Matern Child Health J DOI 10.1007/s10995-013-1374-y

Adverse Childhood Events and Current Depressive Symptoms Among Women in Hawaii: 2010 BRFSS, Hawaii Rosemay A. Remigio-Baker • Donald K. Hayes Florentina Reyes-Salvail

•

 Springer Science+Business Media New York 2013

Abstract Research on the association between adverse childhood events (ACEs) and depression among women in Hawaii is scarce. ACEs have been linked to unfavorable health behaviors such as smoking and binge drinking which are more prevalent in the state compared to the US overall. The concomitant presence of ACEs with smoking or binge drinking may explain the excess depression prevalence in Hawaii compared to the national average. Using data of women residing in the state (2010 Hawaii Behavioral Risk Factor Surveillance System Survey), we examined the association between ACEs count or type (household dysfunction and physical, verbal and sexual abuse) and current depressive symptoms (CDS), in addition to modification by current smoking status (smoked[100 cigarettes in a lifetime and currently smoke) and binge drinking (consumed C4 alcoholic beverage within the past month and in C1 occasion(s)). Evaluation of ACEs before age 18 consisted of 11 indicators. Eight indicators of the Patient Health Questionnaire (PHQ-8) were used to assess CDS. All analyses utilized logistic regression taking into account sampling design. The odds ratio of having CDS between those with versus without ACEs increased per increasing number of ACEs (1 ACE: OR = 2.11, CI = 1.16–3.81; 2 ACEs: OR = 2.90, CI = 1.51–5.58; 3 or 4 R. A. Remigio-Baker (&) Department of Family and Preventive Medicine, University of California, San Diego, 9500 Gilman Drive, MC 0725, La Jolla, CA 92093-0725, USA e-mail: [email protected] R. A. Remigio-Baker
D. K. Hayes Family Health Services Division, Hawai’i Department of Health, 3652 Kilauea Ave, Honolulu, HI 96816, USA F. Reyes-Salvail Behavioral Risk Factor Surveillance System Program, Hawai’i Department of Health, 1250 Punchbowl Street Room 262, Honolulu, HI 96813, USA

ACEs: OR = 3.94, CI = 2.13–7.32; 5? ACEs: OR = 4.04, CI = 2.26–7.22). Household dysfunction (OR = 2.10, CI = 1.37–3.23), physical abuse (OR = 1.67, CI = 1.08–2.59), verbal abuse (OR = 3.21, CI = 2.03–5.09) and sexual abuse (OR = 1.68, CI = 1.04–2.71) were all positively associated with CDS. Verbal abuse had the strongest magnitude of association. Neither current smoking status nor binge drinking modified the relationship between ACEs count (or type) and CDS. In conclusion, the presence of ACEs among women in Hawaii was indicative of CDS in adulthood, notably verbal abuse. Further, a dose response existed between the number of ACEs and the odds for CDS. The concomitant exposure to ACEs and current smoking status or binge drinking did not elevate odds for CDS. Keywords Adverse childhood events (ACEs)
Depressive symptoms
Hawaii population
Women’s health

Introduction According to the Fourth National Incidence Study of Child Abuse and Neglect (NIS-4, 2005–2006), nearly 3 million children were reported abused (29 %) or neglected (71 %) in the US, corresponding to about 1 out of every 25 [1]. Of the incidences of abuse, 57 % were physical, 36 % were emotional and 22 % were sexual in nature [1]. However, these statistics are still an underestimation given the high level of underreported child abuse. In Hawaii, about 4,000–6,000 child abuse and neglect cases were reported annually from 2007 to 2011 [2], an estimation of about 11–16 reports per day. Native Hawaiians had the largest number of cases [2] which might contribute to the disproportionately high percentage of child deaths

