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Adverse childhood experiences linked to health risk behaviors.

Children's development involves the negotiation of numerous developmental tasks across distinct lines of development. Examples of these developmental lines include cognitive development, psycho-sexual development, personality development, psychosocial development, moral development, emotional and social intelligence, and multiple other intelligences. Each developmental stage involves challenges that must be mastered in order for children to move on to the next developmental stage. There are both fluidity of overall development and developmental stages involved in each line that cannot be skipped. Each earlier developmental level provides the platform for subsequent development, meaning that successful resolution of one phase is crucial in order to move onto the next. The child's navigation of these developmental stages does not occur in isolation; development results from the interplay between the individual child and social, cultural, and ecological forces.


It is important to understand the way in which adverse childhood experiences, commonly known as ACEs, or childhood traumas, have the potential to influence the developing child and derail healthy developmental processes. ACEs tend to arise from family system interactions, which take place within a background of family interpretations and meanings. ACEs also influence family culture. Families are further affected by problems in larger social systems, including war, other acts of social violence, ecological crises and economic dysfunctions. Subcultures and larger cultures are affected by the family culture, and the family culture is, in turn, shaped by subcultural and cultural contexts. Within this context, the developing child must manage emotions that may feel overpowering and are frequently invalidated. The child may begin to develop defense mechanisms that shape their behaviors. ACEs also influence the brain chemistry of the developing child, again giving rise to coping behaviors. Alcohol and other drug use, smoking, overeating and other health risk behaviors are strategies young people might adopt in their attempt to cope if ACEs are not effectively addressed.

Since the developing child and his/ her behaviors arise within the cultural and systemic contexts of the family, school and larger structures, it is important to link child and family agencies, schools, mental health settings, substance abuse prevention and treatment settings, and medical settings. Ideally, service providers must consider child and family problems from multiple perspectives and combine interventions with child and family agencies, school systems, the community and larger social policies.

The school system plays a central role in children's lives. Researchers have suggested that acknowledging the role of ACEs in medical problems might enhance the success of health promotion and disease prevention programs already in existence. Similarly, educational systems are likely to increase their efficacy by attending to the prevention and treatment of ACEs among school-age children. In fact, student outcomes are connected to the crucial role that school bonding plays in child development and behaviors, and the adoption of health risk behaviors is related to type of school connectedness.

Healthy Child Development's Contributions to Society

Some researchers maintain that a hierarchy of needs exists and that basic needs must be met before higher-level needs can be addressed. The five levels are physiological needs, safety needs, love/belonging/social needs, esteem needs, and self-actualization needs. Once physiological needs are met, then safety needs emerge, followed by love/belonging/social needs, and next, esteem needs, i.e., the need to contribute and feel accepted. While these first four levels involve some deficiency that must be addressed to feel whole in one's self, the fifth level, self-actualization, involves reaching one's full potential through transcending the self.


The same researchers found that some of the most productive people operated from this level of being, contributing to and thriving in society. Thus, helping people meet their needs, preventing and treating ACEs, leads to more societal members reaching their full potential and benefits society. Building this kind of human capital is profitable for society. Research has found that there are notable returns on every dollar spent on early intervention programs for disadvantaged children; later costs are also decreased. When children do not have to worry about physiological, safety and relational needs, they can focus on the academic achievement that will help them fulfill a role within society and contribute as adults. Healthy emotional development plays out in healthier behaviors, reducing health risks and criminal behaviors.

Thus, early childhood interventions benefit not only the life of the individual served, but improve the lives of other members of society. One of the gains for society--more productive social interactions--can save governments the cost of numerous programs designed to intervene with problematic adult behavior. Some longer-term savings include the costs associated with health risk behaviors such as substance abuse, health and mental health, criminal justice, homeless services and other programs. Families, schools and other systems are all part of human capital development. Early acquisition of skills for young people (upon which later development builds) can often lead to high returns on investment.

