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All Adverse Childhood Experiences Are Not Equal: The Contribution of Synergy to Adverse Childhood Experience Scores

Authors:
Ernestine C Briggs at Duke University Medical Center
Ernestine C Briggs
Lisa Amaya-Jackson at Duke University Medical Center
Lisa Amaya-Jackson
Karen Putnam at University of North Carolina at Chapel Hill
Karen Putnam
Frank W. Putnam
Frank W. Putnam
Frank W. Putnam
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Abstract

The operationalization of childhood trauma and adversity into checklists commonly known as adverse childhood experiences, or ACEs, has become the most widely adopted methodology linking traumatic childhoods to adult outcomes. As the number of self-reported ACEs increase from 0 to 4 or more (4+), most studies find a roughly stepwise progression in risk for a wide range of negative medical and mental health outcomes. A score of 4+ ACEs, has become a de facto cutpoint, increasingly used clinically to define "high risk" status for a myriad of outcomes. Comparisons across studies using a 4+ cutpoint, however, find considerable heterogeneity in the degree of risk for the same outcomes. In addition to sample and methodological differences, certain pairs of ACEs comprising the cumulative ACE score interact synergistically to significantly increase the overall risk beyond the sum (or product) of the contributions of each ACE to the outcome. This article reviews the empirical literature on synergistic ACEs including results from a general population adult and a mixed trauma, youth sample both sufficiently powered to examine over 20 different ACE pairings for possible synergy. Synergistic pairs of ACEs vary by gender and age group. About 30-40% of the variance in outcomes is accounted for by additive synergistic interactions between certain pairs of ACEs. Across studies, sexual abuse is the most synergistically reactive ACE. The article concludes with a discussion of the implications of synergistic ACE pairings for psychologists and other allied professionals across clinical practice, prevention, research, and policy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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All Adverse Childhood Experiences Are Not Equal: The Contribution of
Synergy to Adverse Childhood Experience Scores
Ernestine C. Briggs
1
, Lisa Amaya-Jackson
1
, Karen T. Putnam
2
, and Frank W. Putnam
2
1
UCLA/Duke University National Center for Child Traumatic Stress, Department of Psychiatry and Behavioral Sciences, Duke
University School of Medicine
2
Department of Psychiatry, University of North Carolina at Chapel Hill
The operationalization of childhood trauma and adversity into checklists commonly known as
adverse childhood experiences, or ACEs, has become the most widely adopted methodology
linking traumatic childhoods to adult outcomes. As the number of self-reported ACEs
increase from 0 to 4 or more (4⫹), most studies find a roughly stepwise progression in risk
for a wide range of negative medical and mental health outcomes. A score of 4⫹ACEs, has
become a de facto cutpoint, increasingly used clinically to define “high risk” status for a
myriad of outcomes. Comparisons across studies using a 4⫹cutpoint, however, find con-
siderable heterogeneity in the degree of risk for the same outcomes. In addition to sample and
methodological differences, certain pairs of ACEs comprising the cumulative ACE score
interact synergistically to significantly increase the overall risk beyond the sum (or product)
of the contributions of each ACE to the outcome. This article reviews the empirical literature
on synergistic ACEs including results from a general population adult and a mixed trauma,
youth sample both sufficiently powered to examine over 20 different ACE pairings for
possible synergy. Synergistic pairs of ACEs vary by gender and age group. About 30 – 40%
of the variance in outcomes is accounted for by additive synergistic interactions between certain
pairs of ACEs. Across studies, sexual abuse is the most synergistically reactive ACE. The article
concludes with a discussion of the implications of synergistic ACE pairings for psychologists and
other allied professionals across clinical practice, prevention, research, and policy.
Public Significance Statement
This study reviews evidence that an empiric interaction (synergy) between pairs of adverse childhood
experiences (ACEs) makes larger than expected contributions to outcomes. Sexual abuse, physical
abuse, and neglect are the most synergistic ACEs. The clinical, research, and public policy impli-
cations of synergy are discussed.