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accounted for by this population (42 % of all child deaths in Hawaii) [3]. The reported child maltreatment in the nation in 2011 was 9.1 %, while that in the state was 4.4 %. The much lower rate of child maltreatment in Hawaii might be attributed to the high proportion of Asians in the state [4] whose ‘‘cultural customs and childbearing practices’’ might likely contribute to the underestimation of child abuse and neglect [5]. Specifically, parental authority and child obedience, in addition to the internalization of feelings to maintain family unity, notably in women and children, may contribute to underreporting to authorities and ‘‘disbelief of maltreatment’’ among Asians compared to other race groups [6, 7]. In a study of perceptions of child abuse in Hawaii, 64 % of surveyed participants reported difficulty identifying child maltreatment, particularly emotional abuse [8]. Further, although 39 % stated they knew of individuals who were abused as a child, only 16 % were willing to report to social or child welfare services [8]. Unfortunately, this percentage of intention to report exceeded actual reporting (6.0 % in the same year) [9]. Adverse childhood events (ACEs) are associated with increased risk for psychiatric disorders [10–12], which includes depression in adulthood [13–15]. However, little is known about ACEs in Hawaii and how it relates to depression or current depressive symptoms (CDS) in the state. For Native Hawaiians, the much detested annexation of Hawaii to the US, which created economic burden, roused resentment from seized land, and threatened cultural heritage and national identity [16], may contribute to the high percentage of adult depression in the state (9.7 vs. 9.0 % national average of adults C18 years of age) [17]. It may also reinforce a negative physical and mental household environment that may cultivate ACEs. Women overall are twice as likely to experience depression compared to men [18]. Given depression is linked to incident chronic diseases such as type 2 diabetes [19–26] and cardiovascular disease [27–31], women are at greater risk for these comorbidities. Compared to the US overall, Asian Americans and Native Hawaiians/Pacific Islanders, which constitute a large proportion of the Hawaii population, have a greater age-adjusted percentage of diabetes (9.1 and 23.7 %, respectively, vs. 8.8 %) [32]. Further, the age-adjusted percentage of cardiovascular disease for Native Hawaiians/Pacific Islanders exceeds that of the national estimate (20.2 vs. 11.5 %) [32]. According to a 2007 report, over a third of deaths in Hawaii are due to heart disease, with the highest percentage of morbidity and mortality among Native Hawaiians and Filipinos [33]. Although the rate of cardiovascular disease is lower among Asians in general (notably women), compared to other race groups, it remains as the second leading cause of death among this cohort [34]. Decreasing depression or CDS among women in Hawaii can potentially reduce burden

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from these chronic conditions. However, due to limitations in the diagnosis, treatment and follow-up of depression, there are currently no recommended guidelines for screening [35]. This may leave adverse mental state unmonitored or uncontrolled [35], making it even more important for public health officials to look upstream for preventive means. The reduction or prevention of ACEs among women in Hawaii may potentially decrease the prevalence of chronic diseases in the state (e.g. diabetes, heart disease) through the reduction of depression. Throughout the 1990s, Hawaii’s rate of heavy drinking was 1.3 times higher than that of the US overall [36]. In a Child Death Review Report (2001–2006), a third of the children in the state aged 10–17 years had positive histories of substance abuse, including alcohol, which were consistent with autopsy toxicology screens results [3]. In addition, smoking among high school students in Hawaii was 63 %, 12 % of whom started before age 11 compared to the 7 % national average [37]. Among adults in the state, Hawaiians were the only ethnic group in which women were more likely to smoke than men (23 vs. 20 %) [38], which supports the importance of accounting for the contribution of smoking in the association between ACEs and depression or CDS among women. Studies show that individuals who experienced child abuse are at increased risk for smoking and alcoholism in adulthood, particularly among women [39–43]. These health behaviors are also positively associated with depression [44–47]. In combination with ACEs, these behaviors may further aggravate depressive symptoms. A negative family environment may also promote smoking and binge drinking [48–50]. Poor parent–child relationships, which may include lack of nurturance, high level of criticism and inadequate discipline or supervision, may be partly responsible for early onset and adulthood smoking and excessive alcohol intake [48, 50–54]. Although poor parental practices may affect both children of abusing and non-abusing household, negative family interaction may be more prominent among abusive households [55, 56]. As a consequence, its multiplicative affect to an already adverse environment would only subject children to an even more vulnerable state to engage in adverse behaviors. Assessment of modifiable risk factors in the association between ACEs and depression or CDS, such as smoking and excessive alcohol intake, which may also be linked to poor parent–child relationships, may identify target groups for more effective interventions. In this retrospective cohort study, we evaluated the association between ACEs and CDS among women in the state of Hawaii. We hypothesized that the number and type of ACEs (i.e. household dysfunction and physical, verbal and sexual abuse) will be positively associated with CDS in this population. In addition, we hypothesized that these

