Adverse Childhood Experiences

by

Joan A. Reid

• LAST REVIEWED: 11 January 2018
• LAST MODIFIED: 11 January 2018
• DOI: 10.1093/obo/9780195396607-0233

Introduction

Substantial bodies of research from various fields have consistently documented the long-term, detrimental effects of childhood maltreatment and trauma. In the health science field, a body of research—known as Adverse Childhood Experiences (ACE) studies—has raised awareness among health-care providers of the cumulative or dose-response impact of childhood adversity on long-term health and well-being. Much of research on child maltreatment and trauma presents partitioned prevalence estimates for individual types of family violence and abuse, obscuring the reality that many children are victims of more than one type of abuse or violence. In contrast, ACE researchers designed a composite measure of childhood adversity, labeled an ACE score, calculated by summing eight to ten types of childhood adversities, each measured as either present or absent during childhood regardless of the duration or severity of the adversity. Researchers found that experiencing multiple types of childhood adversity was linked to the leading causes of death in the United States. The mechanisms facilitating the lifelong association between ACEs and poor health have been conceptualized in the ACE Pyramid Framework, which links childhood adversity to chronic health problems and early death by means of social, emotional, and cognitive impairments and health risk behaviors. In alignment with the ACE Pyramid, researchers have investigated the links between ACEs and (1) chronic health problems and early death, (2) mental health risk and suicide, (3) health risk behaviors, (4) violence and offending risk, and (5) risk for further victimization. ACE studies have explored the impacts of ACEs on various health and social outcomes using samples from differing population groups, including community samples, school samples, samples encompassing several birth cohorts, and samples of incarcerated populations. The ACE studies have provided greater understanding of the prevalence and impact of childhood maltreatment and trauma. The body of ACE research has the potential to guide policy aimed at preventing ACEs and to inform intervention strategies—encouraging trauma-informed care—for individuals who have experienced multiple types of childhood adversity. However, many questions remain. The mechanism of the association between ACEs and early death, which types of childhood adversities should be counted, the relative impact of various types of childhood adversities, and differences in ACE effects on men and women and across races or ethnicities have not yet been established.

General Overviews

Kaiser Permanente’s Department of Preventive Medicine in San Diego, in collaboration with the US Centers for Disease Control and Prevention (CDC), conducted the foundational ACE Study. The Kaiser Permanente-CDC ACE Study was one of the largest investigations ever conducted on the impact of childhood adversity on later-life health and well-being. Results of the foundational ACE Study conducted by Kaiser Permanente-CDC are reported in Felitti, et al. 1998. As described in Felitti and Anda 2010, data used in the Kaiser Permanente-CDC Study were drawn from participants’ medical histories completed by health-care providers, physical examinations, and results of laboratory tests. In addition, study participants completed confidential self-report surveys regarding their current health status; their childhood history, including experiences of child maltreatment; and their engagement in health-risk behaviors such as smoking, alcohol or illicit drug use, and driving under the influence. As displayed on the Centers for Disease Control and Prevention Adverse Childhood Experiences web page, the ACE Pyramid depicts a theoretical framework that explains the mechanisms facilitating the association between ACEs and chronic health problems and early death. Kalmakis and Chandler 2015 provides a comprehensive and systematic review of ACE research conducted between 2008 and 2013.

• Centers for Disease Control and Prevention. Adverse Childhood Experiences.

  The ACE Pyramid Framework sets forth the pathway or mechanisms by which ACEs are linked to chronic health problems and early death. The pyramid’s foundational level is “Adverse Childhood Experiences.” The next, subsequent level is “Disrupted Neurodevelopment.” The third level is “Social, Emotional, and Cognitive Impairment.” The fourth level of the pyramid is “Adaptation of Health-Risk Behaviors.” The fifth level is “Disease, Disability, and Social Problems.” The top level of the pyramid is “Early Death.”

• Felitti, Vincent J., and Robert F. Anda. 2010. The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behavior: Implications for healthcare. In The impact of early life trauma on health and disease: The hidden epidemic. Edited by Ruth A. Lanius, Eric Vermetten, and Clare Pain, 77–87. Cambridge, UK: Cambridge Univ. Press.

  DOI: 10.1017/CBO9780511777042.010

  This chapter provides a detailed overview of the Kaiser Permanente-CDC ACE Study, including findings and health-care implications, and would be useful for undergraduate or graduate students.

• Felitti, Vincent J., Robert F. Anda, Dale Nordenberg, et al. 1998. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine 14.4: 245–258.

  DOI: 10.1016/S0749-3797(98)00017-8

  The first journal article to report results of the ACE Study conducted at Kaiser Permanente-CDC, based on the first wave of data collection from over 9,500 participants. Researchers found a strong, dose-response relationship between the number of childhood exposures and risk factors for leading causes of death, including heart disease, cancer, chronic bronchitis or emphysema, hepatitis, stroke, and diabetes.

• Kalmakis, Karen A., and Genevieve E. Chandler. 2015. Health consequences of adverse childhood experiences: A systematic review. Journal of the American Association of Nurse Practitioners 27.8: 457–465.

  DOI: 10.1002/2327-6924.12215

  This review article provides a systematic review of forty-two ACE studies conducted between 2008 and 2013, with specific implications for the nursing profession. Based on the review of studies, the researchers encourage nursing professionals in clinical practice to screen patients for a history of ACEs and craft individualized treatment plans to assist patients to cope more successfully with emotional and biological responses to childhood adversity, thereby minimizing negative health outcomes.