In my end is my beginning: developmental trajectories ...

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In my end is my beginning: developmental trajectories of adverse childhood experiences to late-life suicide a

b

c

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Natalie J. Sachs-Ericsson , Nicole C. Rushing , Ian H. Stanley & Julia Sheffler a

Department of Psychology, Florida State University, FL, USA

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Department of Psychology, Coastal Carolina University, SC, USA

c

Department of Psychology, Florida State University, FL, USA Published online: 11 Aug 2015.

Click for updates To cite this article: Natalie J. Sachs-Ericsson, Nicole C. Rushing, Ian H. Stanley & Julia Sheffler (2015): In my end is my beginning: developmental trajectories of adverse childhood experiences to late-life suicide, Aging & Mental Health, DOI: 10.1080/13607863.2015.1063107 To link to this article: http://dx.doi.org/10.1080/13607863.2015.1063107

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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

Downloaded by [Coastal Carolina University] at 09:38 12 August 2015

(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 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 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 commonly studied ACE is childhood abuse (e.g., sexual, physical, emotional/verbal abuse and neglect). In addition to childhood abuse, ACEs typically include measures of family dysfunction comprised of indices of parental psychopathology, 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 negative effects of childhood abuse, more recently researchers have been evaluating the simultaneous effect of the clustering 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 *Corresponding author. Email: [email protected] Ó 2015 Taylor & Francis

depression, disability and functional limitations in older adults (Shrira & Litwin, 2014) and increased suicidal ideation across the lifetime (Dube, Felitti, Dong, Giles, & Anda, 2003).

Definitions of ACE Definitions of ACE vary across studies (see Gershon, Sudheimer, Tirouvanziam, Williams, & O’Hara, 2013; Greenfield, 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 investigations ever conducted to assess associations between childhood maltreatment and later-life health and wellbeing (see http://www.cdc.gov/violenceprevention/ acestudy) (Dube et al., 2003). In this investigation, the measures of ACE included ‘childhood emotional, physical, 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

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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 suggesting 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 multidisciplinary evidence to develop a heuristic framework through which to understand how ACE may lead to suicide in later life. In conducting and describing research on 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, & Melanson, 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 emotional, 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, Corsentino, Rushing, & Sheffler, 2013) and in clinical samples (Brodsky et al., 2001; Lopez-Castroman et al., 2015; McHolm, MacMillan, & Jamieson, 2003). Having experienced 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 populationattributable 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. Specifically, childhood neglect, psychological and physical abuse was strongly associated with new onset suicidal ideation 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 childhood 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 (Brodsky & Stanley, 2008), researchers concluded that a history of any childhood abuse (e.g., physical, sexual and neglect), but particularly sexual abuse, creates a vulnerability to suicidal behavior in adulthood. In a meta-analysis, 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 associated 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 violence, 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 suicide 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, consistent with the interpersonal theory of suicide (Van Orden et al., 2010), that compared to verbal abuse, violent physical or sexual abuse in childhood had stronger effects on lifetime suicide attempts, whereby more painful experiences 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 expendability (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 relationship 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 associations with suicide attempts in childhood (median significant OR D 3.8), decreasing during teen years (median significant OR D 2.5) and young adulthood (median significant 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 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 association 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 negative 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 perpetrator, and number of perpetrators may have differential impact on its effects (Charles, 2010; Liu et al., 2012; Steel, Sanna, Hammond, Whipple, & Cross, 2004). Additionally, the clustering of co-occurring ACE may differentially 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 physical 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 individual variation in the type or severity of symptom development from ACE. There is likely a complex interaction between abuse-related factors, interactions with others and individual factors as mediators and moderators of outcomes. The complexity in understanding the unique and

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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 latelife 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 interactions (Bani-Fatemi, Howe, & De Luca, 2014). ACE may interact with genetic predisposition to increase risk of mood dysregulation, psychiatric 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 allcause mortality (Kelly-Irving et al., 2013). Functional impairment in older age is associated 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 interpersonal deficits which undermine relationships

Sample size

Population-based, nationally representative sample of community-dwelling adults (over 50)

(over 60; M D 71.9)

Primary care clinic patients (M age D 57) (M D 57 years, SD D 15.2 years)

Four birth cohorts: 1900 1931; 1932 1946; 1947 1961; 1962 1978 (M D 57 years, SD D 15.2 years)

Nationally representative sample (over 60 years)

