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. Author manuscript; available in PMC: 2021 Aug 1.
Published in final edited form as: Schizophr Res. 2020 Jun 8;222:235–242. doi: 10.1016/j.schres.2020.05.045

Adverse Childhood Experiences and Psychotic-like Experiences Are Associated Above and Beyond Shared Correlates: Findings from the Adolescent Brain Cognitive Development Study

Nicole R Karcher 1, Tara A Niendam 2, Deanna M Barch 1,3
PMCID: PMC7572890  NIHMSID: NIHMS1615857  PMID: 32522466

Abstract

Adverse childhood experiences (ACEs) are associated with increased risk for psychotic-like experiences (PLEs). However, ACEs and PLEs are also both associated with several shared factors (e.g., internalizing symptoms, suicidality). Few studies have explicitly examined whether the association between ACEs and PLEs remains over and above shared correlates. To address this question, using 10,800 9-11-year-olds, we examined whether ACEs and school-aged PLEs were associated when accounting for shared correlates, and whether there was evidence of mediation in associations between PLEs, ACEs, and these shared factors. Greater number of ACEs were associated with greater PLEs, including several specific ACEs (e.g., bullying). Importantly, ACEs and PLEs were related even when accounting for shared correlates. Further, PLEs partially mediated the relationships between ACEs and both internalizing symptoms and suicidality, including suicidal behavior. The current study helps clarify the nature of the associations between PLEs and ACE and has important clinical implications for addressing PLEs.

Keywords: adverse childhood experiences, psychotic-like experiences, suicidality, internalizing symptoms, trauma

1. Introduction

Adverse childhood experiences (ACEs) are a common experience worldwide, with the results of the original ACEs study finding that almost two-thirds of participants reported at least one ACEs before adulthood (CDC and Permanente, 2016). Definitions of ACEs vary, and can encompass a range of experiences, including sexual abuse, physical abuse, emotional/psychological abuse, and peer victimization (e.g., bullying) (Afifi et al., 2020). Research indicates that ACEs may result in neural alterations affecting the hypothalamus-pituitary-adrenal (HPA) axis, thereby leading to a host of functional impairments (Isvoranu et al., 2017). For example, ACEs are associated with greater risk for a range of health problems, including increased risk of anxiety disorders, depression, and psychotic disorders (Croft et al., 2019; Loewy et al., 2019). However, research is limited regarding the extent of these associations in school-age children, particularly in relation to psychotic spectrum symptoms. Therefore, the current study examined the associations between ACEs and psychotic-like experiences (PLEs) in a large sample in middle childhood.

PLEs, or nonclinical schizophrenia spectrum symptoms (e.g., unusual beliefs, perceptual abnormalities) in childhood are associated with greater odds of developing psychiatric disorders, including psychotic disorders, during adulthood (Poulton et al., 2000). Importantly, research generally indicates that exposure to childhood ACEs is associated with increased risk of psychotic disorders (Croft et al., 2019; Loewy et al., 2019). A recent meta-analysis found that approximately 87% of individuals at ultra-high risk for psychosis endorse an ACE (Kraan et al., 2015). Some research indicates that specific types of traumatic experiences with intention to harm (Moriyama et al., 2018), such as the experience of bullying (Strauss et al., 2018) or sexual abuse (McGrath et al., 2017), may be most strongly associated with PLEs. However, more work is needed to determine if one or more of these types of ACEs are specifically associated with PLEs, or if there is a more general relationship between ACEs and PLEs.

Critically, ACEs and PLEs are both associated with a number of shared correlates (Figure 1a) (Isvoranu et al., 2017), including everyday stress (Cristobal-Narvaez et al., 2016), impairments in cognition (e.g., fluid cognition) (Mansueto et al., 2019), depression and generalized anxiety (Barzilay et al., 2019), and suicidality (Grivel et al., 2018), including both suicidal ideation and suicidal behavior (e.g., attempts) (Gaweda et al., 2020; Merrick et al., 2017; Yates et al., 2019). In addition, family history of mental illness (e.g., family history of psychosis) is a risk factor for both PLEs and ACEs (Felitti et al., 1998; Polanczyk et al., 2010). However, few studies have examined evidence that the association between ACEs and PLEs remains over and above these shared correlates (Arseneault et al., 2011; Barzilay et al., 2019). For example, ACEs and PLEs might appear to be related because they are both associated with stress, internalizing symptoms, and impaired cognitive function, but may no longer demonstrate an independent relationship to each other once accounting for these shared correlates.

