Type and dose-response effect of adverse childhood experiences in predicting depression: A systematic review and meta-analysis

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Abstract

Background

Researchers have documented that adverse childhood experiences (ACEs) are associated with adverse long-term consequences for mental health, including increased risk for depression. However, the type and dose-response effects of ACE on depression risk need further exploration.

Objective

We aimed to synthesize the evidence on the relationship between ACEs measured by ACE International Questionnaire (ACE-IQ) and depression in type and quantity.

Participants and setting

Individuals with ACEs.

Methods

A systematic search was carried out of all published articles, up to November 2022, in eight electronic databases. Fixed- and random-effect models and dose-response were used.

Results

Exposure to ACEs, including household dysfunction, was associated with a higher risk of depression (ORs ranged from 1.34 to 3.17). The numbers of ACE acted as a nonlinear predictor of depression.

Conclusions

These analyses provided important evidence that ACEs, regardless of type or quantity, may be a risk factor for depression development. Prevention of ACEs and interventions for supporting those affected by ACEs are necessary.

Introduction

Adverse childhood experiences (ACEs) are potentially traumatic events that occur in childhood, including abuse (emotional, physical, or sexual), neglect (emotional or physical), household dysfunction (e.g. witnessing domestic violence, household member drug use, and parental separation and incarceration), and violence (bullying, community violence, or collective violence; World Health Organization [WHO], 2018). Nowadays, exposure to ACEs is highly prevalent. A nationwide retrospective study conducted in the United States by Merrick et al. showed that about 61 % of adults surveyed across 23 states reported that they had experienced at least one type of ACE, and nearly 1 in 4 reported they had experienced four or more types of ACEs (Merrick et al., 2018).

ACEs set the trajectory of poor physical and mental health throughout life. ACEs are associated with most health conditions, such as asthma, arthritis, COPD, cardiovascular disease, diabetes, health risk behaviors, and depression (Merrick et al., 2019; Waehrer et al., 2020). Depression stands out among the most common chronic diseases for the population with ACEs today. ACEs in North America were attributed to about 40 % of depression cases, the highest of any ill health, with estimated annual costs of $82 billion (Bellis et al., 2019).

There are noticeable studies to explore the association between special types of ACEs and depression. For example, Lee et al. (2020) found abuse, neglect, and violence can predict elevated depression, but not household dysfunction. While in Elmore and Crouch's (2020) study, Children exposed to household dysfunction had higher odds of experiencing depression. Therefore, the relationship between different types of ACEs and depression is inconsistent in primary studies. Then, it is noteworthy that maltreatment (abuse and neglect) has received the most empirical attention in meta-analyses on the association between ACEs and depressive disorders (Gardner et al., 2019; Humphreys et al., 2020; Infurna et al., 2016). Household dysfunction and violence are “silent” in their association with depression in meta-analysis. As such, evaluation of the association of a wider range of ACEs with depression is warranted.

A growing body of research points to probing the relationship between the number of ACEs and depression. LeMoult et al. (2020) found that individuals who experienced ACEs had a 2.5 times higher risk to develop youth-onset depression than those without a history of ACE. A meta-analysis by Petruccelli et al. (2019) showed that the risk odds (ORs) of the association between ACEs and depression gradually increased with increasing ACEs, possibly demonstrating the potential cumulative effect of ACEs. However, no previous meta-analysis has been able to fully characterize the shape of the dose-response relationship throughout the exposure of ACEs with depression, more empirical studies that quantify the depression associated with each score of ACE are still needed.

Based on previous research, this paper is dedicated to further study the relationship between ACEs as measured by ACE International Questionnaire (ACE-IQ) and depression about type and quantity. ACE-IQ is one of the most comprehensive tools assessing up to 13 types of ACEs. It includes not only the individual's experiences of being abused or neglected, but also family dysfunction and violence which are not involved in other measurements (Wang et al., 2020). Then, ACE-IQ can be used to explore the relationship between the ACE scores and the health outcome by plotting a dose-response curve (WHO, 2018). We hypothesized that different types of ACEs were significantly associated with depression, and an increase in ACEs increased the risk of depression in a dose-response fashion.

Section snippets

Methods

This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline (Moher et al., 2009).

Results

Our initial search yielded 955 records, of which 548 remained after the removal of duplicates. After a screening of the titles and abstracts of these records, 83 potential articles were found. These full texts were assessed and 74 were excluded. The remaining nine studies (Agbaje et al., 2021; Dorji et al., 2020; Elm, 2020; Huu et al., 2017; Kim, 2017; LeMasters et al., 2021; Mall et al., 2018; Satinsky et al., 2021; Subramaniam et al., 2020) were included in the systematic review and

Discussion

This is the first meta-analysis to investigate the association between different types and scores of ACE-IQ and the risk of depression. Based on 14,238 participants in 9 studies, results showed individuals with one ACE or more were associated with an overall 2.75-fold increase in the odds of depression. Of the different types of ACEs examined in this study, 12 subtypes of ACEs were positively associated with depression. Dose-response meta-analysis showed a non-linear relationship between

Conclusions and implications

The present review indicated that the numbers of ACEs were associated with the risk of depression in a non-linear dose-response relationship. That is, understanding the scores of ACEs will provide health workers with an easy metric for targeting intervention. Next, the effects of household dysfunction and violence on depression were as prominent as neglect and abuse. Thus, healthcare providers who care for individuals raised in all kinds of ACEs should carefully assess the risk for depression.

Funding

This study was supported by a key laboratory of nursing science of Hunan Province, Changsha 410013, China.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

None.

References (39)

  • M.R. Infurna et al.

    Associations between depression and specific childhood experiences of abuse and neglect: A meta-analysis

    Journal of Affective Disorders

    (2016)
  • Y.H. Kim

    Associations of adverse childhood experiences with depression and alcohol abuse among Korean college students

    Child Abuse & Neglect

    (2017)
  • H. Lee et al.

    Adverse childhood experiences (ACEs) on mental disorders in young adulthood: Latent classes and community violence exposure

    Preventive Medicine

    (2020)
  • J. LeMoult et al.

    Meta-analysis: Exposure to early life stress and risk for depression in childhood and adolescence

    Journal of the American Academy of Child & Adolescent Psychiatry

    (2020)
  • T.W. Meeks et al.

    A tune in “a minor” can “b major”: A review of epidemiology, illness course, and public health implications of subthreshold depression in older adults

    Journal of Affective Disorders

    (2011)
  • C.S. Pace et al.

    The adverse childhood experiences-international questionnaire (ACE-IQ) in community samples around the world: A systematic review (part I)

    Child Abuse & Neglect

    (2022)
  • K. Petruccelli et al.

    Adverse childhood experiences and associated health outcomes: A systematic review and meta-analysis

    Child Abuse & Neglect

    (2019)
  • G. Qu et al.

    Positive childhood experiences can moderate the impact of adverse childhood experiences on adolescent depression and anxiety: Results from a cross-sectional survey

    Child Abuse & Neglect

    (2022)
  • M. Subramaniam et al.

    Prevalence, socio-demographic correlates and associations of adverse childhood experiences with mental illnesses: Results from the Singapore mental health study

    Child Abuse & Neglect

    (2020)
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