Keywords: trauma, adverse childhood experiences, ACEs, synergy, children and adolescents
Vincent Felitti, Robert Anda, and colleagues coined the
term “ACE,” an acronym for adverse childhood experi-
ences, in their seminal article (Felitti et al., 1998). The
original 10 ACEs on their questionnaire involved poten-
Editor’s note. This article is part of a special issue, “Adverse Child-
hood Experiences: Translating Research to Action,” published in the
February–March 2021 issue of American Psychologist. Sharon G. Port-
wood, Michael J. Lawler, and Michael C. Roberts served as editors of the
special issue.
Ernestine C. Briggs Xhttps://orcid.org/0000-0003-4446-4715
Lisa Amaya-Jackson Xhttps://orcid.org/0000-0003-3060-9020
Karen T. Putnam Xhttps://orcid.org/0000-0002-7817-476X
Frank W. Putnam Xhttps://orcid.org/0000-0003-3594-2113
Authors’ Note. This project was developed in part under Grant
2U79SM054284 from the Center for Mental Health Services (CMHS),
Substance Abuse and Mental Health Services Administration (SAM-
HSA), U.S. Department of Health and Human Services (HHS). The
views, policies, and opinions expressed are those of the authors and do
not necessarily reflect those of the funding sources listed above. We
would also like to thank Courtney Smith and Jessica Choi for assisting
with manuscript preparation.
Correspondence concerning this article should be addressed to Ernestine
C. Briggs, UCLA/Duke University National Center for Child Traumatic
Stress, Department of Psychiatry and Behavioral Sciences, Duke Uni-
versity School of Medicine, 1121 West Chapel Hill Street, Suite 201,
Durham, NC 27710, United States. Email: ernestine.briggs@duke
.edu
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
American Psychologist
© 2021 American Psychological Association 2021, Vol. 76, No. 2, 243–252
ISSN: 0003-066X https://doi.org/10.1037/amp0000768
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... ACE are commonly assessed using a 10-item survey-the ACE [9]-and typically only the sum of the number of adverse events is analyzed. This research suggests the detrimental effect of a linear increase in the number of ACE ("more rather than fewer"), and that certain types of events may be more harmful than others [10] Research can be advanced by also examining how ACE might be grouped based on frequency (e.g., none, few, or many) and type. For example, endorsement of four or more ACE has widely been accepted as a "high risk" marker for various mental and physical health conditions [10] and further utilization of these clinically-useful cutoff scores may assist clinicians with identifying at-risk patients. ...
... This research suggests the detrimental effect of a linear increase in the number of ACE ("more rather than fewer"), and that certain types of events may be more harmful than others [10] Research can be advanced by also examining how ACE might be grouped based on frequency (e.g., none, few, or many) and type. For example, endorsement of four or more ACE has widely been accepted as a "high risk" marker for various mental and physical health conditions [10] and further utilization of these clinically-useful cutoff scores may assist clinicians with identifying at-risk patients. Additionally, different types of adverse experiences may have differential effects on clinical presentations [10] For example, although childhood abuse has been studied specifically [7] few studies have examined how other kinds of adverse experiences, such as parental divorce or caregiver mental illness, are related to urogenital pain [11]. ...
... For example, endorsement of four or more ACE has widely been accepted as a "high risk" marker for various mental and physical health conditions [10] and further utilization of these clinically-useful cutoff scores may assist clinicians with identifying at-risk patients. Additionally, different types of adverse experiences may have differential effects on clinical presentations [10] For example, although childhood abuse has been studied specifically [7] few studies have examined how other kinds of adverse experiences, such as parental divorce or caregiver mental illness, are related to urogenital pain [11]. ...
