Associations Between Adverse Childhood
Experiences, Psychological Distress, and
Adult Alcohol Problems
Tara W. Strine, PhD, MPH; Shanta R. Dube, PhD, MPH; Valerie J. Edwards, PhD;
Angela Witt Prehn, PhD; Sandra Rasmussen, PhD, MA, MSN, BSN;
Morton Wagenfeld, PhD; Satvinder Dhingra, MPH; Janet B. Croft, PhD
Objective: To examine the medi-
ating role of psychological dis-
tress on the relationship between
adverse childhood experiences
and adult alcohol problems by gen-
der. Methods: Linear and logistic
regression analyses were con-
ducted on 7279 Kaiser-
Permanente members, aged >18
years. Results: Psychological dis-
tress mediated significant pro-
portions of alcohol problems asso-
ciated with childhood emotional
abuse and neglect, physical abuse
and neglect, mental illness in the
household, parental separation or
P
revious research suggests that ad-
verse childhood experiences (ACE)
in the form of abuse, neglect, and
household dysfunction are a significant
risk factor for alcohol and drug abuse1-11
including ever use of alcohol,6,8 early ini-
tiation of alcohol use,6 and adult alcohol
abuse and alcoholism.1,3 Among the more
than 43,000 participants in the 2001-
2002 National Epidemiologic Survey on
Tara W. Strine, Epidemiologist, Centers for
Disease Control and Prevention; Office of Sur-
veillance, Epidemiology and Laboratory Services;
Public Health Surveillance Program Office; Divi-
sion of Behavioral Surveillance; Atlanta, GA. For
full listing of Authors see page 423.
Correspondence Dr Strine; tws2@cdc.gov
408
divorce, sexual abuse, and house-
hold drug use among women and
mental illness in the household,
emotional neglect, physical abuse,
household drug use, and sexual
abuse among men. Conclusion: It
may be important to identify early
childhood trauma and adult psy-
chological distress in programs
that focus on reducing alcohol
abuse.
Key words: alcohol abuse, men-
tal illness, child abuse, child ne-
glect
Am J Health Behav. 2012;36(3):408-423
DOI: http://dx.doi.org/10.5993/AJHB.36.3.11
Alcohol and Related Conditions, those who
experienced 2 or more adverse events in
childhood were almost 1.4 times more
likely to develop alcohol dependence than
were those who experienced either none
or one ACE.12
Studies also suggests that ACEs such
as sexual and physical abuse, neglect,
witnessing of domestic violence, early
parental loss, parental divorce, and out-
of-home-placement are often associated
with subsequent psychological distress
and mood disorders.7,13-20 For example, per-
sons with psychological distress and mood
disorders who are exposed to parental
mental illness in childhood tend to have
an early onset of depression, more de-
pressive episodes, more severe and per-
sistent symptoms, increased number of
suicide attempts, and greater impair-

