Featured Article
Article Title
Differential Associations of Adverse Childhood Experiences and Mental Health Outcomes in U.S. Military Veterans
Authors
Alana Z. Slavin - Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
Ian C. Fischer - Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA, U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, West Haven, CT, USA
Robert H. Pietrzak - Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA, U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, West Haven, CT, USA, Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
Abstract
Adverse childhood experiences (ACEs) are robustly associated with adverse mental health outcomes across the lifespan. Military veterans may be particularly vulnerable to adverse mental health effects of ACEs, given their potentially higher prevalence of childhood traumas and compounding effects of military service-related traumas. To date, however, scarce research has examined the differential impact of individual ACEs on mental health outcomes in population-based samples of veterans. To address this gap, we analyzed data from the National Health and Resilience in Veterans Study (NHRVS), which surveyed a nationally representative sample of 4069 U. S. veterans, to examine the association between specific ACEs and major depressive, generalized anxiety, and post-traumatic stress disorders, and suicidal thoughts and behaviors. Results of multivariable logistic regression analyses revealed that emotional neglect and sexual abuse were most consistently associated with these outcomes, even after adjustment for the number of ACEs endorsed. Collectively, the results of this study underscore the importance of assessing for specific ACEs—most notably childhood emotional neglect and sexual abuse—and treating these potentially unresolved childhood traumas in veterans.
Keywords
Adverse childhood experiences, Posttraumatic stress disorder, Suicide, Depression, Veterans
Summary of Research
ACEs have been consistently linked to poorer life trajectories, including increased risk for mental disorders. Military veterans are more vulnerable to ACEs due to their higher prevalence of childhood traumas and military service-related traumas. The trajectory of ACEs among veterans is thought to begin with early life trauma and abuse, prompting some to escape from their dysfunctional homes by enlisting in the military. Moreover, military-related stressors such as combat exposure, moral injury, and military sexual trauma further compound the risk of poorer mental health outcomes.
Using data from the National Health and Resilience in Veterans Study (NHRVS), researchers analyzed a sample of 4069 U.S. veterans to investigate the impact of ACEs on mental health outcomes in military veterans. The study utilized several measures such as the Adverse Childhood Experiences (ACEs) questionnaire to assess childhood traumas, the Life Events Checklist for DSM-5 to evaluate potentially traumatic exposures (PTEs), and validated self-report instruments including the PTSD Checklist for DSM-5, Patient Health Questionnaire-2 for major depressive disorder (MDD), Generalized Anxiety Disorder-2 for GAD, and questions from the Suicide Behaviors Questionnaire-Revised for suicidal ideation and suicide attempt.
The study found that specific ACEs are associated with adverse mental health outcomes. For example, PTSD was strongly associated with emotional neglect, whereas other ACEs were not associated. Among veterans, childhood emotional neglect and sexual abuse were highlighted as especially critical factors to consider regarding their potential mental health challenges. They were associated with major depressive disorder, generalized anxiety disorder, posttraumatic stress disorder, and suicidal thoughts and behaviors. This underscores a shift from the traditional method of simply tallying up all adverse childhood experiences (ACEs) to recognizing that specific ACEs have unique impacts on mental health outcomes.
Furthermore, these results were interpreted through the lens of the biopsychosocial framework. According to this perspective, biological factors linked to ACEs include long-term stress. On a psychological level, childhood maltreatment and abuse can interfere with the development of secure attachments. Additionally, maladaptive coping mechanisms and difficulties in regulating emotions may play a role in the connection between ACEs and negative mental health outcomes. Socially, ACEs could result in isolation and a pessimistic view of social support.
Translating Research into Practice
Considering ACEs as independent factors: Clinicians and researchers should consider assessing specific ACEs that are most strongly associated with poor mental health outcomes for veterans rather than relying only on the cumulative total of ACEs. Specifically with veterans, sexual abuse and childhood emotional neglect should be examined. By identifying and targeting these individual ACEs, interventions can be tailored to address the unique needs of each veteran.
Recognizing the heightened vulnerability of veterans: Clinicians working with veterans should be aware of their heightened vulnerability to ACEs and consider its potential impact on mental health outcomes when assessing and treating veterans. Integrating this awareness into assessment and treatment protocols can enhance mental health outcomes, offering a tailored approach for veterans' unique needs.
Integrating a biopsychosocial approach: The findings of this study highlight the importance of understanding the biopsychosocial approach to assess and address the multifaceted impacts of ACEs on veterans' mental health. This involves considering biological factors such as chronic stress, psychological factors such as disrupted attachments and maladaptive coping mechanisms, and social factors such as social isolation and negative perceptions of social support.
Other Interesting Tidbits for Researchers and Clinicians
“Several limitations of our study should be noted. First, consistent with the demographic composition of U.S. veterans, the study sample primarily consisted of older, male, white, and married/partnered veterans, which may limit generalizability to more diverse subgroups of veterans. Second, the ACEs questionnaire assesses childhood experiences before the age of 18, and therefore may be prone to recall bias and cohort effects. Third, our study utilized self-reported measures of ACEs, trauma exposures, and psychiatric outcomes, which were not corroborated with clinical interviews. Fourth, given the cross-sectional study design, causal associations between ACEs and poor mental health outcomes cannot be established” (p. 264).