N D 3,493

N D 21,819

N D 17,337

N D 17,337

N D 1610

Draper et al. (2008)

Dube et al. (2001)

Dube et al. (2003)

Sachs-Ericsson et al. (2013)

Mean age not given; population analyzed across the lifespan

Individuals who died by suicide (55 years and older) or made serious attempt

Sample characteristics (age range/mean)

Chou (2012)

Select population studies of older adults Beautrais (2002) N D 53 (death by suicide or serious attempt) N D 269 (controls) Bruffaerts N D 55,299 et al. (2010)

Author (year)

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

Childhood physical (beaten or physically abused by parent/ caregiver) and sexual abuse (raped or sexually molested) occurring at age 15 and under.

(ACEa study Questionnaire) emotional, physical, and sexual abuse; household substance abuse, mental illness, and incarceration; and parental domestic violence, separation, or divorce. (ACEa study Questionnaire)

Childhood physical and sexual abuse before age 15

Stressful life events Childhood physical and sexual abuse, parental loss, financial adversity, illness Childhood sexual abuse (sexual touching and sexual intercourse)

Childhood sexual abuse, parental care, parental bonding.

ACE

Gender, age, and parental externalizing and internalizing symptoms.

Number of ACE experiences Participants’ internalizing & externalizing symptoms. (DSMIV; CIDI; WHO, 1990)

Cohort effects

Covariates: age, sex, birthplace, marital status, educational living arrangements, religion Number of ACE

Revictimization Social Support

Gender

Lifetime mental disorder

Mood disorders, psychiatric admissions, social network

Mediator/moderator covariate


(continued)

Late-life suicide ideation (‘Have you ever seriously thought about committing suicide?’ including only participants who endorsed thoughts after the age of 60

Suicide attempts (also depressed affect, multiple sexual partners, sexually transmitted diseases, smoking, and alcoholism)

Suicide attempt (six health outcomes (depressed affect, lifetime suicide attempts, multiple sexual partners, STD, smoking, alcoholism)

Suicidal ideation and suicidal attempts in the past year

Lifetime suicide ideation, plans, and attempts

Death by suicide, medically serious suicide attempt, or Control

Suicide outcome measure (s)

4 N.J. Sachs-Ericsson et al.

Sample size

7 longitudinal and 2 twin studies (No mean age reported)

Adults ages 18 64 years

M D 44.7 years, SD D 11.6 years

Adults 18 65 years (M D 33.2, SD D 10.7)

Adult patients who had attempted suicide (18C; M D 39.6)

Review article

Meta-analysis N D 8,733

N D 5,618

N D 575

N D 5,838

N D 726

Brodsky and Stanley (2008)

Devries et al. (2014)

Enns et al. (2006)

Hardt et al. (2008)

Joiner et al. (2007)

Lopez-Castroman et al. (2015)

Sexual abuse, physical abuse, and domestic violence

ACE

Impulsivity, Aggression

Gender & Number of ACE


Suicide ideation (Seriously thought about Suicide) Suicide attempt (Made a Serious attempt) Suicidal behavior in depressed adults (Columbia Suicide History Form)


(continued)

Gender, Abuse type; characteristics Suicidal behaviors of perpetrator, characteristics of abuse experience, impulsivity and aggression, diagnostic comorbidity Childhood sexual abuse Controlled for early family violence, Suicide attempts other mental disorders, and other abuse Demographic characteristics, mental Suicide ideation, plans, and attempts Emotional neglect, psychological, disorders, number of ACE physical or sexual abuse, parental pathology, deficient parental bonding Suicide ideation, plans, and attempts Harsh physical punishment, severe Gender sexual abuse, chronic illness, parental loss, parental substance abuse, domestic violence, financial hardship Lifetime suicide attempts Severity of painful abuse, Childhood physical and violent participants’ psychiatric sexual abuse compared to diagnoses, parental psychiatric molestation and verbal abuse symptoms, parental loss, family conflict Emotional abuse, emotional neglect, PTSD (MINI criteria for current or Suicide attempts (semi-structured 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)

Two patient samples who met DSM- Childhood physical or sexual abuse before age 15 (3 questions from III-R criteria for major depressive Columbia Demographic and (M D 39.5) (M D 34.9) Treatment History Interview) Adults Physical and sexual abuse; parental neglect

N D 136

(NCS-R) Nationally representative (age over 18 years)


Brodsky et al. (2001)

Select population and clinical samples Afifi et al. (2008) N D 5,692

Author (year)

Table 1. (Continued )


Aging & Mental Health 5

Sample size

N D 5,877 (NCS)

Meta-analysis of 37 studies published between 1981 and 1995

Adolescents and adults ages 15 54 years.

