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. Author manuscript; available in PMC: 2024 Sep 10.
Published in final edited form as: Subst Use Misuse. 2021 Mar 16;56(6):854–860. doi: 10.1080/10826084.2021.1899230

Associations between Adverse Childhood Experiences and Performance-Enhancing Substance Use among Young Adults

Kyle T Ganson a, Stuart B Murray b, Deborah Mitchison c,d, Misty A W Hawkins e, Harley Layman e, Jennifer Tabler f, Jason M Nagata g
PMCID: PMC11385237  NIHMSID: NIHMS2021016  PMID: 33726612

Abstract

Background and Objective:

Adverse childhood experiences (ACEs) are associated with negative health outcomes, yet their associations with performance-enhancing substance (PES) use are unclear. This study aimed to determine whether ACEs predict greater use of legal and illegal PES in young adults.

Methods:

We analyzed data from the National Longitudinal Study of Adolescent to Adult Health (n = 14,322), Waves I (1994–1995) and III (2001–2002). ACEs included childhood sexual abuse, physical abuse, two neglect indicators, and cumulative ACEs. Legal (e.g. creatine monohydrate) and illegal (e.g. non-prescription anabolic-androgenic steroids; AAS) PES use was assessed.

Results:

Sexual abuse had the greatest effect and predicted higher odds of legal PES use (men: adjusted odds ratio [AOR] 1.66, 95% confidence interval [CI] 1.06–2.59; women: AOR 3.74, 95% CI 1.63–8.59) and AAS use (men: AOR 8.89, 95% CI 5.37–14.72; women: AOR 5.73, 95% CI 2.31–14.18). Among men, a history of physical abuse (AOR 3.04, 95% CI 2.05–4.52), being left alone by a parent/guardian (AOR 2.33, 95% CI 1.50–3.60), and basic needs not being met (AOR 3.47, 95% CI 2.30–5.23) predicted higher odds of AAS use. Among women, basic needs not being met (AOR 2.94, 95% CI 1.43–6.04) predicted higher odds of AAS use. Among both men and women, greater number of cumulative ACEs predicted higher odds of both legal and illegal PES use.

Conclusions:

ACEs predict greater PES use among young adults. Clinicians should monitor for PES use among those who have experienced ACEs and provide psychoeducation on the adverse effects associated with PES use.

Keywords: Adverse childhood experiences, sexual abuse, creatine monohydrate, anabolic steroids, young adults

Introduction

Performance-enhancing substances (PES), both legal (e.g. creatine monohydrate) and illegal (e.g. non-prescribed anabolic-androgenic steroids; AAS) are commonly used among young people, including upwards of 16–35% of adolescent boys who use legal PES and between 3–6% who use AAS (Eisenberg et al., 2012; Nagata, Ganson, Griffiths, et al., 2020). The multisystemic and adverse physiological, psychological, and social outcomes associated with AAS use are well established (Pope et al., 2014). While less is known about the adverse outcomes associated with legal PES use (Ganson et al., 2019), recent evidence illustrates that use of legal muscle-enhancing or weight loss substances and energy supplements, compared to vitamin use, may result in a three-fold greater risk of emergency room visits, disability, or premature death among young people (Or et al., 2019). Importantly, a prospective relationship between legal PES use and future AAS use (Nagata, Ganson, Gorrell, et al., 2020) and alcohol use problems (Ganson et al., 2020) has been recently documented, suggesting a trajectory of increasing severity of substance use problems associated with legal PES use.

Prior research has shown several predictors of PES use among young adults, including lower body mass index, perceiving oneself to be underweight, participation in exercise, sports, and weightlifting, and alcohol use (Ganson et al., 2020; Nagata, Murruy, et al., 2019). However, despite the growing research aimed at understanding the predictors, correlates, and outcomes of PES use, several gaps remain in the knowledge base, particularly the relationships between adverse childhood experiences (ACEs) and PES use. ACEs include “potentially traumatic events” that occur in childhood and adolescence that can include physical and sexual abuse, neglect, the witnessing of violence, household dysfunction, parental substance use and poor mental health, and death or incarceration of a parent (Centers for Disease Control & Prevention, 2019; Felitti et al., 2019; Hughes et al., 2017). It is estimated that between 50 and 60% of children and adolescents experience one or more ACE (Centers for Disease Control & Prevention, 2019; Felitti et al., 2019), highlighting the common nature of these adverse events.

