Adverse Childhood Experiences and Vulnerability to Mood and Anxiety Disorders During the COVID-19 Pandemic
Round 1
Reviewer 1 Report
This report is a study claiming to uniquely advance the literature on childhood adversities associated with mental health outcomes. What differentiates it from other studies is determining whether they interact synergistically with COVID-19-related stressors by including measures of depressive disorders. This claim is questionable based on this Google Scholar search of the topic of research published since 2020, producing “About 211,000 results”: https://scholar.google.ca/scholar?as_ylo=2020&q=Adverse+childhood+experience+and+vulnerability+to+mood+and+2+anxiety+disorders+during+the+COVID-19+pandemic&hl=en&as_sdt=0,5. The authors are asked to read the most relevant of these and explain how this research differs from them.
The research problem is well-specified, and the methods are sufficiently detailed for replicating the study. The weaknesses regard insufficient citations to research published since 2020.
There is more than one referencing style—none are the preferred style. Please redo the references in the required style: https://www.mdpi.com/journal/covid/instructions.
Line by line suggested edits
23 Please add “COVID-19; childhood adversities; stressors” as a Keywords.
26 Please find a supporting citation for 1 of research published since 2020.
30 Please find a supporting citation for 4,5 of research published since 2020.
34 Please find a supporting citation for 7-10 of research published since 2020.
35-36 Please cite research published since 2020 to support the claim of this sentence.
50 Please find a supporting citation for citation 25 of research published since 2020, and spell RERI in full in the text before using the acronym.
67 Please cite research published since 2020 for a Fay adjustment.
92 Change “because its unclear” to “because of its unclear”.
106 Please include a citation to research published since 2020 using the CEVQ
130 Please find a supporting citation for 29 of research published since 2020.
136 Please find a supporting citation for 30 of research published since 2020.
138-139 Please find a citation supporting the claim that this is the first version of Stata to support REFI estimation.
145 Please state the date of the analysis.
198-254 There is no current citation examined in this Discussion. Please find supporting citations for 33-36 of research published since 2020.
Author Response
General comment: The reviewer points out that many recent citations were missed in the original submission and extensive revisions have been made to address this in the revision. Please see the specific references added in the responses provided below. In addition to the new additions described below, the new references also include four recent studies that have examined effects of adversities on mental health. Only one of these examines an interaction and it did so using a symptom rating scale, which is not equivalent to the diagnosis used in this study. In my view, none of the new studies referenced lessen the originality of the current work. These are studies of childhood adversity that have been added:
Jernslett, M.; Anastassiou-Hadjicharalambous, X.; Lioupi, C.; Syros, I.; Kapatais, A.; Karamanoli, V.; Evgeniou, E.; Messas, K.; Palaiokosta, T.; Papathanasiou, E.; Lotzin, A. Disentangling the associations between past childhood adversity and psychopathology during the covid-19 pandemic: The mediating roles of specific pandemic stressors and coping strategies. Child Abuse Negl 2022, 129, 105673.
Lee, H.Y.; Kim, I.; Kim, J. Adolescents' mental health concerns in pre- and during covid-19: Roles of adverse childhood experiences and emotional resilience. Child Psychiatry Hum Dev 2024. Online ahead of print.
Verlenden, J.; Kaczkowski, W.; Li, J.; Hertz, M.; Anderson, K.N.; Bacon, S.; Dittus, P. Associations between adverse childhood experiences and pandemic-related stress and the impact on adolescent mental health during the covid-19 pandemic. J Child Adolesc Trauma 2022, 17, 1-15.
Alradhi, M.A.; Moore, J.; Patte, K.A.; O'Leary, D.D.; Wade, T.J. Adverse childhood experiences and covid-19 stress on changes in mental health among young adults. Int J Environ Res Public Health 2022, 19.
Comment: The format of the references was inconsistent and not aligned with the Journal’s requirements.
Response: The format of the references is now corrected.
Comment: Please add “COVID-19; childhood adversities; stressors” as a Keywords.
Response: These have been added, along with childhood maltreatment, this being the main set of adversities examined.
Comment: Please find a supporting citation for 1 of research published since 2020.
Response: 2 more recent citations have been added:
McKay, M.T.; Cannon, M.; Chambers, D.; Conroy, R.M.; Coughlan, H.; Dodd, P.; Healy, C.; O'Donnell, L.; Clarke, M.C. Childhood trauma and adult mental disorder: A systematic review and meta-analysis of longitudinal cohort studies. Acta Psychiatr Scand 2021, 143, 189-205
Negriff, S. Aces are not equal: Examining the relative impact of household dysfunction versus childhood maltreatment on mental health in adolescence. Soc Sci Med 2020, 245, 112696.
