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Community Ment Health J (2012) 48:187–192

DOI 10.1007/s10597-010-9369-2

ORIGINAL PAPER

Direct and Indirect Effects of Childhood Adversity


on Adult Depression
Marianna LaNoue • David Graeber •
Brisa Urquieta de Hernandez • Teddy D. Warner •

Deborah L. Helitzer

Received: 7 May 2010 / Accepted: 17 November 2010 / Published online: 3 December 2010
Ó Springer Science+Business Media, LLC 2010

Abstract Exposure to adverse events in childhood is a events, were significant. Therefore, partial mediation of the
predictor of subsequent exposure to adverse events in relationship between childhood adversity and adult symp-
adulthood, and both are predictors of depression in adults. toms of depression by adult adverse events was found in the
The degree to which adult depression has a direct effect of sample. Implications for treatment are presented.
childhood adversity versus an indirect effect mediated by
adult adversity has not previously been reported. We report Keywords Childhood adversity  Adult adversity 
data collected from 210 adult participants regarding child- Depression  Mediation
hood and adult adversity and current symptoms of depres-
sion. Mediation of the relationship between childhood
adversity and adult depression by adult adversity was sta- Introduction
tistically assessed to evaluate the relative direct and indirect
effects of childhood adversity on current depression levels in The last 15 years have seen a surge in publications relating
adults. Both the direct effect of childhood adversity on adult adverse childhood events (ACE’s) to a range of important
depression and the indirect effect, mediated by adulthood adult health outcomes, health risk behaviors and psychiatric
disorders (e.g., Felitti et al. 1998; Dube et al. 2003).
M. LaNoue (&) Depression is included among the adult outcomes that have
Department of Family and Community Medicine, MSC09-5040,
been linked to experiences of childhood adversity
University of New Mexico Health Sciences Center, 1 University
of New Mexico, Albuquerque, NM 87131, USA (McLaughlin et al. 2009; Chapman et al. 2004). Evidence
e-mail: MLanoue@salud.unm.edu also suggests that stress or traumatic life events in adulthood
precipitate depression, although the evidence is equivocal
D. Graeber
regarding whether this effect is confined to index or recurrent
Department of Psychiatry, University of New Mexico
School of Medicine, Albuquerque, NM, USA major depressive episodes (Kessler 1997). Clearly, contri-
e-mail: DGraeber@salud.unm.edu butions to depression in adulthood include both childhood
and adulthood precursors, with some studies suggesting that
B. U. de Hernandez
developmental and childhood events are among the strongest
Department of Family Medicine, Carolinas Health
Care System, Charlotte, NC, USA predictor of chronic and intractable depression in adulthood
e-mail: Brisa.Hernandez@carolinashealthcare.org (Riso et al. 2002; Wiersma et al. 2009).
In addition, evidence suggests that individuals who
T. D. Warner  D. L. Helitzer
experienced childhood adversity have an increased inci-
Department of Family and Community Medicine,
University of New Mexico School of Medicine, dence of adult adversity. A significant detrimental long-
Albuquerque, NM, USA term consequence of child maltreatment is subsequent
T. D. Warner victimization in adulthood (Desai et al. 2002) with abused
e-mail: TWarner@salud.unm.edu and neglected children reporting higher overall rates of
D. L. Helitzer adult revictimization and adversity (Widom et al. 2008).
e-mail: Helitzer@salud.unm.edu The literature thus suggests an interaction between adverse

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188 Community Ment Health J (2012) 48:187–192