ment.21-23 Additionally, a dose-response
relationship between number, types, and
severity of maltreatment and poor mental
health outcomes has been noted.18,24-25
Previous research has identified gen-
der differences in adult drinking patterns
(approximately 12.5% of men and 6.4% of
women meeting diagnostic criteria for
alcohol abuse and 20.1% of men and 8.2%
of women meeting the criteria for alcohol
dependence)26 and exposure to ACEs.5 The
majority of studies that have specifically
examined the relationship between ACEs
and drug abuse were conducted with fe-
male participants. According to a litera-
ture review conducted by Simpson and
Miller,9 psychiatric conditions such as
depression and anxiety disorders medi-
ate the relationship between child abuse
and drug and alcohol abuse disorders in
women.
Far less is known about the potential
association between ACEs and alcohol
problems in men. Most studies that have
been conducted on males have concen-
trated on the potential relationships be-
tween childhood sexual abuse and alcohol
use and abuse among adolescent boys. In
a study conducted by Garnefski and
Arends,27 abused boys aged 12 to 19 re-
ported drinking approximately 2 times
the amount of alcohol as that of nonabused
boys. Chandy et al28 found that, as com-
pared to sexually abused females, males
were more likely to binge drink (defined
as consuming 5 or more drinks on one
occasion) and to drink before or during
school. The few studies that have exam-
ined the association between ACEs and
increased risk of problem drinking later
in life among men either examined just
the ACE score3 or implicated only child-
hood sexual abuse.29-31
Additionally, recent research is only
beginning to elucidate the potential me-
diating effect of psychological distress on
the relationship between ACEs and adult
alcohol problems. For example, studies
conducted by Douglas et al4 and Lo and
Cheng 32 suggest that the relationship
between childhood abuse and drug and
alcohol dependence may be partially me-
diated by mood and anxiety disorders.
DeWit et al33 implicate social phobia as
the mediator between adverse life events
and chronic stress in childhood and drug
and alcohol dependence in adulthood.
White and Widom34 concluded that PTSD
among maltreated girls may increase the
™ 2012;36(3):408-423
Am J Health Behav.™
Strine et al
risk of subsequent drug and alcohol use
problems.
Given these differences, this study
examines (1) the gender-specific asso-
ciations among ACEs (individually and
cumulatively), psychological distress, and
self-perceived alcohol problems; and (2)
the possible mediation by psychological
distress of the relationships between ACEs
(individually and cumulatively) and self-
perceived alcohol problems.
METHODS
The Adverse Childhood Experiences
(ACE) Study is the largest study of the
impact of childhood abuse, neglect, and
household dysfunction on health and be-
havioral outcomes in later life in a man-
aged care population35 Adult members of
the Kaiser Permanente Medical Care Pro-
gram in San Diego, California, were of-
fered a free comprehensive medical ex-
amination through the Health Appraisal
Clinic (HAC) as part of their medical ben-
efit program.36 Prior to the medical exami-
nation in April through October 1997,
each Kaiser member attending the San
Diego HAC completed a standardized
health appraisal questionnaire and the
SF-36 questionnaire, which was used as
an assessment of functional health and
well-being.37,38 After the physical exam,
patients were mailed a Family Health
History (FHH) questionnaire that asked
questions about health behaviors (eg, self-
reported alcohol problems) and ACEs (http:/
/www.cdc.gov/ace/index.htm). Participa-
tion in the FHH survey was voluntary, and
the patients were assured that informa-
tion from the survey would not become
part of their medical record.
The FHH is a 168-item questionnaire
that covers a broad range of childhood
exposures, age at initiating health be-
haviors, and current health behaviors.
The following 10 ACE categories were
derived from responses to 27 questions in
the 1997 questionnaire: emotional abuse
(2 questions), physical abuse (2 ques-
tions), sexual abuse (4 questions), emo-
tional neglect (5 questions), physical ne-
glect (5 questions), witnessing of domes-
tic violence against mother or stepmother
(4 questions), residence with someone
who used drugs (1 question), mentally ill
household members (2 questions), sepa-
ration or divorce of parents (1 question),
and incarcerated household members (1
question) (Table 1). Questions from pub-
DOI: http://dx.doi.org/10.5993/AJHB.36.3.11 409
Childhood Experiences, Distress & Alcohol

Table 1
Definitions of Abuse, Neglect, and Household Dysfunction
Before Age 18 Years
Category Definitions

Abuse
Emotional At least one of the following responses:
1.Often or very often a parent or other adult in the household swore at you, insulted you, or put you down.
2. Sometimes, often, or very often acted in a way that made you think that you might be physically hurt.

Physical At least one of the following responses:

1. Sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at you.
2. Sometimes, often, or very often ever hit so hard that you had marks or were injured.

Sexual At least one affirmative (yes) response about an adult or a person at least 5 years older than the respondent:
1. Ever touched or fondled you in a sexual way.
2. Had you touch their body in a sexual way.
3. Attempted oral, anal, or vaginal intercourse with you.
4. Actually had oral, anal, or vaginal intercourse with you.

Neglect
Emotional 5 Childhood Trauma Questionnaire (CTQ) questions (Bernstein, et al, 1994)42 had possible responses of “never
true,”“rarely true,”“sometimes true,”“often true,” or “very often true.” Responses were reverse scored on a Likert
scale ranging from 5 to 1, respectively:
1. There is someone in my family who helped me feel important or special.
2. I felt loved.
3. People in my family looked out for each other.
4. People in my family felt close to each other.
5. My family was a source of strength and support.

A total cumulative score of 15 and higher (moderate to extreme on the CTQ clinical scale) defined childhood emotional
neglect (Bernstein, et al, 1994).42

Physical 5 Childhood Trauma Questionnaire (CTQ) questions (Bernstein, et al, 1994)42 had possible responses of “never
true,’“rarely true,”“sometimes true,”“often true,”or “very often true.”Responses were scored on a Likert scale
ranging from 1 to 5, respectively with items 2 and 5 reversed scored (5 to 1, respectively):
1. You did not get enough to eat.
2. You knew there was someone to take care of you and protect you.
3. Your parents were too drunk or high to take care of the family.
4. You had to wear dirty clothes.
5. There was someone to take you to the doctor if you needed it.

A total cumulative score of 10 or higher (moderate to extreme on the CTQ clinical scale) defined childhood physical
neglect (Bernstein, et al, 1994).42

Household Dysfunction
Witness domes- At least one of the following responses about your mother or stepmother:
tic violence 1. Sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at her.
2. Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard.
3. Ever repeatedly hit over at least a few minutes.
4. Ever threatened or hurt by a knife or gun.

Lived with Affirmative (yes) response about living with anyone (before age 18) who
someone who 1. Used street drugs.
used drugs

Household At least one affirmative (yes) response about a household member who
mental illness 1. Was depressed or mentally ill.
2. Attempted suicide.

