Abstract:

Context  Although significant associations of childhood adversities (CAs) with adult mental disorders have been widely documented, associations of CAs with onset and persistence of disorders have not been distinguished. This distinction is important for conceptual and practical purposes.

Objective  To examine the multivariate associations of 12 retrospectively reported CAs with persistence of adult DSM-IV disorders in the National Comorbidity Survey Replication.

Design  Cross-sectional community survey.

Setting  Household population in the United States.

Participants  Nationally representative sample of 5692 adults.

Main Outcome Measures  Recency of episodes was assessed separately for each of 20 lifetime DSM-IV mood, anxiety, disruptive behavior, and substance use disorders in respondents with a lifetime history of these disorders using the Composite International Diagnostic Interview. Predictors of persistence were examined using backward recurrence survival models to predict time since most recent episode controlling for age at onset and time since onset.

Results  The CAs involving maladaptive family functioning (parental mental illness, substance use disorder, criminality, family violence, physical and sexual abuse, and neglect) but not other CAs were significantly but modestly related to persistence of mood, substance abuse, and anxiety disorders. Number of maladaptive family functioning CAs had statistically significant, but again substantively modest, subadditive associations with the same outcomes. Exposure to multiple other CAs was significantly associated with persistence of mood and anxiety disorders. Associations remained statistically significant throughout the life course, although the substantive size of associations indicated by simulations showing time to most recent episode would increase by only 1.6% (from a mean of 8.3 years to a mean of 8.4 years) in the absence of CAs.

Conclusions  The overall statistically significant associations of CAs with adult DSM-IV/Composite International Diagnostic Interview disorders are due largely to component associations with onsets rather than with persistence, indirectly suggesting that the greatest focus of public health attention on CAs should be aimed at primary rather than secondary prevention.

Significant associations between retrospectively reported childhood adversities (CAs) and diverse adult mental disorders have been documented in numerous epidemiological surveys. These associations are substantial, with more than 30% of adult mental disorders estimated to be directly related to CAs. Previous studies have suggested that the associations are due to increased stress sensitivity that persists into adulthood, making individuals with a history of CAs especially vulnerable to mental disorders triggered by adult stressors. If this is the case, we would expect that CAs would be associated with disorder persistence because most adult episode onsets are recurrences rather than first onsets. However, previous epidemiological studies have largely focused on prevalent disorders or lifetime disorders, with no attempt to distinguish associations of CAs with disorder first onset vs persistence. It would be useful to make this distinction to advance our understanding of the associations of CAs with adult mental disorders. A companion article to this one takes a first step in doing this by analyzing data from the National Comorbidity Survey Replication (NCS-R) and showing that the number of CAs is, in fact, associated with first onsets of a wide range of DSM-IV disorders throughout the life course. The present study takes the next logical step in this line of investigation by examining associations of CAs with persistence of the same DSM-IV disorders in the NCS-R.

Although a handful of previous studies have examined the associations of CAs with illness course, the results have been inconsistent. Some of these studies found significant associations of CAs with illness course, whereas others did not. Limitations of these studies are that they used relatively primitive methods to measure and analyze these associations and that they generally focused on a single mental health outcome. We address the first limitation in 2 ways. First, we use a novel statistical approach to examine the separate and joint associations of CAs with disorder persistence to address the fact that CAs are highly co-occurring and that multivariate associations of co-occurring CAs are generally nonadditive. Second, we use an innovative approach to measure illness course based on a special class of survival models known as backward recurrence models. These models allow us to study the associations of CAs with illness course more sensitively than in previous retrospective studies. We address the second limitation by examining associations of CAs with persistence of a wide range of DSM-IV disorders.

Publisher's Version