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In my end is my beginning: developmental

trajectories of adverse childhood experiences to
late-life suicide
a b c c
Natalie J. Sachs-Ericsson , Nicole C. Rushing , Ian H. Stanley & Julia Sheffler
a
Department of Psychology, Florida State University, FL, USA
b
Department of Psychology, Coastal Carolina University, SC, USA
c
Department of Psychology, Florida State University, FL, USA
Published online: 11 Aug 2015.

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To cite this article: Natalie J. Sachs-Ericsson, Nicole C. Rushing, Ian H. Stanley & Julia Sheffler (2015): In my end is my
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 Aging & Mental Health, 2015
http://dx.doi.org/10.1080/13607863.2015.1063107

In my end is my beginning: developmental trajectories of adverse childhood experiences to

late-life suicide
Natalie J. Sachs-Ericssona*, Nicole C. Rushingb, Ian H. Stanleyc and Julia Shefflerc
a
Department of Psychology, Florida State University, FL, USA; bDepartment of Psychology, Coastal Carolina University, SC, USA;
c
Department of Psychology, Florida State University, FL, USA
(Received 25 February 2015; accepted 9 June 2015)

Objectives: Converging evidence suggests that the sequelae of adverse childhood experiences (ACEs) including childhood
abuse (e.g., sexual, physical, emotional/verbal abuse, neglect) and other ACE (e.g., family dysfunction, parental loss,
parental psychopathology, substance abuse, incarceration, and domestic violence) have pronounced effects on suicidal
behaviors (suicidal ideation, attempts, and death by suicide) in older age. There are fundamental changes in the
developmental trajectory of biological, psychological and behavioral processes that result from ACE and that exert
Downloaded by [University of New England] at 08:46 14 August 2015

influence throughout the life span. Different moderators and mediators may affect the extent and nature of the relationship.
However, the literature on the specific mechanisms whereby ACE affects suicidality in later life has not been well
identified.
Method: We review and draw from extant multidisciplinary evidence to develop a heuristic framework through which to
understand how ACE may lead to suicide in later life.
Results: Proposed mechanisms span biological factors (neurological, gene-environment), psychiatric and health
functioning, and psychosocial development (cognitive biases, coping resources, interpersonal deficits). Evidence suggests
that ACEs affect each of these constructs, and it is likely in the interaction of these constructs with late-life stressors that
suicidality in older adulthood emerges.
Conclusion: ACEs have persistent and multifaceted effects on suicidality in late life. This association is due to multi-varied
pathways. It is believed that the explanatory framework developed herein in which biological, psychological and
behavioral factors are organized, and the role of late-life stressors is highlighted will spark further scientific inquiry into
this important area.
Keywords: late-life suicide; child abuse; psychosocial and cultural aspects

Introduction depression, disability and functional limitations in older

In my end is my beginning (Eliot, 1943). Old age is an
important predictor of death by suicide (Chan, Draper, &
Banerjee, 2007), and adverse childhood experiences
(ACEs) may contribute to late-life suicide. The most com-
monly studied ACE is childhood abuse (e.g., sexual, phys-
ical, emotional/verbal abuse and neglect). In addition to
childhood abuse, ACEs typically include measures of
family dysfunction comprised of indices of parental psy-
chopathology, substance misuse, incarceration, parental
loss, family/domestic violence, and low socioeconomic
status (SES, Green et al., 2010).
While there had been a growing literature on the nega-
tive effects of childhood abuse, more recently researchers
have been evaluating the simultaneous effect of the clus-
tering of ACE. Importantly, childhood sexual, physical
and verbal abuse tend not to occur in isolation but often
co-occur with these other ACE, such that the unique
effects of each specific abuse or ACE are often difficult to
determine (Felitti et al., 1998; Fleming, Mullen, &
Bammer, 1997; Kenny & McEachern, 2000; Molnar,
Buka, & Kessler, 2001). Indeed, there is strong evidence
that ACEs are highly interrelated (Dong et al., 2004).
Moreover, the greater the number of ACE, the greater the
adults (Shrira & Litwin, 2014) and increased suicidal ide-
ation across the lifetime (Dube, Felitti, Dong, Giles, &
Anda, 2003).
Definitions of ACE
Definitions of ACE vary across studies (see Gershon, Sud-
heimer, Tirouvanziam, Williams, & O’Hara, 2013; Green-
field, 2010), leading to difficulties in interpretation of
results. Therefore, in this paper, for each study reviewed
we briefly include the definition of ACE utilized within
the cited study. Perhaps the most well-known definition of
ACE comes from the ACE study, one of the largest inves-
tigations ever conducted to assess associations between
childhood maltreatment and later-life health and well-
being (see http://www.cdc.gov/violenceprevention/
acestudy) (Dube et al., 2003). In this investigation, the
measures of ACE included ‘childhood emotional, physi-
cal, sexual abuse, as well as parental pathology, substance
abuse or incarceration’. In Gershon et al.’s (2013) recent
review of the effects of ACE on psychiatric disorders in
late life, they suggest that the definition of ACE should be
‘acute or chronic stressful events which may be biological

