Psychological Medicine, Page 1 of 16.

© Cambridge University Press 2017 OR I G I N A L A R T I C L E

doi:10.1017/S0033291716003263

The association between childhood adversities and

subsequent first onset of psychotic experiences: a
cross-national analysis of 23 998 respondents from
17 countries

J. J. McGrath1*, K. A. McLaughlin2, S. Saha1, S. Aguilar-Gaxiola3, A. Al-Hamzawi4, J. Alonso5,6,7,

R. Bruffaerts8, G. de Girolamo9, P. de Jonge10, O. Esan11, S. Florescu12, O. Gureje13, J. M. Haro14,
C. Hu15, E. G. Karam16,17,18, V. Kovess-Masfety19, S. Lee20, J. P. Lepine21, C. C. W. Lim22,23,
M. E. Medina-Mora24, Z. Mneimneh25,26, B. E. Pennell25, M. Piazza27,28, J. Posada-Villa29,
N. Sampson30, M. C. Viana31, M. Xavier32, E. J. Bromet33, K. S. Kendler34, R. C. Kessler30 and on
behalf of the WHO World Mental Health Survey Collaborators†
1
Queensland Centre for Mental Health Research, and Queensland Brain Institute, University of Queensland, Australia; 2 Department of Psychology,
University of Washington, Seattle, Washington, USA; 3 Center for Reducing Health Disparities, UC Davis Health System, Sacramento, California,
USA; 4 College of Medicine, Al-Qadisiya University, Diwaniya governorate, Iraq; 5 Health Services Research Unit, IMIM-Hospital del Mar
Medical Research Institute, Barcelona, Spain; 6 Pompeu Fabra University (UPF), Barcelona, Spain; 7 CIBER en Epidemiología y Salud Pública
(CIBERESP), Barcelona, Spain; 8 Universitair Psychiatrisch Centrum – Katholieke Universiteit Leuven (UPC-KUL), Campus Gasthuisberg, Leuven,
Belgium; 9 IRCCS St John of God Clinical Research Centre, IRCCS Centro S. Giovanni di Dio Fatebenefratelli, Brescia, Italy; 10 Department of
Developmental Psychology, Research Program Interdisciplinary Center Psychopathology and Emotion Regulation, University of Groningen,
Groningen, The Netherlands; 11 Department of Psychiatry, University of Ibadan, Nigeria; 12 National School of Public Health, Management and
Professional Development, Bucharest, Romania; 13 Department of Psychiatry, University College Hospital, Ibadan, Nigeria; 14 Parc Sanitari Sant Joan
de Déu, CIBERSAM, Universitat de Barcelona, Barcelona, Spain; 15 Shenzhen Institute of Mental Health & Shenzhen Kangning Hospital, Shenzhen,
China; 16 Department of Psychiatry and Clinical Psychology, Faculty of Medicine, Balamand University, Beirut, Lebanon; 17 Department of Psychiatry
and Clinical Psychology, St George Hospital University Medical Center, Beirut, Lebanon; 18 Institute for Development Research Advocacy and
Applied Care (IDRAAC), Beirut, Lebanon; 19 Ecole des Hautes Etudes en Santé Publique (EHESP), EA 4057 Paris Descartes University, Paris,
France; 20 Department of Psychiatry, Chinese University of Hong Kong, Tai Po, Hong Kong; 21 Hôpital Lariboisière Fernand Widal, Assistance
Publique Hôpitaux de Paris INSERM UMR-S 1144, University Paris Diderot and Paris Descartes, Paris, France; 22 Queensland Brain Institute,
The University of Queensland, St. Lucia, Queensland, Australia; 23 Department of Psychological Medicine, Dunedin School of Medicine, University
of Otago, New Zealand; 24 National Institute of Psychiatry Ramón de la Fuente, Mexico City, Mexico; 25 Survey Research Center, Institute
for Social Research, University of Michigan, Ann Arbor, Michigan, USA; 26 IDRAAC, Beirut, Lebanon; 27 Universidad Cayetano Heredia, Lima,
Peru; 28 National Institute of Health, Lima, Peru; 29 Colegio Mayor de Cundinamarca University, Bogota, Colombia; 30 Department of Health Care
Policy, Harvard Medical School, Boston, Massachusetts, USA; 31 Department of Social Medicine, Federal University of Espírito Santo, Vitoria, Brazil;
32
Department of Mental Health, Faculdade de Ciências Médicas, Chronic Diseases Research Center (CEDOC) and Universidade Nova de Lisboa,
Campo dos Mártires da Pátria, Lisbon, Portugal; 33 Department of Psychiatry, Stony Brook University School of Medicine, Stony Brook, New York,
USA; 34 Department of Psychiatry, Virginia Commonwealth University, USA

Background. Although there is robust evidence linking childhood adversities (CAs) and an increased risk for psychotic
experiences (PEs), little is known about whether these associations vary across the life-course and whether mental dis-
orders that emerge prior to PEs explain these associations.

Method. We assessed CAs, PEs and DSM-IV mental disorders in 23 998 adults in the WHO World Mental Health
Surveys. Discrete-time survival analysis was used to investigate the associations between CAs and PEs, and the influence
of mental disorders on these associations using multivariate logistic models.

Results. Exposure to CAs was common, and those who experienced any CAs had increased odds of later PEs [odds ratio
(OR) 2.3, 95% confidence interval (CI) 1.9–2.6]. CAs reflecting maladaptive family functioning (MFF), including abuse,
neglect, and parent maladjustment, exhibited the strongest associations with PE onset in all life-course stages. Sexual
abuse exhibited a strong association with PE onset during childhood (OR 8.5, 95% CI 3.6–20.2), whereas Other CA
types were associated with PE onset in adolescence. Associations of other CAs with PEs disappeared in adolescence
after adjustment for prior-onset mental disorders. The population attributable risk proportion (PARP) for PEs associated
with all CAs was 31% (24% for MFF).

* Address for correspondence: Professor J. McGrath, Queensland Brain Institute, The University of Queensland, St Lucia, Queensland, Australia.
(Email: j.mcgrath@uq.edu.au)
† The World Mental Health Survey Collaborators are listed in the Appendix.

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 2 J. J. McGrath et al.

Conclusions. Exposure to CAs is associated with PE onset throughout the life-course, although sexual abuse is most
strongly associated with childhood-onset PEs. The presence of mental disorders prior to the onset of PEs does not
fully explain these associations. The large PARPs suggest that preventing CAs could lead to a meaningful reduction
in PEs in the population.

Received 21 September 2016; Revised 20 November 2016; Accepted 21 November 2016

Key words: Childhood adversity, discrete-time survival analysis, maladaptive family functioning, population
attributable risk proportion, psychotic experiences, World Mental Health survey.

