IMPORTANCE Childhood adversity (CA) is a powerful determinant of long-term physical and mental health that is associated with elevated risk for chronic disease and psychopathology. However, the degree to which CA contributes to mortality as a preventable driver of ill-health and death is unknown.
OBJECTIVE To estimate the contribution of CA to health behaviors, including smoking and sedentary behavior, as well as the annual mortality attributable to CA in the US through influences on leading causes of death (eg, cardiovascular disease).
EVIDENCE REVIEW For this systematic review, the PsycINFO and MEDLINE databases were searched on November 15, 2019. The databases were searched for publications from inception (1806 for PsycINFO, 1946 for MEDLINE) to November 15, 2019. Meta-analyses of the associations between CA and morbidity outcomes were included. The population attributable fraction (PAF) was calculated from these associations along with the estimated US prevalence of CA. The PAF was then applied to the number of annual deaths associated with each cause of death to estimate the number of deaths that are attributable to CA. Additionally, the PAF was applied to the incidence of health behaviors to derive the number of cases attributable to CA. Exposure to 1 or more experiences of adversity before the age of 18 years was analyzed, including abuse, neglect, family violence, and economic adversity.
FINDINGS A total of 19 meta-analyses with 20 654 832 participants were reviewed. Childhood adversity accounted for approximately 439 072 deaths annually in the US, or 15% of the total US mortality in 2019 (2 854 838 deaths), through associations with leading causes of death (including heart disease, cancer, and suicide). In addition, CA was associated with millions of cases of unhealthy behaviors and disease markers, including more than 22 million cases of sexually transmitted infections, 21 million cases of illicit drug use, 19 million cases of elevated inflammation, and more than 10 million cases each of smoking and physical inactivity. The greatest proportion of outcomes attributable to CA were for suicide attempts and sexually transmitted infections, for which adversity accounted for up to 38% and 33%, respectively.
CONCLUSIONS AND RELEVANCE The results of this systematic review suggest that CA is a leading contributor to morbidity and mortality in the US and may be considered a preventable determinant of mortality. The prevention of CA and the intervention on pathways that link these e
Stressful life events (SLEs) are strongly associated with the emergence of adolescent anxiety and depression, but the underlying mechanisms remain poorly understood, especially at the within-persons level. We investigated how adolescent social communication (i.e., frequency of calls and texts) following SLEs relates to changes in internalizing symptoms in a multitimescale, intensive, year-long study (N = 30; n = 355 monthly observations; n ≈ 5,000 experiencesampling observations). Within-persons increases in SLEs were associated with receiving more calls than usual at both the month and moment levels and making more calls at the month level. Increased calls were prospectively associated with worsening internalizing symptoms at the month level only, suggesting that SLEs rapidly influence phone communication patterns, but these communication changes may have a more protracted, cumulative influence on internalizing symptoms. Finally, increased incoming calls prospectively mediated the association between SLEs and anxiety at the month level. We identify adolescent social communication fluctuations as a potential mechanism conferring risk for stress-related internalizing psychopathology
We review the three prevailing approaches—specificity, cumulative risk, and dimensional models—to conceptualizing the developmental consequences of early-life adversity and address fundamental problems with the characterization of these frameworks in a recent Perspectives on Psychological Science piece by Smith and Pollak. We respond to concerns raised by Smith and Pollak about dimensional models of early experience and highlight the value of these models for studying the developmental consequences of early-life adversity. Basic dimensions of adversity proposed in existing models include threat/harshness, deprivation, and unpredictability. These models identify core dimensions of early experience that cut across the categorical exposures that have been the focus of specificity and cumulative risk approaches (e.g., abuse, institutional rearing, chronic poverty); delineate aspects of early experience that are likely to influence brain and behavioral development; afford hypotheses about adaptive and maladaptive responses to different dimensions of adversity; and articulate specific mechanisms through which these dimensions exert their influences, conceptualizing experience-driven plasticity within an evolutionary-developmental framework. In doing so, dimensional models advance specific falsifiable hypotheses, grounded in neurodevelopmental and evolutionary principles, that are supported by accumulating evidence and provide fertile ground for empirical studies on early-life adversity.