Adverse Childhood Experiences and Urogenital Pain: Examining the Mediating Effects of Negative Affect and Pain Catastrophizing
Article
  • Feb 2025
  • NEUROUROL URODYNAM
Background Adverse childhood experiences (ACE) are associated with later psychological and somatic problems, including the emotional sequelae of adverse events (depression, anxiety, and catastrophizing) and outcomes such as chronic pain intensity and pain‐related functioning. ACE have rarely been studied in women with pelvic, urogenital, and/or bladder pain (PUBP). Aims Thus, we examined how childhood adversities are related to psychological and pain‐related outcomes in adult women. We also tested whether negative affect and pain catastrophizing mediated the relationship between ACE and pain‐related outcomes. Methods A consecutive series of 310 adult women who presented at a tertiary urology center and reported PUBP completed an intake packet, which included the ACE Questionnaire as well as measures of psychological mediators and pain‐related outcomes. Results Elevated ACEs were significantly associated with higher pain interference and vaginal insertion pain, as well as significantly related to negative affect (depression and anxiety) and pain catastrophizing. Both negative affect and pain catastrophizing were found to mediate the relationship of ACE to pain intensity and interference; however, only pain catastrophizing mediated the relationship between ACE and vaginal insertion pain. Conclusions These results suggest that ACEs may impact some pain‐related outcomes in women with PUBP by influencing negative affect and pain catastrophizing. Thus, these processes are important targets for intervention in individuals with PUBP and a history of adverse childhood events. Trial registration: This study does not require a clinical trial registration because it is not a clinical trial.
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... studies linking adverse childhood experiences (aces) with respiratory outcomes have largely been retrospective and adult focused (chanlongbutra et al., 2018). Prospective studies linking early life adversity with wheezing respiratory disorders in children have examined a range of stress correlates constituting aces, considered one at a time (Pape et al., 2021,Rosa et al., 2018, while many adverse events are co-occurring and can cumulatively impact outcomes (Briggs et al., 2021). although mechanisms are not completely understood, disruption of stress-mediating systems play a key role (Rosa et al., 2018). ...
... Motivated by calls to move the aces paradigm beyond a simple cumulative score (Briggs et al., 2021), we used weighted quantile sum (WQs) regression to derive a weighted aces index encompassing all early adversity measures and estimate the joint association with wheeze frequency. WQs is a supervised ensemble modeling strategy that tests for associations between an outcome of interest and multiple concurrent exposures (carrico et al., 2015). ...
Adverse childhood experiences (ACEs) and repeated wheezing from 6 to 30 months of age: exploring the role of race and ethnicity
Article
Full-text available
  • Mar 2025
Identifying children at risk for respiratory disorders involves understanding early risk factors. This study prospectively examines how specific types of early adversity influence childhood wheeze and how these vary by race and ethnicity. Analyses included N = 746 mother-infant dyads from an urban pregnancy cohort. Mothers completed the Lifetime Stressor Checklist-Revised (LSC-R), Edinburgh Postnatal Depression Scale (EPDS), Spielberger State-Trait Anxiety Inventory (STAI), Posttraumatic stress disorder Checklist–Civilian version (PCL-C), and Traumatic Events Screening Inventory (TESI) when infants were 6 months old to assess adverse childhood experiences (ACEs). Mothers reported child wheeze at 4-month intervals to index wheezing episodes from age 6–30 months. We first assessed independent associations between ACE measures and wheeze frequency using Poisson regression. We then used weighted quantile sum (WQS) regression to derive an ACEs mixture index to estimate joint associations with wheeze frequency in the overall sample and stratified by maternal race and ethnicity adjusting for child sex, maternal asthma and education. There was a 2.05 increase (95% CI = 1.21, 3.49) in wheeze frequency with each quintile increase of the ACEs index in Black/Black Hispanics; the TESI (72%) contributed most strongly to the mixture. In non-Black Hispanics, there was a 1.33 (95% CI = 1.05, 1.67) increase in wheeze frequency with each ACEs quintile increase with EPDS (76%) contributing most strongly. Findings support the need to move the ACEs paradigm beyond a simple cumulative score when examining effects on early respiratory disease risk. Results also highlight how the impact of early life ACEs varies by ethnoracial identity.
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... We observed a direct relationship between CA and PSD in some cases. This may constitute a different underlying etiological pathway from that involving the syndemic, possibly acting through individual CA factors having greater impact, such as childhood sexual abuse (Briggs, Amaya-Jackson, Putnam, & Putnam, 2021). Alternatively, through additive effects of multiple factors, for which there is stronger evidence (Petruccelli, Davis, & Berman, 2019). ...
