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Article

Childhood Maltreatment and Risk of Suicide Attempt: A Nationally Representative Study

Despite considerable advances in our understanding of its neurobiology, suicide continues to be a major public health concern.1 Exposure to childhood maltreatment (ie, abuse and/or neglect) is highly prevalent in the general population2 and considered one of the main environmental risk factors for suicide.3,4

Although there is a well-established relationship between childhood maltreatment and later suicide attempts,5-9 it is unknown whether the effects of childhood maltreatment on this risk occur through diverse, specific mechanisms or through a generalized liability. Although these competing explanations have different implications for intervention, they have never been evaluated empirically. In addition, most published research focused on the effects of childhood maltreatment on suicide risk has relied on samples of convenience and examined a single type of maltreatment (eg, sexual abuse or physical abuse),3,10-13 despite ample evidence that these exposures frequently co-occur.2,14,15 Lastly, most previous studies have not controlled for the presence of psychopathology, which may at least partially mediate the link between childhood maltreatment and suicide attempt.2,12,15-23 To date, it remains unclear whether childhood maltreatment in general or particular types of childhood maltreatment impact on the risk for attempting suicide or on the age at first suicide attempt or the risk of repeated suicide attempts beyond the risk of attempting suicide. In addition to advancing the understanding of the mechanisms through which childhood maltreatment leads to suicide attempts, this knowledge has also important implications for suicide prevention if it allows to better identify, among individuals with a history of childhood maltreatment, those at greater risk for suicide attempt and for repeated suicide attempts beyond the risk of attempting suicide.

We used data from Wave 2 of National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative sample of the US adult population, to examine the effects of 5 types of childhood maltreatment (ie, emotional neglect, physical neglect, emotional abuse, physical abuse, and sexual abuse) on the risk of suicide attempts in the general population, the age of first suicide attempt, and the risk of repeated suicide attempts among suicide attempters, while controlling for demographic characteristics (ie, age, sex, race/ethnicity, and family poverty) and psychopathology. We used a latent variable approach to examine the associations between childhood maltreatment and suicide attempts to disentangle the effects shared among all types of childhood maltreatment versus those that could be specific to some types of maltreatment.

METHOD

Sample

Data were drawn from the 2004-2005 NESARC, the second wave of the NESARC. The Wave 1 NESARC was a nationally representative face-to-face survey of 43,093 civilian noninstitutionalized US residents aged 18 years and older, conducted in 2001-2002 by the US Census Bureau under the direction of the National Institute on Alcoholism and Alcohol Abuse (NIAAA) and described in detail elsewhere.24,25 The overall survey response rate was 70.2%, resulting in 34,653 completed interviews.24 Wave 2 NESARC data were weighted to reflect design characteristics of the NESARC survey and be representative of the US civilian population based on the 2000 census. The research protocol, including written informed consent procedures, received full human subjects review and approval from the US Census Bureau and the Office of Management and Budget.24 The present study analyses are based on the 34,653 participants in Wave 2, which included measures of childhood maltreatment.

Measures

Participants were interviewed face to face with the Alcohol Use Disorder and Associated Disabilities Interview Schedule, DSM-IV version (AUDADIS-IV), a fully structured diagnostic instrument designed for experienced lay interviewers.24

Childhood Maltreatment

Five types of childhood maltreatment were examined: emotional neglect, physical neglect, emotional abuse, physical abuse, and sexual abuse.2 Respondents completed 19 questions regarding exposure to the types of maltreatment occurring before age 17 years adapted from the Conflict Tactics Scale and the Childhood Trauma Questionnaire.2 All response options ranged from never (1) to very often (5), with the exception of emotional neglect, which ranged from “never” to “always” and was reverse coded for the purposes of analysis. A test-retest study of these items indicated excellent intraclass test-retest reliability coefficients ranging from 0.79 for physical abuse to 0.88 for emotional abuse.26 Keyes et al2 found that a 5-factor confirmatory factor analysis model fit the 19 childhood maltreatment items very well.

Suicide Attempt Outcomes

All participants were asked whether they ever attempted suicide. Those who answered positively were further asked about their age at the time of the first/single suicide attempt and whether it happened once or at least 2 times. Among the 1,265 suicide attempters, respectively 25 and 22 participants did not report age at the time of first attempt and whether they made at least 2 suicide attempts. Missing data were imputed using Markov chain Monte Carlo methods.27 Results were unchanged in sensitivity analyses excluding respondents with missing data.