*Corresponding author. Email: sachs@psy.fsu.edu

Ó 2015 Taylor & Francis

 2 N.J. Sachs-Ericsson et al.
or psychological in nature, occurring during childhood
and resulting in a biological and/or psychological stress
response’.
Additionally, a key source of knowledge on the effects
of early-life stress on neurobiology and on the HPA stress
response has been derived from animal models as well as
human models. Indeed, the strongest evidence to date sug-
gesting that the development of the HPA axis may be
affected by early-life stressful experiences comes from
pre-clinical animal studies (Shea, Walsh, Macmillan, &
Steiner, 2005).
Suicide definitions
In this paper, we review and draw from extant multidisci-
plinary evidence to develop a heuristic framework
through which to understand how ACE may lead to sui-
cide in later life. In conducting and describing research on
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suicide, it is helpful to provide definitions of each point
along the continuum of suicidal thoughts and behaviors
(Silverman, Berman, Sandaal, O’Carroll, & Joiner, 2007;
Silverman, Berman, Sanddal, O’Carroll, & Joiner, 2007).
Leading medical organizations, including the Centers for
Disease Control and Prevention (CDC), encourage the use
of standardized nomenclature (Crosby, Ortega, & Melan-
son, 2011). According to the CDC’s uniformed definitions
(Crosby et al., 2011), suicide ideation refers to serious
“thoughts of engaging in suicide-related behavior” (p.
90). Suicide attempts refer to “non-fatal self-directed
potentially injurious behavior with any intent to die as a
result of the behavior” that may or may not result in injury
(p. 21). Suicide (or death by suicide) refers to “death
caused by self-directed injurious behavior with any intent
to die as a result of the behavior” (p. 23). Importantly,
researchers study ideation as well as attempts, since each
are very important predictors of death by suicide (Wenzel
et al., 2011).
ACE and suicide
Research has shown that ACEs (e.g., childhood emo-
tional, physical, sexual abuse, and parental pathology or
loss, substance abuse or incarceration) lead to an
increased risk for suicidal ideation and suicidal attempts
throughout the life span in general population samples
(Dube et al., 2001, 2003; Natalie Sachs-Ericsson, Corsen-
tino, Rushing, & Sheffler, 2013) and in clinical samples
(Brodsky et al., 2001; Lopez-Castroman et al., 2015;
McHolm, MacMillan, & Jamieson, 2003). Having experi-
enced ACE in childhood (physical or sexual abuse,
domestic violence) was found to account for a substantial
proportion of variance in predicting suicidal ideation and
attempts among women (16% and 50%, respectively) and
men (21% and 33%, respectively; Afifi et al., 2008). For
suicide attempts, Dube et al. (2001) found the population-
attributable risk fractions for one or more ACE (e.g.,
childhood emotional, physical, sexual abuse, and parental
pathology or loss, substance abuse or incarceration) were
67%, 64%, and 80% for lifetime, adult, and childhood/
adolescent suicide attempts, respectively.
In one of the few prospective population studies (Enns
et al., 2006), ACE (e.g., emotional neglect, psychological,
physical or sexual abuse, parental pathology, deficient
parental bonding) predicted suicidal behavior. Specifi-
cally, childhood neglect, psychological and physical
abuse was strongly associated with new onset suicidal ide-
ation and suicide attempts. Odds ratios (ORs) ranged from
2.80 to 4.66 for new onset suicidal ideation and from 3.60
to 5.43 for new onset suicide attempts.
While few studies have examined the differential
effects of specific types of ACE on negative outcomes
(Liu, Jager-Hyman, Wagner, Alloy, & Gibb, 2012), there
is limited evidence of unique effects (see Gershon et al.,
2013). However, some research has pointed to both child-
hood sexual and physical abuse as having the strongest
association to suicidal behaviors (Bruffaerts et al., 2010;
Hardt et al., 2008). Others have found sexual abuse to
have the strongest association with suicidal ideation or
attempts (Molnar et al., 2001). In a review article (Brod-
sky & Stanley, 2008), researchers concluded that a history
of any childhood abuse (e.g., physical, sexual and
neglect), but particularly sexual abuse, creates a vulnera-
bility to suicidal behavior in adulthood. In a meta-analy-
sis, Paolucci, Genuis, and Violato (2001) found the
average unweighted and weighted ds for the relationship
between sexual abuse (any unwanted sexual contact) and
suicidality (suicidal ideation, plan or attempt) were .64
and .44, respectively. In a recent meta-analysis, Devries
et al. (2014) found childhood sexual abuse to be associ-
ated with suicide attempts even when a range of different
confounders (including other types of abuse and parental
pathology) were controlled. Specifically, the overall
pooled estimate for the longitudinal studies was OR D
2.43, and the pooled OR from co-twin analysis was 2.65.
In another large meta-analysis (Bruffaerts et al., 2010),
researchers found an association between ACE (physical
abuse, sexual abuse, neglect, parental loss, family vio-
lence, physical illness and financial adversity) and
increased odds of a suicide attempt (OR D 1.3 5.7) and
ideation (OR D 1.2 3.4). However, physical and sexual
abuse consistently yielded the highest odds for both sui-
cide attempt and ideation (OR D 3.7 5.7 and OR D
2.7 3.4, respectively; Bruffaerts et al., 2010).
In regard to abuse type, Joiner et al. (2007) found, con-
sistent with the interpersonal theory of suicide (Van Orden
et al., 2010), that compared to verbal abuse, violent physi-
cal or sexual abuse in childhood had stronger effects on
lifetime suicide attempts, whereby more painful experien-
ces confer elevated suicide risk through habituation to
pain. Nonetheless, they concluded that the overall pattern
of findings suggests that childhood abuse of any type has
the potential to influence increased suicidality throughout
the life span. Indeed, Van Orden et al. (2010) suggest that
early childhood abuse affects all three core constructs of
Interpersonal Theory of Suicide by augmenting feelings of
social alienation (thwarted belongingness) and expendabil-
ity (perceived burdensomeness), in addition to increasing
habituation to and tolerance of pain (acquired capability).
Whereas much of the research on childhood abuse and
suicide has focused on adolescence and young adults,
 Aging & Mental Health
there is a growing body of research showing the relation-
ship between ACE and suicidality continues throughout
the life span. Specifically, Bruffaerts et al. (2010) found
that ACE (childhood physical and sexual abuse, parental
loss, financial adversity, illness) had the strongest associa-
tions with suicide attempts in childhood (median signifi-
cant OR D 3.8), decreasing during teen years (median
significant OR D 2.5) and young adulthood (median sig-
nificant OR D 2.0), and increasing in later adulthood
(median significant OR D 2.3). In a study of older adults,
Beautrais (2002) found that those with serious suicidal
behavior (death by suicide or medically serious attempts)
were more likely than comparison subjects to have been
exposed to childhood sexual abuse. In another study of
older adults (Chou, 2012) sexual abuse was associated
with past-year suicidal ideation (sexually abused OR D
6.2 versus non-abused OR D 2.4, CI D 1.5 to 4.95) but
not past-year suicide attempts. In a large study of older
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adults, Draper et al. (2008) found physical and sexual
abuse to be associated with lifetime suicide attempts.
Specifically, the OR for those with no abuse history was
OR D 1.7, for those who had experienced either physical
or sexual abuse the OR D 8.2 (CI D 4.4 6.3), and for
those experienced both physical and sexual abuse the
OR D 11.6 (CI D 6.0 10.0).
A summary of key articles demonstrating an associa-
tion between ACE and suicidal behavior in older adults,
as well as in general and clinical populations, are reported
in Table 1. Table 2 includes articles cited in this paper
that identified association between ACE and other nega-
tive health and psychological outcomes. The tables also
include the definition of ACE and definition of suicidal
behaviors used in the specific study. Mediators and/or
moderators examined in the study are reported.
Characteristics of ACE and late-life suicide
Researchers have examined specific characteristics of
childhood sexual abuse in relation to negative outcomes
(see Castellini, Maggi, & Ricca, 2014). Aspects of the
sexual abuse such as age when sexual abuse first
started, frequency, severity and characteristics of the per-
petrator, and number of perpetrators may have differen-
tial impact on its effects (Charles, 2010; Liu et al., 2012;
Steel, Sanna, Hammond, Whipple, & Cross, 2004). Addi-
tionally, the clustering of co-occurring ACE may differen-
tially influence the type of negative life outcomes (Barel,
Van, Sagi-Schwartz, & Bakermans-Kranenburg, 2010;
Green et al., 2010; Harford, Yi, & Grant, 2014; P. Pechtel
& Pizzagalli, 2011; Stenager, Christiansen, Handberg, &
Jensen, 2014). As mentioned above, the degree of physi-
cal pain experienced in the abuse has been identified as an
important contributor to suicide risk (Joiner et al., 2007).
Nonetheless, as others have stated (Barker-Collo & Read,
2003), no single variable can, on its own, account for indi-
vidual variation in the type or severity of symptom devel-
opment from ACE. There is likely a complex interaction
between abuse-related factors, interactions with others
and individual factors as mediators and moderators of out-
comes. The complexity in understanding the unique and
3
combined effects of childhood abuse and other ACE on
late-life suicide is daunting. This is due, in great part, to
the multiple effects of ACE on the biological, behavioral
and psychological development of the individual. ACE
have a cascade of rippling negative effects that persist
into older age. Those who are exposed to ACE may be set
on a trajectory of disadvantage that ultimately results in
negative psychological and health outcomes (Irving &
Ferraro, 2006).
Mechanisms underlying ACE and late-life suicide
ACE may affect basic biological and neural mechanisms
that alter an individual’s response to subsequent adversity
and increase risk for health and psychiatric difficulties.
ACE may affect the development of negative cognitive
styles, ineffective coping, and interpersonal difficulties.
These processes may contribute to difficulties coping with
the unique stressors that occur in later life and thus lead to
increased suicidal risk. ACE may increase risk for late-
life suicidal ideation, attempts and death by suicide via
several mechanisms (see Figure 1):
(1) Biological processes:
a. Neurological: ACEs lead to changes in the
developmental trajectory of the brain such that
the individual is much more psychologically
and physiologically sensitive to subsequent
stressors.
b. Gene-environment: suicide is a complex
behavior involving gene-environment interac-
tions (Bani-Fatemi, Howe, & De Luca, 2014).
ACE may interact with genetic predisposition
to increase risk of mood dysregulation, psychi-
atric disorders and suicidal ideation and
behavior.
(2) Psychiatric and health comorbidity:
a. Psychiatric: ACE influences the development
of neuropsychiatric disorders in late-life
(Gershon et al., 2013). Psychiatric disorders
increase risk for suicide.
b. Health functioning: ACE is associated with
increased health problems, disability and all-
cause mortality (Kelly-Irving et al., 2013).
Functional impairment in older age is associ-
ated with suicide (Conwell, Van Orden, &
Caine, 2011b; Draper et al., 2008).
(3) Psycho-social development:
a. Cognitive biases: ACE may shape the child’s
development of cognitive processes associated
with depression, anxiety and suicidal behavior.
b. Problem solving, coping, and modulating
strong affective states: childhood sexual and
physical abuse has been found to lead to the
development of less effective, passive coping
styles that contributes to deficits in ability to
modulate strong affect (Valle & Silovsky,
2002).
c. Interpersonal deficits: ACE leads to interper-
sonal deficits which undermine relationships
 Downloaded by [University of New England] at 08:46 14 August 2015

4
Table 1. Adverse childhood experiences (ACE) and suicide.

Sample characteristics
Author (year) Sample size (age range/mean) ACE Mediator/moderator covariate Suicide outcome measure (s)

Select population studies of older adults

Beautrais (2002) N D 53 (death by Individuals who died by suicide Childhood sexual abuse, parental Mood disorders, psychiatric Death by suicide, medically serious
suicide or (55 years and older) or made care, parental bonding. admissions, social network suicide attempt, or Control
serious attempt) serious attempt
N D 269 (controls) Stressful life events
Bruffaerts N D 55,299 Mean age not given; population Childhood physical and sexual Lifetime mental disorder Lifetime suicide ideation, plans, and
et al. (2010) analyzed across the lifespan abuse, parental loss, financial attempts
adversity, illness
Chou (2012) N D 3,493 Population-based, nationally Childhood sexual abuse (sexual Gender Suicidal ideation and suicidal
representative sample of touching and sexual intercourse) attempts in the past year
community-dwelling adults (over
50)
Revictimization
Draper et al. (2008) N D 21,819 (over 60; M D 71.9) Childhood physical and sexual Social Support Suicide attempt (six health
abuse before age 15 outcomes (depressed affect,
lifetime suicide attempts,
multiple sexual partners, STD,
smoking, alcoholism)
Covariates: age, sex, birthplace,
marital status, educational living
arrangements, religion
Dube et al. (2001) N D 17,337 Primary care clinic patients (M age (ACEa study Questionnaire) Number of ACE
D 57) (M D 57 years, SD D 15.2 emotional, physical, and sexual
N.J. Sachs-Ericsson et al.

years) abuse; household substance

abuse, mental illness, and
incarceration; and parental
domestic violence, separation, or
divorce.
Dube et al. (2003) N D 17,337 Four birth cohorts: 1900 1931; (ACEa study Questionnaire) Cohort effects Suicide attempts (also depressed
1932 1946; 1947 1961; affect, multiple sexual partners,
1962 1978 (M D 57 years, SD D sexually transmitted diseases,
15.2 years) smoking, and alcoholism)
Number of ACE experiences
Sachs-Ericsson N D 1610 Nationally representative sample Childhood physical (beaten or Participants’ internalizing & Late-life suicide ideation (‘Have
et al. (2013) (over 60 years) physically abused by parent/ externalizing symptoms. (DSM- you ever seriously thought about
caregiver) and sexual abuse IV; CIDI; WHO, 1990) committing suicide?’ including
(raped or sexually molested) only participants who endorsed
occurring at age 15 and under. thoughts after the age of 60
Gender, age, and parental
externalizing and internalizing
symptoms.

(continued)
 Downloaded by [University of New England] at 08:46 14 August 2015

Table 1. (Continued )

Sample characteristics
Author (year) Sample size (age range/mean) ACE Mediator/moderator covariate Suicide outcome measure (s)

Select population and clinical samples

Afifi et al. (2008) N D 5,692 (NCS-R) Nationally representative Sexual abuse, physical abuse, and Gender & Number of ACE Suicide ideation (Seriously thought
(age over 18 years) domestic violence about Suicide)
Suicide attempt (Made a Serious
attempt)
Brodsky N D 136 Two patient samples who met DSM- Childhood physical or sexual abuse Impulsivity, Aggression Suicidal behavior in depressed
et al. (2001) III-R criteria for major depressive before age 15 (3 questions from adults (Columbia Suicide History
(M D 39.5) (M D 34.9) Columbia Demographic and Form)
Treatment History Interview)
Brodsky and Review article Adults Physical and sexual abuse; parental Gender, Abuse type; characteristics Suicidal behaviors
Stanley (2008) neglect of perpetrator, characteristics of
abuse experience, impulsivity
and aggression, diagnostic
comorbidity
Devries et al. (2014) Meta-analysis 7 longitudinal and 2 twin studies Childhood sexual abuse Controlled for early family violence, Suicide attempts
N D 8,733 (No mean age reported) other mental disorders, and other
abuse
Enns et al. (2006) N D 5,618 Adults ages 18 64 years Emotional neglect, psychological, Demographic characteristics, mental Suicide ideation, plans, and attempts
physical or sexual abuse, parental disorders, number of ACE
pathology, deficient parental
bonding
Aging & Mental Health

Hardt et al. (2008) N D 575 M D 44.7 years, SD D 11.6 years Harsh physical punishment, severe Gender Suicide ideation, plans, and attempts
sexual abuse, chronic illness,
parental loss, parental substance
abuse, domestic violence,
financial hardship
Joiner et al. (2007) N D 5,838 Adults 18 65 years (M D 33.2, SD Childhood physical and violent Severity of painful abuse, Lifetime suicide attempts
D 10.7) sexual abuse compared to participants’ psychiatric
molestation and verbal abuse diagnoses, parental psychiatric
symptoms, parental loss, family
conflict
Lopez-Castroman N D 726 Adult patients who had attempted Emotional abuse, emotional neglect, PTSD (MINI criteria for current or Suicide attempts (semi-structured
et al. (2015) suicide (18C; M D 39.6) physical abuse, physical neglect past PTSD) interview based on Columbia
and sexual abuse; Childhood Suicide History Form (CSHF,
trauma Questionnaire (CTQ); Oquendo, Halberstam, & Mann,
Bernstein & Fink, 1998)b 2003) and the Section O of the
DIGS; Nurnberger et al., 1994)

