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CONCEPT ANALYSIS
Adverse childhood experiences: towards a clear conceptual meaning
Karen A. Kalmakis & Genevieve E. Chandler
Accepted for publication 9 November 2013
Correspondence to K.A. Kalmakis:
e-mail: kalmakis@nursing.umass.edu
Karen A. Kalmakis PhD MPH FNP-BC
Assistant Professor
University of Massachusetts Amherst, USA
Genevieve E. Chandler PhD RN
Associate Professor
University of Massachusetts Amherst, USA
KALMAKIS K.A. & CHANDLER G.E. (2013) Adverse childhood experiences:
towards a clear conceptual meaning. Journal of Advanced Nursing 00(0), 000–
000. doi: 10.1111/jan.12329
Abstract
Aim. To report an analysis of the concept of adverse childhood experiences.
Background. Adverse childhood experiences have been associated with negative
physical and psychological health outcomes, but this phenomenon lacks the clear,
consistent meaning necessary for use in nursing research, theory development and
practice.
Design. Concept clarification.
Data Sources. The literature search was not limited a priori by date and included
publications with abstracts in English from PubMed, CINAHL, PsychINFO and
Social Abstracts. The search retrieved 128 articles published from 1970–2013.
The search term ‘adverse childhood experiences’ was used, with similar terms
permitted. A snowball approach was used to expand the search to relevant
literature.
Methods. The articles were read and analysed following Norris’s five steps for
concept clarification to refine, elucidate and operationally define the concept and
the context in which it occurred.
Results. Adverse childhood experiences were defined operationally as childhood
events, varying in severity and often chronic, occurring in a child’s family or
social environment that cause harm or distress, thereby disrupting the child’s
physical or psychological health and development.
Conclusion. This concept clarification should raise awareness and understanding
of the diverse nature and shared characteristics of adverse childhood experiences
that are believed to influence the health of individuals as they age. This clarified
concept will help expand research on health consequences of adverse childhood
experiences and interventions to improve health. We recommend promoting a
model of primary care that pays attention to the social and familial influences on
the health of individuals worldwide.
Keywords: adverse childhood experiences, child abuse and family dysfunction,
child maltreatment, childhood trauma, concept clarification, nursing
©2013 John Wiley & Sons Ltd 1
JAN JOURNAL OF ADVANCED NURSING
Introduction
Childhood adversity has been associated since the 1900s
with subsequent psychological and physical health prob-
lems (Pervanidou & Chrousos 2007), including develop-
mental and emotional problems in children (Chan &
Yeung 2009), health-risk behaviours among adolescents
(Clark et al. 2010) and a multitude of persistent, challeng-
ing psychological and physical illnesses among adults
(Chartier et al. 2010, Felitti & Anda 2010). The global
relevance of adverse childhood experiences is illustrated by
multiple research studies on the concept in both developed
and non-developed countries (Table 1). The global
attention given to this concept testifies to its pervasiveness
worldwide.
The phenomenon of adverse childhood experiences itself,
however, remains unclear. This lack of clarity results from
failure to define the concept. The literature provides various
examples of adverse childhood experiences ranging from
physical battering (Jun et al. 2008) to failure to receive love
and comfort (Bloom 2000), but no agreed definition.
Examples of adverse childhood experiences include child
sexual, physical and emotional abuse, as well as household
dysfunction (Anda et al. 2008, Dube et al. 2010), violent
crime, unstable home life (many caregivers and relocations)
(Douglas et al. 2010), poverty and family stress (Wickrama
& Noh 2010). The sources of adverse childhood experi-
ences also vary, from in the family unit (Noll et al. 2007)
to the surrounding social environment (Wickrama & Noh
2010). In many cases, examples are not given; instead, the
concept is defined in terms of scores on instruments such as
the Conflict Tactics Scale (Lu et al. 2008, Wu et al. 2010),
the Traumatic Life Events Scale (Steel et al. 2009) and
What’s My ACEs Score (Felitti et al. 1998). Further obscur-
ing concept clarity are numerous similar terms such as
childhood maltreatment, childhood trauma and child mis-
fortune, which have been used interchangeably with adverse
childhood experiences. Considering the many representa-
Table 1 The global extent of research on adverse childhood
experiences.
