EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 2023, VOL. 14, NO. 2, 2222614 https://doi.org/10.1080/20008066.2023.2222614 BASIC RESEARCH ARTICLE Empirically-derived dimensions of childhood adversity and cumulative risk: associations with measures of depression, anxiety, and psychosis-spectrum psychopathology a b c a,d Alena Gizdic #, Tamara Sheinbaum #, Thomas R. Kwapil and Neus Barrantes-Vidal a Departament de Psicología Clinicá i de la Salut, Universitat Autònoma de Barcelona, Barcelona, Spain; bDirección de Investigaciones Epidemiológicas y Psicosociales, Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Mexico City, Mexico; cDepartment of Psychology, University of Illinois at Urbana-Champaign, Champaign, IL, USA; dCentro de Investigación Biomédica en Red de Salud Mental, Instituto de Salud Carlos III, Barcelona, Spain ABSTRACT ARTICLE HISTORY Background: Investigating different approaches to operationalizing childhood adversity and Received 10 November 2022 how they relate to transdiagnostic psychopathology is relevant to advance research on Revised 30 April 2023 mechanistic processes and to inform intervention efforts. To our knowledge, previous Accepted 25 May 2023 studies have not used questionnaire and interview measures of childhood adversity to KEYWORDS examine factor-analytic and cumulative-risk approaches in a complementary manner. Childhood adversity; Objective: The first aim of this study was to identify the dimensions underlying multiple childhood trauma; subscales from three well-established childhood adversity measures (the Childhood Trauma psychopathology; Questionnaire, the Childhood Experience of Care and Abuse Interview, and the Interview for dimensional models; Traumatic Events in Childhood) and to create a cumulative risk index based on the resulting cumulative risk; schizotypy; dimensions. The second aim of the study was to examine the childhood adversity psychosis; depression; dimensions and the cumulative risk index as predictors of measures of depression, anxiety, anxiety and psychosis-spectrum psychopathology. PALABRAS CLAVE Method: Participants were 214 nonclinically ascertained young adults who were administered Adversidad infantil; trauma questionnaire and interview measures of depression, anxiety, psychosis-spectrum phenomena, infantil; psicopatología; and childhood adversity. modelos dimensionales; Results: Four childhood adversity dimensions were identified that captured experiences in the riesgo acumulativo; domains of Intrafamilial Adversity, Deprivation, Threat, and Sexual Abuse. As hypothesized, the esquizotipia; psicosis; adversity dimensions demonstrated some specificity in their associations with depresión; ansiedad psychopathology symptoms. Deprivation was uniquely associated with the negative symptom dimension of psychosis (negative schizotypy and schizoid symptoms), Intrafamilial 关键词 童年不良经历; 童年创伤; Adversity with schizotypal symptoms, and Threat with depression, anxiety, and psychosis- 心理病理学; 维度模型; 累 spectrum symptoms. No associations were found with the Sexual Abuse dimension. Finally, 积风险; 分裂型; 精神病; 抑 the cumulative risk index was associated with all the outcome measures. 郁; 焦虑 Conclusions: The findings support the use of both the empirically-derived adversity dimensions and the cumulative risk index and suggest that these approaches may facilitate HIGHLIGHTS different research objectives. This study contributes to our understanding of the complexity • We investigated how of childhood adversity and its links to different expressions of psychopathology. different approaches to operationalizing childhood adversity relate to Dimensiones derivadas empíricamente de la adversidad infantil y el transdiagnostic riesgo acumulativo: Asociación con medidas de psicopatología de psychopathology. • Four childhood adversity depresión, ansiedad y del espectro psicótico. dimensions were found to underlie multiple subscales Antecedentes: La investigación de los distintos abordajes para operacionalizar la adversidad from three well- infantil y cómo se relacionan con la psicopatología transdiagnóstica es relevante para avanzar established childhood en la investigación sobre los procesos mecanicistas y para informar los esfuerzos de adversity measures. intervención. Hasta donde sabemos, los estudios previos no han utilizado cuestionarios ni • The childhood adversity medidas de entrevistas de la adversidad infantil para examinar los enfoques analítico dimensions demonstrated factorial y de riesgo acumulativo de manera complementaria. some specificity in their Objetivo: El primer objetivo de este estudio fue identificar las dimensiones subyacentes a associations with the múltiples subescalas de tres medidas de adversidad infantil bien establecidas (el psychopathology Cuestionario de Trauma Infantil, la Entrevista de Experiencias de Cuidado y Abuso en la symptom domains and the cumulative risk index was infancia y la Entrevista de Eventos Traumáticos en la Infancia) y crear un índice de riesgo associated with all the acumulativo basado en las dimensiones resultantes. El segundo objetivo de este estudio outcomes. fue examinar las dimensiones de adversidad infantil y el índice de riesgo acumulativo CONTACT Neus Barrantes-Vidal neus.barrantes@uab.cat ́ Departament de Psicología Clinica i de la Salut, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallés, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Salud Mental, Instituto de Salud Carlos III. # These authors contributed equally and are joint first authors. Supplemental data for this article can be accessed online at https://doi.org/10.1080/20008066.2023.2222614. © 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent. 2 A. GIZDIC ET AL. como predictores de medidas de psicopatología de depresión, ansiedad y del espectro psicótico. Método: Los participantes fueron 214 adultos jóvenes evaluados no clínicamente a quienes se les administraron cuestionarios y medidas de entrevista de depresión, ansiedad, fenómenos del espectro psicótico y adversidad infantil. Resultados: Se identificaron