Thursday, April 5, 2018
Adverse Childhood Experiences: A Helpful or a Harmful Idea?
There’s a great deal of discussion nowadays about adverse childhood experiences (ACEs), as defined by a study in the late ‘90s which interviewed thousands of adults and reported associations between their adult physical and mental health and their early experiences of events like abusive treatment or family conflict (see www.cdc.gov/violenceprevention/acestudy/index.html for much more explanation). Many people have experienced one or two ACEs during their childhood years, but the study reported a positive correlation between having large numbers of ACEs in one’s history and having illness or premature death in adulthood. The ACE study positioned adverse childhood experiences as important factors for public health, and prevention of those experiences as a way to improve adult health in the future.
The adverse childhood experiences studied were not on the whole events that would directly affect health—that is, most of them did not involve physical injury to the child or even failure to provide medical care when needed. The ACE events could be, but most often were not, actual traumas, catastrophic situations in which death or serious injury were feared. The association with later health problems was surprising for those reasons, and it has been argued that the ACEs studied may be proxy measures for other unmeasured events that are the actual cause of later health problems. For example, one of the original questions had to do with whether a person had in childhood or adolescence been sexually approached by someone 5 or more years older. Such an experience might or might not be disturbing—in fact, it might be flattering and pleasurable for a 14-year-old girl to be in a sexual relationship with an admired young man of 20—but the existence of such a sexual experience might indicate parental neglect and lack of supervision, which in turn could be the actual cause of various psychological and physical health effects.
The ACE questionnaire was intended as a “quick and dirty” measure of childhood experiences as recalled and reported by adults. Retrospective studies of this kind are sometimes the best that can be managed, but they are subject to all kinds of obvious problems; people may not remember what happened, or may remember something that did not happen, or may conceal an event out of embarrassment, or may invent some shocking story to impress the interviewer. Without some way to validate the reports, it seems much more accurate to say that the people’s reports of childhood experiences are correlated with their adult health, rather than to say that the experiences themselves are correlated with health.
It’s certainly possible at this point to criticize the ACE study because it did not achieve goals that were never part of the study plan. The study did not try to identify which ACEs had the biggest effect, or whether one of the experiences had the same effect as another. It did not look at interactions between the individual’s developmental age at the time of the experience and the experience itself—for example, a sexual experience with a person at least 5 years older would presumably have a different effect when the pair involved a 7-year-old and a 2-year-old, than when the pair were the 14-year-old and the 20-year-old mentioned earlier. It will be important someday to know about these issues, of course, but we can’t demand this information of research that considered only the number of adverse events experienced in childhood and adolescence, and how that number went statistically with physical and mental health disorders in adulthood.
Information about ACEs has been helpful in that it has directed much attention to preventable adverse events experienced by children. This has been persuasive because authorities and funding agencies can be convinced to invest in resources for families when they see a benefit to public health and its associated costs , but are less likely to do so simply because children are miserable and failing in school or bound for the school-to-prison pipeline. This is a bit like the attention paid to mental illness when it is called a “brain disorder” (which of course it is, in a sense, but hardly the same as a seizure disorder), but not when it is regarded as an unhappy state that the patient could rise above if he or she had some gumption.
But while helpful, ACEs scores can be scary too, when they are misused. It’s important to keep in mind that although an individual child’s high ACEs score is a good reminder to us that help is needed for the family, that score is not a predictor for that child’s life. ACEs scores help us predict events for populations—large numbers of people—but not for individuals. Individuals may display greater or less resilience or vulnerability to adverse events, may experience the events at different ages, and may or may not have sources of support and buffering that protect them from poor physical and mental health consequences. For adults, by the way, a high ACEs score can be frightening when we think about it, but it’s important to realize that many other factors influence health, and some of those are under our control.
A recent discussion on a psychology list revealed that a potentially harmful forensic use of the ACE score seems to be coming into play in legal arguments and decisions. Sentencing often takes into account the probability that a person will repeat a crime in the future, and some are arguing that criminals with high ACE scores are likely to be mentally ill and therefore to have a high probability of re-offending, so they should have lengthy sentences. This is a particularly bad example of trying to use the score to predict an individual’s behavior when the original work had to do with what happened to a population.