Figure 1.

Figure 1.

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Illustration of the potential relationships among ACES, PLEs and shared correlates. A: Representation of evidence that ACEs, PLEs, and a number of factors are all intercorrelated based on prior research; B: A model whereby the shared correlates of ACEs and PLEs mediate the relationship between ACEs and PLEs; C: A model whereby PLEs mediate the relationship between ACEs and these shared correlates.

There is a need for more research on the interrelationships of PLEs, ACEs and their shared correlates, specifically to begin to understand the nature of these associations, including whether PLEs are the mechanism underlying the association between ACEs and other negative psychopathological correlates (i.e., greater anxiety/depression and suicidality). Research has focused on internalizing symptoms and cognitive impairments as potential mediators of the association ACEs and PLEs (Figure 1b) (Gaweda et al., 2019; Mansueto et al., 2019; Williams et al., 2018). There is evidence that depression and anxiety partially mediate the association between trauma and PLEs (Fisher et al., 2013). However, conceptually, previous research also supports the possibility that PLEs lead to increased anxiety and depressive symptoms and suicidal outcomes following a trauma (Conus et al., 2010; Gaweda et al., 2020), suggesting the possibility that PLEs might mediate at least some aspects of the relationships between ACEs and other mental health outcomes (Figure 1c). Along these lines, there is support for PLEs mediating the association between ACEs and suicidality (Gaweda et al., 2020). Thus, while evidence indicates that PLEs mediate the association between ACEs and suicidality, the direction of mediation is less clear for other correlates, such as internalizing symptoms (i.e., whether PLEs mediate the association between ACEs and internalizing symptoms, or whether internalizing symptoms mediate the association between ACEs and PLEs). Clarifying these interrelationships has important clinical implications, including understanding the mechanisms contributing to the development of PLEs and other negative psychopathological correlates.

The current study examined the associations between ACEs and PLEs using data from 9-11-year-olds in the Adolescent Brain Cognitive Development (ABCD) study. First, we examined whether, as expected, greater endorsement of ACEs is associated with greater report of PLEs. We also examined whether PLEs were associated with specific types of ACEs, such as sexual abuse, physical abuse, and bullying. Also, given evidence for shared correlates between ACEs and PLEs, we examined whether the association between ACEs and PLEs remained when accounting for stress, cognitive deficits, internalizing symptoms, family history of psychosis, and suicidality. Lastly, we examined whether there was evidence of PLEs mediating the associated between ACEs and stress, fluid cognition, internalizing symptoms, suicidality or vice versus.

2. Materials and methods

2.1. Participants

A sample of 11,874 individuals was obtained from the ABCD study, a large-scale study tracking 9–11-years-olds recruited from 21 research sites across the United States. Study exclusion criteria are listed in Supplement. All procedures comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. All parents provided written informed consent and all children provided assent.

ABCD data were accessed from the National Institutes of Mental Health Data Archive (Acknowledgments). Participants were removed from analyses due to missing data (n=1,074; Supplemental Table 1). The final sample size was 10,800 individuals (47.9% female; 52.8% White, 20.0% Hispanic, 14.5% African American, 2.2% Asian, and 10.6% Other).