Parental separa- Parents were ever separated or divorced.

tion or divorce

Incarcerated A household member went to prison.

household
member

410

lished surveys were used to construct the
questions regarding ACEs. Questions
adapted from the Conflicts Tactics Scale
(CTS) were used to measure psychologi-
cal and physical abuse during childhood
and to measure domestic violence against
the respondent’s mother or stepmother.39
Four questions adapted from the Wyatt
Sexual History Questionnaire (WSHQ)40
were used to measure contact sexual
abuse during childhood. Questions about
exposure to alcohol or drug abuse during
childhood were taken from the 1988 Na-
tional Health Interview Survey.41 Physi-
cal and emotional neglect were assessed
using the Childhood Trauma Question-
naire (CTQ) short form.42
In addition to examining individual
ACEs, an ACE score was constructed.36, 43-45
Exposure to any type of abuse, neglect, or
household dysfunction counted as one
point; and categories were summed for a
total score between 0 and 10 points.
Self-reported alcohol problems were as-
sessed with the question “Have you ever
had a problem with your use of alcohol?”
“Assessment of the methodological stud-
ies indicate that for the general popula-
tion, self-reports of alcohol use are fairly
accurate.”46 Assuring confidentiality of re-
sponses to survey questions (which was
part of the ACE study protocol) and self-
administering in a private setting (mail
survey in the home for the ACE study) also
can enhance the accuracy of self-reported
alcohol abuse.46,47 In addition, the overall
prevalence in this study of 10.7% is similar
to what has previously been reported in
national surveys (range: 6.0% to 9.7%).46
Current psychological distress is de-
fined as temporary or permanent mal-
adaptive psychological functioning as the
result of stressful life events.48 It was
assessed as a continuous variable using
the Mental Component Summary (MCS)
score, which was calculated from the SF-
36. The SF-36 is a generic, multipurpose,
short-form health survey with 36 ques-
tions and 8 subscales.38,49 The 8 scales
(physical functioning, role physical, bodily
pain, general health, vitality, social func-
tioning, role emotional, and mental health)
form 2 distinct higher-ordered clusters,
physical and mental health, which ac-
counts for 80-85% of the variance in the
8 scales.50,51 The reliability estimates of
the 2 summary scales have generally
exceeded 0.90.37 Predictive studies of va-
lidity have linked SF-36 scales and the
™ 2012;36(3):408-423
Am J Health Behav.™
Strine et al
Figure 1
Mediation Model
Psychological
Distress
W
a b
W
Alcohol
ACEs X problems
c'
Note.
b and c' = both ACE(s) and psychological
distress in the model
summary measures to the clinical course
of depression.52-55 The MCS score is calcu-
lated from a complex set of computer-
generated algorithms. All 8 scales com-
pose the MCS score, but 3 scales (mental
health, role emotional, and social func-
tioning) correlate most highly and con-
tribute most to the scoring.37 The instru-
ment is constructed such that as the
mean score decreases, the level of psy-
chological distress increases. The gen-
eral US population mean norm score for
males is 50.73 and for females is 49.33.37
Mediation analyses were conducted to
identify and explain gender-specific rela-
tionships between ACEs and self-reported
alcohol problems based on the inclusion
of the MCS score as an indicator for psy-
chological distress.56 Psychological dis-
tress was considered a potential mediat-
ing variable when both psychological dis-
tress and ACEs (individual and as a total
score) were independent variables, and
self-reported alcohol problems was the
dependent variable.56,57
Several criteria must be satisfied in
order for mediation analysis to be valid
(Figure 1). First, the independent vari-
able (ACEs) must be significantly associ-
ated with the dependent variable (self-
reported alcohol problems) (a); the medi-
ating variable (psychological distress)
must be significantly associated with the
dependent variable (self-reported alcohol
problems) with the independent variable
(ACEs) included in the model (b); and the
DOI: http://dx.doi.org/10.5993/AJHB.36.3.11 411
Childhood Experiences, Distress & Alcohol