Adverse Childhood Experiences

For all of these reasons, it is important to pay careful attention to the findings and implications of recent, prominent research conducted by Kaiser Permanente and the Centers for Disease Control and Prevention. The Adverse Childhood Experiences Study, involving a sample of 17,000 middle-class adults, demonstrates strong and clear relationships between ACEs, health risk behaviors later in life, and serious medical, mental health, and substance abuse problems. Study participants were given an ACE score based on their experience of 10 specific ACE categories falling under two broad categories of abuse and household dysfunction. In this way, the interrelationship of traumatic occurrences could be measured, while correlating ACE scores with social and health consequences.

Cigarette smoking, overeating, intravenous drug use, sexual risk behaviors, and alcohol abuse and alcoholism are among the health risk behaviors predicted by ACEs. The likelihood that someone will begin using drugs, report problems resulting from drug use, use drugs as a parent, and develop a drug addiction are all correlated with ACE scores. ACEs lead to a much higher risk of experiencing depressive disorders later in life, and higher ACE scores make suicide attempts much more likely. Scores on the mental health scale of the Medical Outcomes Study 36-item Short-Form Health Survey decrease as ACE scores increase, with emotionally abusive family environments leading to more pronounced decreases in mental health scores.


Health risk behaviors also lead to more medical problems, with various public health implications. Substance abuse problems, for example, have already been connected to HIV/AIDS and Hepatitis C. Women's sexual risk behaviors result in infertility, cervical and vaginal cancers, miscarriages, ectopic pregnancies, still births, chronic pelvic pain, sexually transmitted diseases, violence-related trauma, and death. Pneumonia, ocular infections, neurological damage, low birth weight and death are a greater danger to the babies born to these women. It is also important to note that ACE scores among males have been connected with the probability that they will impregnate a teenager, and teenage pregnancy among females increases along with the ACE score. Obesity, liver disease, cancer, chronic lung disease, ischemic heart disease, and skeletal fractures are all correlated with ACE scores.

In addition, there is a connection between the behaviors of homeless people and ACEs, and impaired functioning on the job is related to the ACE score. Job market participation among homeless adults is influenced by substance abuse problems, which are anteceded by ACEs. It is also important to note that approximately three-quarters of incarcerated people suffer from substance abuse problems and that the criminal justice system is further challenged by the high incidence of Hepatitis C and behavioral risk factors for HIV infection. These are all concerns we now realize are connected with ACEs.

The researchers suggest that people attempt to cope with the anger, anxiety and depression related to ACEs by engaging in health risk behaviors such as smoking, alcohol and other drug use, overeating and sexual behaviors. Thus, these health risk behaviors are actually personal solutions that become serious public health problems, including mental illness, substance abuse and a variety of life-threatening medical issues.

The prospect of identifying and assessing ACEs cuts across service delivery systems and fields of practice, calling for strong communication across professions. ACEs typically result from violent interactions institutionalized within family systems, and the authors point to the need to respond with programs preventing and treating the family dynamics producing ACEs, supporting family life and healthy home environments. Effective prevention and treatment of ACEs involves a comprehensive approach to youth development within the context of culture and systems.


It is important to note that the ACE research has been primarily documented in medical journals, with greater connections now being forged with social science literature. Limitations of the ACE research include its use of retrospective reporting and the need for an adequate integrative conceptual framework. In particular, as the ACE findings become part of our social awareness, there is an increasing concern for how to effectively prevent and intervene with ACEs. Social science researchers are beginning to address these limitations by integrating the ACE research with the wealth of social science prevention and intervention research relevant to ACE outcomes (substance abuse, mental illness, health risk behaviors, child abuse, etc.) and employing integrative conceptual frameworks to further ACE informed research across disciplines. An inter-generational perspective realizes the value of combining intervention and prevention efforts to effectively respond to ACEs. Since ACE findings reveal an underlying syndrome at the root of problems that tend to be addressed by separate service delivery systems and diverse professions, the emerging answer to ACEs might be post-disciplinary and integrative.

Heather Larkin is an assistant professor in the School of Social Welfare, the State University of New York at Albany.
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Author:Larkin, Heather
Publication:Policy & Practice
Geographic Code:1USA
Date:Jun 1, 2009
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