2.2. Measures

2.2.1. Symptom Measures

Child participants completed the Prodromal Questionnaire-Brief Child Version (PQ-BC), a 21-item self-report questionnaire that has been previously validated for use with school-age children using the ABCD sample (Karcher et al., 2018). Consistent with previous research (Karcher et al., 2018; Loewy et al., 2011), distress scores were calculated, which are the total number of endorsed questions weighted by level of distress [i.e., 0=no, 1=yes (but no distress), 2–6=yes (1+score on distress scale)]. PQ-BC distress scores were also divided into two separate scores, one for questions pertaining to unusual beliefs and another for perceptual abnormalities in follow-up analyses (Supplemental Table 2) (Karcher et al., 2019).

The parent and child versions of the validated and computerized Kiddie-Structured Assessment for Affective Disorders and Schizophrenia (K-SADS) for DSM-5 (Kobak et al., 2013, April) were used as measures of other psychopathology (Barch et al., 2018). The computerized self-administered parent and child versions of the K-SADS show good to excellent concordance with the clinician-administered computerized K-SADS (Townsend et al., 2020). The ACEs variable was defined as summations of parent-rated child experience of traumatic experiences from the K-SADS, a parent-rated question from the K-SADs about whether the child was bullied at school or in the neighborhood, and seven parent-rated questions of financial adversity from a demographic questionnaire (e.g., “Were evicted from your home for not paying the rent or mortgage?”; see Supplement for all financial adversity questions, results using an alternative definition of ACEs; Supplemental Table 3 for frequencies of endorsement of each ACE). Therefore, our definition of ACEs included a number of traumatic life experiences and chronic financial stress. Information regarding the timing of ACE and onset of PLEs is not available in the ABCD sample, precluding the ability to examine causal associations.

In addition, internalizing symptoms were examined using summations of current child-rated depression and generalized anxiety disorder (GAD) symptoms from the K-SADS (see Supplement for analyses with externalizing symptoms). Suicidality was examined using summations of endorsements of current child-rated suicidal ideation (i.e., thinking of a method for a suicide attempt, suicidal thinking with intent to act, thinking of a specific suicidal plan) and suicidal behavior (i.e., self-injury with intent to die, self-injury and thinking you could die from behavior, made preparation for a suicide attempt, aborted or interrupted suicide attempts, the method of an actual suicide attempt, or a suicide attempt in which they thought they could die) from the K-SADS. Stress was measured using the stress subscale from the parent-rated Child Behavior Checklist (Achenbach, 2009).

2.2.2. Other Measures

Participants completed all National Institutes of Health Toolbox Cognitive Battery (NIHTB-CB) tests (Weintraub et al., 2014). The current study utilized uncorrected NIHTB-CB fluid composite scores, but all analyses include age and sex as covariates (see Supplement and (Weintraub et al., 2013)) for descriptions of individual NIHTB-CB tests and for analyses for total composite scores). The family history of psychotic disorder in first-degree relatives was assessed using the parent-rated Family History Assessment Module Screener (Rice et al., 1995), with each scored as either present or absent.

2.3. Statistical Analyses

The analyses used hierarchical linear models (HLMs), with all multiple comparisons False Discovery Rate corrected (FDR-corrected). Analyses were conducted in R lme4 package (Bates et al., 2015) (multcomp package for multiple comparison analyses (Hothorn et al., 2008)), with family unit and research site modeled as random intercepts, and age, sex (see Supplement for additional analyses of sex differences), and race/ethnicity included as covariates. Results are expressed as standardized estimates (βs) with 95% bootstrapped (5000 iterations) confidence intervals (CIs). Due to significant skew and zero inflation of PQ-BC scores, we also examined log-transformed scores, with consistent results. Differences between significant correlations with each type of ACE were examined using Meng’s z-test procedures (Meng et al., 1992). HLMs examined the association between PLEs and a) number of ACEs, and b) individual ACEs (and ACE composites of accidents, disaster, physical abuse, emotional abuse, and sexual abuse; Table 1). Associations between ACEs and individual PLE items were analyzed using ordered logistic regressions (R package ordinal (Christensen, 2015)). We also examined whether associations between PLEs and number of ACEs remained when accounting for shared correlates, including family history of psychosis, stress, fluid cognition, internalizing symptoms, and suicidality. We performed model-based mediation analyses using the lavaan package in R (Rosseel, 2012) to better understand whether PLEs mediated the association between ACEs and stress, fluid cognition, internalizing symptoms, and/or suicidality.