childhood events and adverse adult events (AAE) in pre- including witnessing parental violence, living with someone
dicting the depressogenic effects of adulthood stressors. It abusing substances (including both drugs and alcohol), liv-
has been previously demonstrated that the effect of child- ing with someone who was mentally ill (including depres-
hood adversity on depression can be mediated by later sion, and suicide or suicide attempt), and ‘non-intact’ family/
stress and life events in adolescents and young adults in home displacement (parental divorce, running away, being
both retrospective and prospective designs. (Turner and sent away from home, familial homelessness, being a refu-
Butler 2003; Hazel et al. 2008). This ‘stress sensitization gee, or spending time in a group home or shelter). There were
model’ suggests that risk for adult depression in the face of a total of eight categories, each indicating a different form of
stressful life events increases when childhood adversity is adversity. The sum of these indicators (range 0–8) was used
present. (Hammen et al. 2000; McLaughlin et al. 2009). as the ACE predictor variable.
Taken together, these findings describe a plausible
model where both childhood and adulthood events are Measurement of Adult Adversity
possible causal factors for adult depression. What is not
clear, however, is the relative degree of prediction of each Adult adverse life events were measured with an 9 point
type of event. In the current study, we sought to simulta- dichotomous scale modeled after the Holmes and Rahe
neously evaluate both childhood and adulthood adversity stress scale (1967) and included the following adverse
as predictors of adult depression symptoms through eval- adult life events: ‘real or perceived threat to physical
uation of a statistical model of mediation. Both the direct integrity’ (having experienced a serious illness or injury or
and indirect effects of childhood adversity on depression in being involved in an event that could have caused such an
adulthood were evaluated. We hypothesized that childhood injury), ‘real or perceived threat to family integrity’ (loss or
adversity would predict depression in adulthood, both illness/serious injury to a child or partner), sexual coercion,
through it’s association with adulthood adversity, and emotional abuse, divorce, mentally ill household member,
independent of this relationship. drug/alcohol abusing household member, loss/displace-
ment from home, and fired/laid off or unemployed while
looking for work. The sum of these nine indicators (range
Method
0–9) was used as the AAE predictor variable.
Data were collected as part of two pilot studies conducted
Measurement of Depression
between 2005 and 2006 aimed at developing and testing a
comprehensive health assessment instrument which inclu-
The PHQ-9 was used to assess current symptoms of
ded items on childhood and adult adversity and current
depression. The PHQ is a self-report measure derived from
depressive symptoms. Both studies were approved by the
the Prime-MD which includes the nine symptoms used for
Institutional Review Board at the University of New Mexico
a diagnosis of depression from the DSM-IV, each scaled
Health Sciences Center. In the first pilot study, participants
from 0 (not at all) to 3 (nearly every day) with a total
responded to flyers posted in primary care clinics asking for
summative score range of 0–27 (Spitzer et al. 1999).
‘‘adults from all backgrounds’’ to participate in a survey
Categorical variables were created using the criteria in
about adverse childhood and adult experiences and overall
Martin et al. (2006) for both ‘major depressive syndrome’
health status. In the second study, participants were invited
(‘MDS’; if five or more of the nine depressive symptoms
via letters from their primary care providers to participate in
are reported to be present at least at ‘more than half the
a study to improve providers’ skills at identifying and
days’, with at least one of the symptoms being depressed
communicating about health risks. All study participants
mood or anhedonia) and ‘other depressive syndrome’
provided written documentation of their informed consent
(‘ODS’; if only two, three or four of the depressive
and were compensated for their time.
symptoms are indicated at more than half the days, with at
least one of the symptoms being depressed mood or
Measures anhedonia). Individuals meeting either of these thresholds
were combined into the category ‘Clinically Significant
Measurement of Childhood Adversity Symptoms’ (CSS), which was used as the dichotomous
outcome variable in analyses.
For purposes of comparison with previous studies (e.g.
Chapman et al. 2004), we used a categorical approach to Mediational Analysis
defining childhood adversity, which included exposure to
sexual, physical, or psychological abuse, and neglect. We Mediation describes a relationship among variables where
further defined four categories of household dysfunction the effect of one variable (X) on another (Y) is transmitted

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Community Ment Health J (2012) 48:187–192 189

