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Keywords:

  • adverse childhood experiences;
  • child abuse and family dysfunction;
  • child maltreatment;
  • childhood trauma;
  • concept clarification;
  • nursing

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Data sources
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author contributions
  12. References

Aim

To report an analysis of the concept of adverse childhood experiences.

Background

Adverse childhood experiences have been associated with negative physical and psychological health outcomes, but this phenomenon lacks the clear, consistent meaning necessary for use in nursing research, theory development and practice.

Design

Concept clarification.

Data Sources

The literature search was not limited a priori by date and included publications with abstracts in English from PubMed, CINAHL, PsychINFO and Social Abstracts. The search retrieved 128 articles published from 1970–2013. The search term ‘adverse childhood experiences’ was used, with similar terms permitted. A snowball approach was used to expand the search to relevant literature.

Methods

The articles were read and analysed following Norris's five steps for concept clarification to refine, elucidate and operationally define the concept and the context in which it occurred.

Results

Adverse childhood experiences were defined operationally as childhood events, varying in severity and often chronic, occurring in a child's family or social environment that cause harm or distress, thereby disrupting the child's physical or psychological health and development.

Conclusion

This concept clarification should raise awareness and understanding of the diverse nature and shared characteristics of adverse childhood experiences that are believed to influence the health of individuals as they age. This clarified concept will help expand research on health consequences of adverse childhood experiences and interventions to improve health. We recommend promoting a model of primary care that pays attention to the social and familial influences on the health of individuals worldwide.

Why is this concept clarification needed?

  • Researchers have investigated adverse childhood experiences without providing a definition of the concept.
  • Lack of a clear meaning of the concept weakens the claim that adverse childhood experiences are associated with negative physical, psychiatric and developmental health outcomes because evidence is weak when built on inconsistent use of a concept.
  • Conceptual clarity is needed to build a programme of nursing research on the relationship between adverse childhood experiences and health outcomes.

What are the key findings?

  • The concept of adverse childhood experiences comprises five characteristics: harmful, chronic, distressing, cumulative and varying in severity.
  • Adverse childhood experiences are operationally defined as childhood events, varying in severity and often chronic, occurring in a family or social environment and causing harm or distress.
  • The concept of adverse childhood experiences is complex and includes numerous in-family and social-environmental sources.

How should the findings be used to influence policy/practice/research/education?

  • A clarified concept is needed to construct theory, develop effective measures and stimulate further research on the effects of adverse childhood experiences on health, thus providing a body of evidence for nursing practice.
  • A clear concept of adverse childhood experiences will raise nurses' awareness of social and familial determinants on health and challenge the way nurses think about the integration of social, physical and mental health.
  • Nurses should be educated to recognize and intervene in cases where adverse childhood experiences are present.

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Data sources
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author contributions
  12. References

Childhood adversity has been associated since the 1900s with subsequent psychological and physical health problems (Pervanidou & Chrousos 2007), including developmental and emotional problems in children (Chan & Yeung 2009), health-risk behaviours among adolescents (Clark et al. 2010) and a multitude of persistent, challenging psychological and physical illnesses among adults (Chartier et al. 2010, Felitti & Anda 2010). The global relevance of adverse childhood experiences is illustrated by multiple research studies on the concept in both developed and non-developed countries (Table 1). The global attention given to this concept testifies to its pervasiveness worldwide.

Table 1. The global extent of research on adverse childhood experiences
CountryAuthors, year
AustraliaBriggs and Price (2009)
Mills et al. (2009)
BrazilMadruga et al. (2011)
CanadaChartier et al. (2010)
Mock and Arai (2011)
Sareen et al. (2013)
EnglandSalmon et al. (2007)
FranceRoustit et al. (2009)
GermanyHardt et al. (2011)
Schafer et al. (2010)
IndiaSingh et al. (2012)
IranPournaghash-Tehrani and Feizabadi (2009)
JapanMasuda et al. (2007)
ManilaRamiro et al. (2010)
New ZealandDanese et al. (2009)
NigeriaOladeji et al. (2010)
PortugalPereira da Silva and da Costa Maia (2013)
South AfricaJewkes et al. (2010)
SwedenCarroll and Davies (1970)
ThailandJirapramukpitak et al. (2011)
United StatesDube et al. (2010)
Felitti et al. (1998)