(continued)
5
 Downloaded by [University of New England] at 08:46 14 August 2015

Table 1. (Continued )

Sample characteristics
Author (year) Sample size (age range/mean) ACE Mediator/moderator covariate Suicide outcome measure (s)

McHolm et al. (2003) N D 347 Women (age 15 64 years) from a
community sample who met
criteria for major depressive
disorder (lifetime prevalence)
Molnar et al. (2001) N D 5,877 (NCS) Adolescents and adults ages
15 54 years.
Paolucci et al. (2001) N D 25,367 Meta-analysis of 37 studies
published between 1981 and
1995
The effect of ACE on biological processes directly related to suicide
Cicchetti et al. (2010) N D 478 School-aged children (ages 6 13;
maltreated; N D 372 M D 9.19)
non-maltreated
Childhood physical abuse (The
Child Maltreatment History Self-
Report; MacMillan et al., 1997)
Sexual abuse, parental verbal and
physical abuse, domestic
violence, parental
psychopathology
Sexual abuse, (e.g., any unwanted
sexual contact)
Childhood maltreatment from
Social Services records:(i.e.,
neglect, emotional maltreatment,
physical & sexual abuse (The
Psychiatric disorders
Current age
Age of onset
Income
Psychiatric disorders, parental
psychopathology, abuse other
than sexual
Gender, socioeconomic status, type
of sexual abuse, age of abuse,
perpetrator, number of abuse
incidents
5-HTTLPR Genotype
Suicide ideation and attempts (two
interview questions: 1) “Have
you ever thought about
committing suicide?” and 2)
“Have you ever attempted
suicide?”)
Suicide ideation and attempts
Recurrent thoughts of death or
suicidal ideation, plans, attempts,
or gestures of self-harm with
death as a possible end result
Suicidal ideation (from Children’s
Depression Inventory; Kovacs,
1992)
N.J. Sachs-Ericsson et al.

Maltreatment Classification
System; Barnett et al., 1993)
Gibb N D 30 General psychiatric inpatient unit Childhood emotional, sexual and 5-HTTLPR genotype Lifetime history of suicide attempts
et al. (2006) (M D 37.31 for 5HTTLPR ss/sl; physical abuse, physical and (intentional self-injury with an
M D 34.93 for 5-TTLPR ll) emotional neglect (CTQ)b intent to die from patients’
medical charts)
Perroud N D 813 Caucasian suicide attempters (M D Childhood emotional, sexual and BDNF Val66Met genotype Violent or non-violent suicide
et al. (2008) 39.8 years) physical abuse, physical and attempts (criteria by Asberg,
emotional neglect CTQ)b Traskman, & Thoren, 1976;
Diagnostic Interview for Genetics
Studies or MINI)
Pregelj N D 359 suicide Caucasian Slovenians from autopsy Stressful life events in childhood BDNF Val66Met Violent and non-violent suicide
et al. (2011) victims; study (suicide victims (M D (physical, emotional, sexual (classification not defined)
N D 201 controls 49.3); controls (M D 47.2) abuse, general trauma, parent
death, divorce or other mental
disorders)

(continued)
 Downloaded by [University of New England] at 08:46 14 August 2015

Table 1. (Continued )

Sample characteristics
Author (year) Sample size (age range/mean) ACE Mediator/moderator covariate Suicide outcome measure (s)

Roy et al. (2010) N D 474 2 subsamples of African American Childhood emotional, sexual and FKBP5, an HPA-axis regulating Suicidal Attempt(defined as “a self-
participants; 112 suicide physical abuse, physical and gene destructive act with some intent
attempters and 362 non-suicide emotional neglect (CTQ)b to end one’s life that was not self-
attempters (M D 45.2 and M D mutilatory in nature”)
34.3)
Roy et al. (2012) N D 474 2 subsamples of African American Childhood emotional, sexual and CRHBP & FKBP5 genotypes Suicidal Attempt (defined as “a self-
participants; 112 suicide physical abuse, physical and (involved in HPA-axis activity) destructive act with some intent
attempters and 362 non-suicide emotional neglect (CTQ)b to end one’s life that was not self-
attempters (M D 45.2 and M D mutilatory in nature”)
34.3)
a
ACE study questionnaire:
Emotional abuse. Emotional abuse was determined from answers to 2 questions from the CTS: (1) “How often did a parent, stepparent, or adult living in your home swear at you, insult you, or put you down?” and (2) “How
often did a parent, stepparent, or adult living in your home act in a way that made you afraid that you might be physically hurt?” Responses of “often” or “very often” to either item defined emotional abuse during childhood.
Physical abuse. A 2-part question from the CTS was used to describe childhood physical abuse: “Sometimes parents or other adults hurt children. How often did a parent, stepparent, or adult living in your home (1) push, grab,
slap, or throw something at you or (2) hit you so hard that you had marks or were injured?” A respondent was defined as being physically abused if the response was “often” or “very often” to the first part or “sometimes,”
“often,” or “very often” to the second part.
Sexual abuse. Four questions were used to define contact sexual abuse during childhood: “Some people, while they are growing up in their first 18 years of life, had a sexual experience with an adult or someone at least 5 years
older than themselves. These experiences may have involved a relative, family friend, or stranger. During the first 18 years of life, did an adult, relative, family friend, or stranger ever (1) touch or fondle your body in a sexual
way, (2) have you touch their body in a sexual way, (3) attempt to have any type of sexual intercourse with you (oral, anal, or vaginal), or (4) actually have any type of sexual intercourse with you (oral, anal, or vaginal)?” A
“yes” response to any of the 4 questions classified a respondent as having experienced contact sexual abuse during childhood.
Battered mother (domestic violence). Four questions from the CTS to define childhood exposure to a battered mother. “Sometimes physical blows occur between parents. How often did your father (or stepfather) or mother’s
boyfriend do any of these things to your mother (or stepmother)? (1) Push, grab, slap, or throw something at her, (2) kick, bite, hit her with a fist, or hit her with something hard, (3) repeatedly hit her over at least a few minutes,
or (4) threaten her with a knife or gun, or use a knife or gun to hurt her.” A response of “sometimes,” “often,” or “very often” to either the first or second question or any response other than “never” to either the third or the
fourth question defined a respondent as having had a battered mother.
Aging & Mental Health

Household substance abuse. Two questions asked whether respondents, during their childhood, lived with a problem drinker or alcoholic or with anyone who used street drugs. An affirmative response to either of these ques-
tions indicated childhood exposure to substance abuse in the household.
Mental illness in household. A “yes” response to the question “Was anyone in your household mentally ill or depressed?” defined this adverse childhood experience.
Parental separation or divorce. This experience was defined as a “yes” response to the question “Were your parents ever separated or divorced?”
Incarcerated household members. This experience was defined as having had childhood exposure to a household member who was incarcerated.
b
Childhood trauma questionnaire (CTQ):
The original CTQ is a 70-item self-administered inventory that was developed to provide reliable and valid retrospective assessment of child abuse and Items on the CTQ ask about experiences in childhood and adolescence and
are rated on a 5-point, Likert-type scale with response options ranging from Never True to Very Often True. The CTQ has five clinical scales physical, sexual, and emotional abuse, and physical and emotional neglect
which have been empirically derived.
Sexual abuse was defined as “sexual contact or conduct between a child younger than 18 years of age and an adult or older person.” Physical abuse was defined as, “bodily assaults on a child by an adult or older person that
posed a risk of or resulted in injury.” Emotional abuse was defined as, “verbal assaults on a child’s sense of worth or well-being or any humiliating or demeaning behavior directed toward a child by an adult or older person.”
Physical neglect was defined as, “the failure of caretakers to provide for a child’s basic physical needs, including food, shelter, clothing, safety, and health care” (poor parental supervision was also included in this definition if it
place children’s safety in jeopardy). Emotional neglect was defined as, “the failure of caretakers to meet children’s basic emotional and psychological needs, including love, belonging, nurturance, and support.”
7
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Table 2. Adverse childhood experiences (ACE) and negative outcomes.
Sample characteristics (age range/
Author (year) Sample size mean age)
Biological processes
Bet et al. (2009) N D 906 Random sample of older men and
women from the Longitudinal
Aging Study Amsterdam (ages
55 85; M D 77)
Caspi et al. (2003) N D 847 Birth cohort of Caucasian non-
Maori followed from age 3 to 26
(M D 26)
Guillaume N D 218 Caucasian suicide attempters
et al. (2013) (M D 39.71) recruited from the
University Hospital of
Montpellier
Karg, et al. (2011) N D 40,749 Meta-analysis of 54 studies
Labont
e et al. (2012) N D 41 French Canadian men (25 with Hx
of severe childhood abuse (M D
37.3) and 16 controls (M D 40.9)
McGowan N D 36 post- Postmortem study examining three
et al. (2009) mortem groups: suicides with child abuse
(M D 34.2), suicides without
abuse (M D 33.8), and controls
(M D 35.8)
Perroud et al. 2011 N D 101 Participants with BPD seeking
dialectical behavior therapy
(M D 30.76)
Uher et al. (2011) N D 847 for Sample 1 D birth cohort followed
Sample 1 from age 3 to 32 (M D 32);
N D 930 Sample 2 D mothers of twins
Sample 2 (M D 33)
8
Predictor variable (s) Mediator/moderator covariates Outcome measure (s)
Childhood adversity (exposed to Glucocorticoid receptor (GR) The Center for Epidemiological
childhood sexual abuse, war; polymorphisms 22/23EK and Studies-Depression Scale (CES-
impaired physical health, death or 9beta D; Radloff, 1977)
separation of parents)
Stressful life events in early twenties 5-HTTLPR Genotype Depressive symptoms (DSM-IV
(Life history calendar, e.g., Sex as a covariate criteria)
employment, financial, housing,
health, and relationship stressors)
Childhood emotional, sexual & HPA-axis related genes CRHR1 and Decision-making skills based on the
physical abuse, physical & CRHR2 Iowa Gambling Task (Bechara,
emotional neglect (CTQ)b Damasio, & Damasio, 2000)
maltreatment (child abuse, child 5-HTTLPR genotype Depression
maltreatment, family
dysfunction) negative life events
(serious health problems,
exposure to natural disasters)
sexual contact, severe physical N/A Epigenetic alterations in the
abuse and/or severe neglect promoters of several genes in
(adapted Childhood Experience hippocampal neurons
of Care and Abuse; Bifulco,
Brown, & Harris, 1994)
N.J. Sachs-Ericsson et al.
Childhood abuse/neglect (sexual N/A neuron-specific glucocorticoid
contact, severe physical abuse receptor (NR3C1) promoter
and/or severe neglect)
Childhood emotional, sexual & N/A NR3C1 methylation status
physical abuse, physical &
emotional neglect (CTQ)b
Childhood maltreatment and
assessment of severity)
Sample 1: observations of rejecting 5-HTTLPR genotype Persistent vs. Single-episode
mother, (b) parental reports of depression based on DSM-IV
harsh discipline, multiple criteria
caregivers, sexual & physical
abuse.
Sample 2 D Childhood emotional,
sexual & physical abuse, physical
& emotional neglect (CTQ)b.
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Table 2. (Continued )

