Beyond Adversity Alone: Heterogeneity in Childhood Experiences and Implications for Mental and Behavioral Health

Abstract

Adverse childhood experiences (ACEs) are preventable, potentially traumatic experiences occurring before age 18 that are associated with a range of adverse health and behavioral outcomes across the life course. Much of the ACE literature has relied on cumulative scores that summarize the number of adversities experienced. Although useful for characterizing cumulative burden, this approach does not retain information about which adversities occur together, whether those patterns differ across populations, or how positive childhood experiences may alter the characterization and consequences of childhood adversity. This dissertation examines heterogeneity in childhood experiences using person-centered approaches, with particular attention to racial and ethnic variation, positive childhood experiences (PCEs), and adult mental and behavioral health. All three studies use pooled 2021-2023 data from the Behavioral Risk Factor Surveillance System. The first study examined whether latent patterns of nine ACEs were structured similarly across six racial and ethnic groups (n = 216,439). A three-class solution characterized by Low, Mixed, and High ACE exposure was broadly recognizable across groups; however, multigroup latent class analysis demonstrated that the class-defining probabilities were not fully invariant. Heterogeneity took two forms: differences in the overall level of endorsement within corresponding classes, and differences in the composition of adversity within them. Subsequent partial invariance analyses showed that between-group heterogeneity was concentrated more strongly in some ACE indicators than others, particularly witnessing violence between adults, and alcohol misuse, mental illness, depression, and suicide in the household, incarceration of a household member, parental separation or divorce, emotional abuse, and physical abuse. These findings demonstrate that similar class labels can conceal meaningful differences in the level and configuration of adversity across populations. The second study focused on non-Hispanic Black adults (n = 18,478) and examined whether ACE configurations differed by sex and whether PCEs modified associations between ACE patterns and adult mental and behavioral health. Different latent class structures emerged for female and male respondents: three classes among female respondents and four among male respondents, including a male-specific separation of mixed adversity into maltreatment- and household-environment-focused patterns. Compared with the Low ACE class, higher-adversity classes were associated with elevated odds of depression, frequent mental distress, current smoking, binge drinking, and heavy drinking, with the strongest and most consistent associations observed for depression. Among male respondents, the maltreatment- and household-environment-focused mixed classes showed comparable associations with depression and frequent mental distress. Evidence of PCE moderation was limited and outcome- and sex-specific: among female respondents only, reporting both PCEs attenuated the association between high adversity and depression. These findings provide further evidence that childhood adversity may be patterned differently within populations often treated as homogeneous, and that commonly measured protective experiences may capture only part of the protective context relevant to this population. The third study examined what changes when PCEs are incorporated alongside ACEs rather than considering adversity alone (n = 220,237). Comparing ACE-only and joint ACE–PCE latent class frameworks demonstrated both substantial correspondence (weighted κ = 0.84) and meaningful differences in class assignment. One in seven respondents was assigned to a different class once PCEs were incorporated. Reclassification was directionally associated with adult depression: reclassification toward higher-adversity and lower-PCE profiles was associated with greater odds of depression, whereas reclassification toward lower-adversity and higher PCE profiles was associated with lower odds. These associations strengthened with increasing classification certainty, suggesting that reclassification reflected substantive differences in childhood experience rather than boundary uncertainty alone. These findings suggest that PCEs may contribute information about childhood experience that is not fully captured by adversity-based classification alone. Together, this dissertation demonstrates that childhood adversity is not simply cumulative but configurational, population-dependent, and situated within broader relational and structural contexts. Advancing ACE research requires attention not only to how much adversity individuals experience, but also to what adversity consists of, how experiences cluster, for whom those configurations differ, and what becomes visible when protective childhood experiences are considered alongside adversity. These findings support approaches to childhood adversity research and prevention that preserve heterogeneity rather than assuming that common scores or class labels represent equivalent childhood experiences across populations. What becomes visible depends, in part, on whom we aggregate and what experiences we allow our models to see.