The Association of Chronic Adversity With Psychiatric Disorder and Disorder Severity in Adolescents

Eur Child Adolesc Psychiatry (2011) 20:459468
DOI 10.1007/s00787-011-0199-8
ORIGINAL CONTRIBUTION
The association of chronic adversity with psychiatric disorder

and disorder severity in adolescents
Corina Benjet Guilherme Borges Enrique Mendez
Clara Fleiz Maria Elena Medina-Mora
Received: 17 November 2010 / Accepted: 30 June 2011 / Published online: 17 July 2011
Springer-Verlag 2011
Abstract The purpose of this paper is to estimate the

impact of chronic adversity on psychopathology in adolescents, taking into account the type of adversity, number
of adversities experienced and type of psychiatric disorder,
as well as to estimate the impact on severity of the disorder.
A total of 3,005 male and female adolescents from the
Mexican Adolescent Mental Health Survey aged 1217 years
were interviewed in a stratified multistage general population probability survey. Assessment of 20 DSM-IV disorders, disorder severity and 12 chronic childhood adversities
were assessed with the adolescent version of the World
Mental Health Composite International Diagnostic Interview (WMH-CIDI-A). Family dysfunction adversities
including abuse presented the most consistent associations
between chronic adversity and psychopathology and their
impact was generally non-specific with regard to the type of
disorder. Parental divorce, parental death and economic
adversity were not individually associated with psychopathology. Among those with a psychiatric disorder, sexual
abuse and family violence were associated with having a
seriously impairing disorder. The odds of having a psychiatric disorder and a serious disorder increased with
increasing numbers of adversities; however, each additional
adversity increased the odds at a decreasing rate. While the
study design does not allow for conclusions regarding
causality, these findings suggest general pathways from
family dysfunction to psychopathology rather than specific
C. Benjet (&) G. Borges E. Mendez C. Fleiz

M. E. Medina-Mora
Department of Epidemiological and Psychosocial Research,
National Institute of Psychiatry Ramon de la Fuente,
Calzada Mexico Xochimilco 101, Colonia San Lorenzo
Huipulco, Mexico City 14370, Mexico
e-mail: cbenjet@imp.edu.mx
associations between particular adversities and particular

disorders, and provide further evidence for the importance
of family-focused intervention and prevention efforts.
Keywords Adolescence Psychopathology Adversity
Abuse Life stress Survival analysis
Introduction
Childhood adversity has long been considered an etiological factor in the development of psychopathology in
diverse theories ranging from attachment theory [1], in
which early deprivation and maternal loss are posited to
lead to psychopathology via maladaptive attachment styles,
Becks cognitive theory of depression [2], in which early
experience is thought to lead to depression via dysfunctional beliefs about the self, the world and the future,
learned helplessness theory [3], in which depression is
considered a result of the perceived absence of control over
the outcome of a situation, to social learning theory that
explains the intergenerational transmission of violence [4],
to name a few. More recently, research has provided other
theoretical explanations such as the impact of early stress
upon the hypothalamicpituitaryadrenal axis and brain
function, the evidence of which comes from both animal
primate and non-primate and human models [58]. Additionally, the unsuccessful search for individual gene candidates consistently associated with specific psychiatric
disorders has led to numerous studies focusing on gene
environment interactions, particularly interactions with
early life stress [911].
Epidemiologic research has provided support for the
association between childhood adversities and psychiatric disorders in adolescence and a few have made
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460
contributions toward establishing causality with longitudinal designs [1216]. However, an important and still
unanswered question to understand the mechanisms of risk
is whether the pathway or pathways from adversity to
pathology are specific or general.
Numerous studies have focused on specific associations
such as child maltreatment and violence with depression
and externalizing disorders [1417], parental loss and
depression [1820], and family adversities and attention
deficit hyperactivity disorder [21, 22]. An important limitation of the research to answer this question has been the
limited array of adversities and mental health outcomes
studied simultaneously. A notable exception is the MECA
Study, which addressed the association between a large
number of discrete proximal adverse life events and a
variety of mental disorders [13].
The failure to include a variety of adversities and psychopathologies has important implications for the interpretation of findings, because adverse childhood experiences do
not occur in isolation, but rather have been found to be
highly related and have a cumulative impact upon mental
health [12, 16, 23, 24], thus obscuring or possibly overestimating associations between any particular adversity with
any particular psychiatric disorder. It may also lead to
assumptions about the specificity of particular adversities
with particular disorders, which may be unfounded. A
review of the literature on stress and child/adolescent mental
health suggests very little specificity between particular
stressors for particular outcomes [25], but conclusions are
limited by the lack of comparability between studies and
breadth of stressors and outcomes. Another limitation has
been that most research has been conducted in developed
countries where there are more service resources to attend to
children who have experienced adversity.
A few comprehensive epidemiological surveys have
now been conducted to help elucidate the individual and
joint effects of a large variety of adverse childhood experiences on psychopathology in adult populations [2631].
Overall, these surveys also suggest little specificity of
effects other than the greater impact of family dysfunction
adversity (such as child abuse and parental pathology) over
non-family dysfunction adversities (such as poverty) and
parental loss (divorce and parental death). Overall, these
studies suggest that childhood adversities are associated
with a 2060% increased risk of psychopathology and are
estimated to account for almost 45% of all childhood-onset
disorders and up to 32% of adult-onset disorders [28, 29].
One limiting commonality of these studies is that they rely
on retrospective adult reports of events, which had taken
place during childhood and adolescence. Additionally,
chronic adversity might not only be associated with the
development of psychopathology, but also to the degree of
impairment or the severity of the disorder among those
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affected [32]. While we previously reported the effects of