Country Authors, year
Australia Briggs and Price (2009)
Mills et al. (2009)
Brazil Madruga et al. (2011)
Canada Chartier et al. (2010)
Mock and Arai (2011)
Sareen et al. (2013)
England Salmon et al. (2007)
France Roustit et al. (2009)
Germany Hardt et al. (2011)
Schafer et al. (2010)
India Singh et al. (2012)
Iran Pournaghash-Tehrani and Feizabadi (2009)
Japan Masuda et al. (2007)
Manila Ramiro et al. (2010)
New Zealand Danese et al. (2009)
Nigeria Oladeji et al. (2010)
Portugal Pereira da Silva and da Costa Maia (2013)
South Africa Jewkes et al. (2010)
Sweden Carroll and Davies (1970)
Thailand Jirapramukpitak et al. (2011)
United States Dube et al. (2010)
Felitti et al. (1998)
Why is this concept clarification needed?
•Researchers have investigated adverse childhood experi-
ences without providing a definition of the concept.
•Lack of a clear meaning of the concept weakens the claim
that adverse childhood experiences are associated with neg-
ative physical, psychiatric and developmental health out-
comes because evidence is weak when built on inconsistent
use of a concept.
•Conceptual clarity is needed to build a programme of nurs-
ing research on the relationship between adverse childhood
experiences and health outcomes.
What are the key findings?
•The concept of adverse childhood experiences comprises
five characteristics: harmful, chronic, distressing, cumula-
tive and varying in severity.
•Adverse childhood experiences are operationally defined as
childhood events, varying in severity and often chronic,
occurring in a family or social environment and causing
harm or distress.
•The concept of adverse childhood experiences is complex
and includes numerous in-family and social-environmental
sources.
How should the findings be used to influence policy/
practice/research/education?
•A clarified concept is needed to construct theory, develop
effective measures and stimulate further research on the
effects of adverse childhood experiences on health, thus
providing a body of evidence for nursing practice.
•A clear concept of adverse childhood experiences will raise
nurses’ awareness of social and familial determinants on
health and challenge the way nurses think about the inte-
gration of social, physical and mental health.
•Nurses should be educated to recognize and intervene in
cases where adverse childhood experiences are present.
2©2013 John Wiley & Sons Ltd
K.A. Kalmakis and G.E. Chandler
tions of the concept, the authors sought to identify the
essential characteristics of adverse childhood experiences
and to clarify their meaning.
Clarity of a concept is crucial for its effective use in
research programmes and translation into practice (Meleis
2011). The purpose of this study was to clarify the meaning
of adverse childhood experiences and to promote better
understanding of the concept, its impact on health globally
and the need for further nursing research in this area. On
the basis of a historical examination of adverse childhood
experiences, a systematic review of the literature and an
analysis of concept characteristics, we propose a definition
and model for adverse childhood experiences.
Background
Interest in childhood adversity has a long history in psy-
chology and psychiatry. Freud (1910) and Bowlby (1952)
believed that circumstances of childhood strongly affected
child development and subsequent adult mental health.
Freud’s psychoanalytic theory, primarily developed from
case studies of adults relating their experience of child
abuse, still has an impact on the study of personality and
motivation (Craig & Baucum 2002). Bowlby thought that
it was essential for children to ‘experience a warm, intimate
and continuous relationship’ with their mother or a perma-
nent mother-substitute (1952, p. 11). In his Attachment
Theory, Bowlby asserted that children must feel secure in
the belief that a parent will be available when needed and
that children may suffer negative mental health
consequences from parental neglect, rejection or deprivation
(Stroebe & Archer 2013). This theory suggests that
violating a child’s sense of security and disrupting the par-
ent–child relationship threatens the child’s psychological
development.
The term ‘battered child syndrome’, which was intro-
duced by Kempe et al. (1962), was used to characterize a
clinical condition of serious physical abuse among children.
Similarly, indicators of childhood adversity have been
described by Felitti et al. (1998), which may result in a
‘battered adult syndrome’ (Foege 1998, p. 354).
For example, major childhood emotional traumas were
found in several morbidly obese participants of a weight
reduction programme (Felitti & Williams 1998). These
patients reported feeling ‘protected’ by their obesity, less
noticed and therefore safer as overweight individuals (Felitti
et al. 2010). This clinical revelation of adverse childhood
experiences affect on adult health outcomes generated fur-
ther investigation of adverse childhood experiences effects
on health outcomes (Dube et al. 2009).