Introduction Moreover, while the evidence linking CAs and life-

time PEs is robust (Morgan & Gayer-Anderson,
Psychotic experiences (PEs), including hallucinations 2016), little is known about the patterning of these
and delusions, are common among the general popula- associations at different stages of development. In par-
tion with a lifetime prevalence of 5.8–12.5% (Nuevo ticular, we are unaware of studies that have examined
et al. 2010; Linscott & van Os, 2013; McGrath et al. whether PEs tend to occur in close proximity to CA
2015). Recent evidence indicates that exposure to child- exposure, or whether CAs are associated with the
hood adversities (CAs) is associated with elevated risk onset of PEs at later periods in the life-course. PEs
of later PEs (Varese et al. 2012; Trotta et al. 2015; that emerge soon after CAs would suggest more direct
Morgan & Gayer-Anderson, 2016), with a meta-ana- and proximal mechanisms, consistent with stress-
lysis reporting that CAs are associated with a 76% related mechanisms (CAs lead to a sensitization pro-
increased risk of PEs (Trotta et al. 2015). cess that renders exposed individuals more reactive
Existing research on CAs and PEs is limited by a to subsequent stressors) (Cristobal-Narvaez et al.
focus on specific types of CAs rather than a compre- 2016). On the other hand, PEs that emerge many dec-
hensive set of CAs. For example, studies have reported ades later might suggest indirect pathways, perhaps
mainly on the following types of CAs and risk of PEs: mediated by the occurrence of mental disorders.
(a) sexual abuse (Read et al. 2003; Shevlin et al. 2007; With regard to the latter possibility, extensive evidence
Kilcommons et al. 2008; Bentall et al. 2012; Murphy suggests that CAs are associated with elevated risk of
et al. 2014; van Dam et al. 2015), (b) child abuse and first onset of a wide range of mental disorders (Green
neglect (Janssen et al. 2004; Arseneault et al. 2011; et al. 2010; Kessler et al. 2010; McLaughlin et al.
Kelleher et al. 2013; van Dam et al. 2015), and (c) bully- 2010b; 2012). We recently demonstrated that most men-
ing and peer victimisation (van Dam et al. 2012; tal disorders are also associated with increased odds of
Kelleher et al. 2013; Wolke et al. 2014; Cristobal- subsequent PE onset (McGrath et al. 2016b). Thus, it
Narvaez et al. 2016). seems reasonable to assume that the association between
CAs rarely occur in isolation (Green et al. 2010; CAs and PEs may be mediated, at least in part, by the
Kessler et al. 2010; McLaughlin et al. 2010b). The path- onset of mental disorders following exposure to CAs. A
ways linking CAs and subsequent mental health are recent analysis of the National Comorbidity Survey
also complex and inter-correlated. For example, an found that the associations of CAs with PEs were
association between parental mental illness and psy- mediated partly by depression and/or anxiety (Sitko
chopathology in the offspring may be influenced by et al. 2014), although the temporal sequence of the associ-
parenting ability (an ‘environmental’ exposure) as ation was not ascertained. Other research suggests that
well as a range of confounding factors including symptoms related to affective or emotional instability par-
shared genetic effects. CAs, like many traditional mea- tially mediate the association between CAs and PEs (Bak
sures of environmental adversity, are modestly to et al. 2005; Kramer et al. 2012; Marwaha et al. 2014). Based
moderately heritable (Kendler & Baker, 2007). Thus, on this initial work, there is a need for studies that explore
more complex models that account for both the type the influence of mental disorders on the relationship
and number of CAs are needed to determine whether between CAs and PEs. Ideally, these studies should
the associations of CAs with PEs are specific to certain explore a range of mental disorders, and ensure that the
types of experiences but not others, and how increasing variables of interest are temporally ordered (i.e. that
levels of exposure influence the risk for PEs. Indeed, sev- CAs occur prior to onset of mental disorders, which
eral prior studies have documented a dose-response occur prior to the onset of PEs), a necessary but not suffi-
relationship between number of CAs and lifetime preva- cient condition to infer causality.
lence of PEs (Janssen et al. 2004; Shevlin et al. 2007; Finally, prior work has estimated the population
Wigman et al. 2011a, b; Bentall et al. 2012; Murphy et al. attributable risk proportions (PARPs) of mental disor-
2013; Muenzenmaier et al. 2015). ders that are associated with CAs, and found sizable

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 Childhood adversities and psychotic experiences 3

PARPs both in the United States and cross-nationally (e.g. was obtained before beginning interviews in all
38–45% of childhood-onset mental disorders; and 28–29% countries. Procedures for obtaining informed consent
of early-adult onset mental disorders) (Green et al. 2010; and protecting individuals (ethical approvals) were
Kessler et al. 2010). Estimates of PARPs related to approved and monitored for compliance by the institu-
psychotic experiences have also been derived from tional review boards of the collaborating organizations
meta-analysis (33%) (Varese et al. 2012), but the relative in each country (Kessler & Ustun, 2008a). Standardized
importance of different types of CAs in contributing to interviewer training and quality control procedures
the onset of PEs in the population remains unknown. were used consistently in the surveys. Full details of
The aims of the present study were to examine the asso- these procedures are described elsewhere (Kessler
ciations between CAs and first-onset of PEs, determine et al. 2006; Kessler & Üstün, 2008b).
whether those associations vary at different stages of the Interviews were administered in two parts to reduce
life-course, and investigate the degree to which tempor- respondent burden. Part 1 was administered to all par-
ally-prior mental disorders explain the association ticipants and included the core diagnostic assessment
between CAs and subsequent PE onset. We also estimated of DSM-IV mental disorders. Part 2 of the interview
the population attributable risk proportion of PEs related included additional questions about PEs, correlates
to CA exposure. We used a large sample of adults drawn and other disorders was administered to respondents
from a cross-national population-based study – the WHO who met lifetime criteria for any Part 1 disorder and a
World Mental Health (WMH) surveys. random proportion of other respondents without any
mental disorders. Part 2 individuals were weighted by
Method the inverse of their probability of selection to adjust for
differential sampling, and therefore provide representa-
Samples tive data on the target adult general population.
The WMH surveys are a coordinated set of community Additional weights were used to adjust for differential
surveys administered in probability samples of the probabilities of selection within households, non-
general population in countries throughout the world response, and to match the samples to population
(www.hcp.med.harvard.edu/WMH; Kessler & Ustun, socio-demographic distributions.
2004). We examined 17 WMH surveys that included
both the CIDI Psychosis Module and items related to Data collection and data items
CAs. These 17 countries are distributed across North The instrument used in the WMH surveys was the
and South America (Colombia, Mexico, Peru, Sao Paulo WHO Composite International Diagnostic Interview
in Brazil, USA); Africa (Nigeria); the Middle East (Iraq, (CIDI) (Kessler & Üstün, 2008b), a validated fully-
Lebanon); Asia (Shenzhen in the People’s Republic of structured diagnostic interview (http://www.hcp.med.
China); and Europe (Belgium, France, Germany, Italy, harvard.edu/wmhcidi/instruments_download.php)
The Netherlands, Portugal, Romania, Spain). All 17 sur- designed to assess the prevalence and correlates of a
veys were based on multi-stage, clustered area probabil- wide range of mental disorders according to the defini-
ity sampling designs (Supplementary Table S1). The tions and criteria of both the DSM-IV and ICD-10 diag-
weighted average response rate across all 17 countries nostic systems. WHO translation, back-translation, and
was 71.9%. harmonisation protocols were used to adapt the CIDI
In keeping with previous studies of PEs (Saha et al. for use in each participating country.
2011a, b; McGrath et al. 2015, 2016a, b), we made the a
priori decision to exclude individuals with PEs who Psychotic experiences
screened positive for possible schizophrenia/psychosis,
and manic-depression/mania. Thus, we excluded respon- The CIDI Psychosis Module included questions about
dents who (a) reported (1) schizophrenia/psychosis or (2) six PE types – two related to hallucinatory experiences
manic-depression/mania in response to the question ‘What (visual hallucinations, auditory hallucinations) and
did the doctor say was causing (this/these) experiences?’; or four related to delusional experiences (thought inser-
(b) reported lifetime use of an antipsychotic medication tion/withdrawal, mind control/passivity, ideas of refer-
for these symptoms. This resulted in the exclusion of 91 ence, plot to harm/follow) (Supplementary Tables S2a,
respondents (0.4% of all respondents), leaving 23998 S2b). The respondents were asked if they ever experi-
respondents for this study (see Supplementary Table S1). enced each PE (e.g. ‘Have you ever seen something that
wasn’t there that other people could not see?’; ‘Have you
ever heard any voices that other people said did not exist?’
Procedures
etc.). Only PEs occurring when the person was ‘not
All surveys were conducted in the homes of respon- dreaming, not half-asleep, or not under the influence of alco-
dents by trained lay interviewers. Informed consent hol or drugs’ were included. Respondents who reported

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 4 J. J. McGrath et al.

