Childhood adversity and the presence and persistence of substance use disorders over the life course among a nationally representative sample of adult women
Substance use disorders affect a substantial proportion of women in the United States. During the past two decades, women-specific antecedents, correlates, and consequences of substance use disorders have been identified, but because of the limitations of extant knowledge, we still know relatively little about precise determinants. Theoretically guided by a life course (Elder, 1974, 1998, 2002) epidemiological perspective (Braveman & Barclay, 2009; Kuh et al., 2003), a social determinants perspective (Marmot, 1999), the Stress Process Model (Pearlin, 1981, 1989, 2005), and the Theory of Fundamental Causes (Link & Phelan, 1995; Phelan et al., 2010), I examined relationships between experiences of childhood adversity (defined as abuse, neglect, household dysfunction), sociodemographic characteristics, and the presence and persistence of different types of substance use disorders (defined as no disorder, alcohol only, drug only, poly-substance). I utilized data on 19,209 women and 13,898 men who participated in two waves of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), and were White, Black, or Hispanic. I conducted weighted multinomial regression analysis, exploratory factor analysis, and logistic regression analysis.
Findings indicated that more than half of women and men in the United States have experienced some type of childhood adversity. More women than men have experienced three or more types of childhood adversity. Also, women and men have experienced different types of childhood adversity. Specifically, more women than men have experienced childhood sexual and emotional abuse, and certain types of childhood household dysfunction, specifically parental problematic substance use, having a battered mom, parental mental illness, and parental suicide attempt. In contrast, fewer women than men have experienced childhood physical abuse, childhood physical and emotional neglect, and having a parent who committed suicide. For women only, exploratory factor analysis indicated that type of childhood adversity may be best reduced to two concepts, i.e., childhood household dysfunction and childhood maltreatment (abuse and neglect).
For both women and men, there was a dose-response relationship between number of types of childhood adversity experienced and likelihood for each type of substance use disorder. However, with more experiences of different types of childhood adversity, the gap between women and men in predicted probability for a disorder narrowed in relation to an alcohol use disorder, it converged in relation to a drug use disorder, and it widened in relation to a poly-substance use disorder. These findings suggest that greater exposure to childhood adversity may act as a force that elevates women’s odds for an alcohol and drug use disorder to levels that approximate or mirror those that are evident among men, and it increases the odds for a poly-substance use disorder more sharply among men than among women.
Analyses focused on only women revealed complexities in the ways that socioeconomic status moderated the relationship between childhood adversity and the occurrence of each type of substance use disorder. For example, higher socioeconomic status heightened women’s odds for an alcohol use disorder in the context of exposure to 1 to 2 types of childhood adversity; but it dampened those odds in the context of exposure to 3 or more types of childhood adversity. In relation to drug use disorders, higher income heightened women’s odds for a disorder in the context of childhood adversity; but those odds were dampened by higher educational attainment and certain employment statuses.
In addition, exposure to more types of childhood adversity increased the odds that women would develop a more severe form of a disorder, i.e., a drug use disorder or a poly-substance use disorder (relative to an alcohol use disorder). Furthermore, the presence of a poly-substance use disorder (relative to an alcohol use disorder) predicted persistence of women’s substance use disorders over three years, net of experiences of childhood adversity and other factors. These findings suggest that more exposure to childhood adversity may propel women to a more severe substance use disorder, which in turn may heighten women’s risk for persistence of that disorder over her life course.
Finally, there were differences by race/ethnicity in the relationship between type of substance use disorder and disorder persistence. White and Black women were each more likely to have a persistent alcohol use disorder than Hispanic women. Black women were more likely to have a persistent drug use disorder than both White women and Hispanic women. Among both Black women and Hispanic women, having a drug use disorder elevated the risk for disorder persistence more than having only an alcohol use disorder; among White women the presence of a drug use disorder did not elevate the risk for disorder persistence more than having only an alcohol use disorder. For White, Black, and Hispanic women, the presence of a poly-substance use disorder was associated with disorder persistence. More research is needed to understand why there are differences by race/ethnicity in the relationship between having an alcohol or drug use disorder and disorder persistence.
Dissertation findings advance understanding of how early life experiences and other social forces act as fundamental causes of different types of substance use disorders among women and men. In relation to women in particular, findings extend current thinking regarding factors that modify the relationship between childhood adversity and different types of substance use disorders. The knowledge gained through identifying and explicating these relationships has the potential to inform evidence-based treatments, but may also be useful for shaping other types of public health initiatives to ameliorate or prevent the occurrence and persistence of substance use disorders.