chronic childhood adversity on lifetime onset of psychopathology in a general population survey of Mexican adults
[31], this current report complements the former by replicating these results in the adolescent population and
including disorder severity.
Over two-thirds of this Mexican adolescent sample
reported at least 1 of 12 childhood adversities studied, the
most common being economic adversity (24.5%) and the
least common sexual abuse (1.7%) [23]. However, over
one-third of these youths met criteria for any disorder
(8.5% any serious disorder), the most common being
anxiety (29.8%), behavioral (15.3%) and mood disorders
(7.2%), and the least frequent being substance use disorders
(3.3%) [33]. It is important to note that not all youths
experiencing childhood adversity develop psychopathology
as demonstrated by these figures. Other risk factors (such
as genetic vulnerability) and protective factors (such as
cognitive abilities, temperament, close relationships with
caring and competent adults, connections to prosocial
peers, neighborhood and school quality) play a role in the
probability of developing a disorder [34, 35].
The purpose, then, of this article is to estimate the
individual and joint effects of a broad range of adversities
upon a broad range of psychiatric disorders and disorder
severity in a general population sample of adolescents from
Mexico City. We hypothesize that the associations of
chronic childhood adversity with psychopathology are nonspecific with regard to the type of adversity or type of
disorder, but that greater adversity will be associated with
greater probability of psychopathology.
Methods
Participants
This report presents secondary analyses of data from the
Mexican Adolescent Mental Health survey [33]. The
sample consists of 3,005 adolescents (52.1% female, 47.9%
male) aged 1217 years selected from a stratified multistage area probability sample representative of nearly two
million adolescents residing in the Mexico City Metropolitan Area. In all strata, the primary sampling units were
census count areas cartographically defined and updated by
the Instituto Nacional de Estadstica, Geografa e Informatica [National Institute of Statistics, Geography and
Informatics] for the Mexican Population and Housing
Census in 2000. Secondary sampling units were city blocks
(or groups of them) selected with probability proportional
to size. All households within these city block units with
adolescents in the age range were selected. One eligible
member from each of these households was randomly
selected using the Kish method of random number charts.

