACEs play a greater role than others for HRQOL with certain ACEs having a greater relative importance according to sex. Additionally, a significant proportion of the long-term impacts of ACE to HRQOL was indirectly through the mediation effect of other explanatory variables.

The role of social support in reducing the long-term burden of cumulative childhood adversity on adulthood internalising disorder

PURPOSE

Previous research indicates that social support is protective for the mental health outcomes of exposure to childhood adversity. However, the impact of social support as a protective factor following exposure to cumulative childhood adversity is understudied with prospective longitudinal data. The aim of this present study was to examine how social support mediates the impact of cumulative exposure to childhood adversity on internalising disorder in adulthood.

METHODS

The Christchurch Health and Development Study (CHDS) is a general population birth cohort, born in 1977 and representative of Christchurch, New Zealand at the time of the cohort members' birth. The present study used a generalised estimating equations (GEE) framework to analyse direct associations between a cumulative measure of childhood adversity (CA) and internalising disorders (major depression, and any anxiety disorder), and indirect associations through social support.

RESULTS

Results indicated a dose-dependent relationship between increased exposure to CA and worsened odds of a diagnosis for major depression and any anxiety disorder, respectively. There was also a significant mediating effect of social support on the direct associations between CA and both major depression (OR (95%CI) =0 .98 (0.97, 0.99), p < 001) and any anxiety disorder (OR (95%CI) = .98 (0.97, 0.99), p < 001).

CONCLUSION

The findings indicate that social support reduces the impact of childhood adversity on adult mental health, and is therefore a target for future work examining potential interventions following CA.

Family and community resilience: a Photovoice study

BACKGROUND

Adverse childhood experiences (ACEs), in combination with adverse community environments, can result in traumatic stress reactions, increasing a person's risk for chronic physical and mental health conditions. Family resilience refers to the ability of families to withstand and rebound from adversity; it involves coping with disruptions as well as positive growth in the face of sudden or challenging life events, trauma, or adversities. This study aimed to identify factors contributing to family and community resilience from the perspective of families who self-identified as having a history of adversity and being resilient during the COVID-19 pandemic.

METHODS

This study used Photovoice, a visual participatory research method which asks participants to take photographs to illustrate their responses to a research question. Participants consisted of a maximum variation sample of families who demonstrated family level resilience in the context of the pair of ACEs during the COVID-19 pandemic. Family members were asked to collect approximately five images or videos that illustrated the facilitators and barriers to well-being for their family in their community. Semi-structured in-depth interviews were conducted using the SHOWeD framework to allow participants to share and elucidate the meaning of their photos. Using thematic analysis, two researchers then independently completed line-by-line coding of interview transcripts before collaborating to develop consensus regarding key themes and interpretations.

RESULTS

Nine families were enrolled in the study. We identified five main themes that enhanced family resilience: (1) social support networks; (2) factors fostering children's development; (3) access and connection to nature; (4) having a space of one's own; and (5) access to social services and community resources.

CONCLUSIONS

In the context of additional stresses related to the COVID-19 pandemic, resilient behaviours and strategies for families were identified. The creation or development of networks of intra- and inter-community bonds; the promotion of accessible parenting, housing, and other social services; and the conservation and expansion of natural environments may support resilience and health.

Associations Between Childhood Trauma and Tobacco Use Outcomes in Adults after Overnight Abstinence

INTRODUCTION

Childhood trauma is known to be associated with nicotine dependence, yet limited smoking outcomes have been examined and few studies have assessed associations between specific trauma subscales and smoking. Additionally, sex differences in trauma-smoking relations are understudied. This study examined associations between childhood trauma and several smoking-related outcomes in adults who smoke after overnight abstinence.

AIMS AND METHODS

People who smoke (N = 205) completed self-report and biochemical assessments evaluating childhood trauma, affect, nicotine dependence, smoking urges, withdrawal, and plasma cortisol and cotinine levels. Smoking outcomes were compared between those with and without a history of moderate to severe childhood trauma among the total sample and by sex.

RESULTS

Relative to those with no to minimal abuse, those with moderate to severe abuse had higher negative affect, withdrawal severity, and plasma cotinine levels. Exploratory analyses revealed that women were more likely than men to have urges to smoke for negative reinforcement and have higher withdrawal severity, but no interactions between abuse group and sex were observed. Examining specific trauma subscales, the moderate to severe emotional abuse group had more severe nicotine dependence, negative affect, and withdrawal compared to the no to minimal group. The moderate to severe sexual abuse group had more severe nicotine dependence and withdrawal compared to the no to minimal group.

CONCLUSIONS

Exposure to childhood trauma is associated with more severe nicotine dependence, negative affect, withdrawal, and higher plasma cotinine levels. Findings also indicate that different types of trauma may differentially affect smoking behaviors.

IMPLICATIONS

This study of adults who smoke finds that childhood trauma history may be a marker for smoking susceptibility and suggests that individuals with experiences of emotional and sexual abuse may require targeted forms of smoking cessation interventions. Moreover, findings suggest that smoking risks may differ for men and women. Findings inform public health interventions intended to reduce cigarette use in individuals with exposure to childhood trauma.

Childhood maltreatment and major depressive disorder in well-being: a network analysis of a longitudinal community-based cohort

BACKGROUND

Little has been done to comprehensively study the relationships between multiple well-being constructs at a time. Even less is known about whether child maltreatment and major depressive disorder (MDD) impact different well-being constructs. This study aims to examine whether maltreated or depressed individuals have specific impacts on well-being structures.

METHODS

Data analyzed were from the Montreal South-West Longitudinal Catchment Area Study (N = 1380). The potential confounding of age and sex was controlled by propensity score matching. We used network analysis to assess the impact of maltreatment and MDD on well-being. The centrality of nodes was estimated with the 'strength' index and a case-dropping bootstrap procedure was used to test network stability. Differences in the structure and connectivity of networks between different studied groups were also examined.

RESULTS

Autonomy and daily life and social relations were the most central nodes for the MDD and maltreated groups [MDD group: strength coefficient (SC) autonomy = 1.50; SCdaily life and social relations = 1.34; maltreated group: SCautonomy = 1.69; SCdaily life and social relations = 1.55]. Both maltreatment and MDD groups had statistical differences in terms of the global strength of interconnectivity in their networks. Network invariance differed between with and without MDD groups indicating different structures of their networks. The non-maltreatment and MDD group had the highest level of overall connectivity.

CONCLUSIONS

We discovered distinct connectivity patterns of well-being outcomes in maltreatment and MDD groups. The identified core constructs could serve as potential targets to maximize the effectiveness of clinical management of MDD and also advance prevention to minimize the sequelae of maltreatment.

Protective factors for psychosocial outcomes following cumulative childhood adversity: systematic review

BACKGROUND

The long-term cumulative impact of exposure to childhood adversity is well documented. There is an increasing body of literature examining protective factors following childhood adversity. However, no known reviews have summarised studies examining protective factors for broad psychosocial outcomes following childhood adversity.

AIMS

To summarise the current evidence from longitudinal studies of protective factors for adult psychosocial outcomes following cumulative exposure to childhood adversity.

METHOD

We conducted a formal systematic review of studies that were longitudinal; were published in a peer-reviewed journal; examined social, environmental or psychological factors that were measured following a cumulative measure of childhood adversity; and resulted in more positive adult psychosocial outcomes.

RESULTS

A total of 28 studies from 23 cohorts were included. Because of significant heterogeneity and conceptual differences in the final sample of articles, a meta-analysis was not conducted. The narrative review identified that social support is a protective factor specifically for mental health outcomes following childhood adversity. Findings also suggest that aspects of education are protective factors to adult socioeconomic, mental health and social outcomes following childhood adversity. Personality factors were protective for a variety of outcomes, particularly mental health. The personality factors were too various to summarise into meaningful combined effects. Overall GRADE quality assessments were low and very low, although these scores mostly reflect that all observational studies are low quality by default.

CONCLUSIONS

These findings support strategies that improve connection and access to education following childhood adversity exposure. Further research is needed for the roles of personality and dispositional factors, romantic relationship factors and the combined influences of multiple protective factors.

Dynamic Interpersonal Therapy for U.S. Veterans in a Primary Care Setting

OBJECTIVE

Brief dynamic interpersonal therapy (DIT) is an evidence-based psychodynamic intervention for depression offered by the U.K. National Health Service and previously studied in the context of a U.S. Department of Veterans Affairs medical center. This study assessed the clinical value of DIT in primary care for veterans with general medical conditions.

METHODS

The authors examined outcome data of veterans (N=30; all but one had ≥1 comorbid general medical conditions) referred to DIT from primary care.

RESULTS

Veterans who began treatment with clinically elevated depression or anxiety experienced a 42% reduction in symptom severity, as measured by the nine-item Patient Health Questionnaire or by the seven-item Generalized Anxiety Disorder questionnaire, respectively, representing large effect sizes.

CONCLUSIONS

Significant decreases in depression and anxiety symptoms suggest the utility of DIT for veterans with comorbid general medical conditions. DIT's dynamically informed framework may improve patients' help seeking, which is relevant for patients experiencing comorbid medical conditions.

