Adverse Childhood Experiences and Internalizing Symptoms Among American Indian Adults with Type 2 Diabetes

Adverse Childhood Experiences and Internalizing Symptoms Among American Indian Adults with Type 2 Diabetes Jessica H. L. Elm Journal of Racial and Ethnic Health Disparities ISSN 2197-3792 J. Racial and Ethnic Health Disparities DOI 10.1007/s40615-020-00720-y 1 23 Your article is protected by copyright and all rights are held exclusively by W. Montague Cobb-NMA Health Institute. This e-offprint is for personal use only and shall not be selfarchived in electronic repositories. If you wish to self-archive your article, please use the accepted manuscript version for posting on your own website. You may further deposit the accepted manuscript version in any repository, provided it is only made publicly available 12 months after official publication or later and provided acknowledgement is given to the original source of publication and a link is inserted to the published article on Springer's website. The link must be accompanied by the following text: "The final publication is available at link.springer.com”. 1 23 Author's personal copy Journal of Racial and Ethnic Health Disparities https://doi.org/10.1007/s40615-020-00720-y Adverse Childhood Experiences and Internalizing Symptoms Among American Indian Adults with Type 2 Diabetes Jessica H. L. Elm 1 Received: 9 July 2019 / Revised: 31 January 2020 / Accepted: 4 February 2020 # W. Montague Cobb-NMA Health Institute 2020 Abstract Background Decades of evidence link adverse childhood experiences (ACEs) to worse health. Despite disproportionate rates of ACEs and health disparities in tribal communities, a gap exists in understanding the effects of ACEs on American Indian (AI) health. The purpose of this study is to estimate frequencies of eight categories of ACEs, assess the risk for internalizing symptoms by each ACE category, and determine if moderate and high levels of ACEs exposures have differential, increasing risk associated with internalizing symptoms for a sample of AI adults with T2D. Methods Five tribal communities participated in a community-based participatory research study. Data from AI adults with T2D were analyzed (N = 192). Frequencies of eight childhood events and situations were assessed, and exposure levels of low (0–1), moderate (2–3), and high levels (4 +) of ACEs were calculated. Odds of screening positive for depression and generalized anxiety disorder (GAD) by each ACE type and moderate and high levels of ACEs were estimated using regression analyses. Results Relative to other studies, exposure estimates for each of the eight ACE categories and moderate and high levels of ACEs were high. Sexual and physical abuse, neglect, and household mental illness were positively associated with depressive symptoms, and physical abuse was positively associated with anxiety symptoms. Exposures to moderate and high levels of ACEs were associated with increased odds of screening positive for current depression in a dose-response fashion. A high level of ACEs exposure was also associated with an increased odds of a positive GAD screening. Conclusions This research extends limited knowledge about ACEs and health among AIs. More research is needed to understand the health consequences of ACEs for a population exhibiting health inequities. Components of strategies for addressing ACEs, mental health, T2D complications, and comorbidities are proposed for AIs generally and AI adults with T2D specifically. Keywords ACEs . Adversity . Child abuse . Stress . Intimate partner violence . Depression . Anxiety . Diabetes mellitus . Health disparities . Health equity . Native American . Historical trauma The landmark CDC-Kaiser studies (data collected from 1995 to 1997) revealed that ten types of childhood stressors [i.e., emotional, physical, and sexual abuse; emotional and physical neglect; intimate partner violence (IPV); living with a parent with a substance or mental health problem; parental separation or divorce; and incarceration of a household member before the age of 18] are common experiences, frequently co-occur, and exert influence on mental and physical health into adulthood [1–6]. These indicators of child maltreatment and maladaptive family functioning are conventionally and collectively known as * Jessica H. L. Elm jelm@jhu.edu 1 Johns Hopkins University, Department of International Health, Bloomberg School of Public Health, Center for American Indian Health, Great Lakes Hub, Duluth, MN, USA adverse childhood experiences (ACEs) [1, 7, 8]. Research consistently demonstrates relationships between an increasing numbers of ACEs exposures and greater risk for mental health impairment [1, 4, 9, 10]. Two mental health categories linked to ACEs are depressive disorders and generalized anxiety disorder (GAD) [11]. For example, odds of major depressive disorder increases by at least two and a half times for individuals exposed to four or more types of ACEs, compared with those with no exposure [4, 5, 9, 10], and exposure to increasing numbers of ACEs is associated with increased risk for GAD [10, 12]. However, research regarding GAD in context of ACEs is limited and inconsistent [13], as most studies that include GAD assess one to a few categories of childhood stressors or a cluster anxiety disorders as the outcome of interest (e.g., [7, 14,15]). Regarding physical health, ACEs have been linked to numerous chronic physical health conditions via direct and indirect pathways [3]. One leading cause of morbidity and mortality that is associated Author's personal copy J. Racial and Ethnic Health Disparities with ACEs is type 2 diabetes (T2D) [1, 