The response rate of eligible respondents was 71%.
Procedures
A verbal and written explanation of the study was given to
both parents and adolescents, after which a signed
informed consent from a parent or legal guardian was
obtained as well as the assent of the adolescent. Interviews
were conducted in the homes of the selected participants by
trained lay interviewers (with previous experience in systematic data collection) who received a 1-week intensive
training prior to fieldwork, booster sessions during fieldwork and in situ supervision. All study participants and
their families were offered information on local mental
health services. The Internal Review Board of the National
Institute of Psychiatry approved the recruitment, consent
and field procedures.
Measures
Psychiatric diagnosis, disorder severity, adversity and ages
of onset were evaluated with the fully structured, computer-assisted World Mental Health adolescent version of
the Composite International Diagnostic Interview (WMHCIDI-A), the development and validity of which is
described elsewhere [36, 37]. The computer-assisted version was administered in which extensively trained lay
interviewers read the questions to the participant directly
from the computer screen; the questions were chosen by
the computer based on previous responses of the participant and complex logical skip patterns. The interviewer
inputs the respondents answers directly into the computer
and consistency checks are programmed such that inconsistent information is probed and corrected. Diagnostic
classification is based on meeting the diagnostic criteria of
the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV) [38]. All disorders used organic
exclusions rules as well as hierarchy definitions to avoid
double counting of disorders in the same person. The disorders were grouped as: mood disorders (major depressive
disorder, bipolar I and II disorder, and dysthymia), anxiety
disorders (specific phobia, social phobia, panic disorder,
agoraphobia without panic disorder, separation anxiety
disorder, generalized anxiety disorder and posttraumatic
stress disorder), substance use disorders (alcohol and drug
abuse, and alcohol and drug abuse with dependence) and
behavioral disorders (oppositional-defiant disorder, conduct disorder, attention deficit/hyperactivity disorder and
intermittent explosive disorder). Age of onset of the disorders was determined by adolescent self-report.
Disorder severity was classified according to the criteria
used in the World Mental Health Survey Initiative, the
461
validity of which is supported by the monotonic association

of this measure of severity with the number of days out of
role [39]. For the purpose of this paper, those classified as
serious were compared with those classified as moderate or
mild. A participants disorder was considered serious if any
one of the following conditions was met: the presence of
bipolar I disorder, substance dependence with a physiological dependence syndrome, a suicide attempt in conjunction with any other disorder or reporting of at least two
areas of role functioning with severe role impairment as
measured by the disorder-specific Sheehan Disability
Scales [40]. All other disorders were classified as moderate
or mild.
Chronic childhood adversity, which included different
forms of parental loss, parental psychopathology, abuse,
physical illness and economic adversity, was evaluated
from the childhood and post-traumatic stress disorder
sections of the WMH-CIDI-A. Each of 12 chronic adversities was classified as present or not present using the
same criteria as the World Mental Health Survey Initiative
[28]. Physical abuse and parental violence were assessed
with a modified version of the Conflict Tactics Scale [41].
Neglect was evaluated with questions often used in child
welfare studies [42]. Sexual abuse was assessed by reading
a definition of rape and then asking about other forms of
abuse or molestation that were chronic. To assess parental
loss, the adolescents were asked whether they lived with
both of their parents. Those who did not were asked
whether this was because their parents had separated or
divorced, a parent had died or some other reason. Those
answering that they went to boarding school, were in foster
care, left home or that their parent was in prison were
classified as other parental loss. Parental pathology was
evaluated using questions from the Family History
Research Diagnostic Criteria Interview and included
parental mental illness, substance problems and criminal
behavior [43]. Participants were considered to have experienced family economic adversity if the family ever
received money from a government assistance program for
poor families or if there was lack of parental employment
most or all of the time during the participants childhood.
Serious physical illness was based on the adolescents
report of having experienced a life-threatening physical
illness. All adversities were considered chronic because of
reporting multiple accounts or continued occurrence.
Statistical analysis
Data were weighted to adjust for differential probabilities
of selection and non-response, as well as post-stratification,
to the total Mexico City Metropolitan Area adolescent
population according to the year 2000 census in the target
age and sex range. The socio-demographic distribution of
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462
the sample is presented elsewhere as well as the prevalence