Table 1.

Model Estimates for Associations between ACEs and PLEs

β lower CI upper CI ta p FDR p
Number of ACEs Endorsed 0.102 0.083 0.120 10.430 <.001 <.001
Types of ACEs
  Accident 0.052 −0.010 0.113 1.646 .10 .25
    Car Accident 0.048 −0.051 0.147 0.944 .35 .50
    Other Significant Accident 0.007 −0.083 0.097 0.145 .89 .89
  Disaster 0.010 −0.069 0.090 0.242 .81 .81
    Fire −0.032 −0.167 0.101 −0.480 .63 .71
    Natural Disaster −0.033 −0.156 0.090 −0.521 .60 .71
  Terrorism 0.063 −0.394 0.522 0.273 .79 .83
  War Zone 0.181 −0.172 0.535 0.989 .32 .50
  Community Violence 0.177 −0.048 0.403 1.528 .13 .35
  Physical Abuse 0.020 −0.084 0.124 0.375 .71 .81
    Shot or Brutally Beaten by Non-family Member −0.422 −0.907 0.058 −1.713 .09 .28
    Shot or Brutally Beaten by Family Member −0.141 −0.632 0.344 −0.563 .57 .71
    Beaten by Family Member 0.083 −0.168 0.335 0.642 .52 .71
  Emotional Abuse 0.098 −0.039 0.237 1.402 .16 .27
    Threatened by Non-Family Member 0.169 −0.088 0.424 1.304 .19 .41
    Threatened by Family Member −0.156 −0.454 0.142 −1.028 .30 .50
  Witnessed Domestic Violence 0.100 0.027 0.174 2.658 .01 .04
  Sexual Abuse 0.093 0.002 0.182 2.006 .045 .23
    Sexual Abuse by Family Member −0.327 −0.666 0.021 −1.854 .06 .24
    Sexual Abuse by Non-Family Member 0.197 −0.080 0.476 1.391 .16 .39
    Sexual Abuse by Peers 0.108 −0.065 0.283 1.219 .22 .42
  Traumatic Grief 0.066 0.022 0.110 2.892 .004 .03
  Bullying 0.304 0.252 0.356 11.461 <.001 <.001
  Financial Adversity 0.046 0.026 0.066 4.563 <.001 <.001
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Abbreviations: ACEs=Adverse Childhood Experiences; PLEs=Psychotic-like Experiences; β=standardized regression coefficient; CI=95% Confidence Interval; t=t-test test statistic; p=p-value; FDR=False Discovery Rate-corrected for multiple comparisons.

a

two-tailed.

3. Results

3.1. Associations between PLEs and ACEs

Greater number of ACEs were associated with greater PLEs (β=.102, p<.001, full model R2=.320, partial R2=.033; Table 1). In terms of covariates, being African American (β=0.306, FDR-corrected p<.001), Hispanic (β=0.225, FDR-corrected p<.001), male (β=−0.053, FDR-corrected p=.004), and younger (β=−0.052, FDR-corrected p<.001) were all significantly associated with greater PLEs.

3.1.1. Associations between PLEs and individual ACEs.

In a model including all of the individual ACEs simultaneously, greater PLEs were associated with several specific ACEs, including witnessing domestic violence (β=0.100, FDR-corrected p=.04; partial R2=.025), traumatic grief (β=0.066, FDR-corrected p=.025; partial R2=.025), bullying (β=0.304, FDR-corrected p<.001; partial R2=.037), and financial adversity (β=0.046, FDR-corrected p<.001; partial R2=.028). Note, these results did not change when removing low frequency ACE items (i.e., <1% reported frequency), or when using ACE composite scores (Table 1). Bullying was significantly more strongly related to PLEs than witnessing domestic violence (Z=16.354, p<.001), traumatic grief (Z=18.593, p<.001), or financial adversity (Z=20.664, p<.001). Furthermore, witnessing domestic violence was significantly more strongly related to PLEs than either traumatic grief (Z=2.866, p=.002) or financial adversity (Z=5.086, p<.001).