The Moderating Effects of Physical Activity on the Relationships between Child Maltreatment and Health Outcomes among Korean Adolescents: A Secondary Analysis of the 2020 Korean Children and Youth Rights Survey

Adverse childhood events (ACEs) are associated with poor health outcomes and behaviors. Research has shown that physical activity (PA) can have a protective effect on the relationship between ACEs and health outcomes. This study aimed to explore the moderating effects of PA on the relationships between ACEs (physical and emotional abuse) and physical and psychological health (depression and self-esteem) among South Korean middle school students. The data used in this study were from the 2020 Korean Children and Youth Rights Survey (KCYRS), which had 2640 participants. The results indicated that PA could lessen the negative effects of emotional abuse on physical health and self-esteem. However, there was no significant moderating effect of PA in the relationship between physical abuse and health outcomes. The findings suggest that, while PA might be a protective factor for individuals exposed to emotional abuse, the effects of abuse on engaging in PA and the benefits of PA can be complex. Further research is needed to understand how different types of ACEs affect individuals and how PA can mitigate negative impacts. Health professionals, educators, and stakeholders should provide more opportunities for PA to support healthy behaviors and prevent negative health outcomes in adulthood for youth exposed to ACEs.

Influence of childhood trauma, HIV infection, alcohol use disorder, and resilience on health-related quality of life in adulthood

Experience of childhood trauma, especially physical, emotional, and sexual abuse, carries a risk for developing alcohol use disorder (AUD) and engaging in risky behaviors that can result in HIV infection. AUD and HIV are associated with compromised self-reported health-related quality of life (HRQoL) possibly intersecting with childhood trauma. To determine whether poor HRQoL is heightened by AUD, HIV, their comorbidity (AUD + HIV), number of trauma events, or poor resilience, 108 AUD, 45 HIV, 52 AUD + HIV, and 67 controls completed the SF-21 HRQoL, Brief Resilience Scale (BRS), Ego Resiliency Scale (ER-89), and an interview about childhood trauma. Of the 272 participants, 116 reported a trauma history before age 18. Participants had a blood draw, AUDIT questionnaire, and interview about lifetime alcohol consumption. AUD, HIV, and AUD + HIV had lower scores on HRQoL and resilience composite comprising the BRS and ER-89 than controls. Greater resilience was a significant predictor of better quality of life in all groups. HRQoL was differentially moderated in AUD and HIV: more childhood traumas predicted poorer quality of life in AUD and controls, whereas higher T-lymphocyte count contributed to better quality of life in HIV. This study is novel in revealing a detrimental impact on HRQoL from AUD, HIV, and their comorbidity, with differential negative contribution from trauma and beneficial effect of resilience to quality of life. Channeling positive effects of resilience and reducing the incidence and negative impact of childhood trauma may have beneficial effects on health-related quality of life in adulthood independent of diagnosis.

Systematic braiding of Smoke-Free Home SafeCare to address child maltreatment risk and secondhand smoke exposure: findings from a pilot study

BACKGROUND

Exposure to secondhand tobacco smoke (SHS) and child maltreatment are preventable threats to child health. Few evidence-based interventions target both SHS and child maltreatment risk. The purpose of this paper is to describe the systematic braiding process of two evidence-based programs to address child SHS in the home and maltreatment perpetration risk, and present results from the formative work and pilot study.

METHODS

The first 4 steps of the systematic braiding process were completed, including the following: (1) the identification of core elements of both programs, (2) the development of an initial draft of the braided curriculum (Smoke-Free Home SafeCare - SFH-SC), (3) an acceptability and feasibility pilot of SFH-SC with caregivers of young children who reported a smoker living in the home (N = 8), and (4) feedback collection on the braided curriculum from SafeCare Providers (N = 9).

RESULTS

Experts identified common pedagogical and theoretical underpinnings for the two programs and braided Smoke-Free Homes: Some Things Are Better Outside into two SafeCare modules. Caregiver feedback from the pilot demonstrated that participants were engaged with SFH-SC and felt supported and comfortable discussing SHS intervention content with the SFH-SC Provider. Caregiver self-reports indicated a slight increase in smoke-free home rules from baseline to follow-up and a notable reduction in parent stress on the Parent Stress Index of 5.9 points (SD = 10.2). SafeCare Provider feedback following intensive review of the curriculum indicated high feasibility for SFH-SC delivery.

CONCLUSIONS

Parent and Provider findings suggest SFH-SC is a viable intervention that has potential to reduce the public health impact of SHS and child maltreatment for at-risk families.

PROTOCOL

The protocol for the pilot is not published elsewhere; however, the full protocol for the hybrid trial can be found here: https://clinicaltrials.gov/ct2/show/NCT05000632 .

TRIAL REGISTRATION

NCT, NCT05000632. Registered 14 July 2021, there is not a separate registration number for the pilot.

Relations Between Stress-Adapted Communication Skills and Toxic Social Networks Among Young Adults with Childhood Adversity

Adverse childhood experiences are associated with deleterious outcomes across the lifespan. However, some individuals who grow up in adverse environments may develop stress-adapted skills or resilience factors that enable them to function in their current lived environments. This study explored whether communication is a stress-adapted skill among young adults with co-occurring forms of childhood adversity and the extent to which these communication skills are implicated in toxic social networks. This cross-sectional study included 384 young adults, ages 18-35 years, who completed an online survey. Mixture modeling was used to conduct latent class models estimating subgroups of young adults with co-occurring forms of early adversity; then, regression models estimated the association between communication skills and toxic social networks among subgroups. Four latent classes were identified: (1) high childhood adversity; (2) high to moderate household dysfunction and emotional abuse; (3) high emotional abuse and moderate physical abuse and emotional neglect; and (4) low or no childhood adversity. Results from regression models indicate that participants classified in the high emotional abuse and moderate physical abuse and emotional neglect class had more adaptive communication skills with friends than their counterparts in the low or no childhood adversity class, and participants in the high childhood adversity or low or no childhood adversity classes with higher communication skills were less likely to report toxic social networks. Findings suggest that stress-adapted communication skills may be one resilience factor that supports adaptation among young adults with early adversity exposures.

Quality of Life among Couples with a Fertility Related Diagnosis

Fertility-related stress can negatively impact infertile couples' quality of life (QoL). Most previous studies have concentrated on the effects of stress and infertility on individual persons, especially women, though infertility affects the QoL of both spouses. Our research aimed to investigate the roles of infertility and stress in couples' quality of life as a single unit. The research sample consisted of 202 spouses, i.e., 101 couples, with a mean age of 39.5 years (SD = 4.9 years) undergoing fertility treatment at Athens Naval Hospital-Assisted Reproduction Unit. Data collection was completed via self-administered questionnaires: the FertiQoL International Questionnaire for measuring the quality of life in infertility and The Demographic Information and Medical History Questionnaire. Data collection was conducted between January and November 2022. Quantitative variables are expressed as mean values (standard deviation) and as median interquartile range, and qualitative variables are expressed as absolute and relative frequencies. Pearson's (r) and Spearman's (rho) correlations coefficients were used to explore the association of two continuous variables. Multiple linear regression analysis was used with dependence on the Ferti-QoL's subscales. The regression equation included terms for participants' demographics and information from their medical history. Adjusted regression coefficients (β) with standard errors (SE) were computed from the results of the linear regression analyses. All reported p values are two-tailed. Statistical significance was set to p < 0.05, and analyses were conducted using SPSS statistical software (version 22.0). We found that greater anxiety and depression were significantly associated with worse quality of life. Additionally, quality of life, according to Ferti-QoL, was significantly worse in women, participants with a high level of education, those with greater depressive symptoms, and those with greater state scores. Findings of this study highlight the need for implementing interventions of supportive care methods, counseling, stress reduction methods, and improving the fertility-related quality of life of infertile couples.

Sexual, Physical, and Emotional Maltreatment in Childhood Are Differentially Associated With Sexual and Physical Revictimization in Adulthood

Childhood maltreatment increases risk for sexual and physical revictimization in adulthood. The goal of the current study was to examine whether this risk is associated with specific maltreatment types (i.e., sexual vs. physical vs. emotional maltreatment vs. neglect) and perpetrators (i.e., mother vs. father). Participants included 720 adult women from North America and the United Kingdom, recruited through the online platform Prolific Academic. The severity of childhood maltreatment and adult physical and sexual victimization were assessed in two separate sessions through self-report questionnaires. All maltreatment types were modeled together to account for their co-occurrence. Greater severity of sexual maltreatment was significantly and independently associated with greater risk for sexual, physical, and sexual + physical revictimization. Further, in the full sample, risk of revictimization was predicted by greater severity of father-perpetrated emotional and physical maltreatment. In contrast, in subgroup analyses focusing on plurisexual (i.e., bi/pansexual) women, risk of revictimization was predicted by greater severity of mother-perpetrated emotional and physical maltreatment. These results suggest that girls with sexual and emotional maltreatment histories are at highest risk for revictimization. Future research identifying the biological, psychological, and social sequelae of these specific exposures may enable the development of specific intervention programs that have the potential for maximum efficacy in preventing further violence against women most at risk.