Childhood exposure to violence is strongly associated with psychopathology. High resting respiratory sinus arrhythmia (RSA) is associated with lower levels of psychopathology in children exposed to violence. High RSA may help to protect against psychopathology by facilitating fear extinction learning, allowing more flexible autonomic responses to learned threat and safety cues. In this study, 165 youth (79 female, aged 9–17; 86 exposed to violence) completed assessments of violence exposure, RSA, and psychopathology, and a fear extinction learning task; 134 participants returned and completed psychopathology assessments 2 years later. Resting RSA moderated the longitudinal association of violence exposure with post-traumatic stress disorder (PTSD) symptoms and externalizing psychopathology, such that the association was weaker among youths with higher RSA. Higher skin conductance responses (SCR) during extinction learning to the threat cue (CS+) was associated with higher internalizing symptoms at follow-up and greater SCR to the safety cue (CS–) was associated with higher PTSD, internalizing, and externalizing symptoms, as well as the p-factor, controlling for baseline symptoms. Findings suggest that higher RSA may protect against emergence of psychopathology among children exposed to violence. Moreover, difficulty extinguishing learned threat responses and elevated autonomic responses to safety cues may be associated with risk for future psychopathology.
COVID-19 presents significant social, economic, and medical challenges. Because COVID-19 has already begun to precipitate huge increases in mental health problems, clinical psychological science must assert a leadership role in guiding a national response to this secondary crisis. In this article, COVID-19 is conceptualized as a unique, compounding, multidimensional stressor that will create a vast need for intervention and necessitate new paradigms for mental health service delivery and training. Urgent challenge areas across developmental periods are discussed, followed by a review of psychological symptoms that likely will increase in prevalence and require innovative solutions in both science and practice. Implications for new research directions, clinical approaches, and policy issues are discussed to highlight the opportunities for clinical psychological science to emerge as an updated, contemporary field capable of addressing the burden of mental illness and distress in the wake of COVID-19 and beyond.
The COVID-19 pandemic has introduced novel stressors into the lives of youth. Identifying factors that protect against the onset of psychopathology in the face of these stressors is critical. We examine a wide range of factors that may protect youth from developing psychopathology during the pandemic. We assessed pandemic-related stressors, internalizing and externalizing psychopathology, and potential protective factors by combining two longitudinal samples of children and adolescents (N = 224, 7–10 and 13–15 years) assessed prior to the pandemic, during the stay-at-home orders, and six months later. We evaluated how family behaviors during the stay-at-home orders were related to changes in psychopathology during the pandemic, identified factors that moderate the association of pandemic-related stressors with psychopathology, and determined whether associations varied by age. Internalizing and externalizing psychopathology increased substantially during the pandemic. Higher exposure to pandemic-related stressors was associated with increases in internalizing and externalizing symptoms early in the pandemic and six months later. Having a structured routine, less passive screen time, lower exposure to news media about the pandemic, and to a lesser extent more time in nature and getting adequate sleep were associated with reduced psychopathology. The association between pandemic-related stressors and psychopathology was reduced for youths with limited passive screen time and was absent for children, but not adolescents, with lower news media consumption related to the pandemic. We provide insight into simple, practical steps families can take to promote resilience against mental health problems in youth during the COVID-19 pandemic and protect against psychopathology following pandemic-related stressors.
IMPORTANCE Many studies have demonstrated an association between early-life adversity (ELA) and executive functioning in children and adolescents. However, the aggregate magnitude of this association is unknown in the context of threat and deprivation types of adversity and various executive functioning domains.
OBJECTIVE To test the hypothesis that experiences of deprivation are more strongly associated with reduced executive functioning compared with experiences of threat during childhood and adolescence.
DATA SOURCES Embase, ERIC, MEDLINE, and PsycInfo databases were searched from inception to December 31, 2020. Both forward and reverse snowball citation searches were performed to identify additional articles.