through a third variable: the mediator (M). Mediation may (4.8%) endorsed symptom levels consistent with a sub-
be either complete (all of the relationship between X and syndromal depressive episode. Therefore, 35 individuals
Y is accounted for by M) or partial (some of the relationship (16.7%) met the criteria for CSS, as defined above (8 males
between X and Y is accounted for by M). In this study, and 27 females with no significant difference in CSS
statistical evidence for mediation of the relationship between the sexes, v2 (1) = 2.25, P [ .10).
between childhood adversity and adult depression status
(‘CSS’) by adulthood adverse events was established using Childhood and Adulthood Adversity
‘mediated logistic regression’, which is an analog of the
Baron and Kenny steps for mediation (1986) for use with a Cumulative exposure to categories are shown in Table 1
dichotomous outcome (MacKinnon and Dwyer 1993). This for both ACE and AAE. 87.6% of the sample reported
procedure rescales the regression coefficients to be com- some exposure to childhood adversity with a mean of 2.97
parable across the three equations. After this rescaling (2.2). An independent samples t-test revealed that ACE
process, the Baron and Kenney (1986) criteria were used to category exposures differed significantly between men and
establish mediation, specifically: (1) that the predictor women t(208) = 3.56, P \ .001 (Mmale = 2.22 (2.00),
variable (ACE) is significantly related to the proposed Mfemale = 3.35 (2.22)).
mediator (AAE); (2) that the proposed mediator variable 193 individuals (91.9% of the sample) reported at least
(AAE) is significantly related to the outcome (CSS) and (3) one adulthood adverse event; 81.9% reported two or more.
that after controlling for the relationships between the The most common events were threat to physical integrity
predictor and the mediator and the mediator and the out- (n = 149, 70.9%), threat to family integrity (n = 114,
come, a previously significant relationship between the 54.3%), and divorce/separation (n = 104, 49.5%). The
predictor (ACE) and the outcome (CSS) is either non-sig- mean number of adult adverse events in the sample was
nificant (evidence for complete mediation) or is significant 3.88 (2.47). Men and women differed significantly on this
but reduced (evidence for partial mediation). This proce- variable, t(208) = 4.3, P \ .001 (Mmales = 2.90 (s = 2.20),
dure allows for a statistical test of the hypothesis that Mfemales = 4.39 (s = 2.52)).
the relationship between childhood adversity and adult
depression is mediated adulthood adversity. We also esti- ACE and AAE as Predictors of CSS
mated the proportion of the entire effect that is mediated
using the equation suggested in MacKinnon and Dwyer The sufficient conditions for mediation were examined by
(1993). first analyzing the individual relationships among the three
variables. We followed convention (i.e. Baron and Kenny
1986) in naming these paths ‘a’ (relationship of the pre-
Results dictor to the mediator), ‘b’ (relationship of the mediator to
the outcome), ‘c’ (the direct effect of the predictor to the
Sample Characteristics outcome), and ‘cprime’ (the effect of the predictor on the
outcome controlling for the mediated effect). The direct
The analyzable sample included 210 participants (99 from effect of childhood adversity on the outcome variable
study one and 111 from study two). The mean age in the (CSS) was significant (path ‘c’); b = .294 (OR = 1.34,
sample was 47.76 (SD = 12.13); 139 (66.2%) were females P \ .001). Further, the direct effect of the mediator (AAE)
and 73 (34.9%) identified themselves as Hispanic. The on the outcome (CSS) was significant (path ‘b’); b = .273
samples were compared to each other via a series of t tests (OR = 1.31, P \ .001). Finally, the effect of the predictor
and contingency table analyses and were found to be similar (ACE) on the mediator (AAE) was significant (path ‘a’)
in ethnicity, sex and education level. Participants in study b = .49, P \ .001.
two were older and had lower depressive symptoms (both
P \ .05). For increased statistical power and greater gener- Mediational Analysis
alizability the samples were combined to test a single model.
Figure 1 shows the results of the estimated regression
Descriptive Results coefficients for the mediational analysis. The coefficients in
this model suggested that a partial mediational relationship
Depression exists between childhood adversity, adult adversity and
clinically significant symptoms of depression at assess-
Current depression symptoms were common; 25 partici- ment, as both path ‘c’ (the direct effect of ACE on CSS)
pants (12%) endorsed symptom levels consistent with a and path ‘cprime’ (the effect of ACE on CSS with the
major depressive episode and an additional ten participants mediator adult adversity in the model) were significant.

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Table 1 Adverse childhood


ACE exposures n CSS n AAE exposures n CSS n
experiences, adverse adult
experiences and prevalence of 0 26 (12.4%) 2 (7.7%) 0 17 (8.1%) 0 (0.0%)
clinically significant symptoms
of depression 1 42 (20.0%) 1 (2.4%) 1 21 (.1%) 4 (19.0%)
2 35 (16.67%) 6 (17.1%) 2 33 (15.7%) 2 (6.1%)
3 27 (12.8%) 4 (14.8%) 3 32 (15.2%) 4 (12.5%)
4 28 (13.3%) 10 (35.7%) 4 23 (10.6%) 1 (4.3%)
5 19 (9.0%) 1 (5.3%) 5 29 (13.8%) 6 (20.7%)
6 14 (6.67%) 3 (21.4%) 6 17 (8.1%) 4 (23.5%)
7 13 (6.2%) 5 (38.4%) 7 19 (9.0%) 8 (42.1%)
8 6 (2.8%) 3 (50.0%) 8 11 (5.2%) 4 (36.4%)
9 7 (3.3%) 2 (28.6%)