Comment: Please find a supporting citation for 4,5 of research published since 2020.
Response: 3 more recent citations have been added:
Ali, S.; Pasha, S.A.; Cox, A.; Youssef, E. Examining the short and long-term impacts of child sexual abuse: A review study. SN Social Sciences 2024, 4, 56.
Xiao, Z.; Murat Baldwin, M.; Wong, S.C.; Obsuth, I.; Meinck, F.; Murray, A.L. The impact of childhood psychological maltreatment on mental health outcomes in adulthood: A systematic review and meta-analysis. Trauma Violence Abuse 2023, 24, 3049-3064.
Salokangas, R.K.R.; Schultze-Lutter, F.; Schmidt, S.J.; Pesonen, H.; Luutonen, S.; Patterson, P.; Graf von Reventlow, H.; Heinimaa, M.; From, T.; Hietala, J. Childhood physical abuse and emotional neglect are specifically associated with adult mental disorders. J Ment Health 2020, 29, 376-384.
Comment: Please find a supporting citation for 7-10 of research published since 2020.
Response: 2 more recent citations have been added:
Davies, P.T.; Thompson, M.J.; Martin, M.J.; Cummings, E.M. The vestiges of childhood interparental conflict: Adolescent sensitization to recent interparental conflict. Child Dev 2021, 92, 1154-1172.
Rousson, A.N.; Fleming, C.B.; Herrenkohl, T.I. Childhood maltreatment and later stressful life events as predictors of depression: A test of the stress sensitization hypothesis. Psychol Violence 2020, 10, 493-500.
Comment: Please cite research published since 2020 to support the claim of this sentence.
Response: The following citation has been added. Even though it is not clearly evident from the title, the manuscript includes a strong expression of concern that childhood adversities might lead to a group that was more vulnerable to pandemic stressors.
Solberg, M.A.; Peters, R.M.; Templin, T.N.; Albdour, M.M. The relationship of adverse childhood experiences and emotional distress in young adults. J Am Psychiatr Nurses Assoc 2024, 30, 532-544.
Comment: Please find a supporting citation for citation 25 of research published since 2020, and spell RERI in full in the text before using the acronym.
Response: I have been unable to find a methodologically-oriented discussion of the sufficient-component cause model published since 2020. Instead, the revised manuscript refers to recent examples of application of the approach, using these citations:
Kondracki, A.J.; Attia, J.R.; Valente, M.J.; Roth, K.B.; Akin, M.; McCarthy, C.A.; Barkin, J.L. Exploring a potential interaction between the effect of specific maternal smoking patterns and comorbid antenatal depression in causing postpartum depression. Neuropsychiatr Dis Treat 2024, 20, 795-807.
Ahmed, W. Additive interaction of family medical history of diabetes with hypertension on the diagnosis of diabetes among older adults in india: Longitudinal ageing study in india. BMC Public Health 2024, 24, 999.
Also, RERI is now spelled out in its first occurrence.
Comment: Please cite research published since 2020 for a Fay adjustment.
Response: This is an established procedure and my searches do not uncover recent citations for it, except some highly technical ones in the biostatistical literature (e.g. simulation studies comparing various solutions to small sample problems that can arise with bootstrapping). Instead, I have referenced the 2023 MHACS user guide and expanded the sentence so that the adjustment seems perhaps less obscure:
“Master weights are provided to investigators by Statistics Canada, as well as a set of 1000 replicate bootstrap weights, which are used with a Fay adjustment to address the need for a multiplicative factor required for application the bootstrap methodology for variance estimation in this survey [36].”
Comment: Change “because its unclear” to “because of its unclear”.
Response: The typographical error has been corrected as recommended.
Comment: Please include a citation to research published since 2020 using the CEVQ
Response: The following citation has been added:
O'Mahony, J.; Bernstein, C.N.; Marrie, R.A. Adverse childhood experiences and psychiatric comorbidity in multiple sclerosis, inflammatory bowel disease, and rheumatoid arthritis in the canadian longitudinal study on aging. J Psychosom Res 2024, 187, 111893
Comment: Please find a supporting citation for 29 of research published since 2020.