estimates for each disorder [33]. We used a discrete-time
event history analysis with time-varying covariates,
implemented using pooled logistic regression with personyears as the units of analysis to study variation in risk of
any DSM-IV disorder, type of disorder and disorder
severity across an array of chronic adversities as defined
above while statistically adjusting for covariates [44, 45].
The main outcomes that we studied were lifetime DSM-IV
disorder, lifetime mood, anxiety, substance and behavioral
disorders and a serious mental disorder. The key predictor
is the type of chronic adversities and the number of
adversities. We used a discrete-time approach instead of
the more traditional continuous-time approach, because the
Mexican Adolescent Mental Health Survey recorded the
time to event (age of onset of a mental disorder, onset of
adversities and other time-dependent variables) at yearly
intervals rather than on a continuous timescale. The pooled
logistic regression analyses allow us to take account of the
temporal ordering of a given adversity and onset of psychiatric disorders [44], and to use design-based estimation
methods to account for survey design effect [46].
Our use of discrete-time event history analyses relied on
retrospective age-at-onset reports to establish a temporal
order between the predictors and the outcomes. Designbased standard errors for logistic regression coefficients
and for pairwise contrasts between them were estimated
using the Taylor linearization method [47] with SUDAAN
version 10.01 [48] and were used in Wald tests for statistical significance and for producing 95% confidence
intervals (CIs) for adjusted odds ratios. The survival
coefficients and their standard errors were exponentiated
and are reported in the form of odds ratios (OR) and 95%
confidence intervals (95% CI).
Bivariate and multivariate associations of the childhood
adversities with lifetime prevalence of DSM-IV/CIDI disorder were estimated using discrete-time survival analysis
described above. Each model controlled for the adolescents age at interview, gender, diagnostic category and
person-year. The first multivariate model for the estimated
effects of childhood adversities included a separate variable for each of the 12 adversities. The second multivariate
model for the estimated effects of childhood adversities
included each of the 12 predictors for type of adversity and
additional predictors for number of family dysfunction
adversities and number of other adversities. This multivariate model was then estimated again for each of four
different classes of psychiatric disorder (mood, anxiety,
substance and behavioral) and another to estimate the
impact upon severity among those adolescents with any
disorder. To estimate the effects of number of adversities,
the first multivariate model included a series of dummy
predictor variables for the number of adversities (e.g., one
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such variable for respondents who experienced exactly one

adversity, another for respondents who experienced exactly
two adversities, etc.) without information about the types
of adversities experienced. The second multivariate model
for the estimated effects of number of adversities included
dummy predictors for the number of adversities as well as
for the types of adversities, with the number of adversities
starting at exactly two rather than exactly one because the
value of the variable for exactly one adversity was perfectly predicted by the 12 variables for the individual
adversities.
Results
The estimated individual and joint associations of childhood adversity and the probability of having any psychiatric disorder are presented on Table 1. The first model
presented, the bivariate model, in which 12 separate
regression equations were performed, one for each adversity, shows that all adversities except parental death,
parental divorce and economic adversity were associated
with psychiatric disorder with odds ratios ranging from 1.4
for other parental loss to 2.1 for physical abuse. To correct
for the possible over-estimation of the effects of individual
adversities due to their interrelatedness, two multivariate
models are also presented in Table 1. The first multivariate
model includes all adversities, but does not account for the
number of adversities, such that the effect of each adversity
is assumed to be equal. In this model, six adversities
remain significant (parent mental illness, physical abuse,
family violence, neglect, physical illness and other parental
loss), albeit with lower odds ratios ranging from 1.3 to 1.7.
Because the family dysfunction adversities have larger
odds ratios overall than the other adversities, it is probable
that the effect of each adversity cannot be assumed to be
equal and, thus, the final multivariate model accounts for
both the type of adversity and the number of family dysfunction adversities and the number of other adversities. In
this final model, 8 of the 12 adversities are significantly
associated with the onset of psychopathology (parent
mental illness, physical abuse, sexual abuse, family violence, neglect, parent criminal behavior, physical illness
and other parental loss) with odds ratios ranging from 1.3
to 2.0. Overall, these odds ratios are slightly lower than
those in the bivariate model, but higher than those of the
first multivariate model. This second multivariate model
was also performed separately for males and females and
no significant sex differences were found for the association of adversities with psychiatric disorder (results not
shown). In all models, the net impacts of any of the
adversities on any mental disorder were modest in effect, in
the range of 1.32.0 in the most complex model of Table 1.
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Table 1 Estimated risk (odds ratios) of having any DSM-IV disorder by chronic adversity in bivariate and multivariate survival models
Bivariate Modela
Multivariate modelb
for type of adversity
Multivariate modelc for type