3.1.2. Associations between individual PLEs and ACEs.

We also examined whether specific types of PLEs were associated with ACEs. First, both unusual beliefs (delusion-like experiences; β=0.047, FDR-corrected p<.001) and perceptual abnormalities (hallucination-like experiences; β=0.036, FDR-corrected p=.001) were associated with ACE composite score. Examining each of the PQ-BC items individually, ACEs were significantly associated with every single item (Zs>2.91, FDR-corrected ps<.01). However, in a model that included each of the 21 PLE items simultaneously predicting ACEs, the only items that were independently significantly associated with greater ACEs were grandiosity (question 4; β=0.056, FDR-corrected p=.003; Supplemental Table 2 for individual items), suspiciousness (question 8; β=0.024, FDR-corrected p=.003), perceptual abnormalities (question 10: β=0.026, FDR-corrected p=.01; question 17: β=0.036, FDR-corrected p=.01), and disorganized speech (question 21; β=−0.026, FDR-corrected p=.04).

3.2. Associations between PLEs, ACEs, and Shared Correlates

Each of the shared correlates were significantly associated with PLEs (Table 2; FDR-corrected ps<.001). Furthermore, almost all of these factors were also associated with ACEs (Table 2; FDR-corrected ps<.05). Importantly, the association between ACEs and PLEs remained significant when accounting for these shared correlates (βs>0.069, FDR-corrected ps<.001; note the associations of PLEs with the shared correlates remained significant when the ACE composite score were in the model; Table 2).

Table 2.

Model Estimates for Associations between PLEs and Shared Correlates, between PLEs and Shared Correlates including ACEs in the Model, and between ACEs and Shared Correlates.

β lower CI upper CI ta p FDR p
Models Predicting PLEs
  Family History of Psychosis 0.037 0.018 0.055 3.875 <.001 <.001
  Stress 0.109 0.090 0.129 10.613 <.001 <.001
  Fluid Cognition −0.068 −0.087 −0.049 −7.021 <.001 <.001
  Internalizing Symptoms 0.370 0.354 0.387 42.962 <.001 <.001
    Depression 0.337 0.320 0.354 38.566 <.001 <.001
    Generalized Anxiety 0.236 0.218 0.253 26.248 <.001 <.001
  Suicidality 0.234 0.216 0.251 26.039 <.001 <.001
    Suicidal Ideation 0.203 0.185 0.221 22.490 <.001 <.001
    Suicidal Behavior 0.123 0.112 0.135 20.633 <.001 <.001
Models Predicting PLEs that also include ACEs as a Predictor
  Family History of Psychosis 0.028 0.009 0.046 2.884 .004 .004
  Stress 0.093 0.073 0.114 8.950 <.001 <.001
  Fluid Cognition −0.064 −0.082 −0.045 −6.602 <.001 <.001
  Internalizing Symptoms 0.365 0.348 0.382 42.274 <.001 <.001
    Depression 0.332 0.314 0.349 37.897 <.001 <.001
    Generalized Anxiety 0.232 0.215 0.249 25.893 <.001 <.001
  Suicidality 0.230 0.212 0.247 25.649 <.001 <.001
    Suicidal Ideation 0.199 0.181 0.216 22.067 <.001 <.001
    Suicidal Behavior 0.121 0.110 0.133 20.408 <.001 <.001
Models Predicting ACEs
  Family History of Psychosis 0.085 0.068 0.104 9.198 <.001 <.001
  Stress 0.169 0.150 0.188 17.403 <.001 <.001
  Fluid Cognition −0.027 −0.043 −0.011 −3.276 .001 .001
  Internalizing Symptoms 0.061 0.046 0.076 7.797 <.001 <.001
    Depression 0.061 0.046 0.076 7.791 <.001 <.001
    Generalized Anxiety 0.030 0.014 0.045 3.781 <.001 <.001
  Suicidality 0.025 0.010 0.041 3.179 .001 .001
    Suicidal Ideation 0.026 0.011 0.042 3.346 .001 .001
    Suicidal Behavior 0.010 0.000 0.021 1.965 .049 .049
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Abbreviations: ACEs=Adverse Childhood Experiences; PLEs=Psychotic-like Experiences; β=standardized regression coefficient; CI=95% Confidence Interval; t=t-test test statistic; p=p-value; FDR=False Discovery Rate-corrected for multiple comparisons.