Response: The following citation has been added:
Volkow, N.D.; Blanco, C. Substance use disorders: A comprehensive update of classification, epidemiology, neurobiology, clinical aspects, treatment and prevention. World Psychiatry 2023, 22, 203-229.
Comment: Please find a supporting citation for 30 of research published since 2020.
Response: The following citation has been added:
Tam, J.; Mezuk, B.; Zivin, K.; Meza, R. U.S. Simulation of lifetime major depressive episode prevalence and recall error. Am J Prev Med 2020, 59, e39-e47.
Comment: Please find a citation supporting the claim that this is the first version of Stata to support REFI estimation.
Response: A citation to the Stata Corp. website called: “What’s new in Stata 18” has been added.
Comment: Please state the date of the analysis.
Response: A statement of the date now occurs in the final sentence of the methods section: “The analysis took place at the Prairie Regional Research Data Centre at the University of Calgary during August to October, 2024.”
Comment: There is no current citation examined in this Discussion. Please find supporting citations for 33-36 of research published since 2020.
Response: 3 more recent citations have been added, providing updates in the form of reviews:
Lippard, E.T.C.; Nemeroff, C.B. The devastating clinical consequences of child abuse and neglect: Increased disease vulnerability and poor treatment response in mood disorders. Am J Psychiatry 2023, 180, 548-564.
Cooke, E.M.; Connolly, E.J.; Boisvert, D.L.; Hayes, B.E. A systematic review of the biological correlates and consequences of childhood maltreatment and adverse childhood experiences. Trauma Violence Abuse 2023, 24, 156-173.
Speranza, L.; Filiz, K.D.; Lippiello, P.; Ferraro, M.G.; Pascarella, S.; Miniaci, M.C.; Volpicelli, F. Enduring neurobiological consequences of early-life stress: Insights from rodent behavioral paradigms. Biomedicines 2024, 12.
Reviewer 2 Report
The topic is interesting about the relationships of adverse childhood experiences and mental health during the Covid19 experience. The experiences are that of the Canadian population.
There are some minor comments to address.
The introduction is quite complete, but probably more information on Covid and mental health could be implemented. Add some more studies (i.e. reviews on the mental health consequences on population worldwide and in your country).
The Ethical approval and the signature of informed consent should be added also in the main text when describing the procedure to collect data. Who is taking the interviews?
Why the response rate is so limited? How can you state that it is representative for the Canadian population?
Have you collected some more information on socio-demographic issues of participants such as job, perceived economic situation, relationship status, etc?
These could be also important information to associate with the other issues.
Recommendations for future research and possible preventive program should be added.
Introduction could be more ample with more studies on covid 19 and mental health. Methods and results are well written and clear. Participants' information is not complete. Discussion is interesting, add some more take home messages.
Author Response
Comment: The introduction is quite complete, but probably more information on Covid and mental health could be implemented. Add some more studies (i.e. reviews on the mental health consequences on population worldwide and in your country).
Response: Please see the comments above. I appreciate the Reviewer’s comment here, which is similarly stated by other reviewers. The literature review for the originally submitted manuscript was incomplete and out of date. This has been improved in the revised manuscript by the addition of 20+ new references. I would like to point out, however, that none of the newly cited studies have used measures of depressive disorders. Also, only one prior study has assessed interactions between pandemic-related stressors and childhood adversities, and the “stressors” in this study (Alradhi et al.) were frustration and isolation, which could also be considered outcomes and even symptoms of depression.
Comment: The Ethical approval and the signature of informed consent should be added also in the main text when describing the procedure to collect data. Who is taking the interviews?
Response: A new sub-section (2.6) has been added for Ethics. Ethical oversight of data collection by Statistics Canada occurs under the auspices of federal legislation (“The Statistics Act”) rather than University-based ERBs. The data are made available to researchers through a legally mandated process that does not require ERB approval.
Also, it is now stated that the interviews were conducted by Statistics Canada staff.
Comment: Why the response rate is so limited? How can you state that it is representative for the Canadian population?
Response: There is a new addition to the “data source” subsection of methods, which explains the rationale for asserting that the sample is representative:
“The sampling frame was based on the 2021 national census, long questionnaire subset. After application of two stages of selection (household and individual respondent, one from each sampled residence), the final sample size was 9,861, resulting in an overall response rate of 25%. Sampling weights were calculated by Statistics Canada to offset design effects (e.g. stratification), and also included adjustments for non-response. According to Statistics Canada: “It is expected that the population was well-covered, due to the high response rate to the 2021 Census” [40].”
