Research ArticleAdverse Childhood Experiences: Expanding the Concept of Adversity
Introduction
The Adverse Childhood Experiences (ACEs) Study1 represented a landmark in medical research, linking childhood experiences of abuse, neglect, and household dysfunction with future health. Between 1995 and 1997, Felitti and colleagues developed the ACEs score concept, representing the burden of childhood adversity experienced by thousands of participants insured by Kaiser Permanente. “Conventional” ACEs scores (i.e., those based on the original Kaiser sample) sum a participant’s reports of exposure to abuse, neglect, and household dysfunction.1 Conventional ACEs scores repeatedly have demonstrated a step-wise, dose-dependent relationship with developing at-risk behaviors, including substance abuse, multiple sexual partners, smoking, and early initiation of sexual activity and pregnancy.2 Even after adjusting for demographics and health-related behaviors, Conventional ACEs scores have been independently associated with early mortality related to mental health and cardiovascular, pulmonary, and liver disease.3, 4, 5, 6, 7
Conventional ACEs studies have led to a conceptual model describing the natural history of childhood adversity, resulting in impairment and adoption of health risk behaviors that promote early disease, disability, social problems, and early death. Many states have integrated ACEs modules into their Behavioral Risk Factor Surveillance System (BRFSS), a telephone survey that gathers information on various health-related questions such as risk and preventive behaviors and disease prevalence. Emerging BRFSS reports confirm that ACEs lead to poor health outcomes.8, 9, 10, 11 Of note, Kaiser ACEs data have been limited to a sample of insured, primarily white, educated participants. Likewise, BRFSS participants who completed the ACEs module are predominantly white, and many have education levels higher than the U.S. average.12, 13 Given the current understanding of health disparities,14 it may be presumed that other unmeasured ACEs also may impact health outcomes, particularly in more-diverse and minority populations. Qualitative data from African American and Latino youth support expanding the concept of childhood adversity to include community-level indicators such as: experiencing racism, witnessing community violence, living in an unsafe neighborhood, experiencing bullying, and a having a history with foster care.15, 16 A recent study by Finkelhor et al.17 assessed Conventional ACEs occurring within the household and additional potential childhood adversities occurring outside the home, such as peer rejection, peer victimization, and community violence exposures. Previously unmeasured ACEs were correlated with mental health symptoms, in some cases more so than Conventional ACEs indicators.11
Though more diverse, the sample assessed by Finkelhor and colleagues17 was still predominantly white and only had a 43% response rate. Second, their method of the prospective data collection from children and their parents may have reduced recall bias, but children’s fear of repercussions from parents or social service workers might have impacted accurate assessments of violence exposures. Third, the Trauma Symptom Checklist for Children, used by Finkelhor et al., “may be better associated with the impact of some childhood events, such as violence exposure, than others and may not necessarily be reflective of what could best predict long-term health effects.” This study expands on previous work by describing the prevalence and demographic variation of Conventional and Expanded ACEs in a more socioeconomically and racially diverse population, with the goal being to understand whether there are unmeasured ACEs that might differentially impact specific demographic groups.
Section snippets
Study Sample
The Philadelphia (PHL) ACEs Survey was conducted as a follow‐up to Philadelphia Health Management Corporation (PHMC)’s 2012 Southeastern Pennsylvania Household Health Survey (HHS). The HHS is a large-scale comprehensive health survey conducted with a representative sample of >13,000 child and adult residents from Southeastern Pennsylvania. Random-digit dialing of land and cell phones was employed to gather information on a wide range of health topics, conditions, and behaviors.
Between November
Results
A total of 1,784 respondents aged ≥18 years participated, resulting in a response rate of 67.1% based on the American Association for Public Opinion Research’s RR3 formula.24 Table 1 provides demographics of the PHL ACEs Survey and Kaiser study populations. Of note, more participants in the PHL ACEs Survey sample reported being black/African American and younger; fewer PHL ACEs Survey respondents reported being white. PHL ACEs Survey participants achieved lower levels of education compared to
Discussion
This study is the first to describe the prevalence of Conventional ACEs scores in a more socioeconomically and racially diverse urban adult population and begins to explore whether Conventional ACEs sufficiently measure adversity among less-affluent, non-white participants. Specifically, this study broadens the concept of childhood adversity by including newly defined adversities (Expanded ACEs) experienced at the community level along with the typical household adversities (Conventional ACEs)
Acknowledgments
We would like to gratefully acknowledge the Institute for Safe Families (ISF) and the members of the Board and all of their supporters and funders for their unwavering commitment to decreasing violence in the lives of families in our region and across our nation. ISF provided the vision for The Philadelphia Adverse Childhood Experiences (ACEs) Project, secured funding, and leveraged connections within the community to bring together like-minded colleagues who could bring this work to fruition
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