A variety of mental health problems in adulthood are related to adverse childhood experiences (ACEs). By age 16, two-thirds of children in the African American community report experiencing at least one traumatic event. The research field of ACEs is relatively young and current research accounts for less than half of ACE exposure types and their individual role in the development of mental illnesses like psychosis. Even fewer bodies of research explore cultural factors between ACEs and attenuated/subclinical psychotic symptoms. The purpose of this research was to explore how ethnic identity amongst African American young adults impacted the presentation and severity of subclinical psychotic symptoms, by way of ACE exposure. A convenience sample of 304 African American college students participated in this study. The results revealed that materialism and individualism subscales of Cultural Misorientation (CM), a measure of ethnic identity, mediated the relationship between adverse childhood experiences and subclinical psychotic symptoms in women. No association was found in men. The results suggest that clinicians and campus counselors should be aware of social cultural factors contributing to mental attenuate/subclinical psychotic symptoms.
Risk factors, Attenuated psychosis syndrome, African American, Childhood adverse experiences, Ethnic identity
National Alliance of Mental Illness  found that one in 17 adults, roughly about 13.6 million, live with a serious mental illness such as bipolar disorder, major depressive disorder, or schizophrenia. Schizophrenia spectrum diagnosis is more commonly assigned to African Americans. Failing to understand and appropriately manage cultural differences will have significant mental health consequences for varied racial/ethnic groups . The purpose of the present study was to examine risk factors of attenuated psychosis syndrome in a sample of African American young adults, specifically to investigate whether a lack of ethnic identity and the presence of adverse childhood experiences (ACEs) put an individual at a higher risk of developing attenuated psychotic symptoms.
Codifying attenuated psychosis syndrome (APS) denotes the groundbreaking peak of a quarter century of research on early psychosis. The proposed diagnostic criteria for APS in DSM-5 (American Psychiatric Association  are as follows: (1) At least one of the following symptoms is present in attenuated form, with relatively intact reality testing and is of sufficient severity or frequency to warrant clinical attention: Delusions, hallucinations, disorganized speech; (2) Symptom(s) must have been present at least once per week in the last 1 month; (3) Symptom(s) must have begun or worsened in the past year; (4) Symptom(s) is sufficiently distressing and disabling to the individual to warrant clinical attention. Symptom(s) is not better explained by another mental disorder, including depressive or bipolar disorder with psychotic features, and is not attributable to physiological effects of a substance or another medical condition; and (5) Criteria for any psychotic disorder have never been met (DSM-5, 2013) .
Individuals who fit the above-mentioned criteria for APS are more likely to develop psychosis and schizophrenia, says William Carpenter, chairman of the task force on schizophrenia spectrum disorders for DSM-5. Therefore, intervening during and even prior to the pre-psychotic period could restructure and even halt this serious mental illness in a large number of people .
Adverse childhood experiences are pervasive among youth and young adults in America, especially among those from diverse cultural backgrounds  and they are associated with multiple mental health problems in adulthood, including schizophrenia and attenuated psychosis syndrome [6,7]. Neurodevelopmental effects of trauma on children's brain has been reported, particularly damage to the stress regulation mechanisms in the hypothalamic pituitary adrenal (HPA) axis . These alterations have been suggested to contribute to a vulnerability to psychopathology under stressful circumstances . High stress sensitivity has been consistently linked to the emergence of positive psychotic symptoms in particular [10-12], therefore possibly accounting for the relationship between trauma and psychosis. Bebbington and colleagues  found that early victimization experiences contribute to the vulnerability to psychosis. Shevlin and colleagues  examined trauma (physical and sexual abuse, and neglect) and psychosis from the National Comorbidity Survey (NCS) Part 2 data. They found that the effects of neglect and sexual abuse, along with physical abuse similarly put a child at risk for psychosis. The first meta-analysis (including 41 studies with 2048 psychotic participants) revealed that people who had suffered childhood adversity were 2.8 times more likely to develop psychosis than those who had not .
Velthorst, et al.  explored trauma history and the association with baseline symptoms in a cohort of individuals at Ultra High Risk (UHR) of developing a psychotic disorder. Results revealed significant associations between a history of particular types of trauma and attenuated psychosis symptoms. A history of physical abuse and ‘other trauma' (e.g. witness of shooting, domestic violence, death of close relative/friend) during childhood correlated significantly with higher intensity of perceptual abnormalities, such as suspiciousness, visual disturbances, grandiose beliefs and low mood, compared to those persons without a trauma history. A history of sexual abuse is also related to perceptual abnormalities; however, these participants' perceptual disturbances included abusive content and PTSD symptoms.