Matern Child Health J Table 1 CDC depression screening tool indicator questions—Patient Health Questionnaire (PHQ-8)

Table 2 Adverse childhood events (ACEs) indicator questions by type

Indicator

Indicator questions: ‘‘Over the last 2 weeks, how many days have you…’’a

Indicator type

Indicator questions: ‘‘Now looking back before you were 18 years of age…?’’

1. Little interest or pleasure

‘‘…had little interest or pleasure in doing things?’’

Household dysfunction

1. ‘‘… did you live with anyone who was depressed, mentally ill, or suicidal?’’

2. Felt depressed

‘‘…felt down, depressed or hopeless?’’

3. Sleep disturbance

‘‘…had trouble falling asleep or staying asleep or sleeping too much?’’

4. Lack of energy

‘‘…felt tired or had little energy?’’

5. Poor eating

‘‘…had a poor appetite or eaten too much?’’

6. Feel like a failure

‘‘…felt bad about yourself or that you were a failure or had let yourself or your family down?’’

7. Poor concentration

‘‘…had trouble concentrating on things, such as reading the newspaper or watching the TV?’’

8. Slow or restless movement or speech

‘‘…moved or spoken so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you were moving around a lot more than usual?’’

2. ‘‘… did you live with anyone who was a problem drinker or alcoholic?’’ 3. ‘‘… did you live with anyone who used illegal street drugs or who abused prescription medications?’’ 4. ‘‘… did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?’’ 5. ‘‘… were your parents separated or divorced?’’ 6. ‘‘… how often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up?’’a Physical abusea

Verbal abuseb

a

Potential answers include: ‘‘Not at all,’’ ‘‘Several days,’’ ‘‘More than half the days,’’ and ‘‘Nearly every day’’

Sexual abusea

7. ‘‘… how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Do not include spanking.’’a 8. ‘‘… how often did a parent or adult in your home ever swear at you, insult you, or put you down?’’b 9. ‘‘… how often did anyone at least 5 years older than you, or an adult, ever touch you sexually?’’a 10. ‘‘… how often did anyone at least 5 years older than you, or an adult, try to make you touch them sexually?’’a

relationships will vary by current smoking and binge drinking status, specifically, a greater magnitude of association will be seen among individuals who smoke and individuals who partake in binge drinking.

11. ‘‘… how often did anyone at least 5 years older than you, or an adult, force you to have sex?’’a a

Methods The current study utilized data from the 2010 Behavioral Risk Factor Surveillance System (BRFSS) Survey, specific to the state of Hawaii, which was operated by the Hawaii State Department of Health (DOH) in collaboration with the CDC. A standardized questionnaire was used each month by trained interviewers to collect data from a probability sample of the non-institutionalized and non-hospitalized US adult population residing in households with a landline telephone. The Council of American Survey Research Organizations (CASRO) response rate, which reflects both telephone sampling efficiency and the degree of participation among eligible respondents contacted [57], was 49.1 %, and the cooperation rate was estimated at 72.2 % [58]. This study was done on a de-identified data set provided by, and in collaboration with, the Hawaii BRFSS program, and qualified as exempt from the Hawaii DOH Institutional Review Board. Detailed information on the sampling methodology, survey weighting procedures, quality assurance of the survey, and other aspects of this survey is available online at http://www.cdc.gov/brfss/index.htm.

