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Questioning the use of adverse childhood experiences (ACEs) questionnaires

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Abstract

Adverse childhood experiences (ACEs) are increasingly recognized as important predictors of poor health outcomes. In response, there is increasing application of ACEs questionnaires in clinical practice and population health surveys. Such efforts are often justified as approaches to identify ACEs, components of trauma-informed care, and/or measures to determine prevalence within epidemiological research. Unfortunately, such measures are often used without evaluating the strengths and limitations of the measures themselves. One of the most commonly used ACEs questionnaires is a ten-question version (ACEs-10), that is composed of two clusters - one asking about different types of child maltreatment, and the other asking select questions about household challenges. Unfortunately, both this questionnaire and its derivatives have substantial drawbacks that warrant careful consideration about their use. Problems include limited item coverage, collapsing of items and response options, a simplistic scoring approach, and the lack of psychometric assessment. These deficiencies are inconsistent with the standards expected for use of measures in healthcare services and research. Given these deficiencies, we recommend that these limitations are addressed before further use of ACEs-10, and its derivatives, for either clinical or research purposes.

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... drawbacks related to conceptual and measurement issues that were unaddressed within the original ACEs study (McLennan et al., 2020;Negriff, 2020;White et al., 2019) and persist in contemporary adaptations of the original ACEs measure (Conway & Lewin, 2022;Finkelhor et al., 2015;Karatekin & Hill, 2019). A meta-analysis by Hughes et al. (2017) found considerable heterogeneity in the outcomes of ACEs, which is likely due to definitional, methodological, and cultural differences across studies (Briggs et al., 2021;Kalmakis & Chandler, 2014). ...
... To move the science of ACEs forward, the theoretical and empirical merits of ACEs must be critically examined. Surprisingly, little effort has been given to clearly conceptualize childhood adversity, which has resulted in several recent critiques of ACEs (Kalmakis & Chandler, 2014;McLennan et al., 2020;White et al., 2019). The current article describes the theoretical limitations of the total ACE score (e.g., combining maltreatment and household dysfunction), expanding on previous critiques of measurement (e.g., McLennan et al., 2020) and providing an explicit conceptualization of childhood adversity that can inform future research and advance our understanding of ACEs. ...
... CONCEPTUALIZING ADVERSITY other scientists (e.g., McLennan et al., 2020). Among the notable critiques, Finkelhor (2018) stated: "The current ACE inventory was also not chosen through a rigorous process of scientific review to establish the best predictors of health outcomes." ...
Article
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The landmark adverse childhood experiences (ACEs) study conducted by Kaiser Permanente and the Centers for Disease Control shook the bedrock of the scientific community, highlighting the commonality of ACEs and identifying a dose–response relationship with poor health outcomes. The seminal findings led to a surge in ACEs research and a growing body of empirical literature; however, the ACEs measure has numerous conceptual and measurement issues that are often overlooked in the research. Such problems include a lack of a clear conceptual definition of what constitutes an ACE, item formulation and coverage, item scoring, and lack of contextual information. The current article aims to integrate existing critiques of the ACEs measure, extend critiques in greater detail, and proffer new ideas related to the conceptualization and study of ACEs. In preference to conceptualizing ACEs consistent with existing literature, we make a case that there are four unique and conceptually distinct subcategories of ACEs that should be conceptualized independently as individual adversities that frequently co-occur. We provide recommendations for researchers and discuss the utility of the ACEs measure as a screening tool.
... Although the ACE and AAE questionnaires are recognized as reliable and valid measures of childhood and adult trauma 43 , concerns have been raised regarding their use, including their approach to obtaining an individual ACE and AAE score by summing responses by awarding one point each to a group of heterogeneous questions 44 . To overcome this issue, we categorized adverse experiences into three groups: abuse (3 items), neglect (2 items) and household adversities (5 items). ...
... Self-reports of attachment are also seen as an indicator of attachment and do not generate detailed descriptions of attachment figures and social relationships 28 . The ACE questionnaire has also some shortcomings, such as limited item coverage and response options (yes or no) 44 . As Baldwin et al. 78 indicated a discrepancy between prospective and retrospective measures of childhood trauma, the retrospective nature of the ACE questionnaire may have distorted some reports on childhood trauma. ...
Article
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Background: As attachment and trauma have been shown to be potential determinants of psychotic dysregulation and of recovery from psychosis, it is essential to better understand the associations between attachment, adverse childhood experiences (ACE) and re- victimization in patients with a psychosis spectrum disorder. Aims: To examine whether the occurrence and severity of ACE and re-victimization are differently associated with the various attachment categories (secure, dismissive, preoccupied and fearful-avoidant) within a population of patients with a psychosis spectrum disorder. Method: In this explorative study in a sample of 273 patients with psychotic disorder, we described the prevalence and severity of ACE and re-victimization and their associations with the four attachment styles in question (secure, dismissive, preoccupied and fearful- avoidant or disorganized). Results: The highest ACE frequencies were found for emotional abuse (36.6%), emotional neglect (36.6%) and domestic violence (32.6%). As well as emotional and physical abuse, emotional and physical neglect were noticeably more frequent in all the insecure attachment classes than in the secure attachment class. Household substance abuse was high in the fearful-avoidant attachment class and parental divorce in the dismissive and fearful- avoidant attachment classes. Re-victimization occurred in 64.5% of the total sample, with a repeatfrequency of 91.6% in the severe ACE class. The fearful-avoidant attachment style was very frequent (33.3%) in the severe re- victimization class. Conclusion: Attachment functioning, interpersonal childhood trauma and re-victimization all deserve greater recognition in populations with a psychosis spectrum disorder. If their associations are well understood, future treatment might be improved.
... B urgeoning research over the past 25 years has highlighted that adverse childhood experiences (ACEs) are one of the most potent threats to public health, yet it has come into question whether we are thinking about ACEs properly. Despite hundreds of studies highlighting that ACEs are associated with greater mental health problems, there are conceptual issues with the ACEs measure that challenge existing findings (McEwen & Gregerson, 2019;McLennan et al., 2020). The foremost conceptual issue related to ACEs framework and measure is determining whether childhood maltreatment and household dysfunction are both indicators of an overall construct of childhood adversity or if maltreatment and household dysfunction are distinct, but related and co-occurring concepts. ...
... The ACEs measure, however, may be effective at detecting more frequent and severe abuse, which may more easily identify women who may most benefit from addressing ACEs in the context of their current mental health problems. Numerous scholars, including ourselves, have been critical of the ACEs measure as both an empirical measure of adversity and a screening tool (Anda et al., 2020;Finkelhor, 2018;Fitzgerald & Gallus, in press;McLennan et al., 2020), and the use of it in such a role should be done holding both the strength and limitations. The use of the ACEs measure as a screening tool should be done intentionally, consider the limitations, and make an informed decision resulting in the benefits outweighing the limitations. ...
Article
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Adverse childhood experiences (ACEs) have been consistently linked to mental health problems. There have been recent conceptual and empirical critiques that suggest maltreatment and household dysfunction to not be combined to create a composite ACE score. Women in correctional custody demonstrate disproportionately high ACE levels and greater mental health problems as to racial minorities. The present study compared the effects of varying operationalizations of the ACEs measure on women’s mental health stratified across race using a sample of White, African American, and Native American women in correctional custody in Oklahoma. The cross-sectional study administered a paper-and-pencil survey to 494 women. Structural equation modeling was used to test hypotheses. Maltreatment was a significant predictor of women’s mental health across all racial groups but demonstrated the strongest effect among African American inmates. Household dysfunction was not a significant predictor of mental health for any racial group. When comparing the maltreatment-only model to the maltreatment and household dysfunction model, and the overall ACE score model, there was little explained variance lost. These findings indicate that maltreatment demonstrates unique associations with women’s mental health and may be the driving force behind the relationship between ACEs and adult mental health among women within correctional custody. Researchers are advised to not use the overall ACE score and instead break down the measure into the maltreatment and household dysfunction subscales.
... There is also a paucity of screening instruments that has good psychometric qualities for socialemotional screening (Dever et al. 2012), and few, other than the ACE Questionnaire-related studies, have been investigated to see if they can support the identification of students with high ACE scores. The original ACE Questionnaire has questionable psychometric qualities in terms of scope, sensitivity and specificity, and reliability and validity (McLennan et al. 2020;Zanotti et al. 2018). The questionnaire also does not bring light to the frequency and intensity of reported experiences and the current level of distress likely to be experienced, in part, because of those events. ...
Article
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The Adverse Childhood Experiences (ACE) Questionnaire has provided the basis for a substantial body of research literature that illuminates the enduring social, emotional, academic, health, and life outcome effects of childhood trauma. Additional studies with children and adolescents suggest a strong neurodevelopmental dose-respondent association with high ACE scores and school academic and behavioral problems. As the national effort to include social-emotional learning (SEL) into Multi-Tiered Systems of Supports (MTSS) moves forward in the public schools, the need for psychometrically sound instruments for data-based decision-making becomes critical. The current study investigated a potential relationship between the ACE Questionnaire to more psychometrically sound screening and broadband instruments (Behavior Assessment System for Children (BASC)-3 Self-Report of Personality Form-Adolescent and BASC-3 Behavioral and Emotional Screening System (BESS) Student Form-Adolescent) that are standardized, norm-referenced, multi-gating in design, and commonly used in educational settings. Results indicate that 62% of the students with elevated ACE scores had at-risk scores on the BESS screener. In addition, elevated at-risk scores on the BESS for the students with self-reported elevated ACE scores correlated with multiple at-risk and clinically significant index and composite scores on the broadband BASC-3. The significant index and composite scores created a unique psychological profile of students with high ACE scores who were experiencing significant current distress along with little perceived social support. The results support the use of SEL screening measures that seamlessly and psychometrically link secondary- and tertiary-level diagnostic tools in a multi-gating format in MTSS.
