Adverse childhood experiences (ACEs) are associated with poor mental health outcomes across the lifespan (Anda et al., 2005; Bremner, 2003; Brodsky and Stanley, 2008; Dube et al., 2001; Felitti et al., 1998; Springer et al., 2007; Norman et al., 2012; Petruccelli et al., 2019; Tran et al., 2022). ACEs encompass a broad range of adverse events during childhood, including physical, verbal, and sexual abuse; physical and emotional neglect; and household dysfunction, such as parental separation (Petruccelli et al., 2019). A growing body of research has demonstrated an association between adverse childhood experiences and various mental health outcomes, including major depressive disorder (MDD), generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), and suicidal ideation (Anda et al., 2005; Bremner, 2003; Brodsky and Stanley, 2008; Dube et al., 2001; Felitti et al., 1998; Springer et al., 2007; Norman et al., 2012; Tran et al., 2022). To date, much of the literature has focused on the “dose-response” relationship between number of ACEs and adverse mental health outcomes, in which individuals with a greater number of ACEs experience higher rates of distress (Felitti et al., 1998; Aronson et al., 2020).

Military veterans may be particularly vulnerable to ACEs given the higher prevalence of childhood traumas and compounding effects of military service-related traumas (Blosnich et al., 2014, 2021; Katon et al., 2015). The prevalence of ACEs among veterans may be higher than the general population, as the military may serve as a route for individuals to leave dysfunctional childhood homes (Blosnich et al., 2014). Indeed, veterans are more likely to report exposure to ACEs relative to non-veterans, which may increase risk for the development of poor mental health outcomes (Blosnich et al., 2014, 2021; Katon et al., 2015). The risk for poor mental health outcomes may be further compounded by various military risk factors, such as combat exposure, moral injury, and military sexual trauma (Mitchell, et al., 2012; Bryan et al., 2015; Holliday et al., 2023; Nichter et al., 2020; Wilson, 2018).

Current understanding of the relationship between ACEs and mental health outcomes among veterans may be further enhanced by addressing three methodological limitations and knowledge gaps (Blosnich et al., 2021). First, there is a lack of research utilizing representative samples, primarily due to most studies being conducted among veterans utilizing Veterans Affairs (VA) healthcare (Blosnich et al., 2021). Given that most U.S. veterans do not utilize VA mental health services (Kline et al., 2022), general population data may help inform the burden of ACEs in the general veteran population. Second, most studies of ACEs and mental health have focused on the relationship between a total count of ACEs and mental health outcomes rather than on the impact of individual ACEs. While some individual ACEs such as child sexual abuse have been examined in relation to adverse mental health outcomes (Adams et al., 2018; Hailes et al., 2019), scarce research has examined how all ten ACEs, which encompass various forms of abuse, neglect, and household dysfunction, may be related to these outcomes. Identifying which specific ACEs are associated with mental health outcomes is important, as it may help inform risk stratification and treatment planning (Wang et al., 2022). Third, research on ACEs and mental health has predominantly focused on PTSD and suicidality as outcomes; research on the relationship between ACEs and other mental health outcomes, including depression and anxiety, has been limited (Blosnich et al., 2021). Elucidation of differential associations between specific ACEs and a broader range of mental health outcomes is needed to clarify the potential role of these experiences in shaping risk for prevalent mental disorders in the veteran population.

To address the aforementioned gaps in the literature, we analyzed data from a large, contemporary, nationally representative sample of U.S. military veterans to evaluate: (1) the prevalence of ACEs among veterans; and (2) the association between specific ACEs and various mental health outcomes of key relevance to military veterans, including PTSD, major depressive disorder, generalized anxiety disorder, suicidal ideation, and past suicide attempts.