Is there a link between childhood adversity, attachment style and Scotland's excess mortality? Evidence, challenges and potential research

Abstract

Background: Scotland has a persistently high mortality rate that is not solely due to the effects of socio-economic deprivation. This "excess" mortality is observed across the entire country, but is greatest in and around the post-industrial conurbation of West Central Scotland. Despite systematic investigation, the causes of the excess mortality remain the subject of ongoing debate.

Discussion: Attachment processes are a fundamental part of human development, and have a profound influence on adult personality and behaviour, especially in response to stressors. Many studies have also shown that childhood adversity is correlated with adult morbidity and mortality. The interplay between childhood adversity and attachment is complex and not fully elucidated, but will include socio-economic, intergenerational and psychological factors. Importantly, some adverse health outcomes for parents (such as problem substance use or suicide) will simultaneously act as risk factors for their children. Data show that some forms of "household dysfunction" relating to childhood adversity are more prevalent in Scotland: such problems include parental problem substance use, rates of imprisonment, rates of suicide and rates of children being taken into care. However other measures of childhood or family wellbeing have not been found to be substantially different in Scotland compared to England. We suggest in this paper that the role of childhood adversity and attachment experience merits further investigation as a plausible mechanism influencing health in Scotland. A model is proposed which sets out some of the interactions between the factors of interest, and we propose parameters for the types of study which would be required to evaluate the validity of the model.

Keywords: Adverse childhood experiences; Attachment; Health inequalities; Mortality; Public health; Scotland; Social determinants of health.

Fig. 1

Association of childhood adversity with some adult physical health problems (shown in blue) and mental health and addiction problems (shown in red). The graph is adapted from Felitti [12], & shows odds ratios adjusted for age, gender, race, and educational attainment for adults exposed to four or more Adverse Childhood Experiences (ACE)

Fig. 2

Model linking childhood stress, trauma and adversity to adult health outcomes, showing the modifying effect of attachment experience

Fig. 3

Cause-specific standardised mortality ratios (standardised by age, gender and area deprivation), 2003-07, for causes of death in Glasgow compared to Liverpool and Manchester (Liverpool and Manchester combined = 100). Mortality associated with physical health problems is shown in blue, and with mental health problems is shown in red. “External causes” includes deaths due to violence, which are not necessarily attributable to mental health problems. The graph is adapted from Walsh et al. [86]