Impacts of adverse childhood experiences on health, mental health, and substance use in early adulthood: A cohort study of an urban, minority sample in the U.S.
Introduction
Expanding on five decades of evidence documenting the deleterious effects of child abuse and neglect (Curtis, 1963, Kempe et al., 1962), research has shown that an array of adverse childhood experiences (ACEs) are associated with similar consequences. The ACE framework has helped to orient and advance the field in at least three ways. First, it acknowledges that similar consequences can result from different antecedent risks, and that these risks typically correlate. Thus, individuals who experience one ACE are often exposed to multiple ACEs. Second, ACEs tend to have a dose-response relationship with many unwanted outcomes. That is, accumulating levels of adversity often produce graded decrements in development and functioning across domains. Third, ACEs can lead to lifelong consequences. It is now widely accepted that early adversity contributes to morbidity and mortality over the life course, although the mechanisms that effectuate long-term outcomes are not well understood.
Much of this progress can be credited to the original ACE Study initiated by the Centers for Disease Control and Prevention and Kaiser Permanente. This investigation involves over 17,000 Kaiser Health Plan members in San Diego, California who were surveyed from 1995 to 1997. Retrospective accounts of ACEs such as abuse and neglect, parental divorce, and household violence were matched to health outcome data gathered from patient medical records. Results have shown that greater exposure to ACEs increases the risk of mortality and many forms of morbidity, including autoimmune, liver, coronary, and pulmonary diseases (Anda et al., 2008, Dong et al., 2003, Dong et al., 2004b, Dube et al., 2009, Felitti et al., 1998). Increasing ACE levels also have been linked to poor self-rated health (Felitti et al., 1998), mental health problems such as mood and anxiety disorders (Anda et al., 2006, Chapman et al., 2004), as well as increased use of tobacco, alcohol, and illicit drugs (Anda et al., 1999, Dube et al., 2002, Dube et al., 2003).
Researchers have recently begun the important work of replicating the ACE Study. For instance, cross-sectional data from the Behavioral Risk Factor Surveillance System (BRFSS; Centers for Disease Control & Prevention, 2011) have been used to correlate ACEs with poor health, disease, and injury (Andersen and Blosnich, 2013, Chapman et al., 2013, Nurius et al., 2012). Other longitudinal investigations have also concluded that increments of ACEs foreshadow physical health and mental health conditions (Afifi et al., 2008, Danese et al., 2009, Schilling et al., 2007). Nevertheless, there are many uncharted areas of ACE scholarship that require further exploration.
For one, there is a lack of ACE research on diverse populations. Most published evidence has originated from seminal ACE Study sample that is comprised of predominantly white (75%), high school graduates (93%) with private health insurance (Felitti et al., 1998). Few studies have examined the impact of early adversity on low-income, urban, minority samples—groups that are at a high risk of ACEs and poor health-related outcomes (Burke, Hellman, Scott, Weems, & Carrion, 2011). In addition, ACE Study respondents averaged 57 years of age (Anda et al., 1999), which helped to illuminate connections between childhood adversity and health later in life. Less is known about the effects of ACEs in early adulthood, however, a developmental period when many mental health symptoms (e.g., depression; substance use) often emerge. Moreover, like the ACE Study, most subsequent investigations have lacked sufficient controls for confounding influences that could account, at least in part, for effects attributed to ACEs.
Finally, although it is often hypothesized that sex moderates associations between adverse experiences and their consequences, empirical tests have produced limited evidence to this effect. Some research suggests that, compared to males, females are at an elevated risk of certain anxiety disorders following potentially traumatic events (Afifi et al., 2008, Olff et al., 2007), but the ACE Study and other similar investigations have shown that adversity increases the risk of poor health and well-being for both males and females (Dube et al., 2002, Dube et al., 2005, Herman et al., 1997, Schilling et al., 2007). Most of these studies have demonstrated descriptive differences based on stratified analyses, which have well-known methodological limitations (Brookes et al., 2004); few studies have tested ACE-by-sex interactions to detect statistically significant differences.
To help close the above gaps in the literature, the current investigation has three objectives. First, using data from a panel study of economically disadvantaged, racial/ethnic minorities we examine the connection between ACEs and indicators of health, mental health, and substance use. Second, in addition to examining each outcome independently, we analyze outcomes in aggregate to estimate the impact of cumulative adversity on cumulative functioning across domains. Third, we test whether the effects of ACEs on health are moderated by sex.
Section snippets
Methods
Data for this investigation originate from the Chicago Longitudinal Study (CLS), which tracks the development of a cohort of racial and ethnic minority children (93% African American; 7% Hispanic) who were born into underprivileged, urban-dwelling families in 1979 or 1980. The study's quasi-experimental design is described in detail elsewhere (Reynolds, 2000, Reynolds and Robertson, 2003). Briefly, the CLS sample included a cohort of 1,539 children who attended public schools offering full-day
Results
Descriptive analyses presented in Table 1 indicate that nearly four out of five CLS participants (79.5%) experienced at least one ACE, and almost half of the sample (48.9%) was exposed to multiple ACEs. Results suggest that rates of exposure to ACEs were higher for males than for females. To illustrate, 25.2% of females and 14.8% of males were not exposed to an ACE, while 5.0% of females and 12.3% of males were exposed to five or more ACEs. In aggregate, females averaged 1.38 outcomes and males
Discussion
Taken together, results confirmed that increased exposure to ACEs was associated with an increased likelihood of poor health, mental health, and substance use outcomes in early adulthood. The hypothesized dose-response relationship between cumulative adversity and cumulative consequences across domains also was supported. The estimated effects of ACEs did not differ between males and females.
Our findings largely correspond with the results of the original ACE Study, though by comparison ACEs
Implications
Although the evidence we present is sobering, the fact that ACEs are alterable conditions also implies that policies and programs that prevent adversity or ameliorate its effects can substantially improve public health. With this aim in mind, applying a public health framework can help to advance ACE-related research and its application in 4 areas: (a) surveillance, (b) risk assessment, (c) prevention and intervention, and (d) dissemination.
In regard to surveillance, as mentioned earlier, BRFSS
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