Women (age 15 64 years) from a community sample who met criteria for major depressive disorder (lifetime prevalence)


General psychiatric inpatient unit (M D 37.31 for 5HTTLPR ss/sl; M D 34.93 for 5-TTLPR ll)

Caucasian suicide attempters (M D 39.8 years)

Caucasian Slovenians from autopsy study (suicide victims (M D 49.3); controls (M D 47.2)

N D 30

N D 813

N D 359 suicide victims; N D 201 controls

Gibb et al. (2006)

Perroud et al. (2008)

Pregelj et al. (2011)

The effect of ACE on biological processes directly related to suicide School-aged children (ages 6 13; Cicchetti et al. (2010) N D 478 M D 9.19) maltreated; N D 372 non-maltreated

Paolucci et al. (2001) N D 25,367

Molnar et al. (2001)

McHolm et al. (2003) N D 347

Author (year)

Table 1. (Continued ) Mediator/moderator covariate

Stressful life events in childhood (physical, emotional, sexual abuse, general trauma, parent death, divorce or other mental disorders)

Childhood emotional, sexual and physical abuse, physical and emotional neglect CTQ)b

Childhood maltreatment from Social Services records:(i.e., neglect, emotional maltreatment, physical & sexual abuse (The Maltreatment Classification System; Barnett et al., 1993) Childhood emotional, sexual and physical abuse, physical and emotional neglect (CTQ)b

Sexual abuse, parental verbal and physical abuse, domestic violence, parental psychopathology Sexual abuse, (e.g., any unwanted sexual contact)

BDNF Val66Met

BDNF Val66Met genotype

5-HTTLPR genotype

5-HTTLPR Genotype

Gender, socioeconomic status, type of sexual abuse, age of abuse, perpetrator, number of abuse incidents

Current age Age of onset Income Psychiatric disorders, parental psychopathology, abuse other than sexual

Psychiatric disorders Childhood physical abuse (The Child Maltreatment History SelfReport; MacMillan et al., 1997)

ACE


(continued)

Lifetime history of suicide attempts (intentional self-injury with an intent to die from patients’ medical charts) Violent or non-violent suicide attempts (criteria by Asberg, Traskman, & Thoren, 1976; Diagnostic Interview for Genetics Studies or MINI) Violent and non-violent suicide (classification not defined)

Suicidal ideation (from Children’s Depression Inventory; Kovacs, 1992)

Recurrent thoughts of death or suicidal ideation, plans, attempts, or gestures of self-harm with death as a possible end result

Suicide ideation and attempts

Suicide ideation and attempts (two interview questions: 1) “Have you ever thought about committing suicide?” and 2) “Have you ever attempted suicide?”)



N D 474

Roy et al. (2012)

2 subsamples of African American participants; 112 suicide attempters and 362 non-suicide attempters (M D 45.2 and M D 34.3) 2 subsamples of African American participants; 112 suicide attempters and 362 non-suicide attempters (M D 45.2 and M D 34.3)


Childhood emotional, sexual and physical abuse, physical and emotional neglect (CTQ)b

Childhood emotional, sexual and physical abuse, physical and emotional neglect (CTQ)b

ACE

CRHBP & FKBP5 genotypes (involved in HPA-axis activity)

FKBP5, an HPA-axis regulating gene


Suicidal Attempt (defined as “a selfdestructive act with some intent to end one’s life that was not selfmutilatory in nature”)

Suicidal Attempt(defined as “a selfdestructive act with some intent to end one’s life that was not selfmutilatory in nature”)


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. 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 questions 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.”

a

N D 474

Sample size

Roy et al. (2010)

Author (year)




Random sample of older men and women from the Longitudinal Aging Study Amsterdam (ages 55 85; M D 77) Birth cohort of Caucasian nonMaori followed from age 3 to 26 (M D 26)

Caucasian suicide attempters (M D 39.71) recruited from the University Hospital of Montpellier Meta-analysis of 54 studies

French Canadian men (25 with Hx of severe childhood abuse (M D 37.3) and 16 controls (M D 40.9)

Postmortem study examining three groups: suicides with child abuse (M D 34.2), suicides without abuse (M D 33.8), and controls (M D 35.8) Participants with BPD seeking dialectical behavior therapy (M D 30.76)