State-level education policies: Opportunities for secondary prevention of child maltreatment

BACKGROUND

Exposure to child maltreatment creates risk for adverse social, health, and economic outcomes across generations. The socioecological model posits the well-being of individuals, including children and youth, is shaped by the larger systems they exist in. Employing state-level policies to position school settings to effectively identify and intervene in instances of child maltreatment is an important secondary prevention opportunity.

OBJECTIVE

This study examines the relationship between state-level policies that call for school based trainings to promote the recognition of and response to child maltreatment, and states' annual rates of substantiated child maltreatment reports.

METHODS

Relevant policies were identified and abstracted to generate measures of policy presence and comprehensiveness. The National Child Abuse and Neglect Data System was used to derive rates of substantiated child maltreatment reports by state and year. Child maltreatment rates were the dependent variable and policy measures were the primary explanatory variables in a difference-in-differences (DD) model series with state-level clustering and year-fixed effects.

RESULTS

The DD model series suggest significant, positive relationships between the presence of policies calling for school-based recognition and response training and child abuse (IRR 1.140, p = 0.04) as well as child physical abuse outcomes (IRR 1.150, p = 0.05). Sensitivity analyses suggest the relationships between policy presence and abuse outcomes were stronger for children than for adolescents.

CONCLUSION

These findings suggest that related policies may be effective secondary prevention tools for child maltreatment.

Interpersonal violence and recurrent headache among adolescents with a history of psychiatric problems

BACKGROUND

Interpersonal violence (IPV) is found to be associated with mental health problems and pain disorders such as headache among children and adolescents. It is well-known that adolescents in need of mental health services have experienced IPV more often than adolescents in the general population. However, there has not been much focus on pain conditions in child and adolescent psychiatric populations.

METHODS

Data from the current study are based on a 3-year follow-up of the CAP-survey, which is a study of adolescents in the child and adolescent psychiatric unit population of St. Olavs Hospital (Trondheim University Hospital). The baseline study was conducted between 2009 and 2011, with 717 participants between 13 and 18 years. All participants were enrolled, or newly referred to the child and adolescent psychiatric clinic. At follow-up, 570 participants completed questionnaire, and 550 completed a diagnostic interview. The participants were aged 16-21 years (mean age 18.6 years).

RESULTS

A third of the adolescents reported frequent headaches (weekly or daily). Adolescents with more severe mental problems were more likely to experience frequent headaches. Adolescents exposed to unpleasant sexual acts or bullying, reported more frequent headaches than non-exposed participants. Participants exposed to three or more types of IPV seemed to be at particularly high risk of experiencing frequent headache.

CONCLUSIONS

Both experiences of interpersonal violence and headache are common in this clinical psychiatric population. Clinicians should assess for headache disorders in addition to psychiatric and trauma assessment and provide need-based treatment to enhance chance of recovery among adolescents in mental health services.

The State of the Science on Adverse Childhood Experiences

The Adverse Childhood Experiences (ACEs) study was conducted to advance understanding of psychological trauma in early life as a possible determinant of adult health. In the past decade, there has been a movement to use the ACEs research questionnaire in a variety of clinical settings to screen individuals and assess their trauma score. But critics argue that the ACEs questionnaire was never intended to be used for individual-level screening, and even that harm can be done by using the questionnaire for this purpose. In the meantime, researchers have developed a protective factor questionnaire that they call the "Positive Childhood Experiences" (PCEs) survey that captures experiences that predict trauma resilience. The objective of this article is to explain the history of the ACEs questionnaire, the current controversy about its use for screening, the emergence of the concept of PCEs, and implications for occupational therapy practitioners and researchers.

Association of childhood trauma, and resilience, with quality of life in patients seeking treatment at a psychiatry outpatient: A cross-sectional study from Nepal

Quality of life is defined by the World Health Organization as "Individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns". It is a comprehensive measure of health outcome after trauma. Childhood maltreatment is a determinant of poor mental health and quality of life. Resilience, however, is supposed to be protective. Our aim is to examine childhood trauma and resilience in patients visiting psychiatry outpatient and investigate their relations with quality of life. A descriptive cross-sectional study was conducted with a hundred patients with trauma and visiting psychiatry outpatient. Standardized tools were applied to explore childhood trauma, resilience, quality of life and clinical diagnoses and trauma categorization. Sociodemographic and relevant clinical information were obtained with a structured proforma. Bivariate followed by multivariate logistic regressions were conducted to explore the relation between childhood trauma, resilience, and quality of life. Poor quality of life was reported in almost one third of the patients. Upper socioeconomic status, emotional neglect during childhood, current depression and low resilience were the determinants of poor quality of life in bivariate analysis. Final models revealed that emotional neglect during childhood and low resilience had independent associations with poor quality of life. Efforts should be made to minimize childhood maltreatment in general; and explore strategies to build resilience suited to the cultural context to improve quality of life.

The Impact of ADHD on Maternal Quality of Life

Childhood attention-deficit/hyperactivity disorder (ADHD) is associated with substantial burden to caregiver quality of life (QoL). However, a paucity of work has focused on quantifying QoL among caregivers of adolescents with a history of ADHD. The purpose of the current study was (1) to quantify maternal QoL in a sample of mothers of adolescents with and without childhood ADHD; and (2) to examine predictors (i.e., parent and child characteristics and behavior) associated with maternal QoL. Participants included mothers of adolescents with (N = 110) and without ADHD (N = 90) ranging in age from 13 to 18 (M = 16.09, 92% male). The Quality Adjusted Life-Year (QALY) was used to calculate maternal QoL using two health domains (i.e., anxiety/depression and disruption in daily activities) commonly impacted by raising youth with ADHD. QALYs are valued monetarily to estimate disease burden. Mothers of adolescents with childhood ADHD experienced significantly worse QoL relative to mothers in the comparison group. Maternal depression, as well as adolescent age, ADHD status, and discipline problems significantly predicted lower levels of maternal QALY health status index, with ADHD being the strongest predictor. This is equal to a reduction in 1.96 QALYs when summed over the course of a child's lifetime and is associated with a loss of $98,000 to $196,000. Results of the investigation help to further elucidate the health impacts incurred by families of adolescents with ADHD and have important public health implications. Further, parental QoL should be considered when conceptualizing the financial and negative health impact of ADHD.

Associations between childhood maltreatment and educational, health and economic outcomes among middle-aged Chinese: The moderating role of relative poverty

BACKGROUND

Despite substantial evidence in developed countries showing that child maltreatment can lead to serious life-long consequences, relatively few studies so far have examined the associations between childhood maltreatment and adulthood outcomes in developing countries, such as China. It also remains unclear as to the impact of relative poverty on the long-term development of maltreated children.

OBJECTIVE

This study aims to investigate the associations between childhood maltreatment and educational, health, and economic outcomes among middle-aged Chinese, as well as explore the moderating effects of relative poverty.

PARTICIPANTS AND SETTING

The participants of this study were the middle-aged respondents (aged 45 to 59) in the 2011, 2013, and 2015 China Health and Retirement Longitudinal Studies (CHARLS) and the CHARLS Life History Survey (N = 24,114).

METHODS

Physical abuse and emotional neglect were measured to investigate childhood maltreatment. Subjective and objective indicators were used to examine relative poverty. A broad range of midlife outcomes were explored, including educational attainment, physical health, mental health, cognitive functions, labor force participation, wage expenditure, and financial strain. Data analyses were conducted using fixed effects model for panel data and a propensity score matching approach.

RESULTS

Childhood physical abuse and emotional neglect were both significantly associated with lower levels of midlife educational attainment, cognitive functions, individual wages, and household expenditures, as well as higher rates of chronic diseases, depressive symptoms, poverty, and welfare involvement. Childhood physical abuse also predicted higher risks of difficulty performing the activities of daily living (ADL), unemployment, and fewer work hours. Early-life exposure to relative poverty was linked to a greater likelihood of childhood maltreatment and mid-life adversities. It further aggravated the negative impacts of childhood maltreatment on middle-age outcomes.

CONCLUSION

Child maltreatment had a profound effect on long-term child development and midlife outcomes in Chinese contexts. Relative poverty in early life was a moderator that exacerbated the outcomes associated with childhood maltreatment.

Trauma-Informed Home Visiting Models in Public Health Nursing: An Evidence-Based Approach

Traumatic experiences can have significant health effects, particularly when they are experienced during childhood. Structural determinants of health including environmental disasters and limited access to mental health services and affordable housing can contribute additional stress for parents with a personal history of childhood adversity. These factors can directly affect their children, contributing to intergenerational trauma. Pregnant people and families with young children are often referred to public health nursing maternal and child home visiting (HV) programs when there are concerns about historical or evolving childhood trauma. The strict eligibility and participation requirements of existing evidence-based maternal and child HV programs can exclude families that have experienced or are experiencing childhood trauma and its effects and can limit innovation by public health nurses, a hallmark of the field. Therefore, we advocate and describe the implementation of the Trauma Informed Approach in Public Health Nursing (TIA PHN) model, which incorporates a trauma-informed approach into a traditional maternal and child HV program in 3 California counties. TIA PHN, which began enrollment in March 2021, involves public health nurses and community health workers and integrates program evaluations in pursuit of evidence-based status. (Am J Public Health. 2022;112(S3):S298-S305. https://doi.org/10.2105/AJPH.2022.306737).