cuatro dimensiones de adversidad infantil que capturaron experiencias en los dominios Adversidad Intrafamiliar, Deprivación, Amenaza, y Abuso Sexual. Como hipotetizamos, las dimensiones de adversidad demostraron alguna especificidad en sus asociaciones con síntomas psicopatológicos. La deprivación se asoció únicamente con la dimensión de síntomas negativos de psicosis (síntomas esquizotípicos negativos y esquizoides), la Adversidad Intrafamiliar con síntomas esquizotípicos y la Amenaza con síntomas de depresión, ansiedad y del espectro psicótico. No se encontraron asociaciones con la dimensión Abuso Sexual. Finalmente, el índice de riesgo acumulativo se asoció con todas las medidas de resultado. Conclusiones: Los hallazgos apoyan tanto el uso de las dimensiones de adversidad derivadas empíricamente como del índice de riesgo acumulativo y sugieren que estos abordajes pueden facilitar objetivos de investigación diferentes. Este estudio contribuye a nuestra comprensión de la complejidad de la adversidad infantil y su nexo con diferentes expresiones de psicopatología. 童年不良经历和累积风险的经验衍生维度：与抑郁、焦虑和精神病谱心理 病理学测量的关联 背景：考查处理童年不良经历的不同方法以及它们与跨诊断心理病理学的关系与推进机制 过程研究和启发干预工作相关。据我们所知，以前的研究没有使用童年不良经历的问卷调 查和访谈测量这样互补的方式来考查因素分析和累积风险方法。 目的：本研究第一个目的是从三个成熟的童年不良经历测量（童年创伤问卷、童年照顾和 虐待经历访谈以及童年创伤事件访谈）确定多个分量表的维度，并确定根据结果维度创建 一个累积风险指数。本研究第二个目的是考查童年不良经历维度和累积风险指数作为抑 郁、焦虑症和精神病谱心理病理学测量的预测因素。 方法：参与者是 214 名非临床确定的年轻人，他们接受了抑郁、焦虑、精神病谱系现象和 童年不良经历的问卷调查和访谈测量。 结果：确定了捕捉了家庭内不良经历、剥夺、威胁和性虐待等领域经历的四个童年不良经 历维度。 正如假设一样，不良经历维度在与心理病理学症状的关联中表现出一些特异性。 剥夺与精神病阴性症状维度（阴性分裂型和分裂样症状）、家庭内不良经历与分裂型症 状、威胁与抑郁、焦虑和精神病谱系症状具有独特关联。未发现与性虐待维度的关联。最 后，累积风险指数与所有结果指标相关联。 结论：研究结果支持使用实证得到的不良经历维度和累积风险指数，并表明这些方法可能 有助于实现不同的研究目标。本研究有助于我们理解童年不良经历的复杂性及其与心理病 理学不同表现形式的联系。 1. Introduction Smith & Pollak, 2021), which has implications for advan- The term childhood adversity refers to a range of nega- cing research on mechanistic processes and the design of tive early-life experiences that constitute deviations intervention efforts (Danese & Lewis, 2022; Lacey & Min- from the expectable environment and are likely to nis, 2020). For example, specificity models (i.e. focusing require considerable adaptation by a child (McLaugh- on the effects of individual adversity subtypes, such as sex- lin, 2016). These experiences include childhood abuse ual abuse) have received considerable theoretical atten- and neglect, bullying, witnessing domestic violence, tion and have been widely investigated. However, the losses, and non-interpersonal experiences, such as acci- evidence of the substantial co-occurrence of different dents and natural disasters (Bifulco & Thomas, 2012; adversity subtypes (and the resulting potential overesti- Butchart et al., 2006). Childhood adversity has been mation of the effects of individual subtypes in such increasingly recognized as a leading risk factor for the models) has highlighted the need for complementary development of multiple psychopathological conditions approaches (Cecil et al., 2017; McLaughlin et al., 2021). and subclinical manifestations, including depression, Currently, the most common approach to measur- anxiety, and psychosis spectrum phenotypes (Copeland ing the effects of childhood adversity is the cumulative et al., 2018; Humphreys et al., 2020; Varese et al., 2012). risk approach (Lacey & Minnis, 2020), which involves Despite the notable progress in the field of childhood calculating a cumulative score by summing the num- adversity over the last decades, researchers continue to ber of adversities an individual experienced. Thus, grapple with challenging conceptual and measurement cumulative risk is an additive model that focuses on issues (Lacey & Minnis, 2020). One such issue concerns the amount (not the kind) of adversities (Evans how best to study the effects of childhood adversity on et al., 2013; Sheridan & McLaughlin, 2020). This the risk for psychopathology (McLaughlin et al., 2021; approach offers several advantages, such as ease of EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 3 interpretation and benefits in terms of statistical outcomes (Hagan et al., 2016; O’Donnell et al., 2017). power (Ettekal et al., 2019; Evans et al., 2013). Further- Of note, studies using empirically-driven methods to more, a robust body of research demonstrates that operationalize adversity have tended to focus on experi- experiencing an increased number of childhood ences of abuse and neglect (Lacey & Minnis, 2020). There- adversities is associated with an increased risk for a fore, more work is needed that incorporates additional range of psychopathological outcomes (Chapman relevant experiences within the family (e.g. role reversal) et al., 2004; Evans et al., 2013; Stein et al., 2022). and other relational environments (e.g. peer bullying). Nevertheless, the cumulative risk approach has been Research has robustly linked childhood adversity considered insufficient to fully characterize the with dimensional and categorical measures of effects of childhood adverse experiences because, depression, anxiety, and psychosis-spectrum phenom- among other things, it does not consider the pattern- ena using various approaches, including cumulative ing of adversities and assumes that all adversities risk (Copeland et al., 2018; Kim et al., 2021; Longden impact development via similar mechanisms (Lacey et al., 2016; Morgan et al., 2020). Although variability & Minnis, 2020; McLaughlin & Sheridan, 2016). in the operationalization of adversity complicates com- Other approaches to operationalizing childhood paring results using other approaches, some notable adversity have focused on deriving dimensions of findings have emerged. For example, depression has adversity. Theory-driven dimensional models suggest been prominently linked with experiences in the that different adversity subtypes share common fea- domain of emotional maltreatment (Humphreys tures that are likely to influence developmental pro- et al., 2020; Mandelli et al., 2015). Meanwhile, in the cesses in similar ways (McLaughlin et al., 2021). In field of psychosis, the adversity-psychosis