Sample 1 D birth cohort followed from age 3 to 32 (M D 32);

Sample 2 D mothers of twins (M D 33)

Sample size

N D 906

N D 847

N D 218

N D 40,749

N D 41

N D 36 postmortem

N D 101

N D 847 for Sample 1

N D 930 Sample 2

Author (year)

Biological processes Bet et al. (2009)

Caspi et al. (2003)

Guillaume et al. (2013)

Karg, et al. (2011)

Labonte et al. (2012)

McGowan et al. (2009)

Perroud et al. 2011

Uher et al. (2011)

Sample characteristics (age range/ mean age)

Table 2. Adverse childhood experiences (ACE) and negative outcomes. Mediator/moderator covariates

Outcome measure (s)

N/A

N/A

5-HTTLPR genotype

Childhood emotional, sexual & N/A physical abuse, physical & emotional neglect (CTQ)b Childhood maltreatment and assessment of severity) Sample 1: observations of rejecting 5-HTTLPR genotype mother, (b) parental reports of harsh discipline, multiple caregivers, sexual & physical abuse. Sample 2 D Childhood emotional, sexual & physical abuse, physical & emotional neglect (CTQ)b.

maltreatment (child abuse, child maltreatment, family dysfunction) negative life events (serious health problems, exposure to natural disasters) sexual contact, severe physical abuse and/or severe neglect (adapted Childhood Experience of Care and Abuse; Bifulco, Brown, & Harris, 1994) Childhood abuse/neglect (sexual contact, severe physical abuse and/or severe neglect)

(continued)

Persistent vs. Single-episode depression based on DSM-IV criteria

NR3C1 methylation status

neuron-specific glucocorticoid receptor (NR3C1) promoter

Epigenetic alterations in the promoters of several genes in hippocampal neurons

Depression

The Center for Epidemiological Glucocorticoid receptor (GR) Childhood adversity (exposed to Studies-Depression Scale (CESpolymorphisms 22/23EK and childhood sexual abuse, war; D; Radloff, 1977) 9beta impaired physical health, death or separation of parents) Depressive symptoms (DSM-IV Stressful life events in early twenties 5-HTTLPR Genotype Sex as a covariate criteria) (Life history calendar, e.g., 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)

Predictor variable (s)



Sample size

Kraaij and de Wilde (2001)

Longitudinal over 50 years N D 194

N D 18558

Community sample of older adults (aged over 65; M D 76.5)

Adult members of the Kaiser Health Plan 55 years (§15.5 years) for women and 57 years (§14.5 years) for men all live births during one week in 1958 (n D 18558)

N D 8,614

Dube et al. (2003)

Kelly-Irving et al. (2013)

Australian older adults with and without history of physical abuse (over 60; M D 71.9)

N D 21,819

Draper et al. (2008)

8613 adults

Population-based, nationally representative sample of community-dwelling adults (over 50)

N D 3,493

Insured women (ages 18 64)


Chou (2012)

Psychiatric and health morbidity Bonomi, et al. (2008) N D 3,568

Author (year)


Number of ACE

Covariates: age, sex, birthplace, marital status, educational living arrangements, religion. Age

Social support

Gender, revictimization

Abuse type or combination of abuse types

Mediator/moderator covariates

Childhood emotional, physical & sexual abuse, parental loss, serious illness, financial difficulties. Life stressors as an adult (domestic violence, illness, etc.) (Life Events Questionnaire (Kerkhof, Schmidtke, BilleBrahe, de Leo, & Lonnqvist, 1994),

Interaction between child abuse and late-life stress Age Gender

Number of adverse or stressful experiences in childhood and in adulthood.

Child in foster care, physical neglect Number of ACE family’s contact with the prison service, 4) parental separation 5) family mental or substance abuse.

(ACE score)a

Childhood physical and sexual abuse before the age of 15.

Childhood physical and sexual abuse (Behavioral Risk Factor Surveillance System; Thompson et al., 2006) Childhood sexual abuse (sexual touching and sexual intercourse)



(continued)

Depression (Geriatric Depression Scale, Brink, Yesavage, Lum, Heersema, Adey, & Rose, 1982)

Cancer risk

Illicit drug use

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)

Women’s health (SF-36; Ware et al., 2000)

Outcome measure (s)


(CTQ)b.