Thus, psychological and physical health theorists and
practitioners, recognizing the impact of adverse childhood
experiences on mental and physical health, have used the
concept in research. Although the consequences of adverse
childhood experiences have been well studied, the concept
has not been consistently operationalized. This inconsistent
operational definition hinders the growth of research on
adverse childhood experiences and interferes with theory
development. To develop a theory about adverse childhood
experiences, it is necessary to articulate what these experi-
ences are, how they differ from related terms such as child
maltreatment and child abuse, what predicts such experi-
ences and what outcomes might be expected following
adverse childhood experiences (Probst 2011).
Concept clarification was deemed the best approach to
find a shared meaning for the concept (Meleis 2011). Our
process of concept clarification was guided by Norris’s
(1982) five steps: (1) observe and describe the concept; (2)
categorize the observations; (3) write an operational defini-
tion for the concept; (4) create a model of the concept; and
(5) formulate hypotheses about the concept.
Data sources
To clarify the concept of adverse childhood experiences, the
literature in nursing, medicine, psychology and sociology
was searched using the PubMed, CINAHL, PsychINFO and
Social Abstracts. These databases were chosen as they pro-
vided the greatest access to a wide array of journals accessi-
ble to the authors. The main search term was ‘adverse
childhood experiences,’ with similar terms used, i.e. ‘child
maltreatment,’ ‘childhood adversity,’ and ‘child trauma.’
Sources were not limited a priori by specific publication
dates; all articles found through the online search process
(N=438) were reviewed for relevance. Sources were
included if they were: (1) in English; (2) peer reviewed; and
(3) focused on multiple forms of adverse childhood
experiences as opposed to a single form, such as child
sexual abuse. This last criterion was chosen to preserve the
intent of the study, i.e. to clarify the concept of adverse
childhood experiences as a plural term. The search was
expanded in a snowball fashion to include pertinent refer-
ences cited in the articles initially reviewed. This process
resulted in 128 articles for review, published from 1970–
2013. Of these, 111 were quantitative research articles, two
were meta-analyses and 15 were review articles. Six
research studies sampled children and 105 sampled adults
who recalled their childhood experiences. Of the 128
reviewed articles, 24 were reports of research conducted
outside the USA. Most sources (n=115) were published
©2013 John Wiley & Sons Ltd 3
JAN: CONCEPT ANALYSIS Adverse childhood experiences
from 2000–2013; 12 were published in the 1990s and one
in 1970.
Both authors independently reviewed each article to
extract data on the search terms, a definition of terms, any
sub-terms (e.g. abuse, neglect), study sample and findings.
The authors met several times to analyse the data. Some
articles were reread to further extract data needed to clarify
the concept, including essential characteristics needed to
identify and recognize it in research and practice. The
authors also examined patterns associated with adverse
childhood experiences such as a relationship with phenom-
ena that occurred before the experiences (antecedents) or as
a result of them (consequences). To appreciate the concept
fully, the context in which it occurred, such as family unit
and social environment, was also analysed.
Results
Observe and describe the concept
Adverse childhood experiences were reported by 60% of
participants in one large study (Centers for Disease Control
& Prevention 2010). These adversities, as reported by adult
participants, affected their health and development as chil-
dren, often influencing their adult health years later (Green-
field & Marks 2009, Dube et al. 2010). Although many
articles used the term ‘adverse childhood experiences’, none
defined the term; instead, they offered examples of adverse
childhood experiences, e.g. physical abuse (Jun et al. 2008),
sexual abuse (Leeners et al. 2010), family dysfunction
(Edwards et al. 2007) or lack of caregiving (Herman et al.
1997). For a complete list of examples of adverse childhood
experiences for the sources reviewed see Table 2. Although
examples of a phenomenon are often used in place of a def-
inition, they do not provide a clear meaning of the concept.
The reader wonders if there are additional examples and if
so, what is included, what is not included and why. Perhaps
more importantly, this vagueness obstructs efforts to con-
duct nursing research and identify and address adverse
childhood experiences in the clinical setting.