Testing syndemic models along pathways to psychotic spectrum disorder: implications for population-level preventive interventions
Article
Full-text available
  • Mar 2025
  • PSYCHOL MED
Background Population-level preventive interventions are urgently needed and may be effective for psychosis due to social determinants. We tested three syndemic models along pathways from childhood adversity (CA) to psychotic spectrum disorder (PSD) and their implications for prevention. Methods Cross-sectional data from 7461 British men surveyed in 5 population subgroups. We tested interactions on both additive and multiplicative scales for a syndemic of violence/criminality (VC), sexual behavior (SH), and substance misuse (SM) according to the presence of CA and adult traumatic life events; mediation analysis of path models; and partial least squares path modeling, with PSD as outcome. Results Multiplicative synergistic interactions were found between VC, SH, and SM among men, who experienced CA and traumatic adult life events. However, when disaggregated, only SM mediated the pathway from CA to PSD. Path modeling showed traumatic life events acted on PSD through the syndemic and had no direct effect on PSD. Higher syndemic scores and living in areas of deprivation characterized men with PSD and CA. Conclusions Our findings support a broad division of PSD into cases due to (i) biological/inherent causes, and (ii) social determinants, the latter including a syndemic pathway determined by CA. Preventive strategies should focus primarily on preventing adverse effects of CA on developmental pathways which result in PSD. Single component prevention strategies may prevent triggering effects of SM on PSD during adolescence/early adulthood among vulnerable individuals due to CA. Future research should determine applicability and transferability of interventions based on these findings to different populations, specifically those experiencing syndemics.
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... Yet, in the study of Salokangas et al. [9], females (71.8%) had been in the majority; and in both our and Salokangas' study, sexual abuse was equally rare and weakly related to female sex. Thus, for the reported dose-response relationship between multiple forms of CAT and mental disorder [57] and its description as the most synergistically reactive CAT domain [58], sexual abuse may mainly add to the overall burden of CAT in those most likely afflicted also by other forms of CAT. ...
Do coping strategies mediate the effects of childhood adversities and traumata on clinical high-risk of psychosis, depression, and social phobia? A cross-sectional study on patients of an early detection service
Article
Full-text available
  • Jan 2025
  • BMC PSYCHIATRY
Background Childhood adversities and traumata (CAT) increase the risk for various mental disorders, including the clinical high-risk of psychosis (CHR-P) state and its main comorbidities, i.e., depression, and social phobia. However, these relations are likely mediated by personal coping behaviors. This cross-sectional study investigates the relationships between the main CAT domains, coping, CHR-P, depression, and social phobia. Methods Using path analyses, we analyzed data of 736 patients (mean age 24 years, 67% male) who presented at an early detection service between 2002 and 2013, answered questionnaires on CAT, coping, depressiveness, and social phobia, and underwent clinical examination for CHR-P according to the recommendations of the Guidance project of the European Psychiatric Association. Results All path models (total sample, males and females) showed good to excellent fit to the data. In all models, higher scores on maladaptive coping mediated the negative effect of emotional abuse on mental health outcomes. Additionally, in the total sample and males, lower scores on adaptive coping mediated the negative effect of emotional abuse and neglect, and physical neglect was associated with lower scores on adaptive coping that, in turn, were linked to depression and social phobia but not CHR-P. Overall, effects of maladaptive coping were higher than those of adaptive coping, although adaptive coping was more diversely associated with CAT. Furthermore, the interrelated depression and social phobia were more widely explained by the models than CHR-P, which was not significantly associated with them. Conclusions Our findings underscore the complex interplay of the CAT domains and their relevant mediators with mental health outcomes that likely reflect underlying sex-specific psychological, social, cultural and neurobiological mechanisms. Supporting a broader view on CAT than the traditional focus on sexual abuse, results indicate an important role of emotional abuse that, descriptively, is most strongly mediated by maladaptive coping strategies on mental health outcomes. A detailed understanding of the effects of CAT will in future help to develop a multi-dimensional, holistic and sex-specific approach to the treatment of patients who have experienced CAT. Trial registration The study was registered in the German Clinical Trial Register (https://drks.de/) as DRKS00024469 at 02/24/2021.