Nationally representative U.S. sample of community dwelling adults (over 20) Participants (over 50) from The Physical Health and Disability Study

National Comorbidity Survey subsample, the average age was 36.2 (SD D 10.8),

National Comorbidity Survey (ages 15 54; M D 33.2)

Population-based study of men and women; Abuse survivors (M D 53.91) and non-abused (M D 53.8)

N D 34,653 (including 7,080 adults over 65) N D 1,090

N D 1,727 With current health problems

N D 5,877

N D 3,635

Raposo et al. (2014)



Springer (2009)

Age across adult cohorts lifetime treatment-seeking number of ACE Self-esteem (Rosenberg self-esteem scale; Rosenberg, 1979)

Adult stressful life events

uniquely effects of abuse experiences, negative inferential style


Childhood physical (beaten or physically abused by parent/ caregiver), sexual abuse (raped or sexually molested), and emotional abuse (ever emotionally abused by caretakers?) (items from the PTSD module of CIDI) Depression (CIDI) Childhood physical (beaten or physically abused by parent/ caregiver) and sexual abuse (raped or sexually molested) from PTSD module of CIDI Family of origin characteristics Self-criticism (Depressive Childhood physical (beaten or Experiences Questionnaire; physically abused by parent/ Blatt, 1979), dependency caregiver), sexual abuse (raped or (Hirschfeld et al., 1977). sexually molested), and verbal abuse (insulted/threatened) from PTSD module of CIDI Family of origin variables, Parental pathology, parental loss Health behaviors, cognition, mental Childhood physical abuse (parent health, and social relations “slapped, shoved, or threw things at them” before age 17 from CT; Straus, 1979)

Perceived stress gender ACEa

Nationally representative sample (over 18)

N D 34,653

McLaughlin et al. (2010)


Childhood emotional, physical, and sexual abuse (Subscales of the Lifetime Experiences Questionnaire; Gibb et al., 2001) (CTSc, Straus, 1979).

University Freshmen 173 high-risk (M D 18.64) and 176 low-risk (M D 18.95) participants

N D 299


Liu, Jager-Hyman, et al. (2012)


Sample size

Author (year)



(continued)

Medical diagnoses (Duke Older Adults Research Survey; Duke University Center for the Study of Aging and Human Development, 1978)

Internalizing symptoms (CIDI) WHO, 1990

Pain from health problems (“How much pain do you experience as a result of your health problems?”)

Past-year mood and anxiety disorders, and lifetime personality disorders Internalizing disorders (DSM-IV psychiatric diagnoses based on the CIDI; World Health Organization, 1990)

Depressive episodes in adulthood (Schedule for Affective Disorders and Schizophrenia-Change Interview; Spitzer et al., 1978) DMS-IV criteria for 12-month prevalence of major depression, posttraumatic stress disorder (PTSD), other anxiety disorders,

Outcome measure (s)


Patients presenting for outpatient treatment (M D 41.9)

Older adults (M D 79.8)

N D 55

N D 253

McGinn et al. (2005)

Wilson et al. (2006)

2.1; 73.9% women) from the Rush Memory and Aging Project

College women (Ages 18 48; M D 21)

N D 99

Fortier et al. (2009)

College students, majority female; (M D 19.3)

Patients with primary mood disorders (over 50; M D 60.6)

N D 163

Talbot et al. (2009)

Psycho-social development Allen et al. (2013) N D 268

Population-based study of men and women (M D 55)

N D 2,051

Springer et al. (2007)


Sample size

Author (year)


CTQb and Parental style (e.g., perception of parents’ attitudes and behaviors toward them before age 16; Parental Bonding Instrument, Parker, Tupling, & Brown, 1979) Composite measures of total adversity, emotional neglect, parental intimidation, parental violence, family turmoil, and financial need (excluding sexual abuse) before age 18 (based mainly on the CTQb)

Childhood sexual abuse

Child maltreatment prior to the age of 13 (i.e., physical abuse, emotional/psychological abuse, and neglect; Comprehensive Child Maltreatment Scale; Higgins & McCabe, 2001)

Childhood sexual abuse (CTQbshort form) "

Childhood physical abuse (parent “slapped, shoved, or threw things at them” before age 17 from CTSc; Straus, 1979)


Age, sex, own education, and parental education,

Borderline personality disorder symptoms (Personality Assessment Inventory (PAI); Morey & Boggs, 1991) Avoidant coping (Coping Strategies Inventory; Tobin et al., 1984) & Trauma symptoms (Trauma Symptom Checklist-40 (TSC-40); Briere & Runtz, 1989) Cognitive style (Young’s Schema Questionnaire (YSQ), Young & Brown, 1990)

Affective dysregulation, from inventory of altered selfcapacities (IASC, Briere & Runtz, 2002).

