(1998). They found a graded relationship between the number of childhood traumas (Table 5-3) and alcoholism, drug abuse, and depressed mood. Similarly, they found a graded relationship with physical disorders, such as severe obesity, cancer, stroke, and chronic bronchitis or emphysema. This study’s findings in relation to suicide attempts were discussed in an earlier section.

PATHWAYS TO SUICIDALITY

The preceding sections spotlight the grim and sometimes enduring impact of childhood trauma, especially sexual abuse and physical abuse, on mental health. Yet most studies are not suited to illuminating the pathways to suicidality. They examine the immediate or short-term effects of trauma in children, typically through a cross-sectional design, or they look much later, at adult populations, to retrospectively assess risk factors. This means that there is knowledge about the beginning and later stages, but not the complex pathways linking the two. Furthermore, most studies are not population- or community-based. Finally, and perhaps most importantly, there have been few attempts to study how the process unfolds by integration of known biological, psychological, and behavioral sequelae of trauma.

The best insight into pathways to suicidality comes from a small body of longitudinal studies (Brown et al., 1999; Fergusson et al., 2000b; Silverman et al., 1996) and a nationally representative, cross-sectional United States study of adults from the National Comorbidity Survey (Molnar et al., 2001a). What emerges from these studies is that childhood trauma induces a range of effects that, over time, can coalesce into diagnosable mental disorders, suicidal ideation, and suicide attempts by adolescence and young adulthood. The underlying mechanisms are not known. The timing of these events is difficult to discern, even from longitudinal studies, because survey questions about physical and sexual abuse are, for legal and ethical reasons, not usually asked until study subjects reach age 18.

One analysis of timing is from the National Comorbidity Survey, which is representative of the United States population (Molnar et al., 2001a). This retrospective, cross-sectional study dealt with child sexual abuse and suicidality. The mean age of onset of sexual abuse was 9 years for females and 11 years for males. The mean age of onset of a mental disorder was 16–17 years. The probability of the first suicide attempt came at an earlier age if the victim of sexual abuse also met criteria for any lifetime mental disorder. This group attempted suicide in adolescence, 8– 12 years before those who had been sexually abused but did not develop a disorder. This finding suggests that detection of both sexual abuse and psychopa-



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