16]. ACEs exposures are also associated with precursors and comorbidities of T2D, some of which lead to T2D-related complications [16,17]. Despite decades of evidence that ACEs lead to worse health [1, 3, 5, 6] and that American Indians (AIs) experience disproportionate rates of ACEs [6, 10, 18,19] and disease [20, 21], there is a gap in understanding the effects of ACEs on health for AIs. The present study estimates frequencies of eight types of ACEs and examines risk for depression and generalized anxiety disorder (GAD) by each singular ACE type and determines whether moderate and high levels of ACEs exposures have differential, increasing risk for internalizing symptoms for a sample of AI adults with T2D. This important research begins to identify factors to be addressed within prevention and early intervention programming, as well as mental health treatment, specifically for AIs managing a chronic health condition. This knowledge is valuable to tribal leaders and health administrators for decision-making processes regarding primary and secondary public health prevention priorities and strategies. Materials and Methods Study Design, Sample, and Procedure The Gathering for Health (G4H) study is a collaborative research endeavor between the University of Minnesota and five tribal nations in the Midwest, Great Lakes region. The broad goal of the project was to advance measurement of stress processes, investigate stress process interactions, and evaluate T2D disease progression and treatment compliance in context of stressor exposures and physical responses to stressors for AIs with a T2D diagnosis. Each of the participating nations passed a tribal resolution in support of the parent study prior to the submission of the research proposal. The study followed community-based participatory research (CBPR) principles. Project methodology and human subjects approval was granted by the University of Minnesota institutional review board (IRB) and the Indian Health Service (IHS) National IRB. All papers resulting from the study are reviewed by the local Community Research Councils (CRCs) from each participating reservation and the IHS National IRB prior to submission for publication. The G4Hstudy involved two major phases. The first was a qualitative phase with two sets of focus groups conducted to identify community relevant stressors and to review and adapt survey instruments. Following the qualitative phase, the CRCs worked in close collaboration with the research team to review items and instruments for breadth, redundancy, and cultural relevance. The second phase of the study involved collection of survey data using computer-assisted personal interviews (CAPI) and laptops and saliva samples across four waves. Cross-sectional data presented in this study are from Phase II, baseline (wave 1) CAPI responses. Baseline data collection began in November 2013 and concluded in November 2015. Participants received a $50 incentive for completion of the CAPI. Tribal health clinics from each tribal community were active partners involved in sampling procedures. Staff at each clinic generated simple random samples based on clinic records and mailed invitations and brochures to potential participants. Inclusion criteria were recent diagnosis of T2D, age 18 or older, and self-reported AI or Alaska Native. A total of 344 individuals were selected for invitation to participate in the study, of which 43 were ineligible, 96 declined participation, and 11 could not be contacted. The baseline study response rate was 67% with 194 participants enrolling in the study. Because our sampling protocol relied on clinic-based staff to send study invitations and record refusals, we could not reliably document reasons for refusal to participate in the study. For these analyses, we included responses from 192 participants who completed the baseline CAPI. Interview visits were conducted by trained community interviewers and scheduled at a location of participants’ choosing. Interviewers gathered signed informed consent and HIPAA authorization forms prior to administering surveys. Survey questions were asked and recorded by the interviewers except for sensitive questions including the childhood adversity series. Participants read, listened, and responded to sensitive questions privately on laptops. Measures Dependent Variables Depressive symptoms were measured using responses to the nine-item Patient Health Questionnaire (PHQ-9; [22]). Individuals were asked to report if they have been bothered by various symptoms over the past 2 weeks (0 = not at all, 1 = several days, 2 = more than half the days, and 3 = almost every day), with a possible range from 0 to 27 and higher scored indicating worse symptoms. Based on recommended scoring, participants with scores of 10 or higher were considered to have met the criteria for moderate depressive symptoms [23, 24] and were coded as “1.” Cronbach’s alpha for the PHQ-9 was .88 in this study. The seven-item generalized anxiety disorder-7 (GAD-7) instrument was used to assess fear and anxiety-type symptoms [25]. Participants were asked how often, during the last 2 weeks, they were bothered by each symptom (0 = not at all, 1 = several days, 2 = more than half the days, and 3 = almost every day), with a possible total score range from 0 to 21 and higher scored indicating worse symptoms. A score of 10 on the GAD-7 is considered an appropriate cutoff score for assessing moderate to severe anxiety. Thus, a dichotomous Author's personal copy J. Racial and Ethnic Health Disparities variable was created to indicate moderate to severe symptomology (>/= 10) [25]. Cronbach’s alpha for the GAD-7 was 0.92 