link is this regard, the Dimensional Model of Adversity and especially robust for the positive symptom dimension Psychopathology (McLaughlin & Sheridan, 2016) is (Gibson et al., 2016; Velikonja et al., 2015), and experi- an influential framework that proposes that childhood ences characterized by an ‘intention to harm’ appear to adversities can be conceptualized along two dimen- be of particular relevance (Arseneault et al., 2011; Mor- sions that have distinct pathways to psychopathology. gan et al., 2020; van Nierop et al., 2014). Even though These dimensions are threat (involving harm or threat the negative dimension of psychosis has received less of harm, e.g. abuse) and deprivation (involving lack of attention (Gibson et al., 2016), evidence indicates stron- expected environmental inputs, e.g. neglect). ger or more consistent associations with neglect than Although empirical support for this approach has with other adverse experiences (Alameda et al., 2021; begun to accumulate (e.g. Miller et al., 2018; Schäfer Bailey et al., 2018; Cristóbal-Narváez et al., 2016). et al., 2023), one limitation is that some adversity sub- Several previous studies in the field have been lim- types do not clearly map onto these dimensions or ited by covering a narrow range of experiences and may include aspects of both (Smith & Pollak, 2021). using checklist measures of adversity. Hence, using On the other hand, researchers have also obtained comprehensive questionnaire and interview measures dimensions using empirically-driven methods, such as should allow for greater precision of models linking factor-analytic approaches, which group childhood childhood adversity and psychopathology (Bifulco & adversities based on the extent to which they are corre- Schimmenti, 2019). Furthermore, research using differ- lated with each other. Factor scores have gained attention ent approaches in a complementary manner may offer in the assessment of several constructs, such as externaliz- useful insights regarding the operationalization of ing and internalizing disorders (Caspi et al., 2014) and, to childhood adversity. For example, in a recent study, a lesser extent, childhood adversity (Brumley et al., 2019). McGinnis et al. (2022) found that different theory-dri- Factor-analytic approaches allow for examining the ven dimensions of adversity and a cumulative measure impact of the specific patterning of childhood adversity (constructed from these dimensions plus an additional subtypes (Lacey & Minnis, 2020) and have benefits for adversity scale) were associated with long-term psychia- improving measurement parsimony (Mersky et al., tric and functional outcomes. They concluded that their 2017). Overall, the empirical literature in this domain is results supported using the cumulative measure for somewhat inconsistent, likely related to differences in estimating relative risk for these outcomes and the the childhood adversity subtypes included across studies adversity dimensions for obtaining mechanistic (Lian et al., 2022; Mersky et al., 2017). Other empiri- insights. Thus, using theoretically – or empirically- cally-driven methods include person-centered derived dimensions of adversity to build a cumulative approaches, such as latent class analysis, which identifies risk index may provide a valuable integration and con- subgroups of individuals with similar patterns of adversi- tribute to the refinement of cumulative models. ties. Although studies vary in the number and compo- sition of classes, several have identified low adversity 1.1. The present study and poly-victimization classes (Debowska et al., 2017; McLafferty et al., 2021) and differential associations Leveraging interview and self-report assessments of a between some adversity classes and mental health range of childhood adversities, the present study used 4 A. GIZDIC ET AL. factor-analytic and cumulative risk approaches in a outcomes in the sample. At time 2 (T2), 214 partici- complementary manner to investigate associations of pants (mean age = 21.4; SD = 2.4; 78% female) com- childhood adversity with transdiagnostic psychopathol- pleted the interview study. Of the participants, 123 ogy assessed in a non-clinically ascertained sample of had elevated scores in one or more of the measures young adults. Specifically, the first aim of the study was of schizotypy and psychotic-like experiences, and 91 to use principal components analysis (PCA) to identify had standard scores < 1.0. The mean time interval the dimensions underlying multiple subscales from between T1 and T2 was 1.7 years (SD = 0.2; range = three well-established childhood adversity measures 1.4–2.2 years). The university ethics committee and to create a cumulative risk index based on the result- approved the study and participants provided ing dimensions. As part of this aim, we sought to exam- informed consent at both assessments. ine whether the PCA-derived childhood adversity dimensions were consistent with those proposed by the 2.2. Measures Dimensional Model of Adversity and Psychopathology, in which experiences of threat and deprivation are distin- Clinical psychologists and trained advanced graduate guished. The second aim of the study was to examine the students in clinical psychology administered the PCA-derived childhood adversity dimensions and the measures described below, along with other measures cumulative risk index as predictors of depression, not used in the present study. anxiety, and psychosis-spectrum symptom dimensions, assessed via questionnaire and interview measures. 