and number of adversities
OR
95% CI
OR
95% CI
OR
95% CI
Parent mental illness
2.0**
1.82.3
1.7**
1.41.9
2.0**
1.62.4
Physical abuse
2.1**
1.82.4
1.6**
1.41.8
1.9**
1.62.3
Sexual abuse
Family violence
2.0**
1.7**
1.52.7
1.42.0
1.3
1.3**
1.01.9
1.11.6
1.9**
1.5**
1.42.5
1.21.9
Neglect
1.7**
1.42.1
1.3*
1.01.6
1.5**
1.21.9
Parent criminal behavior
1.6**
1.41.9
1.2
1.01.5
1.4**
1.11.8
Parent substance use
1.6**
1.32.0
1.0
0.81.3
1.3
1.01.8
Physical illness
1.5**
1.31.8
1.3*
1.01.5
1.3**
1.11.5
Other parent loss
1.4**
1.11.6
1.3*
1.01.5
1.3*
1.01.6
Parent died
1.1
0.81.5
1.1
0.91.5
1.2
0.91.6
Economic adversity
1.0
0.81.2
1.0
0.81.1
1.0
0.91.3
Parent divorce
1.1
0.81.3
1.0
0.81.2
1.0
0.81.3
v212 = 402.6 (p \ 0.0001)
v212 = 170.3 (p \ 0.0001)
Based on discrete-time survival models with person-year, the unit of analysis pooled across 20 different DSM-IV/CIDI disorders, controlling for
age at interview, gender, diagnostic category and person-year (n = 3,005)
*p \ 0.05; **p \ 0.01
a
Twelve separate bivariate models were estimated, one for each childhood adversity with the controls listed in the previous footnote
The model was estimated with all 12 adversities simultaneously in addition to the controls listed in the first footnote
The model was estimated with all 12 adversities and with dummy predictors for number of family dysfunction adversities and number of other
adversities in addition to the controls listed in the first footnote
Using this same interactive multivariate model which

takes into account the type and number of adversities, the
estimated effects of adversities on four different classes of
disorder are presented in Table 2. Physical abuse is associated with risk for all four classes of disorders, ranging
from an odds ratio of 1.9 for anxiety disorders to 2.3 for
behavioral disorders. Sexual abuse, family violence and
parental mental illness are fairly consistently associated
with the different classes of disorders with significant odds
ratios for three of the four classes of disorders, ranging
from 1.4 to 2.6. Other parental loss is specific to anxiety
disorders with 30% greater odds. Physical illness is specific
to anxiety and behavioral disorders, neglect to mood and
behavioral disorders, and parental criminal behavior to
behavioral and substance disorders, the latter with the
greatest odds ratio for any association, 6.6.
The estimated joint associations of childhood adversity
on meeting criteria for a seriously impairing disorder
among adolescents with a DSM-IV disorder within the
prior 12 months are presented in Table 3 in a multivariate
model, which takes into account the type and number of
adversities. Only two adversities, sexual abuse and family
violence, are associated with disorder severity among
youth with any disorder, with odds ratios of 7.6 and 1.9,
respectively.
The estimated probability of the onset of any psychiatric
disorder by the number of chronic adversities experienced
is presented in Table 4. The first multivariate model which