Coexisting concepts
Much of the ambiguity surrounding the concept of adverse
childhood experiences stems from using many similar terms
in the literature. Related terms include childhood maltreat-
ment (Hahm et al. 2010), childhood trauma (Heitkemper
et al. 2011), childhood violence (Greenfield & Marks 2009)
and childhood misfortune (Schafer & Ferraro 2011). These
similar terms, like adverse childhood experiences, include
many forms of childhood adversity. The most common
adversity, child abuse, may be subdivided into physical, sex-
ual or emotional abuse. Childhood physical abuse has been
operationally defined as the ‘deliberate infliction of physical
harm that results in bruising by an adult who is at least
5 years older than a child aged 0–18 years (Brodsky &
Stanley 2008, p. 225). Childhood sexual abuse is defined as
sexual contact with a child, including acts from genital fon-
dling to penetration (Brodsky & Stanley 2008). Psychologi-
cal abuse, perhaps a more elusive form of abuse, refers to
intentional caregiver behaviours that indicate to the child
that he/she is worthless, flawed, unloved, unwanted or in
danger (Leeb et al. 2008).
Besides childhood physical, sexual and psychological
abuse, physical and psychological neglect are often included
under the umbrella terms of childhood maltreatment,
trauma, victimization and misfortune. Indeed, neglect, even
without visible physical signs, can have extremely deleteri-
ous results and is considered a form of adverse childhood
experience (Chartier et al. 2010). Childhood maltreatment,
including child abuse and neglect, is often used interchange-
ably with adverse childhood experiences, although it differs
from the latter term in not capturing family dysfunction or
the influence of the social environment. The term maltreat-
ment, i.e. to treat cruelly or roughly, has been operationally
defined as any act of commission or omission by a parent/
caregiver that results in harm, the potential for harm or
threat of harm to a child (Leeb et al. 2008). Commission is
Table 2 Examples of adverse childhood experiences.
Context Adverse childhood experience
Within the family Physical abuse
Sexual abuse
Emotional abuse
Physical neglect
Emotional neglect
Physical punishment
Witnessing domestic violence
Household member’s substance misuse
Household member’s illness
Household member’s incarceration
Parental separation/divorce
Child separation from family
Social context Poverty/Socioeconomic stratification
Racial segregation
Political conflict
Hospitalization
Community violence
School violence/bullying
Maltreatment by teacher
Natural disaster
4©2013 John Wiley & Sons Ltd
K.A. Kalmakis and G.E. Chandler
further defined as acts of abuse and omission as acts of
neglect (Leeb et al. 2008). Current terms that describe dif-
ferent aspects of childhood adversity have similarities and
common characteristics, but none captures the breadth of
the term adverse childhood experiences.
Distinguishing the concept
The concept of adverse childhood experiences represents a
larger, more overarching concept than the terms child abuse,
neglect and maltreatment. Adverse childhood experiences
encompass not only harmful acts to a child or neglect of a
child’s needs, but also familial and social-environmental
influence. For example, witnessing violence and substance
abuse in the family or social environment are also consid-
ered adverse childhood experiences (Chung et al. 2010).
Adverse childhood experiences also include family dysfunc-
tion (Taylor et al. 2004, Felitti & Anda 2010), i.e. an envi-
ronment where the child is denied a supportive, nurturing
relationship with a parent or other adult in a safe home.
Parents in such households may be unable to fulfil their roles
as family caregiver and protector due to engaging in sub-
stance misuse or criminal activity, having mental illness,
abusing others in the household or lacking knowledge of
child rearing practices (Maughan & McCarthy 1997). Such
parental behaviour can be an antecedent for abuse and
neglect (Runyan et al. 2006). Similar terms, such as ‘risky
families’, have been used to describe families characterized
by conflict and aggression and by relationships that are cold,
unsupportive and neglectful towards the child (Repetti et al.
2002). Disruption in the family and social environment such
as parental discord, divorce and poverty also threaten the
child’s development to a healthy adult (Chartier et al. 2010,
Taylor et al. 2011). Developmental consequences include
interpersonal violence (De Ravello et al. 2008), revictimiza-
tion in adult life (Jirapramukpitak et al. 2011), alcohol mis-
use throughout life (Dube et al. 2006, Strine et al. 2012)
and delinquency (Hahm et al. 2010).
In the familial context, parents are responsible for the
care and welfare of their children. Healthy parental and
parent–child relationships are vital to children’s ability to
develop relationships and a sense of security (Bowlby
1989). Healthy families support their children by making
them feel safe and in control. Lack of family support in the
presence of recurring adversity has an impact on children’s
perceptions of the world around them, thus increasing their
risk of developmental, behavioural and physical health
problems with consequences extending into adulthood. For
example, girls who witnessed interpersonal violence had
poorer health and an increased risk of exposure to such
violence as adults (Cannon et al. 2010). Family dysfunc-
tion, which affects the family dynamic and influences chil-
dren’s experiences, should be included in the definition of
adverse childhood experiences to broaden the concept
beyond childhood victimization or maltreatment.