3.3. Evidence of PLEs Mediating Associations between ACEs and Shared Correlates

Given the evidence for associations between these shared correlates and both ACEs and PLEs, we next examined whether there was evidence of PLEs mediating the associations between ACEs and these shared correlates. There was evidence that PLEs partially mediated the relationship between ACEs and internalizing symptoms (Supplemental Figure 1; indirect effect [path ab] bias-corrected 95%CI:0.028-0.048; proportion mediated=41.30%). In contrast, we found that evidence that internalizing symptoms mediated only 1.55% of the association between ACEs and PLEs.

There was also evidence that PLEs partially mediated the relationship between ACEs and suicidality (Figure 2; indirect effect [path ab] bias-corrected 95%CI:0.017-0.032; proportion mediated=46.30%). In contrast, we found evidence that suicidality only mediated 2.02% of the association between ACEs and PLEs. We found evidence that PLEs mediated 37.50% of the association between ACEs and suicidal ideation and 58.49% of the association between ACEs and suicidal behavior. In terms of other shared correlates (i.e., fluid cognition, and stress, there was evidence that PLEs mediated less than 7.59% of these associations. However, there was evidence that family history of psychosis mediated 28.57% of the association between ACE and PLEs, fluid cognition mediated 8.33% of the association between ACE and PLEs, and stress mediated 20.0% of the association between PLEs and ACEs.

Figure 2.

Figure 2.

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Evidence of psychotic-like experiences (PLEs) mediating the associations between adverse childhood experiences (ACEs) and suicidality. A: The mediation model, including unstandardized regression coefficients, depicting the association between ACEs, PLEs, and suicidality. The mediation analysis partitioned the total variance (total effect) explained by ACEs into the portion that is independent of PLEs (direct effect) and the portion that is accounted for by PLE (indirect effect). B: The proportion of the association between ACEs and each of the suicidality indices that was mediated by PLEs. C: The mediation model depicting the association between ACEs, PLEs, and suicidal ideation. D: The mediation model depicting the association between ACEs, PLEs, and suicidal behavior.

4. Discussion

Using data from the ABCD study, a prospective longitudinal study assessing children aged 9-11-years-old, we found that exposure to adverse experiences during childhood was associated with psychotic-like experiences. Critically, this association was not explained by a range of other predictors of psychotic-like experiences, including genetic risk for psychotic disorders, general stress, cognitive impairment, internalizing symptoms, and suicidality, indicating a relationship between ACEs and PLEs that exists above and beyond these shared correlates. Exposure to adverse experiences in general was associated with psychotic experiences, but several types of adverse experiences were individually associated with PLEs, including bullying, financial adversity, domestic violence exposure, and traumatic grief. The current study also found evidence consistent with PLEs mediating the association between adverse experiences and both internalizing symptoms and suicidality (especially suicidal behavior).

Our findings of an association between adverse experiences and PLEs replicates several lines of previous research connecting trauma and psychotic experiences (Bailey et al., 2018; Cristobal-Narvaez et al., 2016; Croft et al., 2019; Fisher et al., 2013; Loewy et al., 2019; Strauss et al., 2018; Varese et al., 2012). However, some research has failed to find associations between trauma and psychosis (for reviews of studies, including studies that failed to find a significant effect, see (Bailey et al., 2018)), lending credence towards the possibility that childhood and adolescence is a particularly sensitive time for the association between ACEs and PLEs (Croft et al., 2019). It has been hypothesized that the etiological underpinning of the association between ACEs and PLEs may be attributable to trauma leading to impairment in HPA axis functioning, which in turn leads to PLEs (Aas et al., 2019). According to this model, prolonged elevated cortisol levels resulting from ACEs leads to dysfunction in the HPA axis, which in turn can cause long-term increases in glucocorticoids, which may increase dopamine release (consistent with the dopamine hypothesis of schizophrenia (Howes and Kapur, 2009)). Such a consistent increase in glucocorticoids and dopamine could result in the cognitive impairments and symptoms associated with schizophrenia spectrum disorders (Ruby et al., 2014).