problems) through the mediator (psycho-

Table 2 logical distress). Given that the depen-
Descriptive Characteristics dent variable (self-reported alcohol prob-
lems) and the independent variable (ACEs)
of Study Sample are dichotomous, and the mediating vari-
able (psychological distress) is continu-
Women Men ous, the coefficients in the mediation
(n=3922) (n=3357) analyses were measured on 2 different
Characteristics % % scales. When self-reported alcohol prob-
lems was the dependent variable, logistic
Age-group (years) regression analyses were conducted
18-34 11.4 7.3 whereas linear regression techniques
35-54 38.7 36.8 were employed when the dependent vari-
55-74 40.0 44.3 able was psychological distress. In order
75+ 9.8 11.6 to build compatible coefficients in the 2
models, techniques developed by
Mean age (SD) 54.8 (15.4) 57.1 (14.4) MacKinnon and Dwyer60 were utilized to
calculate the Sobel statistic as well as the
Race percentage of the total mediated effect.
White 74.2 76.0 All models were first examined unad-
Black 4.1 4.0 justed and then adjusted for covariates
Hispanic 11.0 10.3 that included age group (18-34, 35-54, 55-
Asian 8.7 6.7 74, and >75 years), race (white, black,
Native American 0.3 0.4 Asian, Native American, and other), edu-
Other 1.7 2.7 cation (no high school diploma, high school
or general educational development
Education equivalence, some college/technical
No high school diploma 7.8 6.4 school, and college graduate), and child-
High school/GED 17.0 12.2 hood exposure to household alcohol prob-
Some college/technical 42.7 38.8 lem (yes or no).
College graduate 32.5 42.6 All 13,330 Kaiser Health Plan mem-
bers who completed standardized medical
Mean MCSa (SD) 51.3 (9.5) 53.2 (8.2) examinations at the HAC between April
and October of 1997 were eligible to par-
Childhood exposure ticipate in the ACE Study. This study
to household problem population consisted of 8667 San Diego,
drinking 27.4 23.1 California Kaiser Permanente Health
Maintenance Organization members who
Self-reported completed the FHH (overall participation
alcohol problem 7.0 15.0 rate was 65% of eligible participants).
Among these, 7279 (84.0%) respondents
Note. had complete information for the study
a Mental Component Summary Score variables; 3922 women and 3357 men.
(MCS) based on SF-36.
RESULTS
Descriptive Statistics
The mean age was 54.8 years among
independent variable (ACEs) must be sig- women and 57.1 years among men, al-
nificantly associated with the mediating most three-fourths of the sample was
variable (psychological distress) (c).58 Sec- white, and over three-fourths had attained
ond, the independent variable (ACEs) must at least some college education (Table 2).
be known to cause the mediation variable The mean MCS score, a continuous indi-
(psychological distress), which in turn cator for psychological distress, was slightly
causes the dependent variable (self-re- lower for women than men (51.3 versus
ported alcohol problems).58 53.2, respectively). Childhood exposure to
The Sobel test59 was used to determine household problem drinking was com-
the significance of the indirect effect of mon and reported by 27.4% of women and
the independent variable (ACEs) on the 23.1% of men. Women were much less
dependent variable (self-reported alcohol likely to self-report alcohol problems than

412
 Strine et al

Table 3
ACE Characteristics of Study Sample, by Gender
Women Men Chi-
(n=3922) (n=3357) square
ACE % % P-value

Abuse
Emotional 11.7 8.2 <0.0001
Physical 24.4 28.3 0.0002
Sexual 24.1 16.7 <0.0001

Neglect
Emotional 16.3 12.0 <0.0001
Physical 8.6 10.4 0.0096

Household dysfunction
Violence against mother 13.6 12.0 0.0344
Parental separation or divorce 25.3 22.5 0.0045
Drug use in household 6.1 5.2 0.1185
Mental illness in household 25.0 14.4 <0.0001
Incarcerated household member 6.9 4.9 0.0004

Total number of ACES

0 36.6 39.4 <0.0001
1 24.5 27.4
2 14.2 15.2
3 9.4 7.2
4+ 15.3 10.8

men (7.0% versus 15.0%, respectively).
The most common ACEs reported by
the study population included physical
abuse (24.4% of women and 28.3% of
men), parental separation or divorce
(25.3% of women and 22.5% of men), and
having a household member with mental
illness during childhood (25.0% of women
and 14.4% of men) (Table 3). Women were
significantly more likely than men to
report childhood experiences of emotional
abuse, emotional neglect, sexual abuse,
exposure to witnessing domestic violence,
parental separation or divorce, mental
illness in the household, and exposure to
an incarcerated household member while
men were more likely to report childhood
experiences of physical abuse and physi-
cal neglect. Women were also signifi-
cantly more likely than men to report
experiencing 4 or more ACEs (15.3% ver-
sus 10.8%, respectively).
Relationship Between ACEs and
Self-reported Alcohol Problems
The prevalence and unadjusted odds of
self-reported alcohol problems was higher
for those with any individual ACE than in
those without that ACE among both men
and women (Figure 2, Table 4). Estimates
for women ranged from 11.3% among those
with childhood physical abuse (versus
5.6% among those who were not physi-
cally abused) to 20.1% among those who
experienced household drug use during
childhood (versus 6.1% who did not expe-
rience household drug use during child-
hood). Estimates for men ranged from
18.8% among persons who experienced
parental separation or divorce during
childhood (versus 13.9% who had not) to
31.8% of men who experienced household
drug use in childhood (versus 14.1% of
those who had not). After adjustment for
sociodemographic characteristics and
childhood exposure to household problem
drinking, 2 independent variables, do-
mestic violence and exposure to an incar-
cerated household member during child-
hood, no longer had significant associa-
tions with the likelihood of self-reporting
alcohol problems among women. After