... There were revisions to variations of the ACEs questionnaire to be more inclusive of low-income nations [30,31], which may support more inclusive assessments. Characters from the MCU and DCEU would benefit from a complete psychological assessment, to include screening measures beyond the ACEs questionnaire [32]. We accept our second hypothesis, as there was no statistically significant difference between ACEs scores in characters in the MCU and DCEU. ...
Article
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Many superhero and villain stories include trauma, which could influence how the public perceives the impact of trauma in their own lives. Our aim was to assess whether total Adverse Childhood Experiences (ACEs) scores were associated with heroism or villainy among Marvel and DC Characters. We watched 33 films, with a total runtime of 77 hours and 5 minutes. We scored 28 characters (19 men, 8 women, and 1 gender fluid). ACEs scores were evenly distributed across heroes/villains (U = 88, z = -.465, p = .642), Marvel/DC universes (U = 95.5, z = -0116, p = .907), and gender (U = 61, z = -.979, p = .328). There was no statistically significant correlation between ACEs scores and status (r(26) = .090, p = .65), universe (r(26) = .022, p = .91), or gender (r(26) = -.188, p = .34). We found that there was no association between ACEs scores and heroism or villainy. Thus, no one is doomed to be a villain just because of early childhood experiences.
... Although systematic screening for ACEs has become increasingly common in practice settings, empirical evidence supporting such screening is scant 107,108 and the practice is rigorously debated. 109,110 The implementation of traumainformed approaches to care, with or without the use of the ACEs questionnaire, 111,112 is essential for safeguarding the wellbeing of children and families navigating the complexities of ACEs within various systems of care. Research demonstrates that the implementation of trauma-informed care within organizations can improve staff knowledge, attitudes, and behaviors related to ACEs and also impact client outcomes, such as shifts in patient perceptions of patient-clinician rapport, as well as reduced risk of recurring hospitalizations. ...
Article
Importance Exposure to adverse childhood experiences (ACEs) before the age of 18 years is a major contributor to the global burden of disease and disability. Objective To meta-analyze data from samples with children 18 years or younger to estimate the average prevalence of ACEs, identify characteristics and contexts associated with higher or lower ACE exposure, and explore methodological factors that might influence these prevalence estimates. Design, Setting, and Participants Studies that were published between January 1, 1998 and February 19, 2024, were sourced from MEDLINE, PsycINFO, CINHAL, and Embase. Inclusion criteria required studies to report the prevalence of 0, 1, 2, 3, or 4 or more ACEs using an 8- or 10-item ACEs questionnaire (plus or minus 2 items), include population samples of children 18 years or younger, and be published in English. Data from 65 studies, representing 490 423 children from 18 countries, were extracted and synthesized using a multicategory prevalence meta-analysis. These data were analyzed from February 20, 2024, through May 17, 2024. Main Outcomes and Measures ACEs. Results The mean age of children across studies was 11.9 (SD, 4.3) years, the age range across samples was 0 to 18 years, and 50.5% were female. The estimated mean prevalences were 42.3% for 0 ACEs (95% CI, 25.3%-52.7%), 22.0% for 1 ACE (95% CI, 9.9%-32.7%), 12.7% for 2 ACEs (95% CI, 3.8%-22.3%), 8.1% for 3 ACEs (95% CI, 1.4%-16.8%), and 14.8% for 4 or more ACEs (95% CI, 5.1%-24.8%). The prevalence of 4 or more ACEs was higher among adolescents vs children (prevalence ratio, 1.16; 95% CI, 1.04-1.30), children in residential care (1.26; 95% CI, 1.10-1.43), with a history of juvenile offending (95% CI, 1.29; 1.24-1.34), and in Indigenous peoples (1.63; 95% CI, 1.28-2.08), as well as in studies where file review was the primary assessment method (1.29; 95% CI, 1.23-1.34). The prevalence of 0 ACEs was lower in questionnaire-based studies where children vs parents were informants (0.85; 95% CI, 0.80-0.90). Conclusions In this study, ACEs were prevalent among children with notable disparities across participant demographic characteristics and contexts. As principal antecedent threats to child and adolescent well-being that can affect later life prospects, ACEs represent a pressing global social issue. Effective early identification and prevention strategies, including targeted codesigned community interventions, can reduce the prevalence of ACEs and mitigate their severe effects, thereby minimizing the harmful health consequences of childhood adversity in future generations.
... The Childhood Trauma Questionnaire (CTQ), the Conflict Tactics Scale, the Childhood Experience of Care and Abuse (CECA) interview, and the Parental Bonding Inventory (PBI) have been reviewed as satisfactory valid and reliable instruments (Hardt & Rutter, 2004). Although the validity and reliability of ACE questionnaire have been criticized (McLennan et al., 2020a(McLennan et al., , 2020b, this instrument has also shown good internal consistency and comparable accuracy to the CTQ (Wingenfeld et al., 2011). The History of Maltreatment and Trauma (HMTF) has shown strong correlations and good content validity when compared to the CTQ (Bailey et al., 2012). ...
Article
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Background Adverse childhood experiences (ACEs) in parental history have been associated with higher self-reported rates of negative parenting behaviors and lower self-reported rates of positive parenting behaviors. Further research is needed to explore the association between parental ACEs and the observed parent–child interaction quality. Parent–child interactions are a potential pathway behind the continuity of ACEs across generations. Objective This review aimed to expand on existing literature by synthesizing evidence on the associations between parental ACEs and parent–child interactions, assessed through videotaped observations, the gold standard for interaction assessment. Methods A systematic literature search conducted in October 2022 in Medline, EMBASE, and PsycInfo identified twenty-four articles. The studies assessed parental childhood adversity and the quality of parent–child interaction across high- and low-risk samples. Results In 79% of studies, higher rates of childhood adversity were related to lower quality of observed parent–child interaction. Childhood abuse and neglect were linked to fewer positive and more negative parenting behaviors. Among household challenges, only witnessing family violence negatively impacted interaction quality. In 58% of studies, ACEs directly influenced interaction, while in 21% this effect was mediated by other factors. This pattern held across different sample types. Conclusions The evidence suggesting a relationship between parental ACEs and lower quality of parent–child interaction is robust, given the reliability and validity of observational measures. Considering the influence of the quality of parent–child interaction on a child’s development, interventions and prevention programs focusing on parent–child interaction should consider screening for parental ACEs.
... By including studies with different methods of measuring ACEs, there may be variability in how ACEs are reported and recorded. This variability can introduce heterogeneity in the analysis, potentially affecting the comparability of results across studies (Baldwin et al., 2019;Lacey et al., 2022;McLennan et al., 2020). To address the potential challenges associated with a broad range of ACEs measurements used across the included studies, this study categorized adverse experiences using the DMAP (McLaughlin & Sheridan, 2016), providing a more structured framework for the analysis. ...
Article
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Adverse childhood experiences (ACEs) are strongly associated with impaired cognitive control, yet research on ACEs’ effects across cognitive control domains—working memory, cognitive flexibility, and inhibitory control—remains sparse. This systematic review and meta-analysis evaluated the overall impact of ACEs on each of these cognitive control domains and explored moderating factors such as age, gender, cognitive control paradigms, and ACEs subtypes based on the dimensional model of adversity and psychopathology. A database search was conducted in SCOPUS, MedLine, PsycINFO, and Web of Science. Only prospective studies were included to ensure temporal order inferences, with at least two data collection points, assessing ACEs at baseline (T1) and cognitive control during follow-up (T2). Thirty-two studies ( N = 26,863) producing 124 effect sizes were analyzed. Three-level meta-analyses revealed small-to-medium negative associations between ACEs and overall cognitive control ( g = −0.32), and in each domain: working memory ( g = −0.28), cognitive flexibility ( g = −0.28), and inhibitory control ( g = −0.32). The negative associations between ACEs and cognitive control were consistent across age, gender, and cognitive control paradigms. ACEs subtypes moderated the association with cognitive flexibility ( p = .04) but not working memory or inhibitory control. Specifically, the deprivation subtype exhibited a stronger negative association with cognitive flexibility compared to threat and threat-and-deprivation subtypes. These findings highlight the pervasive negative impact of ACEs on cognitive control across ages and emphasize the need for targeted interventions. Implications, current gaps, limitations in research, and future study recommendations are discussed.
... These results may be limited due to recall bias, as ACEs reported retrospectively can often lead to minimization of early life adversity, and the ACEs measure used was not an exhaustive list of potential adverse early life experiences, 48 specifically for SGM young people. It should also be noted that the EDS has inherent limitations, as outlined by Bastos and Harnois. ...