Sample characteristics (age range/

Author (year) Sample size mean age) Predictor variable (s) Mediator/moderator covariates Outcome measure (s)

Psychiatric and health morbidity

Bonomi, et al. (2008) N D 3,568 Insured women (ages 18 64)
Chou (2012) N D 3,493 Population-based, nationally
representative sample of
community-dwelling adults (over
50)
Draper et al. (2008) N D 21,819 Australian older adults with and
without history of physical abuse
(over 60; M D 71.9)
Dube et al. (2003) N D 8,614 Adult members of the Kaiser Health
Plan
8613 adults 55 years (§15.5 years) for women
and 57 years (§14.5 years) for
Childhood physical and sexual
abuse (Behavioral Risk Factor
Surveillance System; Thompson
et al., 2006)
Childhood sexual abuse (sexual
touching and sexual intercourse)
Childhood physical and sexual
abuse before the age of 15.
(ACE score)a
Abuse type or combination of abuse
types
Gender, revictimization
Social support
Covariates: age, sex, birthplace,
marital status, educational living
arrangements, religion.
Age
Number of ACE
Women’s health (SF-36; Ware et
al., 2000)
Six mental disorders (ICD-10)
(depressive episode, mixed
anxiety & depression,
generalized anxiety, panic,
phobia, obsessive-compulsive
disorder) and Service utilization
Current physical health (12-item
survey & Common Medical
Morbidities Inventory) and
Mental Health (PHQ-9; Kroenke,
Spitzer, & Williams, 2001;
HADS; Spinhoven et al., 1997)
Illicit drug use
Aging & Mental Health

men
Kelly-Irving N D 18558 all live births during one week in Child in foster care, physical neglect Number of ACE Cancer risk
et al. (2013) 1958 (n D 18558) family’s contact with the prison
service, 4) parental separation 5)
family mental or substance abuse.
Longitudinal over
50 years
Kraaij and de N D 194 Community sample of older adults Childhood emotional, physical & Number of adverse or stressful Depression (Geriatric Depression
Wilde (2001) (aged over 65; M D 76.5) sexual abuse, parental loss, experiences in childhood and in Scale, Brink, Yesavage, Lum,
serious illness, financial adulthood. Heersema, Adey, & Rose, 1982)
difficulties. Life stressors as an
adult (domestic violence, illness,
etc.) (Life Events Questionnaire
(Kerkhof, Schmidtke, Bille-
Brahe, de Leo, & Lonnqvist,
1994),
Interaction between child abuse and
late-life stress
Age
9

Gender

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10
Table 2. (Continued )

Sample characteristics (age range/

Author (year) Sample size mean age) Predictor variable (s) Mediator/moderator covariates Outcome measure (s)

Liu, Jager-Hyman, N D 299 University Freshmen 173 high-risk Childhood emotional, physical, and uniquely effects of abuse Depressive episodes in adulthood
et al. (2012) (M D 18.64) and 176 low-risk sexual abuse (Subscales of the experiences, negative inferential (Schedule for Affective Disorders
(M D 18.95) participants Lifetime Experiences style and Schizophrenia-Change
Questionnaire; Gibb et al., 2001) Interview; Spitzer et al., 1978)
McLaughlin N D 34,653 Nationally representative sample (CTSc, Straus, 1979). Adult stressful life events DMS-IV criteria for 12-month
et al. (2010) (over 18) prevalence of major depression,
posttraumatic stress disorder
(PTSD), other anxiety disorders,
(CTQ)b. Perceived stress
gender
Raposo et al. (2014) N D 34,653 Nationally representative U.S. ACEa Age across adult cohorts lifetime Past-year mood and anxiety
(including 7,080 sample of community dwelling treatment-seeking number of disorders, and lifetime
adults over 65) adults (over 20) ACE personality disorders
Sachs-Ericsson N D 1,090 Participants (over 50) from The Childhood physical (beaten or Self-esteem (Rosenberg self-esteem Internalizing disorders (DSM-IV
et al. (2010) Physical Health and Disability physically abused by parent/ scale; Rosenberg, 1979) psychiatric diagnoses based on
Study caregiver), sexual abuse (raped or the CIDI; World Health
sexually molested), and Organization, 1990)
emotional abuse (ever
emotionally abused by
caretakers?) (items from the
PTSD module of CIDI)
Sachs-Ericsson N D 1,727 With National Comorbidity Survey sub- Childhood physical (beaten or Depression (CIDI) Pain from health problems (“How
et al. (2007) current health sample, the average age was 36.2 physically abused by parent/ much pain do you experience as a
N.J. Sachs-Ericsson et al.

problems (SD D 10.8), caregiver) and sexual abuse result of your health problems?”)
(raped or sexually molested) from
PTSD module of CIDI
Family of origin characteristics
Sachs-Ericsson N D 5,877 National Comorbidity Survey (ages Childhood physical (beaten or Self-criticism (Depressive Internalizing symptoms (CIDI)
et al. (2006) 15 54; M D 33.2) physically abused by parent/ Experiences Questionnaire; WHO, 1990
caregiver), sexual abuse (raped or Blatt, 1979), dependency
sexually molested), and verbal (Hirschfeld et al., 1977).
abuse (insulted/threatened) from
PTSD module of CIDI
Family of origin variables, Parental
pathology, parental loss
Springer (2009) N D 3,635 Population-based study of men and Childhood physical abuse (parent Health behaviors, cognition, mental Medical diagnoses (Duke Older
women; Abuse survivors (M D “slapped, shoved, or threw things health, and social relations Adults Research Survey; Duke
53.91) and non-abused (M D at them” before age 17 from CT; University Center for the Study
53.8) Straus, 1979) of Aging and Human
Development, 1978)

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Table 2. (Continued )

Sample characteristics (age range/

Author (year) Sample size mean age) Predictor variable (s) Mediator/moderator covariates Outcome measure (s)

Springer N D 2,051 Population-based study of men and Childhood physical abuse (parent Family background and childhood Mid-life Depression (CES-D) and
et al. (2007) women (M D 55) “slapped, shoved, or threw things adversities (i.e., parent drinking physical health (modified version
at them” before age 17 from problem, parent marital problem, of the Duke Older Adults
CTSc; Straus, 1979) parental violence, and broken Research Survey; Duke
family) University Center for the Study
of Aging and Human
Development, 1978)
Talbot N D 163 Patients with primary mood Childhood sexual abuse (CTQb- Adjusting for the effects of age, Physical illness burden (CIRS),
et al. (2009) disorders (over 50; M D 60.6) short form) " gender, and education impaired physical functioning
(IADL & PSMS), and bodily pain
(Medical Outcomes Study 36-
Item Short Form)
Psycho-social development
Allen et al. (2013) N D 268 College students, majority female; Child maltreatment prior to the age Affective dysregulation, from Suicide Potential Index (The SPI
(M D 19.3) of 13 (i.e., physical abuse, inventory of altered self- utilizes 20 different criteria
emotional/psychological abuse, capacities (IASC, Briere & constructed from scales of the
and neglect; Comprehensive Runtz, 2002). PAI to provide a composite score
Child Maltreatment Scale; of risk.)
Higgins & McCabe, 2001)
Borderline personality disorder
symptoms (Personality
Assessment Inventory (PAI);
Morey & Boggs, 1991)
Aging & Mental Health

Fortier N D 99 College women (Ages 18 48; M D Childhood sexual abuse Avoidant coping (Coping Strategies Revictimization (Sexual
et al. (2009) 21) Inventory; Tobin et al., 1984) & Experiences Survey; Koss &
Trauma symptoms (Trauma Gidycz, 1985)
Symptom Checklist-40 (TSC-40);
Briere & Runtz, 1989)
McGinn N D 55 Patients presenting for outpatient CTQb and Parental style (e.g., Cognitive style (Young’s Schema Depression (Beck Depression
et al. (2005) treatment (M D 41.9) perception of parents’ attitudes Questionnaire (YSQ), Young & Inventory, Beck & Steer, 1987)
and behaviors toward them Brown, 1990)
before age 16; Parental Bonding
Instrument, Parker, Tupling, &
Brown, 1979)
Wilson N D 253 Older adults (M D 79.8) Composite measures of total Age, sex, own education, and psychosocial adjustment in old age
et al. (2006) adversity, emotional neglect, parental education, (multiple measures of
parental intimidation, parental neuroticism and social
violence, family turmoil, and engagement)
financial need (excluding sexual
abuse) before age 18 (based
mainly on the CTQb)
2.1; 73.9% women) from the Rush
11

Memory and Aging Project

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12
Table 2. (Continued )

Sample characteristics (age range/

Author (year) Sample size mean age) Predictor variable (s) Mediator/moderator covariates Outcome measure (s)

Wright N D 301 College-aged men and women Childhood emotional abuse Self-schemas (YSQ) Depression and anxiety (subscales
et al. (2009) (M D 20.37) (belittling, ridiculing, spurning, from TSC-40)
humiliating, rejecting, extorting,
and terrorizing) and neglect
(ignoring, isolating, lack of praise
or affection, parentification, and
psychological unavailability)
prior to age 15 (LEQ; to assess
parent alcohol abuse/dependence
CAST-6, Hodgins, Maticka-
Tyndale, El-Guebaly, & West,
1993; TSC-40)
Stress and aging
Clark et al. (2004) N D 530 Jewish adults with diagnosis of Exposure to the Nazi Holocaust Recent negative life events (i.e., Suicidal ideation (Suicide item of
Depressive Disorder (over 50; (determined through (1) the negative health problems, the Ham-D; Hamilton, 1960)
M D 75.9) social worker’s clinical notes bereavements, and family and
from structured patient and social relationship difficulties)
family interviews, or (2) the
Modified Life Events Inventory
(LEI m))
Clark et al. (2010) N D 9,377 British birth cohort born in 1958 Childhood adversity (exposure to Psychopathology (anxiety/affective/ Psychopathology (affective and
followed 45 years. traumatic events or chronic mood) at ages 16 (Malaise anxiety disorders; Revised
stressors up to 16 years; i.e., Inventory, Rutter, Tizard, & Clinical Interview Schedule,
neglected appearance, maternal Whitmore, 1970) and 23 (Rutter Lewis, Pelosi, Araya, & Dunn,
N.J. Sachs-Ericsson et al.