™ 2012;36(3):408-423
Am J Health Behav.™ DOI: http://dx.doi.org/10.5993/AJHB.36.3.11 413
Childhood Experiences, Distress & Alcohol

Table 4
Odds Ratios (OR) and 95% Confidence Intervals for the
Unadjusted and Adjusteda Relationships Between ACES and
Self-reported Alcohol Problems, by Gender
Women Men
Unadjusted Adjustedb Unadjusted Adjustedb
ACE OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

Abuse
Emotional
Yes 2.7 (2.0-3.6) 1.7 (1.2-2.3) 1.8 (1.3-2.4) 1.3 (0.9-1.7)
No Referent Referent Referent Referent
Physical
Yes 2.1 (1.7-2.8) 1.5 (1.2-2.0) 1.7 (1.4-2.1) 1.4 (1.1-1.7)
No Referent Referent Referent Referent
Sexual
Yes 2.3 (1.8-3.0) 1.6 (1.3-2.1) 1.7 (1.3-2.1) 1.5 (1.2-1.9)
No Referent Referent Referent Referent
Neglect
Emotional
Yes 2.4 (1.8-3.1) 1.6 (1.2-2.2) 1.9 (1.5-2.5) 1.5 (1.1-1.9)
No Referent Referent Referent Referent
Physical
Yes 2.2 (1.5-3.1) 1.5 (1.1-2.2) 1.6 (1.2-2.1) 1.3 (1.0-1.8)
No Referent Referent Referent Referent
Household Dysfunction
Witnessing domestic violence
Yes 2.1 (1.6-2.8) 1.2 (0.9-1.6) 2.0 (1.6-2.6) 1.2 (0.9-1.5)
No Referent Referent Referent Referent
Parental separation or divorce
Yes 2.2 (1.7-2.9) 1.5 (1.1-1.9) 1.4 (1.1-1.8) 1.0 (0.8-1.3)
No Referent Referent Referent Referent
Drug use in household
Yes 3.8 (2.7-5.4) 2.3 (1.6-3.3) 2.9 (2.0-4.0) 1.7 (1.1-2.4)
No Referent Referent Referent referent
Mental illness in the household
Yes 2.5 (2.0-3.2) 1.7 (1.3-2.2) 2.1 (1.7-2.6) 1.5 (1.2-1.9)
No Referent Referent Referent Referent
Incarcerated household member
Yes 1.8 (1.2-2.7) 1.5 (1.0-2.3) 2.2 (1.5-3.1) 1.6 (1.1-2.3)
No Referent referent Referent Referent

ACE Score
0 Referent Referent Referent Referent
1 1.4 (0.9-2.1) 1.2 (0.8-1.8) 1.3 (1.0-1.7) 1.2 (0.9-1.5)
2 2.6 (1.7-3.9) 1.8 (1.2-2.7) 2.0 (1.5-2.6) 1.6 (1.2-2.1)
3 2.6 (1.7-4.1) 1.5 (0.9-2.5) 1.9 (1.3-2.7) 1.3 (0.9-1.9)
4+ 5.3 (3.7-7.6) 2.7 (1.8-3.9) 3.3 (2.5-4.4) 9.9 (1.4-2.6)

Note.
a Reflect the influence of the demographic variables (age group, race, education, and childhood
exposure to household problem drinking).
b Gender-specific multivariable logistic regression models include age-group, race, education, and
childhood exposure to household problem drinking.

