Adverse childhood experiences, mental health, and excessive alcohol use: Examination of race/ethnicity and sex differences

Abstract

Responses from N = 60,598 interviews from the 2010 Behavioral Risk Factor Surveillance System (the 10 states and the District of Columbia that included the optional Adverse Childhood Experience (ACE) module) were used to test whether associations between childhood adversity and adult mental health and alcohol behaviors vary by race/ethnicity and sex. ACE items were categorized into two types – household challenges and child abuse. Outcomes were current depression, diagnosed depression, heavy drinking and binge drinking. Logistic regression models found ACEs significantly associated with depression and excessive alcohol use, but sex did not moderate any relationships. Race/ethnicity moderated the relationship between ACEs and heavy drinking. In stratified analyses, compared to those not exposed to ACEs, non-Hispanic blacks who experienced either type of ACE were about 3 times as likely to drink heavily; Non-Hispanic whites who experienced child abuse or both ACE types were 1.5–2 times as likely to drink heavily; and Hispanics who experienced household challenges or both ACE types were 1.2 and 11 times as likely to report heavy drinking. ACEs impact depression and excessive alcohol use similarly across men and women. With the exception of heavy drinking, ACEs appear to have the same association with excessive alcohol use across race/ethnicity. It may be prudent to further investigate why the relationship between ACEs and heavy drinking may differ by race/ethnicity such that prevention strategies can be developed or refined to effectively address the needs of all sub-groups.

Introduction

Identifying, understanding, and addressing factors associated with inequitable distribution of health risks and problems, including various forms of violence, is a leading principle that undergirds the field of public health. Understanding factors that place groups at greater risk for poor outcomes can inform development of effective prevention and intervention strategies and help assure that limited resources are used efficiently while addressing the needs of the most vulnerable. With regard to mental health and alcohol use problems a significant amount of evidence exists which indicates that outcomes differ by both sex and race/ethnicity. The current study, thus, aims to further understanding regarding these differences.

Studies have indicated that males are at increased risk for heavy drinking and binge drinking; while females are at increased risk for mental health conditions, such as depression (Hasin, Goodwin, Stinson, & Grant, 2005; Wittchen, Zhao, Kessler, & Eaton, 1994). Additionally, studies have indicated that whites are more likely than racial/ethnic minorities to consume alcohol, engage in at risk alcohol use (Keyes et al., 2015) and to have mood disorders (Hasin et al., 2005; Kessler, Berglund, Demler, & et al., 2003; Williams, González, Neighbors, & et al., 2007). Research also reveals that though some racial/ethnic minorities tend to consume less alcohol they are at greater risk of experiencing substance abuse or dependence (Mulia, Ye, Greenfield, & Zemore, 2009; Witbrodt, Mulia, Zemore, & Kerr, 2014; Zapolski, Pedersen, McCarthy, & Smith, 2014).

A number of factors, from many levels of the social ecology, may influence the processes that give rise to these differences. Given adverse childhood experiences (ACEs) are known to be associated with increased risk of these negative outcomes, one potential explanation may be that the sexes and individuals from different race/ethnic groups are differentially exposed to ACEs and that this may give rise to disparities in mental health and alcohol use outcomes. ACE measures traditionally include different types of child abuse and neglect and several household related challenges (e.g., parental mental health and intimate partner violence, household member incarceration and etc.). Given that racial/ethnic minorities have faced historic and contemporary processes of discrimination that have increased the odds of exposure to social and economic disadvantage (Darity, 2005), and that poverty is highly correlated with child abuse and neglect (Su et al., 2015), it is reasonable to expect that studies would indicate that racial/ethnic minorities would experience higher ACE burden than other groups. Similarly, structural factors may also place females at greater risk of ACE exposure. Certain structural factors (e.g., gender pay inequity) and social norms (e.g., norms not supportive of gender equity; hostile attitudes towards women) may contribute to development of environments that offer female as compared to male children more risk for, or less protection against adversities (Graham-Bermann & Brescoll, 2000; Lansford, Deater-Deckard, Bornstein, Putnick, & Bradley, 2014). Given research has demonstrated that higher ACE exposure is associated with poorer health outcomes (Felitti et al., 1998, Gilbert et al., 2015) it is important to further understanding of population sub-group differences in the burden of ACEs by sex and race/ethnicity and potential differential impact of ACEs on mental health and excessive alcohol use.

Early ACE research, utilizing a clinic based sample in a single state, indicated women more frequently reported ACEs, but did not specify whether differences were statistically significant (Anda et al., 1999). More recent survey based research with representative data from a limited number of states indicates that men and women have similar prevalence of many ACEs. Noted differences include women more frequently report sexual abuse, substance abuse and mental illness in the home, and multiple ACEs (CDC, 2010, Cunningham et al., 2014); and men more frequently report exposure to verbal abuse (Cunningham et al., 2014). The limited extant research on racial/ethnic differences in ACEs is mixed. The few studies that assess differences consistently indicate that compared to non-Hispanic whites, non-Hispanic blacks and Hispanics more often report multiple ACEs (CDC, 2010, Gilbert et al., 2015). One study though indicates non-Hispanic blacks report the lowest prevalence on most ACEs (CDC, 2010); while another study indicates non-Hispanic blacks and Hispanics compared to non-Hispanic whites more frequently report ACEs that are not necessarily directed at the child but are reflective of challenges that exist in the household (Lee and Chen, in progress).

