标题：Relationship Among Adverse Childhood Experiences, History of Active Military Service, and Adult Outcomes: Homelessness, Mental Health, and Physical Health
摘要：Objectives. We determined whether a report of adverse childhood experiences predicts adult outcomes related to homelessness, mental health, and physical health and whether participation in active military service influences the relationship between childhood and adult adversity. Methods. Using data from the 2010 Washington State Behavioral Risk Factor Surveillance System, we tested by means of logistic regression the relationship between adverse childhood experiences and 3 adult outcomes—homelessness, mental health, and physical health—as well as differences among those with a history of active military service. Results. Adverse childhood experiences separately predicted increased odds of experiencing homelessness as an adult and mental health and physical health problems. Childhood adversity increased the likelihood of adult homelessness and poor physical health among individuals with no history of active military service and the likelihood of mental health problems among individuals with a history of active military service. Conclusions. The relationship between childhood adversity and adult adversity changes in degree when history of active military service is controlled, which has implications for Armed Forces recruitment strategies and postmilitary service risk assessment. Adult homelessness is a significant public health problem, with nearly 634 000 individuals (both children and adults) experiencing homelessness in the United States on a single night in January 2012. 1 Individuals reporting veteran status are overrepresented among the adult homeless population: approximately 13% (62 619) of adults experiencing homelessness identified as veterans during the January 2012 homeless point-in-time count, despite representing only an estimated 7.1% of the US population. 2 Other work has estimated that veterans’ risk of homelessness is twice that of nonveterans, underscoring possible differences in the experience of homelessness between veterans and nonveterans. 3 Preventing and ending homelessness among veterans—as well as among Americans generally—is a national priority. 4 Although recent efforts by the US Departments of Housing and Urban Development and Veterans Affairs (VA) appear to be reducing the overall size of the homeless population, 1,5 additional work is needed to understand the factors that contribute to episodes of homelessness. Adult homelessness often occurs in the context of other negative life events and problems. A variety of individual-level factors appear to contribute to, or are correlated with, homelessness, including disability, mental illness, substance abuse disorders, lack of social or human capital, a history of institutional involvement, and exogenous health and income shocks. 6–24 Adverse childhood experiences—including abuse, household dysfunction, and neglect—have been shown to predict a multitude of negative outcomes in adulthood, including mental illness, 25–29 addiction, 26–28,30,31 and chronic disease, 26,32–34 frequently in the context of population-representative samples. Meanwhile, the literature linking childhood adversity with adult homelessness has most frequently focused on individuals experiencing homelessness rather than the general population. Various types of specific childhood adversities have been associated with adult homelessness, such as parental substance abuse 35,36 and childhood abuse and neglect. 36–40 In addition, a number of studies have identified high rates of adverse childhood experiences among the homeless population. 20,41–47 The interest in understanding the shared and distinct contributors to homelessness and related problems among veterans compared with nonveterans is considerable, given the elevated rates of homelessness after military service. 3 Debates surround how active service might contribute to, or detract from, an individual’s likelihood of poor subsequent outcomes. For example, active service might involve additional stressors related to being removed from support networks (e.g., family and friends) in addition to possible combat exposure. Meanwhile, veteran status also makes available a range of services through the VA that are not provided to nonveterans, and military service may act as a turning point that benefits many individuals, especially those from at-risk backgrounds. 48 Although previous research has sought to identify specific risk factors for and pathways to homelessness among veterans, sources of risk do not appear to differ significantly for veterans and nonveterans, with the exception of military service during the post-Vietnam era. 49,50 Several studies looking specifically at the role that childhood adversity—or experiences before an individual entered or left active military service—plays in adult homelessness have included a veteran sample or veteran status as a variable in their models. 20,42,44,51–56 A number of these studies assessed the role of specific adversities, such as family instability, 56 but did not describe the impact of this experience on adult homelessness. A qualitative study linked childhood abuse and neglect 54 to individuals’ decisions to join the military in an effort to escape their family of origin, further linking child abuse and neglect to adult homelessness among this veteran sample. Past work testing links between adverse childhood experiences and adult homelessness is largely based on cross-sectional retrospective studies using exclusively homeless samples or samples of individuals who all reported some sort of childhood adversity. These approaches are limited in their ability to consider alternative pathways, such as individuals who experience high levels of childhood adversity but not homelessness or those who report low levels of adversity in childhood but go on to experience homelessness nonetheless. The complexity of the relationship between adverse childhood experiences and adult homelessness, along with the limitations of the methods used in the existing literature exploring this relationship, underscores the value of a population-based design that uses probability sampling. This design has only been used in 3 of 29 studies published between 1990 and 2012 that explored the relationship between adverse childhood experiences and homelessness 57–59 ; these studies used a limited measure of childhood adversity (i.e., out-of-home placement and living in poverty during first grade). Population-representative approaches allow researchers to test for links between childhood experiences and adult outcomes considering the full range of possible outcomes (e.g., among those who are homeless and nonhomeless) and characteristics (those with and without a history of active military service). Additional work is needed to determine the role that childhood adversity may play in poor adult outcomes for individuals with a history of active military service, as well as whether military service moderates the relationship between adverse childhood experiences and adult homelessness. Two divergent hypotheses exist: military service may mitigate risk by providing alternative socialization and discipline for otherwise at-risk youths or exacerbate risk by increasing exposure to trauma. In this study, we considered how experiences of childhood adversity contribute to adult homelessness and related health and mental health problems. We tested the relationship between adverse childhood experiences and outcomes measured in adulthood for the general population of adults in Washington State, then explored possible differences in the adversity-outcome relationship on the basis of individuals’ participation in active military service. By using data collected through the Washington State Behavioral Risk Factor Surveillance System (BRFSS), we addressed a significant limitation in the existing literature: BRFSS data are collected from a probability-based sample representative of the general population, as well as from subsamples of individuals with a history of active military service. In this study, we aimed to answer 2 questions: Does an individual’s report of adverse childhood experiences predict adult outcomes related to homelessness, mental health, and physical health? Does an individual’s participation in active military service influence the relationship between adverse childhood experiences and adult outcomes related to homelessness, mental health, and physical health?