Social environment, defined as ‘the immediate physical
surroundings, social relationships and cultural milieus in
which defined groups of people function and interact’ (Bar-
nett & Casper 2001, p. 465), represents the larger context
in which adverse childhood experiences occur. For example,
children living in impoverished communities have more
developmental and health problems than children from
affluent communities (Wickrama & Noh 2010, Mock &
Arai 2011). These adverse experiences may stem from prob-
lems in the social environment such as barriers to health-
care access and education (DELSA/HEA/HD: Directorate
for Employment, Labour & Social Affairs Health Commit-
tee, Organisation for Economic Co-operation & Develop-
ment 2008), economic hardship (Bjorkenstam et al. 2013)
and lack of social support (Trocm
eet al. 2005). Social
environment has been found to significantly impact health
and development in both urban (Burke et al. 2011) and
rural communities (Brody et al. 2010). Among persons ages
19–21, cumulative lifetime exposure to childhood adversity
was inversely associated with socio-economic level (Turner
& Lloyd 2003).
Adverse childhood experiences occur regardless of country,
race, ethnicity or gender. Adverse childhood experiences have
been reported around the world from South Africa (Jewkes
et al. 2010) to the Philippines (Ramiro et al. 2010) and from
Germany (Bader et al. 2007) to the USA (Dube et al. 2010).
Race has been associated with greater exposure to adverse
childhood experiences (Turner & Lloyd 2003). For example,
African Americans reported more adverse childhood experi-
ences than their non-Hispanic White and Hispanic counter-
parts (Turner & Lloyd 2003). Both boys and girls experience
adverse childhood experiences. Boys had more adverse child-
hood experiences than girls in one study (Turner & Lloyd
2003), but girls in another study experienced more frequent
sexual abuse and exposure to family substance use (Lamers-
Winkelman et al. 2012). Nonetheless, boys and girls who
were exposed to adverse childhood experiences had compa-
rable maladjustment problems, e.g. psychological distur-
bances, behavioural disorders, anxiety, feelings of loneliness
and alienation, intrusive thoughts, lack of enjoyment in activ-
ities, inattentiveness, disrupted sleep and nightmares (Chan
& Yeung 2009), and lower self-rated health as adults (Char-
tier et al. 2010).
Finally, when discussing the meaning of adverse childhood
experiences, one must also consider the cultural context in
©2013 John Wiley & Sons Ltd 5
JAN: CONCEPT ANALYSIS Adverse childhood experiences
which children live. For example, the perception, interpreta-
tion and response to adverse experiences may be influenced
by culture (Seedat et al. 2004), which must, therefore, be
considered when comparing results of studies on adverse
childhood experiences in different cultures. Nonetheless, sim-
ilar findings of negative health outcomes following adverse
childhood experiences have been reported in studies from
Nigeria (Oladeji et al. 2010) and Manila (Ramiro et al.
2010). On the other hand, cultures do influence the way fam-
ilies care for their children, e.g. using physical punishment as
a form of discipline, gender roles, treatment of women and
the importance of family relationships (Runyan et al. 2006).
Thus, adverse childhood experiences must include not only
family dysfunction but also threatening social environments
and detrimental social mores.
Operational definition: characteristics of adverse
childhood experiences
To clarify the meaning of a concept, one must identify its
salient characteristics. In this section, we propose and dis-
cuss five characteristics of adverse childhood experiences
gleaned from the literature: harmful, chronic, distressing,
cumulative and varying in severity.
Harmful
Adverse experiences are harmful in some way to children.
Here, we consider both harm resulting from negative expe-
riences and harm resulting from lack of positive experi-
ences. In other words, harm may be negative towards a
child in the form of intentional physical, sexual and psycho-
logical abuse, or it may result from omission, such as child
neglect and inadequate supervision (Leeb et al. 2008).
Neglect is harmful as it sends the message that a child sim-
ply does not matter and is not worthy of attention (Klein
et al. 2007). Exposure to domestic violence, a family mem-
ber’s substance misuse, mental illness or verbal threats of
harm create an environment that may also be damaging or
harmful to children (Roustit et al. 2009). Like physical and
sexual abuse, psychological maltreatment and environmen-
tal distress are destructive and put children at risk of devel-
oping health problems (Mock & Arai 2011).