assesses the effects of the number of overall adversities
irrespective of the type of adversity shows increasingly
larger odds ratios with increasing number of adversities.
The increased risk begins at two adversities with an odds
ratio of 1.7 up to an odds ratio of 4.3 for seven adversities.
The second multivariate model, which assesses the effects
of the number of overall adversities on any disorder controlling for the type of adversity, shows a sub-additive
effect of each additional adversity such that the effect of a
second adversity is 80% of the added effect of the first
adversity, the third is slightly more than a half of the added
effect of the first adversity and so on with a progressive
decay, until the fifth and sixth adversities have 0.3 and 0.4
the odds of additional risk for psychopathology.
Discussion
This study contributes to the literature on risk factors for
adolescent psychopathology, by expanding the previously
limited array of adversities and disorders examined
simultaneously to elucidate the individual and joint effects
of chronic adversity, taking into account the type and
number of adversities as well as the type and severity of
psychopathology. The main findings suggest that family
dysfunction adversities such as parent pathology, abuse and
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464
Table 2 Estimated risk (odds ratios) of types and numbers of childhood adversities on four classes of DSM-IV disorders
Mood
Anxiety
OR
95% CI
OR
Substance
95% CI
OR
Behavioral
95% CI
OR
95% CI
Parent mental Illness
2.0**
1.42.9
1.9**
1.52.3
2.1
1.04.4
2.3**
1.73.1
Physical abuse
2.1**
1.52.9
1.7**
1.32.1
2.2*
1.04.7
2.4**
1.73.3
Sexual abuse
2.2**
1.33.9
1.6*
1.02.5
1.1
0.52.9
1.8*
1.13.0
Family violence
1.4
1.01.9
1.4**
1.11.7
2.6**
1.44.7
2.0**
1.42.9
Neglect
2.0**
1.23.2
1.0
0.81.4
2.1
1.04.5
2.8**
1.84.4
1.0
0.61.8
1.1
0.81.5
6.6**
3.213.5
2.2**
1.53.2

Physical illness
1.2
1.3
0.71.9
0.82.0
1.3
1.3**
1.01.9
1.11.5
1.8
0.9
0.74.8
0.32.4
1.5
1.9**
0.92.5
1.42.6
Other parent loss
1.2
0.81.7
1.3*
1.01.6
1.6
0.83.2
1.4
1.01.9
Parent died
1.3
0.82.0
1.2
0.91.7
0.5
0.12.0
1.1
0.71.8
Economic adversity
0.9
0.61.3
1.0
0.81.2
1.4
0.72.6
1.1
0.81.6
Parent divorce
1.1
0.81.6
1.0
0.81.3
0.7
0.31.7
1.2
0.81.9
v212
= 92.1 (p \ 0.0001)
v212
= 141.8 (p \ 0.0001)
v212
= 76.3 (p \ 0.0001)
v212
= 122.5 (p \ 0.0001)
Based on discrete-time survival models with person-year, the unit of analysis pooled separately across four classes of DSM-IV/CIDI disorders,
controlling for number of family dysfunction adversities, number of other adversities, age at interview, gender, and person-year (n = 3,005)
*p \ 0.05; **p \ 0.01
Table 3 Estimated risk (odds ratios) of childhood adversities on
disorder severity among adolescents with a 12-month disorder
Risk of serious disorder
OR
95% CI
Parent mental illness
1.1
0.52.2
Physical abuse
2.1
0.85.3
Sexual abuse
Family violence
7.6**
1.9*
2.920.1
1.13.2
Neglect
1.2
0.43.5
1.2
0.72.1
2.7
1.07.5
Physical illness
0.6
0.21.7
Other parent loss
1.0
0.52.0
Parent died
0.9
0.51.9
Economic adversity
0.5
0.31.1
Parent divorce
1.1
0.52.4
v212 = 52.1 (p \ 0.0001)