suggested in the literature for the finding that childhood


adversity is directly related to adult depression. For example,
childhood adversity has been shown to produce many
changes in the hypothalamic–pituitary–adrenal (HPA) axis
which lead to an over-sensitive stress response, which may
explain their link to depression in adulthood (Penza et al.
2003). It has been demonstrated that certain types of child-
hood adversity may be associated with the endogenous types
of depressive symptoms in adulthood. In a study of major
depression in adult women with histories of childhood
adversity, those with severe physical or sexual abuse and
neglect were more likely to exhibit endogenous depressive
Fig. 1 Comparable standardized regression coefficients in the medi- subtypes which have been associated with HPA dysregula-
ational analyses. These estimates were calculated in three steps but tion (Harkness and Monroe 2002). Further, these changes
are presented for ease of interpretation as a path diagram. The
coefficients presented are the ‘comparable’ coefficients described in
may precipitate depression in adults both in the face of and in
MacKinnon and Dwyer 1993. 1This coefficient is for path cprime the absence of psychosocial stressors (Kendler et al. 1999).
(including the mediated effect). The coefficient for path ‘c’ was .29, Other studies have suggested that adverse childhood events
P \ .001 might predispose individuals to a variety of negative emo-
tional outcomes in adulthood including depression, anxiety,
The proportion of the effect of childhood adversity on CSS dissociation and revictimization mediated by shame, self-
that is not mediated by adulthood adversity was 52.5%. blame, interpersonal difficulties and maladaptive coping
strategies (Whiffen and MacIntosh 2005).
In our sample of 210 adults, exposure to childhood and
Discussion adult adversity was common with a range of 20.5%
(neglect) to 57.6% (physical abuse) for childhood adversity
We sought to measure the direct and indirect effects of and 18.6% (home displacement) to 70.9% (‘threat to
childhood adversity on current depressive symptoms in an physical integrity’) for adult adversity. A majority of par-
adult sample recruited from clinics within a university ticipants had at least one category of childhood adversity
setting. Results indicated that 52.5% of the relationship (almost 88%) and 49% had three or more exposures. In the
between childhood adversity and adult symptoms of existing literature, rates of exposure to childhood adversity
depression is direct, the remaining 47.5% was indirect (i.e. vary greatly across studies, but generally range from about
mediated by intervening adulthood adverse events). 65% (Dube et al. 2003) to about 77% (Turner and Butler
We hypothesized that exposure to adverse childhood 2003) of participants reporting at least one exposure. These
events would predict current adult symptoms of depression differences are likely due, at least in part, to variability for
independent of adult adversity. Our findings suggest that inclusion in exposure categories. The question of what
childhood adversity remains an independent and statistically kinds of experiences (or how many of them) are required to
significant predictor of adult symptoms of current depression be considered to have experienced an event remains
when accounting for the strong relationship between adverse unanswered. In the present study participants had only to
adult events and depression. Several possibilities have been endorse a limited exposure to be included in a category. In

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the physical abuse category, for example, participants had pharmacotherapy alone when compared with patients
to endorse either that ‘sometimes’ they were ‘severely without childhood trauma (Nemeroff et al. 2003). Patients
spanked’; or that ‘more than two or three times’ they were with depression and severe childhood adversity and in
‘pushed, grabbed, shoved or slapped’; or that ‘once or particular sexual abuse may also be an increased risk of
twice’ they were ‘hit so hard they had marks’. The rele- suicidal ideation (Harkness and Monroe 2002). Therefore,
vance of this measurement question for generalizability it is important to screen for suicidality in patients with
across studies and for establishing relationships between depression and histories of childhood adversity. In addi-
childhood experiences and adult outcomes is clear; we are tion, clinicians providing pharmacotherapy for these
hopeful that standardization of measures be pursued for patients should understand the importance of combination
future research in this field. psychotherapy for such patients and recommend this as
The finding that almost half of the sample had three or part of a comprehensive treatment approach.
more events is also consistent with other studies of child-
hood adversity which indicate that individuals exposed to
ACE often experience multiple types of exposure (Dong
et al. 2004), and also suggestive that increasing exposure to References
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