Covariates

All models controlled for age at the time of Wave 2 interview, sex, race/ethnicity (white vs nonwhite), family poverty (considered present if participants reported that their family received money from any government assistance program before they were aged 18 years old), and psychopathology. Psychopathology was assessed with the following variables: any mood disorder (including major depressive disorder, bipolar disorder, and dysthymia), any anxiety disorder (including generalized anxiety disorder, posttraumatic stress disorder [as per DSM-IV used in this study], panic disorder, social anxiety disorder, and specific phobia), any personality disorder (including paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, obsessive-compulsive, and dependent personality disorders), alcohol use disorders, drug use disorders, nicotine dependence, pathological gambling, and attention-deficit/hyperactivity disorder (ADHD). In individuals with a history of suicide attempt, Axis I disorders were assessed at the time of the first suicide attempt. In individuals without a history of attempts, Axis I disorders were assessed on a lifetime basis. Axis II disorders were assessed on a lifetime basis for all respondents. The AUDADIS-IV substance dependence, mood and anxiety disorders, and personality disorders diagnoses demonstrated good to excellent test-retest reliability in clinical and general population samples.25

Statistical Analyses

We performed logistic regressions to determine whether each type of childhood maltreatment was associated with suicide attempt in the general population and/or repeated suicide attempts among suicide attempters, while controlling for sociodemographic characteristics and psychopathology. Among suicide attempters, a Cox proportional hazards regression model28 was used to compare age at first suicide attempt distributions between participants with and without each childhood maltreatment type, while controlling for psychopathology at the time of the first/single suicide attempt and sociodemographic characteristics. This model provides an estimate of the effect of each maltreatment type on age at first suicide attempt. Consistent with prior work,3,29 a participant was considered to have suffered childhood maltreatment if the respondent reported frequent exposure (sometimes, often or very often), except for sexual abuse, which was considered present if the respondent indicated at least 1 episode.

Next, we built upon the same 5-factor confirmatory factor analysis (CFA) model previously fit by Keyes et al2 and performed a second-order CFA model to determine whether a shared maltreatment factor fit the underlying structure of childhood maltreatment. We examined measures of goodness-of-fit, including the comparative fit index (CFI), the Tucker-Lewis index (TLI), and the root mean squared error of approximation (RMSEA).30 Comparative fit index and TLI values greater than 0.95 and values of RMSEA less than 0.06 are commonly used to indicate good model fit and were used as cutoffs.

Finally, we used a structural equation model to assess shared and specific effects of the different types of childhood maltreatment on each suicide attempt outcome. Specifically, while controlling for sociodemographic characteristics and psychopathology, we successively examined (1) the effect of the shared maltreatment factor (representing the shared effects of the 5 latent dimensions underlying the structure of childhood maltreatment) on each suicide attempt outcome and (2) the effects of the 5 types of childhood maltreatment on each suicide attempt outcome above and beyond their shared effects through the childhood maltreatment factor. Response options (scores from 1 to 5) for each of the 19 maltreatment items were modeled as ordered categorical indicators of the maltreatment factors, which were analyzed as latent variables.

Since the 5 childhood maltreatment factors frequently co-occur, an advantage of modeling a second-order latent abuse factor is that their shared and specific effects are disambiguated in an easier way than if they were to be included as multiple separate predictors mutually adjusted for one another.31 The relationships examined between the specific maltreatment factors and each suicide attempt outcome are interpreted as the direct effects because they indicate effect of the specific maltreatment type that is not mediated through the shared maltreatment factor. To avoid including effects that could be significant due to multiple testing and because of the large sample size,27,32,33 we decided a priori to evaluate statistical significance using a 2-sided design with α set at .005.

All analyses were conducted in Mplus Version 7.127 to take into account the complex sample design of the NESARC survey. The default estimator for the analysis was the variance-adjusted weighted least squares, a robust estimator appropriate for ordered categorical and dichotomous observed variables such as the ones used in the present study.27

RESULTS

Comparing Rates of Childhood Maltreatment Among Individuals With and Without a Lifetime History of Suicide Attempt

After adjusting for sociodemographic characteristics and psychopathology, all types of childhood maltreatment were significantly associated with a lifetime history of suicide attempt in the general population and with a younger age at first suicide attempt among attempters (Table 1). Sexual abuse showed the strongest association with suicide attempt and age at first suicide attempt following these adjustments. By contrast, there were no significant differences in the rates of any type of childhood maltreatment between individuals with single versus multiple suicide attempts. Therefore, we did not examine this outcome using structural equation models framework.