Mental health-related quality of life by sex and sexual identity among U.S. adults with alcohol and tobacco use disorder

INTRODUCTION

Alcohol use disorder (AUD) and tobacco use disorder (TUD) are more severe among some sexual minority subgroups. It is less understood whether mental health indicators also differ by sexual identity among those with more severe forms of AUD and TUD. We examined differences in mental health-related QoL by sex-specific sexual identity subgroup among those meeting criteria for moderate-to-severe AUD or moderate-to-severe TUD.

METHODS

We analyzed data from the National Epidemiologic Study of Alcohol and Related Conditions-III (2012-2013; n = 36,309). Our analyses focused on those meeting criteria for past-year moderate-to-severe AUD (n = 2341) and past-year moderate-to-severe TUD (n = 3675). Using multivariable linear regression, we examined associations of sex-specific sexual identity subgroups with mental health-related QoL, while controlling for (a) sociodemographic characteristics, (b) disorder severity, and (c) risk and protective factors (adverse childhood experiences, parental history of substance misuse, stressful life events, and social support).

RESULTS

Among those with past-year moderate-to-severe AUD, gay men and heterosexual, bisexual, and gay/lesbian women had significantly lower mental health-related QoL compared to heterosexual men in fully adjusted models. Among those with past-year moderate-to-severe TUD, gay men and heterosexual and gay/lesbian women had significantly lower mental health-related QoL compared to heterosexual women. Bisexual and heterosexual women were not significantly different in fully adjusted models.

DISCUSSION

Clinicians should consider the variability in mental health-related QoL among those with moderate-to-severe AUD and TUD particularly for women and sexual minorities. Consideration of current and past stressors and the degree of social support may be beneficial when conducting assessments and forming treatment plans.

In young women, a link between childhood abuse and subliminal processing of aversive cues is moderated by impulsivity

BACKGROUND

Childhood maltreatment is a serious public health concern. The association between child maltreatment, adverse behaviors, mental health outcomes, and alterations to brain function and structure have begun to be characterized. Less is known about the specific associations of maltreatment subtypes with cue-response to evocative cues and the moderating effects of confounding mental health/behavioral variables.

METHODS

Fifty-four emerging adult women (aged 18-24) completed assessments for behaviors, mental health, and childhood maltreatment. They participated in a fMRI task featuring passive viewing of evocative (33 ms) cues presented by "backward masking" to prevent conscious processing. Correlations of abuse/neglect scores, behavioral/mental health factors, and brain function were assessed. Follow-up analyses investigated the moderating effects of behavioral/mental health factors on maltreatment and brain relationships.

RESULTS

Greater frequency of childhood abuse and neglect were correlated with higher scores of impulsivity, depressive symptoms, and anxious attachment. Childhood abuse was positively associated with increased medial orbitofrontal cortical (mOFC) response to aversive (vs. neutral) cues. Among the behavioral/mental health variables, only impulsivity appeared to have a moderating effect on the relationship between childhood abuse and brain response to aversive cues.

CONCLUSIONS

The link between childhood abuse and a heightened mOFC response to "unseen" aversive stimuli, moderated by impulsivity, adds to the growing literature on the impact of prior adversity on brain function. These findings offer further understanding for the way in which childhood maltreatment affects the brain processing of negative stimuli, helping to explain the well-documented link between childhood maltreatment and a variety of adverse outcomes in adulthood.

A mediational analysis of adverse experiences in childhood and quality of life in adulthood

OBJECTIVES

This study examined associations of three prevalent adverse childhood experiences (ACEs) - parents' problematic alcohol use (PPAU), parental separation/divorce, and lack of support from a trusted adult-with adult quality of life (QoL), and potential mediators of associations.

METHODS

Data were from a representative survey (N = 28,047) in Norway that assessed ACEs, QoL, and potential mediators: enduring perceptions of childhood hardships (Difficult Childhood Questionnaire; DCQ), current mental distress, and current social isolation. Latent regression analyses examined potential mediators.

RESULTS

Each ACE was positively associated with perceptions of childhood as difficult (higher DCQ scores). In turn, ACEs were negatively associated with adult QoL through indirect effects. Lack of support from a trusted adult had the strongest negative association with adult QoL, compared to PPAU and parental separation/divorce. The association between the ACEs and QoL was explained through the mediators of mental distress and social isolation.

CONCLUSIONS

Of the examined ACEs, lack of support from a trusted adult had the strongest negative impact on adult QoL. Adult support to vulnerable children could potentially ameliorate adult consequences of ACEs. In addition, adults reporting difficulties due to childhood adversities may benefit from therapeutic interventions that address both psychological distress and isolation.

Childhood Maltreatment, Mental Well-Being, and Healthy Lifestyle in Patients With Chronic Thromboembolic Pulmonary Hypertension

Introduction

Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially life-threatening condition associated with high morbidity and mortality. However, advances in medical, surgical and interventional treatment have markedly improved the outcome of patients with CTEPH. Additional factors potentially influencing quality of life (QoL) and outcome in CTEPH are yet to be defined. Child maltreatment is a major risk factor for unfavorable behavioral, mental as well as physical health outcomes and has been associated with decreased QoL. To date, no study assessed the impact of childhood trauma in patients with CTEPH.

Methods

Patients with CTEPH were invited to complete the Childhood Trauma Questionnaire (CTQ). Data were compared to prevalence data from the German population. Mental well-being was assessed using the Hospital Anxiety and Depression Scale (HADS) and quality of life was measured using the WHO Quality of Life Questionnaire (WHOQOL). Furthermore, lifestyle factors and physical health parameters were studied.Logistic regression analysis was used to investigate a possible impact of child maltreatment on markers of disease severity.

Results

One-hundred and seven patients with CTEPH completed the CTQ. These patients reported higher rates of emotional abuse and physical abuse and emotional neglect compared to the German population while rates of physical neglect and sexual abuse did not differ between patients and German population with prevalence of 20.6% for emotional abuse, 20% for physical abuse, 22% for emotional neglect, 46% for physical neglect, and 6% for sexual abuse in patients with CTEPH. Higher CTQ scores were associated with anxiety symptoms as well as negatively associated with QoL. No direct impact of childhood trauma on CTEPH severity was found.

Conclusion

We found a higher rate of child maltreatment in patients with CTEPH in comparison to the German population. Correlations suggest moderate associations between CTQ scores and mental health and QoL. Child maltreatment had no significant impact on disease severity. Further investigation on proper interventions to support affected patients is needed.

Childhood Trauma in Patients With PAH-Prevalence, Impact on QoL, and Mental Health-A Preliminary Report

BACKGROUND/OBJECTIVE

Child maltreatment is associated with increased risk of psychological consequences, contributes to morbidity and has long lasting effects on mental health and quality of life. Child maltreatment has not been assessed in patients with pulmonary arterial hypertension (PAH). We examined the prevalence of child maltreatment and determined their impact on disease severity in patients with PAH.

METHODS

A cross-sectional observational multicenter study at two PH centers in Germany was conducted. Patients with a confirmed diagnosis of PAH were given a self-administered questionnaire. Child maltreatment using the Childhood Trauma Questionnaire (CTQ), quality of life (QoL), anxiety, depression, and lifestyle factors were assessed and enhanced by clinical parameters 6-min walk distance (6MWD), WHO functional class (WHO FC), and serum levels of N-terminal fragment of pro-brain natriuretic peptide (NT-proBNP). Prevalence rates of child maltreatment were compared to the general population and impact of child maltreatment on disease severity was calculated by logistic regression analysis.

RESULTS

Two-hundred and seventeen patients, 71% female and a median age of 56 years were enrolled in this study. Patients with PAH had higher rates of emotional abuse and lower rates of physical neglect compared to the German population while rates of emotional neglect, physical abuse, and sexual abuse did not differ between patients and German population. Patients with any form of child maltreatment were more likely to be active smokers, had a worse QoL and more anxiety or depression. Moderate associations between child maltreatment, mental health, QoL, lifestyle factors and clinical parameters could be observed. Logistic regression analysis showed a significant impact of CTQ-total score on disease severity with an OR of 1.022 (95%-CI: 1.001-1.042, p = 0.035).

CONCLUSION

We found a higher rate of child maltreatment in patients with PAH in comparison to the German population. Correlations suggest moderate associations between CTQ-scores and mental health as well as QoL. Child maltreatment had significant impact on disease severity. However, effects were moderate. We conclude that child maltreatment has effects on mental health and quality of life in patients with PAH and may have limited effect on disease severity.