Adjusting for the effects of age, gender, and education

Family background and childhood adversities (i.e., parent drinking problem, parent marital problem, parental violence, and broken family)



(continued)

psychosocial adjustment in old age (multiple measures of neuroticism and social engagement)

Depression (Beck Depression Inventory, Beck & Steer, 1987)

Revictimization (Sexual Experiences Survey; Koss & Gidycz, 1985)

Suicide Potential Index (The SPI utilizes 20 different criteria constructed from scales of the PAI to provide a composite score of risk.)

Mid-life Depression (CES-D) and physical health (modified version of the Duke Older Adults Research Survey; Duke University Center for the Study of Aging and Human Development, 1978) Physical illness burden (CIRS), impaired physical functioning (IADL & PSMS), and bodily pain (Medical Outcomes Study 36Item Short Form)

Outcome measure (s)


Nationally representative sample (U.S.; M D 33.2)

War Veterans (ages 54 89)

47 World War II, Korean Conflict, and Vietnam War veterans Adults with a history of depression (M D 19.86)

N D 5,877

N D 47

Qualitative focus group study N D 66

Cromer and Sachs-Ericsson (2006)

Davison et al. (2006)

N D 133

British birth cohort born in 1958 followed 45 years.

N D 9,377

Clark et al. (2010)

Liu et al. (2013)

Jewish adults with diagnosis of Depressive Disorder (over 50; M D 75.9)

College-aged men and women (M D 20.37)

N D 530

N D 301

Wright et al. (2009)


Stress and aging Clark et al. (2004)

Sample size

Author (year)

Table 2. (Continued ) Mediator/moderator covariates

Childhood emotional, physical, and sexual abuse CTQb; Bernstein et al., 2003)

Exposure to the Nazi Holocaust (determined through (1) the social worker’s clinical notes from structured patient and family interviews, or (2) the Modified Life Events Inventory (LEI m)) Childhood adversity (exposure to traumatic events or chronic stressors up to 16 years; i.e., neglected appearance, maternal absence, parental divorce, and parental physical and sexual abuse) Childhood physical (beaten or physically abused by parent/ caregiver) and sexual abuse (raped or sexually molested) from PTSD module of the CIDI Combat in early adulthood

Negative cognitive styles (cognitive style questionnaire; Alloy, 2000) Age and gender

Current life stressors (number of endorsed stressors; e.g., experienced break-up, death of a close friend or relative, or had been laid off) Potential intrapersonal risk and resilience factors

Psychopathology (anxiety/affective/ mood) at ages 16 (Malaise Inventory, Rutter, Tizard, & Whitmore, 1970) and 23 (Rutter Scales, Rutter, 1967)

Recent negative life events (i.e., negative health problems, bereavements, and family and social relationship difficulties)

Self-schemas (YSQ) Childhood emotional abuse (belittling, ridiculing, spurning, 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, MatickaTyndale, El-Guebaly, & West, 1993; TSC-40)



(continued)

Negative dependent life events (Life Events Scale and Life Events Interview; Safford et al., 2007)

Late-onset stress symptomatology (Qualitative)

Adult health problems (number of conditions)

Psychopathology (affective and anxiety disorders; Revised Clinical Interview Schedule, Lewis, Pelosi, Araya, & Dunn, 1992) at age 45

Suicidal ideation (Suicide item of the Ham-D; Hamilton, 1960)

Depression and anxiety (subscales from TSC-40)

Outcome measure (s)


Holocaust survivors with (M D 75.9) and without PTSD (M D 78.7)

N D 28

Yehuda et al. (2007)

Current PTSD (DSM-IV criteria; Clinician Administered PTSD SCALE; Blake et al., 1995)

Early traumatic stress (Holocaust trauma, sexual, physical or emotional abuse, other traumatic experiences during the wars and the terrorist attacks in Israel, combat trauma, death of close relatives after the Holocaust, lifethreatening illnesses and traffic accidents) Current PTSD (Structured Clinical Interview for DSM-IV; Spitzer, Gibbon, & Williams, 1998)


PTSD (current or remitted)