in this study. Independent Variables Eight categories of childhood adversities were assessed using items from the Adverse Childhood Experiences International Questionnaire (ACE-IQ) [26]. The ACE-IQ retrospectively measures ACEs that occurred during the first 18 years of life. With the exception of neglect, items and methods for scoring were chosen to closely align with those used in the Behavioral Risk Factor Surveillance System survey [27]. For sexual abuse (4 items), emotional abuse (1 item), physical abuse (2 items), neglect (1 item), and exposure to household violence (1 item), participants were given the options to respond: “never,” “once,” “a few times,” “many times,” and “do not know/refused.” For items related to living with a substance abuser, someone with mental illness, and someone who had been incarcerated during childhood, participants were asked to respond “yes,” “no,” and “do not know/refused.” A dichotomous variable for each ACE category was created. Participants were considered exposed if they answered “once,” “a few times,” “many times” to any question in a category, or “yes,” respectively (0 = not exposed, 1 = exposed). One exception was neglect, which is not included in the BRFSS survey yet remains a salient ACE category [1, 28]. The neglect variable was dichotomized as 1 (exposed) if the participant responded “many times,” otherwise the participant was considered not exposed [26]. A count “ACE score” index was calculated by summing the exposures to the eight ACE variables (range = 0 to 8) for respondents who completed questions for at least 4 of the ACE categories. Two control variables were included in analyses: age (in years) and gender (male = 0, female = 1). Analyses Statistical analyses were conducted using Stata version 14 and listwise deletion. Descriptive statistics (Tables 1 and 2) and bivariate correlations were calculated for all variables. Separate logistic regression models were conducted to estimate the associations between each of the eight ACE variables and positive depression and GAD screenings (Table 3). Logistic regressions were also used to estimate the risk of a positive depression and GAD screen by moderate (2–3) and high (4–8) ACE scores (referent group: low score = 0–1) (Table 4). Both unadjusted and adjusted models were generated. Adjusted models controlled for gender and age. Significance was set at p < 0.05. Table 1 Sociodemographic characteristics of Gathering for Healthstudy participants (N = 192) Percent (%) Age (years) Female Resides on reservation Relationship status Married Divorced Other Employment status Full time Part-time Unemployed Disabled Retired Student Other Educational attainment Less than high school High school/equivalent Some college/vocational* College degree Advanced degree Per capita household income Mean (SD) 46.3 (12.2) 56% 78% 31% 23% 46% 49% 11% 12% 12% 4% 3% 9% 13% 32% 41% 13% 1% $9767 ($8901) *Some college, technical, or vocational certificate, or associate’s degree Results Just over one-half (56%) of the study participants were female. The mean age of the sample was 46.3 years (SD = 12.21). Average per capita household income was $9767 (SD = $8901). Other sociodemographic characteristics of study participants are summarized in Table 1. Eighteen percent (18.3%) of participants screened positive for depression and 14.5% screened positive for GAD (not shown in tables). Among G4H participants, the highest reported adversity was physical abuse (59.6%). Similar rates were estimated across emotional abuse, exposure to household violence, and household substance abuse (48.9%, 47.8%, and 48.1%, respectively). Sexual abuse was reported by almost a third of respondents (29.1%), as was having a household member who was incarcerated while growing up (31.8%). Almost a quarter of the sample reported living with a household member with mental illness or suicidality (21.7%; Table 2). Eighty-three percent (83.0%) of the G4H sample reported exposure to at least one ACE type. Frequencies of exposure to one and two types of ACEs were 15.9% and 15.4%, respectively. Thirteen percent (12.6%) of study participants endorsed three types of ACE exposures. Thirty-nine percent of respondents had an ACE score of four or more (not shown in tables). Author's personal copy J. Racial and Ethnic Health Disparities Table 2 Proportion of American Indian adults with type 2 diabetes (T2D) from the Gathreing for Health (G4H) and adults from a nationally representative sample (BRFSS) with T2D who experienced each ACE category G4H BRFSS with T2D Sexual abuse (n = 175) Emotional abuse (n = 182) Physical abuse (n = 178) Neglect (n = 181) 29.1% 48.9% 59.6% 12.4% 11.6% 33.7% 16.7% n/a Household violence (n = 180) Household substance abuse (n = 181) Household mental illness/suicide (n = 180) Household incarceration (n = 179) 47.8% 48.1% 21.7% 31.8% 18.0% 29.9% 16.1% 6.6% ACE Categories and Internalizing Symptoms substance abuse and depression and GAD screeners (OR = 2.23, p = 0.08) approached statistical significance. Table 3 shows the relationship between individual ACE categories and depression and GAD symptoms in unadjusted and adjusted models. In unadjusted models, there was a statistically significant increase in odds for screening positive for depression or GAD for 6 out of 8 ACE categories (range in odds = 2.19–4.04). After adjusting for age and gender, physical abuse was the only ACE to be associated with an increase in odds of screening positive for both internalizing disorders (depression OR = 4.11; GAD OR = 3.01). Independently, sexual abuse, neglect, and household mental illness each increased the odds of screening positive for depression by about three