These results are also consistent with the idea that PLEs are associated with several specific types of trauma, notably bullying, financial adversity, witnessing domestic violence, and traumatic grief. Associations with bullying are consistent with several previous studies, possibly due to bullying leading to distorted cognitions (i.e., mild delusional ideation or unusual beliefs) and increased suspiciousness (Jack and Egan, 2018). Other possibilities include that social deficits associated with PLEs make children more susceptible to bullying (Strauss et al., 2018) or perhaps that suspiciousness may lead to interpreting other children’s behavior as bullying. The association with financial adversity supports several lines of research implicating a relationship between financial stress and lower socioeconomic status with PLEs (Mansueto and Faravelli, 2017), perhaps as a result of chronic stress (Burns et al., 2014). The current results also support at least one previous study finding an association between PLEs and bereavement (Mansueto and Faravelli, 2017). Furthermore, the association with witnessing domestic violence is consistent with the hypothesis that being the indirect target of abuse can also be associated with PLEs. A key question is how this more indirect type of stress relates to PLEs. One speculative hypothesis is that this more indirect form of ACE lends itself to the development of PLEs at least in part as due to general elevations in stress and/or appraisals that the child might make even when they are not direct target of the abuse. For example, the child might develop increased suspiciousness as a result of feeling increased anxiety in the home or may view the home as unsafe as a result of witnessing domestic violence (Kelleher et al., 2015).

There was also some evidence that particular types of PLEs were specifically associated with ACEs. Consistent with previous research (Kline et al., 2016), an item relating to suspiciousness was associated with ACEs even when using all PQ-BC items as predictors, congruent with the idea that exposure to ACEs may lead to greater mistrust for others and suspiciousness (Fisher et al., 2013). This relationship is also consistent with the possibility that elevated levels of suspiciousness following exposure to ACEs may reflect hypervigilance or wariness on the part of the victim. In contrast, it is also possible that the experience of hypervigilance may have in part lead to the development of PLEs. Furthermore, the current study also replicated an association between ACEs and grandiosity (Kline et al., 2016), consistent with the speculative hypothesis that experiences of trauma may result in children developing distorted cognitions regarding ‘special abilities’ as a coping mechanism. Lastly, the results also indicate, consistent with previous work, that perceptual abnormalities are associated with ACEs (Bailey et al., 2018). It should be noted that the aforementioned possibilities all rely on the premise that the experience of ACEs leads to the formation of PLEs, as the field is increasingly finding evidence for a causal association between the two constructs (Bendall et al., 2008). However, it is also possible that either: a) the two share an underlying common set of mechanisms, or b) the experience of PLEs leads to greater experience of ACEs, although there is notably less support for the latter idea.

Mediation analyses found evidence for PLEs mediating the association between ACEs and both internalizing symptoms and suicidality. One possible explanation for these interrelationships is that the experience of trauma leads to the development of distorted cognitive appraisals, which manifest as PLEs (Appiah-Kusi et al., 2017; Gaweda et al., 2019), and that these distorted appraisals in turn lead to other mental health consequences, including increased anxiety, depression, and suicidality. Few studies have examined the interrelationships between PLEs, ACEs, and shared correlates such as internalizing symptoms and suicidality (Gaweda et al., 2020; Williams et al., 2018). Recent work indicates that PLEs, as well as cognitive biases and depression, partially mediate the relationship between ACEs and suicidality in young adults (Gaweda et al., 2020). In school-age children, the current study found that PLEs mediated the relationship between ACEs and suicidal behavior. We also found evidence for PLEs partially mediating the association between ACEs and internalizing symptoms. Evidence that over 58% of the association between ACEs and suicidal behavior was mediated by PLEs indicates that reducing distressing PLEs may be a critical target in efforts to reduce suicidality already evident in this childhood population (current suicidality endorsed by 4.4% of this sample). Finally, we found evidence consistent with shared correlates (i.e., family history of psychosis, fluid cognition, and stress) mediating associations between ACEs and PLEs, consistent with previous work (Gibson et al., 2019; Williams et al., 2018).

