Adverse Childhood Experiences and Lifelong Health Article Discussion
#1 Define ACEs. #2 What 8 experiences are included in ACEs? #3 What new adverse experiences did Finkelhor add to previous scales? #4 What is the cost of childhood abuse and neglect annually in America? #5 What changes does the American Academy of Pediatrics recommend to address toxic stress? Is our health a matter of how well we are raised? EDITORIAL Adverse Childhood Experiences and Lifelong Health I N MORE THAN 60 ARTICLES SINCE 1998, INTERnist Vincent Felitti, MD, pediatrician Robert Anda, MD, MS, and others have studied the relationship of childhood adversity and a variety of lifelong physical and emotional outcomes. Adverse Childhood Experiences and Lifelong Health Article Discussion
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1,2 Using a retrospective study design, they surveyed 17 337 adult health maintenance organization members (average age, 57 years) about crucial events during childhood and linked those events in a dose-response manner with cardiovascular disease; cancer; AIDS, and other sexually transmitted diseases; unwanted, often-highrisk pregnancies; chronic obstructive pulmonary disease; and a legacy of self-perpetuating child abuse. While it is hard to believe, many medical and child welfare professionals did not see the links among child abuse and other common social problems with poor health and premature death in adulthood.3 See also page 70 These 8 adverse childhood experiences (or ACEs), as they have come to be called, include exposure of a child before age 18 years to emotional abuse, physical abuse, contact sexual abuse, alcohol/substance abuse, mental illness, criminal behavior, parental separation/divorce, and domestic violence. While there have been questions about the validity of the study design, studies using ACEs have moved to less affluent samples to fit within an accepted universal ecobiodevelopmental framework for understanding health promotion and disease prevention across the lifespan and are supported by recent additional advances in neuroscience, molecular biology, and the social sciences.3-9 In this issue, Finkelhor et al10 seek to improve on this conceptual model and strengthen our understanding of the relationship between childhood adversity and lifelong health. Using data from telephone interviews in 2008 combined with a nationally representative sample of 2020 US children in a study not designed to measure the ACEs (the National Survey of Children’s Exposure to Violence10), the authors obtained incidence and prevalence estimates for a wide range of childhood victimizations and other adversities. They performed a secondary analysis that reconstructed the traditional ACE items and found that the current ACEs do predict current stress among adolescents in a dose-related fashion Adverse Childhood Experiences and Lifelong Health Article Discussion.
Adolescent stress is thought to be a crucial mediator linking ACEs with longer-term health problems and illness and is a likely predictor of long-term negative life events.11 The authors then posit that there are problems methodologically with the retrospective nature of the current ACEs, which also miss things we know are problems associated with adult adversity, such as poor peer relationships, poor school performance, poverty, and unemployment. They then add additional variables to the original ACEs to see what contributes more to psychological distress, choosing new items that have been suggested by relationships of child maltreatment with childhood stress in current research. These additional adverse experiences include having parents who always argue, being friendless, having someone close with a bad illness or serious injury, peer victimization, property victimization, and exposure to community violence. In their models, the authors found that the prediction of current childhood stress was significantly improved by removing some of the original ACEs and adding others in these domains. While this is encouraging, they conclude that “our understanding of the most toxic adversities is still incomplete because of complex interrelationships among them.”10 While there is no doubt that childhood adversity causes and/or contributes to adult adversity, the results of the study by Finkelhor et al10 do help us to better understand toxic stress during childhood and potential critical situations in which we can intervene as families, communities, and a society. Using a study design with more predictive ACEs that measure adversity during childhood will minimize memory error and bias to achieve a more accurate and comprehensive assessment of childhood events Adverse Childhood Experiences and Lifelong Health Article Discussion.
We will then be able to better identify children and families at risk before there is childhood stress or other measurable harm. Finkelhor et al10 are correct to say that we know enough to move to intervention and prevention. The seemingly large costs of child abuse and neglect ($80 billion in the US in 201212) pale in comparison with the economic and human burden of adult poor health and premature death. Some have said “Fight Crime, Invest in Kids,”13 and our response needs to include more than reactionary child welfare and criminal justice responses. Why do we not offer counseling to all children with psychological maltreatment or exposure to domestic violence?14-17 We need to connect the dots in childhood and adolescent trauma to improve the response of all the first responders (including physicians), publicize that these experiences have JAMA PEDIATR/ VOL 167 (NO. 1), JAN 2013 95 WWW.JAMAPEDS.COM ©2013 American Medical Association. All rights reserved. Downloaded From: http://jamanetwork.com/ by George Morris on 04/20/2016 downstream poor medical and mental health outcomes, optimize and expand the treatments we know work, and increase public support for these interventions.18 More immediately, we should be appalled if future health care reform does not include universal home visiting for newborns and their families because this has been clearly shown to improve numerous child health and developmental outcomes. As pediatricians, we have unique roles in preventing the adverse consequences of toxic stress using routine anticipatory guidance that strengthens family social supports, encourages positive parenting techniques, and facilitates a child’s social, emotional, and language skills. We should start in our medical home with identification and intervention and then move out of the office and into homes, schools, and the community while advocating for a growing number of evidence-based programs. The American Academy of Pediatrics19 has recommended that we (1) adopt the ecobiodevelopmental framework, (2) incorporate the growing scientific knowledge linking childhood adversity with lifelong health effects into pediatric training, (3) be more proactive in educating parents and other child welfare professionals about the long-term consequences of childhood stress, (4) be vocal advocates for the development and implementation of evidence-based interventions that reduce toxic stress or mitigate its effects, and (5) have our medical homes strengthen anticipatory guidance and screening for children and families at risk, with development of innovative service-provision adaptations and local resources to address the risks of toxic stress Adverse Childhood Experiences and Lifelong Health Article Discussion.