414

Figure 2
Prevalence of Self-Reported Alcohol Problems by
ACE Status and Gender
adjustment for the same covariates among
men, the likelihood of self-reporting alco-
hol problems was no longer significantly
associated with childhood exposures to
emotional abuse, physical neglect, do-
mestic violence, or parental separation
or divorce. After adjustment for
sociodemographic characteristics and
childhood exposure to household problem
drinking, women who reported 4 or more
ACEs were 2.7 times (95% CI: 1.8-3.9)
more likely and men who reported 4 or
more ACEs were 1.9 times (95% CI: 1.4-
2.6) more likely to self-report alcohol prob-
lems compared to those who reported no
ACEs.
Relationship Between ACEs and
Psychological Distress
The mean MCS score, an indicator of
psychological distress, was lower among
those with any ACE compared to those
without the given ACE among both
™ 2012;36(3):408-423
Am J Health Behav.™
Strine et al
women and men, suggesting increased
psychological distress (Figure 3). In the
adjusted linear regression models
among women, all associations between
the individual ACEs and the psychologi-
cal distress indicator were significant
at P-value<0.05 except for that in which
the independent variable was a child-
hood exposure to incarcerated house-
hold members (data not shown). Among
men, all adjusted associations with the
psychological distress indicator were
significant except for those in which
the independent variable was domestic
violence, parental separation or divorce,
or incarcerated household member. As
the ACE score increased in both ad-
justed and unadjusted linear regres-
sion models, the level of psychological
distress also increased (P-value<0.0001
for both women and men) (ie, mean
score decreased as number of ACEs
increased).
DOI: http://dx.doi.org/10.5993/AJHB.36.3.11 415
Childhood Experiences, Distress & Alcohol
Figure 3
Mean Mental Component Summary Score* by
ACE Status and Gender
Relationship Between Psychological
Distress and Self-reported Alcohol
Problems
In the adjusted models, the association
between psychological distress and self-
reported alcohol problems after adjusting
for the different ACEs was significant for
females (P-value <0.0001) and males (P-
value <0.0001).
Mediating Role of Psychological
Distress on the Relationship Between
ACEs and Self-reported Alcohol
Problems
Among women, after adjustment for
sociodemographic characteristics and
childhood exposure to household problem
drinking, the psychological distress indi-
cator explained or mediated a significant
proportion (P-value<0.05) of self-reported
alcohol problems associated with emo-
tional abuse (18.5%) and neglect (15.9%),
physical abuse (14.9%) and neglect
(14.7%), mental illness in the household
(15.3%), parental separation or divorce
416
(10.9%), sexual abuse (9.9%), and house-
hold drug use (5.6%) (Table 5). Among
men, psychological distress also medi-
ated a significant proportion (p-value<0.05)
of self-reported alcohol problems associ-
ated with mental illness in the household
(28.6%), emotional neglect (25.7%), physi-
cal abuse (19.5%), household drug use
(13.2%), and sexual abuse (6.5%) after
adjustment for sociodemographic char-
acteristics and childhood exposure to
household problem drinking.
Discussion
This study begins to close 2 gaps in the
existing literature. First, much of the
research to date examining the relation-
ship between ACEs and problem drinking
has been limited to women.61-63 The stud-
ies that have been conducted among men
have concentrated primarily on the in-
creased risk of problem drinking as the
result of childhood sexual abuse.27-30,64 This
research examines the relationship be-
tween problem drinking and a variety of
 Strine et al

Table 5
Adjusted Mediation Statistics, by Gender
Computer Coefficients (SE) a Sobel test b %
Mediated c
Test Statistic P-
Type of ACE a b c’ c (SE) value

Women
Abuse
Emotional -0.539 (0.070) 0.134 (0.031) -0.084 (0.028) -0.103 (0.028) -3.77 (0.019) 0.00016 18.5%
Physical -0.499 (0.072) 0.134 (0.031) -0.094 (0.032) -0.111 (0.032) -3.67 (0.018) 0.00024 14.9%
Sexual -0.352 (0.078) 0.139 (0.031) -0.116 (0.031) -0.128 (0.031) -3.18 (0.015) 0.00146 9.9%

Neglect
Physical -0.338 (0.079) 0.144 (0.031) -0.063 (0.029) -0.074 (0.029) -3.16 (0.015) 0.00158 14.7%
Emotional -0.551 (0.069) 0.134 (0.031) -0.091 (0.030) -0.108 (0.030) -3.80 (0.019) 0.00014 15.9%

Household Dysfunction
Mental illness
in household -0.570 (0.069) 0.128 (0.031) -0.114 (0.032) -0.134 (0.032) -3.72 (0.020) 0.00020 15.3%

Household
drug use -0.210 (0.083) 0.144 (0.031) -0.095 (0.025) -0.101 (0.025) -2.21 (0.014) 0.02696 5.6%

Parental
separation
or divorce -0.287 (0.082) 0.144 (0.031) -0.075 (0.033) -0.084 (0.033) -2.79 (0.015) 0.00523 10.9%

Men
Abuse
Physical -0.445 (0.069) 0.129 (0.027) -0.067 (0.027) -0.083 (0.026) -3.86 (0.015) 0.00011 19.5%
Sexual -0.170 (0.076) 0.133 (0.027) -0.082 (0.025) -0.087 (0.025) -2.04 (0.011) 0.04138 6.5%

Neglect
Emotional -0.484 (0.068) 0.129 (0.027) -0.049 (0.025) -0.067 (0.025) -4.00 (0.016) 0.00006 25.7%

Household
dysfunction
Mental illness
in household -0.609 (0.062) 0.125 (0.027) -0.056 (0.025) -0.079 (0.025) -4.22 (0.018) 0.00002 28.6%

Household
drug use -0.280 (0.077) 0.134 (0.027) -0.052 (0.023) -0.060 (0.023) -2.94 (0.013) 0.00329 13.2%

Note.
Sobel test and proportion of mediation obtained from logistic regression models that adjusted for
covariates including age-group, race, education, and childhood exposure to household problem
drinking; P-values drawn from the normal distribution under the assumption of a 2-tailed z-test.
The hypothesis is that the mediated effect equals zero.
a Excel spreadsheet and SPSS dichotomous outcome continuous variable syntax created by Nathaniel
R. Herr (February, 2006), Adopted from Kenny, 2006. Available at http://nrherr.bol.ucla.edu/
Mediation/logmed.html.
b Sobel test. http://people.ku.edu/~preacher/sobel/sobel.htm
c Equation (c-c’)/c

types of maltreatment (ie, physical, emo-
tional, and sexual abuse, physical and
emotional neglect, domestic violence,
parental separation or divorce, drug use
in household, mental illness in house-
hold, and incarceration of household mem-
ber) by gender. Second, the potential
mechanisms linking child maltreatment
to alcohol problems have been largely
unexplored.65 This study examined one
possible causal pathway, the potential
mediating effect of psychological distress.

