Adverse Childhood Experiences

Using Evidence to Advance Research, Practice, Policy, and Prevention

Gordon J. G. Asmundson, Tracie O. Afifi

• Publisher: Academic Press
• Year: 2019
• ISBN:
  9780128160664
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

Adverse Childhood Experiences: Using Evidence to Advance Research, Practice, Policy, and Prevention defines ACEs, provides a summary of the past 20 years of ACEs research, as well as provides guidance for the future directions for the field. It includes a review of the original ACEs Study, definitions of ACEs, and how ACEs are typically assessed. Other content includes a review of how ACEs are related to mental and physical health outcome, the neurodevelopmental mechanisms linking ACEs to psychopathology, sexual violence and sexual health outcomes, and violence across the lifespan. Important and contemporary issues in the field, like reconsidering how ACEs should be defined and assessed, the appropriateness of routine ACEs screening, thinking about ACEs from a public health and global perspective, strategies for preventing ACEs, understanding ACEs and trauma-informed care and resilience, and the importance of safe stable and nurturing environments for children are discussed. Adverse Childhood Experiences is a useful evidence-based resource for professionals working with children and families, including physicians, nurses, social workers, psychologists, lawyers, judges, as well as public health leaders, policy makers, and government delegates.

• Reviews the past 20 years of ACEs research
• Examines ACEs and mental and physical health
• Discusses the neurodevelopment mechanisms of ACEs and psychopathology
• Examines ACEs and violence across the lifespan
• Reconsiders the definition and assessment of ACEs
• Examines the issue of routine ACEs screening
• Discusses ACEs from a public health and global perspective
• Summarizes effective ACEs prevention, trauma-informed care, and resilience
• Provides recommendations for the future directions of the ACEs field

Section 1

Chapter 1

Twenty years and counting: The past, present, and future of ACEs research

Shanta R. Dube Department of Population Health Sciences, School of Public Health, Georgia State University, Atlanta, GA, United States

Abstract

In 1995, the landmark CDC-Kaiser ACE Study was launched to examine the contribution of early-life adversities to multiple behavioral risks and adverse health outcomes across the lifespan. Since the seminal study, there have been multiple ACE Study replications and applications of the research findings. This chapter outlines the history of the original ACE Study, and current efforts in the field to address and prevent early childhood trauma.

Keywords

ACEs; Research translation; Prevention; Policy; Legislation

Introduction

A little over two decades ago, the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente in San Diego launched the landmark CDC-Kaiser ACE Study (Felitti et al., 1998). This groundbreaking study of adverse childhood experiences (ACEs) documented the contribution of early-life stress and trauma to the leading and actual causes of death in the US across the lifespan. Since being launched, numerous ACEs efforts across various disciplines have focused on crossvalidation through study replications and research translation. Realizing that ACEs are widespread, multiple systems and settings are now actively applying the research findings.

The ACE Study was conducted among an adult cohort born between 1900 and 1978 who retrospectively assessed their childhood adversities. One of the most striking findings from the ACE Study is that within the cohort, all generations with one or more early-life adversities were at greater risk for substance abuse, mental illness, and perpetrating violence compared to those reporting no ACEs. Thus, ACEs science provides empirical support on the importance of breaking the intergenerational cycle of these early-life exposures. By virtue of these findings, a dual- or multigenerational approach emphasizes the importance of recognizing ACEs among adults to promote their healing and recovery, in order to prevent future exposure to the next generation of children. This chapter outlines the history of the CDC-Kaiser ACE Study, citing the original published studies. Current efforts to address and prevent early childhood trauma along with proposed future directions are discussed.

Past: Initial clinical observations leading to the ACE Study

In the early 1990s, Felitti (1993) conducted a case-control study to examine how life events correlated with obesity among adults entering a weight management program compared to a control group of nonobese, slender adults. Through interviews, the study indicated that the prevalence of childhood abuse (e.g., sexual and physical), early parental loss, and parental alcoholism was higher among obese adults compared to nonobese, slender adults. The study also revealed that obesity among adults served as their protection from unwanted attention and excess food intake as a means to cope with emotional distress. His research also documented the correlation between current depression and current family and marital problems in obese adults compared to nonobese, slender adults. The findings from this initial observational study served as a springboard for the ACE Study (Felitti et al., 1998), which would be one of the most extensive epidemiological studies to examine the long-term health consequences of multiple, co-occurring forms of childhood abuse, childhood neglect, and related household stressors.