times (OR range 2.95–3.10). The relationships between emotional abuse and a positive depression screen (OR = 2.16, p = 0.06) and household Table 3 Levels of Cumulative ACEs and Internalizing Symptoms Levels of ACE exposure (i.e., low, moderate, and high) were created using 8 ACE variables. Moderate (2–3) and high (4–8) ACE scores were distinguishable in terms of increasing odds of positive depression and GAD screeners, as compared to the referent group (low ACEs, 0–1). Specifically, controlling for gender and age, participants with a moderate ACE score had 3.62 times the odds of screening positive for depression compared to those with a low ACE score. Respondents who were classified as having high ACE scores had five and a half (5.56) and nearly four (3.80) times the odds of screening positive for depression and GAD, respectively. Odds of a positive screen for depressive and generalized anxiety disorder by adverse childhood experiences category (N = 186) Depressive symptoms OR (CI) – unadjusted Anxiety symptoms OR (CI) – unadjusted Depressive symptoms OR (CI) Anxiety symptoms OR (CI) Sexual abuse Emotional abuse Physical abuse 3.04 (1.36, 6.80)** 2.23 (1.03, 4.84)* 4.04 (1.58, 10.38)** 2.31 (0.97, 5.54)a 1.97 (0.85, 4.58) 2.77 (1.06, 7.27)* 2.95 (1.26,6.89)* 2.16 (0.99, 4.72) a 4.11 (1.60, 10.61)** 2.01 (0.76, 4.67) 1.81 (0.746, 4.40) 3.01 (1.09, 8.29)* Neglect Household violence Household substance abuse Household mental illness/suicide Household incarceration 3.32 (1.30, 8.50)* 1.54 (0.73, 3.28) 2.19 (1.00, 4.78)* 2.93 (1.07, 8.01)* 1.78 (0.77, 4.09) 2.48 (1.05, 5.87)* 3.10 (1.17, 8.18)* 1.46 (0.68, 3.13) 2.08 (0.95, 4.58) a 2.43 (0.81, 7.29) 1.60 (0.66, 3.87) 2.24 (0.90, 5.56) a 3.26 (1.42, 7.45)** 2.72 (1.12, 6.63)* 3.01 (1.26, 7.16)* 1.81 (0.68, 4.82) 1.24 (0.56, 2.74) 1.95 (0.84, 4.52) 1.30 (0.55, 2.81) 1.88 (0.76, 4.67)` Adjusted models control for age and gender * p = < 0.05 ** a p = < 0.01 Approached significance p < = 0.09 Author's personal copy J. Racial and Ethnic Health Disparities Table 4 Odds of screening positive for depression and generalized anxiety disorder by moderate and high adverse childhood experiences scores among Gathering for Health participants (n = 178) Moderate ACEs (2 or 3, referent 0–1) High ACEs (4 or more, referent 0–1) Depressive symptoms OR (CI) – unadjusted Anxiety symptoms OR (CI) – unadjusted Depressive symptoms OR (CI) Anxiety symptoms OR (CI) 3.35 (0.98, 11.45) p = 0.053 2.56 (0.72, 9.06) 3.62 (1.04, 12.49)* 3.45 (0.91, 13.11) p = 0.07 5.73 (1.83,17.94) ** 3.89 (1.21,12.48) * 5.56 3.80 (1.76,17.54) (1.12,12.87) ** * Adjusted models control for age and gender *= < 0.05 **= < 0.01 Discussion Although all populations are at risk for exposure to childhood stressors [6], AIs experience inequities related to ACEs as a result of historically traumatic events and intergenerational effects. Understanding the process and outcomes of colonization and genocide is key for insight into disproportionate rates of ACEs in tribal communities. One example from recent history involves the coerced placement of AI children into long-term boarding schools for the purpose of assimilation [29, 30]. Under the “care” of the government and in collaboration with churches, indigenous students were abused and neglected [31,32]. This era of ethnocide not only interrupted the transmission of knowledge regarding healthy child-rearing practices but resulted in symptoms which include complex grief and trauma, guilt, anger, shame, and substance abuse [32,33]. Like other oppressed groups who have experienced massive group trauma, effects of historically traumatic events often reverberated transgenerationally [34,35]. Ultimately, parenting capacity and parent-child attachment remain compromised for distal generations of AIs [35, 36]. In summary, cumulative individual, interpersonal, and community-wide traumatic interruptions dismantled traditional child-rearing and increased incidence of mental health and substance abuse struggles for AI parents. These intergenerational effects continue to leave some native children vulnerable to adversity [37]. Thus, today’s disproportionate rates of ACEs in Indian Country reflect colonial atrocities of the past and contribute to AI health inequities. Recalling America’s genocidal past supports ethical rationale about why research about ACEs and health inequities in tribal communities is important. This study is among the first to investigate ACEs and internalizing symptoms for AIs. Frequencies of eight types of ACEs and levels of low, moderate, and high ACE scores were calculated for an adult sample of AIs with T2D. Risk of internalizing symptoms was also estimated by each of the eight categories and by moderate and high levels of ACEs exposures. Major findings from this study were that exposure to a high level of ACEs significantly increased the odds of screening positive for current depression by roughly five and a half times and screening positive for current GAD by nearly four times compared with participants exposed to a low level of childhood adversity. Another important result is that the moderate ACEs exposure level was associated with increased odds of a positive depression screen by over three and a half times compared with a low ACE score. Findings on increased risk for depression by moderate and high ACEs levels follow a similar dose-response relationship pattern identified in prior ACEs studies [1, 5]. Regarding GAD, little research has been conducted on associations with ACEs. Findings from this study contribute to the knowledge about risk for GAD in context of exposure to a high levels of ACEs. Prior research is inconsistent regarding