Feature

Adverse childhood experiences ‘a population-level concern’

More than 60% of Americans have experienced at least one instance of adversity in their childhood, including physical, emotional or sexual abuse and parental separation or divorce, according to a study recently published in JAMA Pediatrics. Several studies have shown that a higher number of adverse childhood experiences, or ACEs, can jeopardize health in adulthood.

According to the CDC, adults who experienced higher levels of adversity in childhood are more likely to develop obesity, diabetes, depression, suicidality, sexually transmitted diseases, heart disease, cancer, stroke, chronic obstructive pulmonary disease and injuries like broken bones. With nearly one-quarter of adults experiencing three or more of these events in their lifetime, screening and prevention are at the forefront of many researchers’ work.

Melissa T. Merrick, PhD, a senior epidemiologist at the CDC and first author of the JAMA Pediatrics study, told Infectious Diseases in Children that although all people are at risk for ACE exposure, some demographics are at increased risk, including individuals who identify as black, Hispanic or multiracial; lesbian, gay or bisexual; those who received less than a high school education; those earning less than $15,000 annually; and those who are unemployed.

“We know that some of the reasons are because of historical, structural and social factors that influence the conditions in which certain people learn, live, work and play,” she said. “I think that there is a dominant narrative that when kids have ACEs, people are maltreating their kids or engaging in bad parenting practices. This is a population-level concern. It’s the conditions in which people are raising children that is putting a lot of stress on them. We believe at the CDC that the key to preventing these early adversities in the first place is moving away from the family bubble and really looking at the conditions and the context in which people are learning and growing and developing.”

Melissa T. Merrick
Robert Sege

The original ACE study conducted in 1998 by Kaiser Permanente and the CDC provided numerous insights into the long-term effects of adversity in childhood. However, more recent research suggests childhood trauma can affect not just the health and achievement of an individual during adulthood, but it can also affect their offspring.

Effects of prolonged stress

The human body is equipped to handle a range of adversity. Several systems have the ability to adapt to help an individual persevere. According to an AAP technical report, the most extensively studied physiologic responses include the hypothala-mic-pituitary-adrenocortical axis and the sympathetic-adrenomedullary system. These systems release increased levels of stress hormones, including corticotropin-releasing hormone, cortisol, norepinephrine and adrenaline. The authors of the report said that although occasional increases in these stress hormones can assist the body in survival, prolonged exposure can be toxic, causing long-term negative effects on multiple organ systems. Researchers from Harvard have also suggested that children who experience prolonged stress develop suppressed immune function and impaired memory, as well as metabolic syndromes, bone mineral loss and muscle atrophy.

Robert D. Sege, MD, PhD, a professor of medicine and pediatrics at Tufts University School of Medicine and director of the Center for Community-engaged Medicine at Tufts, told Infectious Diseases in Children that cortisol can also cause changes to the developing brain. Additionally, a review published in BMC Pediatrics suggests childhood adversity can also catalyze psychologic concerns, developmental delays, asthma, recurrent infection, somatic complaints, sleep issues and changes in weight.

Although these events affect the health and well-being of patients, it remains unclear whether the age at which children face adversity affects their overall health.

“There is some controversy about whether age is a factor in the effect of ACE exposure because those who study the brain say that the most vulnerable periods are when children are between the ages of 1 and 3 years and during adolescence, when our brain is rapidly growing and changing,” Sege said. “However, data on this topic are difficult to collect since most ACE data are based on adult recall.”

A study conducted by Larry A. Feig, PhD, professor of developmental, molecular and chemical biology at Tufts University School of Medicine, and colleagues previously demonstrated that when male mice were exposed to severe stress but were uninvolved with parenting, their female offspring displayed elevated anxiety and reduced social interactions with other mice.

According to Feig, stress appears to promote behavior defects across generations by altering the levels of specific microRNAs in sperm that influence development in offspring. In a new study, his research group found that these micro­RNAs were similarly altered in men reporting high ACE scores, raising the possibility that early life stress could affect not only individuals but also their children.

“This could possibly explain, in part, why the children of people exposed to many adverse childhood experiences seem to be more susceptible to psychiatric disorders,” Feig said.

Although the findings suggests these biochemical changes in sperm can influence the next generation, Feig added that because these are epigenetic changes, they may be reversible by altering the environment before a man has children.

Screening and prevention

Although the effects of ACEs on a child’s development and the potential health outcomes have been established, most ACE studies are conducted well after the adversity occurred. Pediatricians can play a vital role in screening for ACEs in real time and help to mitigate the negative effects of exposure.

Sege and colleagues from the AAP’s Committee on Child Abuse and Neglect, along with the American Academy of Child and Adolescent Psychiatry and the National Center for Child Traumatic Stress reiterated in a clinical report that often, a pediatrician may be asked to treat behavioral problems in children. The authors said many children with a history of abuse, neglect or abandonment can exhibit anger or aggression, sexually reactive behaviors and issues with attention, and pediatricians can be on the lookout for those issues. However, Sege said the current list of known ACEs falls short of capturing the full range of childhood traumas, and he does not believe the country is ready for widespread screening.