absence, parental divorce, and Scales, Rutter, 1967) 1992) at age 45

parental physical and sexual
abuse)
Cromer and N D 5,877 Nationally representative sample Childhood physical (beaten or Current life stressors (number of Adult health problems (number of
Sachs-Ericsson (U.S.; M D 33.2) physically abused by parent/ endorsed stressors; e.g., conditions)
(2006) caregiver) and sexual abuse experienced break-up, death of a
(raped or sexually molested) from close friend or relative, or had
PTSD module of the CIDI been laid off)
Davison N D 47 War Veterans (ages 54 89) Combat in early adulthood Potential intrapersonal risk and Late-onset stress symptomatology
et al. (2006) resilience factors (Qualitative)
Qualitative focus 47 World War II, Korean Conflict,
group study and Vietnam War veterans
Liu et al. (2013) N D 66 Adults with a history of depression Childhood emotional, physical, and Negative cognitive styles (cognitive Negative dependent life events (Life
(M D 19.86) sexual abuse CTQb; Bernstein style questionnaire; Alloy, Events Scale and Life Events
et al., 2003) 2000) Interview; Safford et al., 2007)
N D 133 Age and gender

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Table 2. (Continued )

Sample characteristics (age range/

Author (year) Sample size mean age) Predictor variable (s) Mediator/moderator covariates Outcome measure (s)