™ 2012;36(3):408-423
Am J Health Behav.™ DOI: http://dx.doi.org/10.5993/AJHB.36.3.11 417
Childhood Experiences, Distress & Alcohol
We found that ACEs and psychological
distress were associated with an increased
risk of self-reported alcohol problems in
both men and women but that for each
gender, these relationships varied by type
of ACE. In other words, for each gender,
different ACEs were associated with self-
reported alcohol problems and the
strengths of these associations varied.
Among women, our results confirmed pre-
vious suggesting that a variety of ACEs
including abuse (emotional, physical,
sexual), neglect (emotional, physical), and
household dysfunction (parental separa-
tion or divorce, drug use in household,
and mental illness in household)61,66 were
related to self-reported alcohol problems.
Among men, we found that, in addition to
sexual abuse, self-reported alcohol prob-
lems may also be related to physical abuse,
emotional neglect, and various types of
household dysfunction (drug use in house-
hold, mental illness in household, and
incarcerated household member).
Given, the size of the study, we were
also able to address the potential impact
of psychological distress on the relation-
ship between ACEs and self-reported alco-
hol problems by gender. While psychologi-
cal distress mediated the relationships
between a greater number of ACEs and
self-reported alcohol problems among
women, the relationships that did exist
were markedly greater in men. Approxi-
mately 26% of the relationship between
emotional neglect and self-reported alco-
hol problems in men was mediated
through psychological distress as was 29%
of the relationship between mental ill-
ness in the household and self-reported
alcohol problems (as opposed to 15.9% and
15.3% respectively, among women).
Much research has already examined
potential biases and limitations of the
ACE Study data. Research conducted by
Felitti et al36 determined that respondent
and nonrespondent groups were similar
with regard to sociodemographic charac-
teristics (eg, percentages of women, mean
years of education, and marital status),
self-rated health, engagement in adverse
health behaviors (eg, smoking and other
substance abuse), and presence of chronic
diseases (eg, heart attack, stroke, chronic
obstructive lung disease, hypertension,
and diabetes). Edwards et al67 conducted
research examining potential recall bias
and found no evidence of response rate
bias; persons who did not participate in
418
the ACE Study experienced childhood
sexual abuse at the same rate as those
who agreed to participate and those who
participated in the study were equally as
likely as those who did not to attribute
current mental and physical health prob-
lems to childhood sexual abuse. Test-
retest reliability research was conducted
by Dube, Williamson, Thompson, Felitti,
and Anda et al68 who found that childhood
sexual, physical, and emotional abuse, as
well as forms of household dysfunction
(ie, mental illness in household, sub-
stance abuse in household, parental dis-
cord or divorce, incarcerated household
member, and domestic violence), showed
good to substantial Cohen’s Kappa agree-
ment as defined by Fleiss69 and Landis
and Koch70 (range = 0.46–0.86).
Other limitations should be consid-
ered. There are several limitations spe-
cific to the self-reported alcohol problem
question in this survey. First, there is no
information on the type of problem, the
extent of the problem, or when the prob-
lem existed. Second, the question only
captures those who recognize that they
have a problem with alcohol. Notably, how-
ever, assessment of methodological stud-
ies indicates that, for the general popula-
tion, self-reports of alcohol use are fairly
accurate.46 Furthermore, assuring respon-
dents of the confidentiality of their re-
sponses, which was part of the ACE Study
protocol, and providing responses in a
private setting (mail survey in the home
for the ACE Study) also enhances the
accuracy of self-reported alcohol abuse.46,47
Finally, the question assessing self-re-
ported alcohol problems in this survey
ask the respondent if they have “ever”
had a problem with alcohol. Given this, it
is possible that the alcohol problem pre-
ceded the ACEs. However a study con-
ducted by Schuck and Widom62 provides
support for making a causal inference
between ACEs and the development of
alcohol symptoms, particularly among
women. Longitudinal studies using more
detailed data on alcohol amount and pat-
terns may help further clarify the asso-
ciations between ACES, psychological dis-
tress, and alcohol use and abuse.
Other limitations should also be con-
sidered. First, only 65% of the eligible
participants were included in the study.
Second, given, the cross-sectional na-
ture of the ACE Study, the temporal rela-
tionships between psychological distress