STUDY SELECTION Articles were selected for inclusion if they (1) had a child and/or adolescent sample, (2) included measures of ELA, (3) measured executive functioning, (4) evaluated the association between adversity and executive functioning, (5) were published in a peer-reviewed journal, and (6) were published in the English language. No temporal or geographic limits were set. A 2-reviewer, blinded screening process was conducted.
DATA EXTRACTION AND SYNTHESIS PRISMA guidelines were used to guide data extraction and article diagnostics (for heterogeneity, small study bias, and p-hacking). Article quality was assessed, and data extraction was performed by multiple independent observers. A 3-level meta-analytic model with a restricted maximum likelihood method was used. Moderator analyses were conducted to explore heterogeneity.
MAIN OUTCOMES AND MEASURES Primary outcomes included measures of the 3 domains of executive functioning: cognitive flexibility, inhibitory control, and working memory.
RESULTS A total of 91 articles were included, representing 82 unique cohorts and 31 188 unique individuals. Deprivation, compared with threat, was associated with significantly lower inhibitory control (F1,90 = 5.69; P = .02) and working memory (F1,54 = 5.78; P = .02). No significant difference was observed for cognitive flexibility (F1,36 = 2.38; P = .12). The pooled effect size of the association of inhibitory control with deprivation was stronger (Hedges g = −0.43; 95% CI, −0.57 to −0.29) compared with threat (Hedges g = −0.27; 95% CI, −0.46 to −0.08). The pooled effect size of the association of working memory with deprivation was stronger (Hedges g = −0.54; 95% CI, −0.75 to −0.33) compared with threat (Hedges g = −0.28; 95% CI, −0.51 to −0.05).
CONCLUSIONS AND RELEVANCE Experiences of both threat and deprivation in childhood and adolescence were associated with reduced executive functioning, but the association was stronger for exposure to deprivation. Efforts to address the consequences of ELA for development should consider the associations between specific dimensions of adversity and specific developmental outcomes.
The ability to identify and label one’s emotions is associated with effective emotion regulation, rendering emotional awareness important for mental health. We evaluated how emotional awareness was related to psychopathology and whether low emotional awareness was a transdiagnostic mechanism explaining the increase in psychopathology during the transition to adolescence and as a function of childhood trauma—specifically, violence exposure. In Study 1, children and adolescents (N = 120, age range = 7–19 years) reported on emotional awareness and psychopathology. Emotional awareness was negatively associated with psychopathology (p-factor) and worsened across age in females but not males. In Study 2 (N = 262, age range = 8–16 years), we replicated these findings and demonstrated longitudinally that low emotional awareness mediated increases in p-factor as a function of age in females and violence exposure. These findings indicate that low emotional awareness may be a transdiagnostic mechanism linking adolescent development, sex, and trauma with the emergence of psychopathology.
Adolescence is a period of increased vulnerability for internalizing problems,
particularly following exposure to stressful life events. We examine how patterns of emotion regulation and brain structure and function predict internalizing problems during the COVID-19 pandemic, as well as moderate the association between pandemic-related stressors andvinternalizing problems.
Data are from a longitudinal sample (N=145, aged 10-15) strategically assessed at three crucial timepoints: prior to the pandemic, early during the stay-at-home order period, and again six months later. We examined associations of neural structure and function during an emotional processing task prior to the pandemic, use of emotion regulation strategies prior to and during the pandemic, and pandemic-related stressors with internalizing problems.
Greater exposure to pandemic-related stressors was associated with higher levels of internalizing symptoms both early (ß = .437, p<.001) and later (ß = .225, p = .004) in the pandemic. Youth who reported more frequent use of maladaptive emotion regulation strategies, including rumination (ß = .204,p = .026) and expressive suppression (ß = .177, p = .023), also had higherinternalizing problems. Higher left amygdala activation to neutral relative to fearful faces prior tothe pandemic was associated with greater internalizing symptoms (ß =-.229, p = .007), and astrongerrelation between pandemic-related stressors and internalizing problems (ß = -.186, p = .014).