The current study has a number of limitations. First, we do not have information regarding the timing of ACES and onset of PLEs to disentangle causal associations between these two constructs. Additionally, we assessed early PLEs in middle childhood; although a limited subset of participants endorsing PLEs will later develop schizophrenia spectrum diagnoses (Poulton et al., 2000), for a larger subset, PLEs will be a transient phenomena. Thus, future research should examine the degree to which more clinically relevant PLEs (e.g., sustained PLEs) are more strongly associated with ACE than transient PLEs. Longitudinal analyses will be required to examine these relationships. Another limitation is our measure of ACEs is based on parent report of the child’s experience of events, which is inherently limited by the parent’s knowledge of the event and willingness to report (Chan, 2012). This lack of knowledge or willingness to report may have contributed to low prevalence rates for several of the ACEs (e.g., 0.8% reporting their child has been beaten by a parent). The low prevalence rates of several of the ACEs, combined with evidence that PLEs were specifically associated with the most frequently endorsed ACE items, indicates that future research will need to assess the generalizability of the associations between PLEs and specific ACEs. In addition, we could not exactly replicate the traditional definition of ACEs (CDC and Permanente, 2016) due to lack of information about parental incarceration. Instead of using the traditional definition, we chose to focus on trauma as opposed to household challenges, such as divorce or parental incarceration. Future waves of ABCD data can examine the traditional definition of ACEs, as information regarding parental incarceration will become available when full year 1 data is released (see Supplement for results using a modified version of the traditional definition of ACEs, with results generally replicating). Furthermore, there is some conceptual overlap between questions of the PQ-BC inquiring about depersonalization experiences and severe dissociation associated with trauma, which may inflate the association between PLE and ACEs. However, the PQ-BC questions most strongly associated with ACEs did not assess depersonalization or derealization. In addition, a limitation of the current study is that self-report of PLEs in the ABCD study is not followed up with a clinical interview. Lastly, associations with other self-reports were in the small-moderate range (βs≤.15; although note for the association between bullying and PLE, β=.304), although findings are consistent with the existing literature (Croft et al., 2019; Fisher et al., 2013; Gaweda et al., 2020) and are generally expected in a non-help seeking childhood population without schizophrenia spectrum disorder diagnoses.

The current research makes an important contribution finding an association between ACEs and PLEs, demonstrating that this relationship exists above and beyond associations with shared correlates, consistent with previous work (Barzilay et al., 2019). Furthermore, this work points to some specificity in this relationship both on the part of ACEs and PLEs, with certain ACEs more strongly associated with PLEs, including bullying, financial adversity, witnessing domestic violence, and traumatic grief. Furthermore, in terms of PLEs, suspiciousness, grandiosity, and perceptual abnormalities may be more strongly associated with ACEs. Lastly, this work found evidence consistent with PLEs mediating associations between trauma and both internalizing symptoms and suicidality. This work has important implications regarding mechanisms underlying the development of negative psychological outcomes and implications for treatment pathways following trauma. The results of the current study suggest that subsequent to a client’s disclosure of trauma, clinicians should assess PLEs. Additionally, following client endorsement of PLEs, clinicians should consider using evidence-based assessments to determine the presence of trauma and, if found, trauma-focused interventions that address PLEs (Folk et al., 2019) as a tool for potentially reducing associated internalizing symptoms and suicidality following trauma.

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