and ACEs and between psychological dis-
tress and self-reported alcohol problems
were inferred from previous studies.4,32-
34,62,71
Third, the ACE Study specifically
assesses stress and trauma within the
childhood family environment and does
not explore broader environmental or po-
tential genetic factors or other potential
victimization or abuse that has occurred
over the life course. Fourth, due to the
nature of many of the variables (eg, abuse,
neglect, household dysfunction, alcohol
abuse) there may be social desirability
bias. Fifth, the ACE study does not contain
information on number or severity of ACE
events, which according to Schilling,
Aseltine, and Gore72 is more important in
determining emotional and behavioral
functioning than the cumulative fre-
quency of different types of adversities
experienced. Sixth, the ACE study does
not include the age of the respondent at
the time of the reported abuse. According
to a study conducted by Thornberry, Henry,
Ireland, and Smith,73 maltreatment that
occurs during adolescence is more strongly
associated with alcohol use and abuse
than maltreatment that occurs during
childhood. Seventh, given that persons in
the ACE Study are older and more edu-
cated than the general population, the
generalizability of the study may be lim-
ited. Notably, however ACE Study esti-
mates of maltreatment and household
dysfunction are similar to population-
based surveys.74 In 2 population-based
surveys of adults,75,76 16% of men reported
sexual abuse and 31% reported physical
abused; these findings are similar to the
16% and 30% of men, respectively, in the
ACE Study data collected in aggregated
survey years of 1995-1997.74 Similarly,
27% of women reported sexual abused in
the Finkelhor, et al75 study compared to
the 25% in the ACE Study.74 In contrast,
the 2009 Behavioral Risk Factor Surveil-
lance (BRFSS), the largest study of ACEs
in the general US population observed
that 59% of 26,000 adults in 5 states
reported at least one ACE, almost 7% of
men and 17% of women reported sexual
abuse during childhood, and 14% of men
and 15% of women reported physical
abuse.77 Eighth, it is not plausible that
women would have more exposure to sev-
eral of the ACEs (eg, household dysfunc-
tion) than men. This suggests that women
are more sensitive to several of the ACE
measures or are more willing to report
™ 2012;36(3):408-423
Am J Health Behav.™
Strine et al
them. Ninth, while psychological distress
was examined as a mediator in this analy-
sis, it is possible that it could be a con-
founder with unknown factors (eg, genet-
ics). Tenth, the data are from 1997. Fi-
nally, the questions about ACEs ask the
respondents to report childhood events.
Retrospective reporting can result in re-
call bias. However, longitudinal follow-up
studies of adults with documented child-
hood abuse histories suggested that ret-
rospective reports of childhood abuse of-
ten underrepresented actual events78-80
and that recall may not be as inaccurate
as originally anticipated.81-83
Given that alcohol use, alcoholism, and
alcohol abuse among men tends to be
higher than for women, the findings in
this study suggest that behaviors among
men may be influenced by early childhood
factors. The use of alcohol in this context
may be a mechanism to cope with dis-
tress and unresolved trauma, since alco-
hol is known to have mood modulating
effects.84,85 Given this, it may be impor-
tant to identify early childhood trauma
and adult psychological distress in pro-
grams that focus on reducing alcohol
abuse.
Acknowledgments
The findings and conclusions in this
article are those of the authors and do not
necessarily represent the official posi-
tion of the Centers for Disease Control
and Prevention. „
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 Strine et al

List of Authors and Affiliations

Tara W. Strine, Epidemiologist, Centers for Disease Control and Prevention; Office of
Surveillance, Epidemiology and Laboratory Services; Public Health Surveillance Pro-
gram Office; Division of Behavioral Surveillance; Atlanta, GA.
Shanta R. Dube, Lead Health Scientist, Office on Smoking and Health, National
Center for Chronic Disease Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, GA.
Valerie J. Edwards, Psychologist, Emerging Investigations and Analytic Methods
Branch, Division of Adult and Community Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta
GA.
Angela Witt Prehn, Core Faculty, Public Health, School of Health Sciences, College of
Health Sciences, Walden University, Minneapolis, MN.
Sandra Rasmussen, Clinical Director of Williamsville Wellness, Faculty at Walden
University, Senior Faculty at Cambridge College, Mechanicsville, VA.
Morton Wagenfeld, Faculty at Walden University, Faculty at Western Michigan
University, Walden University, Minneapolis, MN.
Satvinder S. Dhingra, Northrop Grumman Corporation, Contractor, Division of
Behavior Surveillance, Public Health Surveillance Program Office, Office of Surveil-
lance, Epidemiology and Laboratory Services, Centers for Disease Control and Preven-
tion, Atlanta, GA.
Janet B. Croft, Chief, Emerging Investigations and Analytic Methods Branch, Division
of Adult and Community Health, National Center for Chronic Disease Prevention and
Health Promotion, Centers for Disease Control and Prevention, Atlanta GA.

™ 2012;36(3):408-423
Am J Health Behav.™ DOI: http://dx.doi.org/10.5993/AJHB.36.3.11 423
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