Moderating Effects of Physical Activity on the Relationship between Adverse Childhood Experiences and Health-Related Quality of Life

The effects of adverse childhood experiences (ACEs) on health-related quality of life (HRQOL) and their associations with physical activities (PA) are well-documented. However, the specific effects of different types of ACEs (e.g., child abuse and household dysfunction) on HRQOL and the role of PA are inconclusive. The purpose of this study is to find the buffering role of PA as a moderator that may reduce the negative impact of ACEs in general and the specific effects of different types of ACEs on HRQOL, perceived physical health, and mental health over time. The 2019 Behavioral Risk Fact Surveillance System (BRFSS), a state-based surveillance system supported by the CDC in the U.S., was used for this study. A total of 127,370 respondents from 17 states were selected for this study. First, descriptive statistics were generated and correlation analyses were conducted to find the association among variables and examine the possible predictors of HRQOL. Moderation models were then tested using Structural Equation Modeling (SEM). HRQOL in adults is negatively associated with ACEs, but is positively associated with PA. We found buffering effects of physical activity in the following relationships: (1) child abuse and HRQOL, (2) child abuse and perceived physical health, (3) ACEs and perceived mental health, (4) child abuse and perceived mental health, and (5) household dysfunction and perceived mental health. Our findings suggest that improvement of PA level is a significant predictor of improved HRQOL of adults with ACEs.

The Impact of COVID-19 on the Delivery of an Evidence-Based Child Maltreatment Prevention Program: Understanding the Perspectives of SafeCare® Providers

Child maltreatment (CM) is a global public health problem. Evidence-based home visiting programs, such as SafeCare®, reduce CM risk, and enhance parent-child relationships and other protective factors. As the result of the COVID-19 pandemic and resulting restrictions, SafeCare Providers transitioned from home to virtual delivery for the SafeCare curriculum. The purpose of this study is to 1) examine active SafeCare Providers' opinions on the feasibility and effectiveness of SafeCare via remote delivery, and 2) better understand workforce concerns for human service professionals within the context of COVID-19 mitigation efforts. Data are from a cross-sectional survey of SafeCare Providers (N = 303) in the United States, Canada, and Australia. The majority of Providers reported they were actively delivering SafeCare virtually and were comfortable with the delivery format. Providers indicated that the majority of SafeCare families are making progress on target skills, and that engagement is high among many families. Some service delivery challenges were reported, ranging from family data plan limitations to difficulty with delivery of specific components of the SafeCare curriculum related to modeling and assessment. The impact of COVID-19 on Providers' daily routines, stress level, and work-life balance has been significant. Remote, virtual delivery of CM prevention programming offers the opportunity to continue serving vulnerable families in the midst of a pandemic. Barriers related to family technology and data access must be addressed to ensure reach and the effective delivery of prevention programming during the pandemic and beyond.

Evaluating child maltreatment and family violence risk during the COVID-19 Pandemic: Using a telehealth home visiting program as a conduit to families

The COVID‐19 pandemic has affected many child maltreatment risk factors and may have affected maltreatment among vulnerable families. We surveyed 258 certified providers of an evidence‐based home visiting program, SafeCare, about their perception of the impact of the pandemic on the families they serve. We examined if the providers perceived an overall change in child maltreatment and family violence risk among the families with young children they served and factors that may have contributed to changes. Regressions estimated the relationship between providers’ assessment of families’ ability to social distance, emotional struggles, and access to public resources/services with providers’ perception of child maltreatment and family violence risk in the home. Findings indicate that 87% of providers believed maltreatment risk had increased during the pandemic. Providers serving families who were unable to social distance due to employment were more likely to report increased supervisory neglect and material neglect among the families they serve. Providers reporting that families were struggling with elevated frustration levels also reported more family conflict and material neglect among the families they serve. Results from this research can inform strategic decision‐making for policies and programs that address the challenges low‐income families with young children face in emergency situations.

Sex Differences in the Relationship Between Child Maltreatment, Recent Bereavement, and Average Heart Rate

The study explores the sex differences in cardiovascular outcomes among bereaved individuals. In addition, the study differentiates the impact of child maltreatment and recent loss on the physical health of adult men and women. This study conducted a secondary analysis of data drawn from the Biomarker Subproject of the National Survey of Midlife Development in the United States (n = 1,255). Analysis included a series of regression models estimated in Stata version 15.1. A main effect for both sex and loss was observed. Both male and female respondents with loss had higher average heart rates as compared to male respondents without loss. Interestingly, being a female without loss was also associated with a higher average heart rate as compared to males without loss. The findings suggest that sex differences in cardiovascular functioning do occur and that these differences may be exacerbated by experiences of trauma and loss, and this relationship has implications for assessment and intervention.

Overall and Gender-specific Associations between Dimensions of Adverse Childhood Experiences and Mental Health Outcomes among Homeless Adults: Associations Générales et Sexospécifiques Entre les Dimensions des Expériences Défavorables de L'enfance et les Résultats de Santé Mentale Chez les Adultes Sans Abri

OBJECTIVE

The associations between adverse childhood experiences (ACEs) and psychopathology have been well-established in the general population. Research on ACEs in the homeless population has been limited. This study examined whether ACE exposure is associated with specific mental health outcomes among a national sample of homeless adults with mental illness and whether this association varies according to ACE dimension and gender.

METHODS

This cross-sectional study utilized data from a national sample of 2,235 homeless adults with mental illness in Canada to evaluate their sociodemographic characteristics, exposure to ACEs, and mental health outcomes. Exploratory and confirmatory factor analyses were conducted to identify and confirm ACE dimensions (maltreatment, sexual abuse, neglect, divorce, and household dysfunction) from individual ACE items. Multivariable logistic regression was used to examine the associations between total ACE score and ACE dimensions with mental illness diagnoses and psychopathology severity.

RESULTS

The mean total ACE score among all study participants was 4.44 (standard deviation [SD]: 2.99). Total ACE score was positively associated with several mental illness diagnoses and psychopathology severity. Unique associations were found between specific ACE dimensions and poor mental health outcomes. The prevalence of almost all ACEs was significantly higher among women. Yet, associations between several ACE dimensions and poor mental health outcomes existed uniquely among men.

CONCLUSIONS

There are unique and gender-specific associations between specific ACE dimensions and mental health outcomes among homeless adults. Better understanding of the mechanisms underlying these associations is needed to inform screening, prevention, and treatment efforts, particularly given the very high prevalence of ACEs among this vulnerable and marginalized population.

The impact of childhood sexual abuse and adverse childhood experiences on adult health related quality of life

BACKGROUND

Adverse childhood experiences (ACEs) have been shown to be associated with adult physical, psychological, and socioeconomic well-being, indicative of poor health-related quality of life (HRQoL). However, the association between child sexual abuse (CSA) and adult HRQoL, independent of other ACEs, has been less well examined.

OBJECTIVES

To examine associations between self-reported CSA, including the nature of CSA, and adult HRQoL.

PARTICIPANTS

Data are from 10,624 respondents to CSA and HRQoL questions on the 2015 Texas Behavioral Risk Factor Surveillance System survey.

METHODS

Analyses included chi square and t-tests to compare sociodemographic and HRQoL differences among those with and without history of CSA. Multivariable logistic regressions were used to evaluate associations between nature of CSA and HRQoL, controlling for covariates.

RESULTS

The prevalence of self-reported CSA in the sample was 10.3%. Compared to the non-exposed group, individuals exposed to CSA were more likely to report their general health as poor (AOR, 1.51; 95% CI, 1.09-2.09), report 14 or more physical unhealthy days (AOR, 1.46; 95% CI, 1.06-2.02), 14 or more mental unhealthy days (AOR, 1.86; 95% CI, 1.30-2.64), and 14 or more activity limitation days (AOR, 2.22; 95% CI, 1.58-3.10) in a month. HRQoL outcomes were worse for respondents who reported being forced to have sex as a child compared with those who reported being touched or forced to touch someone.

CONCLUSIONS

Self-reported CSA is associated with lower HRQoL. The association varies by the nature of reported sexual abuse. Understanding the long-term impacts of CSA can inform adult treatment options and policies to prevent and treat CSA.

Building Resilience Through Sport in Young People With Adverse Childhood Experiences

Interventions focused on young people at risk of anti-social and criminal behaviour frequently involve physical exercise and/or participation in sporting activities as a primary vehicle to bring about behavioural change in both the short to medium term. Anecdotal evidence suggests that sporting activities positively influence individual well-being alongside a sense of purpose and belonging centred around sporting clubs and activities. Empirically, participation in sport has been identified as a key resilience factor for young people with numerous Adverse Childhood Experiences (ACEs) and investment and policy initiatives target investment in these opportunities. However, the psychological mechanisms which underpin these improvements in well-being and building of resilience are less clearly articulated. This article will review current and developing research in this field to synthesise future applications of sport-related interventions with young people, with a particular emphasis on furthering understanding of the pathways to capacity building at individual and community level which sport and exercise can generate.

