Relationship Distress as a Mediator of Adverse Childhood Experiences and Health: Implications for Clinical Practice with Economically Vulnerable Racial and Ethnic Minorities

• DOI: http://doi.org/10.1111/famp.12392
• Author: Ryan G. Carlson,Andrew P. Daire,Sejal M. Barden,Naomi J. Wheeler
• Published date: 01 December 2019
• Date: 01 December 2019

Relationship Distress as a Mediator of Adverse

Childhood Experiences and Health: Implications for

Clinical Practice with Economically Vulnerable

Racial and Ethnic Minorities

NAOMI J. WHEELER*

ANDREW P. DAIRE*

SEJAL M. BARDEN

†

RYAN G. CARLSON

‡

Adverse childhood experiences (ACE) are interpersonal sources of distress negatively cor-

related with physical and mental health, as well as maladaptive intimate partner conflict

strategies in adulthood. Economically vulnerable racial and ethnic minorities repo rt the

greatest disparities in exposure to ACE, as well as relationship distress and health. Yet, lit-

tle is known about the connections between ACE, relationship distress, and health. We

therefore tested a theoretical model for the mediating role of relationship distress to explain

the ACE-health connection with a sample (N=96) predominantly racial/ethnic minorities

(87%) with low income. We applied partial least squares structural equation modeling with

bootstrapping (N=500). Relationship distress strengthened the predictive relationship

between ACE and health, and accounted for 42% of the variance in health. The results pro-

vide preliminary support for relationship distress as a social determinant of health dispar-

ities with implications for interdisciplinary health intervention.

Keywords: Adverse Childhood Experiences; Health; Relationship Distress; PLS-SEM

Fam Proc 58:1003–1021, 2019

Chronic illnesses annually contribute over one trillion dollars to the economic burden

(DeVol & Bedroussain, 2007), affect half of adults over the age of 18, and are the lead

cause of death and disability in the United States (Ward, Schiller, & Goodman, 2014).

Moreover, chronic illnesses, such as cancer or hypertension, disproportionately affect

racial and ethnic minorities in terms of diagnosis, negative disease trajectory, and sur-

vivorship rates (Clegg, Li, Hankey, Chu, & Edwards, 2002; Hicken, Lee, Morenoff, House,

& Williams, 2014; Zonderman, Ejiogu, Norbeck, & Evans, 2014). Similarly, individuals

with low income are five times more likely to report poor mental and physical health when

compared to moderate-income counterparts (Stanford Center on Poverty and Inequality,

*Department of Counseling and Special Education, Virginia Commonwealth University, Richmond, VA.

†

Department of Counselor Education and School Psychology, University of Central Florida, Orlando, FL.

‡

Department of Educational Studies, College of Education, University of South Carolina, Columbia, SC.

Correspondence concerning this article should be addressed to Naomi J. Wheeler, School of Education,

Department of Counseling and Special Education, Virginia Commonwealth University, P.O. Box 842020,

Richmond, VA 23284-2020. E-mail: njwheeler@vcu.edu.

The data collected for this manuscript were supported by the Department of Health and Human Ser-

vices (DHHS), Administration for Children and Families, Office of Family Assistance, grant: 90FM0039-

01-00. Any opinions, findings, conclusions, or recommendations are those of the authors and do not neces-

sarily reflect the views of US DHHS, Office of Family Assistance.

1003

Family Process, Vol. 58, No. 4, 2019 ©2018 Family Process Institute

doi: 10.1111/famp.12392

2016). We note that race, ethnicity, and income are unique factors, each with their own

nuanced contribution to stress and health. However, the overlap between groups illumi-

nates a high-risk population for health concerns and targeted intervention—we refer ence

this population as economically vulnerable (i.e., low-income), ethnically and racially

diverse individuals.

Ample evidence exists to support the contribution of socially based inequalities as

health determinants (i.e., social determinants of health). For instance, socioeconomic posi-

tion and relationship distress influence health behavior and health outcomes (Ahnquist,

Wamala, & Lindstrom, 2012; Miller, Hollist, Olsen, & Law, 2013; Mize, 2017). In addition,

stress associated with chronic illness negatively influenced family relationship dynamics

such as impaired communication and adjustment to the illness as well as to new house-

hold responsibilities (Dalteg, Benzein , Fridlund, & Malm, 2011; Sav et al., 2015). Yet,

most of these studies included a predominantly married, white, and middle-income demo-

graphic. Moreover, a paucity of research exists for sources of social health determinants,

such as relationship distress within the family system, which are influential to habits,

behavior, and overall health. Given that economically vulnerable, ethnically and racially

diverse individuals are often underrepresented in research and underserved in health

intervention services (American Journal of Managed Care, 2006), as well as evidence that

individuals with economic disadvantage experience more negative consequences of rela-

tionship distress (Choi & Marks, 2013), a critical need exists to identify social and sys-

temic factors (i.e., components of family relational health such as relationship sustaining

behavior and conflict management, perceived relationship satisfaction, or support) that

contribute to negative health patterns among this group.

Theoretical Foundation and Operational Definitions

Economically disadvantaged individuals and couples often have fewer resources for

support and coping (Karney, Story, & Bradbury, 2005). In turn, individuals with low

income experience disparities in relationship distress and stability (Amato, 2010;

Mansfield, Dealy, & Keitner, 2013). Financial tension and stress associated with economic

disadvantage are influential for individual mental health, as well as partner and parent–

child relationships (Conger et al., 1990, 1992). The Family Stress Model demonstrated the

influence of economic pressures to parental depression, whereby increased financial strain

was also associated with marital instability, harsher parenting approaches, and greater

risk for divorce among Caucasian families from the Midwest farming community. Furth er-

more, researchers replicated the Family Stress Model with an urban and racially diverse

sample (Parke et al., 2004) as well as with a more div erse definition of the family system

(e.g., single-parent families; Neppl, Senia, & Donnellan, 2016).

Economic stress permeates individual well-being and translates to greater relationship

distress. Additionally, the strained marital dynamics associated with economic stress may

persist inter-generationally—children from the initial Conger et al. study who reported

parental responsiveness and positive marital affect also reported greater relationship

quality and positive relationship behaviors (e.g., conflict management) as emerging adults

in their own partner relationships (Conger, Cui, Bryant, & Elder, 2000). Thus, financial

stress influenced relationship behaviors (e.g., effort, coping) for the couple and the parent–

child dyad. Moreover, models like the biobehavioral family model (BBFM; Wood, 1993)

explain the role of family relationships as contributors to health or disease activity as a

function of emotional climate and individual biobehavioral reactivity to stressors (i.e.,

mental health and psychophysiological stress).

For the current investigation, we explored the theorized associations between these

three demonstrated areas of disparity (i.e., relationship distress, childhood adversity, and

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