Research consistently shows that ACEs lead to a variety of negative biopsychosocial health outcomes, including alcohol and drug use, suicidal behavior, depression, obesity, and risky and maladaptive behaviors across the lifespan (Felitti et al., 2019; Hughes et al., 2017). The ACE model (Centers for Disease Control & Prevention, 2019) and corresponding evidence suggests that the adoption of these health-risk behaviors and negative biopsychosocial health outcomes are a result of the social, emotional, and cognitive impairment caused by the toxic stress of traumatic childhood events (Anda, 2007; Anda et al., 2006). This stress leads to physiological dysregulation, such as aberrant responses across multiple body systems, including the cardiovascular, inflammatory, and neuroendocrine (Baumeister et al., 2016; Kalmakis et al., 2015; Lacey et al., 2020; Voellmin et al., 2015; Wiss & Brewerton, 2020), all of which impact a person’s ability to self-regulate by using healthy behaviors or by avoiding unhealthy coping behaviors, particularly during emerging adulthood (Lackner et al., 2018; Shin et al., 2018).

Emerging adulthood comprises the developmental period from the ages 18 to 25 years and is a formative stage of establishing a sense of self and independence from parents and/or guardians, as well as developing critical coping strategies (Arnett, 2000; Reifman et al., 2007). Emerging adulthood is often when young people’s health lifestyles codify, with some establishing maladaptive behavior patterns, including binge drinking, substance use, and sedentary behaviors (Daw et al., 2017). ACEs may contribute to poorer health trajectories in emerging adulthood, as young people with a greater number of ACEs may engage in patterns of more health-compromising and risky behavior (Reifman et al., 2007), which may include PES use.

Considering the significant adverse impacts of ACEs, particularly relating to substance use, the aim of this study was to determine the associations between experiencing ACEs, including sexual abuse, physical abuse, and neglect, and use of both legal and illegal PES among young adult men and women. Additionally, we aim to determine whether experiencing a greater number of cumulative ACEs increases the likelihood of use of both legal and illegal PES in young adulthood. To our knowledge, this is the first study to investigate these associations, and the new understanding will help inform whether ACEs are a potential risk factor for PES use and/or whether PES use is used as a coping behavior to self-regulate after experiencing childhood trauma.

Methods

We analyzed longitudinal cohort data from the National Longitudinal Study of Adolescent to Adult Health (Add Health), Waves I (1994–1995) and III (2001–2002; n = 14,322). Add Health is a nationally representative longitudinal cohort study which sampled adolescents throughout the United States and followed them into adulthood (Harris et al., 2017). The baseline sample was collected from 1994–1995 when participants were between the ages 11 and 18 years. Systematic sampling methods and implicit stratification were utilized to ensure that the selected high schools (n = 80) and paired middle schools were representative of US schools with respect to geographical region, size, urbanicity, type (i.e. public, private, charter), and race/ethnicity. The University of North Carolina Institutional Review Board approved all Add Health study procedures and written informed consent was obtained. Further details about the study design can be found elsewhere (Harris et al., 2017).

Measures

Dependent variables

PES use was measured using two questions that were both assessed at Wave III. Legal PES use in the past year: participants were asked if they had used “legal performance-enhancing substances for athletes (such as Creatine monohydrate or Andro)” in the past year. Anabolic-androgenic steroids, lifetime use: participants were asked if, since 1995, they had ever taken “steroids or anabolic steroids” without a doctor’s permission. Response choices for both PES questions included “yes” or “no.”

Independent variables

ACEs were retrospectively measured using four questions that were all assessed at Wave III. Physical abuse: participants were asked “How often had your parents or other adult care-givers slapped, hit, or kicked you?” Sexual abuse: participants were asked “How often had one of your parents or other adult care-givers touched you in a sexual way, forced you to touch him or her in a sexual way, or forced you to have sexual relations?” Neglect by being left alone by a parent/guardian: participants were asked “By the time you started 6th grade, how often had your parents or other adult care-givers left you home alone when an adult should have been with you?” Neglect by basic needs not being met: participants were asked “How often had your parents or other adult care-givers not taken care of your basic needs, such as keeping you clean or providing food or clothing?” Response options for all ACEs questions were recoded to never and any. A composite ACEs score was also created that ranged from zero to four ACEs experienced.