Studies have also begun to look at gender differences in schizophrenia by way of ACEs. The incidence of schizophrenia has been found to be higher in men who have been exposed to ACEs than women who had similar experiences [16-18]. Victimization experiences are found to be linked to psychosis differentially for female and male participants, with the odds ratios correlated with rape being significantly higher for male participants .
Some African Americans at the conscious level have become alienated from their natural African orientation through their internalization of the European worldview . Their behaviors may reflect a rejection of their natural African dispositions. The African worldview can indicate psychological communal, spiritual, collective survival thrust as opposed to the European worldview of individualism and materialism. Cultural Misorientation (CM) is said to represent that foreign psychological or psychopathological disposition in the African personality, which allows African Americans, as a result of their contemporary circumstances, to unknowingly value and participate in European cultural indoctrination through the practice of European cultural values, rituals, and customs. Kambon  employs the psychological construct of CM to define and explain the intense, pervasive, and sustained contradictory psychological functioning and behaviors among African Americans reflecting an antithetical cultural orientation, which is operating from a foreign worldview framework. CM, or lack of African ethnic identity, can be a risk factor of mental illness, including APS.
The purpose of this study was to explore the roles that CM play on the overall presentation of attenuated psychotic symptoms, by way of ACE exposure.
This research used a correlational research design. Participants included a convenience sample of 304 African American college students, 199 (65.46%) women and 105 (34.54%) men from a Historically Black College and University in the southeastern region of the United States. Participants were at least 18 years of age and fairly balanced in major. Table 1 displays participant demographic information. Majority of participants experienced an ACE (83.2%) compared to those who did not identify a history of ACEs (16.8%); 68.1% of participants experienced more than one ACE.
Table 1: Demographic Characteristics by Gender (Mean ± SD or N (%)). View Table 1
Demographic, Developmental, and Family History included information on age, gender, education, GPA, marital status, employment, living arrangements, brain injury, parental Social Economic Status and education level. Questions regarding previous psychiatric contacts and hospitalizations, family history, and medical conditions were also probed.
Adverse Childhood Experiences Scale the ACE scale is a 10-item inventory that retrospectively measures cumulative experiences of childhood trauma. The ACE scale is intended to measure the association of multiple types of abuse with different types of health outcomes . Total sums range between 0 and 10. The scale does not take into account the frequency of each type of abuse but rather a cumulative account of the types of ACE experienced. ACE has appropriate internal consistency (Cronbach's alpha of 0.814, Larkin, n.d.). The participant alpha of ACE-10 for the current study was 0.916.
Prodromal Questionnaire- Brief Version PQ-BV;  PQ-BV is a 16-item instrument that measures the risk for psychosis among clinical and nonclinical samples. The instrument measures the presence of negative symptoms, perceptual abnormalities such as hallucinations, and unusual thought content like delusional ideas and paranoia. Both a dichotomous and 4-point Likert scale is used to identify the risk for psychosis or subclinical psychotic symptoms, as the respondent must first respond "true" or "false". The respondent proceeds using the 4-point Likert scale only if their initial response is "true". The Cronbach's alpha of the PQ-16 is 0.80, endorsing 6 or more symptoms specify a high true positive rate (87%) and high specificity (87%; ). The participant alpha/internal consistency of PQ-16 for the present study was 0.896.
DSM-5 Level 1 Cross - Cutting Symptom Measure-Adult. The 23-item instrument assesses mental health domains across 13 psychiatric domains deemed important across psychiatric diagnoses (American Psychiatric Association) . Each item inquiries about how much (or how often) the individual has been bothered by the specific symptom during the past 2 weeks. Only results yielded from the psychosis domain was used for analysis. A 5-point likert scale is utilized to rate the items from 0 = none/not at all to 4 = severe/nearly every day. The participant alpha/internal consistency of DSM-23 for the current study was 0.883 and 0.591 for the DSM psychosis domain.
