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This article reviews the Adverse Childhood Experiences (ACE) Study that examined the association between multiple childhood traumas and health outcomes in adults. These findings have significant public health implications for individuals exposed to childhood trauma, and the authors present a vision for a children's mental health care and wellness infrastructure in the United States derived from the Report of the Surgeon General's Conference on Children's Mental Health.
Prior research on the impact of childhood abuse and trauma has been limited in scope. Previous studies have focused mainly on single forms of adversities. Stressful life events do not occur in pure forms, and research is needed to assess effects of multiple trauma and abuse on adult health risk outcomes. The Adverse Childhood Experiences (ACE) Study examined the association between multiple childhood trauma and health outcomes in adults (Felitti et al., 1998). Questionnaires on adverse childhood experiences were mailed to 13,494 adults who completed a standardized medical evaluation in a large California HMO, with the final sample consisting of 9,508 participants. Respondents and nonrespondents did not differ concerning gender or years of education. However, respondents were older than nonrespondents and were more likely to be white.
The questionnaire assessed seven categories of adverse experiences: 1) psychological abuse; 2) physical abuse; 3) sexual abuse; 4) violence against the respondent's mother; 5) living with household members who were substance abusers; 6) living with individuals who were mentally ill or suicidal; or 7) living with individuals who had ever been imprisoned. The researchers instructed respondents to limit their responses to events that occurred during the first 18 years of life. Additional health risk factors and disease conditions used to assess adult health status were: smoking, severe obesity, physical inactivity, depressed mood, suicide attempts, alcoholism, any drug abuse, parental drug abuse, high numbers of lifetime sexual partners, a history of having a sexually transmitted disease (STD), ischemic heart disease, cancer, stroke, chronic bronchitis, emphysema, diabetes, hepatitis or jaundice, and any skeletal fracture.
Logistic regression was used to examine the association between adverse childhood experiences (range=0 to 7) and health outcomes controlling for significant demographic factors. Of the total sample, more than half (52%) of the respondents experienced one or more types of adverse childhood exposures, and 6.2% reported four or more exposures. Significant correlations were found among all categories of adverse childhood experiences; however, no multicollinearity existed between independent variables. Those with multiple categories of childhood exposure were more likely to have multiple health risk factors later in life.
The graded relationship among the seven categories of adverse childhood exposures and each of the adult health risk factors and diseases studied was highly significant (p<0.001) (Figure 1). These data provide evidence that adverse childhood exposure to trauma and household dysfunctions are significantly associated with negative health outcomes in adults. Clearly, these issues warrant further study utilizing longitudinal designs.
Public Health Care Implications for Children
Although this study is limited by its use of retrospective data, these findings have several important public health care implications for children exposed to trauma. Appropriate interventions could potentially address major health issues, such as drug abuse, depression, suicide attempts, STDs, obesity, ischemic heart disease and cancer, which sometimes occur in adult survivors of childhood trauma and abuse. These findings call for public health care interventions at the primary, secondary and tertiary levels.
Preventive programs need to target homes that are at high risk for family violence and dysfunction and where children are at an increased risk for exposure to abuse or trauma. Practitioners need to engage these individuals and their families in comprehensive home assessments and structured interventions that are aimed toward promoting more adaptive family functioning. Entire communities need to be educated regarding the potential harmful effects of prolonged exposure to family dysfunction and childhood trauma. Parental support groups, affordable day care services and greater access to community resources need to be offered to caretakers to reduce family disintegration and cumulative stress. Caretakers also need to be guided in connecting with their natural helping networks that will allow them to share child care responsibilities (reducing parental isolation) and modify harmful parenting practices that perpetuate increased exposure to family trauma.
Children exposed to ongoing trauma at home need to be correctly assessed by trained public and mental health care practitioners to circumvent further possible psychological, behavioral and physical decline. Symptoms of chronic exposure to trauma include a lifetime history of major depressive disorders, alcohol/drug use/dependency and anxiety disorders (Briere and Runtz, 1990). Symptoms of hypervigilance and increased antisocial behaviors in children may be incorrectly attributed solely to attention-deficit/hyperactivity disorder and other behavioral diagnoses. Skillful assessments and interventions are treatment imperatives for children exposed to violence and disruption at home. Public health care workers should facilitate and encourage enrollment in drug treatment, primary care and mental health care programs for individuals exposed to chronic trauma who show early signs of drug use and poor biopsychosocial functioning.
The developmental and behavioral consequences of repeated exposure to violence call for an effective assessment response by mental health care professionals. Curtailing poor health outcomes in adults requires a thorough assessment for family dysfunction and individual trauma in children. Such behaviors may manifest as extreme hopelessness or fatalistic behaviors later in life.
We contend that evidence-based prevention strategies could prevent exposure to adverse childhood experiences or ameliorate the poor health and mental health outcomes of being exposed to adverse childhood experiences (Henggeler et al., 1992; Olds et al., 1998). Prevention strategies need to be nested within a comprehensive mental health care and wellness infrastructure to have effectiveness and wide dissemination.
