Pharmacology
Discussion
Adversity and Depression Treatment Disparities
Discussion related to early life adversity’s impact on the development of depression in later life. Student will research methods to improve treatment disparities among children and young adults who experience early adversity.
Read Stern, K. R. & Thayer, Z. M. (2019). Adversity in childhood and young adulthood predicts young adult depression. This is Module 8.
Research on your own to uncover methods to improve statistics found in the attached literature. Post for your peers what you find that could be useful to close the gap and offer potential improvement in the treatment disparity of adversity and its impact on development of depression.
For the Discussion (Include the corresponding number below as you respond in your initial post):
1. What did you take from the literature attached to the discussion board?
2. What literature did you find on your own that might be helpful for this population?
3. What resources and tools would you need to help implement helpful interventions in the primary care setting?
ORIGINAL ARTICLE
Adversity in childhood and young adulthood predicts young adult
depression
Kaija R. Stern1 • Zaneta M. Thayer1
Received: 7 September 2018 / Accepted: 15 June 2019 / Published online: 28 June 2019
� Swiss School of Public Health (SSPH+) 2019
Abstract
Objectives Adversity experience, in both childhood and adulthood, has been associated with the development of
depression. However, it is currently unclear how variation in timing and duration of adversity across childhood and young
adulthood affects the extent of depression symptomology.
Methods Data were analyzed from 2610 individuals from the National Longitudinal Study of Adolescent to Adult Health
in the USA. Adversity in childhood and adulthood was evaluated using instruments similar to the adverse childhood
experiences questionnaire, and associations were assessed by Poisson regression.
Results Any adversity experience was associated with significantly elevated depression symptoms in young adulthood.
Individuals who experienced adversity during both childhood and adulthood had significantly higher depression symptoms
than those experiencing adversity during only childhood or adulthood, suggesting a potential dose–response relationship
between duration of adversity experience and depression symptomology.
Conclusions These results suggest that any adversity experience increases depression symptoms in young adulthood and
that cumulative adversity is particularly detrimental. While long-term interventions to reduce adversity exposure would be
most efficacious, interventions to reduce adversity at any period would still be beneficial.
Keywords Adverse childhood experiences � Cumulative load � Developmental programming � Allostatic load �
Mental health
Introduction
Adverse childhood experiences (ACEs) are known to
contribute to poor health outcomes in later life (Choi et al.
2017; Felitti et al. 1998; Sheikh 2018a, b, c; Thayer et al.
2017). These adversities include distinct traumas such as
abuse or the incarceration of a parent (Anda et al. 2004;
Felitti et al. 1998) or can be part of everyday life, such as
living in poverty or in an area of high neighborhood
violence (Metzler et al. 2017; Wade et al. 2014). ACEs
have been associated with the development of conditions
ranging from diabetes mellitus (Sheikh 2018a, b, c) to
autoimmune diseases (Dube et al. 2009) and frequent
headaches (Anda et al. 2010), among others. One outcome
that has been repeatedly associated with ACEs, and that is
of potential interest from the perspective of public health,
is depression (Chapman et al. 2004; Cheong et al. 2017;
Kim 2017; Remigio-Baker et al. 2014). Factors that influ-
ence depression are important to understand because this
condition often precedes the development of physical
health conditions such as chronic pain (Currie and Wang
2005), ischemic heart disease (Hippisley-Cox et al. 1998),
and type II diabetes (Engum 2007). Understanding how
and why ACEs influence depression could therefore help to
reduce not only depression symptomology, but other health
conditions as well.
Importantly, those who experience ACEs may also be at
risk for trauma exposure in later life (Burke et al. 2011).
Individuals with high ACE scores are more likely to report
Major revision: 27 April 2019.
Minor revision: 04 June 2019.
Electronic supplementary material The online version of this
article (https://doi.org/10.1007/s00038-019-01273-6) con-
tains supplementary material, which is available to autho-
rized users.
& Zaneta M. Thayer
Zaneta.Marie.Thayer@Dartmouth.edu
1
Dartmouth College, Hanover, USA
123
International Journal of Public Health (2019) 64:1069–1074
https://doi.org/10.1007/s00038-019-01273-6(0123456789().,-volV)(0123456789().,- volV)
https://doi.org/10.1007/s00038-019-01273-6
http://crossmark.crossref.org/dialog/?doi=10.1007/s00038-019-01273-6&domain=pdf
https://doi.org/10.1007/s00038-019-01273-6
unemployment, economic stress, psychological distress,
and incompletion of high school than those with lower
ACE scores, and these components can increase the risk of
subsequent trauma exposure and adversity in adulthood
(Metzler et al. 2017; Sheikh 2018a, b, c). The correlation
between childhood and adult adversity exposure is impor-
tant to consider because adult exposure to trauma has been
independently associated with mental and physical health
conditions that have been similarly reported in response to
ACEs (Brumley et al. 2017; Cheval et al. 2019).