Pandemic-related stressors are strongly associated with internalizing problems in adolescents, and individual differences in emotional reactivity and regulation and their underlying neural mechanisms contribute to stress-related vulnerability. Interventions that reduce pandemic-related stressors and foster adaptive emotion regulation skills may protect against adolescent psychopathology during this period of heightened exposure to stress.
The ability to regulate emotions is key to goal attainment and well-being. Although much has been discovered about neurodevelopment and the acquisition of emotion regulation, very little of this work has leveraged information encoded in whole-brain networks. Here we employed a network neuroscience framework to parse the neural underpinnings of emotion regulation skill acquisition, while accounting for age, in a sample of children and adolescents (N = 70, 34 female, aged 8–17 years). Focusing on three key network metrics—network differentiation, modularity, and community number differences between active regulation and a passive emotional baseline—we found that the control network, the default mode network, and limbic network were each related to emotion regulation ability while controlling for age. Greater network differentiation in the control and limbic networks was related to better emotion regulation ability. With regards to network community structure (modularity and community number), more communities and more crosstalk between modules (i.e., less modularity) in the control network were associated with better regulatory ability. By contrast, less crosstalk (i.e., greater modularity) between modules in the default mode network was associated with better regulatory ability. Together, these findings highlight whole-brain connectome features that support the acquisition of emotion regulation in youth.
Spanking remains common around the world, despite evidence linking corporal punishment to detrimental child outcomes. This study tested whether children (Mage = 11.60) who were spanked (N = 40) exhibited altered neural function in response to stimuli that suggest the presence of an environmental threat compared to children who were not spanked (N = 107). Children who were spanked exhibited greater activation in multiple regions of the medial and lateral prefrontal cortex (PFC), including dorsal anterior cingulate cortex, dorsomedial PFC, bilateral frontal pole, and left middle frontal gyrus in response to fearful relative to neutral faces compared to children who were not spanked. These findings suggest that spanking may alter neural responses to environmental threats in a manner similar to more severe forms of maltreatment.
The association between low socioeconomic status (SES) in childhood and increased risk for psychopathology is well established, but the mechanisms explaining this relationship are poorly understood. Here, we investigate the potential role of difficulties in executive functioning (EF) as a mechanism linking childhood and adolescent SES with externalizing and internalizing psychopathology.
We examined whether difficulties with EF mediated the association between SES and externalizing and internalizing psychopathology in two cross-sectional samples of children and adolescents (Study 1: N = 94, ages 6–18, 51.1% male; Study 2: N = 259, ages 8–16, 54.1% male) from diverse SES backgrounds in the United States. EF was measured through behavioral tasks and parent-reported behavioral regulation (BR).
In both samples, children and adolescents from lower SES families were more likely to experience both externalizing and internalizing psychopathology than youth from more advantaged backgrounds and exhibited greater EF difficulties – they had lower performance on a task measuring inhibitory control and lower parent-rated BR. Reduced inhibitory control and BR, in turn, were associated with higher externalizing and internalizing psychopathology. In Study 1, difficulties with BR mediated the association of low-SES with both externalizing and internalizing psychopathology. In Study 2, low inhibitory control mediated the association between low-SES and externalizing psychopathology. These findings largely persisted after adjusting for exposure to violence, a form of adversity that is common in children from low-SES backgrounds.
These findings suggest that reduced EF may be an underlying mechanism through which low-SES confers risk for psychopathology in children and adolescents.