PEs were then asked a probe question about the age of concordance with diagnoses based on blinded clinical
onset of PEs (i.e. ‘How old were you the very first time interviews (Haro et al. 2006). In keeping with our pre-
(this/either of these things/any of these things) happened vious research, standardized diagnostic hierarchy rules
to you?’). among the disorders assessed were applied where
appropriate (Kessler et al. 2005; McGrath et al. 2016a).
Childhood adversity

The WMH surveys assessed a range of family-related Statistical analysis

CAs (see Kessler et al. 2010). Eleven dichotomously
Discrete-time survival analyses with person-year as the
scored CAs occurring before age 18 were assessed
unit of analysis was used to investigate the associations
(full details are provided in Supplementary material
between CAs and PEs. A person-year dataset was cre-
S3). Age-of-exposure data were collected for other par-
ated such that each year in the life of each respondent
ental loss, parental divorce, parental death in the CIDI
(up to and including the age of onset of PE or in those
childhood section (e.g. ‘How old were you when your
without PE, their age at interview) was treated as a
father/ mother died’), while the data on sexual abuse
separate observational record. Age-of-exposure dates
were collected using questions in the post-traumatic
were available for sexual abuse, other parental loss,
stress disorder section. As with previous analyses of
parental divorce and parental death, otherwise age 4
CAs in the WMH surveys (Green et al. 2010; Kessler
years was set as a default age-of-exposure, in keeping
et al. 2010), we undertook an exploratory factor ana-
with previous analyses for CAs used in the WMH
lysis via promax rotation (Supplementary Table S4),
studies (Bruffaerts et al. 2010; Green et al. 2010). In all
and confirmed that two meaningful groups of CAs
analyses, the temporal order required the onset of
were identified: (a) ‘Maladaptive Family Functioning’
CAs to precede that of PEs. We first estimated bivariate
(MFF) CAs, and (b) ‘Other CAs’. Seven CAs loaded
associations of CAs with PEs followed by a series of
onto the MFF factor (parental mental illness, substance
multivariate models: (a) M1 included all CAs simultan-
disorder and criminal behaviour, family violence,
eously into the models without considering number of
physical abuse, sexual abuse and neglect) and four
CAs (type model), (b) M2 used only number of CAs
CAs (parental death, parental divorce, other parental
based on MFF and/or Other CAs (number model),
loss and economic adversity) loaded onto the Other
and (c) M3 based on both type and number of CAs
CA factor. All subsequent analyses examined CAs
(multivariate interactive model). We also examined if
grouped by MFF and Other CAs.
there were gender differences in the associations
between CAs and PEs. In order to choose a model
Mental disorders
for subsequent analyses, we examined both (a) model
The WMHS CIDI assessed lifetime history of 21 mental fitting measures [Bayesian Information Criterion
disorders including mood disorders (major depressive (BIC), Akaike’s Information Criterion (AIC); Akaike,
disorder, bipolar disorders); anxiety disorders [panic 1974; Schwarz, 1978], and (b) χ² tests in order to com-
disorder, generalized anxiety disorder (GAD), specific pare the odds ratios between CA types and/or number
phobia, social phobia, agoraphobia without panic, indicators as predictors of PEs.
post-traumatic stress disorder (PTSD), separation anx- Next, we re-estimated associations based on the
iety disorder (SAD) further divided into childhood most informative model for PE onsets occurring in
SAD and adult separation anxiety disorder]; behaviour four life-course stages: childhood (4–12 years); adoles-
disorders (intermittent explosive disorder, attention cence (13–19 years); young adulthood (20–29 years);
deficit disorder, oppositional defiant disorder, conduct and later adulthood (530 years). This allowed us to
disorder); eating disorder (anorexia nervosa, bulimia examine whether the associations of CAs with PE
nervosa, and binge eating disorder); and substance use onset varied across the life-course. Then, we examined
disorders (alcohol abuse, alcohol dependence, drug the strength and pattern of association between CAs
abuse, and drug dependence). The disorders that and PEs when adjusted for 21 temporally ordered
require childhood onset (e.g. attention deficit disorder, mental disorders (i.e. the mental disorder occurred
oppositional defiant disorder, conduct disorder, separ- after the CA age-of-exposure but prior to the onset of
ation anxiety disorder) were included in Part 2 and are PEs).
limited to respondents in the age range 18–39 or 18–44 Finally, the PARPs were calculated based on the pro-
years (depending on site) because of concerns about portion of PE associated with the CA in the bivariate
recall bias among older respondents (Kessler et al. models. PARPs can be interpreted as the expected pro-
2007). All other disorders were assessed for the full portion of reduction in the outcome prevalence if CAs
sample age range. Clinical reappraisal studies indicate were eradicated (Cole & MacMahon, 1971; Rothman &
that lifetime diagnoses based on the CIDI have good Greenland, 2005). In order to assess the differential

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 Childhood adversities and psychotic experiences 5

Table 1. Prevalence of childhood adversities (CA) among those with and without psychotic experiences

Without psychotic With psychotic

experience experience Total
(n = 22 337) (n = 1661) (n = 23 998)

Type of childhood adversity %a S.E. %a S.E. %a S.E.

I. Maladaptive family functioning CAs

Parental mental illness 6.5 0.2 17.3 1.2 7.1 0.2
Parental substance disorder 3.6 0.2 9.0 1.1 3.9 0.2
Parental criminal behaviour 2.4 0.1 7.3 0.9 2.7 0.1
Family violence 6.1 0.2 15.9 1.2 6.7 0.2
Physical abuse 7.5 0.2 21.7 1.4 8.3 0.2
Sexual abuse 1.2 0.1 5.8 1.0 1.5 0.1
Neglect 4.3 0.2 14.0 1.3 4.8 0.2
Any maladaptive family functioning CAs 20.3 0.4 45.9 2.0 21.7 0.4
II. Other CAs
Parental death 13.4 0.3 14.3 1.1 13.5 0.3
Parental divorce 5.1 0.2 11.6 1.2 5.5 0.2
Other parental loss 5.9 0.2 11.2 1.1 6.2 0.2
Economic adversity 2.9 0.1 5.7 0.8 3.0 0.1
Any other CAs 22.8 0.4 32.3 1.7 23.4 0.4
III. Any childhood adversities 36.6 0.5 59.8 1.8 37.9 0.5
IV. Total number of childhood adversities
Exactly 1 adversity 13.4 0.4 21.6 1.5 13.8 0.3
Exactly 2 adversities 13.4 0.3 14.6 1.3 13.5 0.3
53 adversities 6.9 0.2 19.7 1.4 7.6 0.2

a
Estimates were based on weighted data.

impact of three country level strata on PE risk, we con- followed by parental mental illness (17.3%). Among
ducted post-hoc analyses by including interaction terms those with PEs, 19.7% had been exposed to three or
between CAs and country income strata. Details of the more CAs, whereas the comparable proportion in
country strata classification have been published else- those without PEs was 6.9%.
where (McGrath et al. 2015).
As the WMH data are both clustered and weighted,
the design-based Taylor series linearization implemen- The influence of type and number of CAs
ted in SUDAAN software was used to estimate stand- Table 2 summarizes the associations between CAs and
ard errors and evaluate the statistical significance of subsequent first onset of PEs using type and/or num-
coefficients. Survival coefficients were exponentiated ber of CAs in both bivariate and multivariate models.
and are reported as odds ratios (ORs). Significance In the bivariate model, all CAs with the exception of
tests were evaluated using 0.05-level two-sided tests. parental death were significantly associated with
increased odds of subsequent PEs. Respondents with
exposure to any CA had twice the odds of subsequent
Results onset PEs compared to respondents with no CAs (OR
2.3, 95% CI 1.9–2.6). The ORs ranged from 1.7–4.0 for
Prevalence of CAs in those with and without PEs
MFF CAs and 1.4–1.9 for Other CAs, with the highest
More than one-third of respondents (n = 10,015, 37.9%) ORs associated with sexual abuse (OR 4.0, 95% CI
reported exposure to at least one CA before age 18 2.6–6.3) physical abuse (OR 2.8, 95% CI 2.3–3.3), and
years (Table 1). The prevalence of CA exposure parental criminal behaviour (OR 2.7, 95% CI 2.0–3.7).
among respondents with PEs was 59.8% compared to In general, the ORs in the multivariate model that
36.6% in those with no PEs. Among respondents controlled for all CA types were smaller than in the
with PEs, there was wide variation in the frequency bivariate model, due to the high co-occurrence of
of exposure to specific types of CAs, with the highest CAs (see M1 multivariate model, Table 2). In the multi-
prevalence reported for physical abuse (21.7%) variate model, the ORs for PEs associated with specific

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 6 J. J. McGrath et al.