Based on discrete-time survival models with person-year the unit of
analysis pooled across 20 different DSM-IV/CIDI disorders, controlling for age at interview, gender, diagnostic category, person-year,
type of adversity, number of dysfunctional family adversities and
number of other adversities (n = 1,168)
*p \ 0.05; **p \ 0.01
violence present consistent modest associations between

chronic adversity and psychopathology, and their impact is
generally non-specific with regard to the type of disorder.
It is important to note that these adversities probably
impact on mental health both through environment (i.e.,
reduced parenting capacity and chaotic unpredictable
123
environments) and genetic vulnerability (more evident for

parental mental illness and substance abuse, but also possible for abuse and violence) [34]. Additionally, adversities
may affect mental health through the impact of early stress
upon brain development and functioning [58]. Parental
divorce, parental death and economic adversity are not
individually associated with psychopathology in this sample. A few adversities are more specific to certain types of
disorder such as other parental loss to anxiety disorders,
physical illness to anxiety and behavioral disorders and
parent criminal behavior to substance and behavioral disorders, though these specificities should be interpreted with
caution. Among those with a psychiatric disorder, sexual
abuse and family violence only are associated with having
a seriously impairing disorder, whereas in another study,
most of all family dysfunction adversities were associated
with impairment in adults with psychopathology [49]. The
odds of having a psychiatric disorder increase with
increasing numbers of adversities; however, each additional adversity increases the odds at a decreasing rate
perhaps suggesting a ceiling effect on the number of
adversities. In keeping with Kraemer and colleagues
proposed conceptualization of risk factors, the results
suggest that family dysfunction adversities should be
conceptualized as overlapping risk factors as they are
moderately correlated [23] and their shared effect on psychopathology is greater than the individual effect of any
one adversity [50].
Some limitations of this study should be noted. First, the
cross-sectional retrospective design and retrospectively
reported ages of onset do not allow for conclusions
465
Table 4 Estimated effects (odds ratios) of number of chronic adversities on risk of DSM-IV disorders using multivariate survival models
Simple modela
OR
Complex modelb
95% CI
OR
95% CI
Number of adversities
0
1.2
1.01.5
1.7**
1.52.0
0.8
0.61.1
2.5**
2.03.1
0.6
0.31.1
2.7**
2.23.2
0.4**
0.20.8
5
6
2.5**
3.4**
1.54.0
1.57.6
0.3**
0.4*
0.10.6
0.10.9
4.3**
3.06.0
10
11
12
v27 = 291.8 (p \ 0.0001)
v25 = 18.9 (p = 0.002)
Based on discrete-time survival models with person-year, the unit of analysis pooled across 20 different DSM-IV/CIDI disorders, controlling for
age at interview, gender, diagnostic category and person-year (n = 3,005)
*p \ 0.05; **p \ 0.01
a
The model was estimated with dummy predictors for number of adversities with the controls noted in the first footnote without any information
about the types of adversities
The model was estimated with dummy predictors for number of adversities as well as for the types of adversities in addition to the controls
noted in the first footnote
regarding causality. The use of discrete-time survival

models based on retrospective reports of ages of onset
provide greater support for directionality, but cannot provide as much evidence as a prospective longitudinal design.
While measures were taken to reduce recall bias and
inaccuracy in the dating of events (such as the use of
anchoring events or stages and quality control programs to
search for response inconsistencies), some bias is likely to
remain; furthermore, we cannot rule out that adolescents
meeting criteria for psychiatric disorder are more likely to
recall or report adversity. Additionally these childhood
adversities, such as family dysfunction or poverty, are
likely to have been present during most of these youths
lifetime and thus to have preceded the onset of disorder. A
second limitation is that psychiatric diagnosis was based on
adolescent report alone. It is generally deemed ideal to use
multiple informants for child/adolescent diagnosis, and
while the research literature has reported generally low
concordance between parent and child reports [51, 52], a
new approach has been proposed and successfully tested to
integrate reports from multiple informants [53]. While this
study does not have multiple informants for diagnoses,
adolescent reports are likely to be more reliable than child
reports as suggested by the increasing introspection and
cognitive maturity of adolescents reflected by the greater
variance explained by child reports as a function of age in