Confounding and demographic variables

All confounding variables were assessed at Wave I. Alcohol use: participants were asked “Have you had a drink of beer, wine, or liquor–not just a sip or taste of someone else’s drink–more than 2 or 3 times in your life?” Cigarette use: participants were asked “Have you ever tried cigarette smoking, even just 1 or 2 puffs?” Responses choices for alcohol use and cigarette use included “yes” or “no.” Illicit drug use: participants were asked “During your life, how many times have you used any of these types of illegal drugs (LSD, PCP, ecstasy, mushrooms, speed, ice, heroin, or pills)?” Responses were recoded to none and any. Depression screen was measured by a version of the Center for Disease Epidemiology-Depression (CES-D) scale. A composite score of ≥ 16 indicated risk for clinical depression as has been done previously (Nagata et al., 2018).

Demographic variables included self-reported age, race/ethnicity, and household income. Age in years was calculated from the date of birth and the date of the Wave I interview. Race/ethnicity was based on the categories created by the Add Health survey design: non-Hispanic white; non-Hispanic Black/African American; Latino/Hispanic; non-Hispanic Asian or Pacific Islander; American Indian/Native American; or other. Household income was based on parents’ response in Wave I (when subjects were 11–18 years old) to the question: “About how much total income, before taxes, did your family receive in 1994? Include your own income, the income of everyone else in your household, and income from welfare benefits, dividends, and all other sources.” This variable was intended to be a proxy for socio-economic status. Gaussian normal regression imputation method was used to impute income for the 1,638 parents who either refused to answer the income question or stated they did not know, similar to the method used in previous studies (Nagata, Ganson, Griffiths, et al., 2020).

Statistical analysis

Multiple logistic regressions were used to analyze a history of ACEs (physical abuse, sexual abuse, two neglect indicators, and cumulative ACEs), which was retrospectively assessed at Wave III as predictors of past year legal PES use and lifetime AAS use measured at Wave III, while adjusting for confounding (alcohol use, cigarette use, illegal drug use, depression score) and demographic variables (age, race/ethnicity, and household income). Analyses were stratified by sex given differing rates of legal and illegal PES use among men and women (Nagata, Ganson, Griffiths, et al., 2020). All analyses included Add Health’s preconstructed sample weighting to provide a sample that was representative of the US population (Chen & Harris, 2020) and were performed in 2020 using Stata 15.1.

Results

Among the diverse sample of 14,322 participants, 15.5% of men and 1.1% of women reported legal PES use, while 2.9% of men and 0.8% of women reported AAS use. Among both men (43.2%) and women (37.8%), neglect by being left alone by a parent/guardian was the most common form of ACEs experienced, followed by physical abuse (men: 29.9%; women: 27.0%), neglect by basic needs not being met (men: 14.5%; women: 8.7%), and sexual abuse (men: 4.4%; women: 4.6%). The majority of both men (47.8%) and women (51.5%) reported experiencing zero ACEs. Table 1 outlines the full descriptive results of all variables under study.

Table 1.

Descriptive characteristics of 14,322 young adult participants in the National Longitudinal Study of Adolescent Health.

Men Women
n = 6,767 n = 7,555
Demographic characteristics (Wave III, 18–26 years) Mean ± SE / %a Mean ± SE / %a
 Age, years 21.9 ± 0.1 21.7 ± 0.1
 Race/ethnicity
  White (non-Hispanic) 67.4% 68.4%
  Black/African American (non-Hispanic) 15.1% 15.9%
  Hispanic/Latino 12.1% 11.4%
  Asian/Pacific Islander (non-Hispanic) 3.7% 3.1%
  American Indian/Native American 0.6% 0.5%
  Other 0.9% 0.6%
 Household income, US dollars (Wave I, 11–18 years old) 45.0 ± 1.7 46.5 ± 1.8
Baseline substance use & mental health outcomes (Assessed at Wave I, 11–18 years old)
 Alcohol, ever use 55.9% 54.9%
 Cigarette, ever use 57.3% 57.3%
 Illegal drugs, ever use 7.5% 7.3%
 Depression screen (CES-D 10-item) 45.6% 53.7%
Self-reported adverse childhood experiences (Assessed at Wave III, 18–26 years)
 Sexual abuse 4.4% 4.6%
 Physical abuse 29.9% 27.0%
 Neglect: left alone by parent/guardian 43.2% 37.8%
 Neglect: basic needs not being met 14.5% 8.7%
 Cumulative adverse childhood experiences score
  0 47.8% 51.5%
  1 29.6% 29.5%
  2 15.0% 13.6%
  3 4.5% 3.9%
  4 3.1% 1.6%
Legal performance-enhancing substance (PES) use (Assessed at Wave III, 18–26 years) 15.5% 1.1%
Anabolic-androgenic steroid use (Assessed at Wave III, 18–26 years) 2.9% 0.8%
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CES-D = Center for Disease Epidemiology-Depression.