Table 2. Bivariate and multivariate associations between childhood adversities (CA) and the subsequent first onset of psychotic experiences

M1 M2 M3
Multivariate Multivariate Multivariate
Bivariatea typeb numberc type + numberd
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

I. MFF CAs
Parental mental illness 2.5* (2.1–3.0) 2.0* (1.6–2.3) – 2.2* (1.8–2.7)
Parental substance disorder 1.7* (1.3–2.1) 0.9 (0.7–1.2) – 1.1 (0.8–1.5)
Parental criminal behaviour 2.7* (2.0–3.7) 1.7* (1.3–2.3) – 2.0* (1.4–2.8)
Family violence 2.1* (1.7–2.5) 1.2 (0.9–1.5) – 1.4* (1.0–1.8)
Physical abuse 2.8* (2.3–3.3) 2.0* (1.6–2.4) – 2.2* (1.8–2.7)
Sexual abuse 4.0* (2.6–6.3) 2.7* (1.7–4.2) – 3.0* (1.9–4.8)
Neglect 2.2* (1.8–2.8) 1.1 (0.9–1.5) – 1.4* (1.0–1.8)
Any MFF 2.7* (2.3–3.2) – – –
Joint significance of all seven MFF CA indicators – χ27 = 213.3* – χ27 = 114.2*
Differences in the ORs of the seven MFF CA indicators χ26 = 41.7*
Number of MFF CA indicators
1 – – 2.2* (1.8–2.6) –
2 – – 2.8* (2.2–3.6) 0.9 (0.6–1.2)
53 – – 4.0* (3.1–5.2) 0.6* (0.3–1.0)
Joint significance of the three number of MFF CA measures – – χ23 = 135.3* χ22 = 5.1
II. Other CAs
Parental death 1.2 (1.0–1.4) 1.1 (0.9–1.3) – 1.1 (0.9–1.3)
Parental divorce 1.5* (1.2–1.9) 1.3* (1.0–1.7) – 1.3* (1.0–1.7)
Other parental loss 1.7* (1.3–2.1) 1.3 (1.0–1.6) – 1.3 (0.9–1.7)
Economic adversity 1.9* (1.4–2.5) 1.4* (1.0–1.9) – 1.4 (0.9–2.1)
Any Other CAs 1.4*(1.2–1.7) – – –
Joint significance of all four Other CA indicators – χ24 = 18.6* – χ24 = 7.2
Differences in the ORs of the four Other CA indicators χ23 = 3.0
Number of Other CA indicators
1 – – 1.2 (1.0–1.4) –
2 – – 1.5* (1.2–2.1) 1.0 (0.6–1.5)
53 – – 1.8 (1.0–3.4) 0.9 (0.4–2.2)
Joint significance of the three number of Other CA measures – – χ23 = 11.9* χ22 = 0.0
III. Total CAs
Any childhood adversities 2.3* (1.9–2.6) – – –
Joint significance of all 11 CA indicators – χ211 = 326.6* – χ211 = 133.3*
Differences in the ORs of the 11 CA indicators χ210 = 52.8*
AIC – 18954.9 18987.3 18954.0
BIC – 19355.8 19329.3 19402.0

OR, Odds ratio; CI, confidence interval; MFF, maladaptive family functioning; AIC, Akaike’s Information Criterion; BIC,
Bayesian Information Criterion.
*Significant at the 0.05 level, two-tailed test.
a
Each model was estimated with one childhood adversity entered at a time as predictor of psychotic experiences onset
controlling for country, person-year dummies, age cohort and sex.
b
M1: Model was estimated with dummy variables for all childhood adversities entered simultaneously as predictors of
psychotic experiences onset including the controls specified in note a.
c
M2: Model was estimated with dummy variables for number of MFF CAs (exactly 1 MFF, exactly 2 MFF and 53 MFF)
and number of Other CAs (exactly 1 Other CA, exactly 2 Other CAs and 53 Other CAs) entered simultaneously as predictors
of psychotic experiences onset including the controls specified in note a.
d
M3: Model was estimated with dummy variables for type and number of childhood adversities (starting at exactly 2 MFF
and 53 MFF, exactly 2 Other CA and 53 Other CAs) entered simultaneously as predictors of psychotic experiences onset
including the controls specified in note a.
Total number of person-years used across all models = 9 75 199.

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 Childhood adversities and psychotic experiences 7