Van der Child survivors of the Holocaust Early traumatic stress (Holocaust Diurnal cortisol patterns and cortisol
Hal-Van (M D 64.6) trauma, sexual, physical or reactivity to a stressor
Raalte et al. (2008) emotional abuse, other traumatic
experiences during the wars and
the terrorist attacks in Israel,
combat trauma, death of close
relatives after the Holocaust, life-
threatening illnesses and traffic
accidents)
Yehuda et al. (2005) N D 65 Combat with PTSD (M D 65.6), Current PTSD (Structured Clinical Hippocampal volume Learning and memory performance
Combat without PTSD (M D Interview for DSM-IV; Spitzer, (California Verbal Learning
67.6) and non-combat Veterans Gibbon, & Williams, 1998) Test)
(M D 65.1)
urinary cortisol levels,
Yehuda et al. (2007) N D 28 Holocaust survivors with (M D Current PTSD (DSM-IV criteria; PTSD (current or remitted) Urinary cortisol levels
75.9) and without PTSD (M D Clinician Administered PTSD
78.7) SCALE; Blake et al., 1995)
a
ACE study questionnaire: see footnote from Table 1.
b
Childhood trauma questionnaire (CTQ): see footnote from Table 1.
c
The conflict tactics scale (CTS): the CTS focuses on “conflict tactics” the method used to advance one’s own interest within a conflict. It measures five categories of behaviors: “negotiation”, “psychological aggression”,
“physical assault”, “sexual coercion” and “injury.” each of the five categories is then further subdivided into two subscales: “negotiation” is subdivided into “cognitive” and “emotional”, while the other four categories are sub-
divided into “minor” and “severe.” there are six items in “negotiation”, eight in “psychological aggression,” twelve in “physical assault,” seven in “sexual coercion,” and six in “injury.”
Aging & Mental Health
13
 14 N.J. Sachs-Ericsson et al.
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Figure 1. ACE and late-life suicide.
and lower social support contributing to per-
ceived social disconnectedness.
(4) Aging, late-life stressors:
a. Late life is associated with unique stressors. It
is likely in the interaction of the above domains
(biological, psychiatric and health, and psycho-
social development) with late-life stressors that
suicidality in older adulthood emerges.
Below we outline the developmental effects of ACE
that may increase risk for late-life suicidal ideation,
attempts and death by suicide within each of the above
domains.
The effect of ACE on biological processes
Neurological development
ACE (including childhood sexual, physical and emotional
abuse as well as other forms of maltreatment) are typically
described in the neurobiological literature as early stres-
sors. This area of research had drawn upon animal models
as well as human research paradigms. Incorporating
insight gained from clinical and epidemiological studies
and from basic research, ACE or stressors have been
found to influence the developmental trajectory of the
brain (Bale et al., 2010; Christine Heim, Shugart, Craig-
head, & Nemeroff, 2010), affecting brain anatomy and
functioning with lifelong consequences for mental health
(McCrory, De Brito, & Viding, 2012; Twardosz &
Lutzker, 2010). The neurobiological sequelae of early
stressors likely contribute to the emergence of psychiatric
disorders during development (Teicher et al., 2003).
The brain has an extended postnatal development with
a distinct sensitivity to stress (Teicher et al., 2003;
Teicher, Tomoda, & Andersen, 2006). Extensive research
has found that early stressors (including childhood abuse
and neglect) lead to modification of typical processes of
brain development (e.g., neurogenesis, synaptic overpro-
duction and pruning, and myelination) (Teicher et al.,
2004; Twardosz & Lutzker, 2010). Converging
interdisciplinary data have demonstrated that early rela-
tional trauma (e.g., disruption in the developmental pro-
cess of attachment, poor parenting, parental loss,
childhood physical and sexual abuse, and neglect) nega-
tively impacts the developmental trajectory of the right
brain, dominant for attachment, affect regulation, and
stress modulation (Schore, 2002), differences that persist
years after stressors have ceased (Pechtel & Pizzagalli,
2011). These anatomical and functional differences are
associated with emotional and behavioral regulation
(McCrory et al., 2012) and may lead to an increase in
impulsivity a characteristic associated with suicide,
albeit in an indirect and distal relationship (Anestis,
Soberay, Gutierrez, Hernandez, & Joiner, 2014)
Additionally, early stressors increase the hypothala-
mic pituitary adrenal axis (HPA) stress response; the
HPA axis plays a central role in response to threat (Chris-
tine Heim, Newport, Mletzko, Miller, & Nemeroff, 2008).
If the HPA is activated chronically, the brain becomes
more responsive to subsequent threats throughout life
(Heim et al., 2010; Loman & Gunnar, 2010). These abnor-
malities in the HPA axis are also associated with a dysre-
gulation in the serotonergic system (Pompili et al., 2010),
an established substrate for suicidal behavior (Braquehais,
Oquendo, Baca-Garc
ıa, & Sher, 2010).
The aging brain is also uniquely sensitive to stress
(Lupien, McEwen, Gunnar, & Heim, 2009), especially
among those who experienced earlier stressors (e.g., com-
bat stress, child abuse, and aging survivors of the Holo-
caust) (Sapolsky, 1999; van der Hal-Van Raalte,
Bakermans-Kranenburg, & van Ijzendoorn, 2008). These
processes lead the individual to cope less efficiently with
age related stressors, increasing emotional dysregulation
and leading to an increased risk for suicidality in late life.
Gene-environment
Risk for suicide in late life is likely influenced by a com-
plex interplay of genes and environment. In their review,
Turecki, Ernst, Jollant, Labont
e, and Mechawar (2012)
 Aging & Mental Health
concluded that animal and human data suggest that early-
life adversity increases risk of suicide by influencing emo-
tional, behavioral and cognitive phenotypes affecting the
epigenetic regulation of genes, the HPA axis, and other
systems involved in responses to stress. Similarly, Van
Heeringen and Mann (2014) concluded that early-life
adversity and epigenetic mechanisms might explain some
of the link between suicide risk and brain circuitry and
neurochemistry abnormalities.
It may be that genetic polymorphisms confer risk for
psychiatric disorders and suicide following triggering
events such as ACE, or it may be that stressful events in
childhood modify the effects of genes and neural develop-
ment, increasing vulnerability to suicide in later adult-
hood. Variability in the expression of these gene-
environmental effects is likely related to the type of abuse,
age when abuse first occurred, as well as the frequency
and severity of abuse (Lupien et al., 2009). In the investi-
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gation of the gene-environmental effects, candidate genes
have been selected based on their implication to suicide or
mood regulation and include the serotonin transporter
gene, brain-derived neurotropic factor (BDNF), and genes
regulating the HPA (Costanza et al., 2014).
A polymorphism in the promotor region of the seroto-
nin transporter gene (5-HTTLPR) augments ACE (e.g.,
child abuse, child maltreatment, family dysfunction) and
other negative life events (serious health problems, expo-
sure to natural disasters) on adult depression (see Karg,
Burmeister, Shedden, & Sen, 2011). The polymorphism
results in long or short alleles, with the less functional
short allele associated with reduced transcriptional activ-
ity of serotonin, increased stress sensitivity, and vulnera-
bility to depression (Caspi et al., 2003). Several
researchers have found that the 5-HTTLPR short allele in
conjunction with ACE (i.e., neglect, emotional maltreat-
ment, physical abuse, sexual abuse) increases risk of
suicidal ideation in adolescents (Cicchetti, Rogosch,
Sturge-Apple, & Toth, 2010; Gibb, McGeary, Beevers, &
Miller, 2006; Roy, Gorodetsky, Yuan, Goldman, &
Enoch, 2010). Gibb et al. (2006) found that 5-HTTLPR
genotype moderated the link between childhood physical
and sexual, but not emotional, abuse and adult psychiatric
patients’ suicide attempts. There is also an interaction
between the 5-HTTLPR and ACE (e.g., harsh discipline,
emotional, physical, and sexual abuse, neglect, parental
loss, parental rejection) in the prediction of depression in
midlife (Uher et al., 2011), and in late life (Ritchie et al.,
2009). There is an interaction between the 5-HTTLPR
and lifetime stressors (e.g., exposure to serious injury or
death; or serious injury or death of a loved one) and the
prediction of depression in late life (Goldman, Glei, Lin,
& Weinstein, 2010).
Brain-derived neurotrophic factor (BNDF) is associ-
ated with late-life depression, suicidal ideation, and regu-
lation of serotonin transporter function. The BDNF gene
contains a functional polymorphism (Val66Met) leading
to reduced BDNF expression. Using animal models, it
was found that acute and chronic stress appeared to affect
methylation and modify expression of BNDF (Roth,
Lubin, Funk, & Sweatt, 2009). Examining data from
15
individuals who had attempted suicide, Perroud et al.
(2008) found that Val66Met modulates the effect of child-
hood sexual abuse on the degree of violence of the suicide
attempt. They proposed that childhood sexual abuse elicits
brain structural modifications through BDNF dysfunction
and enhances the risk of violent suicidal behavior in adult-
hood (Perroud et al., 2008). Although BDNF and ACE
interactions have not been tested in older adults, emerging
research from young and middle-age adults suggest an
association with depression and suicide in conjunction
with ACE (e.g., physical, emotional and sexual abuse,
other traumatic experiences, parental pathology, parent’s
death, divorce or mental disorders) (Aguilera et al., 2009;
Perroud et al., 2008; Pregelj et al., 2011).
ACE are also thought to alter development of systems
that regulate the stress response, such as glucocorticoid
receptor (GR) expression and corticotrophin releasing
hormone (CRH) activity, enhancing sensitivity to stress
and mood disorders later in life. ACE (e.g., sexual abuse,
physical abuse, physical neglect, emotional abuse and
neglect) may have long-term effects on decision-making
through an interaction with key HPA axis genes that
increase suicidal behavior (Guillaume et al., 2013). For
example, ACE (e.g., sexual, physical and emotional
abuse, and neglect) have been found to be associated with
epigenetic modifications of the GR gene NR3C1 (Perroud
et al., 2011). Among suicide decedents with a history of
ACE (e.g., sexual contact, severe physical abuse and/or
severe neglect), GR expression in hippocampal neurons
post-mortem is decreased compared to suicide decedents
without a history of ACE (Labont
e et al., 2012; McGowan
et al., 2009). Haplotypes of the FKBP5 gene, which mod-
erates GR activation, have also been found to interact
with ACE (physical, sexual and emotional abuse, and
neglect) to increase the risk for attempted suicide (Roy
et al., 2010). Furthermore, certain gene gene environ-
ment interactions (e.g., CRHBP gene, which regulates
availability of CRH, and FKBP5) are influenced by ACE
(physical, sexual and emotional abuse, and neglect) and
increase risk for suicide attempts (Roy, Hodgkinson,
DeLuca, Goldman, & Enoch, 2012). In a study of older
adults, the GR gene moderated the link between ACE
before the age of 18 (e.g., sexual abuse, parental loss, war
experiences, impaired physical health,) and late-life
depression (Bet et al., 2009).
Suicide is a complex behavior involving not only
genetics and environment but also gene-environment
interactions (Bani-Fatemi et al., 2014). Future research on
the epigenetic effects in older adults who experienced
ACE and risk for suicide is certainly warranted, especially
in relation to late-life stressors that often accompany
aging processes.
Psychiatric and health morbidity
Psychiatric disorders
ACE (e.g., childhood sexual, physical and emotional
abuse) have been found to be a powerful risk factor for
the development of mental health problems (Edwards,
 16 N.J. Sachs-Ericsson et al.
Holden, Felitti, & Anda, 2003; Green et al., 2010; Polusny
& Follette, 1995; Sugaya et al., 2012), and this risk does
not attenuate with age (Clark, Caldwell, Power, & Stans-
feld, 2010). Psychiatric disorders are, in turn, an important
risk factor for suicidal behavior.
Afifi et al. (2008) found that the estimated attributable
fractions for psychiatric disorders related to having expe-
rienced any ACE (childhood sexual or physical abuse,
domestic violence) ranged from 22% to 32% among
women and 20% to 24% among men. A particularly
strong link has been identified between childhood physi-
cal, sexual abuse and neglect and the mood and anxiety
disorders (Heim et al., 2008, 2010; Liu et al., 2012;
Sachs-Ericsson et al., 2010). For example, researchers
found that people who were verbally abused had 1.6 times
as many symptoms of depression and anxiety as those
who had not been verbally abused and were twice as
likely to have suffered a mood or anxiety disorder over
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their lifetime (Sachs-Ericsson, Verona, Joiner, &
Preacher, 2006). The combination of ACE (e.g., sexual,
physical, emotional abuse and neglect) and mood and anx-
iety disorders substantially increases risk for suicide
attempts (Lopez-Castroman et al., 2015). For example in
one study of depressed women from a community sample,
childhood physical abuse was found to be a significant
correlate of suicidal ideation, whereas the number of psy-
chiatric disorders were predictive of suicide attempts
(McHolm et al., 2003). Additionally, ACE (e.g., sexual
physical and emotional abuse, neglect, and parental loss)
is associated with Post-Traumatic Stress Disorder (PTSD)
symptoms and self-regulatory disturbances (Cloitre et al.,
2009).
Unfortunately, the association between abuse experi-
ences (e.g., sexual abuse, emotional abuse) and other
ACE (parental loss, parental maladjustment, and serious
respondent physical illness, and family economic adver-
sity) and psychiatric disorders persists, decades later, into
older age (Chou, 2012; Gershon et al., 2013; Kraaij & de
Wilde, 2001; McLaughlin, Conron, Koenen, & Gilman,
2010). For example, Chou (2012) found in a large epide-
miological sample of older adults that childhood sexual
abuse was associated with high rates of psychiatric disor-
ders, psychiatric hospitalizations, and suicidal ideation.
Additionally, in the National Comorbidity Survey-Repli-
cation, researchers (McLaughlin et al., 2010) found the
association between ACE (e.g., economic adversity,
parental loss, parental maladjustment, physical abuse, sex-
ual abuse, and neglect) and current psychiatric disorders
to persist throughout the life course. In a population-based
study including 7080 adults 65 years older (Raposo,
Mackenzie, Henriksen, & Afifi, 2014), those who experi-
enced ACE (e.g., emotional, physical, sexual abuse or