Structure of Childhood Maltreatment

The second-order CFA of the 5 childhood maltreatment factors measured by a single common maltreatment factor provided an excellent fit to the data (CFI = 0.983, TLI = 0.980, and RMSEA = 0.038).

Effects of Childhood Maltreatment Types on the Risk of Suicide Attempt

After adjusting for sociodemographic characteristics and mental disorders, the latent variable representing the shared effect of all childhood maltreatment types increased the risk of suicide attempt (Figure 1). Furthermore, beyond the effect due to the latent shared maltreatment factor, the sexual abuse factor had a significant (P < .005) direct positive effect on the risk of suicide attempt (see Supplementary eFigure 1 at PSYCHIATRIST.COM). By contrast, after adjusting for the shared maltreatment factor, physical neglect and emotional abuse had negative coefficients in the model, suggesting that these types of maltreatment increased the risk of suicide attempt to a lesser extent than sexual abuse.

Effects of Childhood Maltreatment Types on Age at First Suicide Attempt

After adjusting for sociodemographic characteristics and mental disorders, the latent shared maltreatment factor significantly decreased the age at first suicide attempt among suicide attempters (Figure 2 and Supplementary eFigure 2). There were no direct effects from any type of childhood maltreatment beyond the effect due to the latent shared maltreatment factor.

DISCUSSION

In a large nationally representative sample, all types of childhood maltreatment were strongly associated with the risk of suicide attempt and with earlier age at first suicide attempt among attempters, and their effect occurred mostly through a latent dimension representing the shared effects of maltreatment, independently of sociodemographic characteristics and Axis I and Axis II disorders. Furthermore, sexual abuse had direct effects on the risk of suicide attempt above and beyond the shared effects of all types of childhood maltreatment. We also found that childhood maltreatment did not significantly increase the risk of repeated suicide attempts among suicide attempters. Several novel findings emerged in the present study.

We found that the associations of each type of childhood maltreatment with increased risk for suicide attempt and earlier age of first suicide attempt among attempters were mostly mediated through a latent variable accounting for the shared effects of the different types of maltreatment, rather than directly through each type of maltreatment. Although the mechanisms linking childhood maltreatment and suicidal behavior remain unknown, several explanations may contribute to this association. First, childhood maltreatment can disrupt developmental processes related to strengthening of emotional regulation and associated interpersonal skills, including insecure attachment styles, impairments in emotional perception and reward processing,10,34 and increased impulsivity and neuroticism.10,35-41 These disruptions may decrease the threshold for suicidal behavior in individuals experiencing stressful events.10,34 Second, the higher rates of suicide attempt in individuals with childhood maltreatment may result from epigenetic modifications.42 For example, McGowan et al43 found that childhood maltreatment may increase the risk of suicide by altering hypothalamic-pituitary-adrenal (HPA) stress responses through the epigenetic hypermethylation of the Nr3C1 gene. Third, the long-term decreased social support associated with childhood maltreatment44 could also contribute to increased risk of attempting suicide.

Although much of the association between childhood maltreatment and risk of suicide attempt was mediated through the shared maltreatment factor, sexual abuse increased the risk of suicide attempt, above and beyond the effect of that factor. The stronger effect of childhood sexual abuse on the risk of suicide attempt is consistent with epidemiologic evidence indicating that sexual abuse (1) constitutes one of the main risk factors for suicide attempt45,46 and is more strongly associated with suicidal behavior than other forms of childhood maltreatment3,10,46-49 and (2) has longer-term impact on psychosocial functioning.50,51 Childhood sexual abuse may differ from other types of childhood adversity in its greater capacity to disrupt the underlying neurobiological structures involved in stress response52 and to increase the sensitivity to depressogenic life experiences53 and the susceptibility to environmental influences.54 It is also likely that the dysregulation of the HPA axis, which is more strongly associated to childhood sexual abuse than to other types of childhood maltreatment,54 may be moderated by the genetic background of the individual such as 5-HTTLPR, FKBP5, and Val66Met polymorphisms.54-57 Finally, family environmental correlates of suicide attempts, including increased family discord and low social support, are more prevalent among sexually abused children58 and may also contribute to this association.

