Childhood Adversity and Depression

See article by Hovens et al

The link between childhood adversity and depression has been studied extensively.1-4 These studies have focused on a wide range of childhood experiences, including sexual abuse, physical abuse, emotional abuse, neglect, parental death, parental divorce, and other parental loss (such as placement in foster care). There is robust evidence that childhood adversity is associated with an increased risk of lifetime major depression in a dose-response manner1-4; the higher the number of childhood adversities an individual reported, the higher the probability of lifetime depression. In addition, childhood adversity has been linked to unfavorable clinical characteristics of depression, such as more comorbidity, earlier age at onset of depression, higher symptom severity, longer illness duration, and more relapses.3,5-7

Certain childhood adversities seem to have a greater impact on the development and course of depression than others.5-8 The different impact of childhood adversities has also been addressed in the National Comorbidity Survey Replication (NCS-R).2,6 Factor analysis grouped 12 childhood adversities into 2 categories: those reflecting "maladaptive family functioning" (sexual abuse, physical abuse, neglect, parental mental illness, parental substance abuse, criminal behavior, and domestic violence) and "other childhood adversities" (parental death, parental divorce, other parental loss, childhood physical illness, and family economic adversity). The report of multiple childhood adversities was the norm; 51.2% among those with death of a parent to 95.1% among those with neglect.2 Individuals in the "maladaptive family functioning" group were most vulnerable to develop and persist in depression. This supports the assumption that it is not a childhood adversity, per se, that elevates the risk of developing psychopathology, but rather the quality of the childhood home environment.2,6,9

In the current issue, Hovens and colleagues10 provide new evidence for this assumption; parental death, parental divorce, and other parental loss did not predict the occurrence of depression, whereas sexual abuse, physical abuse, psychological abuse, and emotional neglect did.10 In particular, they found that emotional neglect was the most important predictor of the occurrence of depression. Emotional neglect was also the most prevalent childhood adversity reported in the depressed group (n = 97) of their study. About 20% of this group reported they had experienced emotional neglect on a regular basis. In a group of chronically depressed individuals (n = 395), this number goes up to 53%.5 Hovens et al10 state that the serious and lifelong consequences of emotional neglect on adult psychopathology have not been recognized for a long time. Most studies have focused on childhood adversities such as sexual abuse, physical abuse, and (physical) neglect. Emotional neglect is often not specifically asked for, and thus is underreported, while the studies that focus on emotional neglect show its importance, especially when it comes to chronic depression.5

Since childhood adversities, and especially those related to maladaptive family functioning, have been linked to more unfavorable clinical characteristics of depression, it is not surprising that these childhood adversities are also associated with poor treatment response for depression.3 However, it may also be the case that this group of patients needs another treatment approach.11 Research has suggested that individuals with and without a history of childhood adversity may react differently to treatment. In a large group of chronically depressed patients (N = 681), a differential response to psychotherapy (Cognitive Behavioral Analysis System of Psychotherapy) versus pharmacotherapy was found as a function of the presence of childhood adversity (sexual abuse, physical abuse, neglect, and parental loss).11 Psychotherapy was superior over pharmacotherapy for chronically depressed patients who reported childhood adversity. This suggests that there may be important differences in the etiology and pathogenesis of depression in individuals with and without a history of childhood adversity.11

Indeed, biological studies have indicated such differences.12-15 Although research on neurobiological changes in response to childhood adversity is still nascent and, as of yet, based on very mixed samples of children or adults with diverse experiences of childhood adversity, there is a growing body of evidence that childhood adversity contributes to stress-induced changes in a child’s neurobiological systems. These changes may be adaptive at first, but may become maladaptive in the long run by increasing the risk for psychopathology, such as depression.12-15 Importantly, these neurobiological changes in response to childhood adversity may not be permanent; children in foster care experienced a normalization of stress-induced cortisol responses after their foster parents underwent an attachment-based intervention.16 Studies on the interaction of genes and environment underline these findings; positive environmental influences, such as social support, can buffer genetic and environmental risk for depression and promote resilience.13,15,17 In support of this, Kaufman et al18 found that children with genetic vulnerability and a history of childhood adversity (physical abuse, sexual abuse, neglect, emotional abuse, and exposure to domestic violence) were less likely to develop depression if they had social support. The same accounts for positive aspects of the family environment.19 Other findings also suggest that preventive and therapeutic interventions that focus on fostering child-adult relationship quality, creating a positive self-concept, and promoting self-control in young children may help build children’s mental health and resilience to family adversities.20

These findings underline the importance of early interventions. However, children at risk may not always be easy to identify. One way of identifying these children is screening the offspring of help-seeking (depressed) adults, since we know that adults with mental health problems who have experienced childhood adversities (such as sexual abuse, physical abuse, emotional abuse, physical neglect, and emotional neglect) are more likely to expose their offspring to childhood adversities.21 Therefore, several clinical implications can be made. First, clinicians in mental health care should inquire about childhood adversities, especially those related to maladaptive family functioning, and subsequently screen the offspring as a standard procedure. Second, since childhood adversity can have such great impact on depression, clinicians should take this into account in their subsequent management of depression. For example, when necessary, treatment should focus on family functioning, helping patients and their family to break the intergenerational cycle of childhood adversity and depression. Finally, research on treatments targeting the biological and psychological vulnerabilities of depressed patients with a history of childhood adversity should be encouraged.

Submitted: August 19, 2014; accepted September 9, 2014.

Potential conflicts of interest: None reported.

Funding/support: None reported.

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aDepartment of Psychiatry, GGZ inGeest, Amsterdam, the Netherlands.

*Corresponding author: Jenneke E. Wiersma, PhD, Department of Psychiatry, GGZ inGeest, A. J. Ernststraat 1187, Amsterdam, Netherlands 1081 HL, the Netherlands (j.wiersma@ggzingeest.nl).

J Clin Psychiatry 2015;76(7):e906-e907

dx.doi.org/10.4088/JCP.14com09454

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