neglect; household dysfunction, parental loss, domestic
violence, parental pathology, parental incarceration) had
higher odds of having mood disorders (OR D 1.73; 95%
CI D 1.32 2.28), anxiety disorders (OR D 1.48; 95% CI
D 1.20 1.83), and personality disorders (OR D 2.11;
95% CI D 1.75 2.54), after adjusting for covariates.
The vast majority of older adults who die by suicide
are found to have had a psychiatric disorder. For example,
Conwell, Van Orden, and Caine (2011a) found that across
multiple studies 71% to 97% of individuals who died by
suicide (aged 65 years and older) had a psychiatric illness
at the time of death. Mood disorders are a key risk factor
for late-life suicide (Beautrais, 2002; Conwell, Duber-
stein, & Caine, 2002; Conwell et al., 2011b; Van Orden
et al., 2010), especially in conjunction with early physical
abuse (McHolm et al., 2003).
Whereas there is a formidable relationship between
ACE (e.g., emotional, physical and sexual abuse, domes-
tic violence, parental psychopathology, loss or incarcera-
tion) and attempted suicide throughout the life span
(Dube et al., 2001), researchers have suggested that the
association appears to be explained, in part, through psy-
chiatric disorders (Bedi et al., 2011; Dube et al., 2001;
Sachs-Ericsson et al., 2013). For example, using epidemi-
ological data on older adults (60C), researchers (Sachs-
Ericsson et al., 2013) found childhood physical or sexual
abuse had a direct effect on suicidal ideation as well as an
indirect effect through the participant’s externalizing psy-
chiatric symptoms. However, in some population studies,
the relationship between child sexual abuse and suicidal
behavior was partially, but not wholly, mediated by psy-
chiatric disorders (Molnar et al., 2001).
The risk for suicidal behavior among older individuals
with psychiatric disorders may increase in the face of
some of the unique challenges and stressors associated
with older age. Increased stressors coupled with the dis-
tinct problems some experience in older age may deplete
previous coping mechanisms, especially among those
who have psychiatric problems and a history of ACE.
Health functioning
Within the context of a life-course prospective, ACE
experiences can cumulatively and interactively influence
future health outcomes through complex life histories, or
sequences of experiences within interconnected life
domains (Greenfield, 2010; Miller, Chen, & Parker,
2011). In the ‘Biological Embedding Model’, Miller et al.
(2011) synthesize knowledge across several behavioral
and biomedical literatures to explain how a diverse set of
ACE (physical, sexual, emotional abuse, family dysfunc-
tion, low socio-economic and other indices of childhood
maltreatment) affects health functioning of the individual
throughout the life course. They suggest that ACE get
“programmed” through epigenetic markings, affecting
pro-inflammatory tendencies. Acting in concert with
genetic liabilities, the resulting inflammation drives for-
ward pathogenic mechanisms that ultimately foster
chronic disease.
Among people exposed to major stressors in early life
(e.g., physical, sexual, and emotional abuse, family dys-
function parental loss, placement in foster care, parental
pathology and substance use, low SES), there are elevated
rates of morbidity and mortality from chronic diseases of
aging (Kelly-Irving et al., 2013; Miller et al., 2011).
Childhood sexual and physical abuse are associated with
increased physical health problems and disability (Sachs-
Ericsson, Blazer, Plant, & Arnow, 2005), and such
 Aging & Mental Health
functional impairment in older age is associated with
death by suicide (Conwell et al., 2011b; Draper et al.,
2008; Draper, 2014).
Several studies have found a strong association
between physical, emotional, and sexual abuse and health
problems in adulthood (Norman et al., 2012; Sachs-Erics-
son et al., 2005; Springer, Sheridan, Kuo, & Carnes,
2007). Older adults who reported childhood sexual and
physical abuse are at a higher risk of medical illnesses,
pain, and functional impairment (Draper et al., 2008;
Sachs-Ericsson, Kendall-Tackett, & Hernandez, 2007;
Talbot et al., 2009). Specifically, in a large patient popula-
tion study of older adults (Draper et al., 2008), multivari-
ate models indicated that participants who had
experienced either childhood sexual or physical abuse had
a greater risk of poor physical and mental health. Addi-
tionally, findings from a quantitative meta-analysis com-
paring results from 78 effect sizes across 24 studies of
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child abuse (literature keywords search included: child
abuse, child maltreatment, child sexual abuse, child physi-
cal abuse, child emotional abuse, child neglect), revealed
that child abuse was associated with an increased risk of
negative physical health outcomes in adulthood, with neu-
rological and musculoskeletal problems yielding the larg-
est effect sizes, followed by respiratory problems,
cardiovascular disease, gastrointestinal and metabolic dis-
orders (Wegman & Stetler, 2009). In a large population
study (Kelly-Irving et al., 2013), researchers found that
the odds of having a cancer before age 50 increased two-
fold among woman who had two or more ACE (e.g.,
placed in child care, child physical or sexual abuse, or
neglect, parental psychopathology, parental loss, or incar-
ceration). Dube et al. (2003) conducted a retrospective
study of 17,337 adult health maintenance organization
members examining the relationships between ACE (e.g.,
childhood emotional, physical, sexual abuse, and parental
pathology, loss, or incarceration) and six health problems
(depressed affect, suicide attempts, multiple sexual part-
ners, sexually transmitted diseases, smoking, and alcohol-
ism) across four successive birth cohorts. The number of
ACE increased the risk for each health problem in a con-
sistent, strong, and graded manner across all four birth
cohorts. There was a remarkable similarity of the effect of
ACE on each cohort. Others have also found that there
appears to be a graded association between multiple ACE
(e.g., physical, sexual and emotional abuse; parental
pathology, substance abuse, parental loss, domestic vio-
lence) and an array of adult health problems (Bonomi,
Cannon, Anderson, Rivara, & Thompson, 2008; Dube
et al., 2001; Dube, Felitti, Dong, Chapman, et al., 2003).
Two important mechanisms that may underlie the
association between ACE and health problems include
negative health behaviors and neuroimmunological dysre-
gulation with associated inflammation. ACE (e.g., emo-
tional, physical, and sexual abuse; domestic violence,
parental separation, psychopathy, incarceration) are asso-
ciated with negative health behaviors that have conse-
quences to health in late life including smoking, substance
use, obesity, and sexually risky behaviors (Anda et al.,
1999; Basile et al., 2006). For example, in a large
17
epidemiological sample of middle aged adults (Springer,
2009) physical abuse was found to be related to negative
health behaviors (i.e., smoking, obesity) which, in turn,
were associated with poor physical health. These negative
health behaviors can contribute to individuals’ poorer
health status in late adulthood and thereby serve as poten-
tial causal mechanisms linking child abuse (e.g., child-
hood physical, sexual and emotional abuse) to poorer
health status in aging adults (Greenfield, 2010).
Second, chronic and acute stress is associated with
neuro-immunological dysregulation and inflammation
which are implicated in a variety of disease states
(Altemus, Cloitre, & Dhabhar, 2003; Archer, Fredriksson,
Schϋtz, & Kostrzewa, 2011; Heim & Nemeroff, 2002;
O’Donovan, Neylan, Metzler, & Cohen, 2012). Physical,
sexual, and emotional abuse and neglect have been found
to be related to inflammation in mid-life women, increas-
ing risk for multiple chronic diseases that have an inflam-
matory pathophysiology (such as cardio-vascular diseases
and diabetes) (Matthews, Chang, Thurston, & Brom-
berger, 2014). Miller et al. (2011) suggest that over the
life course, these proinflammatory tendencies associated
with ACE (e.g., childhood sexual, physical and emotional
abuse, family dysregulation, low SES, and other forms of
childhood maltreatment) drive inflammation and the path-
ogenic systems that ultimately lead to chronic disease.
Chronic inflammation increases risk for diseases of aging
(O’Donovan et al., 2012). Inflammation may be a com-
mon cause of multiple age-related diseases or a final com-
mon pathway by which disease leads to disability and
adverse outcomes in older adults (Singh & Newman,
2011).
There is an increased risk for suicide among older
adults with physical illnesses (e.g., cancer, heart failure,
chronic obstructive lung disease, seizure disorder, urinary
incontinence, moderate pain, and prostate cancer) (Juur-
link, Herrmann, Szalai, Kopp, & Redelmeier, 2004;
Llorente et al., 2005; Quan, Arboleda-Florez, Fick, Stuart,
& Love, 2002; Stenager et al., 2014). Somatic illness is
associated with elderly suicides, particularly for men
(Almeida et al., 2012). Additionally, there is a strong
association between the cumulative number of illnesses
and risk of suicide (Juurlink et al., 2004).
However, it is not altogether clear if the effects of
physical illness on suicide in older adults would remain
after adjusting for comorbid affective disorders or other
psychopathologies. In this regard there is a high rate of
psychiatric disorders, particularly anxiety and depression
associated with the occurrence of severe medical illness
in older age (Parpa, Tsilika, Gennimata, & Mystakidou,
2015). Conwell et al. (2002) point out that suicidal idea-
tion among seriously ill people was extremely rare in the
absence of clinically significant mood disturbance. None-
theless Draper (2014) has pointed out that among older
adults there are several specific health problems that exac-
erbate suicidal risk including medical illness related to
depression, as well as severe and uncontrollable pain.
Draper (2014) also noted that older adults with poor
health are physically more vulnerable and, thus, more
likely to succumb to a suicide attempt. Clearly, addressing
 18 N.J. Sachs-Ericsson et al.
underlying psychiatric and health comorbidities to reduce
distressing symptoms and functional limitations is critical
in reducing suicidal risk among older adults. Heim et al.
(2010) suggest that patients presenting with depression
should be screened for childhood abuse, and if early abuse
had occurred, these patients will likely need more inten-
sive treatment. Future research should investigate the
extent to which early childhood abuse experiences should
be directly addressed in psychotherapeutic interventions
among individuals presenting with psychiatric disorders.
Abuse and psycho-social development
The development of maladaptive cognitive styles
ACE, and in particular emotional and verbal abuse, may
shape the child’s development of cognitive processes that
have been found to be associated with depression and anx-
iety (Gibb & Abela, 2008; Sachs-Ericsson et al., 2006).
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Negative cognitive style (Abramson, Metalsky, & Alloy,
1989) has been defined as a characteristic way of attribut-
ing the causes of negative life events to stable and global
factors (e.g., I failed my spelling test because I am stupid),
inferring negative consequences (e.g., I will always be a
failure), and making self-critical judgments of one’s char-
acter (e.g., I am worthless) (Alloy et al., 2004; Seligman,
Abramson, Semmel, & von Baeyer, 1979), as well has
having dysfunctional attitudes and maladaptive self-sche-
mas (e.g., no one will ever love me) (Beck, 1987).
There is a growing body of evidence that child abuse,
and particularly verbal and emotional abuse, confers risk
for development of a negative cognitive style (Gibb,
2002; Liu et al., 2012), which is a risk factor for depres-
sion (Alloy et al., 1999; Sachs-Ericsson et al., 2006). Ver-
bal or emotional abuse may play a powerful role in the
development of a negative attributional style because the
abuser supplies the young child with the internalized, self-
blaming statements associated with suicidal behavior
(e.g., ‘you are worthless, you are stupid, you are a burden,
I wish you were never born’). These types of cognitions
develop early in childhood and persist into older age,
which, in turn, leaves the individual more vulnerable to
age related decline. In their review, Alloy, Abramson,
Smith, Gibb, and Neeren (2006) discuss the role of cogni-
tive vulnerability as a mediator between experiencing
poor-parenting and depression. Research has confirmed
that poor parenting styles and early childhood abuse (e.g.,
childhood emotional, physical, and sexual abuse and
neglect) predicts negative cognitive styles, which may, in
turn, influence the relationship between such early abuse
and depression and anxiety (McGinn, Cukor, & Sander-
son, 2005; Wright, Crawford, & Del Castillo, 2009).
Cognitive appraisals of a sexual abuse experience may
mediate the effects of the abuse experience on subsequent
health outcomes (Spaccarelli, 1994). Brodsky and Stanley
(2008) suggest that sexual abuse may be related to the
development of suicidal behavior because of attributions
related to guilt and self-blame regarding the sexual abuse.
Other researchers have found that internal attributions of
blame made during childhood regarding the sexual abuse
were significantly predictive of overall adulthood
symptomatology, as well as presence of suicide attempts
(Barker-Collo & Read, 2003). Cognitive-behavioral ther-
apy (CBT) specifically focuses on addressing maladaptive
cognitions (Thompson, Gallagher-Thompson, & Dick,
1995), and, thus, may be useful in addressing trauma-
related schemas regarding the world, self, and others in
older adults who experienced childhood sexual abuse
(Hankin, 1997).
Coping, problem solving, and modulating strong
affective states
ACE, and in particular childhood sexual abuse, are related
to the development of poor coping strategies, ineffective
problem solving, and difficulties modulating strong affect.
These characteristics are associated with late-life suicide.
Research on child sexual abuse has shown that such expe-
riences facilitate the development of coping and problem
solving strategies that were possibly functional at the time
of the sexual abuse (e.g., avoidant and passive strategies),
but such strategies create difficulties modulating negative
affect and coping with distress later in life (Cant
on-Cort
es
& Cant
on, 2010; Gagnon & Hersen, 2000; Walsh, Fortier,
& DiLillo, 2010).
Coping methods are often described as either effective
(e.g., directly addressing a problem) or ineffective (e.g.,
avoidance) (Walsh et al., 2010). Coping strategies associ-
ated with ACE (e.g., physical and sexual abuse, domestic
violence, parental rejection, parental substance abuse) are
often characterized as passive (Futa, Cindy, Hansen, &
