The relationship between type, timing and duration of exposure to adverse childhood experiences and adolescent self-harm and depression: findings from three UK prospective population-based cohorts

Abstract

Background: Adverse childhood experiences (ACEs) are well-established risk factors for self-harm and depression. However, despite their high comorbidity, there has been little focus on the impact of developmental timing and the duration of exposure to ACEs on co-occurring self-harm and depression.

Methods: Data were utilised from over 22,000 children and adolescents participating in three UK cohorts, followed up longitudinally for 14-18 years: the Avon Longitudinal Study of Parents and Children (ALSPAC), the Millennium Cohort Study (MCS) and the Environmental Risk (E-Risk) Longitudinal Twin Study. Multinomial logistic regression models estimated associations between each ACE type and a four-category outcome: no self-harm or depression, self-harm alone, depression alone and self-harm with co-occurring depression. A structured life course modelling approach was used to examine whether the accumulation (duration) of exposure to each ACE, or a critical period (timing of ACEs) had the strongest effects on self-harm and depression in adolescence.

Results: The majority of ACEs were associated with co-occurring self-harm and depression, with consistent findings across cohorts. The importance of timing and duration of ACEs differed across ACEs and across cohorts. For parental mental health problems, longer duration of exposure was strongly associated with co-occurring self-harm and depression in both ALSPAC (adjusted OR: 1.18, 95% CI: 1.10-1.25) and MCS (1.18, 1.11-1.26) cohorts. For other ACEs in ALSPAC, exposure in middle childhood was most strongly associated with co-occurring self-harm and depression, and ACE occurrence in early childhood and adolescence was more important in the MCS.

Conclusions: Efforts to mitigate the impact of ACEs should start in early life with continued support throughout childhood, to prevent long-term exposure to ACEs contributing to risk of self-harm and depression in adolescence.

Keywords: ALSPAC; Adverse childhood experiences; E‐Risk; MCS; accumulation of risk; cohort; depression; developmental timing; self‐harm.

Figure 1. Timeline of exposure and outcome measures for each aim by cohort

Figure 2. Forest plots showing the association between ACEs and outcomes by cohort.

(A) Self-harm alone. (B) Depression alone. (C) Co-occurring self-harm and depression. Note: The dots on the forest plots represent the adjusted relative risk ratio (RRR) point estimates and the lines extending either side of them represent the 95% confidence intervals. The Avon Longitudinal Study of Parents and Children (ALSPAC); the Millennium Cohort Study (MCS); the Environmental Risk (E-Risk) Longitudinal Twin Study. ASB, Parental antisocial behaviour

Figure 3. Comparison of the association between ACEs and self-harm alone, depression alone and co-occurring self-harm and depression across the three cohorts.

The three Venn diagrams show comparison of the findings for the associations between ACEs and self-harm alone, depression alone and co-occurring self-harm and depression by cohort (The Avon Longitudinal Study of Parents and Children (ALSPAC); The Millennium Cohort Study (MCS); The Environmental Risk (E-Risk) Longitudinal Twin Study). Results are shown where there is evidence of some association according to the 95% confidence intervals for adjusted relative risk ratios

Figure 4

The best-fitting life-course hypothesis selected by the least absolute shrinkage and selection operator (lasso) for the association between each adverse childhood experience and self-harm, depression and co-occurring self-harm and depression (at age 16 years) in ALSPAC and (at age 14 years) MCS, multiply imputed data. Early childhood refers to exposure between birth and 5 years of age, middle childhood refers to exposure between 6 and 10 years of age, early adolescence refers to exposure between 11 and 13 years of age and accumulation refers to cumulative exposure to the same ACE across multiple time-points in early childhood, middle childhood and adolescence