Chronic or recurring
Adverse childhood experiences often recur and are chronic
manifestations. Distinguishing between acute and chronic
events in childhood is important as chronic adversities have
been associated with greater risk for psychopathology
(Jirapramukpitak et al. 2011) and physical illness (Schafer
& Ferraro 2011). These experiences are considered to
represent prolonged or frequent exposures to injury over
time (van der Kolk 2005) rather than a single event. The
term ‘event’ indicates an occurrence with a distinct begin-
ning and end. Although a single event may in some cases
result in significant health consequences, it is not the typical
pattern of childhood adversity. Chronicity was a character-
istic of adverse childhood experiences in a majority of
research studies reviewed (De Ravello et al. 2008, Chartier
et al. 2010, Dunn et al. 2011). Adverse childhood experi-
ences can be single traumatic events, but the concept is
more often manifested as chronic exposure to hardship over
time.
Distressing
Adverse childhood experiences distress children. ‘Stress’ and
‘distress’ are related and often used interchangeably in
health care, but do not have the same meaning. Stress
results in a systematic neurobiological response (McEwen
& Gianaros 2010), whereas distress is the result of expo-
sure to stress, often over a period of time (Selye 1976). A
child exposed to frequent or chronic stress becomes dis-
tressed, which may lead to negative psychological and phys-
ical health outcomes (Dube et al. 2009). Stress and
resulting distress may follow a single traumatic event, or
may result from chronic exposure to daily hassles (Wheaton
1994). Lack of perceived control over events was also
found to significantly affect the stress response (Miller et al.
2007). As adverse experiences occur in childhood when
children are not in a position of control, adverse childhood
experiences should be considered uncontrollable events and,
as such, result in greater distress. The resulting health
impacts of stress/distress are discussed under the
consequences of adverse childhood experiences.
Cumulative
Nearly all the studies reviewed mention cumulative effect.
Synonymous terms such as dose response (Jirapramukpitak
et al. 2011), graded response (Chartier et al. 2010) and
compounded effect (De Ravello et al. 2008) have also been
used to indicate that adverse childhood experiences have an
additive effect on the health of affected individuals. The
term ‘complex trauma’ has been adopted by many in the
field of childhood trauma to indicate experiences of multi-
ple, chronic and prolonged events (van der Kolk 2005). For
example, children exposed to interpersonal violence were
found to be exposed to other types of childhood adversity,
e.g. witnessing violence or parental substance abuse
(Lamers-Winkelman et al. 2012). Indeed, the overlap of
many different forms of adverse childhood experiences
makes it more difficult to specify and separate the
6©2013 John Wiley & Sons Ltd
K.A. Kalmakis and G.E. Chandler
experiences and consequently to determine the effect of one
single adverse experience (Maughan & McCarthy 1997).
This accumulation or overlap of adversities appears to
affect health outcomes. The more adverse childhood experi-
ences children suffered, the poorer they rated their health in
adulthood (Chartier et al. 2010).
Varying in severity
Adverse childhood experiences have also been characterized
as varying from less to more severe. Some forms of adverse
childhood experiences, such as childhood physical and sex-
ual abuse, have been considered to be more severe than
others (Benedetti et al. 2011), but witnessing violence had
the same effect on children’s development and behaviour as
being the victim of violence (Sternberg et al. 2006). This
confusion over severity may be explained by evidence that
a child’s individual resilience and support networks signifi-
cantly affect his or her response to adverse experiences
(Chan & Yeung 2009). The severity of an adverse child-
hood experience cannot be easily determined and seems to
depend, at least in part, on the individual child. This inter-
pretation is supported by reports that individuals who grew
up in the same home and experienced the same adversity,
but interpreted their experiences differently, differed in the
number of chronic depressive episodes (Brown et al. 2007)
and in the development of psychopathology (Laporte et al.
2011). The experience of adversity is also influenced by a
child’s racial and ethnic background (Turner & Lloyd
2003). Including ‘experiences’ in the concept suggests that
children’s perceptions of the adversity are an important part
of the phenomenon.
In summary, adverse childhood experiences occur in fam-
ily and social environments and can be recognized by five
identified characteristics: harmful to the child; the result of
acute traumas or insidious, repeated exposures to less
severe events; cause distress; often cumulative; and vary in
severity. However, the severity does not lend itself to objec-
tive rating, but rather varies according to individual inter-
pretation by the child. Finally, when clarifying the meaning
of adverse childhood experiences, particularly as it applies
to nursing and health care, it is important to discuss the
many consequences that result from adverse childhood
experiences.