“I think that the ACE study added a valuable element to our understanding of child and adult health, but physicians should be aware that this study was done in the 1990s in a middle-class group of mostly white people living in the Northwest,” Sege said. “As a consequence, some of the stress that our children experience now — whether it is related to the effects of racism, war, immigration or being a refugee — were not included in the study. However, there is every reason to believe that they are just as powerful a problem growing up as the things that were included.”

Sege said ACEs are generally understood by pediatricians in the context of clinical problem solving, and that certain behaviors — such as the ones mentioned in the AAP’s clinical report — should make pediatricians question how their patients are being affected.

“From an internal sampling of pediatricians, the AAP found that many did not know about the ACE study and did not understand their role in primary prevention,” Merrick added. “However, they understood their role when it came to screening and referral to services.”

In the clinical guidance, it is suggested that attentive parenting and reducing exposure to stressful environments and stimuli can reduce the likelihood of negative health outcomes. Although this can help reduce some of the negative outcomes related to ACEs, pediatricians can be part of other important strategies to prevent long-lasting health problems.

The CDC says these strategies — including voluntary home-visiting programs, intimate partner violence prevention, and social support for parents — can help children live to their full potential in a child-appropriate environment. These environments, according to Merrick, do not just include the children’s home and local communities.

“Safe, stable, nurturing environments in the home and in communities are important, but we are increasingly expanding this need to the broader sociopolitical environment,” Merrick said. “We know that there are some policies that are supportive of children and others that are not. We want safe and supportive environments and relationships for all children. Science has demonstrated that one child can do better when all children are doing better.”

The AAP’s clinical guidance recommends that pediatricians and physicians working with children can be a valuable resource for families with children who have experienced adversity. Merrick added that pediatricians are in a unique position in their communities to promote policies that support children who have had adverse experiences and to prevent future adverse experiences from happening.

“We all have to remember that as professionals, we wear multiple hats,” Merrick said. “You might wear your pediatrician hat day to day, but pediatricians are also community members. They may have children in school or go to church. We all have a role to play in promoting safe, stable and nurturing relationships and environments in all these contexts. It is really about understanding how we interact with our community in a professional and social sense.” – by Katherine Bortz

Disclosures: Feig, Merrick and Sege report no relevant financial disclosures.

More than 60% of Americans have experienced at least one instance of adversity in their childhood, including physical, emotional or sexual abuse and parental separation or divorce, according to a study recently published in JAMA Pediatrics. Several studies have shown that a higher number of adverse childhood experiences, or ACEs, can jeopardize health in adulthood.

According to the CDC, adults who experienced higher levels of adversity in childhood are more likely to develop obesity, diabetes, depression, suicidality, sexually transmitted diseases, heart disease, cancer, stroke, chronic obstructive pulmonary disease and injuries like broken bones. With nearly one-quarter of adults experiencing three or more of these events in their lifetime, screening and prevention are at the forefront of many researchers’ work.

Melissa T. Merrick, PhD, a senior epidemiologist at the CDC and first author of the JAMA Pediatrics study, told Infectious Diseases in Children that although all people are at risk for ACE exposure, some demographics are at increased risk, including individuals who identify as black, Hispanic or multiracial; lesbian, gay or bisexual; those who received less than a high school education; those earning less than $15,000 annually; and those who are unemployed.

“We know that some of the reasons are because of historical, structural and social factors that influence the conditions in which certain people learn, live, work and play,” she said. “I think that there is a dominant narrative that when kids have ACEs, people are maltreating their kids or engaging in bad parenting practices. This is a population-level concern. It’s the conditions in which people are raising children that is putting a lot of stress on them. We believe at the CDC that the key to preventing these early adversities in the first place is moving away from the family bubble and really looking at the conditions and the context in which people are learning and growing and developing.”

Melissa T. Merrick
Robert Sege

The original ACE study conducted in 1998 by Kaiser Permanente and the CDC provided numerous insights into the long-term effects of adversity in childhood. However, more recent research suggests childhood trauma can affect not just the health and achievement of an individual during adulthood, but it can also affect their offspring.

Effects of prolonged stress

The human body is equipped to handle a range of adversity. Several systems have the ability to adapt to help an individual persevere. According to an AAP technical report, the most extensively studied physiologic responses include the hypothala-mic-pituitary-adrenocortical axis and the sympathetic-adrenomedullary system. These systems release increased levels of stress hormones, including corticotropin-releasing hormone, cortisol, norepinephrine and adrenaline. The authors of the report said that although occasional increases in these stress hormones can assist the body in survival, prolonged exposure can be toxic, causing long-term negative effects on multiple organ systems. Researchers from Harvard have also suggested that children who experience prolonged stress develop suppressed immune function and impaired memory, as well as metabolic syndromes, bone mineral loss and muscle atrophy.