2.2.1. Childhood adversity measures PCA is an exploratory approach, and we did not At T1, participants completed the Childhood Trauma make specific hypotheses regarding the number and Questionnaire-Short Form (CTQ-SF; Bernstein & nature of the PCA-derived dimensions. However, we Fink, 1998), a self-report measure that assesses sexual expected that the resulting dimensions would show abuse, physical abuse, emotional abuse, emotional at least some degree of specificity in their associations neglect, and physical neglect. CTQ items are answered with psychopathology symptoms. To provide a robust on a 5-point Likert-type scale ranging from ‘never test of this hypothesis and consistent with current rec- true’ to ‘very often true’ and are summed to obtain a ommendations (Cecil et al., 2017; Sheridan & score for each subtype of maltreatment. McLaughlin, 2020), the childhood adversity dimen- At T2, participants were administered two inter- sions were examined simultaneously to determine view measures, the Childhood Experience of Care their unique effects. Finally, we expected that higher and Abuse (CECA; Bifulco et al., 1994) and the Inter- cumulative adversity would be associated with higher view for Traumatic Events in Childhood (ITEC; Lob- levels of symptoms. bestael et al., 2009; Lobbestael & Arntz, 2010). The CECA is a semi-structured, investigator-based inter- view that focuses on objective aspects of childhood 2. Methods experiences. The following CECA scales were used: Parental antipathy, role reversal, parental discord, vio- 2.1. Participants and procedure lence between parents, and bullying. The scales are The present study is part of the Barcelona Longitudi- rated on a 4-point scale ranging from ‘marked’ to ‘lit- nal Investigation of Schizotypy Study (BLISS; Bar- tle/none,’ based on specific rating rules and bench- rantes-Vidal et al., 2013a, 2013b). Participants were mark thresholds. When applicable, overall scale students from the Universitat Autonòma de Barcelona ratings were obtained (i.e. peak rating taking into who completed a battery of self-report and interview account behaviour from both mother and father measures. Specifically, at time 1 (T1), 589 undergradu- figure; see Sheinbaum et al., 2015). CECA scores ates completed self-report questionnaires as part of were reversed such that higher scores indicate greater mass-screening sessions. Usable screening data was severity. The ITEC is a semi-structured interview that obtained from 547 participants (42 were excluded assesses sexual abuse, physical abuse, emotional abuse, due to the invalid protocols). The mean age was 20.6 emotional neglect, and physical neglect. Every years (SD = 4.1) and 83% were women. A subset of endorsed ITEC item is followed by questions covering 339 participants was invited to take part in an inter- different parameters of the experience, including the view study with the goal of assessing 200 individuals. age of onset, perpetrator(s), duration, and frequency. Those invited included all 189 who had standard These parameters are rated according to predefined scores based upon sample norms of at least 1.0 on answer categories and are used to calculate composite one or more measures of schizotypy and psychotic severity scores for each maltreatment subtype. like experiences, and 150 randomly selected partici- pants who had standard scores < 1.0 on these 2.2.2 Psychopathology measures measures. This enrichment procedure was done to At T1, participants completed the depression and increase the variance associated with mental health anxiety subscales of the Symptom Checklist- 90- EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 5 Revised (SCL-90-R; Derogatis, 1977), the suspicious- examine their unique contribution. In the regression ness subscale of the Schizotypal Personality Question- analyses examining the cumulative risk approach, the naire (SPQ; Raine, 1991), and the Wisconsin cumulative risk index was entered as the sole predictor. Schizotypy Scales (WSS). The WSS are composed of The cumulative index was calculated by summing the the Perceptual Aberration Scale (Chapman et al., dichotomized factor scores (dichotomized as ‘present = 1978), the Magical Ideation Scale (Eckblad & Chapman, 1’ or ‘absent = 0’ at the 75th percentile; see Evans et al., 1983), the Revised Social Anhedonia Scale (Eckblad 2013). Bootstrap procedures with 2,000 samples were et al., 1982), and the Physical Anhedonia Scale (Chap- used for the regression models. man et al., 1976). The WSS reliably yield two factors, positive and negative schizotypy, that account for 80% of their variance. Participants were assigned posi- 4. Results tive and negative schizotypy dimensional scores based Descriptive statistics for all study variables are displayed upon norms from 6,137 American young adults (Kwa- in Table 1. The intercorrelations of the childhood adver- pil et al., 2007). Note that the factor structure under- sity subscales are reported in the Supplemental Material. lying the WSS was found to be invariant across Spanish and American samples (Kwapil et al., 2012). At T2, we used the Structured Clinical Interview for 4.1. PCA of childhood adversity subscales DSM–IV Axis II Disorders (SCID–II; First et al., 1997) The parallel analysis indicated that a four-factor sol- to assess schizophrenia-spectrum personality disorders. ution best accounted for the data. The Kaiser- Dimensional scores were computed by summing indi- Meyer-Olkin measure verified the sampling adequacy vidual item ratings for each personality disorder. for the PCA (KMO = .77) and Bartlett´s test of spheri- Depression was assessed via interview with the Calgary city was significant (χ2 (105) = 1270.22, p < .001). The Depression Scale for Schizophrenia (CDSS; Addington PCA yielded five components with Eigen values et al., 1992) and via questionnaire with the Beck greater than 1. However, following the parallel analy- Depression Inventory-II (BDI; Beck et al., 1996). All sis, we retained the first four factors. of the measures are widely used and demonstrate good psychometric properties in young adult samples. Table 1. Descriptive statistics for the childhood adversity subscales and the psychopathology measures. 