Consequences
The link between adverse childhood experiences and nega-
tive long-term health outcomes is supported by strong evi-
dence. For example, an early study found that adverse
childhood experiences were associated with many leading
causes of death, including cardiovascular disease, cancer
and diabetes (Felitti et al. 1998). These relationships were
confirmed in later research, which expanded the range of
negative health consequences to migraines (Tietjen et al.
2012), insomnia (Bader et al. 2007), premature death
(Brown et al. 2009), obesity (Dube et al. 2009), more
chronic medical conditions such as diabetes, heart disease
and liver disease (Greenfield & Marks 2009), suicidal idea-
tion and substance use disorder (Jirapramukpitak et al.
2011), depression (Cannon et al. 2010), anxiety (McLaugh-
lin et al. 2010) and psychosis (Benedetti et al. 2011). In
addition, adverse childhood experiences have been associ-
ated with several health-risk behaviours including smoking
(Ford et al. 2011), substance misuse (Douglas et al. 2010)
and risky sexual behaviour (Hahm et al. 2010, Ramiro
et al. 2010). Indeed, the more adverse experiences, the
greater the effects on a child’s mental and physical health
(Briere & Jordan 2009, Chartier et al. 2010, Jirapramukpi-
tak et al. 2011). This strong evidence of the long-term neg-
ative health consequences of adverse childhood experiences
cannot be ignored.
Our synthesis of data from the literature on adverse
childhood experiences and our own research and practice
knowledge with the long-term effects of childhood adversity
have resulted in this operational definition:
Adverse childhood experiences are childhood events, varying in
severity and often chronic, occurring within a child’s family
or social environment that cause harm or distress, thereby dis-
rupting the child’s physical or psychological health and develop-
ment.
S
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i
r
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m
e
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t
F
a
m
i
l
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Abuse Number
Severity
Frequency
Child
Health Disruption
Distress
Harm
Neglect
Household
disfunction
Figure 1 Model of adverse childhood
experiences.
©2013 John Wiley & Sons Ltd 7
JAN: CONCEPT ANALYSIS Adverse childhood experiences
Create a model
Our model of adverse childhood experiences represents the
social environment that surrounds the family and the family
environment that surrounds the developing child (Figure 1).
The concept of adverse childhood experiences includes
harm to the child in the form of abuse or neglect, exposure
to domestic violence, substance abuse, criminal activity or
other forms of family dysfunction. Furthermore, adverse
childhood experiences vary in number, severity and fre-
quency, indicating a potential for increasing harm and dis-
tress to negatively affect the child’s health.
The social environment, e.g. poverty, racism, gender
inequality and neighbourhood violence, may adversely
influence the family by increasing its vulnerability, in turn
adversely affecting children in the family. In some
instances, the social environment may directly affect the
child, such as through school violence, which, in turn, may
affect the family. Children may also be harmed by events
originating in the social environment, but not in the family,
e.g. bullying and gang violence. Adverse childhood experi-
ences can be considered a constellation of related negative
events and lack of positive events in the family or social
environment.
In the model, the child, family and social environment
are mutually dependent and inseparable. What affects one,
affects all. Just as the family and social environment may
be sources of stress, they may also be sources of support
protecting the child from social violence or poverty. This
model provides a framework for future research to test rela-
tionships between its different elements. For example, one
could use the model to frame a study to examine the rela-
tionship between social support and health disruption in
adults with histories of adverse childhood experiences. Fur-
thermore, the model provides order and consistency for the
evidence gleaned through research, which can be used to
further develop theory about the association of adverse
childhood experiences and health.
Formulate hypotheses
The process by which adverse childhood experiences lead
to negative health outcomes in adulthood is not yet fully
understood. Childhood adversity has been theorized to
result from alterations in the neurobiological stress
response, leading to disease and dysfunction (McEwen &
Gianaros 2010). The neurobiological stress response contin-
ues to be studied as a possible pathway from adverse child-
hood experiences to disease (Schafer et al. 2010, Suglia
et al. 2010, Blair et al. 2011).
In addition, the mechanisms are unknown by which the
long-term health of individuals with histories of childhood
adversity is affected by social support and personal
characteristics such as resilience and coping. However, ret-
rospective reflections on childhood experiences were found
to be influenced by social experiences (Batcho et al. 2011).
