Abstract:

Context  Although significant associations of childhood adversities (CAs) with adult mental disorders have been documented consistently in epidemiological surveys, these studies generally have examined only 1 CA per study. Because CAs are highly clustered, this approach results in overestimating the importance of individual CAs. Multivariate CA studies have been based on insufficiently complex models.

Objective  To examine the joint associations of 12 retrospectively reported CAs with the first onset of DSM-IV disorders in the National Comorbidity Survey Replication using substantively complex multivariate models.

Design  Cross-sectional community survey with retrospective reports of CAs and lifetime DSM-IV disorders.

Setting  Household population in the United States.

Participants  Nationally representative sample of 9282 adults.

Main Outcome Measures  Lifetime prevalences of 20 DSM-IV anxiety, mood, disruptive behavior, and substance use disorders assessed using the Composite International Diagnostic Interview.

Results  The CAs studied were highly prevalent and intercorrelated. The CAs in a maladaptive family functioning (MFF) cluster (parental mental illness, substance abuse disorder, and criminality; family violence; physical abuse; sexual abuse; and neglect) were the strongest correlates of disorder onset. The best-fitting model included terms for each type of CA, number of MFF CAs, and number of other CAs. Multiple MFF CAs had significant subadditive associations with disorder onset. Little specificity was found for particular CAs with particular disorders. Associations declined in magnitude with life course stage and number of previous lifetime disorders but increased with length of recall. Simulations suggest that CAs are associated with 44.6% of all childhood-onset disorders and with 25.9% to 32.0% of later-onset disorders.

Conclusions  The fact that associations increased with length of recall raises the possibility of recall bias inflating estimates. Even considering this, the results suggest that CAs have powerful and often subadditive associations with the onset of many types of largely primary mental disorders throughout the life course.

Significant associations between retrospectively reported childhood adversities (CAs) and adult illness have been documented in numerous studies. The first such studies focused on only a single CA, such as parental death or neglect, and 1 mental disorder, most often depression. Subsequent studies showed that retrospectively reported CAs are often highly clustered, requiring examination of multiple CAs to avoid overestimating associations involving particular CAs. These studies also found that CAs are often nonspecific in their associations with many different mental disorders, making it useful to examine multiple outcomes to avoid overly narrow interpretations.

Subsequent studies created summary CA scales and documented dose-response relationships with adult outcomes. However, such indices implicitly assumed that each CA has the same effect and that joint effects are additive. These assumptions are almost certainly incorrect. Indeed, a preliminary examination of these assumptions in the National Comorbidity Survey (NCS) showed that some CAs have stronger associations with adult outcomes than do others and that joint associations are nonadditive. That study also found that these associations sometimes attenuate with age, a specification generally, but not always, ignored in subsequent studies.

The present study builds on these earlier NCS findings by analyzing the CAs assessed in the NCS Replication (NCS-R). Associations between retrospectively reported CAs and mental disorders can be upwardly biased owing to recall failure, nevertheless, it is useful to examine associations based on such retrospective data because they provide upper estimates that avoid the problem of downward bias due to systematic sample attrition in estimates based on long-term prospective data. We examine associations of CAs with the first onset of diverse DSM-IV disorders based on several competing multivariate models. A companion study examines associations of CAs with lifetime persistence of the same disorders.

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