Accounting for experiences of adversity in both child-
hood and adulthood is therefore necessary in order to
determine whether increased depression is the result of
adversity experienced during early life, as suggested by
ACE studies, or whether it instead results from cumulative
exposure to adversity in both childhood and adulthood. The
purpose of this study is therefore to determine how varia-
tion in timing and duration of adversity experience relates
to depression symptomology in young adulthood using data
from a nationally representative sample in the USA.
Methods
Data come from Wave I and Wave IV of the National
Longitudinal Study of Adolescent to Adult Health (Add
Health). Add Health participants (grades 7–12) were orig-
inally selected from 132 nationally representative schools
across the USA. A classroom questionnaire was adminis-
tered to an original set of 90,000 students between 1994
and 1995, and approximately 17 students from each school
were randomly selected for an at-home interview, which
occurred in 1995. The current study utilized the publicly
available version of the data sets that includes 6504 indi-
viduals from Wave I (completed in 1998), Wave II, Wave
III, and Wave IV. Of the Wave I respondents, 92.5% were
contacted during Wave IV data collection; 80.3% of these
participants completed the Wave IV questionnaire. Data for
Wave IV, which includes 5114 individuals in the public
data set, were collected in 2008 as an in-home survey. Data
collection was carried out by RTI International, using
computer-assisted self-interviewing instruments. The cur-
rent secondary analysis of data from Add Health was
approved by the Institutional Review Board of Dartmouth
College (Study #30900).
Measures
Adverse childhood experiences
Following a coding scheme created by Brumley et al.
(2017), the following variables extracted from Waves I and
IV were coded to represent either the absence (0 = no
exposure) or presence (1 = exposure) during childhood of:
physical abuse (Wave IV), sexual abuse (Wave IV), par-
ental incarceration (Wave IV), poverty status (Wave I),
community violence (Wave I), neglect (Wave IV), and
parental alcoholism (Wave I) (see Online Resource
Table 1). Individuals were then categorized as having been
exposed to none versus any of those adverse childhood
experiences.
Adverse adulthood experiences
In order to make a direct comparison between adversities in
childhood and adulthood, a similar metric for adverse
adulthood experiences was developed for the Add Health
data set using data from Wave IV (Brumley et al. 2017).
Like ACEs, the following variables were coded to repre-
sent either the absence (0 = no exposure) or presence
(1 = exposure) of: physical abuse, sexual abuse, incarcer-
ation, poverty status, community violence, neglect, and
alcoholism. Individuals were then categorized as having
been exposed to none versus any of those adverse adult-
hood experiences (see Online Resource Table 1).
Depression
Add Health assesses depression symptoms using a modi-
fied version (9 questions) of the Center for Epidemiological
Studies Depression Scale (CES-D). The CES-D is widely
used to measure depression symptoms in population-based
studies. It has been demonstrated to be both consistent and
reliable (Radloff 1977; Zhang et al. 2012). The CES-D
version used in Add Health Wave IV asked individuals to
report the frequency of particular sentiments over a given
period of time (either a month or a week). Each item
ranged from 1 (never) to 4 (always/everyday). These
statements included: ‘‘You felt depressed’’, ‘‘You felt sad’’,
‘‘You felt that people disliked you’’, ‘‘You could not shake
off the blues, even with the help of your family and
friends’’, ‘‘You felt that you were too tired to do things’’,
‘‘You had trouble keeping your mind on what you were
doing,’’ and ‘‘You were bothered by things that don’t
usually bother you’’. In addition, scores for the following
statements were reverse-scored and added to the composite
depressive score: ‘‘You enjoyed life’’ and ‘‘You felt you
were just as good as other people’’. As this study looked at
depression as an outcome in adulthood, only depressive
symptoms from Wave IV were included in this study
(mean participant age 27.7 years). Each depressive symp-
tom was given a dichotomous score (0 = never, 1 = once
or more than once), and these scores were summed to yield
a depression scale ranging from 0 to 9.
1070 K. R. Stern, Z. M. Thayer
123
Covariates
Previous research has found significant associations
between depression and age, sex, self-reported ethnicity,
and education level (Riolo et al. 2005). Thus, these vari-
ables were considered as possible covariates in our model.
