Current IssuesA Critical Assessment of the Adverse Childhood Experiences Study at 20 Years
Section snippets
INTRODUCTION
This year marks the 20th anniversary of publication in this journal of the first of many articles on the adverse childhood experiences (ACEs) research by Drs. Felitti, Anda, and colleagues.1 As we celebrate the impact of this seminal research, it is also imperative to assess critically its serious limitations: an unrepresentative study population and narrow operationalization of childhood adversity lead to undercounting adverse experiences and misrepresenting their social distribution. Placing
UNDERSTANDING AND MEASURING ADVERSITY
The ACE index by Felitti and Anda utilizes a narrow definition of adversity, measuring childhood exposure to emotional, physical, and sexual abuse and household dysfunction using a 10-item questionnaire. These adversities, originally identified in an unrepresentative study population, focus on decontextualized households and do not include broader social factors, such as poverty and racism, highlighted in the social determinants of health framework.2 Nor do they include aspects of urban
IMPLICATIONS OF EARLY ADVERSITY OVER THE LIFE COURSE
The Felitti and Anda study of ACEs understandably focuses on adult health risks because the data come from retrospective reports by and health records of adult Kaiser Permanente patients. By contrast, the rich and distinctive neuroscience/biology research literature includes studies of children and adolescents and highlights the developmental implications of adversity for children. It thus complements and extends the focus of the original ACE research.5, 17, 18 Research also underlines the life
RECOGNIZING PROTECTIVE FACTORS AND BUILDING RESILIENCE
Felitti, Anda, and their colleagues established a deficit model of health and child development that highlights adversities.1 That model should be supplemented by attention to protective relationships that buffer the detrimental effects of adversity and alter the development of brain architecture in positive ways.10 The neuroscience of child development offers that supplement through its exploration of brain plasticity and interactions between genetic and environmental factors leading to
WIDENING PREVENTION EFFORTS TO INCLUDE SOCIAL POLICY
Felitti et al.1 acknowledged the importance of upstream prevention in their original study, noting that prevention of ACEs would only come from social changes that provide support for improved family environments. Integrating childhood adversity research into the social determinants of the health framework widens the horizon for preventive action to include policies that reduce structural causes of adversity and strengthen social supports for parents.
Neuroscience indicates that promoting the
CONCLUSIONS
On the 20th anniversary of the seminal research by Felitti and Anda, it is time to situate it and the movement it has generated in the broader frameworks of the social determinants of health and the biology/neuroscience of early childhood adversity. By doing so, researchers and practitioners can (1) produce more sensitive and representative indicators of childhood adversity that more accurately gauge its social distribution within patient populations and within communities; (2) underline the
ACKNOWLEDGMENTS
We wish to thank Bruce McEwen, Ann Beaudry, and two anonymous reviewers for their reading and helpful comments on earlier drafts of this paper.
No financial disclosures were reported by the authors of this paper.
REFERENCES (32)
- et al.
Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) study
Am J Prev Med
(1998) - et al.
Childhood poverty: specific associations with neurocognitive development
Brain Res
(2006) - et al.
et al. Household and community-level Adverse Childhood Experiences and adult health outcomes in a diverse urban population
Child Abuse Negl
(2016) - et al.
Adverse Childhood Experiences: expanding the concept of adversity
Am J Prev Med
(2015) - et al.
A new framework for addressing adverse childhood and community experiences: the Building Community Resilience model
Acad Pediatr
(2017) - et al.
Socioeconomic status and the developing brain
Trends Cogn Sci
(2009) - et al.
The intergenerational effects of early adversity
- et al.
Toward a new biology of social adversity
Proc Natl Acad Sci U S A
(2012)
Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention
JAMA
Race, racism and health: disparities, mechanisms, and interventions
J Behav Med
From Best Practices to Breakthrough Impacts: A Science-Based Approach to Building a More Promising Future for Young Children and Families
Improving the Adverse Childhood Experiences Study scale
JAMA Pediatrics
Cited by (90)
Expanding the ACEs index beyond the household: A gendered assessment of the adversity-delinquency nexus
2024, Journal of Criminal JusticeThe Work, Play, and Worship Environments as Social Determinants of Health
2023, Primary Care - Clinics in Office PracticeRisks of adverse childhood experiences on healthcare utilization and outcomes in early childhood
2023, Child Abuse and NeglectRelationships Between Recent Adverse Childhood Experiences (ACEs) and Somatic Symptoms in Adolescence
2024, Journal of Child and Family Studies