Witnessing domestic violence, the occurrence of physical abuse, and the occurrence of sexual abuse were defined by either a response of ‘‘once’’ or ‘‘more than once’’ to each corresponding question as oppose to ‘‘never’’ b

The occurrence of verbal abuse was defined by a ‘‘more than once’’ response versus ‘‘once’’ or ‘‘never’’

Current Depressive Symptoms (CDS) Assessment To assess depressive symptomatology suggestive of major or minor depression, we used the CDC Depression Screening Tool, Patient Health Questionnaire (PHQ-8), adapted for telephone survey [59–61]. CDS were defined as: (1) responding 7 or more days to one or both of the following questions: (a) ‘‘Over the last 2 weeks, how many days have you had little interest or pleasure in doing things?’’; and/or (b) ‘‘Over the last 2 weeks, how many days have you felt down, depressed or hopeless?’’; and (2) responding 7 or more days to a total of at least 2 of the indicators listed in Table 1: (1) little interest or pleasure, (2) felt depressed, (3) sleep disturbance, (4) lack of energy, (5) poor eating, (6) felt like a failure, (7) poor concentration, and (8) slow or restless movement or speech. Table 1 provides additional description of each of these indicators.

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Adverse Childhood Events (ACEs) Assessment ACEs were assessed using 11 questions to define the environment before 18 years of age (Table 2). Each question was adapted from large, validated survey instruments measuring the frequency of these ACEs [62]. To evaluate ACEs count, the number of ACEs was categorized as follows: 0, 1, 2, 3 or 4, and 5 or more. In addition to investigating the number of ACEs, the 11 questions were also evaluated by type (i.e. household dysfunction, physical abuse, verbal abuse and sexual abuse) as previously combined [62]. Covariates Modification by current smoking status and binge drinking was evaluated. Current smoking was defined as having smoked at least 100 cigarettes in a lifetime and currently smoke. Binge drinking was defined as having consumed 4 or more alcoholic drinks on one or more occasion(s) during the past 30 days. In addition to evaluating current smoking status and binge drinking, covariates used for adjustment included age (categorized by quintiles: 18–42, 43–54, 55–62, 63–72, 73–99), race/ethnicity (White, Hawaiian, Filipino, Japanese, Other), education (below high school, high school graduate, attended college/technical school, graduated college/technical school), and meeting emotional support needs (always/usually, sometimes, rarely/never).

95 % confidence intervals (CI) to evaluate the association between depressive symptoms, the dependent variable, and its individual association with ACEs count, household dysfunction, physical abuse, verbal abuse and sexual abuse independent of age, race/ethnicity, education, emotional support and current smoking status. Adjustment for binge drinking was not included, as this did not contribute much change between the unadjusted and adjusted estimate. The analyses were of unadjusted models and individual adjustments by demographics (age, race/ethnicity, education), emotional support, and current smoking status. A fully-adjusted model including all covariates was also investigated. As the estimates after adjustment for individual demographic variables and emotional support were generally similar to that of the fully-adjusted models, the findings for the unadjusted, adjusted for smoking and fullyadjusted models were presented (a total of 15 models). All analyses took into account the sampling design. To assess modification, cross-product terms were created between ACEs (both count and type) and current smoking status, along with ACEs and binge drinking. Multiplicative interactions were evaluated to test whether the association between ACEs count or type and CDS differed by current smoking status or binge drinking. p values were considered significant at a two-sided alpha \0.05. Analyses were completed using STATA (StataCorp. 2012. Stata Statistical Software: Release 12. College Station, TX, USA).

Results Analyses Of the 6,552 participants surveyed, 3,868 (59.0 %) were women, of whom 344 had a missing observation for CDS and 47 additional were excluded for having any missing covariate value. We excluded 172 individuals for the evaluation of ACEs count against CDS who did not complete the ACEs portion of the survey (N = 3,305). For the analyses between household dysfunction or physical abuse and CDS, 18 participants with a missing exposure value were excluded (N = 3,459 for each analysis). Assessing the relationship between verbal abuse and CDS, 47 individuals were removed from the study sample for a missing exposure value (N = 3,430). Lastly, in the analyses between sexual abuse during childhood and CDS, 40 individuals had a missing exposure value (N = 3,437). Household dysfunction and sexual abuse consisted of multiple items, all of which had to be non-missing to be considered for analyses. The distribution of population characteristics was compared by CDS status using Student’s ‘t’ and v2 tests for continuous and categorical variables, respectively. Logistic regression was utilized to obtain odds ratios (ORs) and