types of CAs varied significantly (χ210 = 52.8, p < 0.001). early adulthood, later adulthood), whereas Other
The CAs that remained significantly associated with CAs, as a set, were associated with PE onset only dur-
PEs in this model were parental mental illness, parent ing adolescence. A test for variation in the ORs across
criminal behaviour, physical and sexual abuse, parent life-course stages was significant for MFF CAs (χ221 =
divorce, and economic adversity. For these CAs, the 39.8, p = 0.008), but not in Other CAs, (χ212 = 9.4, p =
adjusted ORs ranged from 1.7–2.7 for MFF CAs and 0.66). When examining the associations of particular
1.3–1.4 for Other CAs. The highest adjusted ORs CA types with PE onset across the life-course, only
(52) were found for sexual abuse (OR 2.7, 95% CI two MFF CAs (parental mental illness, physical
1.7–4.2), physical abuse (OR 2.0, 95% CI 1.6–2.4), and abuse) were significantly associated with increased
parental mental illness (OR 2.0, 95% CI 1.6–2.3). We odds of subsequent PE onset across each of the four
further examined whether there were gender differ- life-course stages. Across particular CA types, only sex-
ences in the associations of the latter three CAs with ual abuse showed significant variation across life-course
subsequent PE onset (data not shown). The sex-specific stages with respect to subsequent PE onset (χ23 = 15.2, p =
associations were similar for parental mental illness 0.002). The highest OR for sexual abuse and PE onset
(females: OR 1.9, 95% CI 1.5–2.4; males: OR 2.0, 95% was during childhood (4–12 years) (OR 8.5, 95% CI
CI 1.4–2.9). For physical abuse, the OR (95% CI) was 3.6–20.2), and further analyses confirmed that respon-
somewhat higher for males (2.3, 1.7–3.0) compared to dents exposed to sexual abuse were more likely to
females (1.7, 1.3–2.3), whereas for sexual abuse, the OR have their PE onset during childhood (4–12 years)
was higher and significant for females (2.7, 1.7–4.4) and compared to older years (513; χ21 = 5.5, p = 0.019).
lower and non-significant for males (1.7, 0.8–3.6). In summary, MFF CAs are associated with PEs in all
In the model examining number of CAs only (i.e. life-course stages, whereas Other CAs are associated
exactly 1, exactly 2, 53 CAs), there was a monotonic with PEs only in adolescence. Moreover, while MFF
increase in the odds of PEs in respondents exposed CAs are associated with PEs across all life-course
to a greater number MFF CAs, indicating a dose- stages, sexual abuse was more strongly associated
response relationship between number of CAs and with PEs that emerge during childhood (4–12 years).
PEs. A similar pattern of increasing odds of PEs was
observed as the number of Other CAs increased (see
M2 multivariate model, Table 2).
Associations between CAs and PEs adjusting for
When we examined more complex models using
mental disorders
type and number simultaneously in the multivariate
models (M3), the OR associated with number of MFF Next, we examined the associations of CAs with PEs
and Other CAs were for the most part lower than adjusting for mental disorders that were temporally
1.0, indicating a pattern of sub-additive interactions, prior to the onset of PEs (Table 4). There were slight
whereby the incremental association of each additional reductions in the ORs associated with particular CA
CAs lessens in magnitude as the number of CAs types after adjusting for mental disorders (M4) com-
increases. Taking into account the BIC and AIC as pared to the unadjusted model (M1). However, the
well as the pattern of findings across the models, we associations of both MFF CAs and Other CAs with
chose indicators only for type of MFF and Other CAs PEs remained significant as a set after adjusting for
as the most informative model for subsequent analyses mental disorders. We also examined the association
(Table 2, model M1). of CAs with PEs within the subgroup of respondents
In summary, we observed that exposure to CAs is without any mental disorders that were temporally
associated with an increased odds of subsequent prior to the onset of PEs (M5). As a set, associations
onset of PEs, that different CA types vary in their asso- for MFF CAs remained significant with PEs, but the
ciation with subsequent PEs, and that there was a relationship became non-significant for Other CAs.
dose-response relationship between higher numbers Of interest, the OR (95% CI) for the relationship
of CA types and increased risk of subsequent PEs. between sexual abuse and PEs was 6.7 (2.5–18.0).
Finally, we examined the role of temporally-prior
mental disorders in the associations of CAs and PEs
Associations between CAs and subsequent onset of
across life-course stages (Table 5). The pattern of
PEs across four life-course stages
findings was similar to the unadjusted life-course mod-
Table 3 shows the associations between CAs and sub- els, with one exception. As a set, MFF and Other CAs
sequent onset of PEs in four life-course stages (see M1). were no longer associated with PE onsets during ado-
MFF CAs, as a set (i.e. when all MFF types were con- lescence after adjustment for temporally prior mental
sidered together), were associated with onset of PEs disorders. The association between sexual abuse and
in all four life-course stages (childhood, adolescence, PEs during childhood persisted.

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Table 3. Multivariate associations between childhood adversities (CA) and the subsequent first onset of psychotic experiences in each of four life-course stagesa

8 J. J. McGrath et al.
Test for the significance
Childhood, Adolescence, Young adulthood, Later adulthood, Test for significance of the slope differences
age 4–12b age 13–19c age 20–29d age 530e difference: (childhood across 4 life course stages
(p-years = 2 86 818) (p-years = 1 64 230) (p-years = 1 98 248) (p-years = 3 25 903) v. other 3 life-course stages)
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) χ2 (p-value) χ2 (p-value) χ2 (p-value)

I. MFF CAs
Parental mental illness 2.1* (1.4–3.0) 2.3* (1.5–3.5) 1.6* (1.2–2.1) 1.8* (1.2–2.8) χ21 = 0.0 (0.937) χ23 = 1.5 (0.674) χ221 = 39.8* (0.008)
Parental substance disorder 0.9 (0.5–1.5) 1.0 (0.6–1.7) 0.9 (0.6–1.4) 1.0 (0.5–2.0) χ21 = 0.1 (0.776) χ23 = 0.1 (0.992)
Parental criminal behaviour 2.3* (1.2–4.4) 1.6 (0.9–2.8) 1.7 (0.9–3.2) 1.2 (0.7–2.0) χ21 = 2.3 (0.130) χ23 = 2.5 (0.481)
Family violence 1.5 (0.9–2.7) 1.4 (0.9–2.1) 1.1 (0.7–1.6) 0.9 (0.6–1.4) χ21 = 1.9 (0.171) χ23 = 3.1 (0.373)
Physical abuse 2.1* (1.4–3.3) 1.5* (1.0–2.2) 1.9* (1.3–2.8) 2.2* (1.5–3.2) χ21 = 0.0 (0.959) χ23 = 3.7 (0.300)
Sexual abuse 8.5* (3.6–20.2) 1.8* (1.0–3.1) 1.1 (0.6–2.0) 2.8* (1.5–5.1) χ21 = 5.5* (0.019) χ23 = 15.2* (0.002)
Neglect 1.4 (0.9–2.3) 0.9 (0.6–1.4) 1.2 (0.8–1.8 1.1 (0.7–1.7) χ21 = 0.6 (0.423) χ23 = 2.5 (0.472)
Joint significance of all χ27 = 131.3* χ27 = 41.2* χ27 = 53.4* χ27 = 65.8*
seven MFF CA indicators
II. Other CAs
Parental death 1.4 (0.8–2.4) 0.9 (0.6–1.3) 1.4 (0.9–2.0) 0.9 (0.6–1.3) χ21 = 2.4 (0.122) χ23 = 5.7 (0.129) χ212 = 9.4 (0.665)
Parental divorce 1.2 (0.7–2.3) 1.3 (0.9–1.9) 1.2 (0.8–1.8) 1.4 (0.9–2.0) χ21 = 0.0 (0.855) χ23 = 0.0 (0.998)
Other parental loss 1.4 (0.8–2.6) 1.2 (0.7–1.8) 1.2 (0.7–1.9) 1.4 (0.9–2.2) χ21 = 0.1 (0.717) χ23 = 1.0 (0.792)
Economic adversity 1.2 (0.6–2.3) 1.9* (1.2–3.2) 1.1 (0.5–2.3) 1.2 (0.7–2.1) χ21 = 0.2 (0.651) χ23 = 2.6 (0.455)
Joint significance of all four χ24 = 4.3 χ24 = 12.6* χ24 = 3.2 χ24 = 6.6
Other CA indicators

OR, Odds ratio; CI, confidence interval; MFF, maladaptive family functioning.
*Significant at the 0.05 level, two-tailed test.
a
Model was estimated with dummy variables for all childhood adversities entered simultaneously as predictors of psychotic experiences onset controlling for country, person-years,
age cohort and sex.
b
Model is restricted to person-years between 4 and 12.
c
Model is restricted to person-years between 13 and 19.
d
Model is restricted to person-years between 20 and 29.
e
Model is restricted to person-years > 29.
 Childhood adversities and psychotic experiences 9

Table 4. Multivariate associations between childhood adversities (CA) and the subsequent first onset of psychotic experiences

Base model from Base model and additionally Base model but restricted to
Table 2a control for mental disordersb those with no mental disorderc
(py = 9 75 199) (py = 9 75 199) (py = 5 95 792)
OR (95% CI) OR (95% CI) OR (95% CI)

I. MFF CAs
Parental mental illness 2.0* (1.6–2.3) 1.5* (1.3–1.8) 1.9* (1.2–3.1)
Parental substance disorder 0.9 (0.7–1.2) 0.9 (0.7–1.2) 1.5 (0.9–2.7)
Parental criminal behaviour 1.7* (1.3–2.3) 1.7* (1.2–2.3) 1.9 (1.0–3.7)
Family violence 1.2 (0.9–1.5) 1.0 (0.8–1.3) 1.0 (0.6–1.7)
Physical abuse 2.0* (1.6–2.4) 1.8* (1.4–2.1) 2.5* (1.7–3.8)
Sexual abuse 2.7* (1.7–4.2) 2.2* (1.4–3.5) 6.7* (2.5–18.0)
Neglect 1.1 (0.9–1.5) 1.1 (0.9–1.4) 1.2 (0.6–2.1)
Joint significance of all seven χ27 = 213.3* χ27 = 97.6* χ27 = 79.3*
MFF CA indicators
II. Other CAs
Parental death 1.1 (0.9–1.3) 1.1 (0.9–1.3) 0.9 (0.6–1.3)
Parental divorce 1.3* (1.0–1.7) 1.3 (1.0–1.6) 0.9 (0.5–1.5)
Other parental loss 1.3 (1.0–1.6) 1.2 (1.0–1.6) 1.3 (0.8–2.1)
Economic adversity 1.4* (1.0–1.9) 1.3 (1.0–1.8) 1.6 (0.9–3.1)
Joint significance of all four χ24 = 18.6* χ24 = 13.5* χ24 = 4.8
Other CA indicators

py, Person-years; OR, odds ratio; CI, confidence interval; MFF, maladaptive family functioning.
*Significant at the 0.05 level, two-tailed test.
a
See note b in Table 2 for a description of model 1.
b
Model specification is as above and additionally control for 21 DSM-IV mental disorders and exactly 2 and 53 DSM-IV
mental disorders.
c
Base model but restricted to those without prior history of mental disorder temporally prior to the onset of PEs.