Article
Purpose: The purpose of this study was to assess the relationship between adverse childhood experiences (ACEs) exposure, perceived discrimination, and anxiety and depressive symptoms in sexual and gender minoritized (SGM) adults in the United States. Methods: Respondents (n = 4445) from a national Qualtrics research panel completed a web-based survey. Guided by the stress proliferation (mediation model) and stress sensitization (moderation model) models, we examined the relationships between ACEs and perceived discrimination and the severity of anxiety and depressive symptoms in adulthood. Results: Cumulative ACEs exposure was positively associated with everyday discrimination scale (EDS) scores. ACEs and EDS scores had a significant direct association with anxiety and depressive symptoms. We found support for EDS as a mediator for anxiety (β = 0.12, p < 0.001) and depressive symptoms (β = 0.14, p < 0.001) and for ACEs as a moderator of the relationship between EDS and anxiety (β = −0.04, p = 0.004) and depressive (β = −0.05, p = 0.001) symptoms. Conclusions: These findings suggest that both stress proliferation and stress sensitization likely contribute to disparities in anxiety and depressive symptoms in SGM adults. This finding supports the integration of social safety and minority stress perspectives regarding health disparities in SGM populations. Exposure to early life adversity likely alters neurodevelopment, which in turn increases awareness of the lack of social safety in adulthood, reduces capacity to cope with minority stress exposure, and ultimately contributes to increased anxiety and depressive symptoms. Prevention efforts should focus on building positive and compensatory childhood experiences.
... Further, prospective and retrospective reports of childhood adversity have shown to have low agreement (Baldwin et al., 2019). Second, the ACEs questionnaire is not a standardized measure of childhood adversity, is not predictive at the individual level, and does not include all relevant items such as peer victimization and community violence (Anda et al., 2020;McLennan et al., 2020). Therefore, caution needs to be exercised when interpreting these results and further studies are needed to establish more reliable ways to measure early adversity. ...
Article
Adverse childhood experiences (ACEs) increase risk for mental and physical health disorders in adulthood, particularly in individuals from sexual and ethnic minority groups. The effects of ACEs on health may be mediated by the immune system. The exact mechanisms by which an environmental exposure, such as childhood adversity, can affect the immune system are still unknown. The primary aim of this study was to determine whether early adversity is associated with significant changes in the expression of a predefined set of immune–related genes, known as the conserved transcriptional response to adversity (CTRA), in a diverse group (African American and Latino) of sexual minority men (SMM) (n = 259). Participants included HIV positive and negative males, with a median age of 31 years (range = 19–46 years), from the mSTUDY. Expression data from 53 CTRA genes were obtained at baseline and 12-month follow-up. Childhood adversity was measured with the 10-item ACEs questionnaire. Wilcoxon rank sum and chi-squared tests were used to assess differences in sociodemographic variables, HIV status, smoking, weekly alcohol use, and methamphetamine use between exposed (cumulative ACEs ≥ 1) and unexposed groups (cumulative ACEs = 0). As we had transcriptional data from two timepoints, linear mixed models were used to determine associations between ACEs (cumulative score, dichotomous measure (exposed/unexposed), childhood maltreatment, household dysfunction, abuse and neglect subscales) and CTRA gene expression. Exploratory subgroup analysis was conducted in younger (≤ median age) and older (> median age) participant groups. There were no statistically significant differences in sociodemographic variables and substance use between the exposed and unexposed groups. There were no significant associations between any of the ACEs variables and CTRA gene, suggesting that early adversity does not influence immune-related gene expression in a group of ethnically diverse SMM. Further studies are needed to assess the biological effects of ACEs in adulthood.
... This exploration of the HD domain across these studies indicated that HD can be measured as an independent construct rather than only a sub-construct of ACEs. Often, HD is embedded under the broader paradigm of ACEs and is measured compositely, with individuals receiving an overall score based on their ACE exposures rather than domain-specific scores (McLennan et al., 2020;Mersky et al., 2017). However, it should be noted that these studies did not specifically define the items as a part of the HD domain but measured them as individual constructs using various instrument(s) that have several similarities with the HD domain that are usually assessed under ACEs. ...
Article
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Adverse childhood experiences, such as household dysfunction (HD), play a central role in how adolescents establish, experience, and navigate the challenges of relationship formation, maintenance, and dissolution. HD exposures have been independently associated with dating violence (DV) perpetration in both adolescents and adults. However, research examining the association between the concurrent effect of HD on DV perpetration, especially among adolescents remains scarce. Thus, we conducted a scoping review to accumulate and summarize existing research regarding the impact of HD on DV perpetration among adolescents aged 10 to 17 years in the United States. We used three electronic databases, Medline (Ovid), PsycINFO, and EMBASE, to search for studies published in English between 2013 and August 2023. A total of 14 studies were retained for this review after full-text screening. Most of the included studies (64%) were longitudinal. Concerning HD measurement, 71% of studies evaluated witnessing intimate partner violence (IPV), and the remaining 29% assessed family conflict, both using different instruments. Regarding DV measurement, 43% of studies utilized the Safe Dates Abuse measures to assess various forms of DV perpetration. Findings from 3/4 (75%) studies that evaluated family conflict found it to be a significant predictor of DV perpetration. Additionally, 8/10 (80%) studies that assessed exposure to IPV reported significant associations with various forms of DV perpetration among adolescents. None of the included studies measured HD comprehensively; thus, measurement development is imperative. Findings from this review may help initiate the development of a more comprehensive HD measure, promote early intervention, and foster resilience among adolescents.
... The Community Violence domain has 3 categoriesbullying, witnessing community violence, and collective violence. The ACE-IQ has been criticized for omitting some ACEs that may be in international settings, the non-standardized manner in which the questions are phrased, and a dearth of psychometric validation of its items (McLennan et al., 2020). Nevertheless, it was proven valid and reliable in resource-limited settings, and it permits comparison of findings across countries which can contribute to context-specific intervention and advocacy (Agbaje et al., 2021;Kidman et al., 2019). ...
Article
Exposure to adverse childhood experiences (ACEs) is associated with harmful biopsychosocial and behavioural outcomes in adulthood and with reduced community capacity. We investigated the prevalence of ACEs and differential risk of adverse adult outcomes based on latent class assignment in a resource- limited, high violence, and understudied setting of urban Haiti, i.e., Cité Soleil. 100% (N= 673; 41.4% men, 58.6% women, mean age 28.5) reported at minimum one ACE, 70% reported physical and emotional abuse as ACEs, and 47% reported experience of child sexual abuse (CSA). We identified 3 distinct latent classes and evaluated associations between ACE class membership and correlates (e.g., experience of non-partner sexual violence as adults [NPSV], suicidal ideation [SI], substance use to manage stress). Family dysfunction (domestic violence, substance abuse, mental illness, divorce, or incarceration of caregivers) existed across all three classes. Patterns of ACEs reported by members of Class 2 support their identification as a distinct class that is at greatest risk for adverse adult outcomes. Specifically, the increased odds of exposure to CSA distinguished members of Class 2 from Classes 1 and 3. Members of Class 2 also had increased odds of substance use, SI, fear of going outside, NPSV experience, and hypervigilance. Class 2 members further showed reduced odds of education, access to health care, and being men survivors of NPSV. The prevalence of ACEs in this sample are unprecedented. Haiti needs ACE prevention and compassionate but trauma-informed care at the population level.
... The Adverse Childhood Experiences (ACEs) Questionnaire (Felitti et al., 1998) was originally a 17-item measure. It is commonly used as a 10-item measure (ACEs-10, e.g., [McLean & Jennings, 2012;McLennan et al., 2020]) to measure adverse experiences that occurred before the age of 18. Individuals who are beyond the age of 18 can take it in retrospect, while those below 18 can use it to self-report their current situation. ...
Thesis
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Achieving a personal sense of identity is one of the core developmental tasks in adolescence (Erikson, 1956), and attaining developmental tasks at the expected time makes the individual happy and accepted within the society (Havighurst, 1956). Individuals’ life experiences are pertinent to personal identity (Côté, 1996). However, past experiences may be particularly dangerous when they are adverse (Novais et al., 2021). AlShawi & Lafta (2015) found an association between childhood experiences and the buildup of self-esteem, but scarce literature has examined ACEs along the lines of identity functioning. This research, therefore, explores ACEs as they relate to identity consolidation, identity disturbance, and lack of identity among emerging adults. Specifically, it aims to investigate the predictive tendencies of ACEs in achieving consolidated identity or experiencing disturbed identity and lack of identity. It also examines the quality and quantity of peer relationships as moderators of the relationship between ACEs and identity functioning. In support of hypotheses 1 to 3, SEM and path analysis revealed a negative relationship between ACEs and identity functioning. Specifically, ACEs negatively predicted identity consolidation but positively predicted identity disturbance and lack of identity. Further, the quality and quantity of peer relationships did not moderate the relationship between ACEs and identity functioning. This study provides more insight into the negative impact of ACEs on psychosocial development. Results, limitations, implications, and suggestions for further studies were discussed.
... We used a range of ACEs typically identified in ACE research tools used by the World Health Organization and US Centers for Disease Control and Prevention. However, there is continuing debate about whether other childhood adversities (eg, peer victimisation, community violence) should be included in ACE measurements [61][62][63] and how this would affect relationships with trust requires further studies. Moreover, our results did not measure the severity of ACEs, length of exposure, frequency and age of occurrence, 61 all of which may be important in the development of trust. ...