Ages (years), sex (male/female), and race/ethnicity (White,
Hispanic, Black, or African-American, American Indian or
Native American, Asian or Pacific Islander, or other) were
extracted from Wave I of the survey. Education level
(college/no college) was assessed during Wave IV.
Data analysis
Statistical analysis was performed in STATA 15.0. We first
investigated bivariate associations between participant
characteristics and exposure to ACEs with Chi-squared
tests (categorical variables) and t-tests (continuous vari-
ables). Adversity categories were then constructed by
separating individuals into four groups: those that had
experienced adversity in neither childhood nor adulthood,
those that experienced adversity only in childhood, those
that experienced adversity only in adulthood, and those that
experienced adversity in both childhood and adulthood. We
then used Poisson regression to predict depression scores
for the adversity categories, with no adversity experience
as the reference group. We calculated both unadjusted and
adjusted models, with the adjusted model controlling for
age, sex, self-reported ethnicity, and education level.
Conventional statistical thresholds were observed
(p \ 0.05).
Results
Sample characteristics and bivariate analysis results are
provided in Table 1. Among individuals included in the
sample, approximately half were female, two-thirds were
White, and approximately one-third had a college degree
by time of the Wave IV questionnaire. Men and college
graduates were significantly less likely to experience
ACEs. Those who experienced ACEs were significantly
more likely to experience adversity in adulthood, and to
have higher depression symptomology. African-Ameri-
cans, American Indians, and Asian Americans were sig-
nificantly more likely to experience ACEs than Whites.
Individuals who experienced adversity in childhood
only, adulthood only, or who experienced cumulative
adversity, had significantly higher depression scores than
those who experienced no adversity at both time points
(Table 2). When comparing differences in depression
scores among the three adversity groups, we found that
individuals in the cumulative adversity group had signifi-
cantly higher depression symptoms relative to childhood-
and adulthood-only adversity groups (Online Resource
Table 2). Although members of the childhood-only
adversity group appeared to have higher depression
symptoms than members of the adulthood-only
adversity
group, this difference was not statistically significant
(Online Resource Table 3).
Discussion
Here, we have assessed whether timing or duration of
adversity exposure in childhood and early adulthood pre-
dicts depression symptoms among young adults from a
nationally representative sample in the USA. Individuals
who experienced adversity in childhood were significantly
more likely to experience adversity in adulthood. Consis-
tent with prior ACEs research, we found that childhood
adversity was associated with significantly higher depres-
sion symptoms in adulthood (Chapman et al. 2004; Cheong
et al. 2017; Honkalampi et al. 2005; Remigio-Baker et al.
2014). However, this work adds to these prior studies by
also assessing adverse experiences in young adulthood.
Similar to those experiencing adversity only in childhood,
those individuals who experienced adversity only in
adulthood had higher depression symptoms than those who
experienced no adversity. Finally, we found that individ-
uals that experienced cumulative adversity had the highest
depression scores, suggesting a potential dose–response
relationship between duration of adversity experience and
depression symptoms.
This study is notable for assessing adversity in both
childhood and early adulthood in relation to depression,
rather than evaluating adversity during childhood or early
adulthood in isolation. In addition, it was conducted among
a nationally representative sample from the USA.
Nonetheless, there are several limitations that must be
acknowledged. First, the included sample size is relatively
small (N = 2610), compared to the entire Add Health study
(N = 5114). There are also several potential issues with a
secondary data analysis. The questions that assessed
adversity during childhood were not entirely consistent in
wording with those assessed during adulthood. That said,
the manner in which ACE questions were paired with
similar, although not always identical, adult adversity
questions is consistent with prior studies that looked at both
childhood and adulthood adversities in this data set
(Brumley et al. 2017). In addition, some variables that
would ideally be controlled for, including parental
depression and childhood depression, were not collected.
Individuals surveyed in Wave IV are young adults (mean
age 27.7 years), and therefore, different patterns of
1071
123
depression could manifest at older ages. However,
depression scores are often correlated across time (Nolen-
Hoeksema and Ahrens 2002), suggesting that individuals
with high depression scores in young adulthood are likely
to exhibit higher depression scores in later life as well.
Finally, our ACE measure is based on one that was
previously published and developed specifically for
assessing ACEs in the Add Health study (Brumley et al.