Cultural Misorientation-Short Form (CM-SF)  the CM-SF is a 30-item personality assessment instrument designed to assess the condition of cultural misorientation across 6 subscales. The six subscales are: Materialism orientation, individualism orientation, alien-self orientation, anti-self-orientation, self-destructive orientation, and integration orientation. A 5-point likert scale is utilized to assess CM-SF total and six-sub scores with responses ranging from 1 = Strongly Disagree to 5 = Strongly Agree. CM-SF scores can range from 30 to 150 points. Minimal CM-SF score ranges from 30-50 points; this score range reflects the weakest Eurocentric orientation and behavioral expression. Moderate CM-SF S score ranges from 50.1-100 points reflecting orientation and behaviors to a much greater degree than Minimal CM-SF but to a lesser degree than Severe CM-SF. Severe CM-SF score ranges from 100.1-150 points and reflects the Eurocentric orientation and behavioral expression to the greatest degree. Cronbach's Alpha coefficients range in the 0.80 s for the total CMS and from 0.50 to the upper 0.70 s for the six subscales [24,25]. The participant alpha/internal consistency of CM-SF-30 for the current study is 0.736. Cronbach's alphas for the subscales are 0.571 (materialism orientation), 0.488 (individualism orientation), 0.125 (alien-self orientation), 0.370 (anti-self-orientation), 0.514 (self-destructive orientation) and 0.503 (integration orientation).
Upon obtaining IRB approval from the university and permission of the professors, students were invited to participate in this study. After obtaining informed consent, students were administered the questionnaires in one setting, which took about 35 minutes. The first author thoroughly debriefed participants after they completed the questionnaires and reiterated the importance of confidentiality issues in the study.
Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 20 and Statistical Analysis System (SAS). A set of Pearson correlation analysis was run to explore the relationships between adverse childhood experiences scores, CM scores and attenuated psychosis syndrome scores. A structural equation model (SEM) was used to analyze the mediating effect that CM has, if any, on the relationship between adverse childhood experiences and APS. This multivariate statistical technique estimated the multiple and interrelated dependence in a single analysis and the degree to which each variable account for one's susceptibility to attenuated psychotic symptoms.
The study was conducted to evaluate risk factors of attenuated psychosis syndrome in African American young adults. With respect to the relationship between ACE exposure and attenuated psychosis syndrome, the Pearson correlation analysis revealed no significant relationship (r = -0.073, p = 0.206) between ACE exposure and APS total scores. That is, participants who reported adverse childhood experiences were not likely to endorse more attenuated psychotic symptoms. The relationship between ACE exposure types and attenuated psychosis syndrome total scores were not significant either [abuse (PBQ r = -0.108, p = 0.061; DSM psychosis r = -0.032, p = 0.582), household dysfunction (PBQ r = -0.050, p = 0.382; DSM psychosis r = 0.029, p = 0.617), and neglect (PBQ r = -0.045, p = 0.433; DSM psychosis r = 0.003, p = 0.965)]. However, an unexpected negative significant relationship between childhood abuse exposures and symptom severity was observed (r = -0.126*, p = 0.028), indicating that participants who reported more instances of childhood abuse tended to report less symptom severity. Furthermore, there were no significant relationships between ACE exposure types and DSM psychosis subscale scores.
The bivariate Pearson correlational analysis showed significant negative correlation between ACE and the number of attenuated psychotic symptoms endorsed in female participants for PBQ total scores, but not for DSM psychosis total scores, as seen in Table 2. Unexpectedly in a similar trend, the ACE scores and the severity of attenuated psychotic symptoms were significantly negatively correlated. Results indicated that as one experienced more adverse experiences she reported less symptom severity. With regard to ACE exposure types and their individual role in the development of psychosis, only childhood abuse exposures were significantly related to APS total scores (r = -0.195**, p = 0.006) and severity scores (r = -0.193**, p = 0.006). Neither household dysfunction nor neglect were significantly related to APS total and severity scores. The Pearson correlation analyses between childhood household dysfunction and APS total and severity scores showed the following results: PQB total scores (r = -0.119, p = 0.094), DSM psychosis total scores (r = 0.028, p = 0.691), and PBQ severity (r = -0.104, p = 0.145). The results reflecting the relationship between childhood neglect and APS total and severity scores were as follows: PQB total scores (r = -0.102, p = 0.153), DSM psychosis total scores (r = 0.014, p = 0.847), and PBQ severity scores (r = -0.105, p = 0.141).
Table 2: Correlation between Adverse Childhood Experiences and Attenuated Psychotic Symptoms in Females. View Table 2
In contrast, there was no evidence of significant relationships among the variables in male participants. Specifically, no significance was found between ACE and psychotic symptoms among men for either the number of attenuated psychotic symptoms endorsed (PBQ r = 0.057, p = 0.561; DSM psychosis r = 0.010, p = 0.918) or the severity of the symptoms (r = 0.006, p = 0.949), and between ACE exposure types and APS total scores [abuse (PBQ r = 0.044, p = 0.655; DSM psychosis r = -0.051, p = 0.608), household dysfunction (PBQ r = 0.063, p = 0.525; DSM psychosis r = 0.045, p = 0.649), and neglect (PBQ r = 0.051, p = 0.608; DSM psychosis r = 0.016, p = 0.871)]. Moreover, the Pearson correlation analyses between ACE exposure types and severity of risk for developing psychosis revealed no significant relationships: Abuse (r = -0.009, p = 0.931), household dysfunction (r = 0.017, p = 0.860), and neglect (r = 0.001, p = 0.991).