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Psychological and Biological Theories of Child and Adolescent Traumatic Stress Disorders
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  • Feb 2025
The current chapter provides an overview of the leading psychobiological theories of childhood traumatic stress disorders. Incorporating learning, cognitive, biological, interpersonal, developmental, and intergenerational perspectives, these theoretical models provide clinicians with a guiding framework for conceptualizing the origins, course, and contributing (risk and protective) factors for child and adolescent traumatic stress disorders. Clinicians, therefore, have a powerful set of concepts and tools for understanding the processes that must be assessed and targeted for treatment in order to enable children, adolescents, and families to recover from traumatic stress disorders. The chapter includes a description of the biopsychosocial factors associated with the origin and course of children’s traumatic stress disorders, a review of the prominent theories of child and adolescent traumatic stress disorders and how they account for these factors, and consideration of the implications of these theories for clinical assessment and treatment of childhood traumatic stress disorders.
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Network analysis of adverse and positive childhood experiences in a national sample of university students
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  • Jan 2025
Background Adverse childhood experiences (ACEs) and positive childhood experiences (PCEs) often co-occur and interact to exert long lasting impacts on health and other outcomes. However, current analytical approaches fall short in exploring the complex interplay between ACEs and PCEs, particularly within non-Western contexts. Objective This study used network analysis to examine the complexity and interplay of ACEs and PCEs in a large sample of Chinese young adults. Methods Leveraging data collected from 9,468 Chinese university students through online surveys between August and November 2020, we examined ACE items (n = 6,458), PCE items (n = 9,249), and ACE x PCE items combined (n = 6,365) for this study. ACEs were assessed using the Chinese version of the WHO ACE-International Questionnaire, while PCEs were measured using the Chinese Positive Childhood Experiences Scale. We first conducted zero-order tetrachoric correlation analysis, followed by network estimation using the Ising model with the eLasso method. We visualized the networks using the plot function from the IsingFit R package. Network communities were detected using the Walktrap algorithm, and network sensitivity and stability were assessed. Results Network analysis revealed a high degree of connectivity within both ACEs and PCEs networks. Emotional abuse and household violence emerged as central nodes in the ACEs network, while family support and having a harmonious family environment were central in the PCEs network. The combined ACEs x PCEs network highlighted significant inverse associations between specific adverse and positive experiences, with emotional neglect closely linked with an inability to talk about feelings with family. The Walktrap algorithm identified distinct clusters within the networks, such as abuse and household dysfunction in the ACEs network, and family support and positive school experiences in the PCEs network. Conclusions Our findings confirm that ACEs and PCEs tend to co-occur and demonstrate that network analysis can elucidate their complex and intertwined nature. The findings suggest the need for culturally sensitive interventions that address both ACEs and PCEs to promote resilience and well-being in Chinese young adults.
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Additive Dose Response Models: Defining Synergy
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Full-text available
  • Nov 2019
In synergy studies, one focuses on compound combinations that promise a synergistic or antagonistic effect. With the help of high-throughput techniques, a huge amount of compound combinations can be screened and filtered for suitable candidates for a more detailed analysis. Those promising candidates are chosen based on the deviance between a measured response and an expected non-interactive response. A non-interactive response is based on a principle of no interaction, such as Loewe Additivity or Bliss Independence. In a previous study, we introduced, an explicit formulation of the hitherto implicitly defined Loewe Additivity, the so-called Explicit Mean Equation. In the current study we show that this Explicit Mean Equation outperforms the original implicit formulation of Loewe Additivity and Bliss Independence when measuring synergy in terms of the deviance between measured and expected response, called the lack-of-fit. Further, we show that computing synergy as lack-of-fit outperforms a parametric approach. We show this on two datasets of compound combinations that are categorized into synergistic, non-interactive, and antagonistic.