We also found that no type of childhood maltreatment predicted repeated suicide attempts among individuals who ever attempted suicide. This finding is in contrast with some studies conducted in clinical samples45,59-61 but consistent with data derived from 2 nationally representative samples of the US general population.62 Individuals with history of multiple suicide attempts could be considered as a unique subgroup of suicide attempters.62-66 Using Beck’s theory of modes,41 a previous study63 suggested that the suicidal mode in individuals with a history of multiple suicide attempts becomes highly accessible in memory and requires minimal triggering stimuli to be activated.63 Building upon this model, our results suggest that underlying mechanisms of childhood maltreatment leading to increased risk of suicide are different from the mechanisms associated with repeated suicide attempts.

Our findings have important implications. From the etiologic point of view, they indicate that effects of childhood maltreatment on the risk of attempting suicide and on the age of suicide attempt among attempters occur mostly through a broad latent factor, representing the shared vulnerabilities triggered by the experience of childhood maltreatment. These results underscore the importance of adopting dimensional approaches in the study of childhood maltreatment and suicidal behavior, which may help disentangle biological and psychological mechanisms underlying the shared and specific associations of childhood maltreatment types with suicide attempt. In addition, our findings suggest that the mechanisms that link childhood maltreatment to increased risk of suicide are independent of risk factors leading to multiple suicide attempts. From a clinical point of view, our results extend prior work67,68 and underscore the key role of all types of maltreatment in suicide attempts. Because these childhood experiences increase the risk of suicide attempt mainly through a broad liability, our findings also suggest that preventing actual child maltreatment thanks to universal and selective interventions that have been successfully applied67 and the use of indicated interventions targeting this dimension in victims of childhood maltreatment could lead to substantial progress in suicide prevention.

This study should be interpreted in light of some limitations. First, retrospective reporting of childhood maltreatment may be subject to recall bias.2,15,69 However, longitudinal studies testing the validity of retrospective child maltreatment self-report, including childhood sexual abuse, generally find more false-negatives than false-positives.70-72 Second, for participants who attempted suicide before age 17, our analysis of suicide lifetime attempts did not allow us to establish the temporal precedence between the exposure to childhood maltreatment and suicide outcomes.73,74 Nonetheless, suicide attempts and mental disorders are rare in prepubescence,3,4 and additional analyses excluding participants who attempted suicide at age 12 or under did not modify the statistical significance of effects of childhood maltreatment on suicide attempt and age at first suicide attempt among attempters (eFigures 3 and 4). In addition, although it remains possible that there could be a third variable related to both, suicide attempts are unlikely to lead in most cases to childhood maltreatment. Last, information on approximate age at onset of each childhood maltreatment type, parental history of having been themselves victims of childhood maltreatment, and family environmental context (such as family discord), which have been found to be linked with higher suicidal intent,10,49,58 was not available in NESARC.

Despite these limitations, our findings underscore the pernicious long-term effects of childhood maltreatment on the risk of suicidal behavior. Preventing childhood maltreatment may have broad benefits to reduce not only the suffering of these children and adolescents but also the burden of suicide.

Submitted: July 29, 2014; accepted October 23, 2014.

Disclosure of off-label usage: The authors have determined that, to the best of their knowledge, no investigational information about pharmaceutical agents that is outside US Food and Drug Administration-approved labeling has been presented in this activity.

Financial disclosures: Dr Oquendo receives royalties for use of the Columbia Suicide Severity Rating Scale; has received financial compensation from Pfizer for the safety evaluation of a clinical facility in 2006, unrelated to this study; has received unrestricted educational grants and/or lecture fees from AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Janssen, Otsuka, Pfizer, Sanofi-Aventis, and Shire; and her family owns stock in Bristol-Myers Squibb. Dr Limosin is a member of the speakers/advisory boards for Janssen, Euthérapie, Lundbeck, and Roche. Drs Hoertel, Franco, Wall, Wang, and Blanco have no personal affiliations or financial relationships with any commercial interest to disclose relative to the article.

Funding/support: Supported by National Institutes of Health grants DA019606, DA023200, MH076051, and MH082773 (Dr Blanco); the New York State Psychiatric Institute (Drs Blanco, Oquendo, and Wall); and a fellowship grant from Public Health Expertise (Dr Hoertel).

Role of the sponsors: The sponsors had no additional role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Additional information: The original data set for the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) is available from the National Institute on Alcohol Abuse and Alcoholism (http://www.niaaa.nih.gov).

Supplementary material: Available at PSYCHIATRIST.COM.

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