Conference Paper
Background A major factor associated with individuals’ adoption of public health advice, or engagement with health, social and other services, is level of trust in information sources and service providers. Individuals exposed to child maltreatment and other ACEs often have poorer health outcomes across the life course and consequently, may benefit disproportionately from accessing and accepting health advice and support. However, little information is available on how ACEs impact trust in health advice and support services. Such information is critical when considering how best to reach such vulnerable populations and mitigate inequities associated with ACEs. Objective Using a national survey sample (Wales) we examine relationships between exposure to ACEs and levels of trust in different sources of information and support services across the life course. Methods Data were collected using a randomised, stratified face to face survey delivered in peoples’ homes across Wales (n=2007). ACEs measured included: verbal, physical and sexual abuse; parental separation/divorce; witnessing domestic violence; and living within a household where mental illness, alcohol or drug misuse was present, or where a household member was incarcerated. Results Individuals with ≥4 ACEs (vs. 0 ACEs) were between two and three times more likely to have low trust in GPs, hospital doctors, nurses and pharmacists. For health services in general those with ≥4 ACEs were 3.23 time more likely to report low trust in such services. Moreover, increasing ACE counts were also significantly associated with lower trust in social services, police, charities and government. Thus, adjusted prevalence of low trust in police increased from 17.0% (0 ACEs) to 43.8% (≥4 ACEs). Conclusions Public health and care systems rely on trust as a mechanism to ensure advice is followed and for fidelity to treatment. Those with ACEs may require disproportionate amounts of public sector or charitable support and may benefit more from services but results here suggest they are less likely to trust such services and the advice they provide. Trauma informed approaches are required that understand, for those with ACEs, who are the most credible communicators and how best to develop trust in essential support services.
... The instruments we used may have failed to ascertain both the level of adverse events during childhood due to underreporting, but some life events that might confer additional risk for substance misuse, and violence in adulthood. For example, the death of a parent or family member, economic deprivation, peer victimization, and violence in the community during childhood, have been considered to contribute to adverse consequences later in life (Jones et al., 2020;McLennan et al., 2020). In addition to establishing an ACE norm among females who perpetrate violence, further research to explore the interrelatedness of ACEs and their possible associations with specific types of crime including non-violent crimes would be valuable and lead to a greater understanding of not only female victimization, but the possible differentiation of female violence as a result of "fighting back" as previously described in the context of intimate partner violence, the role of extensive victimization, along with undiagnosed head injury. ...
Article
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Women who use violence represent one of the fastest growing groups within the Australian prisoner population, including Aboriginal women who are more likely to be incarcerated than non-Aboriginal women for violent crimes. Many incarcerated women report histories of adverse childhood experiences (ACEs) and intimate partner violence. This exploratory study examines baseline data from a sample of 167 women in 3 Western Australia women’s prisons enrolled in a gender-specific violent behavior program. It describes their exposure to intimate partner violence, head injury, and childhood adversities. Overall, 94% of women had experienced at least one childhood adversity (median 6), and 94% reported being a victim of physical violence by a current or former intimate partner. Aboriginal women were more likely than non-Aboriginal women to report that a family member was incarcerated as a child ( p = .001). There was an association between an increased number of ACEs and head injury with a loss of consciousness ( p = .008). Overall, these results present a harrowing picture of childhood exposure to adversity and violence in adulthood. Successful rehabilitation of women incarcerated for violent crimes should be cognizant of the histories of extreme violence endured by most of these women.
... We used a range of ACEs typically identified in ACE research tools used by the World Health Organization and US Centers for Disease Control and Prevention. However, there is continuing debate about whether other childhood adversities (eg, peer victimisation, community violence) should be included in ACE measurements [61][62][63] and how this would affect relationships with trust requires further studies. Moreover, our results did not measure the severity of ACEs, length of exposure, frequency and age of occurrence, 61 all of which may be important in the development of trust. ...
Article
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Introduction Trust in health and other systems can affect uptake of public health advice and engagement with health services. Individuals who had adverse childhood experiences (ACEs) are more likely to experience ill health at earlier ages. Ensuring their engagement with health and other services is important in improving their life course prospects, but little is known about how ACEs affect trust in such services and the information they provide. Methods Data were collected via a national household survey of residents in Wales (aged ≥18 years, n=1880, November 2022–March 2023). Questions measured ACE exposure and trust in health, social, police, charities and government, and health and general information provided by a variety of professionals and sources. Results Individuals with ACEs were more likely to report low trust in health advice from hospital doctors, general practitioners (GPs), nurses, pharmacists, and NHS 111, an online and telephone urgent care service (eg, adjusted low trust prevalence: GPs, 0 ACEs 5.3%, ≥4 ACEs 10.4%; NHS 111, 0 ACEs 11.9%, ≥4 ACEs 24.1%). Low trust in services also increased with ACEs, with low trust in police being 3.8 times more likely with ≥4 ACEs (vs 0 ACEs). The highest adjusted prevalence of low trust in a service was for government, rising from 48.4% (0 ACEs) to 73.7% (≥4 ACEs). Low trust in general advice and information from TV/radio programmes rose from 17.6% (0 ACEs) to 30.1% (≥4 ACEs); low trust in social media was higher with an equivalent rise from 61.6% to 75.6%. Conclusion Breaking intergenerational cycles of ill health and inequity requires engaging and influencing those with ACEs. However, a history of ACEs was associated with lower trust in supporting institutions, systems and professionals. Empirical data on which resources are most trusted by those with ACEs should be used to facilitate better communications with this vulnerable group.
... We have chosen to focus on the different forms of CM as diverse effects of e.g. sexual abuse compared to neglect are described [26,27] instead of using a simplistic approach by collapsing items in one total score thus losing a lot of important information [28]. However, as different types of CM are highly interrelated [29] and the cumulative effect of CM types is well known [30] we have decided to use both approaches, focusing on individual forms of CM and a summary score of experienced CM forms. ...
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Maternal experience of child maltreatment (CM) has been associated with maternal and child mental health. However, evidence about the course of child mental health and maternal CM is scarce. Therefore, this study aims to compare trajectories of mental health in children according to maternal CM exposure and maternal mental health. We included 327 mothers and their singleton child from the Ulm SPATZ Health Study, a prospective birth cohort study. Child mental health was determined by the Strength and Difficulties Questionnaire (SDQ) at the age of 4, 5, 6, and 7 years and maternal CM by the Childhood Trauma Questionnaire (CTQ). Results display that maternal CM is associated with more behavioural and emotional difficulties in children, a trend that tends to increase with older child age. The sum of maternal mental health problems across this time course mediates this association. Male child sex is associated with more mental health problems in the child and the mother. These results provide an important first insight into the relevance of maternal CM on the trajectories of mental health in the offspring and highlight the importance of chronicity and severity of maternal mental health. Further prospective research in cohorts with longer follow-ups up into adolescence and adulthood is needed.
... The use of screeners to assess ACEs has been widely discussed in the greater literature, with critics suggesting that widespread screening for ACEs may be premature (Finkelhor, 2018) due to potential ethical issues and the failure to consider a set of criteria necessary to meet before implementing any routine health screening program (Dobrow et al., 2018;McLennan, McTavish, & MacMillan, 2020). Items on an instrument treat all exposures to categories of ACEs equally when some may be more traumatic or have greater impacts on outcomes than others (Dube, 2020;McLennan, MacMillan, & Afifi, 2020;Ports et al., 2016). Instruments also fail to capture the variability in responses to ACEs, yet people with ACEs do not all exhibit the same symptoms or experience similar negative health outcomes (Finkelhor, 2018). ...
Article
Adverse childhood experiences (ACEs) are potentially traumatic events occurring in the household or community that hold painful or distressing outcomes for children immediately and in their future (Centers for Disease Control and Prevention, 2019). School counselors work with children and young adolescents suffering from negative mental health outcomes as a result of ACEs (Hunt et al., 2017; Jimenez et al., 2016; Kaess et al., 2013; Kerker et al., 2015; Koball et al., 2021; Zhang & Mersky, 2020). Further, school counselors often work with minoritized populations, who are at a greater risk for racialized trauma (Cronholm et al., 2015; Merrick et al., 2018; Thurston et al., 2018). Research has not identified the extent to which school counselors are aware of ACEs and use that knowledge to inform their practice. This study fills a gap in the literature by investigating how school counselors understand and address ACEs, using a descriptive phenomenological approach. We identified three themes and various subthemes from the data and offer discussion and implications of the research for school counselors and counselor educators.
... However, this may have introduced heterogeneity to the sample which should be acknowledged as a limitation, emphasizing the need for cautious interpretation and consideration of potential confounding variables in the generalization of the findings. Additionally, there are inherent limitations associated with the use of the ACE questionnaire, including issues related to scoring methods and the relatively limited range of adverse experiences considered (McLennan, MacMillan, & Afifi, 2020). Moreover, concerns regarding recall bias and underreporting when retrospectively measuring adversity have been systematically raised (Widom, Raphael, & DuMont, 2004). ...
Article
Background: Evidence overwhelmingly suggests that adverse childhood experiences (ACEs) is a risk factor for poor mental health outcomes. However, the specific mechanisms via which ACEs confer an increased risk of psychopathology are less well understood. Objective: The study modelled the effect of empathy and perceived social support (PSS) on mental health outcomes in a mixed clinical and non-clinical population, within the context of exposure to ACEs. Participants and setting: A total of 575 participants (comprising a treatment-receiving and community-based sample), aged 18 to 65 completed self-report measures assessing early adversity, PSS, empathy, and mental health outcomes. Methods: Multiple mediation analyses were used to investigate whether empathy and PSS mediated the relationship between self-reported ACEs and mental health outcomes, and whether affective and cognitive empathy affected differentially the link between emotional neglect and psychological distress. Results: Results revealed a statistically significant indirect effect of ACEs on adult mental health through affective empathy and PSS. Emotional neglect was the only type of adversity significantly correlated with both dimensions of empathy. The indirect effect of emotional neglect on mental health outcomes via cognitive and affective empathy was also statistically significant. Conclusions: Study results highlight the role of affective empathy and PSS as transdiagnostic mechanisms influencing the pathway between early adversity and adult mental health, and the importance of taking these into account when designing interventions aiming to promote well-being among those who have experienced childhood adversity.