Hippocampal volume


urinary cortisol levels, Urinary cortisol levels

Learning and memory performance (California Verbal Learning Test)

Diurnal cortisol patterns and cortisol reactivity to a stressor

Outcome measure (s)

b

ACE study questionnaire: see footnote from Table 1. 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 subdivided 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.”

a

Combat with PTSD (M D 65.6), Combat without PTSD (M D 67.6) and non-combat Veterans (M D 65.1)

Child survivors of the Holocaust (M D 64.6)


N D 65

Sample size

Yehuda et al. (2005)

Van der Hal-Van Raalte et al. (2008)

Author (year)





14


Figure 1. ACE and late-life suicide.

and lower social support contributing to perceived 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 psychosocial 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 stressors. 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, Craighead, & 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 overproduction and pruning, and myelination) (Teicher et al., 2004; Twardosz & Lutzker, 2010). Converging

interdisciplinary data have demonstrated that early relational trauma (e.g., disruption in the developmental process of attachment, poor parenting, parental loss, childhood physical and sexual abuse, and neglect) negatively 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 hypothalamic pituitary adrenal axis (HPA) stress response; the HPA axis plays a central role in response to threat (Christine 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 abnormalities in the HPA axis are also associated with a dysregulation in the serotonergic system (Pompili et al., 2010), an established substrate for suicidal behavior (Braquehais, Oquendo, Baca-Garcıa, & 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., combat stress, child abuse, and aging survivors of the Holocaust) (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 complex interplay of genes and environment. In their review, Turecki, Ernst, Jollant, Labonte, and Mechawar (2012)


Aging & Mental Health concluded that animal and human data suggest that earlylife adversity increases risk of suicide by influencing emotional, 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 development, increasing vulnerability to suicide in later adulthood. Variability in the expression of these geneenvironmental 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 investigation 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 serotonin transporter gene (5-HTTLPR) augments ACE (e.g., child abuse, child maltreatment, family dysfunction) and other negative life events (serious health problems, exposure 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 activity of serotonin, increased stress sensitivity, and vulnerability to depression (Caspi et al., 2003). Several researchers have found that the 5-HTTLPR short allele in conjunction with ACE (i.e., neglect, emotional maltreatment, 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 associated with late-life depression, suicidal ideation, and regulation 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 childhood 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 adulthood (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 (Labonte et al., 2012; McGowan et al., 2009). Haplotypes of the FKBP5 gene, which moderates 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 environment 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


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, & Stansfeld, 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 experienced 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 physical, 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 their lifetime (Sachs-Ericsson, Verona, Joiner, & Preacher, 2006). The combination of ACE (e.g., sexual, physical, emotional abuse and neglect) and mood and anxiety 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 psychiatric 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 experiences (e.g., sexual abuse, emotional abuse) and other ACE (parental loss, parental maladjustment, and serious respondent physical illness, and family economic adversity) 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 epidemiological sample of older adults that childhood sexual abuse was associated with high rates of psychiatric disorders, psychiatric hospitalizations, and suicidal ideation. Additionally, in the National Comorbidity Survey-Replication, researchers (McLaughlin et al., 2010) found the association between ACE (e.g., economic adversity, parental loss, parental maladjustment, physical abuse, sexual 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 experienced 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, Duberstein, & 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, domestic violence, parental psychopathology, loss or incarceration) and attempted suicide throughout the life span (Dube et al., 2001), researchers have suggested that the association appears to be explained, in part, through psychiatric disorders (Bedi et al., 2011; Dube et al., 2001; Sachs-Ericsson et al., 2013). For example, using epidemiological data on older adults (60C), researchers (SachsEricsson 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 psychiatric symptoms. However, in some population studies, the relationship between child sexual abuse and suicidal behavior was partially, but not wholly, mediated by psychiatric 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 distinct 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 dysfunction, 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 forward pathogenic mechanisms that ultimately foster chronic disease. Among people exposed to major stressors in early life (e.g., physical, sexual, and emotional abuse, family dysfunction 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 (SachsEricsson, 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-Ericsson 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 population study of older adults (Draper et al., 2008), multivariate models indicated that participants who had experienced either childhood sexual or physical abuse had a greater risk of poor physical and mental health. Additionally, findings from a quantitative meta-analysis comparing results from 78 effect sizes across 24 studies of child abuse (literature keywords search included: child abuse, child maltreatment, child sexual abuse, child physical abuse, child emotional abuse, child neglect), revealed that child abuse was associated with an increased risk of negative physical health outcomes in adulthood, with neurological and musculoskeletal problems yielding the largest effect sizes, followed by respiratory problems, cardiovascular disease, gastrointestinal and metabolic disorders (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 twofold 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 incarceration). 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 partners, sexually transmitted diseases, smoking, and alcoholism) across four successive birth cohorts. The number of ACE increased the risk for each health problem in a consistent, 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 violence) 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 dysregulation with associated inflammation. ACE (e.g., emotional, physical, and sexual abuse; domestic violence, parental separation, psychopathy, incarceration) are associated with negative health behaviors that have consequences 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