3. Statistical analysis Observed Possible Measure Mean SD Range Range We first calculated descriptive statistics for the study Adversity subscales variables and Pearson correlations among the child- CTQ Emotional abuse 7.07 3.19 5–22 5–25 CTQ Physical abuse 5.42 1.35 5–17 5–25 hood adversity subscales. To obtain the childhood CTQ Sexual abuse 5.39 1.87 5–25 5–25 adversity dimensions, we performed a PCA with an CTQ Emotional neglect 9.27 3.43 5–21 5–25 CTQ Physical neglect 5.91 1.52 5–14 5–25 oblique (Promax) rotation, given that dimensions of ITEC Emotional abuse* 3.96 4.50 0–22.58 NA childhood adversity are not expected to be indepen- ITEC Physical abuse* 0.93 2.59 0–25.46 NA ITEC Sexual abuse* 0.17 0.94 0–9.52 NA dent. A parallel analysis was conducted to determine ITEC Emotional neglect* 1.51 2.97 0–15.20 NA the optimal number of factors to retain in the PCA ITEC Physical neglect* 1.59 3.22 0–21.40 NA CECA Bullying 1.61 0.92 1–4 1–4 (Lim & Jahng, 2019). Factors were retained if their CECA Parental discord 1.70 1.00 1–4 1–4 associated eigenvalue was larger than the 95th percen- CECA Violence between 1.13 0.48 1–4 1–4 parents tile of the corresponding eigenvalues derived from the CECA Antipathy 1.57 0.91 1–4 1–4 random dataset (Ledesma & Valero-Mora, 2007). In CECA Role reversal 1.59 0.87 1–4 1–4 addition, following guidelines by Hair et al. (2014), Psychopathology measures the cut-off used for interpreting factor loadings from Positive schizotypy* 0.31 1.18 –1.28–5.13 NA the PCA was .40. When the childhood adversity sub- Negative schizotypy* 0.21 1.22 –1.63–5.18 NA Suspiciousness 2.97 2.05 0–8 0–8 scales loaded above .40 on more than one factor, Paranoid symptoms 1.53 2.08 0–12 0–14 they were interpreted as belonging to the factor on Schizoid symptoms 0.90 1.54 0–8 0–14 Schizotypal symptoms 1.00 1.93 0–13 0–18 which they had the highest loading. SCL-90-R Anxiety 6.99 5.64 0–29 0–40 Linear regression analyses were computed to compare SCL-90-R Depression 12.33 8.23 0–43 0–52 CDSS Depression 1.21 2.07 0–13 0–27 the PCA-derived childhood adversity factor scores and BDI Depression 5.33 5.33 0–29 0–63 the cumulative risk index as predictors of ten question- Note1: CTQ= Childhood Trauma Questionnaire; ITEC= Interview for Trau- naire and interview measures of depression, anxiety, matic Events in Childhood; CECA= Childhood Experience of Care and Abuse; SCL-90-R=Symptom Checklist-90-Revised; CDSS= Calgary and psychosis-spectrum psychopathology. Note that Depression Scale for Schizophrenia; BDI=Beck Depression Inventory-II. the factor scores and cumulative index were examined SD=Standard Deviation; NA: Not applicable. in separate regression models. In the regression analyses Note2: *Total range of ITEC severity scores are calculated for each individ- ual based on a formula that includes parameters such as the age of examining the dimensions as predictors, the childhood onset, proximity to the perpetrator, and duration; The WSS dimensional adversity factor scores were entered simultaneously to scores are standardized scores with a mean of zero and SD of 1. 6 A. GIZDIC ET AL. Table 2 presents the factor loadings of the rotated 4.2. Associations of the childhood adversity four-factor solution. The four factors explained 63% dimensions and the cumulative risk index with of the total variance and their intercorrelations ranged psychopathology from -.04 to .49. Factor 1 accounted for 32.3% of the Table 3 shows the results of the linear regression ana- variance and was related to subscales indexing Intrafa- lyses examining the PCA-derived childhood adver- milial Adversity, including CECA parental discord, sity dimensions and the cumulative risk index as CECA role reversal, CECA violence between parents, predictors of the questionnaire and interview CECA antipathy, and ITEC emotional neglect. Factor measures of depression, anxiety, and psychosis-spec- 2 explained 12.4% of the variance and was mostly trum psychopathology (the bivariate correlations related to subscales indexing Deprivation, including between the adversity dimensions and outcomes are ITEC physical neglect and CTQ physical and presented in Supplemental Table 2). The results of emotional neglect. Factor 3 accounted for 10.1% of the regression analyses using the childhood adversity the variance and was related to adversities indexing factor scores as predictors showed that Intrafamilial Threat, including CECA bullying by peers, ITEC Adversity was significantly associated with schizoty- emotional and physical abuse, and CTQ emotional pal symptoms, Deprivation with negative schizotypy and physical abuse. Finally, Factor 4 accounted for and schizoid symptoms, and Threat with all the out- 8.1% of the variance and was mostly related to experi- come measures except for schizoid symptoms and ences of Sexual Abuse, including ITEC and CTQ sex- CDSS depression. Sexual Abuse was not associated ual abuse. Although the highest factor loading per with these outcomes. The results of the regression subscale was used to interpret the factors, the follow- analyses using the cumulative risk index as a predic- ing subscales had secondary loadings on an additional tor showed that cumulative risk was significantly factor: ITEC emotional abuse on Factor 1, CECA vio- associated with all the outcome measures. The lence between parents on Factor 4, and CTQ models using the adversity dimensions explained emotional abuse, CTQ physical abuse, and ITEC between 8.5% and 25.3% of the variance in the psy- emotional neglect on Factor 2. chopathology symptoms, whereas those using the cumulative risk index explained between 5% and 17.3% of the variance. Table 2. Results of the principal components analysis with As seen in Table 3, the total effects tended to be lar- promax rotation. ger for the adversity dimensions model (average effect Adversity subscales Factor scores size across the ten analyses of .18 [medium effect]) 1 Intrafamilial 2 3 4 Sexual compared to the cumulative approach (average effect Adversity Deprivation Threat Abuse size of .12 [small effect]). All of the individual betas CECA Parental .875 −.119 −.011 .073 discord for the Intrafamilial Adversity, Deprivation, and Sex- CECA Role .771 .082 −.048 −.029 ual Abuse dimensions were small effects. However, reversal CECA Violence .524 −.087 −.218 .458 the effects sizes tended to be larger for the Threat between dimension, especially for