persistence of GAD as a result of ACES [7] which may help explain the lack of association between current GAD symptoms and moderate ACEs exposure. It is probable that some participants previously experienced GAD and recovered or that some may experience increased anxiety symptoms in the future [7]. Findings from the current study demonstrate an elevated proportion of participants exposed to a high number of ACEs and each of the eight ACEs categories compared with other studies. In this study, 39% of participants reported experiencing four or more types of ACEs, whereas the most recent national report on ACEs estimates that 15.6% of Americans experience four or more types of ACEs [6]. Sexual abuse was reported by 29% of the G4H sample; whereas for both a national sample of adults with T2D and nationally representative sample, the rate was 12% (Table 2) [35, 36]. In a recent AI adult study, sexual abuse was estimated to be 16% [10]. Rates of emotional abuse appear to be disproportionately high among G4H participants. Close to half of G4H respondents reported experiencing emotional abuse compared with 34% of the nationally representative sample with T2D [38]. In prior AI studies, estimated emotional abuse rates range from 23 to 48% [10, 37, 39, 40]. For physical abuse, comparing rates across studies is challenging because of overestimation in these data (i.e., our estimate includes spanking). However, we take note of the difference across studies (59.6% versus 17–18%) (see also Table 2) because physical abuse was the only form of adversity significantly correlated with positive screenings of both depression and GAD. In the G4H study, the prevalence of living with an individual with mental illness or who exhibited suicidality was the lowest of all ACEs that were investigated (21.7%); however, this rate was still high Author's personal copy J. Racial and Ethnic Health Disparities compared to other national studies (16–17%) [38, 41]. Furthermore, approximately 18% of nationally representative samples, with and without T2D, reported witnessing IPV when growing up versus 48% of the G4H sample who witnessed IPV or other forms of household violence. In this study, having grown up among household substance abuse was high (48.1%) compared to the national samples (27.6– 29.9%) [38, 41]. Lastly, in our study, we found that over one-third (31.8%) of respondents reported having grown up with a household member who went to jail or prison versus 6.6–7.9% in national samples [38, 41]. These analyses identify positive correlations between four categories of ACEs (i.e., sexual and physical abuse, neglect, and having grown up with a household member with mental illness) and a positive depression screen, when controlling for age and gender. Physical abuse was also significantly associated with a positive GAD screen. Exposure to emotional abuse and a household member with substance abuse challenges approached significance for increased risk for depressive symptoms, while the same was true for household member substance abuse and a positive GAD screen. Despite the low sample size, this study observed trending associations between both household violence and incarceration with a positive internalizing disorder screening. Implications Primary prevention of ACEs and secondary prevention and treatment of internalizing symptoms and comorbidities are important goals, particularly for populations at greater risk for poor health and early mortality. Our research team supports tribal nations as they exercise their sovereign rights to define their own trauma-informed approaches to disease prevention and health promotion and services. Potential disease prevention and health promotion and services strategy components regarding ACEs, mental health struggles, T2D-related complications, and comorbidities are discussed here. First, this study supports the need for integrated health care with an effective screening, referral, assessment, and treatment system within AI serving health clinics. As supported by prior research and analyses from this study, universal mental health screenings are appropriate for all AIs, including patients with T2D, because of widespread high levels of ACEs exposures, serious threats to mental health, and comorbidities [10]. This is exemplified in recent findings that AIs remain at highest risk for exposure to four or more types of ACEs compared with other racial groups. This same study estimated that elimination of ACEs could reduce depression by 44.1% [6]. Aligned with prior study findings and as shown in the current study, a positive screen for internalizing symptoms likely indicates early life stressor exposures that contribute to current mental health status. Thus, a positive depression or GAD screening in the primary care setting should result in referral to behavioral health for a comprehensive biopsychosocial assessment to determine need for mental health treatment. For those referred to treatment, ACEs are likely a relevant factor in addressing internalizing symptoms. AIs with T2D and internalizing symptoms tend to have reduced medication adherence [42] and increased risk for secondary complications [17]. In addition to improving quality of life for TD2 patients who reduce internalizing symptoms, mental health treatment may act as prevention for T2D-related complications (e.g., amputation, blindness) and multimorbidities [17, 43, 44]. For tribal communities, many barriers stand in the way of implementing well-functioning integrated health care (e.g., referrals from primary care to behavioral health, referrals to services often not available at tribal health clinics). One major challenge is that