... This operationalization of counting the number of specific adversities was named the ACE score and it attracted substantial interest as both a tool for screening and for studying etiological factors of disease [30,60]. The use of the cumulative ACE score, however, has been challenged on both these fronts [26,55]. A person who experienced parental incarceration at age four could conceivably receive the same ACE score as a teenager who was subjected to sexual abuse at fifteen. ...
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Background Research on childhood adversity and psychopathology has begun investigating the dimension of timing, however the results have been contradictory depending on the study population, outcome and how adverse life events (ALEs) were operationalized. Additionally, studies so far typically focus only on a narrow range of psychiatric diagnoses or symptoms. The current cross-sectional study aimed to examine the association between timing, type and chronicity of ALEs and adolescent mental health problems. Methods Adolescents from a population-based cohort oversampled on emotional and behavioral problems (mean age 14.8; range 12–17, N = 861) were included in the current analysis. Primary caregivers were interviewed on what ALEs adolescents experienced. ALEs were defined in two ways: (1) broad operationalization, including school difficulties, parental divorce, and family sickness; and (2) physically threatening abuse only, including physical and sexual violence. After looking at lifetime ALEs, we turned to chronicity, timing and sex differences. We focused on overall psychiatric symptoms as well as specific domains of emotional and behavioral problems, assessed using the Youth Self Report (YSR) and psychotic experiences assessed using the Prodromal Questionnaire-16 (PQ-16). A series of linear models adjusted for sociodemographic and parental factors were used. Results Lifetime ALEs were associated with all types of psychopathology, with relatively bigger effect sizes for broad than for physical ALEs. The latter associations were found to be more robust to unmeasured confounding. The 9–12 age period of experiencing both broad and physical ALE’s was most saliently associated with any psychopathology. Girls were more at risk after experiencing any ALEs, especially if the adversity was chronic or ALEs took place after the age of 12. Conclusions Broad as well as physical ALEs are associated with psychopathology, especially ALEs experienced during the 9–12 age period. Physical ALEs may be more useful in investigating specific etiological factors than broad ALEs. Sex differences may not emerge in lifetime measures of ALEs, but can be important for chronic and later childhood adversity.
... The Adverse Childhood Experience (ACE; 43), another widely used questionnaire, covers traumatic experiences not included in the CTQ such as parental domestic violence, incarceration and divorce or separation. However, this questionnaire has been criticized because it encompasses few traumatic experiences and the wording of the items is very broad and vague making it difficult to interpret results (44). ...
Article
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Introduction Childhood trauma is not restricted to abuse or neglect and other potentially traumatic experiences need to be pondered in practice and research. The study aimed to collect validity evidence of a new measure of exposure to a broad range of potentially traumatic experiences, the Childhood Interpersonal Trauma Inventory (CITI), by evaluating whether the CITI provides important additional information compared to a gold standard measure of childhood trauma. Methods The sample consisted of 2,518 adults who completed the CITI and self-reported measures of trauma (Childhood Trauma Questionnaire; CTQ) and psychiatric symptoms (PTSD Checklist for DSM-5; Kessler Psychological Distress Scale; Dissociative Experiences Scale). Results First, the sensitivity to properly detect participants having been exposed to childhood maltreatment, as measured by the CTQ (here used as the gold standard), ranged between 64.81% and 88.71%, and the specificity ranged between 68.55% and 89.54%. Second, hierarchical regressions showed that the CITI predicted between 5.6 and 14.0% of the variance in psychiatric symptoms while the CTQ only captured a very small additional part of variance (0.3 to 0.7%). Finally, 25% (n = 407) of CTQ-negative participants screened positive at the CITI. The latter reported higher severity of psychiatric symptoms than participants without trauma, suggesting that the CITI permits the identification of adults exposed to significant traumas that remain undetected using other well-validated measures. Discussion The findings underscore the utility of the CITI for research purposes and the latter’s equivalence to a gold standard self-reported questionnaire to predict negative outcomes.
... Related to Black transgender populations specifically, the research indicates that increased violence, trauma and abuse-including fatalities towards this population in a number of studies (Kawano et al., 2022;LaMartine, 2020;Sherman et al., 2022;Tobin-Tyler, 2023;Waldron, 2021). Coupled with the results demonstrating non-linearity of ACEs in predicting suicidality, it is critical that future research scrutinize the ACEs framework both conceptually and methodologically, so it is consistent with a culturally informed approach that acknowledges the unique lived experiences of vulnerable groups (Barboza, 2018;Bernard et al., 2021;McLennan, MacMillan, & Afifi, 2020). ...
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Background: This study examines the effect of adverse childhood experiences (ACEs) on lifetime suicide attempts (LSA) across five gender subgroups (i.e., transgender men, transgender women, transgender non-binary, cisgender men and cisgender women). Objective: To examine (1) the prevalence of LSA across gender identity subgroups; (2) whether the association between ACEs and LSA is moderated by gender identity subgroup; (3) depressive symptoms, alcohol use disorder, social support, and social well-being as mechanisms linking ACEs with LSA; and (4) the moderating role of gender identity on the four putative mediators. Participants and settings: We used nationally representative data from a population-based survey of N = 1368 transgender and cisgender individuals collected between 2016 and 2019. Methods: Structural equation modeling was used to explore the indirect effect of depressive symptoms on the relation between ACEs and LSA, and the moderating impact of gender identity. Results: LSA was significantly more prevalent among transgender respondents (cisgender man = 5 %; cisgender woman = 9 %; transgender man = 42 %; transgender woman = 33 %; transgender non-binary = 37 %; p < 0.001). Individuals with more ACEs had a greater risk of engaging in LSA regardless of gender identity; however, moderation results showed that the impact of each additional ACE on LSA was stronger for individuals with transgender identities: the likelihood of engaging in LSA was statistically similar for transgender men with no ACEs and cisgender men with all 8 ACEs. Indirect effects of ACEs on LSA via depressive symptoms were also observed, and the mediating effect was moderated by gender identity. Conclusions: By examining the mechanisms linking childhood adversity to LSA, this study demonstrates that not all ACEs impact gender minority subgroups equally.
... While not minimizing the harm divorce/separation can have on youth (see D'Onofrio & Emry, 2019; Garriga & Pennoni, 2020), ACEs tied to maltreatment tend to have a greater impact on mental health concerns, future victimization, and behavioral outcomes (see Courtright, 2020;Fox et al., 2015;Ports et al., 2017). Though the impact of specific ACE types was outside the scope of the current study, this concern is noteworthy and an essential consideration regarding how ACEs are measured, scored, and used to guide treatment for justice-involved youth (see McLennan et al., 2020). ...
Article
Background: Youth in the U.S. juvenile justice system are exposed to adverse childhood experiences(ACEs) at higher rates than youth in the general public. Additionally, research has demonstrated ACEs can vary by race/ethnicity and gender. However, little is known about how ACEs are experienced across gendered racial/ethnic groups of justice-involved youth. Objective: To address this gap, this exploratory study is the first to apply an intersectional lens to examine the prevalence of ACEs among a group of justice-involved youth in the U.S. Participants & setting: Using secondary data, this study examines ACEs by gender, race/ethnicity, and six gendered racial/ethnic groups of justice-involved youth referred to the Division of Youth and Family Services (DYFS) in Milwaukee, Wisconsin. Methods: Descriptive analyses are presented by gender and race/ethnicity separately, followed by gendered racial/ethnic groups to understand differential rates of exposure to ACEs. Results: The study’s findings align with previous research and reinforce that justice-involved youth experience higher rates of adversity than the general public. The results also support the feminist pathway’s perspective within an intersectional context, emphasizing the importance of accounting for race/ethnicity and gender simultaneously to identify the unique experiences of ACEs among justice-involved youth. Conclusion: Recommendations related to these findings and considerations surrounding ACE measures are discussed. Specifically, findings from this study stress the importance of accounting for gender and race/ethnicity simultaneously when measuring experiences of adversity. This is a critical step to providing equitable treatment and services to address trauma-related needs across gendered racial/ethnic groups of system-involved youth.
... Historically, the cumulative risk model has often been operationalized using a single summary score that quantifies total adversity exposure (Evans et al., 2013;Lacey & Minnis, 2020). This summary score approach, however, tends to overlook the clustering of adversities, a limitation frequently criticized in the context of the cumulative risk model (Lacey & Minnis, 2020;McLennan et al., 2020). By incorporating item-level data into the IS-RDM, our model considered intersubject similarity influenced not only by the overall quantity of adversity experienced but also by the specific endorsements of individual adversities. ...
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Adverse experiences throughout development confer risk for a multitude of negative long-term outcomes, but the processes via which these experiences are neurobiologically embedded are still unclear. Adolescence provides an opportunity to understand how these experiences impact the brain’s rapidly changing structure. Two models are central to current adversity conceptualizations: a cumulative risk model, where all types of experiences are combined to represent accumulating stress, and a dimensional model, where certain features of experience (e.g., threat or deprivation) exert unique neurophysiological influence. In this registered report, we extended upon previous research by using a form of representational similarity analysis to examine whether the dimensional and cumulative risk models of adversity predict cortical thinning in frontoparietal and frontotemporal networks and volumetric changes in subcortical regions throughout adolescence. Drawing from a longitudinal sample of 179 adolescent girls (ages 10–13 years at the first wave) from Lane County, Oregon, United States, and up to four waves of follow-up data, we found that operationalizing adversity by similarity in threat and deprivation provided better prediction of brain development than similarity in overall adversity. However, these dimensions do not exhibit unique associations with developmental changes in the hypothesized brain changes. These results underscore the significance of carefully defining adversity and considering its impact on the entire brain.