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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 potential causal mechanisms linking child abuse (e.g., childhood 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, increasing risk for multiple chronic diseases that have an inflammatory pathophysiology (such as cardio-vascular diseases and diabetes) (Matthews, Chang, Thurston, & Bromberger, 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 pathogenic systems that ultimately lead to chronic disease. Chronic inflammation increases risk for diseases of aging (O’Donovan et al., 2012). Inflammation may be a common cause of multiple age-related diseases or a final common 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) (Juurlink, 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 ideation among seriously ill people was extremely rare in the absence of clinically significant mood disturbance. Nonetheless Draper (2014) has pointed out that among older adults there are several specific health problems that exacerbate 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

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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 intensive 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 anxiety (Gibb & Abela, 2008; Sachs-Ericsson et al., 2006). Negative cognitive style (Abramson, Metalsky, & Alloy, 1989) has been defined as a characteristic way of attributing 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 character (e.g., I am worthless) (Alloy et al., 2004; Seligman, Abramson, Semmel, & von Baeyer, 1979), as well has having dysfunctional attitudes and maladaptive self-schemas (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 depression (Alloy et al., 1999; Sachs-Ericsson et al., 2006). Verbal 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, selfblaming 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 cognitive 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, & Sanderson, 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 therapy (CBT) specifically focuses on addressing maladaptive cognitions (Thompson, Gallagher-Thompson, & Dick, 1995), and, thus, may be useful in addressing traumarelated 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 experiences 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 (Canton-Cortes & Canton, 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 associated 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). Spaccarelli (1994) found that among individuals who have experienced early sexual abuse, coping processes played a crucial mediating role in the development of symptomatology. 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 solving strategies in individuals who have attempted suicide (Pollock & Williams, 2004; Pollock & Williams, 1998). Among older adults, ‘problem-focused’ and ‘emotionfocused’ coping were protective against suicidal ideation, while ‘passive coping’ elevated the risk of suicidal ideation (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 difficulties 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 exploitation) 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 capability for suicide (Law, Khazem, & Anestis, 2015). Thus, ACEs are associated with subsequent difficulties modulating negative affect, and difficulties in this 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 appropriate environment that promotes the child’s ability to learn coping styles that help in modulating strong affective states (Futa, Nash, Hansen, & Garbin, 2003). Additionally, these effects may persist into older age (Wilson et al., 2006). Researchers have found that older adults who have suicidal ideation have difficulties with emotional 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 dysregulation 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 associated 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

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psychosocial functioning in older age. Interpersonal difficulties result in decreased social support, and social support 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, sexual or emotionally abuse) that begins with insecure attachment 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 autonomy), 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 exposure 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) contribute to people becoming vigilant for threat and mistrusting 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 interpersonal relationships and can contribute to suicidal ideation (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 wellbeing and reducing suicidality. There is a cognitivebehavioral 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 experience over the life course. These skills are quite complex and include self-regulation, ability to navigate difficult situations, and self-knowledge as to how to maintains one’s sense of well-being. This, in turn, explains why there are


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generally higher levels of overall affective well-being in older adults. Even when remembering negative past experiences, 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 inescapable stress occurs, the SAVI posits that age related advantages 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) concluded 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 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 Neurotoxicity 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 stressors, 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 difficulties associated with aging may contribute to perceived burdensomeness, a component of the interpersonal-psychological theory of suicide. Acute and chronic stressors (and in particular interpersonal 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 experienced 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 population study, McLaughlin et al. (2010) found that ACE (emotional, physical abuse, and neglect, parental dysfunction, family violence) were associated with increased vulnerability 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 mechanism 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 experienced 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 additional 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 functioning 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 particular 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 behaviors. 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 suggests that the mechanisms between ACE and late-life suicide 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 components 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 established 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 experienced 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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