Congressional allocations for IHS consistently fall short of meeting the level of need for patient services. This can leave administrators and providers with difficult decisions regarding prioritizing service delivery. For example, screening is one specific service that suffers as a result of inadequate resources [45]. Thus the above recommendation to implement consistent screening, referral, assessment, and treatment as part of a larger integrated care and behavioral health agenda is far from reality for many tribal clinics unless Congress acts to increase appropriations for IHS. Findings from this study regarding the high levels of trauma-based behavioral health challenges among those with chronic physical health issues suggest that increased funding to support implementation and expansion of integrated health care may have dramatic effects in reducing healthcare costs in the long term. It is recommended that Congress propose to fully fund IHS in order to support effective integrated health care. The Special Diabetes Program for Indians (SDPI) is a federal funding mechanism that fills health services gaps while addressing the T2D epidemic in tribal communities. Tribal programming focused on improving physical health, diabetes education, and T2D prevention is supported through SDPI and has been modestly successful thus far (e.g., reducing levels of obesity through lifestyle modifications) [46]. The present study supports updating SDPI program development guidelines to increase tribal capacity for mental health screenings, referral, assessment, and treatment which may boost the effectiveness of SDPI programs. Furthermore, it is echoed that additional research findings be translated into policy and practice for promoting mental health for AIs managing T2D (e.g., increased access to cultural activities) [47]. Existing models and programs for preventing and addressing ACEs and promoting intergenerational health can be adopted or adapted to serve tribal communities [48, 49]. One Author's personal copy J. Racial and Ethnic Health Disparities model is Self-healing Communities which helps build capacity by relying on strong leadership to link, enrich, and establish strategies and service systems to improve well-being. The model works by engaging community members, service providers, experts, funders, and other key partners to create linkages and foster dynamic, adaptable support systems that assist individuals on a continual basis, not limited by the duration of involvement with an individual service. This ongoing support is achieved through embedding resources within a community context and through taking a social network approach [48]. Programs such as Family Spirit, an early childhood home visiting program for AI mothers and children, may have long-term effects in reducing intergenerational ACEs exposure. This program decreases internalizing symptoms and substance use among AI mothers [49], reducing the likelihood that the next generation will grow up in a household with mental illness and substance abuse. Limitations and Future Research Similar to other studies examining the effects of ACEs, this study uses cross-sectional retrospective data. Although caution should be taken when drawing causal inferences from these associations, well-established methods were used in this study to draw comparisons between nationally representative samples and AIs. Data derived from this research involves a retrospective report of childhood events that, for many respondents, took place decades ago. For the current generation, childhood adversity frequencies could vary significantly. Future studies should use prospective data to examine causal relationships between ACEs and health outcomes, as well as additional stressors that contribute the mental distress for AIs, particularly those with T2D [50, 51]. Longitudinal analyses should also examine ACEs in relation to T2D management and complications, such as internalizing symptoms as mediating factors. Future work should consider a more expansive assessment of mental disorders, beyond those screened for in this study and which have been found to influence physical health for AIs with diabetes [52]. Along these lines, comorbid mental health conditions in context of living with T2D are deserving of additional attention from researchers. Other considerations for future research should include addressing potential shortcomings involved when administering the conventional Kaiser/CDC ACEs index. This index has limited validity testing with diverse populations and with current pediatric populations [53, 54]. There may be alternative or additional ACEs, outside of those presented in this study, that drive health outcomes for AIs and people of color (e.g., discrimination). Lastly, it is also important to determine if there are distinct patterns and compositional variations of ACEs that AIs experience. Conclusion This research expands knowledge about ACEs among AIs, particularly those living with T2D. Frequencies for eight categories of ACEs and levels of low, moderate, and high ACEs were calculated. Risk for internalizing symptoms was assessed for each of the eight ACE categories and for moderate and high levels of ACEs. High frequencies of each of the ACE categories and for high ACEs exposures were identified. Risk for screening positive for depression and GAD increased in relation to higher levels of ACEs. Components for strategies for addressing ACEs, mental health, T2D complications, and comorbidities were offered with acknowledgement that tribes are sovereign entities and make their own decisions. More research is needed to understand the health consequences that may result