In summary, the pattern of associations between leading to unstable and imprecise estimates. Otherwise,
CAs and subsequent PEs remained similar in models this exposure was also associated with comparable esti-
adjusted for mental disorders, apart from weakening mates in middle and high income strata countries.
of the association between MFF or Other CAs and PE
onset in adolescence after accounting for temporally
prior mental disorders. Discussion

Based on the largest study of PEs and CAs to date, we

PARPs between CAs and PEs confirmed that CAs are associated with a more than two-
The overall PARP for PEs associated with CAs was fold increased odds of subsequent first onset of PEs,
30.9% (Supplementary Table S5) with most of this pro- which is similar but slightly higher than the pooled esti-
portion attributable to MFF CAs (24%). With regard to mate from a recent systematic review (Trotta et al. 2015).
individual CAs, physical abuse had the highest PARP We also confirmed a dose-response relationship between
(8.2%), followed by parental mental illness (6.9%). higher numbers of CA types and odds of subsequent PEs,
consistent with previous literature (Janssen et al. 2004;
Wigman et al. 2011b; Kelleher et al. 2013; Muenzenmaier
Post-hoc analysis
et al. 2015; van Dam et al. 2015). Additionally, we contrib-
We conducted an additional analysis to assess the differ- uted four novel findings: first, that CAs involving MFF
ential impact of three country-level strata on PEs risk were more strongly related to PEs than Other CAs;
using interaction terms between CAs and country strata. second, that CAs involving MFF were associated with
While the overall joint effect was significant (χ222 = 40.4, onset of PEs across all stages of the life-course; third,
p = 0.001), we found that the pairwise estimates for indi- that temporally prior mental disorders appeared to
vidual CAs on PEs were all non-significant except for explain the association of CAs with PE onset in adoles-
‘economic adversity’ (data not shown). This particu- cence, but not other life-course stages; and finally, that
lar CA was rarely reported in low income countries, CAs involving MFF may account for nearly one-quarter

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Table 5. Multivariate associations between childhood adversities (CA) and the subsequent first onset of psychotic experiences in each of four life-course stages with adjustment for mental disordersa

10 J. J. McGrath et al.
Test for the significance
Childhood, Adolescence, Young adulthood, Later adulthood, Test for significance of the slope differences
age 4–12b age 13–19c age 20–29d age 30+e difference: (childhood across 4 life-course stages
(py = 2 86 818) (py = 1 64 230) (py = 1 98 248) (py = 3 25 903) v. other 3 life-course stages)
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) χ2 (p value) χ2 (p value) χ2 (p-value)

I. MFF CAs
Parental mental illness 2.0* (1.4–2.8) 1.7* (1.1–2.7) 1.2 (0.9–1.6) 1.6* (1.0–2.4) χ21 = 0.7 (0.415) χ23 = 3.3 (0.345) χ221 = 53.6* (0.000)
Parental substance disorder 0.9 (0.5–1.5) 1.0 (0.6–1.7) 0.9 (0.6–1.5) 1.0 (0.5–2.0) χ21 = 0.0 (0.847) χ23 = 0.1 (0.990)
Parental criminal behaviour 2.4* (1.3–4.5) 1.5 (0.8–2.7) 1.8 (0.9–3.3) 1.2 (0.7–1.9) χ21 = 2.8 (0.095) χ23 = 2.8 (0.417)
Family violence 1.5 (0.9–2.7) 1.2 (0.8–1.8) 1.0 (0.6–1.5) 0.7 (0.5–1.1) χ21 = 3.4 (0.064) χ23 = 5.4 (0.146)
Physical abuse 2.1* (1.3–3.3) 1.3 (0.9–1.9) 1.7* (1.2–2.5) 2.0* (1.3–2.9) χ21 = 0.1 (0.830) χ23 = 4.0 (0.260)
Sexual abuse 9.3* (3.7–23.8) 1.5 (0.9–2.7) 0.9 (0.5–1.8) 2.1* (1.1–4.1) χ21 = 7.4* (0.007) χ23 = 15.7* (0.001)
Neglect 1.4 (0.9–2.3) 0.9 (0.5–1.4) 1.1 (0.7–1.8) 1.0 (0.7–1.6) χ21 = 0.8 (0.364) χ23 = 2.3 (0.514)
Joint significance of all 7 MFF CA χ27 = 109.0* χ27 = 13.0 χ27 = 19.7* χ27 = 32.3*
indicators
II. Other CAs
Parental death 1.4 (0.7–2.4) 0.9 (0.6–1.3) 1.3 (0.9–2.0) 0.8 (0.6–1.2) χ21 = 2.3 (0.126) χ23 = 6.0 (0.111) χ212 = 10.0 (0.612)
Parental divorce 1.2 (0.7–2.2) 1.3 (0.9–1.9) 1.2 (0.8–1.8) 1.3 (0.9–1.9) χ21 = 0.0 (0.981) χ23 = 0.0 (0.999)
Other parental loss 1.4 (0.8–2.6) 1.1 (0.7–1.8) 1.2 (0.7–1.9) 1.3 (0.9–2.0) χ21 = 0.2 (0.638) χ23 = 1.0 (0.806)
Economic adversity 1.3 (0.7–2.5) 1.7* (1.1–2.8) 1.0 (0.5–2.3) 1.1 (0.6–2.0) χ21 = 0.3 (0.597) χ23 = 2.8 (0.424)
Joint significance of all 4 Other CA χ24 = 4.4 χ24 = 9.3 χ24 = 2.7 χ24 = 4.8
indicators

py, Person-years; OR, odds ratio; CI, confidence interval; MFF, maladaptive family functioning.
*Significant at the 0.05 level, two-tailed test.
a
Model was estimated with dummy variables for all childhood adversities entered simultaneously as predictors of psychotic experiences onset controlling for country, person-years,
age cohort, sex and 21 DSM-IV mental disorders.
b
Model is restricted to person-years between 4 and 12.
c
Model is restricted to person-years between 13 and 19.
d
Model is restricted to person-years between 20 and 29.
e
Model is restricted to person-years >29.
 Childhood adversities and psychotic experiences 11