That is, positive perspectives on childhood experiences were
correlated with social support, spiritual growth and
health-promoting behaviours in adulthood, whereas nega-
tive perspectives were correlated with increased distress and
troubled relationships in adulthood (Batcho et al. 2011).
Adolescents’ perceived availability of social support has also
been directly associated with fewer self-reported trauma
symptoms (Bal et al. 2003). Children’s resilience and
support networks were suggested in a meta-analysis to
moderate the effects of living with violent families (Chan &
Yeung 2009). These areas of research beckon nurses to
investigate how to improve health outcomes for individuals
with adverse childhood histories.
Discussion
A clear and agreed on meaning for adverse childhood expe-
riences promotes not only recognizing and understanding
their complex and important role in human development
and health but also building a body of research united by
one conceptual understanding. The definition of the concept
provided here reflects a middle-range explanatory theory.
Our model not only clarifies the concept of adverse
childhood experiences by specifying their characteristics,
context and related consequences but also promotes a bet-
ter understanding of their impact on health. The model
explains the relationships between social-environmental and
family sources of adverse childhood experiences and the
development of health problems.
‘Adverse childhood experiences’ is an overarching con-
cept that includes various childhood experiences; this article
is but an early step in developing the concept. Attempts to
create an exhaustive list of examples for adverse childhood
experiences have been particularly challenging. We had dif-
ficulty determining which childhood experiences should be
included and which should be excluded. Physical abuse,
sexual abuse and neglect have frequently been used as
examples of adverse childhood experiences. However, other
types of adverse childhood experience should perhaps be
considered such as acute physical illness, accidental injury,
natural disasters, or horrific events such as school shoot-
ings. The case for inclusion is supported by evidence that
these forms of childhood trauma have health consequences,
including posttraumatic stress disorder (Luo et al. 2012).
8©2013 John Wiley & Sons Ltd
K.A. Kalmakis and G.E. Chandler
Limitations
The task of clarifying adverse childhood experiences was
challenging due to their scope. The plethora of literature in
psychology, medicine, sociology and nursing made it
impractical to review every research study that examined
childhood adversity or review article on adverse childhood
experiences. However, the authors maintained an audit trail
of the decision-making and analytic processes and after
reviewing 128 articles, agreed that enough articles had been
reviewed to clarify the concept as no new data emerged
from analysis. Concept development is a dynamic ongoing
process; the concept is not static and its definition probably
will, and should, continue to be developed over time.
Conclusion
The concept of adverse childhood experiences is important
to nurse scientists who study the aetiology of disease, health
consequences of social environments and interventions to
improve health. As nurses become more aware of the con-
nection between adverse childhood experiences in its many
forms and negative health outcomes, the focus in practice
should be on creating an integrated model of primary care
that includes attention to social and familial influences on
health (Waite et al. 2010). The authors recommend that
nurses challenge the existing medical paradigm that pro-
motes a separation of mental and physical health care.
Nurses are encouraged to consider the effect of adverse
childhood experiences on their patients’ psychological and
physical well-being (Felitti et al. 2010).
Exposure to adversity in childhood violates children’s
basic human rights (Jewkes et al. 2010). To increase nurses’
recognition of adverse childhood experiences in their clien-
tele and enhance nursing research on this topic, we propose
this operational definition of adverse childhood experiences:
childhood events that vary in severity are often chronic and
occur in a child’s family or social environment to cause
harm or distress, thereby disrupting the child’s physical or
psychological health and development. Accounting for all
the scenarios where adverse childhood experiences may
occur is not possible, but our operational definition allows
for further examination of the concept in nursing and is
meant to raise nurses’ awareness and encourage thoughtful
reflection and discussion on its application to practice and
research.
Adverse childhood experiences have significant health
ramifications. Nurses must engage in research on adverse
childhood experiences and in translating research evi-
dence into practice and education. Understanding and
appreciating the effect of adverse childhood experiences on
health is critical to shaping a future healthcare delivery sys-
tem that better meets the needs of individuals, families and
communities worldwide.
Funding
This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
All authors have agreed on the final version and meet at
least one of the following criteria [recommended by the
ICMJE (http://www.icmje.org/ethical_1author.html)]:
•substantial contributions to conception and design,
acquisition of data, or analysis and interpretation of
data;
•drafting the article or revising it critically for important
intellectual content.
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JAN: CONCEPT ANALYSIS Adverse childhood experiences