The bivariate correlational analysis of the relationship between CM and APS produced a set of significant findings. CM was positively correlated to endorsed attenuated psychotic symptoms and the severity of those symptoms (Table 3). Specifically, participants who presented higher levels of CM were more likely to report attenuated psychotic symptoms and their reported symptoms are more severe. The Pearson correlation analyses between CM subscales and APS total scores and severity scores revealed that materialism and individualism orientations were independently related to APS (Table 4). Thus, as one endorsed higher levels of materialism and individualism they reported more psychotic symptoms and the symptoms they experienced were more severe.
Table 3: Correlation between Attenuated Psychotic Symptoms and Cultural Misorientation. View Table 3
Table 4: Correlation between Attenuated Psychotic Symptoms and Cultural Misorientation Subscales. View Table 4
The multiple regression analysis with SEM was used to examine the mediating effects of CM between childhood abuse and APS. CM total scores did not mediate the relationship between childhood abuse and APS, however, CM materialism and individualism subscales mediated the relationship between childhood abuse and APS, as seen in Figure 1 and Figure 2. Adding the subscales to the model increased the fit of the model significantly (-0.19 to -0.41), suggesting that physical-material objectification (materialism) and an I/Me emphasis in life (individualism) increased the childhood abuse-attenuated psychosis syndrome relationship. Thus, the likelihood of endorsing attenuated psychotic symptoms is higher in those individuals who presented materialistic and individualistic cultural misorientation. Analyses only included female participants as no association was found between ACE and psychotic symptoms among men.
Figure 1: CM Materialism mediating effect on Childhood Abuse and Attenuated Psychosis Syndrome. Numbers are path coefficients. All path coefficients are statistically significant (P < 0.05). Solid lines represent significant paths. The presented model was based on female participants exposed to childhood abuse. View Figure 1
Figure 2: CM Individualism Mediating Effect on Childhood Abuse and Attenuated Psychosis Syndrome. Numbers are path coefficients. All path coefficients are statistically significant (P < 0.05). Solid lines represent significant paths. The presented model was based on female participants exposed to childhood abuse. View Figure 2
Results support the construct of psychosis proneness by way of childhood abuse for African American young adult females. This is consistent with the results of Fisher, et al.  study, which reveals a significant relationship between childhood abuse and psychosis. We found an unexpected negative correlation between childhood abuse and attenuated psychosis syndrome. Women who experienced more childhood abuse reported fewer psychotic symptoms while the existing research suggests a positive correlation between the variables [6,14,26,27]. Recent research  indicates that university level education is associated with a decreased risk for developing psychotic symptoms in adulthood. Since participants from the present study included African American college students, it is likely that they had overcome child adversity and became more resilient. In addition, their motivation to pursue higher education may have served as a protective factor against mental illnesses such as APS. Another explanation for the non-significant findings is that the study was done on a non-clinical sample with college students and that college students have limited life history and opportunity for some symptoms to unfold. A longitudinal study may prove interesting in examining symptom development (or lack thereof) over time.
Another difference between current results and those of other studies is that although the present study and Fisher, et al.'s  study found no compelling evidence that ACE was associated with risk for psychosis in men, several studies indicated otherwise [14,16,28]. The results of the present study might be due to the disproportionate number of males (34.54%) in the sample. Thus, a larger male sample size should be included in future studies.
The significance of considering one's ethnic identity when assessing one's psychosis proneness has received increasing attention in the past decade. Data from the current SEM analysis revealed that ethnic identity could mediate the relationship between childhood abuse and APS. When CM subscales materialism and individualism were included as mediators, the direct effect between childhood abuse and the number of psychotic symptoms endorsed changed into indirect effects of childhood abuse on individualism and materialism, and individualism and materialism on attenuated psychosis syndrome. Thus, the current study showed that CM subscales, materialism and individualism served as risk factors that enhance the relationship between childhood abuse and APS. Previous research shows that experiencing childhood trauma is associated with an increased risk for psychiatric disorders [29,30]. Exposure to childhood trauma (including stressors related with low socioeconomic status) damages brain regions associated with the regulation of stress  resulting in increased neurochemical reactivity to stress and maladaptive coping responses to stressors. In other words, African Americans with some aspects of cultural misorientation (individualism and materialism) are at heightened risk of developing psychosis. African ethnic identity is associated with positive mental well-being in African Americans [20,32,33]. Apparently, embracing and adopting an identity that is congruent with one's own ethnicity produces more favorable outcomes in people of African descent. Further, adopting a non-congruent ethnic identity produces severely detrimental health outcomes [20,34]. Clearly, African Americans with CM are experiencing cognitive dissonance (internal psychological inconsistency). Whether they actively avoid this contradiction or rationalize it, the cognitive dissonance is detected at the neurological , thereby increasing risk for psychopathology.