of all PE onsets in the population. We discuss each of these contribute to other early-onset mental disorders that
in turn. emerge following exposure to CAs. With respect to vul-
First, we examined whether the association of CAs nerability factors, we found that parental mental illness
with PEs varied according to CA types. To date, was associated with an increased odds of PEs. This
prior research has neither included a wide range of finding, which could reflect shared genetic vulnerabil-
CA types, nor used statistical models that acknowl- ities and/or adverse environmental exposures (e.g. sub-
edged the inter-correlated nature of CAs. Although optimal parenting), is consistent with other studies that
all CAs were associated with PEs when examined have reported an association between family history of
one-at-a-time, when examined together, only four mental disorder and lifetime prevalence of PEs
CAs reflecting MFF (parental mental illness, parental (Kelleher & Cannon, 2011; Varghese et al. 2011;
criminal behaviour, physical abuse, and sexual abuse) Jeppesen et al. 2015). Alternatively, CAs might increase
and two Other CAs (parental divorce, economic adver- risk for this early-life variant of PEs only among indivi-
sity) remained associated with subsequent PEs. duals who developed psychopathology following CA
Second, CAs involving MFF were associated with PE exposure as has been shown in other disorders such as
onsets in every stage of the life-course, whereas Other PTSD (Breslau et al. 2008; Koenen et al. 2008).
CAs were associated only with PEs in adolescence. Sexual abuse exhibited a particularly strong associ-
We have recently presented the age-of-onset curve for ation with PEs that emerge during childhood (4–12
PEs – the median (interquartile range; IQR) was 26 (17– years), with an 8.5 fold increased odds of PE emer-
41) years, indicating that PEs commence across a sur- gence among respondents who were sexually abused.
prisingly wide age range (McGrath et al. 2016b). Our Clinicians and researchers have long been aware of
findings suggest that Other CAs might increase the the association between childhood sexual abuse and
risk for PEs through mechanisms that have proximal clinical psychotic disorders (e.g. schizophrenia) (Read
consequences (Bentall et al. 2014; Morgan & Gayer- et al. 2005; Cutajar et al. 2010), and thus the link
Anderson, 2016). In contrast, MFF CAs appear to create between this exposure and PEs has been of interest
a generalized diathesis for PEs that persists across the (Morgan & Gayer-Anderson, 2016). Many studies
life-course. This diathesis could involve a variety of have previously reported links between sexual abuse
emotional, neurobiological, and cognitive processes and PEs (Read et al. 2003; Shevlin et al. 2007; Bentall
that are influenced by CAs, including heightened vul- et al. 2012; Murphy et al. 2014; van Dam et al. 2015;
nerability to stress (McLaughlin et al. 2010c), elevated Cristobal-Narvaez et al. 2016). Identifying mechanisms
emotional reactivity and poor emotion regulation skills that explain this association is important for targeting
(McLaughlin et al. 2010a; 2015; McCrory et al. 2011; interventions to prevent the onset of PEs in children
Heleniak et al. 2016), and deficits in cognitive control who have been sexually abused (e.g. psychotherapy
(DePrince et al. 2009). Each of these domains, in turn, aimed at reducing psychological vulnerabilities). Our
has been proposed as mechanisms that may underlie findings suggest that intervening mental disorders do
PEs (Freeman et al. 2007; Bentall et al. 2009, 2014; not play a meaningful role in this pathway.
Morgan & Gayer-Anderson, 2016). CAs related to MFF Fourth, CAs were associated with a substantial pro-
may differentially lead to social differentiation and portion of PE onsets in the population, and the bulk of
social defeat (at the individual and/or family level), the population attributable risk involves MFF CAs.
which has been linked to risk of PEs (Morgan & This suggests that – assuming the association of CAs
Gayer-Anderson, 2016). Identifying the precise mechan- with PEs is causal – nearly one-third of PEs could be
isms through which MFF CAs influence risk for PEs and prevented if exposure to CAs was eliminated or if
determining why this vulnerability persists throughout interventions were developed that could mitigate the
the life-course are key areas for future research. risk pathways linking CAs to PEs. Similarly high
Third, associations between CAs and PEs were PARPs have been observed for other mental disorders
largely unchanged in childhood and adulthood after associated with CAs (Green et al. 2010; Kessler et al.
adjustment for mental disorders that began prior to 2010; McLaughlin et al. 2012), underscoring the signifi-
the onset of PEs. In contrast, CAs were no longer asso- cance of CAs in shaping the distribution of psycho-
ciated with PE onset in adolescence after accounting pathology in the population.
for prior-onset mental disorders. We have previously The current study has several limitations which
identified an association between mental disorder deserve comment. We excluded those who were
and PEs (McGrath et al. 2016a). Our findings suggest screen-positive for possible psychotic disorders (based
that prior mental disorders might be particularly import- on self-report, use of antipsychotic medications to
ant as a pathway to PEs in adolescence among youths treat PEs). However, we did not have access to valid
with exposure to CAs. It is possible that the vulnerability measures of clinical psychotic disorders in our sample,
factors that predispose to adolescent-onset PEs also and thus it is feasible that a small proportion of

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 12 J. J. McGrath et al.

respondents with clinical psychosis were included in ScD, Robert M. Bossarte, PhD, Evelyn J. Bromet, PhD,
the analyses. We also relied on retrospective reports Ronny Bruffaerts, PhD, Brendan Bunting, PhD, Jose
about age of onset, which might have led to a recall Miguel Caldas de Almeida, MD, PhD, Graca Cardoso,
bias. For some CAs, we were not able to determine an MD, PhD, Alfredo H. Cia, MD, Stephanie Chardoul,
age of onset, and used a default of age 4 which is the Somnath Chatterji, MD, Alexandre Chiavegatto Filho,
standard earliest age of onset for disorders and expo- PhD, Pim Cuijpers, PhD, Louisa Degenhardt, PhD,
sures within the WMH studies. However, we note that Giovanni de Girolamo, MD, Ron de Graaf, MS, PhD,
several prospective studies have confirmed the associ- Peter de Jonge, PhD, Koen Demyttenaere, MD, PhD,
ation between CAs and subsequent PEs (Arseneault David D. Ebert, PhD, Sara Evans-Lacko, PhD, John
et al. 2011; Fisher et al. 2013; Kelleher et al. 2013; Rossler Fayyad, MD, Fabian Fiestas, MD, PhD, Silvia Florescu,
et al. 2014; Wolke et al. 2014). While we were able to MD, PhD, Sandro Galea, DrPH, MD, MPH, Laura
explore a much wider range of CAs than previous studies, Germine, PhD, Stephen E. Gilman, ScD, Dirgha J.
we focused on family-related exposures and we lacked Ghimire, PhD, Meyer D. Glantz, PhD, Semyon
information on childhood bullying. In light of the grow- Gluzman, MD, Oye Gureje, PhD, DSc, FRCPsych,
ing body of evidence linking this particular type of CA Josep Maria Haro, MD, MPH, PhD, Meredith G.
with PEs, this would be an important exposure to include Harris, MPH, PhD, Yanling He, MD, Hristo Hinkov,
in future studies (Kelleher et al. 2008; van Dam et al. 2012; MD, Chi-yi Hu, PhD, MD, Yueqin Huang, MD, MPH,
Fisher et al. 2013; Wolke et al. 2014). We did not adjust for PhD, Aimee Nasser Karam, PhD, Elie G. Karam, MD,
multiple comparisons in this study which may lead to Norito Kawakami, MD, DMSc, Ronald C. Kessler,
inflation of Type I errors. In the current analyses we PhD, Andrzej Kiejna, MD, PhD, Karestan C. Koenen,
have focused on PEs as a class only, however there is evi- PhD, Viviane Kovess-Masfety, MSc, MD, PhD,
dence to suggest that certain types of CAs (e.g. sexual Carmen Lara, MD, PhD, Sing Lee, PhD, Jean-Pierre
abuse) may be linked to hallucinations more than delu- Lepine, MD, Itzhak Levav, MD, Daphna Levinson,
sions (Bentall et al. 2014). We plan to explore this research PhD, Zhaorui Liu, MD, MPH, Silvia S. Martins, MD,
question in future studies. PhD, Herbert Matschinger, PhD, John J. McGrath,
PhD, Katie A. McLaughlin, PhD, Maria Elena Medina-
Mora, PhD, Zeina Mneimneh, PhD, MPH, Jacek
Conclusions
Moskalewicz, DrPH, Fernando Navarro-Mateu, MD,
Based on the largest single study to date, our cross- PhD, Matthew K. Nock, PhD, Siobhan O’Neill, PhD,
national study confirms the association between CAs Mark Oakley-Browne, MB, ChB, PhD, Johan Ormel,
and the subsequent onset of PEs. CAs related to MFF PhD, Beth-Ellen Pennell, MA, Marina Piazza, MPH,
are associated with PEs that emerge across the life ScD, Stephanie Pinder-Amaker, PhD, Patryk
span, and intervening mental disorders do not account Piotrowski, MD, PhD, Jose Posada-Villa, MD, Ayelet
for this finding. Childhood sexual abuse was strongly M. Ruscio, PhD, Kate M. Scott, PhD, Vicki Shahly,
associated with PEs that emerged during childhood. PhD, Tim Slade, PhD, Jordan W. Smoller, ScD, MD,
While we have more than enough evidence linking Juan Carlos Stagnaro, MD, PhD, Dan J. Stein, FRCPC,
CAs with adverse mental and physical health out- PhD, Amy E. Street, PhD, Hisateru Tachimori, PhD,
comes (Scott et al. 2010), the robust literature now link- Nezar Taib, MS, Margreet ten Have, PhD, Graham
ing CAs and PEs can provide important clues to Thornicroft, PhD, Yolanda Torres, MPH, Maria
aetiopathogenesis of PEs and mental disorders Carmen Viana, MD, PhD, Gemma Vilagut, MS,
(Heleniak et al. 2016). These, in turn, can inform clinic- Elisabeth Wells, PhD, Harvey Whiteford, PhD, David
ally-targeted interventions designed to reduce the bur- R. Williams, MPH, PhD, Michelle A. Williams, ScD,
den of mental disorders in those exposed to CAs Bogdan Wojtyniak, ScD, Alan M. Zaslavsky, PhD.
(Bentall et al. 2014; Morgan & Gayer-Anderson, 2016).

