Pathways from Childhood Adversities to Substance Use Disorder Among Older Adults

Background and Purpose: Emerging research weighs childhood adversities as important predictors of health disparities in older adults. A life course perspective articulates that cumulative exposures to adverse experiences and economic hardships not only deteriorate mental and physical health throughout the life, but also elevate the use of licit and illicit substances. Limited studies examine how pathways for earlier adverse experiences are associated with substance use in late-life. The present study aims to examine whether depression and adulthood economic hardship are mediating pathways between multiple childhood adversities and risk for substance use disorder (SUD) in older adults.  

Methods: Data came from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)-III. We included study participants ages 55 and older (N=10,495). The dependent variable was DSM-5 SUD (1=lifetime alcohol, tobacco, or any illicit drug use disorder, 0=otherwise). The independent variables were (1) Adverse Childhood Experiences (ACEs) subgroups identified by 10 indicators (physical abuse, physical neglect, emotional abuse, emotional neglect, sexual abuse, family violence, living with a family member with substance use, incarceration, mental illness, or a suicidal attempt) and (2) childhood economic adversity (1=received government financial assistance, 0=no). The mediating variables were (1) depression (1=lifetime DSM5 major depressive disorder, 0=no) and (2) adulthood economic hardship (1=declared bankruptcy, experienced homelessness, or had enormous debt in the past 12 months, 0=none). We first identified classes of ACEs using latent class analysis (LCA) with the 10 ACEs indicators. After identifying ACEs subgroups, we conducted path analyses to examine (1) direct relationships from the ACEs subgroups and childhood economic adversity to SUD and (2) the mediating roles of depression and adult economic hardship in the relationships, controlling for individual characteristics.

Results: In the study sample, 35% met criteria for SUD and 18% major depression, 10.5% had adulthood economic hardship, and 7% experienced childhood economic adversity. The LCA evaluation using a variety of fit statistics identified four ACEs subgroups: no/low ACEs (70.7%; reference group), physical and emotional maltreatment (17.5%), family dysfunction (e.g., family violence, substance use, incarceration; 4.5%), and high/multiple ACEs in high family violence/dysfunction (7.3%). Results of the path analysis indicated significant associations in all paths from independent variables to SUD. Older adults with low levels of ACEs were less likely to have a SUD compared to the other three ACEs subgroups (β=.08, p< .001 for those with physical/emotional maltreatment; β=.09, p< .001 for those with high levels of ACEs; β=.05, p<.001 for those with family dysfunction). Childhood economic adversity also increased the risk of a SUD (β=.04, p< .001). These associations were significantly mediated through depression and adulthood economic hardship.       

Discussion and Implications: Our study supports that ACEs and childhood economic adversity directly increase risk of SUD in later life and that depression and economic hardship mediate these pathways. The findings suggest that social workers and health practitioners consider a history of exposures to earlier adverse experiences, consequences of lifetime depression, and adulthood economic hardship in interventions for older adults with SUD.