2017). In this measure, four ACE variables were collected
in Wave IV, simultaneously with adult adversity and
Table 1 Sample characteristics of study participants, comparing those who did and did not have adverse childhood experiences. (United States
2018)
Variables Total sample
(N = 2610)
No
ACE
(N = 1595)
ACE
(N = 1015)
p value
Age (at Wave I); mean (standard deviation) 14.69 (1.76) 14.66 (1.78) 14.74 (1.74) 0.27
Female; n (%) 1462 (56%) 925 (58%) 528 (52%) 0.001
College graduates; n (%) 940 (36%) 702 (44%) 254 (25%) \ 0.001
Ethnicity
White; n (%) 1723 (66%) 1117 (70%) 619 (61%) Reference
African-American; n (%) 548 (21%) 287 (18%) 254 (25%) \ 0.001
American Indian; n (%) 104 (4%) 48 (3%) 51 (5%) 0.001
Asian; n (%) 78 (3%) 64 (4%) 30 (3%) \ 0.001
Other; n (%) 131 (5%) 80 (5%) 61 (6%) 0.008
Experienced adversity in adulthood; n (%) 1253 (48%) 622 (39%) 619 (61%) \ 0.001
Adult depression score (Center for Epidemiologic Studies Depression Scale);
mean (standard deviation)
5.31 (3.86) 4.76 (3.46) 6.17 (4.27) \ 0.001
Mean (standard deviation) values reported for continuous variables, while percentages are presented for categorical variables. Two-tailed t-tests
(continuous variables) and Pearson Chi-squared tests (categorical variables) were used to evaluate differences between individuals with and
without adverse childhood experiences
Table 2 Poisson regression model predicting depression score in adulthood among participants varying in timing and duration of exposure to
adversity. (United States 2018)
Unadjusted model
coefficients
Unadjusted model 95% confidence
intervals
Adjusted model
coefficients
Adjusted model 95% confidence
intervals
No adversity Reference Reference
Childhood
adversity only
0.311 0.259, 0.362 0.292 0.240, 0.344
Adulthood
adversity only
0.250 0.205, 0.295 0.242 0.195, 0.289
Cumulative
adversity
0.426 0.382, 0.469 0.400 0.355, 0.446
Female 0.229 0.195, 0.263
Age – 0.004 – 0.034, 0.005
College graduate 2 0.137 – 0.175, – 0.099
Hispanic 0.054 – 0.332, 0.456
African-American 0.103 0.062, 0.144
American Indian 0.130 0.040, 0.212
Asian 0.249 0.163, 0.334
Other ethnicity 0.106 0.036, 0.180
Adjusted model R
2
0.0234 0.0401
Adjusted model controls for gender, age, education level, and ethnicity, with White, male, and no college graduation used as reference categories
for categorical variables. Bold = p \ 0.01
1072 K. R. Stern, Z. M. Thayer
123
depression scores, as opposed to during Wave I. These
cross-sectionally obtained data are therefore potentially
subject to both recall and mood congruency bias (Zupan
et al. 2017). Mood congruency bias suggests that a par-
ticipant’s current mood will determine the affective
memory being recalled (Elliott et al. 2004). However, the
ACE questions that were asked retrospectively involved
explicit recall, such as parental incarceration, physical
abuse, and sexual abuse, potentially minimizing bias.
Experimental evidence also suggests that individuals with
depression are not more prone to mood congruency (Cheng
et al. 2015). Additional research from an older sample is
needed to verify these results, ideally with questions that
were asked prospectively and identically over multiple
waves.
Conclusions
Studies that assess adversity in both childhood and adult-
hood are needed in order to understand whether timing and
duration of adversity are important in predicting the
development of adverse health outcomes. In this analysis,
we found that individuals who experienced adversity in
childhood, in early adulthood, or at both time points had
significantly higher depression scores in adulthood com-
pared to those who never experienced adversity. In addi-
tion, there was a dose–response relationship between
duration of adversity experience and depression sympto-
mology, with those experiencing adversity in both child-
hood and young adulthood having significantly higher
depression symptoms than those who experienced adver-
sity at only one time point. Additional research among a
sample including middle-aged and elderly adults is needed
to fully understand the effects that adverse experiences
across the life course have on depression.
Compliance with ethical standards
Conflict of interest The authors declare no conflict of interest.
Informed consent Written informed consent was obtained from all
individuals included in this study.
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- Adversity in childhood and young adulthood predicts young adult depression
Abstract
Objectives
Methods
Results
Conclusions
Introduction
Methods
Measures
Adverse childhood experiences
Adverse adulthood experiences
Depression
Covariates
Data analysis
Results
Discussion
Conclusions
References