from childhood adversities for AIs. Acknowledgements The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The author thanks the project’s community members and research council members: Sidnee Kellar, Rose Barber, Robert Miller, Tweed Shuman, Lorraine Smith, Sandy Zeznanski, Patty Subera, Tracy Martin, Geraldine Whiteman, Lisa Perry, Trisha Prentice, Alexis Mason, Charity Prentice-Pemberton, Kathy Dudley, Mona Nelson, Eileen Miller, Geraldine Brun, Murphy Thomas, Hope Williams, Betty Jo Graveen, Daniel Chapman, Jr., Mary SikoraPetersen, Tina Handeland, Phillip Chapman, Sr., GayeAnn Allen, Frances Whitfield, Doris Isham, Stan Day, Jane Villebrun, Beverly Steel, Muriel Deegan, Peggy Connor, Michael Connor, Ray E. Villebrun, Sr., Pam Hughes, Cindy McDougall, Melanie McMichael, Robert Thompson, and Sandra Kier. Funding Information This study was funded by the National Institutes of Health’s National Institute of Diabetes and Digestive and Kidney Diseases (grant number DK091250) and National Institute of Drug Abuse (grant number 3R01DA039912-03S1). Compliance with Ethical Standards Conflict of Interest Jessica H. L. Elm declares that she has no conflict of interest. Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed Consent Informed consent was obtained from all individual participants included in the study. References 1. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study. Am J Prev Med. 1998;14(4):245–58. Author's personal copy J. Racial and Ethnic Health Disparities 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. Dong M, et al. The interrelatedness of multiple forms of childhood abuse, neglect, and household dysfunction. Child Abuse Negl. 2004;28(7):771–84. Nurius PS, Fleming CM, Brindle E. Life course pathways from adverse childhood experiences to adult physical health: a structural equation model. J Aging Health. 2017;31:211. Jones TM, Nurius P, Song C, Fleming CM. Modeling life course pathways from adverse childhood experiences to adult mental health. Child Abuse Negl. 2018;80(February):32–40. Chapman DP, Whitfield CL, Felitti VJ, Dube SR, Edwards VJ, Anda RF. Adverse childhood experiences and the risk of depressive disorders in adulthood. J Affect Disord. 2004;82(2):217–25. M. T. Merrick et al., “Vital signs : estimated proportion of adult health problems attributable to adverse childhood experiences and implications for prevention — 25 States, 2015–2017,” 2019. Green JG, Gruber MJ, Sampson NA, Zaslavsky AM, Kessler RC, McLaughlin KA. Childhood adversities and adult psychiatric disorders in the national comorbidity survey replication II. Arch Gen Psychiatry. 2010;67(2):124. Mersky JP, Janczewski CE, Topitzes J. Rethinking the measurement of adversity: moving toward second-generation research on adverse childhood experiences. Child Maltreat. 2017;22(1):58–68. Merrick MT, Ports KA, Ford DC, Afifi TO, Gershoff ET, GroganKaylor A. Unpacking the impact of adverse childhood experiences on adult mental health. Child Abuse Negl. 2017;69:10–9. Warne D, Dulacki K, Spurlock M, Meath T, Davis MM, Wright B, et al. Adverse childhood experiences (ACE) among American Indians in South Dakota and associations with mental health conditions, alcohol use, and smoking. J Health Care Poor Underserved. 2017;28(4):1559–77. Sareen J, Henriksen CA, Bolton SL, Afifi TO, Stein MB, Asmundson GJG. Adverse childhood experiences in relation to mood and anxiety disorders in a population-based sample of active military personnel. Psychol Med. 2013;43:73–84. Poole JC, Dobson KS, Pusch D. Anxiety among adults with a history of childhood adversity: psychological resilience moderates the indirect effect of emotion dysregulation A R T I C L E I N F O. J Affect Disord. 2017;217:144–52. Fernandes V, Osó Rio FL. Are there associations between early emotional trauma and anxiety disorders? Evidence from a systematic literature review and meta-analysis. Eur Psychiatry. 2015;30: 756. Kessler RC, Davis CG, Kendler KS. Childhood adversity and adult psychiatric disorder in the US National Comorbidity Survey. Psychol Med. 1997;27(5):1101–19. Soenke M, Hahn KS, Tull MT, Gratz KL. Exploring the relationship between childhood abuse and analogue generalized anxiety disorder: the mediating role of emotion dysregulation. Cognit Ther Res. 2010;34:401. Huffhines L, Noser A, Patton SR. The link between adverse childhood experiences and diabetes. Curr Diab Rep. 2016;16(6):1–15. American Diabetes Association. Standards of medical care in diabetes - 2019. Diabetes Care. 2019;42(Supplement 1):S1–S193. Administration for Children and Families, “Child Maltreatment 2017,” Wasington, DC, 2019. Kenney MK, Singh GK. Adverse childhood experiences among American Indian/Alaska native children: the 2011–2012 national survey of children’s health. Scientifica (Cairo). 2016;2016:1–14. Shiels MS, Chernyavskiy P, Anderson WF, Best AF, Haozous EA, Hartge P, et al. Trends in premature mortality in the USA by sex, race, and ethnicity from 1999 to 2014: an analysis of death certificate data. Lancet. 2017;389(10073):1043–54. Indian Health Service, “Indian Health Disparities,” 2018. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med. 2001;16: 606–13. 23. Gilbody S, Richards D, Barkham M. Diagnosing depression in primary care using self-completed instruments. Gen Pract. 2007;2(August):650–2. 24. Manea L, Gilbody S, McMillan D. Optimal cut-off score for diagnosing depression with the patient health questionnaire (PHQ-9): a meta-analysis. Cmaj. 2012;184(3):E191–6. 25. Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Intern Med. 2006;166(10):1092–7. 