PES = Performance-enhancing substance (such as Creatine monohydrate or Andro).

a

All means and percentages are calculated with weighted data to reflect the representative proportion in the target US population.

Results from multiple logistic regression analyses revealed significant associations between ACEs and both legal and illegal PES use among men and women (Table 2).

Table 2.

Associations between ACEs and legal/illegal PES use in young adults 24–32 years of age.

Men
Legal PES Use AAS Use
Self-reported adverse childhood experiences (assessed at Wave III) Adjusted odds ratioa (95% CI) Adjusted odds ratioa (95% CI)
 Sexual abuse 1.66 (1.06–2.59) * 8.89 (5.37–14.72) ***
 Physical abuse 1.42 (1.15–1.74) ** 3.04 (2.05–4.52) ***
 Neglect: left alone by parent/guardian 1.20 (1.01–1.45) * 2.33 (1.50–3.60) ***
 Neglect: basic needs not being met 1.18 (0.89–1.55) 3.47 (2.30–5.23) ***
Cumulative adverse childhood experiences score
 0 Ref. Ref.
 1 1.22 (0.99–1.50) 1.18 (0.69–2.04)
 2 1.24 (0.93–1.66) 1.52 (0.84–2.76)
 3 1.23 (0.81–1.88) 2.93 (1.39–6.14) **
 4 2.12 (1.28–3.49) ** 14.56 (8.00–26.47) ***
Women
Legal PES Use AAS Use
Self-reported adverse childhood experiences (assessed at Wave III) Adjusted odds ratioa (95% CI) Adjusted odds ratioa (95% CI)
 Sexual abuse 3.74 (1.63–8.59) ** 5.73 (2.31–14.18) ***
 Physical abuse 2.60 (1.55–4.37) *** 1.85 (0.94–3.62)
 Neglect: left alone by parent/guardian 2.05 (1.07–3.93) * 1.78 (0.90–3.54)
 Neglect: basic needs not being met 1.41 (0.59–3.37) 2.94 (1.43–6.04) **
Cumulative adverse childhood experiences score
 0 Ref. Ref.
 1 1.77 (0.78–4.01) 1.36 (0.58–3.18)
 2 2.80 (1.26–6.23) * 1.18 (0.30–4.63)
 3 3.26 (0.95–11.25) 4.20 (1.49–11.85) **
 4 9.31 (3.45–25.15) *** 11.53 (4.34–30.63) ***
Open in a new tab

Boldface indicates statistical significance

*

p < .05,

**

p < .01,

***

p < .001.

ACEs = Adverse childhood experiences.

PES = Performance-enhancing substance (such as Creatine monohydrate or Andro).

AAS = Anabolic-androgenic steroids.

a

Adjusted for age, race/ethnicity, household income, baseline alcohol use, baseline cigarette use, baseline illicit drug use, and baseline depression screen.

Legal performance-enhancing substances use

Among men, experiencing sexual abuse (adjusted odds ratio [AOR] 1.66, 95% confidence interval [CI] 1.06–2.59), physical abuse (AOR 1.42, 95% CI 1.15–1.74), and being left alone by a parent/guardian (AOR 1.20, 95% CI 1.01–1.45) were associated with higher odds of using legal PES, while adjusting for demographic and confounding variables. Among women, experiencing sexual abuse (AOR 3.74, 95% CI 1.63–8.59), physical abuse (AOR 2.60, 95% CI 1.55–4.37), and being left alone by a parent/guardian (AOR 2.05, 95% CI 1.07–3.93) were associated with higher odds of using legal PES, while adjusting for demographic and confounding variables. Among both men and women, a cumulative ACE score of four (men: AOR 2.12, 95% CI 1.28–3.49; women: AOR 9.31, 95% CI 3.45–25.15) was associated with higher odds of using legal PES, while adjusting for demographic and confounding variables. Among women, a cumulative ACE score of two (AOR 2.80, 95% CI 1.26–6.23) was associated with higher odds of using legal PES, while adjusting for demographic and confounding variables.