Supplementary material
Appendix. WMH Survey Collaborators
The supplementary material for this article can be
The WHO World Mental Health Survey collaborators found at https://doi.org/10.1017/S0033291716003263.
are: Tomasz Adamowski, PhD, MD, Sergio Aguilar-
Gaxiola, MD, PhD, Ali Al-Hamzawi, MD, Mohammad
Acknowledgements
Al-Kaisy, MD, Abdullah Al Subaie, MBBS, FRCP,
Jordi Alonso, MD, PhD , Yasmin Altwaijri, MS, PhD, The World Health Organization World Mental
Laura Helena Andrade, MD, PhD, Lukoye Atwoli, Health (WMH) Survey Initiative is supported by the
MD, PhD, Randy P. Auerbach, PhD, William G. National Institute of Mental Health (NIMH; R01
Axinn, PhD, Corina Benjet, PhD, Guilherme Borges, MH070884), the John D. and Catherine T. MacArthur

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https://doi.org/10.1017/S0033291716003263
 Childhood adversities and psychotic experiences 13

Foundation, the Pfizer Foundation, the US Public Mental Health, Faculty of Medical Sciences, NOVA
Health Service (R13-MH066849, R01-MH069864, and University of Lisbon, with collaboration of the
R01 DA016558), the Fogarty International Center Portuguese Catholic University, and was funded by
(FIRCA R03-TW006481), the Pan American Health Champalimaud Foundation, Gulbenkian Foundation,
Organization, Eli Lilly and Company, Ortho-McNeil Foundation for Science and Technology (FCT) and
Pharmaceutical, GlaxoSmithKline, and Bristol-Myers Ministry of Health. The Romania WMH study projects
Squibb. We thank the staff of the WMH Data ‘Policies in Mental Health Area’ and ‘National Study
Collection and Data Analysis Coordination Centres for regarding Mental Health and Services Use’ were carried
assistance with instrumentation, fieldwork, and consult- out by National School of Public Health & Health
ation on data analysis. None of the funders had any role Services Management (former National Institute for
in the design, analysis, interpretation of results, or prep- Research & Development in Health, present National
aration of this paper. The views and opinions expressed School of Public Health Management & Professional
in this report are those of the authors and should not be Development, Bucharest), with technical support of
construed to represent the views of the sponsoring orga- Metro Media Transilvania, the National Institute of
nizations, agencies, or governments. Statistics – National Centre for Training in Statistics, SC.
The Colombian National Study of Mental Health Cheyenne Services SRL, Statistics Netherlands and were
(NSMH) is supported by the Ministry of Social funded by Ministry of Public Health (former Ministry of
Protection. The ESEMeD project is funded by the Euro- Health) with supplemental support of Eli Lilly Romania
pean Commission (Contracts QLG5-1999-01042; SRL. The São Paulo Megacity Mental Health Survey is
SANCO 2004123, and EAHC 20081308), the Piedmont supported by the State of São Paulo Research
Region (Italy)), Fondo de Investigación Sanitaria, Insti- Foundation (FAPESP) Thematic Project Grant 03/00204-
tuto de Salud Carlos III, Spain (FIS 00/0028), Ministerio 3. The Shenzhen Mental Health Survey is supported by
de Ciencia y Tecnología, Spain (SAF 2000-158-CE), the Shenzhen Bureau of Health and the Shenzhen
Departament de Salut, Generalitat de Catalunya, Bureau of Science, Technology, and Information. The
Spain, Instituto de Salud Carlos III (CIBER CB06/02/ US National Comorbidity Survey Replication (NCS-R)
0046, RETICS RD06/0011 REM-TAP), and other local is supported by the National Institute of Mental Health
agencies and by an unrestricted educational grant (NIMH; U01-MH60220) with supplemental support
from GlaxoSmithKline. Implementation of the Iraq from the National Institute of Drug Abuse (NIDA), the
Mental Health Survey (IMHS) and data entry were car- Substance Abuse and Mental Health Services Adminis-
ried out by the staff of the Iraqi MOH and MOP with tration (SAMHSA), the Robert Wood Johnson
direct support from the Iraqi IMHS team with funding Foundation (RWJF; Grant 044708), and the John
from both the Japanese and European Funds through W. Alden Trust. Evelyn Bromet has funding from CDC/
United Nations Development Group Iraq Trust Fund NIOSH (U01OH010712; R. Kotov; PI; U01OH010718,
(UNDG ITF). The Lebanese Evaluation of the Burden B. Luft, PI; and U01OH010718, A. Gonzalez, PI) and
of Ailments and Needs Of the Nation (L.E.B.A.N.O. NIA (R01AG049953, S. Clouston, PI). John McGrath
N.) is supported by the Lebanese Ministry of Public received John Cade Fellowship APP1056929 from the
Health, the WHO (Lebanon), National Institute of National Health and Medical Research Council.
Health/Fogarty International Center (R03 TW006481-
01), anonymous private donations to IDRAAC, Declaration of Interest
Lebanon, and unrestricted grants from, Algorithm,
AstraZeneca, Benta, Bella Pharma, Eli Lilly, Glaxo In the past 3 years, Dr Kessler received support for his
Smith Kline, Lundbeck, Novartis, Servier, Phenicia, epidemiological studies from Sanofi Aventis, was a con-
sultant for Johnson & Johnson Wellness and Prevention,
UPO. The Mexican National Comorbidity Survey
(MNCS) is supported by The National Institute of and served on an advisory board for the Johnson &
Psychiatry Ramon de la Fuente (INPRFMDIES 4280) Johnson Services Inc. Lake Nona Life Project. Dr
Kessler is a co-owner of DataStat, Inc., a market research
and by the National Council on Science and Technology
(CONACyT-G30544- H), with supplemental support firm that carries out healthcare research.
from the PanAmerican Health Organization (PAHO).
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