PAGE BREAK

Robert D. Sege, MD, PhD, a professor of medicine and pediatrics at Tufts University School of Medicine and director of the Center for Community-engaged Medicine at Tufts, told Infectious Diseases in Children that cortisol can also cause changes to the developing brain. Additionally, a review published in BMC Pediatrics suggests childhood adversity can also catalyze psychologic concerns, developmental delays, asthma, recurrent infection, somatic complaints, sleep issues and changes in weight.

Although these events affect the health and well-being of patients, it remains unclear whether the age at which children face adversity affects their overall health.

“There is some controversy about whether age is a factor in the effect of ACE exposure because those who study the brain say that the most vulnerable periods are when children are between the ages of 1 and 3 years and during adolescence, when our brain is rapidly growing and changing,” Sege said. “However, data on this topic are difficult to collect since most ACE data are based on adult recall.”

A study conducted by Larry A. Feig, PhD, professor of developmental, molecular and chemical biology at Tufts University School of Medicine, and colleagues previously demonstrated that when male mice were exposed to severe stress but were uninvolved with parenting, their female offspring displayed elevated anxiety and reduced social interactions with other mice.

According to Feig, stress appears to promote behavior defects across generations by altering the levels of specific microRNAs in sperm that influence development in offspring. In a new study, his research group found that these micro­RNAs were similarly altered in men reporting high ACE scores, raising the possibility that early life stress could affect not only individuals but also their children.

“This could possibly explain, in part, why the children of people exposed to many adverse childhood experiences seem to be more susceptible to psychiatric disorders,” Feig said.

Although the findings suggests these biochemical changes in sperm can influence the next generation, Feig added that because these are epigenetic changes, they may be reversible by altering the environment before a man has children.

Screening and prevention

Although the effects of ACEs on a child’s development and the potential health outcomes have been established, most ACE studies are conducted well after the adversity occurred. Pediatricians can play a vital role in screening for ACEs in real time and help to mitigate the negative effects of exposure.

Sege and colleagues from the AAP’s Committee on Child Abuse and Neglect, along with the American Academy of Child and Adolescent Psychiatry and the National Center for Child Traumatic Stress reiterated in a clinical report that often, a pediatrician may be asked to treat behavioral problems in children. The authors said many children with a history of abuse, neglect or abandonment can exhibit anger or aggression, sexually reactive behaviors and issues with attention, and pediatricians can be on the lookout for those issues. However, Sege said the current list of known ACEs falls short of capturing the full range of childhood traumas, and he does not believe the country is ready for widespread screening.

PAGE BREAK

“I think that the ACE study added a valuable element to our understanding of child and adult health, but physicians should be aware that this study was done in the 1990s in a middle-class group of mostly white people living in the Northwest,” Sege said. “As a consequence, some of the stress that our children experience now — whether it is related to the effects of racism, war, immigration or being a refugee — were not included in the study. However, there is every reason to believe that they are just as powerful a problem growing up as the things that were included.”

Sege said ACEs are generally understood by pediatricians in the context of clinical problem solving, and that certain behaviors — such as the ones mentioned in the AAP’s clinical report — should make pediatricians question how their patients are being affected.

“From an internal sampling of pediatricians, the AAP found that many did not know about the ACE study and did not understand their role in primary prevention,” Merrick added. “However, they understood their role when it came to screening and referral to services.”

In the clinical guidance, it is suggested that attentive parenting and reducing exposure to stressful environments and stimuli can reduce the likelihood of negative health outcomes. Although this can help reduce some of the negative outcomes related to ACEs, pediatricians can be part of other important strategies to prevent long-lasting health problems.

The CDC says these strategies — including voluntary home-visiting programs, intimate partner violence prevention, and social support for parents — can help children live to their full potential in a child-appropriate environment. These environments, according to Merrick, do not just include the children’s home and local communities.

“Safe, stable, nurturing environments in the home and in communities are important, but we are increasingly expanding this need to the broader sociopolitical environment,” Merrick said. “We know that there are some policies that are supportive of children and others that are not. We want safe and supportive environments and relationships for all children. Science has demonstrated that one child can do better when all children are doing better.”

The AAP’s clinical guidance recommends that pediatricians and physicians working with children can be a valuable resource for families with children who have experienced adversity. Merrick added that pediatricians are in a unique position in their communities to promote policies that support children who have had adverse experiences and to prevent future adverse experiences from happening.

“We all have to remember that as professionals, we wear multiple hats,” Merrick said. “You might wear your pediatrician hat day to day, but pediatricians are also community members. They may have children in school or go to church. We all have a role to play in promoting safe, stable and nurturing relationships and environments in all these contexts. It is really about understanding how we interact with our community in a professional and social sense.” – by Katherine Bortz

Disclosures: Feig, Merrick and Sege report no relevant financial disclosures.