Comment: Have you collected some more information on socio-demographic issues of participants such as job, perceived economic situation, relationship status, etc?
Response: This information is available in the dataset, but apart from the demographic table, was not included in the analysis. In the revised manuscript this is acknowledged in the limitations section:
“There are many additional variables, such as social support, marital status, employment etc. that may modify the associations reported in the study. Future research should incorporate such factors in the analyses.”
Comment: Recommendations for future research and possible preventive program should be added.
Response: There was some discussion of these issues (e.g. primary prevention) in the original draft, but in response to this feedback two new statements have been added to the discussion:
“The synergy identified in this study likely represents an example of synergies previously reported between childhood adversities and later stressful events. These results should encourage continued research into the clinical management of depression and anxiety in populations exposed to traumas and adversities.”
“There are also implications for secondary prevention. Screening for depression may be a strategy to enhance earlier detection in some settings. The predictive value of screening instruments depends on their sensitivity and specificity and the “base rate” of depression in the underlying population. Often, screening is more effective in high risk populations, and the findings of this of this study help to characterize childhood adversities as a characteristic of high risk populations.”
Reviewer 3 Report
This is a very important contribution to the literature. The article is succinct and well-written. It makes sense that adverse childhood experiences add to the vulnerability of individuals during COVID and this evidence is made clear in this short article.
The literature review is strong, utilizing 36 references.
Line #46 Insert "to" before "examine"
The Materials and Methods Section provides good detail. The Assessment of pandemic-related stressors is very good, along with the explanation for why items 11 and 14 were excluded. Good explanation of the MHACS and the measurements.
Line #92 insert "of" before "its unclear"
In the Assessment section, the authors do a good job of describing the differences in DSM-IV and DSM-5. The authors may want to include the updated citation and reference to DSM-5-TR.
Line #129 " single diagnosis" rather than "diagnoses"
I am not a research methodologist/statistician and I hope another reviewer can be helpful here.
While the overall response rate is just 25%, it is a huge sample at 9,861.
Table 1 looks very good and is easy to read due to the juxtaposition of adverse experiences below the pandemic stressors.
Line #169 "both the" instead of "the both"
Line # 192 "variable"
In the Discussion section, the first two paragraphs are especially strong.
I especially like the emphasis on primary prevention--finances, physical health, and relationship issues.
If possible, I'd like to see the author speculate more on the lack of relationship with substance abuse.
While the limitations paragraph is very good, it is a personal preference to not end an article on that note. It's not a hot issue, but I would choose to make the limitations paragraph the next-to-last paragraph. Thus switching the last two paragraphs makes sense to me. I'd also encourage the author to add to the final paragraph more specific recommendations for other researchers.
Author Response
Comment: The literature review is strong, utilizing 36 references.
Response: It is now stronger due to the addition of 20+ more references.
Comment: Line #46 Insert "to" before "examine"
Response: Thank you. The typographical error has been corrected.
Comment: The Materials and Methods Section provides good detail. The Assessment of pandemic-related stressors is very good, along with the explanation for why items 11 and 14 were excluded. Good explanation of the MHACS and the measurements.
Response: Thank you. The issue about exclusion of is even more important now that Alradhi et al. is cited, as those authors considered isolation and frustration to be pandemic stressors.
Comment: Line #92 insert "of" before "its unclear"
Response: Corrected.
Comment: In the Assessment section, the authors do a good job of describing the differences in DSM-IV and DSM-5. The authors may want to include the updated citation and reference to DSM-5-TR.
Response: This has been added to the revised manuscript.
Comment: Line #129 " single diagnosis" rather than "diagnoses"
Response: Thank you, this is corrected.
Comment: While the overall response rate is just 25%, it is a huge sample at 9,861.
Response: In response to a comment by Reviewer 2, the implications of the low sample size are now discussed in more detail.
Comment: Table 1 looks very good and is easy to read due to the juxtaposition of adverse experiences below the pandemic stressors.
Response: Thank you.
Comment: Line #169 "both the" instead of "the both"
Response: Thank you, corrected.
Comment: Line # 192 "variable"
Response: Thanks you, corrected.
Comment: If possible, I'd like to see the author speculate more on the lack of relationship with substance abuse.