Exposure to childhood adversity is a powerful risk factor for psychopathology. Despite extensive efforts, we have not yet identified effective or scalable interventions that prevent the emergence of mental health problems in children who have experienced adversity. In this modified Delphi study, we identified intervention strategies for effectively targeting both the neurodevelopmental mechanisms linking childhood adversity and psychopathology – including heightened emotional reactivity, difficulties with emotion regulation, blunted reward processing, and social information processing biases, as well as a range of psychopathology symptoms. We iteratively synthesized information from experts in the field and relevant meta-analyses through three surveys, first with experts in intervention development, prevention, and childhood adversity (n = 32), and then within our study team (n = 8). The results produced increasing stability and good consensus on intervention strategy recommendations for specific neurodevelopmental mechanisms and symptom presentations and on strength of evidence ratings of intervention strategies targeting youth and parents. More broadly, our findings highlight how intervention decision making can be informed by meta-analyses, enhanced by aggregate group feedback, saturated before consensus, and persistently subjective or even contradictory. Ultimately, the results converged on several promising intervention strategies for prevention programming with adversity-exposed youth, which will be tested in an upcoming clinical trial.
Stressful life events (SLEs) are strongly associated with the emergence of adolescent anxiety and depression, but the underlying mechanisms remain poorly understood, especially at the within-persons level. We investigated how adolescent social communication (i.e., frequency of calls and texts) following SLEs relates to changes in internalizing symptoms in a multitimescale, intensive, year-long study (N = 30; n = 355 monthly observations; n ≈ 5,000 experience-sampling observations). Within-persons increases in SLEs were associated with receiving more calls than usual at both the month and moment levels and making more calls at the month level. Increased calls were prospectively associated with worsening internalizing symptoms at the month level only, suggesting that SLEs rapidly influence phone communication patterns, but these communication changes may have a more protracted, cumulative influence on internalizing symptoms. Finally, increased incoming calls prospectively mediated the association between SLEs and anxiety at the month level. We identify adolescent social communication fluctuations as a potential mechanism conferring risk for stress-related internalizing psychopathology.
There is a strong positive association between childhood socioeconomic status (SES) and academic achievement. This disparity may, in part, be explained by differences in early environmental experiences and language development. Cognitive stimulation—including language exposure, access to learning materials, caregiver involvement in children’s learning, and variety of experiences—varies by SES and may link SES to language development. Childhood language development in turn is associated with academic achievement. In the current longitudinal study of 101 children (60–75 months), SES was positively associated with cognitive stimulation and performance on language measures. Cognitive stimulation mediated the association between SES and children’s language. Furthermore, children’s language mediated the association between SES and academic achievement 18 months later. In addition to addressing broader inequalities in access to resources that facilitate caregivers’ abilities to provide cognitive stimulation, cognitive stimulation itself could be targeted in future interventions to mitigate SES-related disparities in language and academic achievement.
Adolescents exposed to violence are at elevated risk of developing most forms of psychopathology, including depression, anxiety, and alcohol abuse. Prior research has identified emotional reactivity and difficulties with emotion regulation as core mechanisms linking violence exposure with psychopathology. Scant research has examined behavioral responses to distress as a mechanism in this association. This study examined the association of violence exposure with distress tolerance—the ability to persist in the face of distress—and whether lower distress tolerance linked violence exposure with subsequent increases in depression, anxiety, and alcohol abuse problems during adolescence. Data were collected prospectively in a sample of 287 adolescents aged 16–17 (44.3% male; 40.8% White). At Time 1, participants provided self-report of demographics, violence exposure, and psychopathology, and completed a behavioral measure of distress tolerance, the Paced Auditory Serial Addition Task. Four months later, participants (n = 237) repeated the psychopathology assessments. Violence exposure was associated with lower distress tolerance (β = -.21 p = .009), and elevated concurrent psychopathology (β = .16-.45, p = .001-.004). Low distress tolerance was prospectively associated with greater likelihood of abusing alcohol over time (OR = .63, p = .021), and mediated the association between violence exposure and greater levels (β = .02, 95% CI [.001, .063]) and likelihood (OR = .03, 95% CI [.006, .065]) of alcohol use over time. In contrast, low distress tolerance was not associated concurrently or prospectively with internalizing symptoms. Results persisted after controlling for socio-economic status. Findings suggest that distress tolerance is shaped by early experiences of threat and plays a role in the association between violence exposure and development of problematic alcohol use in adolescence.