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Overall, 1,831 (55.4 %) participants had at least 1 ACE. Of these, 36.1 % reported only 1 ACE, 20.8 % reported 2 ACEs, 24.7 % reported 3 or 4 ACEs and 18.5 % reported 5 or more ACEs (data not shown). By ACEs type, 40.0 % of the participants reported household dysfunction during childhood, 23.6 % reported physical abuse, 25.9 % reported verbal abuse and 15.2 % reported sexual abuse (data not shown). The population characteristics stratified by CDS status are provided in Table 3. Individuals with CDS, constituting of about 6.5 %, were more likely to be current smokers (27.5 vs. 11.7 %) compared to participants without CDS. Surprisingly, they were also more likely to report receipt of needed emotional support (15.1 vs. 9.3 % for responding ‘Always/Usually’ and 25.8 vs. 9.1 % for responding ‘Sometimes’). CDS were also associated with more ACEs, and a greater account of household dysfunction (60.3 vs. 38.7 %), physical abuse (38.9 vs. 22.5 %), verbal abuse (51.0 vs. 23.5 %) and sexual abuse (22.0 vs. 12.7 %). In fully-adjusted models, current smoking status was not found to modify the association between CDS and ACEs count (p = 0.352), household dysfunction (p = 0.140),

Matern Child Health J Table 3 Characteristics of women in Hawaii by current depressive symptoms (CDS) status: Behavioral Risk Factor Surveillance System Survey

Table 4 Odds ratio (OR) and 95 % confidence interval (CI) for the association between current depressive symptoms and adverse childhood events (ACEs) count and ACEs type

Variables

ACEs

CDS status % No

Total (state)

93.5

% Yes 6.5

p value

NA

Demographics Age categories 41.9

46.9

43–54

21.3

21.4

55–62

12.9

16.0

63–72

11.4

7.4

73–99

12.5

8.3

White

26.6

27.5

Hawaiian

13.1

14.0

Race/ethnicity (best identified)

0.456

Filipino

15.9

11.7

Japanese

26.6

22.5

Other

17.9

24.4

3.7

8.2

25.8

32.3

Education level Below high school graduate High school graduate

0

30.2

31.6

Graduated from college/technical school

40.3

27.9

1

1.0 (referent) 2.11 (1.16, 3.81)*

2.92 (1.51, 5.64)*

2.75 (1.41, 5.35)*

2.90 (1.51, 5.58)*

4.17 (2.33, 7.48)*

3.84 (2.12, 6.96)*

3.94 (2.13, 7.32)*

5 or more

5.18 (3.02, 8.88)*

4.28 (2.50, 7.32)*

4.04 (2.26, 7.22)*

1.0 (referent) 2.45 (1.68, 3.57)*

1.0 (referent) 2.23 (1.51, 3.30)*

1.0 (referent) 2.10 (1.37, 3.23)*

Physical abuse (N = 3,459) No Yes

1.0 (referent) 2.19 (1.46, 3.29)*

Verbal abuse (N = 3,430) No 1.0 (referent) Yes

3.44 (2.34, 5.05)*

1.0 (referent) 1.94 (1.27, 2.97)* 1.0 (referent) 3.20 (2.16, 4.75)*

1.0 (referent) 1.67 (1.08, 2.59)* 1.0 (referent) 3.21 (2.03, 5.09)*

Sexual abuse (N = 3,437) No

11.7

27.5

\0.001*

Binge drinking (yes)

11.2

11.4

0.962

Yes

1.0 (referent) 1.84 (1.18, 2.88)*

1.0 (referent) 1.73 (1.10, 2.72)*

1.0 (referent) 1.68 (1.04, 2.71)*

* Significant at p \ 0.05 a

Quality of life \0.001*

How often do you get needed emotional support Always/usually

9.3

15.1

Sometimes

9.1

25.8

81.5

59.1

0

44.9

19.8

1

21.1

20.1

2

11.8

15.2

3 or 4

12.8

23.5

9.4

21.5

ACEs \0.001*

Number of ACEs

Typea

Fully-adjusted: adjusted for age, race/ethnicity, education, emotional support and current smoking

physical abuse (p = 0.641), verbal abuse (p = 0.406) or sexual abuse (p = 0.451) (data not shown). This variable, however, was shown as a potential confounder/mediator as supported by the attenuation of estimates after adjustment (data not shown); thus, it was included in the fully-adjusted models. Interaction by binge drinking was also found null for the association between CDS and ACEs count (p = 0.701), household dysfunction (p = 0.489), physical abuse (p = 0.438), verbal abuse (p = 0.119) and sexual abuse (p = 0.819) (data not shown).