... Additionally, due to the low prevalence and conceptual similarity of items 9-11, these were combined into a single dichotomous measure of any sexual abuse (α = 0.83). Otherwise, ACEs were operationalized individually rather than as a composite or sum measure to avoid equating fundamentally different types of childhood adversity (McLennan et al., 2020). ...
... The ACE literature faces this challenge-both the composition and scoring of ACE measures vary widely across studies (Bethell et al., 2017;Finkelhor et al., 2015); moreover, some researchers create ad hoc measures when a validated ACE instrument is unavailable (e.g., Jones et al., 2021). This variability, in addition to known limitations of the ACE questionnaire, has led some to question the use of the ACE measure altogether (McLennan et al., 2020). With these challenges in mind, the goal of the present scoping review is to summarize the methods used to define and measure PCEs in the existing literature. ...
Article
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Positive childhood experiences are garnering increased attention, as they may prevent exposure to, and mitigate the effects of, adverse childhood experiences on development. While many studies around the world have used the Benevolent Childhood Experience (BCE) scale, the prevalent use of ad hoc measures increases variability in study methods, limiting comparability of study findings. We conducted a scoping review to summarize existing methods to measuring positive childhood experiences. A search of the PubMed, PsychINFO, and SCOPUS databases was conducted to identify relevant articles published from January 2010–May 2023. Sixty-six articles were included in the review. The BCE scale is the most used measure to assess positive childhood experiences; many ad hoc measures were based on the recently developed Healthy Outcomes from Positive Experiences framework. Included studies predominantly used a cumulative score to assess positive childhood experiences, and all found evidence of promotive and/or protective effects of positive childhood experiences on various behavioral and health outcomes. Taken together, findings reveal heterogeneity in measurement of positive childhood experiences, highlighting the need for consistent operationalization of positive childhood experiences. Agreement and consistency in the measurement of positive childhood experiences will improve interpretation of research findings and appropriate implications for policy.
... This operationalization of counting the number of specific adversities was named the ACE score and it attracted substantial interest as both a tool for screening and for studying etiological factors of disease (Gilbert et al., 2015;Purewal et al., 2016). The use of the cumulative ACE score, however, has been challenged on both these fronts (Finkelhor, 2018;McLennan et al., 2020). A person who experienced parental incarceration at age four could conceivably receive the same ACE score as a teenager who was subjected to sexual abuse at fifteen. ...
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Research on childhood adversity and psychopathology has begun investigating the dimension of timing, however the results have been contradicting depending on the study population, outcome and how adverse life events (ALEs) were operationalized. Additionally, studies so far typically focus only on a narrow range of psychiatric diagnoses or symptoms.
... The ACEs questionnaire quantified the presence of types of adversity in childhood using a score of 1 for any affirmative answer and 10 as the maximum score [15][16][17]. The types of childhood adversity described in the ACEs questionnaire are increasingly being recognized as important predictors of poor health outcomes [18], and this instrument has increasingly been used and promoted as a screening tool at the individual level [19]. The 17-question LEC-5 was included with the intent of measuring how respondents experienced critical incident stress and at what frequency. ...
Article
Recently, burnout has amassed considerable attention because of deleterious effects on workers and the work environment. Frequently, EMS clinicians find themselves prone to experiencing burnout, yet little is known about etiologies in this population. To estimate prevalence and predictors of burnout in EMS clinicians. This was a cross-sectional survey study of nine EMS agencies from North Carolina selected based on geography and population. Emergency medical technicians (EMTs), advanced EMTs, and paramedics were included. Emergency medical responders and air medical personnel were excluded if those positions were a primary occupational function. The Professional Quality of Life (ProQOL) Scale was used to assess burnout. Parametric and nonparametric testing was used to assess factors potentially affecting burnout. Factors significant in univariate analyses were included in a hierarchical linear regression model to determine unique predictors of burnout while controlling for confounders. The area under the curve (AUC) of the receiver operating characteristic (ROC) was used to determine model predictability. A total of 686 EMS clinicians completed the survey. Overall, 57.3% (n = 393) were likely to have burnout. Of the 328 respondents who were likely to have burnout, 254 (77.4%) and 211 (75.1%) also were identified as likely to suffer from compassion fatigue or vicarious trauma, respectively. Overall, 152 (22.2%) were likely to suffer from all three stress disorders, 118 (56.5%) of which scored high enough to potentially produce immune system dysregulation. Prior suicidal thoughts ((sr2 = 0.042, p < 0.001), attempts (sr2 = 0.025, p < 0.001) or the presence of vicarious trauma (sr2 = 0.040, p < 0.001) accounted for 4.2%, 2.5%, and 4.0% of model variance, respectively. Years of field experience (sr2 = 0.035, p < 0.001) and credential level (sr2 = 0.011, p = 0.005) accounted for 4.6% of model variance. Finally, a respondent’s experience or knowledge of debriefing (sr2 = 0.008, p = 0.023); experiencing adversity in childhood in the form of familial mental illness, depression, or suicide (sr2 = 0.009, p = 0.016); or the incarceration of a family member (sr2 = 0.010, p = 0.011) accounted for a combined 2.7% of model variance. Model predictability showed an AUCROC of 81.5%. This study showed a nearly 60% prevalence of occupational burnout in the group of EMS clinicians surveyed, making burnout of considerable concern in this population. Further study is needed to address occupational factors that contribute to burnout in EMS clinicians.
... Similarly, while repeated measures of adversity were obtained, some of the measures (physical abuse, for example) were not included in every wave. Thus, when translating findings from this study into clinical practice or policy, care should be taken due to the possibility of missing measures and insufficient validity of obtained measures (McLennan et al., 2020). Finally, while a strength of our study was our ability to measure ACEs occurring at different points in time in early childhood, ACEs were reported by caregivers and not youth themselves. ...
Article
Background: Sleep is critical for physical, mental, and emotional health. This may be particularly true for adolescents experiencing rapid physiological changes. Relatively little is known about how adverse childhood experiences (ACEs) are implicated in adolescent experiences with sleep. Objective: We use data (from the Future of Families and Child Wellbeing Study (FFCWS, n = 3444) to assess the relationship between early ACE exposure (by age 5) and various adolescent sleep outcomes. We anticipate that early ACEs will be associated with poor adolescent sleep outcomes. Methods: FFCWS data includes survey responses from parents and/or primary caregivers and children at birth and approximately one, three, five, nine, and 15 years later. The FFCWS over-sampled unmarried parents with low educational attainment, income, and from marginalized racial-ethnic groups. Models of sleep outcomes included ordinary least squares, Poisson, negative binomial, logistic, and order logistic regression, as appropriate. Results: Despite a high number of ACEs, adolescent hours of sleep were consistent with published recommendations. Other measures of sleep indicated adolescents in the sample experience worse sleep on most other measures. ACE exposure was associated with difficulty falling asleep and staying asleep. More ACEs was also related with problematic sleep environments (i.e., place slept) and increased snoring. There was some evidence that ACEs were related to less sleep on weekends and increased social jet lag (different patterns of sleep between weekdays and weekends). Conclusions: Our findings suggest that ACEs could be important diagnostic data for clinicians in primary care and behavioral sleep medicine practice.
... Yet, evidence to support the utility of an ACE screening tool has been equivocal at best (e.g., Campbell, 2020;Dube, 2018). Others have also echoed concerns regarding the translational nature of ACE research into practice and have highlighted that the relatively narrow range of ACE items conventionally examined in research lack sensitivity and specificity (Finkelhor, 2018;McLennan et al., 2020), and that the simple additive scoring approach may overlook the differential impact of specific ACEs on health (Negriff et al., 2022). ACEs research has clearly illuminated the fundamental importance of childhood trauma and adversity on population health and human development; however, in some ways, the translation of ACEs research to practice has outpaced psychometric work to develop and confirm robust measurement approaches. ...
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Adverse childhood experiences (ACEs) are conventionally measured using a cumulative-risk index without consideration of distinct measurement properties across racial and ethnic groups. Drawing from the 2018–2020 National Survey of Children's Health (N=93,759; 48% female; average age: 9.52years), we assess the measurement invariance of a latent-factor ACE model across five groups: Hispanic children (14%) and non-Hispanic White (73%), Black (7%), Asian/Pacific Islander (5%), and American Indian/Alaskan Native (1%) children. Results support configural and full metric invariance across groups. However, several ACE item thresholds differed across groups. Findings highlight the potential utility of a latent factor approach and underscore the need to assess differences across racial and ethnic groups in terms of the optimal conceptualization and measurement of ACEs.
... Only four of the measures were designed for adult retrospective self-report (Bethell et al., 2017). Several shortcomings in the available set of ACE instruments have been identified, with the most common challenges relating to limited item coverage, collapsing of items and response options, simplistic scoring approach, and the lack of overall psychometric assessment, including reliability and validity testing (Holden et al., 2020;McLennan et al., 2020). Reidy et al. (2021) exemplified how altering measurement schemes impacts the interpretation of ACE-related research findings. ...
