To the Editor Bethell et al1 find a dose-response association between positive childhood experiences (PCEs) and depression/poor mental health (D/PMH) and adult-reported social/emotional support after accounting for exposure to adverse childhood experiences. In nonrandomized (real-world) data, treatment selection can be biased by unobservable confounders or inadequately measured explanatory variables, including, in this case, drug use additional to alcohol, exercise, income, wealth, education, race/ethnicity, comorbidities, family and friends, community engagement, job stress, sleep, and major life events. In this case, PCEs may serve as a proxy for such unobservable factors, suggesting that the observed adjusted odds ratio of 0.28 (95% CI, 0.21-0.39; P < .001) for D/PMH among those reporting 6 to 7 PCEs indeed implies a moderate degree of causality after adjusting for age, race/ethnicity, and annual income.
Gong CL, Yieh L, Hay JW. Validating the Importance of Positive Childhood Experiences on Adult Mental Health. JAMA Pediatr. 2021;175(2):204. doi:10.1001/jamapediatrics.2020.0094
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