\0.001*

Household dysfunction (yes)

38.7

60.3

Physical abuse (yes)

22.5

38.9

0.002*

Verbal abuse (yes)

23.5

51.0

\0.001*

Sexual abuse (yes)

12.7

22.0

0.020*

With the exception of the section ‘ACEs Type’, percentages are based on calculations using the participants who completed all 11 indicators for ACEs (N = 3,305) * Significant at p \ 0.05 a

1.0 (referent) 2.03 (1.15, 3.58)*

3 or 4

Yes

Current smoking (yes)

5 or more

1.0 (referent) 2.16 (1.23, 3.79)*

Household dysfunction (N = 3,459)

Health behavior

Rarely/never

Fully-adjusteda OR (CI)

2

No

0.035*

Attended college/technical school

Adjusted for Current Smoking Status OR (CI)

ACEs count (N = 3,305)

0.096

18–42

Unadjusted OR (CI)

The percentages for each type of ACE are based on calculations using the participants who completed all corresponding items (household dysfunction [N = 3,459]; physical abuse [N = 3,459]; verbal abuse [N = 3,430]; sexual abuse [N = 3,437])

ACEs Count In either the unadjusted or fully-adjusted models, a significant association between ACEs count and CDS resulted if any occurrence of childhood maltreatment was reported. Further, the magnitude of association increased with increasing number of ACEs (1 vs. 0: OR = 2.10, CI = 1.16–3.81; 2 vs. 0: OR = 2.89, CI = 1.51–5.58; 3 or 4 vs. 0: OR = 3.94, CI = 2.13–7.32; 5? vs. 0: OR = 4.04, CI = 2.26–7.22; Table 4).

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ACEs Type Women residing in Hawaii with accounts of household dysfunction during childhood were more than twice as likely to have depression in adulthood compared to their counterparts (fully-adjusted: OR = 2.10, CI = 1.37–3.23). Similarly, the unadjusted and adjusted odds of CDS in adulthood for individuals who experienced physical, verbal or sexual abuse were also greater compared to those non-exposed, with verbal abuse having the strongest magnitude of association (fully-adjusted: physical abuse: OR = 1.67, CI = 1.08– 2.59; verbal abuse: OR = 3.21, CI = 2.03–5.09; sexual abuse: OR = 1.68, CI = 1.04–2.71; Table 4).

Conclusions Overall, significant positive associations between CDS and the number of ACEs, household dysfunction, physical abuse, verbal abuse and sexual abuse independent of sociodemographic characteristics (age, race/ethnicity and education), emotional support and current smoking status were found among women residing in Hawaii. The odds ratio for CDS was greatest with the presence, versus absence, of verbal abuse compared to other ACEs type, and no modification by current smoking status or binge drinking was found. In a state with a predominant population whose culture and childrearing practices may promote underreporting of ACEs, the estimates in this study are likely conservative. Our findings support the results of previous studies of other populations. Evaluating health maintenance organization members in a primary care clinic, Chapman et al. [13] found similar odds ratios for verbal/emotional, physical and sexual abuse among women using lifetime or recent prevalence of depression, with verbal/emotional abuse having the greatest magnitude of association. Although Chapman et al. [13] analyzed indicators for household dysfunction individually, the relative magnitude and direction of association was also similar to our findings. The results also support Goldberg et al. [63] revealing physical and sexual abuse significantly associated with depression independent of chronic pain, in addition to the relationship between psychological maltreatment and depression found by Ferguson and Dacey in a cohort of female health care providers [64]. The increasing estimate per accumulation in the number of ACEs found in the study also supported findings by Chapman et al. [13]. Research show early stressors such as child abuse can lead to neurological changes and brain dysfunction that can affect mental health in adulthood. The hypothalamicpituitary-adrenocortical (HPA) axis, which is responsible for regulating stress response, may be hindered by early