Article
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Background The research on adverse childhood experiences (ACEs) has deepened our understanding of the long-lasting and cumulative effects of childhood adversities. However, the instruments measuring ACEs have several shortcomings, including limited item coverage, collapsing of items and response options, simplistic scoring, and inadequate psychometric assessments. Objective To design and conduct preliminarily psychometric testing for a brief new self-report instrument—the THL Adverse Childhood Experiences questionnaire (ACE-THL)—with a comprehensive set of clearly formulated items and appropriate response options. Methods A previously published process model was applied to develop the ACE-THL questionnaire, which was validated by cognitive interviews (N = 20). Interviewers and interviewees completed the questionnaire separately for a cross-informant comparison. In a separate survey panel validation, the respondents filled out the ACE-THL twice, two weeks apart (N = 513, with 426 in the follow-up). Interview data were used to improve item clarity, and test–retest reliability and structural validity were assessed with repeated survey data. Results The final 14-item questionnaire, including 12 ACE items and two items measuring protective experiences, was highly acceptable to the respondents. In the factor analysis of the quantitative data, a sufficiently single-dimensional construct was found, remaining stable in retesting two weeks later. The internal consistency (omega) of the a priori one-dimensional model was 0.89 and 0.90 at baseline and follow-up, respectively. The high test–retest reliability (mean score rank order correlation 0.93) of the ACE-THL indicated that the probed perceptions of childhood experiences are stable. Conclusion Based on the initial validation, the 14-item ACE-THL questionnaire is a reliable and valid instrument to measure adverse childhood experiences, as well as protective experiences.
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Objectives Adverse Childhood Experiences (ACE) may be associated with unintended pregnancies (UPs). Our aim was to investigate whether there is an association between a history of ACE, type of ACE or number of ACE and the risk for UPs and if this risk is mediated by psychiatric vulnerabilities. Study design A cross-sectional study with participants recruited from the OLVG hospital was performed. Pregnant patients older than 18 years, literate in either Dutch or English were included. Patients with florid psychosis were excluded. ACEs were self-reported and assessed via the Childhood Trauma Questionnaire, pregnancy intention was extracted from the patient database and psychiatric vulnerability was self-reported. The association between ACE and UPs was analyzed by means of logistic regressions, followed by a mediation analysis with psychiatric vulnerability Results A total of 269 participants, mostly with a university degree (66.5%) and with a mean age of 34 (SD 4.306) were included; 20.1% had at least one ACE and 22.3% had an UP. There was no significant association between UPs and a history of ACE regardless of the type and number of ACE. Conclusions Future studies should replicate our findings onf the associationimpact of ACEs and psychiatric vulnerabilities on pregnancy intention within a larger, and more representative sample.
Chapter
Both Australia’s Family Law Act and State child protection legislation refer to criteria for decision-making as being the best interests of a child and avoiding harm to a child. It is important for interested parties to identify agreed measures of a child’s well-being, including screens that can be used to identify children’s mental status. However, no screens have been identified for universal use in Australia. This chapter draws attention to screens that have potential to be used widely to assess the mental health status of children.
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Purpose of Review This review includes recent literature on adverse childhood experiences (ACEs) and perinatal mental health. We summarize key findings, including meta-analytic reviews and emerging data on broad risks for psychopathology, mechanistic pathways, protective factors, and ACEs screening within clinical care contexts. Recent Findings ACEs are associated with small to moderate risks for perinatal depression and anxiety. There is increasing evidence ACEs are also associated with other mental health concerns and transdiagnostic symptoms during pregnancy and postpartum. Possible mechanistic factors include a range of biological and psychosocial variables. Unique effects of benevolent childhood experiences (BCEs) on perinatal mental health are also notable. Summary Continued emphasis on associations between ACEs and perinatal mental health concerns beyond depression and anxiety is needed. More empirical attention to mechanistic and protective factors, including benevolent childhood experiences, is also warranted. Although ACEs screening in clinical settings may be feasible and acceptable, implementation should occur within a healing centered engagement framework.
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Research on adverse childhood experiences and resilience (the process of overcoming trauma) has been dominated by studies originating in wealthy democracies of the global north. We call for more global and ecological approaches not only for documenting the true global burden of childhood adversity, but also for advancing the science of resilience and understanding pathways to overcoming trauma. We identify several forms of trauma that need better consideration in prevalence estimates, including state, political, and institutional violence, crisis migration, climate change and related natural disasters, and global health crises such as theCOVID-19 pandemic. We also need more nuanced analyses of culture and place and to recognize that the global south and global north are not monolithic concepts.We offer illustrative examples of how more global, ecological approaches can enhance our understanding of pathways to overcoming even high dosages of childhood adversity. One of the key insights of ACEs research, the dose-response relationship between trauma burden and outcomes, has been extended to research on resilience. Concepts that capture the total “dose” of positive assets and resources (people’s resilience portfolios) are showing how people might overcome even high doses of trauma. This work can become more global by including incorporating strengths and healing processes common in collectivist, versus individualistic, cultures. It can become more ecological by recognizing that physical environments—both natural and human-made built aspects—play key roles in resilience.Recognizing the intersectionality among these elements can take us to the next generation of trauma and resilience science
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PÄÄASIAT • Haitallisia lapsuudenkokemuksia on tärkeää pystyä kartoittamaan sisällöltään kattavalla, selkeällä ja psykometrisesti toimivalla kyselylomakkeella. • Kuvaamme uuden Lapsuuskokemuksia-kyselyn (ACE-THL) kehittämis- ja validointiprosessin. • Validoimme kyselyä laadullisella haastatteluaineistolla sekä määrällisellä mittaus- ja toistomittausaineistolla. • Uudessa Lapsuuskokemuksiakyselyssä on 14 väittämää, joihin vastataan viisiportaisella vastausasteikolla. Kyselylomake julkaistaan tämän julkaisun liitteenä ja sitä voi käyttää vapaasti tieteellisessä tutkimuksessa.
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Importance Inquiry into what childhood experiences are associated with antisocial behaviors in adulthood is necessary for prioritizing and informing efforts for effective prevention. Objective To examine whether harsh physical punishment in the absence of child maltreatment and child maltreatment with and without harsh physical punishment are associated with antisocial behaviors in adulthood. Design, Setting, and Participants Cross-sectional study using data on the general US population obtained from the National Survey on Alcohol and Related Conditions Wave 3 from April 2012 to June 2013. Participants were civilian, noninstitutionalized adults 18 years and older. This study used a multistage probability sampling design (response rate, 60.1%). Data were analyzed from January 25 to November 27, 2018. Exposures Harsh physical punishment included pushing, grabbing, shoving, slapping, and hitting. Child maltreatment included physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, and exposure to intimate partner violence. Main Outcomes or Measures Lifetime antisocial personality disorder behaviors since age 15 years were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 based on Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria. Results The number of study participants was 36 309, with 15 862 men (weighted percentage, 48.1%) and 20 447 women (weighted percentage, 51.9%); mean (SE) age was 46.54 (0.19) years. The prevalence of harsh physical punishment and child maltreatment was 18.1% and 46.7%, respectively. Harsh physical punishment only (adjusted β, 0.62; 95% CI, 0.50-0.75), child maltreatment only (adjusted β, 0.65; 95% CI, 0.60-0.69), and harsh physical punishment and child maltreatment (adjusted β, 1.46; 95% CI, 1.38-1.54) were associated with adult antisocial behaviors. It is estimated that harsh physical punishment and/or child maltreatment might account for approximately 45.5% of antisocial behaviors among men in the United States and 47.3% antisocial behaviors among women in the United States. Conclusions and Relevance Harsh physical punishment and child maltreatment appear to be associated with adult antisocial behaviors. Preventing harsh physical punishment and child maltreatment in childhood may reduce antisocial behaviors among adults in the United States.
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Background: In 1968, Wilson and Jungner published 10 principles of screening that often represent the de facto starting point for screening decisions today; 50 years on, are these principles still the right ones? Our objectives were to review published work that presents principles for population-based screening decisions since Wilson and Jungner's seminal publication, and to conduct a Delphi consensus process to assess the review results. Methods: We conducted a systematic review and modified Delphi consensus process. We searched multiple databases for articles published in English in 1968 or later that were intended to guide population-based screening decisions, described development and modification of principles, and presented principles as a set or list. Identified sets were compared for basic characteristics (e.g., number, categorization), a citation analysis was conducted, and principles were iteratively synthesized and consolidated into categories to assess evolution. Participants in the consensus process assessed the level of agreement with the importance and interpretability of the consolidated screening principles. Results: We identified 41 sets and 367 unique principles. Each unique principle was coded to 12 consolidated decision principles that were further categorized as disease/condition, test/intervention or program/system principles. Program or system issues were the focus of 3 of Wilson and Jungner's 10 principles, but comprised almost half of all unique principles identified in the review. The 12 consolidated principles were assessed through 2 rounds of the consensus process, leading to specific refinements to improve their relevance and interpretability. No gaps or missing principles were identified. Interpretation: Wilson and Jungner's principles are remarkably enduring, but increasingly reflect a truncated version of contemporary thinking on screening that does not fully capture subsequent focus on program or system principles. Ultimately, this review and consensus process provides a comprehensive and iterative modernization of guidance to inform population-based screening decisions.