Garbin, 2003; Leitenberg, Gibson, & Novy, 2004). Spac-
carelli (1994) found that among individuals who have
experienced early sexual abuse, coping processes played a
crucial mediating role in the development of symptom-
atology. In one population study (Fortier et al., 2009),
childhood sexual abuse severity was associated with the
use of avoidant coping, which, in turn, predicted greater
levels of trauma symptomatology. In their notable review
of the literature on child sexual abuse and coping, Walsh
et al. (2010) suggested that individuals who have more
adaptive means of managing their sexual abuse-related
negative emotions may experience less long-term distress
than those who have greater difficulty processing such
emotions.
Indeed, there are deficits in coping and problem solv-
ing strategies in individuals who have attempted suicide
(Pollock & Williams, 2004; Pollock & Williams, 1998).
Among older adults, ‘problem-focused’ and ‘emotion-
focused’ coping were protective against suicidal ideation,
while ‘passive coping’ elevated the risk of suicidal idea-
tion (Marty, Segal, & Coolidge, 2010). Older depressed
suicide attempters report more negative problem-solving
orientations (i.e., negativistic attitude toward solving
problems) and greater tendencies to engage in impulsive
or careless problem-solving strategies (Van Orden &
Conwell, 2011).
Ineffective coping and problem solving lead to diffi-
culties regulating negative affect in the face of subsequent
stressors. This is likely further exacerbated by the higher
levels of impulsivity associated with early, physical or
 Aging & Mental Health
sexual abuse and other ACE (Brodsky et al., 2001).
Impulsivity is one risk factor for suicidal behaviors, and,
thus, impulsivity may link ACE (e.g., physical and/or
emotional ill-treatment, sexual abuse, neglect or exploita-
tion) to suicidal behaviors (see (Braquehais et al., 2010;
Short & Nemeroff, 2014). Research has found that
emotional dysregulation contributes to suicidality even
after accounting for psychological disorders (Rajappa,
Gallagher, & Miranda, 2012). Indeed, Linehan (1993)
proposes that the pathogenesis of suicidal behaviors are
the interaction of emotional dysregulation and emotional
invalidating experiences such as childhood sexual,
physical and emotional abuse. Furthermore, emotionally
dysregulated individuals have been found to engage in
painful and/or provocative behaviors elevating the capa-
bility for suicide (Law, Khazem, & Anestis, 2015).
Thus, ACEs are associated with subsequent difficul-
ties modulating negative affect, and difficulties in this
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area are associated with late-life suicide. As others have
pointed out, maltreating parents, who likely have their
own coping deficits, are not likely to provide the appropri-
ate environment that promotes the child’s ability to learn
coping styles that help in modulating strong affective
states (Futa, Nash, Hansen, & Garbin, 2003). Addition-
ally, these effects may persist into older age (Wilson
et al., 2006). Researchers have found that older adults
who have suicidal ideation have difficulties with emo-
tional regulation (Lynch, Cheavens, Morse, & Rosenthal,
2004), and affective dysregulation has been found to
mediate the relationship between ACE (e.g., physical,
emotional abuse, and neglect) and measures of suicide
risk (Allen, Cramer, Harris, & Rufino, 2013).
Thus, among older abuse survivors, treatments that
address coping skills for managing emotional dysregula-
tion may be quite important in reducing distress and thus
reducing suicide risk. Finally, as Walsh et al. (2010) point
out, coping strategies are amenable to change and are,
therefore, practical targets for intervention among those
dealing with the negative sequelae of ACE. For example,
studies suggest that coping strategies among sexual abuse
victims that are based on seeking social support are asso-
ciated with decreased symptomatology (Filipas & Ullman,
2001; Murthi & Espelage, 2005). Indeed, enhancing one’s
social support has emerged in the literature as an effective
coping strategy that may play a role in the relationship
between ACE and adult adjustment (Walsh et al., 2010).
However, individuals who experienced ACE may have
more difficulties than others maintaining social networks
due to deficits in interpersonal functioning.
Interpersonal functioning
Emotionally abused or neglected children show enduring
interpersonal deficits and social problems (Hildyard &
Wolfe, 2002). Childhood emotional and physical abuse
predicted indices of family closeness in middle-aged
adults (Savla et al., 2013). Wilson et al. (2006) found that
ACE (e.g., sexual, physical and emotional abuse, family
dysfunction, parental psychopathology, substance abuse
and family separations) were associated with less adaptive
19
psychosocial functioning in older age. Interpersonal diffi-
culties result in decreased social support, and social sup-
port deficits are an important risk factor for late-life
suicide.
In a review of the literature on the effects of childhood
maltreatment on attachment styles, Toth and Cicchetti
(1996) proposed that there is a cascade of interpersonal
consequences in maltreated children (e.g., physical, sex-
ual or emotionally abuse) that begins with insecure attach-
ment relationships, moves to negative representational
models of the self and others, and eventuates in impaired
social functioning. Wilson et al. (2006) suggested that
ACE (e.g., abuse and other forms of family dysfunction)
may arrest specific childhood developmental tasks (e.g.,
ability to form secure attachments, development of auton-
omy), which, in turn, are associated with less adaptive
psychosocial functioning in older age (Wilson et al.,
2006). Teicher et al. (2006) speculated that exposure to
verbal aggression in childhood serves as a potent negative
model for interpersonal communication. The child’s expo-
sure to aggression within the context of the family
increases the likelihood of the child developing coercive
or aggressive conflict resolution strategies (Bugental &
Shennum, 2002). Furthermore, ACE (physical, sexual,
and emotional abuse, family dysfunction, low SES) con-
tribute to people becoming vigilant for threat and mis-
trusting of others (Miller et al., 2011). These processes
influence interpersonal functioning by eliciting increased
conflict and rejection and less social and family support.
These interpersonal difficulties may play a pivotal role
in the development of suicidal behaviors (e.g., suicide
attempts and suicide; Foster, 2011; Johnson et al., 2002).
Lack of a sense of belonging may result from poor inter-
personal relationships and can contribute to suicidal idea-
tion (McLaren, Gomez, Bailey, & Van Der Horst, 2007;
Vanderhorst & McLaren, 2005). Westefeld et al. (2014)
suggest that older adults with interpersonal difficulties
may perceive themselves as having less social support,
which may lead to suicidal behavior. In this regard both
Durkheim’s Theory of Suicide (Durkheim, 1951) as well
as the Interpersonal Theory of Suicide (Van Orden et al.,
2010) strongly implicate social disconnectedness at the
core of suicidal behavior. Addressing social isolation
among older adults is critical in increasing their well-
being and reducing suicidality. There is a cognitive-
behavioral social skills training module for older adults
that may be useful in improving social and interpersonal
functioning (Granholm et al., 2005).
Early adverse childhood experiences, late-life stressors
and suicide
Why is it that some individuals in late-life become more
susceptible to suicide? The Strength and Vulnerability
Integration (SAVI) theory (Charles, 2010) posits that
emotion regulation skills generally improve with experi-
ence over the life course. These skills are quite complex
and include self-regulation, ability to navigate difficult sit-
uations, and self-knowledge as to how to maintains one’s
sense of well-being. This, in turn, explains why there are
 20 N.J. Sachs-Ericsson et al.
generally higher levels of overall affective well-being in
older adults. Even when remembering negative past expe-
riences, such skills may enhance the older adult’s ability
to regulate negative emotion. However, these enhanced
emotional regulation strategies are more likely to dissipate
if prolonged current stressor occur in late-life. If inescap-
able stress occurs, the SAVI posits that age related advan-
tages will be attenuated. This may, in particular, be the
case for individuals who have had ACE in part because
they are more reactive to late-life stressors. Importantly,
and as discussed below, late-life stressors often precede
suicidal behaviors (Conwell et al., 2002).
In their review of the literature on effects of stress on
the brain, behavior and cognition (data obtained animals
and humans models of aging), Lupien et al. (2009) con-
cluded that exposure to earlier stressors contributes to the
brain being even more reactive to stressors in older age.
There is evidence for an accelerated age-related decline in
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aging trauma survivors (e.g., combat exposure, holocaust
survivors) (van der Hal-Van Raalte et al., 2008; Yehuda,
Golier, Tischler, Stavitsky, & Harvey, 2005; Yehuda,
Morris, Labinsky, Zemelman, & Schmeidler, 2007).
The brain regions that undergo the most rapid decline
as a result of aging are the most highly vulnerable to the
effects of stress hormones (Lupien et al., 2009). The Neu-
rotoxicity hypothesis (Lupien et al., 2009) proposes that
prolonged exposure to stress hormones in childhood
reduces the brain’s ability to later resist further insults
associated with aging, increasing the neurotoxicity and
neuronal death. Stress related glucocorticoids have a
heightened toxic effect on the brain when it is undergoing
age-related changes. Together, these processes lead the
individual to cope less efficiently with age related stres-
sors, increase emotional dysregulation, and lead to an
increased risk for suicidality. ACE (e.g., early abusive or
neglectful parenting, high family conflict, parental loss,
and other maltreatment) have also been found to impact
cognitive performance in older adulthood (Luecken,
2006). Draper (2014) further suggests that cognitive diffi-
culties associated with aging may contribute to perceived
burdensomeness, a component of the interpersonal-psy-
chological theory of suicide.
Acute and chronic stressors (and in particular interper-
sonal difficulties) are predictive of suicidal behavior
(Bryan, Clemans, Leeson, & Rudd, 2015; Foster, 2011;
Zhang, Jia, Zhang, Wang, & Liu, 2015). Unfortunately,
individuals exposed to ACE are more likely to experience
subsequent negative life events. Indeed, in one study
childhood emotional abuse prospectively predicted
greater stress generation (Liu, Choi, Boland, Mastin, &
Alloy, 2013). Second, among individuals who experi-
enced earlier childhood sexual or physical abuse, they
appear to have a more intense response to such stressors
(Cromer & Sachs-Ericsson, 2006). In a large general pop-
ulation study, McLaughlin et al. (2010) found that ACE
(emotional, physical abuse, and neglect, parental dysfunc-
tion, family violence) were associated with increased vul-
nerability to current mood and anxiety disorders in
association with adult stressors. The ‘sensitization’
hypothesis posits that prior exposure to any trauma
sensitizes people to respond more intensely to subsequent
stressors (e.g., Resnick, Yehuda, Pitman, & Foy, 1995;
Yehuda, Boisoneau, Lowy, & Giller, 1995). The mecha-
nism underlying this process is an altered neurobiology
that occurs after initial exposure to earlier stressors
(Heim, Newport, Bonsall, Miller, & Nemeroff, 2001;
Heim et al., 2000).
Older age presents unique life challenges such as role
changes, loss, retirement, and increased health problems
any of which may increase stress and deplete resources of
the aging individual. For individuals who have experi-
enced ACE, such challenges may be particularly difficult.
The effects of negative life events in older age have been
found to be greater for individuals who endured ACE
(e.g., low SES, emotional abuse and neglect; Kraaij & de
Wilde, 2001). Furthermore, there may be a re-emergence
of symptoms in late-life related to earlier trauma (e.g.,
childhood sexual abuse; war time combat) in the context
of losses associated with aging. Thus, older survivors of
such experiences may be especially vulnerable to addi-
tional challenges associated with aging (Cook, 2001;
Davison et al., 2006; Gagnon & Hersen, 2000).
Stressful life events in older adults are associated with
suicidality (Conwell et al., 2002), and this association has
been found to be even stronger among those with early
trauma (e.g., holocaust survivors; Clarke et al., 2004).
Somatic illness appeared to be an important stressor in
elderly suicides, particularly for men (Heikkinen &
Lonnqvist, 1995). Conwell et al. (2002) suggested that
stressful life events cluster in the weeks and months
before suicide attempts in elders and that physical func-
tioning and other losses are the most common stressors in
older adults who die by suicide. These findings suggest
that providers of services for older adults should pay par-
ticular attention to the occurrence of negative life events,
especially among those who have experienced ACE.
Conclusion
ACEs have potent and persistent effects later in life,
including increased risk for suicidal thoughts and behav-
iors. In this paper, we synthesized the literature on ACE,
late-life psychopathology and suicide, and in doing so,
developed a testable explanatory model. This model sug-
gests that the mechanisms between ACE and late-life sui-
cide span distinct yet interrelated domains: biological,
psychiatric, physical health, and psychosocial functioning.
It is proposed that ACE affects one or more of these
domains, which, in the presence of potentiating stressors
later in life, leads to suicidality. As described, the compo-
nents of this model have emerging empirical support.
However, the integration of these components has not yet
undergone empirical scrutiny; this is an important future
research direction.
In identifying and organizing mechanisms implicated
in the link between ACE and late-life suicidality, points
of intervention emerge. Given the sequelae of early abuse,
the high rates of suicide among older adults, and the estab-
lished relationship between ACE and suicide in later life,
further research into this area is warranted. It is hoped that
 Aging & Mental Health
the framework described herein will generate scientific
questions and more precisely delineate the long-lasting
effect of ACE on suicidality among older adults. Insofar
as these additional research questions translate to clinical
prevention and treatment efforts, for those who experi-
enced such early childhood abuse in one’s end need not
be one’s beginning.
Disclosure statement
No potential conflict of interest was reported by the authors.
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