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stressors that have been shown to exacerbate stress-induced glucocorticoid response and the genetic expression of corticotrophin-releasing hormone [65, 66]. An uncontrolled HPA axis can lead to depression in adulthood, particularly among women [67, 68], and this is supported by studies demonstrating heightened cortisol reactivity to stress among women with early abuse and depression [69–71]. In Hawaii, the prevalence of depression is greater compared to that of the US [17], which may place residents at greater odds for depression-induced chronic diseases. More so, the state consists predominantly of an Asian and Native Hawaiian/Pacific Islander population, each of which has greater age-adjusted percentage of diabetes compared to the US overall [32]. In addition, heart disease is more prevalent among Native Hawaiians/Pacific Islanders compared to the national estimate [32]. The rate of these depression-related chronic diseases in Hawaii may be significantly decreased by preventing or reducing ACEs. The number of reported child abuse in Hawaii [72] is lower than that acknowledged in a study of perceptions of child maltreatment [8]. This demonstrates a problem in reporting, possibly hindered by cultural stigma [5]. The high percentage of individuals in the state with difficulty in identifying child maltreatment [8] may further lead to underestimation. Programs for parents and family members to detect child abuse and to advocate a healthy physical and mental environment for their children may discourage the occurrence or continuance of ACEs, promote reporting, and decrease the prevalence of CDS and other associated chronic diseases. Also, for health care workers in Hawaii, especially individuals who work with women, training which focus on the contribution of ACEs on depression or CDS in later life, and related chronic diseases, may promote more vigilant monitoring and assessment for ACEs in routine clinical examinations. It may also increase advocacy in preventing or reducing child maltreatment, and encourage evaluation for ACEs that may lead to and/or sustain CDS in adulthood as a part of therapy. Our findings suggest that the excess percentage of depression cases in Hawaii beyond the national estimate can be decreased, at least in part, through these interventions. Future studies are needed to determine the most appropriate approach to decrease the prevalence of ACEs and, potentially, CDS in adulthood, among women in the state. Some limitations of this study include the use of selfreported data in which recall or social desirability bias may influence the estimate towards the null. We also used the PHQ-8 survey which does not diagnose clinical depression. However, it has been previously validated against other diagnostic instruments [60, 61, 73]. In addition, we did not consider treatment for depression. Individuals who may have had previous encounters with childhood abuse, which required mood regulation, may have had their

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mental condition controlled by adulthood. The BRFSS data also excluded institutionalized or hospitalized individuals who may be more representative of persons who have experienced ACEs and adult depression or elevated depressive symptomatology. The study strengths include the availability of multiple measures of ACEs and the use of a probability sample, which allows for inference to a known population. Further, the data consists of a large representative sample of diverse populations. This study evaluated the association between ACEs and CDS among women in Hawaii. The findings suggest individuals with ACEs should be monitored for CDS, and those who tested positive may benefit from therapy that addresses issues related to child maltreatment. The positive association found in this study supports the promotion of a more comprehensive assessment of ACEs during clinical evaluations, which, through education and support, may encourage disclosure. In a population in which the culture or childrearing practices of a predominant group may dissuade acknowledgement of child abuse, interventions that promote a healthy physical and mental environment in the household, and train parents and family members to identify ACEs, may decrease stigma against the admission of ACE occurrence and encourage reporting. Future studies may include the investigation of the association between the number of occurrence of each ACEs type and CDS, one that accounts for depression treatment, and an evaluation of attitudes towards reporting ACEs in Hawaii. A life course prospective study in which children are assessed for ACEs and followed-up over time for incident depression, in addition to studies on the association between ACEs and chronic conditions such as diabetes and heart disease may also be warranted. Acknowledgments This research was in collaboration with the Hawaii DOH, Family Health Services Division, and funded through the Health Resources and Services Administration, Maternal and Child Health (MCH) Bureau’s Graduate Student Internship Program. The authors appreciate the assistance from Cheryl Prince, Dave Goodman, and Charlan Kroelinger from the MCH Epidemiology Program, Applied Sciences Branch, Division of Reproductive Health, National Center for Chronic Disease Prevention and Public Health Promotion, CDC, for scientific guidance on this analysis and manuscript. Conflict of interest interest.

None of the authors have any conflicts of

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