Long-Term Profiles of Bullying Victims and Aggressors: A Retrospective Study

Bullying is a widespread and worrying phenomenon, related to many different personal, behavioral, and social variables which can modulate it and its outcomes, also in the long term. These relationships are usually studied in children and adolescents, but less often in adults who have suffered or perpetrated bullying in the past. The present work explored the long-term characteristics of bullying victims and aggressors using a retrospective design. A sample of 138 adults of different ages completed an on-line protocol that included measures of bullying and victimization, substance use, sensitivity to reward and punishment, social skills, antisocial behavior, emotional regulation strategies, depression, anxiety, stress, self-esteem, and risk of suicide. The sample was divided into three groups (victims, aggressors, and controls) based on their responses to bullying-related questions. A set of Multiple Analyses of Variance with group as a fixed factor was carried out for each dependent variable. Victims and aggressors did not significantly differ in their self-reported substance consumption. Victims showed higher global depression, anxiety and stress in the past than aggressors (M = 34.66, SD = 11.74; aggressors: M = 19.70, SD = 16.53), higher emotional lack of control (M = 23.97, SD = 10.62; controls: M = 17.11, SD = 7.95) and rejection (M = 21.72, SD = 7.24; controls: M = 16.33, SD = 5.67), lower self-esteem (M = 27.72, SD = 6.70; controls: M = 31.60, SD = 6.60), and a larger frequency of suicidal thoughts (in the past) than controls. Aggressors showed higher sensitivity to reward (M = 12.03, SD = 3.66; controls: M = 8.42, SD = 3.92), larger communicational and relational skills (M = 22.10, SD = 7.20; controls: M = 17.96, SD = 7.16), and lower emotional sensitivity (M = 14.80, SD = 4.10; controls: M = 16.76, SD = 2.21). Accordingly, the logistic regression analysis identified sensitivity to reward and low psychological adjustment as the main predictors of the aggressor and victim profiles, respectively. The present results are discussed considering the extant literature on bullying and may help to improve prevention programs for this relevant social scourge.

Depression Partially Mediates the Association of Adverse Childhood Experiences with Pain Intensity in Patients with Chronic Pelvic Pain Syndrome: Results from a Cross-Sectional Patient Survey

OBJECTIVE

Adverse childhood experiences (ACEs), such as emotional and physical maltreatment, are linked to chronic pelvic pain syndrome (CPPS) in adults. Psychological factors are important in understanding CPPS. We aimed to determine the nature and frequency of ACEs in male and female patients with CPPS and to investigate whether somatic symptoms and psychological comorbidities mediate the relationship of ACE severity with pain intensity.

DESIGN

Cross-sectional study.

SETTING

Interdisciplinary outpatient clinic for CPPS in Hamburg, Germany.

SUBJECTS

Individuals with CPPS (n = 234) who were 18 to 84 years of age.

METHODS

Using a self-administered questionnaire, we assessed the history of ACEs (ACE Scale), pain intensity (McGill Pain Questionnaire), somatic symptoms (Patient Health Questionnaire-15]), depression (Patient Health Questionnaire-9), and anxiety (Generalized Anxiety Disorder Scale). Parallel mediation analysis was conducted to examine whether the association of ACE severity with pain intensity is mediated by somatic symptoms, depression, and anxiety.

RESULTS

Emotional abuse and neglect were reported more than twice as often as physical abuse and neglect (37.2% vs 17.1%). Depression partially mediated the association of ACE severity with pain intensity in the whole study population. In sex-stratified analyses, different patterns of associations were observed, but somatic symptoms predicted pain intensity in both sexes.

CONCLUSIONS

Emotional maltreatment was highly prevalent, supporting an increased consideration of psychological factors in CPPS and indicating the need to screen for ACEs in patients with CPPS. Findings further suggest that depression and somatic symptoms may be important targets for therapeutic interventions in patients with CPPS who have a history of childhood adversity.

Childhood Maltreatment and Its Interaction with Hypothalamic-Pituitary-Adrenal Axis Activity and the Remission Status of Major Depression: Effects on Functionality and Quality of Life

Relationships among childhood maltreatment (CM), hypothalamic-pituitary-adrenal (HPA) axis disturbances, major depressive disorder (MDD), poor functionality, and lower quality of life (QoL) in adulthood have been described. We aimed to study the roles of the remission status of depression and HPA axis function in the relationships between CM and functionality and QoL. Ninety-seven patients with MDD and 97 healthy controls were included. The cortisol awakening response, cortisol suppression ratio in the dexamethasone suppression test, and diurnal cortisol slope were assessed. Participants completed measures of psychopathology, CM, functionality, and QoL. Multiple linear regression analyses were performed to study the relationships between CM and functionality and QoL. Only non-remitted MDD patients showed lower functionality and QoL than controls, indicating that depressive symptoms may partly predict functionality and QoL. Cortisol measures did not differ between remitted and non-remitted patients. Although neither HPA axis measures nor depression remission status were consistently associated with functionality or QoL, these factors moderated the effects of CM on functionality and QoL. In conclusion, subtle neurobiological dysfunctions in stress-related systems could help to explain diminished functionality and QoL in individuals with CM and MDD and contribute to the persistence of these impairments even after the remission of depressive symptoms.

Experiences of family violence and parental unavailability in childhood in relation to parental socioeconomic position and psychological problems: a cohort study of young Swedish women 1990-2013

Background

Despite the high prevalence and severe consequences for health and wellbeing, epidemiological research of neglected emotional needs during childhood is scarce and little is known about its relation to parental socioeconomic position (SEP). This study investigates the prevalence of family violence and parental unavailability in childhood and its association with parental SEP and parental psychological problems in four strata of young Swedish women examined 1990, 1995, 2000, and 2013.

Method

The sample comprised 976 women (mean age 22, range 20–25) living in Sweden. Secular trends for family violence, parental rejection and unavailability were analyzed using logistic regression as a function of year of examination. The associations with parental SEP and parental psychological problems were assessed using logistic regression with results in terms of odds ratios (OR) and 95% confidence intervals.

Results

Gendered patterns were observed in the associations between parental psychological problems and family violence and parental unavailability. Maternal psychological problems were associated with maternal rejection OR 6.8 (3.5–13.0), maternal lack of time OR 2.4 (1.2–5.0), and paternal rejection OR 1.9 (1.1–3.5). Paternal psychological problems were associated with paternal rejection OR 4.0 (2.1–7.7), paternal lack of time OR 4.9 (2.3–10.6), and experiencing family violence OR 4.9 (2.1–11.6). Low and medium parental SEP were associated with experience of family violence in childhood OR 3.1 (CI 1.1–8.5) and OR 3.4 (1.7–6.9), respectively. No changes between 1990 and 2013 were observed for the prevalence of any of the outcomes.

Conclusions

A stable prevalence of family violence and parental unavailability was reported by young women examined between 1990 and 2013. Lower socioeconomic position was associated with family violence while the association with parental unavailability was non-significant. Gendered patterns were observed in the association between parental psychological problems and family violence, where paternal but not maternal psychological problems were associated with family violence. Further, maternal psychological problems were associated with paternal rejection while paternal psychological problems were not associated with maternal rejection. Gendered patterns of parental unavailability need further studies.

Association of adverse childhood experiences with diabetes in adulthood: results of a cross-sectional epidemiological survey in Singapore

OBJECTIVES

Several studies have linked diabetes mellitus to adverse childhood experiences (ACEs). While a number of studies have examined the association between ACEs and diabetes in Western populations, few have done it in Asian populations. The current study aimed to examine (1) the association between ACEs and diabetes, including the association after age stratification, and (2) the association of comorbid depression, resource use and health-related quality of life (HRQoL) among those with diabetes and ACEs in Singapore.

SETTINGS

Participants were surveyed in their homes or any other preferred venue of their choice.

PARTICIPANTS

6126 individuals aged 18 years and above were randomly selected among Singapore residents.

DESIGN

Cross-sectional nationwide epidemiological study.

RESULTS

Exposure to any ACE was not associated with increased odds of diabetes; however, those who had experienced parental separation, death or divorce of a parent had higher odds of diabetes. In addition, we observed significant interaction between age and ACEs in relation to odds of diabetes. ACEs were significantly associated with higher odds of diabetes mainly in the younger age group. The prevalence of major depressive disorder was significantly higher among those with diabetes and ACEs than those with diabetes alone (3.7% and 0.3% respectively).

CONCLUSIONS

Efforts to promote regular exercise and healthy lifestyles both in the population and among those with diabetes must continue for the prevention and management of diabetes. The findings emphasise the need to create more awareness of both the prevalence and impact of ACEs among those treating chronic diseases.

Worse Than Death: Survey of Public Perceptions of Disability Outcomes After Hypothetical Traumatic Brain Injury

OBJECTIVE

The aim of this study was to determine the health utility states of the most commonly used traumatic brain injury (TBI) clinical trial endpoint, the Extended Glasgow Outcome Scale (GOSE).

SUMMARY BACKGROUND DATA

Health utilities represent the strength of one's preferences under conditions of uncertainty. There are insufficient data to indicate how an individual would value levels of disability after a TBI.

METHODS

This was a cross-sectional web-based online convenience sampling adaptive survey. Using a standard gamble approach, participants evaluated their preferences for GOSE health states 1 year after a hypothetical TBI. The categorical GOSE was studied from vegetative state (GOSE2) to upper good recovery (GOSE8). Median (25th percentile, 75th percentile) health utility values for different GOSE states after TBI, ranging from -1 (worse than death) to 1 (full health), with 0 as reference (death).