The current study examined how one's ethnic identity influences psychosis proneness. The present findings indicate that elements of one's ethnic identity, such as cultural misorientation, puts African American youth or young adults at increased risk of severe mental illness, such as viewed by the cultural aspects of individualism and materialism. It is projected that 70 to 80% of the African population in America are said to be affiliated at the moderate to severe levels of cultural misorientation . In other words, the majority of African Americans in America are operating in a manner that can be detrimental to their overall well-being. As a result, future research should further examine how those aspects of culture actually play a role in mediating the relationship between childhood abuse and APS. For instance, Wallace and Constantine  found that for both African American women and men, higher degrees of Africentric cultural values were associated with greater perceived stigma about counseling and greater self-concealment. Considering that increased Africentric knowledge is accompanied by increase knowledge of history, it is reasonable to conclude that the knowledge of 1) Intentional human rights violations such as the U.S. Public Health Service Syphilis Study at Tuskegee, 2) Discrimination in health care , and 3) Disparities in health outcomes  logically creates a level of distrust of health care professions, including the mental health profession. Alternatively, a topic to be explored in further research might be to examine help seeking behaviors as they relate to individualism. Could individualism be one of a "variety of help-seeking behaviors" described that reduces the probability of help seeking in African [39-41]. Additionally, some research has shown that African Americans display more materialistic attitudes when compared to other groups . That is, they are concerned with material comforts or the acquisition of wealth and physical possessions, rather than with spiritual, cultural, or intellectual values. Historically, people of African descent have been disenfranchised and experience discrimination , which impacts their educational opportunities, employment and earning potential, living conditions and overall health; One would expect some degree of concern, even preoccupation, relative to basic material needs. It would be important to identify the sub-group of African Americans for which this is accurate since results indicate if one is overly concerned about possessing material things, it may affect one's well-being.
Accordingly, it is worth exploring the implementation of mental health education programs not only in college settings, but at all educational levels to educate students about their own cultural beliefs and practices and about the consequences of adhering to an antithetical ethnic identity, including individualistic and materialistic orientations. Educating students that while individuality and the desire for material things might be harmless, focusing on them too much can be harmful to one's mental health. This study provides some support that at least some aspects of cultural misorientation can be detrimental to African Americans. It would be important to educate African Americans about what CM is, its negative impact, and what can be done to guard against it . Furthermore, helping to reduce materialistic and individualistic desires that have become detrimental should also be a central focus of implemented mental health programs. Lastly, this study solely consisted of African Americans from a historically black university. Future research should consider including African American participants from various college settings, such as predominately white institutions (PWI's), as one's choice of schooling might affect cultural beliefs and identities.
There are limitations with the current study. First, this study had more female participants than male participants. This might account for the insignificance found amongst male participants, thus, future studies should be inclusive of balanced male and female participants. Second, the PQB was designed to serve as a screening tool of APS and should be used with a diagnostic instrument, such as the Structured Interview of Prodromal Syndromes (SIPS) .
In spite of the limitations, this study was the first, to our knowledge, to explore the role that ethnic identity measured by CM plays in the relationship between ACEs and APS. It is also one of the few studies to empirically include a DSM-5 related Cross cutting measure, examining its relationship to other measures. The research findings suggested that the two cultural factors, CM materialism and individualism subscales, mediated the ACE-attenuated psychosis relationship. This study has shown that adverse childhood experiences, though, do not directly increases psychosis risk, are both common and destructive among the African American population. Therefore, we should not only focus on Cultural Misorientation as a risk factor, but also childhood adverse life experiences, of APS among African American young adults. More studies are needed to explore different risk factors of mental illness in general and APS in particular.
We thank all participants for this study. We appreciate Ms. Tanisha Pelham for her assistance in SEM analysis.
We followed our Institutional Review Board ethical guidelines in conducting this study.