outcomes such as schizotypal parentsa and paranoid personality disorder symptoms. The ITEC Emotional .513 .455 −.070 −.044 neglecta beta values in the regression analyses represent the CECA Antipathy .506 .047 .345 −.179 results for the residualized predictors after partialling CTQ Physical −.077 .860 −.218 −.016 neglect out variance from the other three adversity dimen- ITEC Physical .221 .727 −.131 .045 sions. Examination of the correlations in Supplemen- neglect CTQ Emotional −.051 .709 .158 .004 tal Table 2 indicates that bivariate associations of the neglect individual adversity dimensions tended to be on the CECA Bullying −.194 −.202 .859 .114 ITEC Emotional .461 −.125 .706 .002 order of small-medium effects for Intrafamilial Adver- abusea sity and Deprivation, and medium effects for the ITEC Physical .190 −.020 .578 −.086 Threat dimension. There were no significant corre- abuse CTQ Emotional −.048 .479 .517 .071 lations with the Sexual Abuse dimension (all the values abusea were below .1). CTQ Physical −.142 .421 .482 .064 abusea ITEC Sexual .015 −.012 .051 .904 abuse CTQ Sexual −.066 .081 .119 .875 5. Discussion abuse Percentage of 32.25% 12.40% 10.05% 8.07% This study aimed to (1) identify the dimensions Variance underlying multiple subscales from three well-estab- Eigenvalue 4.84 1.86 1.51 1.21 lished childhood adversity measures and (2) use Note1: Highest factor loadings for a given factor are bolded. Note2: aThis subscale has a loading of .40 or above on more than one these dimensions and a cumulative risk index factor. based on them as predictors of depression, anxiety, EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 7 Table 3. Linear regressions examining prediction of psychopathology measures by the childhood adversity dimensions and the cumulative risk index. Regression models Adversity dimensions Cumulative risk Intrafamilial Adversity Deprivation Threat Sexual abuse Total effect Risk index Total effect Criteria β f2 β f2 β f2 β f2 R2 f2 β R2 f2 Questionnaire Positive Schizotypy .094 .01 .150 .02 .169* .02 .095 .01 .116*** .13 .356*** .092*** .10 Negative Schizotypy −.113 .01 .215** .04 .216** .04 −.008 .00 .114*** .13 .316*** .067*** .07 Suspiciousness −.009 .00 .138 .02 .317*** .09 .031 .00 .160*** .19 .415*** .173*** .21 SCL-90 Anxiety .091 .01 .133 .01 .256*** .06 .045 .00 .153*** .18 .336*** .113*** .13 SCL-90 Depression .132 .02 .040 .00 .358*** .12 .093 .01 .205*** .26 .391*** .153*** .13 BDI Depression .130 .02 .009 .00 .263** .06 .018 .00 .115*** .13 .288*** .083*** .10 Interview Paranoid Symptoms .080 .01 .012 .00 .434*** .18 .010 .00 .226*** .29 .401*** .161*** .19 Schizoid Symptoms .028 .00 .152* .02 .180 .03 −.005 .00 .091*** .10 .225** .050*** .05 Schizotypal Symptoms .168* .03 .085 .01 .362** .13 .037 .00 .253*** .34 .373*** .139*** .16 CDSS Depression .151 .02 .028 .00 .181 .03 .006 .00 .085*** .09 .249** .062*** .07 p < .05, ** p < .01, *** p < .001. Note 1: Bootstrap procedures (with 2,000 samples) were employed. Note 2: SCL-90 = Symptom Checklist-90-Revised; CDSS = Calgary Depression Scale for Schizophrenia; BDI = Beck Depression Inventory-II Note 3: According to Cohen (1992), f2 values above .15 are medium effect sizes (in bold). and psychosis-spectrum psychopathology. To our abuse loaded separately from other forms of abuse knowledge, this is the first investigation to use ques- (Brown et al., 2013; Ford et al., 2014). Together, this tionnaire and interview measures of adversity to evidence appears to bolster the view that sexual examine factor-analytic and cumulative-risk abuse may be considered a distinct form of adversity approaches in a complementary manner. Our results (Cohen-Cline et al., 2019) – even distinct from those identified four meaningful childhood adversity that also share an element of threat. Alternatively, dimensions and showed that both approaches to the findings could be related to issues previously operationalizing adversity (i.e. empirically-derived reported to attenuate the association between sexual dimensions and cumulative risk) yielded significant and non-sexual maltreatment (i.e. the overall low associations with the measures of psychopathology. base rate of sexual abuse and that most cases are As hypothesized, the adversity dimensions demon- accompanied by other maltreatment subtypes; see strated some specificity in their associations with Vachon et al., 2015). Additional research across the psychopathology symptom domains. Further- diverse sample types may help clarify the nature of more, the cumulative risk index was associated this finding. with all the outcomes. Overall, the study contributes Another consideration concerning the threat- to current efforts to elucidate how different deprivation distinction is that CTQ physical and operationalization approaches can inform our emotional abuse cross-loaded onto the Deprivation understanding of the complexity of childhood dimension. This finding seems to be consistent adversity and its links to different expressions of with the common co-occurrence of experiences of psychopathology. abuse and neglect, which has been proposed to com- plicate distinguishing among these experiences in research using data-driven approaches (Sheridan 5.1. Childhood adversity dimensions et al., 2020). In this regard, the fact that CTQ, but Regarding the first aim of the study, the results ident- not ITEC, subscales cross-loaded onto Deprivation ified four childhood adversity dimensions that cap- may suggest that interview measures that assess tured experiences in the domains of Intrafamilial multiple features of maltreatment are better able Adversity, Deprivation, Threat, and Sexual Abuse. than self-reports to differentiate between the The finding that the dimensions distinguished domains of abuse and neglect. This possibility is in between experiences of threat and deprivation pro- line with several researchers’ contention that in- vides empirical support to the conceptual distinction depth interview measures that allow for probing proposed by the Dimensional Model of Adversity and clarification offer greater precision in their and Psychopathology. At the same time, however, assessment of environmental experience (Bifulco & the results did not fully align with the model, as not Schimmenti, 2019; Fisher et al., 2015; Lobbestael all of the proposed threat-related adversities clustered et al., 2009). together in our data. Most notably, the CTQ and ITEC We also found that Intrafamilial Adversity sexual abuse subscales formed a coherent separate explained the most variance in our data, indicating dimension. This resonates with the results of large fac- that the threat-deprivation model is insufficient to tor-analytic studies of adversity items in which sexual account for the variability in childhood adversity. 