RESULTS

Of 3508 eligible participants, 3235 (92.22%) completed the survey. Participants rated lower GOSE states as having lower utility, with some states rated as worse than death, though the relationship was nonlinear and intervals were unequal between health states. Over 75% of participants rated a vegetative state (GOSE2, absence of awareness and bedridden) and about 50% rated lower severe disability (GOSE3, housebound needing all-day assistance) as conditions worse than death.

CONCLUSIONS

In the largest investigation of public perceptions about post-TBI disability, we demonstrate unequally rated health states, with some states perceived as worse than death. Although limited by selection bias, these results may guide future comparative-effectiveness research and shared medical decision-making after neurologic injury.

The impact of adverse childhood experiences on healthcare utilization in children

BACKGROUND

Adverse childhood experiences (ACEs) are related to long-term negative outcomes. The impact of these experiences on healthcare utilization in children has been understudied.

OBJECTIVE

To examine the impact of ACEs on children's healthcare utilization, medical diagnoses, and pharmacological treatment.

PARTICIPANTS AND SETTING

Children aged 6 months to 17 years who were screened for ACEs in the Behavioral Health Department or in primary care locations as part of an initial consultation visit and who had at least one subsequent healthcare visit during the study period were included in the study.

METHODS

Adverse childhood experiences were measured using the ACE screening questionnaire designed by Felitti et al. (1998). Data from the year following administration of the ACE screening tool were retrospectively extracted from the electronic health record.

RESULTS

Overall, 1,183 children met study inclusion criteria. Children with any reported ACEs were more likely to no show appointments (1-3 ACEs incidence rate ratio (IRR) [95 % confidence interval (CI)]: 1.40 [1.11-1.77]; 4+ ACEs IRR [95 % CI]: 1.41 [1.08-1.84]) and to use emergency services (1-3 ACEs IRR [95 % CI]: 1.24 [1.00-1.53]; 4+ ACEs: IRR [95 % CI]: 1.42 [1.11-1.81) than children with no ACEs. Those with 4+ ACEs used the telephone nurse advisor less frequently (1-3 ACEs IRR [95 % CI]: 0.67 [0.53-0.84]; 4+ ACEs IRR [95 % CI]: 0.69 [0.53-0.90]). Although ACE scores were associated with healthcare utilization, insurance status was more robustly associated with healthcare utilization than ACE score.

CONCLUSIONS

Healthcare systems may employ results from this study to adopt trauma-informed care initiatives. Ensuring that all patients have insurance may be a first step toward improving healthcare utilization.

Resilience as a Mediator between Adverse Childhood Experiences and Prescription Opioid Misuse among U.S. Adults

Studies have shown some linkage between adverse childhood experiences (ACEs) and prescription opioid misuse. While preventable, once an individual is exposed to ACEs, they can have irreparable health impacts. Resilience could have protective effects on preventing those with ACEs from adulthood health-risk behaviors. Objectives: To examine how resilience mediates the association between ACEs and adulthood prescription opioid misuse among U.S. adults. Methods: Adult respondents (n = 33,613) from the National Epidemiologic Survey on Alcohol and Related Conditions-III (2012-2013) were included. A count of ten types of ACEs constituted the ACE score (range: 0-10). A latent variable was created to measure resilience based on the Connor-Davidson Resilience Scale. Generalized structural equation modeling (GSEM) was utilized to conduct the mediation analysis. The Problem Behavior Theory was used to guide covariate selection. Results: The GSEM measurement model estimated the latent variable resilience and determined that tolerance of negative effects, self-control, acceptance of change, and spiritual influence were all associated with resilience, holding personal competence constrained for estimation purposes. Respondents with a higher ACE score were more likely to misuse prescription opioids in the past year (OR = 1.08; p < 0.01), where 40.8% of the association was mediated by resilience (indirect effect OR = 1.06). Conclusion: Reducing prescription opioid misuse is an essential step in alleviating the current opioid epidemic. Findings suggested that resilience mediated the relationship between ACEs and adulthood prescription opioid misuse. To prevent adults with ACEs from misusing prescription opioids, interventions designed to address ACEs' impact should include behavioral and educational components for enhancing the priority dimensions of resilience.

The impact of adverse childhood experiences on the health and health behaviors of young Australian women

BACKGROUND

Adverse childhood experiences have been linked to poor health and adverse health behavior in adulthood.

OBJECTIVE

This study aimed to estimate the prevalence of adverse childhood experiences among young Australian women (aged 20-25) and examine associations between adverse childhood experiences and adult health behaviors and physical and mental health.

PARTICIPANTS AND SETTINGS

Data were from the 1989-95 cohort of the Australian Longitudinal Study on Women's Health, who completed the Adverse Childhood Experiences Scale at Survey 3 in 2015 (N = 8609).

METHODS

Outcomes included: self-rated health, sexual health, psychological distress, depression, anxiety, suicide ideation, self-harm, substance abuse (drinking, smoking, illicit drugs), severe obesity, and exercise. Prevalence of childhood adversities were presented, with the association between childhood adversity and outcomes evaluated using log-binomial multivariable regressions (99% CI).

RESULTS

While 59% of women reported experiencing at least one childhood adversity, 10% of participants reported adverse childhood experiences across four or more categories, indicating a significant burden of risk for young Australian women. Women reporting four or more categories had higher rates of poor physical health (adjPR = 1.79, 99% CI = 1.51-2.12), sexually transmitted infections (adjPR = 1.36, 99% CI = 1.11-1.67), and poor mental health (adjPR = 2.78, 99% CI = 2.34-3.32), and increased rates of severe obesity (adjPR = 2.14, 99% CI = 1.61-2.86) and smoking (adjPR = 2.23, 99% CI = 1.89-2.64).

CONCLUSION

Using nationally representative data, this study shows adverse childhood experiences directly impact physical and mental health, and health behaviors in adulthood among young Australian women. The management of health and wellbeing in adulthood should look beyond the contemporaneous factors, incorporating a focus on how childhood adversity may negatively influence health behavior, health and wellbeing in later life.

A life-span approach to examining older vulnerable population's subjective well-being: the role of adversity and trauma

OBJECTIVES

Using the life course guidance, the goal of this study was to examine the degree to which previously experienced adversity and trauma was associated with subjective well-being among older adults.

METHODS

Data from the Health and Retirement Study (1992-2012) was used to examine these trends over time. We used multilevel models to test for specific individual change across time. The study sample included older community dwellers aged 55 and over (N = 5,649).

RESULTS

In terms of early childhood adversities, 77% experienced at least one trauma and 72% experienced at least one trauma in adulthood. Adverse childhood experiences and adulthood trauma were predictors of depressive symptoms, poorer self-rated health, and worse life satisfaction. Older black, other race, and Hispanic groups have poorer subjective well-being overtime compared to whites.

CONCLUSION

Findings suggested exposure to childhood adversities and adulthood trauma increases depressive symptoms, poor self-rated health, and low satisfaction of life over time. Findings from this study provide insight into how life course exposure of adversity and trauma among older adults showed a negative trend over time.

Adverse Childhood Experiences among Adults in North Carolina, USA: Influences on Risk Factors for Poor Health across the Lifespan and Intergenerational Implications

Adverse childhood experiences (ACEs) are a critical determinant and predictor of health across the lifespan. The Appalachian region of the United States, particularly the central and southern portions, experiences worse health outcomes when compared to the rest of the nation. The current research sought to understand the cross-sectional relationships between ACEs, social determinants of health and other health risk factors in one southcentral Appalachian state. Researchers used the 2012 and 2014 North Carolina Behavioral Risk Factor Surveillance System (BRFSS) for analyses. An indicator variable of Appalachian county (n = 29) was used to make comparisons against non-Appalachian counties (n = 71). Analyses further examined the prevalence of ACEs in households with and without children across Appalachian and non-Appalachian regions, and the effects of experiencing four or more ACEs on health risk factors. There were no statistically significant differences between Appalachian and non-Appalachian counties in the prevalence of ACEs. However, compared with adults in households without children, those with children reported a higher percentage of ACEs. Reporting four or more ACEs was associated with higher prevalence of smoking (prevalence ratio [PR] = 1.56), heavy alcohol consumption (PR = 1.69), overweight/obesity (PR = 1.07), frequent mental distress (PR = 2.45), and food insecurity (PR = 1.58) in adjusted models and with fair or poor health only outside Appalachia (PR = 1.65). Residence in an Appalachian county was independently associated with higher prevalence of food insecurity (PR = 1.13). Developing programs and implementing policies aimed at reducing the impact of ACEs could improve social determinants of health, thereby helping to reduce health disparities.

The Direct and Indirect Influences of Adverse Childhood Experiences on Physical Health: A Cross-Sectional Study

A growing and significant body of research has documented the close relationship between adverse childhood experiences (ACEs) and health outcomes in adults. Less is known about the complex pathways through which ACEs exert their influence. This article examines the direct relationship between the quality of perceived physical health and childhood adversities. The association between the adversities and the physical health with other psychological and social variables is also analyzed. Data were collected from a sample of 170 subjects, using tools to assess adverse childhood experiences, physical health-related quality of life, socioeconomic vulnerability, emotion regulation, coping strategies, attachment, and social support. Results showed a high frequency of ACEs among the adult population, and the correlation with poor physical health was highly significant. Regression equations to predict physical health also revealed the following as significant variables: wishful thinking, social withdrawal, and cognitive restructuring as coping styles; reappraisal to achieve emotion regulation; fear of rejection or abandonment, and desire for closeness in relation to attachment figures; hardship; and poor financial support. The relationship between the different forms of ACE and social vulnerability identifies the important indirect contribution of childhood adversity to health and socioeconomic conditions in adulthood.