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Practitioner Review: Twenty years of research with adverse childhood experience scores – Advantages, disadvantages and applications to practice
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Background Adverse childhood experience (ACE) scores have become a common approach for considering childhood adversities and are highly influential in public policy and clinical practice. Their use is also controversial. Other ways of measuring adversity ‐ examining single adversities, or using theoretically or empirically driven methods ‐ might have advantages over ACE scores. Methods In this narrative review we critique the conceptualisation and measurement of ACEs in research, clinical practice, public health and public discourse. Results The ACE score approach has the advantages – and limitations – of simplicity: its simplicity facilitates wide‐ranging applications in public policy, public health and clinical settings but risks over‐simplistic communication of risk/causality, determinism and stigma. The other common approach – focussing on single adversities ‐ is also limited because adversities tend to co‐occur. Researchers are using rapidly accruing datasets on ACEs to facilitate new theoretical and empirical approaches but this work is at an early stage, e.g. weighting ACEs and including severity, frequency, duration and timing. More research is needed to establish what should be included as an ACE, how individual ACEs should be weighted, how ACEs cluster, and the implications of these findings for clinical work and policy. New ways of conceptualising and measuring ACEs that incorporate this new knowledge, while maintaining some of the simplicity of the current ACE questionnaire, could be helpful for clinicians, practitioners, patients and the public. Conclusions Although we welcome the current focus on ACEs, a more critical view of their conceptualisation, measurement, and application to practice settings is urgently needed.
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Adverse Childhood Experiences (ACEs) and Risk of Childhood Delays in Children Ages 1–5
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Adverse childhood experiences (ACEs) have been found to be important contributors to negative health outcomes throughout the lifespan. Birth to 5 years represent a critical period for brain development impacting cognitive, emotional, and social competencies. This study aims to determine the association between overall ACE score and risk of developmental, social, or behavioral delay in a sample of children ages 1–5 years from the National Survey of Children’s Health (N = 21,139). Approximately 1 in 4 (27.3%) children were found to have moderate to high risk of developmental, social, or behavioral delays. A dose–response relationship was found between ACEs and risk of delay with results ranging from 24.2% among children with 0 ACEs to 42.2% among those with 4 or more ACEs. Additional ACEs increased risk of delay by 17%. (OR = 1.17, 95% CI = 1.09–1.25). The data currently supports a strong correlation between ACE score and risk of delay among children ages 1–5.
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Screening for Adverse Childhood Experiences (ACEs) in Primary Care: A Cautionary Note
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Adverse childhood experiences (ACEs), such as experiencing or witnessing violence or abuse or living with a parent with mental illness or substance use disorder, have been shown to have a powerful influence on subsequent mental and physical health and life expectancy. Exposure to ACEs has been linked to more than 40 negative health conditions, including poor mental health, substance use disorder, adverse health behaviors, chronic physical disease, and shortened life span.¹ A meta-analysis of 37 studies that examined 23 health outcomes found that individuals who reported more than 4 ACEs had higher odds of cancer, heart disease, respiratory disease, and poor self-rated health (odds ratios ranging from 2 to 3); mental illness, alcohol use disorder, and risky sexual behavior (odds ratios ranging from 3 to 6); and drug use disorder and interpersonal or self-directed violence (odds ratios greater than 7).² Early childhood adversity and high levels of “toxic stress” have been found to have widespread and longstanding effects on multiple systems, and have been associated with reduced immunity, high levels of inflammation, shortened telomeres, subsequent poor health outcomes, and premature mortality.
