Differences by Veteran/civilian status and gender in associations between childhood adversity and alcohol and drug use disorders

Abstract

Purpose

To examine differences by US military Veteran status and gender in associations between childhood adversity and DSM-5 lifetime alcohol and drug use disorders (AUD/DUD).

Methods

We analyzed nationally representative data from 3119 Veterans (n = 379 women; n = 2740 men) and 33,182 civilians (n = 20,066 women; n = 13,116 men) as provided by the 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III). We used weighted multinomial logistic regression, tested interaction terms, and calculated predicted probabilities by Veteran status and gender, controlling for covariates. To test which specific moderation contrasts were statistically significant, we conducted pairwise comparisons.

Results

Among civilians, women had lower AUD and DUD prevalence than men; however, with more childhood adversity, this gender gap narrowed for AUD and widened for DUD. Among Veterans, in contrast, similar proportions of women and men had AUD and DUD; with more childhood adversity, AUD-predicted probability among men surpassed that of women. Childhood adversity elevated AUD probability among civilian women to levels exhibited by Veteran women. Among men, Veterans with more childhood adversity were more likely than civilians to have AUD, and less likely to have DUD.

Conclusions

Childhood adversity alters the gender gap in AUD and DUD risk, and in ways that are different for Veterans compared with civilians. Department of Defense, Veterans Affairs, and community health centers can prevent and ameliorate the harmful effects of childhood adversity by adapting existing behavioral health efforts to be trauma informed, Veteran sensitive, and gender tailored.

Appendices

Appendix 1

See Table 4.

Table 4 Era of active US military duty among Veterans by gender, NESARC-III weighted data (n = 3119)

Appendix 2: Operationalization of key variables

Alcohol and drug use disorders (AUD, DUD)

Lifetime AUD diagnoses required at least 2 of the 11 DSM-5 criteria in the past year or prior to the past year [34]. Diagnoses before the past year required clustering of at least two criteria within a 1-year period [34]. DUD included sedative or tranquilizer, cannabis, amphetamine, cocaine, club drug (e.g., ecstasy, ketamine), nonheroin opioid, heroin, hallucinogen, and solvent/inhalant [35]. Tobacco use disorders were omitted. Consistent with DSM-5, lifetime DUD diagnoses required at least 2 of the 11 criteria arising from use of the same substance in the past year or prior to the past year [35]. Diagnoses before the past year required clustering of at least 2 criteria for the same drug within a 1-year period [35].

Childhood adversity

NESARC assessed adverse childhood events occurring before age 18 using questions that were a subset of items from the Conflict Tactics Scale [36] and the Childhood Trauma Questionnaire [37]. Respondents were asked to respond to all questions pertaining to abuse or neglect (except emotional neglect) on a five-point scale (never, almost never, sometimes, fairly often, or very often). Emotional neglect questions employed an alternative five-point scale of never true, rarely true, sometimes true, often true, or very often true. All questions pertaining to general household dysfunction required yes/no responding (except questions regarding having a battered mother, which used the same scale as for the items on abuse or neglect) (Table 5).

Table 5 Operationalization of childhood adversity

We considered 11 types of childhood adversity, which we defined to be consistent with definitions employed in the Adverse Childhood Experiences study [20, 26] and epidemiological research on childhood adversity [19, 23].

Physical abuse was defined as a response of “sometimes” or greater to either question when asked how often a parent or other adult living in the respondent’s home (1) pushed, grabbed, shoved, slapped, or hit the respondent; or (2) hit the respondent so hard it left marks or bruises, or caused an injury.

Emotional abuse was identified as a response of “fairly often” or “very often” to any question when asked how often a parent or other adult living in the respondent’s home (1) swore at, insulted, or said hurtful things to the respondent; (2) threatened to hit or throw something at the respondent (but did not do it); or (3) acted in any other way that made the respondent afraid he/she would be physically hurt or injured.

Sexual abuse was examined using four questions that examined the occurrence of sexual touching or fondling, attempted intercourse, or actual intercourse by any adult or other person when the respondent did not want the act to occur or was too young to understand what was happening. Any response other than “never” on any of the questions was coded as sexual abuse.

Physical neglect was defined as any response other than “never” to five questions that asked about experiences of being made to do difficult or dangerous chores, being left unsupervised when too young to care for self or going without needed clothing, school supplies, food, or medical treatment.

Emotional neglect was defined by five questions asking whether respondents felt a part of a close-knit family or whether anyone in the family of origin made the respondent feel special, wanted the respondent to succeed, believed in the respondent, or provided strength and support. Following prior research, the five items were reverse-scored and summed; scores of 15 or greater were coded as emotional neglect [19, 20, 26].

Parental substance abuse was a form of household dysfunction that was assessed with two questions asking whether a parent or other adult living in the home had a problem with alcohol or drugs. A response of “yes” to either question was defined as parental substance abuse.

To characterize the history of having a battered mother, respondents were asked whether the respondent’s father, stepfather, foster/adoptive father, or mother’s boyfriend had ever done any of the following to the respondent’s mother, stepmother, foster/adoptive mother, or father’s girlfriend: (1) pushed, grabbed, slapped, or threw something at her; (2) kicked, bit, hit with a fist, or hit her with something hard; (3) repeatedly hit her for at least a few minutes; or (4) threatened to use or actually used a knife or gun on her. Any response of “sometimes” or greater for questions 1 or 2, or any response except “never” for questions 3 or 4, was defined as having a battered mother.

For the other measures of household dysfunction, respondents were asked to answer with either “yes” or “no” whether a parent or other adult in the home (1) went to jail or prison; (2) was treated or hospitalized for mental illness; (3–4) attempted or actually committed suicide. A response of “yes” to any of these questions was coded as household dysfunction.