Response: I find myself unable to go as far as one might like with such speculation, but have added a new citation and an example:
“For example, while the neurobiology of addiction is incompletely understood, much research has focused on reward circuits such as dopamine projections from the ventral tegmental area to the nucleus accumbens [60] in contrast to the emphasis on the hypothalamic-pituitary-adrenal axis and inflammatory processes that have received most attention in the depression and anxiety disorder literature.”
Comment: While the limitations paragraph is very good, it is a personal preference to not end an article on that note. It's not a hot issue, but I would choose to make the limitations paragraph the next-to-last paragraph. Thus switching the last two paragraphs makes sense to me. I'd also encourage the author to add to the final paragraph more specific recommendations for other researchers.
Response: The limitations paragraph is now the penultimate paragraph in the paper.
Reviewer 4 Report
The subject of the reviewed article refers to the relationship between important childhood adversities, reinforced by pandemic-related stressors, and an increased susceptibility to mood, anxiety, and substance use disorders. A closer understanding of this relationship is of great importance from the point of view of prevention and effective therapy of the above disorders, especially in the context of experiences related to the COVID-19 pandemic. The advantage of the research conducted by the author is its wide scope (sample size 9,861). However, the reliance on cross-sectional data taken from a national study, conducted by a national statistical agency, may raise questions about their quality. The author mentions this in the “Discussion” section (in the part related to limitations of the study). In terms of methodology, the article meets the appropriate requirements for scientific papers. However, I would suggest changing its structure by separating the "Conclusions" section at the end of the text. This change will make the article more transparent for the potential reader. After this change, I support the publication of the reviewed work.
The subject of the reviewed article refers to the relationship between important childhood adversities, reinforced by pandemic-related stressors, and an increased susceptibility to mood, anxiety, and substance use disorders. A closer understanding of this relationship is of great importance from the point of view of prevention and effective therapy of the above disorders, especially in the context of experiences related to the COVID-19 pandemic. The advantage of the research conducted by the author is its wide scope (sample size 9,861). However, the reliance on cross-sectional data taken from a national study, conducted by a national statistical agency, may raise questions about their quality. The author mentions this in the “Discussion” section (in the part related to limitations of the study). In terms of methodology, the article meets the appropriate requirements for scientific papers. However, I would suggest changing its structure by separating the "Conclusions" section at the end of the text. This change will make the article more transparent for the potential reader. After this change, I support the publication of the reviewed work.
Author Response
Comment: I would suggest changing its structure by separating the "Conclusions" section at the end of the text. This change will make the article more transparent for the potential reader. After this change, I support the publication of the reviewed work.
Response: The final paragraph now stands as a Conclusions section, and has been expanded slightly so that it is stated in a more conclusive fashion.
Round 2
Reviewer 1 Report
Thank you to the authors for the changes they have made to their manuscript. All have improved it significantly. A few remain.
Line by line suggested edits
66 Please find a supporting citation for 37 of published research since 2020.
200 Please remove the italics for “[52]”.
337–Although the authors have improved the references, they are missing details regarding the preferred style. Here is a link to the Instructions for Authors outlining the style: https://www.mdpi.com/journal/covid/instructions.
Author Response
Comment: 66 Please find a supporting citation for 37 of published research since 2020.
Response: With some additional searching, I did find some. The following have been added.
Pearce, N.; Greenland, S. On the evolution of concepts of causal and preventive interdependence in epidemiology in the late 20(th) century. Eur. J. Epidemiol. 2022, 37, 1149-1154.
Diaz-Gallo, L.M.; Brynedal, B.; Westerlind, H.; Sandberg, R.; Ramskold, D. Understanding interactions between risk factors, and assessing the utility of the additive and multiplicative models through simulations. PloS One 2021, 16, e0250282.
Whitcomb, B.W.; Naimi, A.I. Interaction in theory and in practice: Evaluating combinations of exposures in epidemiologic research. Am. J. Epidemiol. 2023, 192, 845-848.
Comments: 200 Please remove the italics for “[52]”.
337–Although the authors have improved the references, they are missing details regarding the preferred style. Here is a link to the Instructions for Authors outlining the style: https://www.mdpi.com/journal/covid/instructions.
Response: Sorry about this, what happened with the references is that I was unable to import the MDPI template for EndNote (due to some problem with administrative rights on my university-managed laptop). Impatient to wait for IT support, I made my own, but in retrospect my template only applied to journal articles and not to web pages or books and I neglected to bold the year and use punctuation in the Journal abbreviations. I think it is now fixed.