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Synergistic adversities and behavioral problems in traumatized children and adolescents
Article
  • Aug 2020
  • CHILD ABUSE NEGLECT
Objective This study investigated synergy of commonly co-occurring pairs of childhood traumas/adversities to determine: 1) if synergistic pairings differ by gender and/or age grouping; and 2) if some traumas/adversities were more synergistically reactive. Methods A sample of 10,355 clinic-referred youth (1.5–18 years) from the National Child Traumatic Stress Network Core Data Set was divided by gender and categorized into salient age groups (1.5−5 years, 6−12 years, and 13−18 years). Attributable Proportion (AP), a biomedically relevant metric, was calculated to assess additive synergy for behavior problems on the CBCL. Results Overall, only four pairs of adversities were synergistic. Three involved sexual abuse with physical abuse, parental loss, and domestic violence. When the sample was analyzed by Gender X Age group, however, a more complicated picture emerges. Twelve of the twenty-one possible pairings (57 %) show additive synergy in one or more categories. The mean AP accounted for approximately 40 % of outcome variance. Males had more synergistic pairings (16) than females (7). The average synergistic effect was higher for males (42 % of variance) than females (36 % of variance). The vast majority of synergy occurs in the 6−12 and 13−18 age groups. Sexual abuse was the most synergistically reactive trauma, pairing most frequently (16) followed by physical abuse (10) or neglect (9). Conclusion Sexual abuse was malignantly synergistic, frequently pairing with other adversities, followed by physical abuse, neglect, and domestic violence. The findings underscore that all ACEs are not equal in their contributions to commonly assessed outcomes. The findings also have considerable implications for prevention, intervention, and future research.
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Dissecting racial bias in an algorithm used to manage the health of populations
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  • Oct 2019
Racial bias in health algorithms The U.S. health care system uses commercial algorithms to guide health decisions. Obermeyer et al. find evidence of racial bias in one widely used algorithm, such that Black patients assigned the same level of risk by the algorithm are sicker than White patients (see the Perspective by Benjamin). The authors estimated that this racial bias reduces the number of Black patients identified for extra care by more than half. Bias occurs because the algorithm uses health costs as a proxy for health needs. Less money is spent on Black patients who have the same level of need, and the algorithm thus falsely concludes that Black patients are healthier than equally sick White patients. Reformulating the algorithm so that it no longer uses costs as a proxy for needs eliminates the racial bias in predicting who needs extra care. Science , this issue p. 447 ; see also p. 421
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Protective factors that buffer against the intergenerational transmission of trauma from mothers to young children: A replication study of angels in the nursery
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  • Feb 2019
This replication study examined protective effects of positive childhood memories with caregivers (“angels in the nursery”) against lifespan and intergenerational transmission of trauma. More positive, elaborated angel memories were hypothesized to buffer associations between mothers’ childhood maltreatment and their adulthood posttraumatic stress disorder (PTSD) and depression symptoms, comorbid psychopathology, and children's trauma exposure. Participants were 185 mothers ( M age = 30.67 years, SD = 6.44, range = 17–46 years, 54.6% Latina, 17.8% White, 10.3% African American, 17.3% other; 24% Spanish speaking) and children ( M age = 42.51 months; SD = 15.95, range = 3–72 months; 51.4% male). Mothers completed the Angels in the Nursery Interview (Van Horn, Lieberman, & Harris, 2008), and assessments of childhood maltreatment, adulthood psychopathology, children's trauma exposure, and demographics. Angel memories significantly moderated associations between maltreatment and PTSD (but not depression) symptoms, comorbid psychopathology, and children's trauma exposure. For mothers with less positive, elaborated angel memories, higher levels of maltreatment predicted higher levels of psychopathology and children's trauma exposure. For mothers with more positive, elaborated memories, however, predictive associations were not significant, reflecting protective effects. Furthermore, protective effects against children's trauma exposure were significant only for female children, suggesting that angel memories may specifically buffer against intergenerational trauma from mothers to daughters.
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Is Sexual Abuse a Unique Predictor of Sexual Risk Behaviors, Pregnancy, and Motherhood in Adolescence?
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  • Jul 2018
This study tested sexual abuse as a unique predictor of subsequent adolescent sexual behaviors, pregnancy, and motherhood when in company with other types of maltreatment (physical abuse, neglect) and alternative behavioral, family, and contextual risk factors in a prospective, longitudinal study of maltreated (n = 275) and comparison (n = 239) nulliparous females aged 14–19 years old assessed annually through 19 years old. Hierarchical regression was used to disentangle risk factors that account for the associations of maltreatment type on risky sexual behaviors at 19 years old, adolescent pregnancy, and adolescent motherhood. Findings indicate that sexual and physical abuse remain significant predictors of risky sexual behaviors, and that sexual abuse remains a significant predictor of adolescent motherhood when alternative explanatory variables are controlled.
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