From 1995 to 1997, over 17,000 adult health maintenance organization (HMO) members who made appointments for an overall health assessment took part in the ACE Study across two separate waves. Two weeks after their clinic visit at Kaiser Permanente’s Department of Preventive Medicine in San Diego, California, individuals were sent the Family Health History Questionnaire (Felitti et al., 1998) to complete in the privacy of their home. In the first wave, the Family Health History Questionnaire included eight categories of ACEs. Assessment included three forms of abuse (i.e., physical, emotional, and sexual) and exposure to five types of household dysfunction while growing up (i.e., witnessing mother being treated violently, living with substance abuse in the home, living with mentally ill household member, absence of household member due to incarceration, and parental discord/divorce).

Felitti et al. (1998) examined seven of the eight ACEs—physical abuse, emotional abuse, sexual abuse, growing up in a home exposed to untreated mental illness, household substance abuse, witnessing mother treated violently, and absence of household member due to incarceration—in relationship to the actual and leading causes of death in the US. In the second wave of the ACE Study, measures of physical and emotional neglect were added, increasing the total number of childhood adversities examined to a total of 10 (Dube et al., 2001).

The CDC-Kaiser ACE Study led to the following summary findings:

1. (1) Childhood exposure to abuse, neglect, domestic violence, and related household stressors are widespread and commonly occur across all populations. In the Kaiser Permanente study cohort that was predominately White, well-educated adults with good healthcare, close to two-thirds of the respondents reported experiencing at least one adversity, and close to 40% reported two or more ACEs (Felitti et al., 1998). Additionally, 1 in 6 men and 1 in 4 women experienced childhood sexual abuse (CSA), with the contribution of CSA to depression, substance use, and marital problems in adulthood being similar for both genders, highlighting the importance in recognizing that all children, girls and boys, are vulnerable to this form of abuse (Dube et al., 2005).
2. (2) Childhood exposure to abuse, neglect, domestic violence, and related household stressors are an interrelated group of commonly occurring adverse childhood experiences. When exposed to any one category of ACEs, 81% to 98% of respondents reported experiencing one or more additional childhood adversities and 58% to 90% of respondents reported experiencing two or more ACEs (Dong et al., 2004). By enumerating the total number of childhood adversities reported, the ACEs score provided evidence of dose-response relationships between childhood adversities and numerous health, social, and behavioral outcomes (Felitti et al., 1998).
3. (3) Childhood exposure to abuse, neglect, domestic violence, and related household stressors contribute to important social, behavioral, and health outcomes across the lifespan. ACEs are associated with a wide range of health problems that begin in adolescence as behavioral risks and continue into adulthood as a disease, behavioral risks, and social outcomes of importance in society today (see Fig. 1). The Life Course Epidemiology Model (Ben-Shlomo & Kuh, 2002), which includes recognition of these experiences as nonbiological exposures with an intergenerational cycle, is an essential framework by which the long-term impact of ACEs must be studied.

   

   
   

   Fig. 1 The cycle and impact of ACEs across the lifespan and generations.

4. (4) Childhood exposure to abuse, neglect, domestic violence, and related household stressors contribute to health outcomes that transcend a 100 years of social and secular trends to change behaviors and prevent disease (Dube, Anda, Felitti, Dong, & Giles, 2003). Study participants born between 1900 and 1978 who reported ACEs had an increased odds of alcohol problems, smoking, illicit drug use, sexual risk behaviors, and mental illness across four separate birth cohorts from 1900 to 1978 (Dube et al., 2003). The findings from this particular study support the supposition that ACEs have a strong influence on health, despite the time period when individuals were born.
5. (5) Childhood exposure to abuse, neglect, domestic vio...