Anabolic-androgenic steroid use

Among men, all forms of ACEs were associated with higher odds of using AAS, while adjusting for demographic and confounding variables, including experiencing sexual abuse (AOR 8.89, 95% CI 5.37–14.72), physical abuse (AOR 3.04, 95% CI 2.05–4.52), being left alone by a parent/guardian (AOR 2.33, 95% CI 1.50–3.60), and basic needs not being met (AOR 3.47, 95% CI 2.30–5.23). Among women, experiencing sexual abuse (AOR 5.73, 95% CI 2.31–14.18) and basic needs not being met (AOR 2.94, 95% CI 1.43–6.04) were associated with higher odds of using AAS, while adjusting for demographic and confounding variables. Among both men and women, a cumulative ACE score of three (men: AOR 2.93, 95% CI 1.39–6.14; women: AOR 4.20, 95% CI 1.49–11.85) and four (men: AOR 14.56, 95% CI 8.00–26.47; women: AOR 11.53, 95% CI 4.34–30.63) were associated with higher odds of using AAS, while adjusting for demographic and confounding variables.

Discussion

This study is the first to illustrate that ACEs predict higher odds of using both legal and illegal PES among young adult men and women. Of particular note, experiencing sexual abuse as a child increased the likelihood of young adult men using AAS nearly nine-fold and young adult women using AAS nearly six-fold. Similarly, experiencing sexual abuse had the greatest effect on legal PES use among both men and women. These findings are consistent with prior research showing that ACEs, including sexual abuse in particular, are associated with substance use in adulthood (Felitti et al., 2019; Hughes et al., 2017). Our results emphasize that legal PES (e.g. creatine monohydrate), which are easily accessible and unregulated (Ganson et al., 2019), and AAS should be included as substances used among people who have experienced ACEs.

In addition to the specific individual ACEs predicting both legal and illegal PES use, we found that experiencing cumulative ACEs increased the odds of using both legal and illegal PES for both men and women. Among men, experiencing four ACEs increased the likelihood of using AAS to over 14-fold, while, among women, experiencing four ACEs increased the likelihood of using AAS to over 11-fold. Experiencing four ACEs was also strongly associated with legal PES use among both men and women. These results further emphasize the cumulative adverse effect experiencing multiple ACEs can have on adverse outcomes, such as substance use (Hughes et al., 2017).

There are particularly salient theoretical justifications that explain the strong associations between ACEs and both legal and illegal PES use found in this study. These justifications can be framed by the crucial developmental period of emerging adulthood, where individuals are solidifying their identity and future behavioral patterns and coping skills (Arnett, 2000; Reifman et al., 2007). Men and women may use both legal and illegal PES to develop a larger, more muscular body to protect against additional interpersonal traumas. For men in particular, increasing muscularity after childhood sexual trauma may be intended to protect against threats to masculinity. This has been outlined by the precarious manhood perspective (Vandello et al., 2008), which posits that men whose masculinity is threatened may seek to exaggerate their strength (Frederick et al., 2017). For women, prior research has shown a link between physical and sexual abuse among those who use AAS (Ip et al., 2010). This AAS use and excessive weight training among women may be a direct response to the trauma with the intention of protecting against future assault (Gruber & Pope, 1999). It is also possible that the use of substances to accelerate health goals despite the risk for negative physical side effects or even criminal consequences may represent the prioritization of short-term goal or emotional states over long term mental and physical health outcomes, suggesting use of problematic coping strategies (Leban & Gibson, 2020). Despite these theoretical understandings, future qualitative research should focus on explicating the relationship between ACEs and PES use from the lived experiences of individuals.