Exposure to stressful life events is strongly associated with internalizing psychopathology, and identifying factors that reduce vulnerability to stress-related internalizing problems is critical for development of early interventions. Drawing on research from affective science, we tested whether high emotion differentiation—the ability to specifically identify one’s feelings—buffers adolescents from developing internalizing symptoms when exposed to stress. Thirty adolescents completed a laboratory measure of emotion differentiation before an intensive yearlong longitudinal study in which exposure to stress and internalizing problems were assessed at both the moment level (n = 4,921 experience-sampling assessments) and month level (n = 355 monthly assessments). High negative and positive emotion differentiation attenuated moment-level coupling between perceived stress and feelings of depression, and high negative emotion differentiation eliminated month-level associations between stressful life events and anxiety symptoms. These results suggest that high emotion differentiation buffers adolescents against anxiety and depression in the face of stress, perhaps by facilitating adaptive emotion regulation.
Attention biases to emotion are associated with symptoms of internalizing and externalizing psychopathology in children and adolescents. It is unknown whether attention biases to emotion and their associations with different symptoms of psychopathology vary across development from early childhood through young adulthood. We examine this age-related variation in the current study. Participants (N = 190; ages: 4–25) completed survey-based psychopathology symptom measures and a dot-probe task to assess attention bias to happy, sad, and angry relative to neutral faces. We tested whether linear or non-linear (e.g., spline-based models) associations best characterized age-related variation in attention to emotion. We additionally examined whether attention biases were associated with depression, anxiety, and externalizing symptoms and whether these associations varied by age. No age-related differences in attention biases were found for any of the emotional faces. Attention biases were associated with psychopathology symptoms, but only when examining moderation by age. Biased attention to angry faces was associated with greater symptoms of anxiety and depression in adolescents and young adults, but not children. Similarly, biased attention to happy faces was associated with externalizing symptoms in adolescents and young adults, but not in children. In contrast, biased attention to happy faces was associated with greater anxiety symptoms in children, but not in adolescents or young adults. Biased attention toward social threat and reward becomes more strongly coupled with internalizing and externalizing symptoms, respectively, during the transition to adolescence. These findings could inform when interventions such as attention bias modification training may be most effective.
The depression gap refers to higher rates of depression among women than men. Change in the depression gap over time may elucidate social causes of this disparity—such as unequal college attendance or employment status. We conducted a meta-regression analysis to estimate variation in the depression gap over time by age, accounting for potential sources of variation between studies. Electronic databases and bibliographies were searched for English language studies from January 1980–October 2019. 144 independent estimates from United States-representative samples met selection criteria (n=813,189). The depression gap was summarized as prevalence ratios (PR) among studies using diagnostic instruments, and standardized mean differences among symptom-based studies. Primary study measures were baseline study year (range: 1982-2017), and age (range: 10-60+). Compared with respondents ages 60+, depression prevalence was greater among respondents aged 10-19 (PR=1.26; 95% CI=1.02, 1.56). Over time, the depression gap did not change among adults, but increased among adolescents (age by time interaction PR=1.05; 95% CI=1.01, 1.08). Results were similar for symptom-based studies. The present study finds no evidence of a change in the depression gender gap for US adults, however, the gap increased among adolescents. Greater attention to factors driving this widening disparity in adolescent depression is needed.
Although increasing numbers of children have socially transitioned to live in line with their gender identities, little is known about factors associated with their wellbeing. This study examines the associations between parent-reported family, peer, and school support for a youth’s gender identity, as well as an objective measure of state-level support, with parent-reported internalizing symptoms in 265 transgender youth (67.2% transgender girls, 32.8% transgender boys), ages 3–15 years (M = 9.41, SD = 2.62). Parents who reported higher levels of family, peer, and school support for their child’s gender identity also reported fewer internalizing symptoms; the objective measure of state-level support was not related to internalizing symptoms. Additionally, peer and school support buffered against the association between gender-related victimization and internalizing symptoms, as reported by parents. This work demonstrates that even among transgender youth with families who supported their transitions, parents see better well-being in their children when they also see more support for the child’s gender identity from family, peers, and schools.