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Background: A growing body of research identifies the harmful effects that adverse childhood experiences (ACEs; occurring during childhood or adolescence; eg, child maltreatment or exposure to domestic violence) have on health throughout life. Studies have quantified such effects for individual ACEs. However, ACEs frequently co-occur and no synthesis of findings from studies measuring the effect of multiple ACE types has been done. Methods: In this systematic review and meta-analysis, we searched five electronic databases for cross-sectional, case-control, or cohort studies published up to May 6, 2016, reporting risks of health outcomes, consisting of substance use, sexual health, mental health, weight and physical exercise, violence, and physical health status and conditions, associated with multiple ACEs. We selected articles that presented risk estimates for individuals with at least four ACEs compared with those with none for outcomes with sufficient data for meta-analysis (at least four populations). Included studies also focused on adults aged at least 18 years with a sample size of at least 100. We excluded studies based on high-risk or clinical populations. We extracted data from published reports. We calculated pooled odds ratios (ORs) using a random-effects model. Findings: Of 11 621 references identified by the search, 37 included studies provided risk estimates for 23 outcomes, with a total of 253 719 participants. Individuals with at least four ACEs were at increased risk of all health outcomes compared with individuals with no ACEs. Associations were weak or modest for physical inactivity, overweight or obesity, and diabetes (ORs of less than two); moderate for smoking, heavy alcohol use, poor self-rated health, cancer, heart disease, and respiratory disease (ORs of two to three), strong for sexual risk taking, mental ill health, and problematic alcohol use (ORs of more than three to six), and strongest for problematic drug use and interpersonal and self-directed violence (ORs of more than seven). We identified considerable heterogeneity (I2 of >75%) between estimates for almost half of the outcomes. Interpretation: To have multiple ACEs is a major risk factor for many health conditions. The outcomes most strongly associated with multiple ACEs represent ACE risks for the next generation (eg, violence, mental illness, and substance use). To sustain improvements in public health requires a shift in focus to include prevention of ACEs, resilience building, and ACE-informed service provision. The Sustainable Development Goals provide a global platform to reduce ACEs and their life-course effect on health. Funding: Public Health Wales.
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Poor children confront widespread environmental inequities. Compared with their economically advantaged counterparts, they are exposed to more family turmoil, violence, separation from their families, instability, and chaotic households. Poor children experience less social support, and their parents are less responsive and more authoritarian. Low-income children are read to relatively infrequently, watch more TV, and have less access to books and computers. Low-income parents are less involved in their children's school activities. The air and water poor children consume are more polluted. Their homes are more crowded, noisier, and of lower quality. Low-income neighborhoods are more dangerous, offer poorer municipal services, and suffer greater physical deterioration. Predominantly low-income schools and day care are inferior. The accumulation of multiple environmental risks rather than singular risk exposure may be an especially pathogenic aspect of childhood poverty.
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Deciding whether to screen for adverse childhood experiences (ACEs), like screening for any risk factor or health condition, should be informed by a systematic approach. The following questions, derived from key principles of health screening, are used to systematically evaluate the recommendation for ACEs screening: (1) Does an evidence-based intervention exist that will improve outcomes for high-risk groups identified through screening? (2) Is this evidence-based intervention available for those screening positive? (3) Is the screening approach accurate? (4) What are the potential harms associated with screening? (5) Are there positive findings from experimental trials using proposed screening approaches? (6) Have other critical domains been considered? Substantial gaps are identified in attempting to answer each of these questions when applied to ACEs screening. With the current state of knowledge, it cannot be assumed that potential gains from implementing ACEs screening outweigh potential harms.
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Emerging evidence shows that child abuse is a predictor of adult psychopathology and a potent stimulus that may alter brain development. However, consensus on how best to measure child abuse is not evident. This systematic review aimed to critically appraise the methodological quality and measurement properties of published child abuse measures and examined the strength of evidence of these instruments for research use using the COnsensus-based Standards for the selection of health Measurement InstrumeNts (COSMIN) checklist as well as determined which measures were capable of providing information on the developmental timing of abuse. A systematic search of electronic databases identified 52 eligible measurement instruments from 2095 studies. Only 15% (n=8) of the instruments had strong to moderate levels of evidence for three or more of the nine COSMIN criteria. No instrument had adequate levels of evidence for all criteria, and no criteria were met by all instruments. Overall, our results indicate there is no single instrument that is superior to all others across settings and populations. Furthermore, the availability of measures capable of capturing the effects of child abuse on brain development and associated behavioral phenotypes are limited. Refined instruments with a focus on capturing abuse events during sensitive periods of development are warranted in addition to further evaluation of the psychometric properties of these instruments.
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This article argues that it is still premature to start widespread screening for adverse childhood experiences (ACE) in health care settings until we have answers to several important questions: 1) what are the effective interventions and responses we need to have in place to offer to those with positive ACE screening, 2) what are the potential negative outcomes and costs to screening that need to be buffered in any effective screening regime, and 3) what exactly should we be screening for? The article makes suggestions for needed research activities.
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This study examines whether the items from the original Adverse Childhood Experiences (ACE) scale can be improved in their prediction of health outcomes by adding some additional widely recognized childhood adversities. The analyses come from the National Survey of Children's Exposure to Violence 2014, a telephone survey conducted from August 2013 through April 2014 with a nationally representative sample of 1,949 children and adolescents aged 10-17 and their caregivers who were asked about adversities, physical health conditions and mental health symptoms. The addition of measures of peer victimization, peer isolation/rejection, and community violence exposure added significantly to the prediction of mental health symptoms, and the addition of a measure of low socioeconomic status (SES) added significantly to the prediction of physical health problems. A revised version of the ACES scale is proposed. Copyright © 2015 Elsevier Ltd. All rights reserved.
Article
Background Adverse childhood experiences (ACEs), including child abuse and family dysfunction, are linked to leading causes of adult morbidity and mortality. Most prior ACE studies were based on a nonrepresentative patient sample from one Southern California HMO. Purpose To determine if ACE exposure increases the risk of chronic disease and disability using a larger, more representative sample of adults than prior studies. Methods Ten states and the District of Columbia included an optional ACE module in the 2010 Behavioral Risk Factor Surveillance Survey, a national cross-sectional, random-digit-dial telephone survey of adults. Analysis was conducted in November 2012. Respondents were asked about nine ACEs, including physical, sexual, and emotional abuse and household member mental illness, alcoholism, drug abuse, imprisonment, divorce, and intimate partner violence. An ACE score was calculated for each subject by summing the endorsed ACE items. After controlling for sociodemographic variables, weighted AORs were calculated for self-reported health conditions given exposure to zero, one to three, four to six, or seven to nine ACEs. Results Compared to those who reported no ACE exposure, the adjusted odds of reporting myocardial infarction, asthma, fair/poor health, frequent mental distress, and disability were higher for those reporting one to three, four to six, or seven to nine ACEs. Odds of reporting coronary heart disease and stroke were higher for those who reported four to six and seven to nine ACEs; odds of diabetes were higher for those reporting one to three and four to six ACEs. Conclusions These findings underscore the importance of child maltreatment prevention as a means to mitigate adult morbidity and mortality.
Article
Child maltreatment remains a major public-health and social-welfare problem in high-income countries. Every year, about 4-16% of children are physically abused and one in ten is neglected or psychologically abused. During childhood, between 5% and 10% of girls and up to 5% of boys are exposed to penetrative sexual abuse, and up to three times this number are exposed to any type of sexual abuse. However, official rates for substantiated child maltreatment indicate less than a tenth of this burden. Exposure to multiple types and repeated episodes of maltreatment is associated with increased risks of severe maltreatment and psychological consequences. Child maltreatment substantially contributes to child mortality and morbidity and has longlasting effects on mental health, drug and alcohol misuse (especially in girls), risky sexual behaviour, obesity, and criminal behaviour, which persist into adulthood. Neglect is at least as damaging as physical or sexual abuse in the long term but has received the least scientific and public attention. The high burden and serious and long-term consequences of child maltreatment warrant increased investment in preventive and therapeutic strategies from early childhood.
Article
To present initial findings on the validity of a recently developed maltreatment inventory, the Childhood Trauma Questionnaire (CTQ), in a sample of adolescent psychiatric patients. Three hundred ninety-eight male and female adolescents (aged 12 to 17 years) admitted to the inpatient service of a private psychiatric hospital were given the CTQ as part of a larger test battery. Structured interviews were also conducted with the primary therapists of 190 of the patients to obtain ratings of abuse and neglect based on all available data, including clinical interviews with patients and their relatives and information from referring clinicians and agencies. Principal-components analysis of the CTQ items yielded five rotated factors-emotional abuse, emotional neglect, sexual abuse, physical abuse, and physical neglect-closely replicating the factor structure in an earlier study of adult patients. The internal consistency of the CTQ factors was extremely high both in the entire sample and in every subgroup examined. When CTQ factor scores were compared with therapists' ratings in a series of logistic regression analyses, relationships between the two sets of variables were highly specific, supporting the convergent and discriminant validity of the CTQ. Finally, when therapists' ratings were used as the validity criterion, the CTQ exhibited good sensitivity for all forms of maltreatment, and satisfactory or better levels of specificity. These initial findings suggest that the CTQ is a sensitive and valid screening questionnaire for childhood trauma in an adolescent psychiatric inpatient setting.
Article
The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described. A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease. Logistic regression was used to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (range: 0-7) and risk factors for the leading causes of death in adult life. More than half of respondents reported at least one, and one-fourth reported > or = 2 categories of childhood exposures. We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and diseases that were studied (P < .001). Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, > or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life. We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.
Adverse childhood experiences (ACEs): Using evidence to advance research, practice, policy and prevention
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Screening for adverse childhood experiences (ACEs) in an integrated pediatric care model
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SAMHSA's concept of trauma and guidance for a trauma-informed approach
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