Numerous studies have linked adverse childhood experiences to poor mental health outcomes (Afifi, Boman, Fleisher, & Sareen, 2009; Afifi et al., 2008, Anda et al., 2002, Chapman et al., 2004, Dube et al., 2001; Edwards, Holden, Felitti, & Anda, 2003; Isohookana, Riala, Hakko, & Räsänen, 2012; Lu, Mueser, Rosenberg, & Jankowski, 2008; Schilling, Aseltine, & Gore, 2007; Schilling et al., 2008; Stein, Leslie, & Nyamathi, 2002; Young, Abelson, Curtis, & Nesse, 1997) and problem substance use behaviors, motives, and outcomes in adulthood (Afifi et al., 2009, Anda et al., 2007, Anda et al., 2002, Chung et al., 2010, Douglas et al., 2010; Dube, Anda, Felitti, Edwards, & Croft, 2002; Dube et al., 2003, Dube et al., 2006, Felitti et al., 1998; Rothman, Edwards, Heeren, & Hingson, 2008; Stein et al., 2002). Additionally, a number of studies have linked individual and combined adversities to adolescent outcomes, such as early initiation of alcohol use, binge drinking, and heavy episodic drinking (Dube et al., 2006, Rothman et al., 2008; Shin, Edwards, & Heeren, 2009). Evidence regarding mediators of relationships between adversities and such outcomes in adolescence and adulthood is currently limited. An understanding of factors that moderate such relationships is also lacking as studies have rarely examined race/ethnicity and sex differences in the impact of ACEs on these outcomes. Furthermore, the limited extant research primarily focuses on assessing sex differences and findings have been mixed.

For example, a community-based study of childhood adversity that drew its sample from public schools in a major U.S. metropolitan area cautiously reports (because the number of male students that reported sexual victimization was small) that among these youth sexual abuse was more detrimental to male than female depression and drug use (Schilling et al., 2007). Another study conducted in northern Europe suggests accumulation of ACEs (i.e., experiencing three or more) increases the risk of hopelessness in women, but not men (Haatainen et al., 2003). A study utilizing a community based U.S. urban sample did not detect sex differences in the relationship between ACEs and mental health and substance use outcomes (Mersky, Topitzes, & Reynolds, 2013). In contrast, a study on race/ethnicity and sex differences that utilized a sample from male and female correctional facilities in the U.S. found associations between sexual abuse and depression were stronger for men and greatest for non-Hispanic black men; while net of exposure to several types of ACEs, non-Hispanic Blacks and Hispanics were significantly less depressed than non-Hispanic white men and women (Roxburgh & MacArthur, 2014). The only other study we are aware of that identifies racial/ethnic differences in ACE impact reports associations between parental alcohol or drug use and cumulative ACEs (i.e., experiencing five or more) and depression among non-Hispanic whites but not non-Hispanic blacks or Hispanics (Schilling et al., 2007). Since the few studies on sex and race/ethnic specific associations of ACEs, mental health, and substance use problems lack consistency – utilize very different samples (e.g., U.S. metropolitan area school district, urban, and correctional samples as well as a European community based sample), assess different outcomes (e.g., hopelessness, depression, alcohol use, and drug use) – and offer mixed findings, both with respect to sex and race/ethnicity, additional research is needed to better understand whether these factors moderate the impact of ACEs on these outcomes. As strategies regarding how best to intervene and or prevent early and long-term implications of ACEs on mental health and alcohol use are developed and refined, they should also build on what is known about whether sex and race/ethnicity act as moderators. Such information may help inform whether and in what ways strategies should focus on the needs of population sub-groups.

Additionally, studies on ACEs have typically examined individual and cumulative effects of ACEs as compared to the impacts of direct forms of adversity (e.g., experiences directed at the child – child abuse) and indirect forms of adversity (e.g., experiences within the household that can affect the child – household challenges). A significant number of studies on ACEs have also relied on clinic-based samples (Afifi et al., 2008, Anda et al., 2007, Chapman et al., 2004, Chung et al., 2010, Dube et al., 2001, Dube et al., 2002, Dube et al., 2003, Dube et al., 2006, Lu et al., 2008, Young et al., 1997). Thus, to address gaps in the current literature we will utilize data from the largest, on-going, U.S. state-based, random digit dialed health survey system, the Behavioral Risk Factor Surveillance System (BRFSS), which in recent years has included an optional ACE module. Namely, the current paper will examine whether: (1) relationships between ACEs and outcomes such as depression and excessive alcohol use differ by race/ethnicity and sex; and (2) impacts differ by exposure type [e.g., child abuse (direct) and household challenges (indirect)].

Given previous research indicating female and non-Hispanic white vulnerability to depression; male and non-Hispanic white vulnerability to risky alcohol behaviors; as well as the more limited information on risk of ACEs, broadly measured, to female and non-Hispanic white mental health the study hypotheses are as follows: (1) the association between ACEs and mental health outcomes will be stronger for women as compared to men and non-Hispanic whites as compared to other racial/ethnic groups; and (2) the association between ACEs and excessive alcohol use (including heavy drinking and binge drinking) will be stronger for men as compared to women and non-Hispanic whites as compared to other racial/ethnic groups. Similarly, given that ACEs can impact in direct and indirect ways, we expect individuals who report direct experiences (e.g., child abuse) will be at greater risk for poor outcomes than those who report indirect experiences (e.g., household challenges). We also expect that those who report they had both direct and indirect experiences (e.g., both child abuse and household challenges) will be at greatest risk for depression and excessive alcohol use.