Depression and its association with adverse childhood experiences in people with substance use disorders and comorbid medical illness recruited during medical hospitalization

AIMS

People who have experienced adverse childhood experiences (ACEs) are more susceptible to substance use disorder (SUD) and depression. The present study examined depression prevalence in hospitalized patients with SUD and examined the association of individual ACEs with major depression. Depression rates 3 months after discharge were also examined.

METHODS

Medical inpatients with SUD were recruited from Temple University Hospital. Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9) at baseline and 3 months post-discharge. Participants were also assessed using an ACE scale at baseline.

RESULTS

Of 79 baseline participants, 48% (38) had moderate to severe major depressive disorder (MDD) with PHQ-9 scores ≥15. Among those with baseline MDD, 38% (9/24) continued to have MDD 3 months post discharge, and 42.9% (12/28) of those without MDD at baseline met criteria at 3 months. Sixty-three percent (50/79) of the participants reported 4+ ACEs at baseline. Two ACEs, Household Incarceration and Household Mental Illness, were significantly associated with having MDD at baseline and 3 months (adjusted mean PHQ-9 total score increase (SE) and p-value: 2.97 (1.35), p < .05; 5.32 (1.37), p < .005, respectively).

CONCLUSIONS

In this exploratory study, nearly half of medical inpatients with substance use disorder had moderate to severe major depression, with a similar percentage of participants having MDD as outpatients at 3 months. Approximately two thirds of participants reported four or more adverse childhood experiences at baseline. Inpatient medical hospitalization should be utilized as an opportunity to engage people with SUD in multidisciplinary treatment including psychiatric, trauma informed care, and substance abuse treatment.

Childhood Adversity and Health After Physical Abuse

BACKGROUND

Involvement with Child Protective Services (CPS) provides an opportunity to recognize those children at risk for ongoing adverse childhood experiences (ACEs). The relationship between ACEs and child health among CPS-involved children and the role of primary care providers (PCPs) in moderating this relationship is unknown.

METHODS

We conducted a convergent mixed-methods study of caregivers of children age 2 to 12 years with a CPS finding of physical abuse, modeling the association between cumulative ACEs and child health-related quality of life (HRQoL) using the PedsQL4.0, a validated 23-item survey of multidimensional health, with and without the moderator of a patient-centered medical home. Interviews elicited descriptions of a child's experience with ACEs, the impact of ACEs on child health, and the role of a PCP in this context.

RESULTS

One hundred seventy-eight surveyed caregivers reported a mean of 5.5 (±3.3) ACE exposures per child. In a fully adjusted model, each ACE resulted in a 1.3-point (95% confidence interval: 0.7-2.0) reduction in HRQoL, a clinically important difference in HRQoL associated with ACE exposures. This association was explained by reduced psychosocial HRQoL and was not moderated by a patient-centered medical home. Twenty-seven interviewed caregivers described the influence of ACEs on a child's health. Many felt that a trusted PCP could support a child's well-being after such experiences.

CONCLUSIONS

Children with CPS involvement have ACE exposures that are associated with reduced HRQoL. Although PCPs are often unaware of CPS involvement or other ACEs, many caregivers welcome the support of a child's PCP in improving child well-being after adversity.

Adverse childhood experience and adult persistent pain and disability: protocol for a systematic review and meta-analysis

BACKGROUND

A growing body of research highlights the pervasive harms of adverse childhood experiences (ACEs) on health throughout the life-course. However, findings from prior reviews and recent longitudinal studies investigating the association between types of ACEs and persistent pain have yielded inconsistent findings in the strength and direction of associations. The purpose of this review is to appraise and summarize evidence on the relationship between ACEs and persistent pain and disability outcomes in adulthood. The specific aims are (1) to determine whether there is a relationship between exposure to ACE and persistent pain and disability in adults and (2) to determine whether unique and cumulative ACEs exposures (number and type) increase the risk of developing persistent pain and disability in adulthood.

METHOD

A systematic review and meta-analysis of observational studies will be conducted. Our eligibility criteria are defined following a PECOS approach: population, adults with persistent (≥ 3 months) musculoskeletal and somatoform painful disorders exposed to single or cumulative direct ACEs alone (i.e., physical, sexual, emotional abuse or neglect) or in combination to indirect types of ACE (e.g., parental death, exposure to domestic violence) in the first 18 years of life; comparators, unexposed individuals; outcomes, measurements for persistent pain (≥ 3 months) and disability using discrete and/or continuous measures; and settings, general population, primary care. A comprehensive search of MEDLINE (Ovid) and nine other pertinent databases was conducted from inception to 29 August 2019 using a combination of key words and MeSh terms (the search will be updated prior to conducting the analyses). Pairs of reviewers will independently screen records and full text articles, and a third reviewer will be consulted in cases of disagreement. Data will be extracted using Endnote and Covidence and a meta-analysis will be conducted using Review Manager (RevMan) Version 5.3. The Scottish Intercollegiate Guidelines Network (SIGN) and the Joanna Briggs Institute (JBI) checklists will be used to assess the quality of the included studies. If heterogeneity is high, the findings will be presented in narrative form.

DISCUSSION

The present review will help consolidate knowledge on persistent pain and disability by evaluating whether frequency and type of adverse childhood experiences produces the most harm. Findings may help inform practitioners and policy-makers who endeavor to prevent and/or mitigate the consequences of ACEs and promote healthy development and well-being of children, youth, and families.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020150230.

Effect of the SafeCare© intervention on parenting outcomes among parents in child welfare systems: A cluster randomized trial

Child maltreatment has long-lasting negative impacts, and interventions are needed to improve caregiver's parenting skills to prevent maltreatment. This paper reports on a randomized trial comparing the SafeCare© model to services as usual (SAU) for child-welfare referred caregivers. SafeCare is an 18-session behavioral parenting program that teaches skills in positive parent-child interactions, home safety, and child health. SAU is generally unstructured and includes support, crisis management, referrals for need, and parenting education. Teams of providers at nine sites were randomized to implement SafeCare (19 teams; 119 providers) or continue SAU (17 teams; 118 providers). Two-hundred eighty eight caregivers (193 SafeCare; 95 SAU) with children aged 0-5 who were receiving services agreed to complete a baseline and 6-month assessment. Assessments measured positive parenting behaviors, parenting stress, protective factors, and neglectful behaviors using validated scales. Participants were primarily white (74.6%), female (87.0%), and low-income (68.6%), and had a mean age of 29. Latent change score models (LCSM) using a sandwich estimator consistent with the trial design were used to examine changes in 13 outcomes. Results indicated that SafeCare had small to medium effects for improving several parenting outcomes including supporting positive child behaviors (d = 0.46), proactive parenting (d = 0.25), and two aspects of parenting stress (d = 0.28 and .30). No differential change between groups was found for other indicators, including all indicators of neglect. Parenting programs such as SafeCare offer a promising mode of intervention for child welfare systems. Scale-up of parenting programs can improve parenting, improve child outcomes, and potentially reduce maltreatment. CLINICALTRIAL.GOV REGISTRATION NUMBER: NCT02549287.

Benefit-cost analysis of Promoting First Relationships®: Implications of victim benefits assumptions for return on investment

BACKGROUND

Child abuse and neglect (CAN) cost United States society $136 billion to $428 billion annually. Preventive interventions that reduce CAN may improve people's lives and generate economic benefits to society, but their magnitude is likely to vary greatly with assumptions about victim costs avoided through intervention.

OBJECTIVE

We examined the implications of different assumptions about avoided victim costs in a benefit-cost analysis of Promoting First Relationships® (PFR), a 10-session attachment and strengths-based home visiting intervention.

PARTICIPANTS AND SETTING

Participants were 247 child protection-involved but intact families in Washington State randomized to receive PFR (n = 124) or resource and referral (n = 123).

METHODS

We monetized intervention effects on out-of-home placements and implicit effects on CAN and calculated net present values under three scenarios: (1) benefits from avoided system costs, (2) additional benefits from avoided tangible victim costs, and (3) additional benefits from avoided tangible and intangible quality-of-life victim costs. For scenarios 2 and 3, we varied the CAN effect size and estimated the effect size at which PFR was reliably cost beneficial.

RESULTS

PFR's societal net benefit ranged from $1 (scenario 1) to $5514 - $25,562 (scenario 2) and $7004 - $32,072 (scenario 3) (2014 USD). In scenarios 2 and 3, PFR was reliably cost beneficial at a CAN effect size of approximately -0.25.

CONCLUSIONS

PFR is cost beneficial assuming tangible victim costs are avoided by PFR. Research into the long-term health and economic consequences of reducing CAN in at-risk populations would contribute to comprehensive, accurate benefits models.