Mental Health Care and Wellness Infrastructure
The Office of the Surgeon General has identified eight goals to improve the mental health care infrastructure for children in United States (Office of the Surgeon General, 2000) (Figure 2). This comprehensive infrastructure is necessary if we are to effectively address the languishing nature of mental health care services for children. The success of this project will depend on an unprecedented collaboration and commitment by three core federal and state departments that strongly shape the context in which children live: the U.S. Department of Health and Human Services (HHS), the U.S. Department of Education (DOE), and the U.S. Department of Justice (DOJ). Although children and adolescents with serious emotional disturbances are more likely to receive treatment from a program supported by the HHS, most children who receive mental health care in the United States are within the jurisdiction of the DOE (Burns et al., 1995). However, the greatest need for a mental health care services overhaul may be within the DOJ. For example, incarcerated children who have been traumatized as a victim and a perpetrator of violent offenses need extensive mental health care attention but are unlikely to receive adequate care (Simpatico et al., 2002). The multisystemic partnership proposed by the Surgeon General is the first step in addressing the crises in mental health care services for America's youth.
Goal 1: Promote public awareness of children's mental health care issues and reduce the stigma associated with mental illness. Campaigns should help identify early indicators for mental health while promoting social, emotional and behavioral well-being.
Goal 2: Continue to develop, disseminate and implement scientifically proven prevention and treatment services. Advancements in neurological, cognitive, social and psychological development will aid the design of better screening assessment and treatment tools.
Goal 3: Improve the assessment and recognition of mental health care needs in children. Increasing the understanding of policy-makers and practitioners may accomplish this goal by identifying early mental health care needs in preschool, child care, education, health care, welfare, juvenile justice and substance abuse treatment settings. Since most of the children with mental health care needs are under the purview of the DOE, promoting cost-effective and proactive systems of behavioral support within schools will be necessary.
Goal 4: Significant disparities exist between non-white and white use of mental health care services. Increasing culturally competent white and non-white health care professionals and research on service delivery disparities will be extremely useful in attaining this difficult goal of reducing such disparities. Other avenues toward the elimination of the broad disparities include developing policies for uninsured children; encouraging alternative prevention/intervention strategies; and co-locating mental health care services with other key systems such as education, primary care, welfare, juvenile justice and substance abuse treatment.
Goal 5: Improve the infrastructure of children's mental health care services, including support for scientifically proven interventions across professions. The primary objective for this goal is twofold: review incentives and disincentives for health care providers to assess the mental health needs of children; and provide incentives to agencies, programs and individual practitioners to use scientifically proven and cost-effective prevention and intervention strategies.
Goal 6: Increase access to and coordination of quality mental health care services. Health care professionals must develop a common language to describe children's mental health that considers cultural, ecological and familial context. There is an additional need for a universal measurement system across all major service sectors that is age-appropriate and culturally and gender sensitive. Improving access to services and involving key community stakeholders in the design and delivery of services to their communities are also critical.
Goal 7: Train frontline providers to recognize and manage mental health care issues and educate mental health care providers in scientifically proven prevention and treatment services.
Goal 8: Monitor the access to and coordination of quality mental health care services. This goal may be maintained by establishing formal partnerships among federal research regulatory and service agencies, professional associations, and families/caregivers to transfer evidence-based knowledge.
We have empirical evidence that exposure to adverse childhood experiences is cumulatively associated with negative health outcomes in adults. Following the U.S. Surgeon General's report on children's mental health, we propose developing public mental health care and wellness systems that will support prevention and intervention of children's exposure to adverse childhood experiences by using evidence-based strategies that can be widely disseminated (Bell, 2002).
Bell CC (2002), Connecting the Dots. In: Youth in Crisis-Uniting for Action. Proceedings of the Seventeenth Annual Rosalynn Carter Symposium on Mental Health Policy. Atlanta: Mental Health Program of The Carter Center, pp44-46.
Briere J, Runtz M (1990), Differential adult symptomatology associated with three types of child abuse histories. Child Abuse Negl 14(3):357-364.
Burns BJ, Costello EJ, Angold A et al. (1995), Children's mental health service use across service sectors. Health Aff 14(3):147-159 [see comment].
Felitti VJ, Anda RF, Nordenberg D et al. (1998), Relationship of child abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 14(4):245-258 [see comments].
Henggeler SW, Melton GB, Smith LA (1992), Family preservation using multisystemic therapy: an effective alternative to incarcerating serious juvenile offenders. J Consult Psychol 60(6):953-961.
Office of the Surgeon General (2000), Report of the Surgeon General's Conference on Children's Mental Health: A National Action Agenda. HSS. Available at: www.surgeongeneral.gov/topics/cmh/childreport.htm. Accessed Feb. 13, 2003.
Olds DL, Hill PL, Mihalic SF, O'Brien RA (1998), Blueprints for Violence Prevention; Book Seven: Prenatal and Infancy Home Visitation by Nurses. Boulder, Colo.: Center for the Study and Prevention of Violence. Institute of Behavioral Science, University of Colorado at Boulder.
Simpatico TA, Alaimo CJ, DeCarlo A et al. (2002), Cultural disparities in mental health service use for mentally ill offenders. Presented at the 54th Institute on Psychiatric Services. Chicago;Oct. 11.