8 A. GIZDIC ET AL. Four CECA subscales and one ITEC subscale loaded with threat-related adversities (McLaughlin, 2016; primarily onto this dimension. While shared method McLaughlin et al., 2020). variance may have contributed to the clustering of In line with our expectations, the results with the CECA subscales, the finding that CECA bullying adversity dimensions demonstrated the presence of loaded exclusively onto Threat appears to strengthen specific effects. In particular, Deprivation showed a the interpretation that these negative environmental unique association with the negative dimension of experiences within the family environment represent psychosis across self-report and interview-based a distinct construct. That ITEC emotional neglect assessments. This parallels meta-analytic findings loaded primarily onto this dimension may reflect demonstrating associations between neglect and nega- that this subscale’s assessment of the failure to meet tive symptoms (Alameda et al., 2021; Bailey et al., a child’s emotional needs also taps into elements 2018) and extends such findings by showing an associ- associated with other poor parenting behaviors (e.g. ation over-and-above the variance accounted for by those related to role reversal). Although previous other adversity dimensions. Moreover, these results research has not assessed the same adversity subtypes support prior theorizing that the absence of expected included in our study, the emergence of this dimen- environmental inputs may shape the risk for deficit- sion is broadly consistent with earlier findings that like features, such as diminished emotional experience adversities related to household dysfunction tend to and social disinterest (Gallagher & Jones, 2013). form a separate factor (Ford et al., 2014; Mersky In addition, Intrafamilial Adversity was uniquely et al., 2017). associated with schizotypal PD symptoms. This is important considering that identifying environmental precursors to schizotypal PD can contribute to our etiological understanding of the schizophrenia spec- 5.2. Associations of childhood adversity with trum (Kwapil & Barrantes-Vidal, 2015). However, the psychopathology measures the symptom heterogeneity that characterizes schizo- Regarding the second aim of the study, we found that typal PD complicates the interpretation of this when the adversity dimensions were modelled finding – particularly because positive, negative, and together, they tended to explain more variance in the disorganized symptoms are thought to involve differ- outcomes than the cumulative risk index. This dove- ent developmental pathways (Barrantes-Vidal et al., tails with epidemiological research comparing latent 2015). Thus, future work considering the multidimen- maltreatment factors with a cumulative maltreatment sional nature of this construct may better elucidate its score (Brumley et al., 2019) and supports the utility of associations with childhood adversity. Finally, it is this empirical approach. Additionally, the analyses worth noting that the Sexual Abuse dimension was with the adversity dimensions showed that Threat not associated with our other adversity dimensions was a significant predictor of depression, anxiety, or our outcome measures both in the regression and and psychosis-spectrum psychopathology. Notably, bivariate analyses. While there is ample research within the psychosis symptom domains, Threat was demonstrating links between sexual trauma and psy- more consistently associated with phenotypes invol- chopathology (Noll, 2021), the evidence in nonclinical ving positive psychotic features, which is in keeping populations is less consistent (Vachon et al., 2015). with research pointing to the relevance of adversities However, some caution should be taken in interpret- characterized by an ‘intention to harm’ in conferring ing the results for the Sexual Abuse dimension. This risk for reality distortion (Arseneault et al., 2011; van is likely driven by the fact that a very small proportion Nierop et al., 2014). Our results pertaining to Threat of participants reported any sexually abusive experi- are also in agreement with a recent study that found ences (only about 10% did so on the CTQ, with the that a dimension of threat-related adversities was majority reporting the lowest rating for such experi- associated with anxiety and depressive disorders ences). This may in part reflect less willingness of par- (McGinnis et al., 2022). It is of note that we found ticipants to report sexual abuse relative to other forms Threat to be associated with self-reported depressive of abuse. Therefore, additional work is needed to symptoms across two time points using different examine these associations in vulnerable populations instruments, but not with interview-rated symptoms. with greater sexual abuse prevalence and severity. Although the reason for this discrepancy is unclear, The current study also found that the cumulative it may be partly due to a relatively low representation risk index was associated with all the symptoms – indi- of CDSS ratings in our sample, which had lower mean cating that an undifferentiated measure of adversity scores than those reported in a study that established provides broad (and undifferentiated) associations reference values in a healthy sample (Müller