There are additional potential adverse outcomes that may result from the use of both legal and illegal PES. For example, the pursuit of muscularity and strength among both men and women after experiencing childhood trauma, especially via unhealthy methods like substance use, may result in further psychopathology, such as muscle dysmorphia (Cafri et al., 2008; Gruber & Pope, 1999), eating disorders (Nagata, Murray, et al., 2019; Rodgers et al., 2018), problematic alcohol use (Ganson et al., 2020), as well as the progression from legal PES use to AAS use (Nagata, Ganson, Gorrell, et al., 2020). This further emphasizes the significance of the results from this study for medical, mental health, and public health professionals.

Implications

There are significant clinical implications from the study findings, which are in part due to the high prevalence of ACEs (Merrick et al., 2018) and legal and illegal PES use (Eisenberg et al., 2012; Nagata, Ganson, Griffiths, et al., 2020) found in this study and in more contemporary research. Additionally, this study is among the first to identify an association between ACEs and legal and illegal PES use among a longitudinal cohort study. Given the continued increase in muscularity-oriented disordered eating (Murray et al., 2016; Nagata, Brown, et al., 2019), including PES use (Nagata, Ganson, Griffiths, et al., 2020), among young people, these results provide important implications for clinicians. This includes assessing for and monitoring legal and illegal PES use among patients who have reported ACEs. Clinicians can also provide important psychoeducation about the known adverse physiological, psychological, and social outcomes associated with legal (Ganson et al., 2020; Nagata, Ganson, Gorrell, et al., 2020; Or et al., 2019) and illegal PES use (Pope et al., 2014). The results from this study further support the need for early efforts aimed at reducing childhood trauma to ensure the healthy development of all young people. This includes recommendations put forth by the Centers for Disease Control and Prevention (Centers for Disease Control & Prevention, 2019), as well as state-level screening initiatives such as those in California (Office of the California Surgeon General & Department of Health Care Services, 2020). The results from this study also identify PES use as a unique target for intervention programming and public policy aimed at regulating the sale of legal PES, such as those in Massachusetts (The Commonwealth of Massachusetts, 2020), New York (State of New York, 2020), and California (State of California, 2020).

Strengths and limitations

Strengths of this study include the use of a large and diverse, nationally representative sample of US young adults, as well as the use of multiple ACEs measures. Despite these strengths, there are several limitations to be noted. First, the measures are based on self-report, which may increase social desirability bias. Second, the ACEs measures were assessed at Wave III, which has the potential for retrospective recall bias. Additionally, this limits our analyses and findings in assessing prospective associations between ACEs and PES use. Third, there is a potential for unmeasured confounders that may influence the associations between ACEs and PES use. Furthermore, it is important to not misappropriate the ACEs score with a screening or diagnostic tool of a particular risk behavior or health outcome (Anda et al., 2020). Fourth, the Add Health data used in this study is nearly 20 years old; however, ACEs (Centers for Disease Control & Prevention, 2019; Crouch et al., 2019; Merrick et al., 2018; Stoltenborgh et al., 2013) and PES use (LaBotz & Griesemer, 2016; Nagata, Ganson, Griffiths, et al., 2020) continue to be prevalent among the population, indicating that our findings have relevance today. Lastly, while androstenedione (“andro”) was considered legal in the United States at the time of data collection in 2001–2002, it should be noted that this substance was banned in 2004 in the US and is also considered a banned substance by the World Anti-Doping Agency.

Conclusion

The results from this study show that among both men and women, experiencing ACEs is associated with use of legal and illegal PES in young adulthood. Experiencing sexual abuse, as well as reporting a cumulative score of four ACEs, had the greatest effect on legal and illegal PES use. Future research could use qualitative methods to better understand the social impact of ACEs on PES use. These findings have important implications for clinical professionals and policymakers given the prevalence of PES use and ACEs.

Acknowledgements

We would like to thank Sam Benabou for providing editorial assistance. This research uses data from Add Health, a program project directed by Kathleen Mullan Harris and designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris at the University of North Carolina at Chapel Hill, and funded by grant P01-HD31921 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, with cooperative funding from 23 other federal agencies and foundations. Information on how to obtain the Add Health data files is available on the Add Health website (https://addhealth.cpc.unc.edu). No direct support was received from grant P01-HD31921 for this analysis.

Financial disclosure

The authors report no financial disclosures.

Footnotes

Declaration of interest

The authors declare that they have no conflict of interest. The authors alone are responsible for the content and writing of the article.

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