26. World Health Organization, “Adverse Childhood Experiences International Questionnaire (ACE-IQ) Guidance for Analysing ACE-IQ.” 27. Centers for Disease Control and Prevention, “No Title,” Behavioral Risk Factor Surveillance System ACE Data, 2019. [Online]. Av a i l a b l e : h t t p s : / / w w w. c d c . g o v / v i o l e n c e p r e v e n t i o n / childabuseandneglect/acestudy/ace-brfss.html?CDC_AA_refVal= https%3A%2F%2Fwww.cdc.gov%2Fviolenceprevention% 2Facestudy%2Face_brfss.html. 28. Huang H, Yan P, Shan Z, Chen S, Li M, Luo C, et al. Adverse childhood experiences and risk of type 2 diabetes: a systematic review and meta-analysis. Metabolism. 2015;64(11):1408–18. 29. Chalcraft EL. Assimilation’s agent: my life as a superintendent in the Indian boarding school system. Lincoln: University of Nebraska Press Lincoln & NE; 2004. 30. Wilkins DE, Stark HK. American Indian Politics and the American Political System, 3rd ed. Lanham: Rowman & Littlefield; 2011. 31. Brave Heart MYH. Gender differences in the historical trauma response among the Lakota Maria yellow horse Brave Heart, PhD. J Health Soc Policy. 1999;10(4):1–21. 32. Brave Heart MYH. The return to the sacred path: healing the historical trauma and historical unresolved grief response among the Lakota through a psychoeducational group intervention. Smith Coll Stud Soc Work. 1998;68(3):287–305. 33. McIlwaine JR, Schafer BD. Investigating child sexual abuse in the American Indian community. Am Indian Q. 1992;16(2):157–67. 34. Berant E. Transgenerational transmission of trauma in children of holocaust survivors: a case study. Rorschachiana J Int Soc Rorschach. 2002;25:28–57. 35. Horejsi C, Craig BHR, Pablo J. Reactions by native American parents to child protection agencies: cultural and community factors. Child Welfare. 1992;71(4):329–42. 36. Brave Heart MYH. The historical trauma response among natives and its relationships with substance abuse. Psychoact Drugs. 2003;35(1):7–13. 37. Wurster HE, Sarche M, Trucksess C, Morse B, Biringen Z. Parents’ adverse childhood experiences and parent-child emotional availability in an American Indian community: relations with young children’s social-emotional development. Dev Psychopathol. 2019:1–12. 38. Campbell JA, Farmer GC, Nguyen-Rodriguez S, Walker R, Egede L. Relationship between individual categories of adverse childhood experience and diabetes in adulthood in a sample of US adults: does it differ by gender? J Diabetes Complicat. 2018;32(2):139–43. 39. Mersky JP, Janczewski CE. Racial and ethnic differences in the prevalence of adverse childhood experiences: Findings from a low-income sample of U.S. women. Child Abuse Negl. 2018;76(December 2017):480–7. 40. Brockie TN, et al. The relationship of adverse childhood experiences to PTSD, depression, poly-drug use and suicide attempt in reservation-based native American adolescents and young adults. Am J Community Psychol. 2015;55(3–4):411–21. 41. Merrick MT, Ford DC, Ports KA, Guinn AS. Prevalence of adverse childhood experiences from the 2011-2014 Behavioral risk factor surveillance system in 23 states. JAMA Pediatr. 2018;172(11): 1038–44. Author's personal copy J. Racial and Ethnic Health Disparities 42. 43. 44. 45. 46. 47. 48. Aronson BD, Sittner KJ, Walls ML. The mediating role of diabetes distress and depressive symptoms in type 2 diabetes medication adherence gender differences. Health Educ Behav. 2019:1–9. Kim CJ, Schlenk EA, Kim DJ, Kim M, Erlen JA, Kim SE. The role of social support on the relationship of depressive symptoms to medication adherence and self-care activities in adults with type 2 diabetes. J Adv Nurs. 2015;71(9):2164–75. Bruce S. Prevalence and determinants of diabetes mellitus among the Metis of western Canada. Am J Hum Biol. 2000;12(4):542–51. Substance Abuse and Mental Health Services Administtaion and Indian Health Service. “The National Tribal Behavioral Health Agenda,” 2016. Jiang L, Johnson A, Pratte K, Beals J, Bullock A, Manson SM. Long-term outcomes of lifestyle intervention to prevent diabetes in American Indian and Alaska native communities: the special diabetes program for Indians diabetes prevention program. Diabetes Care. 2018;41(7):1462–70. Brockie TN, Elm JHL, Walls ML. Examining protective and buffering associations between sociocultural factors and adverse childhood experiences among American Indian adults with type 2 diabetes: a quantitative, community-based participatory research approach. BMJ Open. 2018;8(9):e022265. L. Porter, K. Martin, and R. Anda, “Self-healing communities,” 2016. 49. Barlow A, et al. Paraprofessional-delivered home-visiting intervention for American Indian teen mothers and children: 3-year outcomes from a randomized controlled trial. Am J Psychiatry. 2015;172(2):154–62. 50. Elm JHL, Walls ML, Aronson BD. Sources of stress among Midwest American Indian adults with type 2 diabetes. Am Indian Alsk Native Ment Health Res. 2019;26(1):33–62. 51. Walls M, Sittner K, Aronson B, Forsberg A, Whitbeck L, al’Absi M. Stress exposure and physical, mental, and behavioral health among American Indian adults with type 2 diabetes. Int J Environ Res Public Health. 2017;14(9):1074. 52. Aronson BD, Palombi LC, Walls ML. Rates and consequences of posttraumatic distress among American Indian adults with type 2 diabetes. J Behav Med. 2016;39(4):694–703. 53. Koita K, et al. Development and implementation of a pediatric adverse childhood experiences (ACEs) and other determinants of health questionnaire in the pediatric medical home: a pilot study. PLoS One. 2018;13(12):1–16. 54. Wade R Jr, et al. Household and community-level adverse childhood experiences and adult health outcomes in a diverse urban population. Child Abuse Negl. 2016;52(52):135–45. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.