et al., with psychopathology outcomes. This converges 2005). On the whole, the results with the Threat with the literature showing that the accumulation of dimension are consistent with theoretical and empiri- adverse experiences is pivotal in conferring risk for cal accounts of the patterns of multifinality associated various psychopathological outcomes, including EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 9 depression, anxiety, and psychosis-spectrum phenom- would enhance generalizability. Finally, additional ena (Copeland et al., 2018; Evans et al., 2013; Kim studies are necessary to examine the extent to which et al., 2021; Morgan et al., 2020). Furthermore, the the findings apply to the clinical expression of these findings support the predictive value of focusing on phenotypes. the cumulative effect of empirically-derived adversity dimensions, which to our knowledge had not been previously examined. Thus, we believe that a risk 5.4. Conclusions and Future Directions score constructed from individual adversity dimen- In sum, this study investigated different approaches to sions offers a refinement of cumulative indices that operationalizing childhood adversity and their links to merits further investigation. transdiagnostic psychopathology. The use of compre- The results of this study suggest that both operatio- hensive adversity measures allowed us to obtain a fine- nalization approaches may offer complementary grained characterization of the environment that is information to the field. From a theoretical perspec- not typically afforded by epidemiological research tive, drawing on previous literature (e.g. Bentall and thus complements existing literature in the field. et al., 2014; Evans et al., 2013), it seems plausible Using longitudinal designs and investigating the mod- that the experiences comprising the childhood adver- erators of the links identified in the present study rep- sity dimensions could shape certain developmental resents an important avenue for future research. For processes in partially specific ways while also contri- example, some research has found sex differences in buting to a general vulnerability that cumulatively the exposure and effects of childhood adversities impacts the expression of psychopathology. From a (e.g. Haahr-Pedersen et al., 2020). Therefore, future research standpoint, we believe the results highlight work with sex-balanced samples may consider investi- a point that other scholars have made (Henry et al., gating sex as a moderating variable. Furthermore, 2021; McGinnis et al., 2022) – namely, that the optimal dimensional models have suggested some specificity operationalization approach may be goal-dependent. in the mechanisms linking different childhood adver- For instance, while the empirically-derived dimen- sity dimensions with psychopathology (McLaughlin sions may facilitate identifying potential specificity et al., 2021). In this regard, elucidating mediating and underlying mechanisms, the cumulative approach mechanisms and their specificity is a relevant next may help maximize adversity-outcome associations step that may help identify potential targets for inter- and facilitate investigating complex interactions with vention. Continued work in this area is crucial to other levels of explanation (e.g. genetic factors). advance our understanding of risk and resilience in the service of informing preventive intervention and 5.3. Strengths and limitations clinical practice for individuals who have experienced childhood adversity. A strength of the current study is the comprehensive assessment of childhood adversity and psychopathol- ogy conducted with both questionnaire and interview Acknowledgements measures. In particular, employing in-depth interview Authors contribution. Alena Gizdic: formal analyses, writ- measures of childhood adversity serves to minimize ing-original draft, review and editing, visualization; Tamara biases associated with subjective responding (Bifulco Sheinbaum: conceptualization and methodology, writing- & Schimmenti, 2019; Lobbestael et al., 2009). In original draft, review and editing, visualization, data cura- tion; Thomas R. Kwapil: conceptualization and method- addition, the focus on subclinical phenotypes is con- ology, statistical consultation, review and editing; Neus sidered to facilitate etiological research as participants Barrantes-Vidal: conceptualization and methodology, do not present with the critical confounding factors supervision, funding acquisition, resources, data curation, associated with clinical status, such as high comorbid- investigation, project administration, writing original ity, biographical disruption, stigma, medication side draft, review and editing. effects, etc. (e.g. Barrantes-Vidal et al., 2015). The limitations of the study include its cross-sec- Disclosure statement tional nature, which limits inferences about the causal effects of childhood adversities. In addition, our use of No potential conflict of interest was reported by the author(s). a predominantly female university student sample may restrict the generalizability of the findings. In Funding this regard, we note that a recent review found that college student samples tend to produce similar This work was supported by Ministerio de Ciencia e Inno- vación (PSI2017-87512-C2-1-R; PID2020-119211RB-I00) findings than non-student samples in the field of and Generalitat de Catalunya (Suport als Grups de Recerca trauma research (Boals et al., 2020). Nevertheless, 2021SGR01010). Neus Barrantes-Vidal is supported by the research in community samples with a more represen- ICREA Acadèmia Research Award (Institució Catalana de tative distribution of sociodemographic characteristics Recerca i Estudis Avançats) of the Catalan government; 10 A. GIZDIC ET AL. Alena Gizdic was supported by the Spanish Ministry of Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for Science and Innovation (grant number FPU18/04901 the Beck Depression Inventory-II. 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