this aforementioned study. Adolescents perceptions of
their parents mental health is likely to be less accurate and
is a limitation to be considered. Finally, while this study
reports a broader array of adversities and psychiatric disorders than most, not all possible adversities or pathologies
were included nor were street children or institutionalized
youth included in the sample, presumably groups at greater
risk for both adversity and psychopathology.
Parental death, parental divorce and economic adversity
stand out for their lack of association with psychopathology in all models. While this is consistent with our findings
in the Mexican adult population and with the National
Comorbidity Survey in the USA, this is inconsistent with
many other studies that focus exclusively on parental loss
[5456]. These findings do not support the idea of parental
loss per se having a unique effect on psychopathology.
Perhaps the positive findings of some prior studies are due
to not controlling for other adversities related to parental
loss. It may also be that the context of loss is crucial for
determining outcome such that the presence of a caring
parent substitute might mitigate the impact of parental loss
while the loss of an abusive parent might have a beneficial
impact upon mental health. In studies with adolescents
orphaned by AIDS, stigma accounts for worse mental
123
466
health outcomes, whereas having a natural mentor contributes to better mental health outcomes [57, 58]. Additionally, the Mexican context might partially mitigate
potentially negative consequences of parental loss in that
extended family members, particularly grandparents, often
substitute for parents (i.e., look after children when parents
work, migrate to larger cities or the USA to find employment or pass away), thus potentially buffering the negative
impact of loss. With regard to economic adversity, it may
be that the lack of variability (i.e., the large proportion with
economic adversity) may hinder the ability to find differences, or that the impact of living in poverty is less when
ones reference group also lives in poverty. Needless to
say, these results are consistent with the finding that low
socioeconomic status was not a risk factor for psychiatric
disorders in Mexican-American youth, though it was for
European American youth [59].
Because many of these adolescents are still experiencing
adversity or little time has passed for the development of a
psychiatric disorder, these data may represent only the
acute effect of adversity on psychopathology. Only longitudinal data can address conclusively the persistence of
these disorders or the new onset of disorder later in life.
However, retrospective reports of adults do suggest longterm effects, such that these disorders persist into adulthood and that those experiencing childhood adversity have
greater odds of developing new psychiatric disorders years
afterward [28, 31]. The majority of associations for individual adversities are rather modest (representing 30% to
twofold odds in our most comprehensive models). While
some adversities such as sexual abuse, parental death and
neglect are fairly infrequent (1.7, 5.6 and 5.7%, respectively), others are quite common such as witnessing
domestic violence (19.4%) and being a victim of physical
abuse (13.8%) [23]. The common occurrence of some
adversities, despite the modest associations with psychiatric disorders, points to the public health relevance of
childhood adversities. Additionally, the greater risk for
multiple adversities, which when interpreted in light of our
prior findings that most youth who experience at least one
adversity also experience others, an average of 2.8 [23],
suggests a non-trivial proportion of adolescent psychiatric
disorders attributable to childhood adversities. In conclusion, these findings suggest general pathways from family
dysfunction to psychopathology and provide further evidence for the importance of family-focused intervention
and prevention efforts.
Acknowledgments This work was supported by the National
Council on Science and Technology in conjunction with the Ministry
of Education (Grant No. CONACYT-SEP-SSEDF-2003-CO1-22),
and CONACYT (Grant No. CB2006-01-60678) allowed for continued analyses of adversity. The survey was carried out in conjunction
with the World Health Organization World Mental Health (WMH)
123

Survey Initiative. We thank the WMH staff for assistance with
instrumentation, fieldwork and data analysis.
Conflict of interest
None.
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