We can use the ACEs to identify children and families now who will suffer later if we fail to act. We need to act now as physicians, professionals, and community leaders to reduce childhood adversity and promote lifelong health. Vincent J. Palusci, MD, MS Published Online: November 26, 2012. doi:10.1001 /jamapediatrics.2013.427 Author Affiliations: New York University School of Medicine, Frances L. Loeb Child Protection and Development Center, Bellevue Hospital, New York, New York. Correspondence: Dr Palusci, New York University School of Medicine, Frances L. Loeb Child Protection and Development Center, Bellevue Hospital, 462 First Ave, Room GC65, New York, NY 10016 ([email protected]). Conflict of Interest Disclosures: None reported. REFERENCES 1. Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACE) Study: major findings by publication year. http://www.cdc.gov/ace/year.htm. Accessed June 15, 2012. 2. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245-258. 3. Weiss MJS, Wagner SH. What explains the negative consequences of adverse childhood experiences on adult health? insights from cognitive and neuroscience research. Am J Prev Med. 1998;14(4):356-360. 4. Dube SR, Williamson DF, Thompson T, Felitti VJ, Anda RF. Assessing the reliability of retrospective reports of adverse childhood experiences among adult HMO members attending a primary care clinic. Child Abuse Negl. 2004;28(7):729-737. 5. Anda RF, Felitti VJ, Bremner JD, et al. The enduring effects of abuse and related adverse experiences in childhood: a convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci. 2006;256(3):174-186. 6. Flaherty EG, Thompson R, Litrownik AJ, et al. Effect of early childhood adversity on child health. Arch Pediatr Adolesc Med. 2006;160(12):1232-1238. 7. Ramiro LS, Madrid BJ, Brown DW. Adverse childhood experiences (ACE) and health-risk behaviors among adults in a developing country setting. Child Abuse Negl. 2010;34(11):842-855. 8. Shonkoff JP, Garner AS; Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232-e246. 9. Shonkoff JP, Richter L, van der Gaag J, Bhutta ZA. An integrated framework for child survival and early childhood development. Pediatrics. 2012;129(2):e460-e472. 10. Finkelhor D, Shattuck A, Turner H, Hamby S. Improving the Adverse Childhood Experiences Study Scale [published online November 26, 2012]. JAMA Pediatr. 2013;167(1):70-75. 11. Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2008. 12. Gelles RJ, Perlman S. Estimated Annual Cost of Child Abuse and Neglect. Chicago, IL: Prevent Child Abuse America; 2012. 13. Fight Crime. Invest in Kids. http://www.fightcrime.org/. Accessed June 15, 2012. 14. Cohen JA, Mannarino AP, Iyengar S. Community treatment of posttraumatic stress disorder for children exposed to intimate partner violence: a randomized controlled trial. Arch Pediatr Adolesc Med. 2011;165(1):16-21. 15. Layne CM. Developing interventions for trauma-exposed children: a comment on progress to date, and 3 recommendations for further advancing the field Adverse Childhood Experiences and Lifelong Health Article Discussion.
Arch Pediatr Adolesc Med. 2011;165(1):89-90. 16. Palusci VJ, Ondersma SJ. Services and recurrence after psychological maltreatment confirmed by child protective services. Child Maltreat. 2012;17(2):153-163. 17. Perrin EC, Sheldrick RC. The challenge of mental health care in pediatrics. Arch Pediatr Adolesc Med. 2012;166(3):287-288. 18. Asnes AG, Leventhal JM. Connecting the dots in childhood and adolescent trauma. Arch Pediatr Adolesc Med. 2011;165(1):87-89. 19. Garner AS, Shonkoff JP; the American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics. Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics. 2012;129 (1):e224-e231 http://pediatrics.aappublications.org/content/129/1/e224. Accessed June 15, 2012. JAMA PEDIATR/ VOL 167 (NO. 1), JAN 2013 96 WWW.JAMAPEDS.COM ©2013 American Medical Association. All rights reserved. Downloaded From: http://jamanetwork.com/ by George Morris on 04/20/2016 ARTICLE Improving the Adverse Childhood Experiences Study Scale David Finkelhor, PhD; Anne Shattuck, MA; Heather Turner, PhD; Sherry Hamby, PhD Objective:
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To test and improve upon the list of adverse childhood experiences from the Adverse Childhood Experiences (ACE) Study scale by examining the ability of a broader range to correlate with mental health symptoms. Design: Nationally representative sample of children and adolescents. Setting and Participants: Telephone interviews with a nationally representative sample of 2030 youth aged 10 to 17 years who were asked about lifetime adversities and current distress symptoms. Main Outcome Measures: Lifetime adversities and participants, but the association was significantly improved (from R2 =0.21 to R2 =0.34) by removing some of the original ACE scale items and adding others in the domains of peer rejection, peer victimization, community violence exposure, school performance, and socioeconomic status. Conclusions: Our understanding of the most harmful childhood adversities is still incomplete because of complex interrelationships among them, but we know enough to proceed to interventional studies to determine whether prevention and remediation can improve long-term outcomes. Adverse Childhood Experiences and Lifelong Health Article Discussion