The phenomenon of adverse childhood experiences itself, however, remains unclear. This lack of clarity results from failure to define the concept. The literature provides various examples of adverse childhood experiences ranging from physical battering (Jun et al. 2008) to failure to receive love and comfort (Bloom 2000), but no agreed definition. Examples of adverse childhood experiences include child sexual, physical and emotional abuse, as well as household dysfunction (Anda et al. 2008, Dube et al. 2010), violent crime, unstable home life (many caregivers and relocations) (Douglas et al. 2010), poverty and family stress (Wickrama & Noh 2010). The sources of adverse childhood experiences also vary, from in the family unit (Noll et al. 2007) to the surrounding social environment (Wickrama & Noh 2010). In many cases, examples are not given; instead, the concept is defined in terms of scores on instruments such as the Conflict Tactics Scale (Lu et al. 2008, Wu et al. 2010), the Traumatic Life Events Scale (Steel et al. 2009) and What's My ACEs Score (Felitti et al. 1998). Further obscuring concept clarity are numerous similar terms such as childhood maltreatment, childhood trauma and child misfortune, which have been used interchangeably with adverse childhood experiences. Considering the many representations of the concept, the authors sought to identify the essential characteristics of adverse childhood experiences and to clarify their meaning.

Clarity of a concept is crucial for its effective use in research programmes and translation into practice (Meleis 2011). The purpose of this study was to clarify the meaning of adverse childhood experiences and to promote better understanding of the concept, its impact on health globally and the need for further nursing research in this area. On the basis of a historical examination of adverse childhood experiences, a systematic review of the literature and an analysis of concept characteristics, we propose a definition and model for adverse childhood experiences.

Background

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Data sources
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author contributions
  12. References

Interest in childhood adversity has a long history in psychology and psychiatry. Freud (1905) and Bowlby (1952) believed that circumstances of childhood strongly affected child development and subsequent adult mental health. Freud's psychoanalytic theory, primarily developed from case studies of adults relating their experience of child abuse, still has an impact on the study of personality and motivation (Craig & Baucum 2002). Bowlby thought that it was essential for children to ‘experience a warm, intimate and continuous relationship’ with their mother or a permanent mother-substitute (1952, p. 11). In his Attachment Theory, Bowlby asserted that children must feel secure in the belief that a parent will be available when needed and that children may suffer negative mental health consequences from parental neglect, rejection or deprivation (Stroebe & Archer 2013). This theory suggests that violating a child's sense of security and disrupting the parent–child relationship threatens the child's psychological development.

The term ‘battered child syndrome’, which was introduced by Kempe et al. (1962), was used to characterize a clinical condition of serious physical abuse among children. Similarly, indicators of childhood adversity have been described by Felitti et al. (1998), which may result in a ‘battered adult syndrome’ (Foege 1998, p. 354).

For example, major childhood emotional traumas were found in several morbidly obese participants of a weight reduction programme (Felitti & Williams 1998). These patients reported feeling ‘protected’ by their obesity, less noticed and therefore safer as overweight individuals (Felitti et al. 2010). This clinical revelation of adverse childhood experiences affect on adult health outcomes generated further investigation of adverse childhood experiences effects on health outcomes (Dube et al. 2009).

Thus, psychological and physical health theorists and practitioners, recognizing the impact of adverse childhood experiences on mental and physical health, have used the concept in research. Although the consequences of adverse childhood experiences have been well studied, the concept has not been consistently operationalized. This inconsistent operational definition hinders the growth of research on adverse childhood experiences and interferes with theory development. To develop a theory about adverse childhood experiences, it is necessary to articulate what these experiences are, how they differ from related terms such as child maltreatment and child abuse, what predicts such experiences and what outcomes might be expected following adverse childhood experiences (Probst 2011).

Concept clarification was deemed the best approach to find a shared meaning for the concept (Meleis 2011). Our process of concept clarification was guided by Norris's (1982) five steps: (1) observe and describe the concept; (2) categorize the observations; (3) write an operational definition for the concept; (4) create a model of the concept; and (5) formulate hypotheses about the concept.

Data sources

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Data sources
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author contributions
  12. References

To clarify the concept of adverse childhood experiences, the literature in nursing, medicine, psychology and sociology was searched using the PubMed, CINAHL, PsychINFO and Social Abstracts. These databases were chosen as they provided the greatest access to a wide array of journals accessible to the authors. The main search term was ‘adverse childhood experiences,’ with similar terms used, i.e. ‘child maltreatment,’ ‘childhood adversity,’ and ‘child trauma.’ Sources were not limited a priori by specific publication dates; all articles found through the online search process (= 438) were reviewed for relevance. Sources were included if they were: (1) in English; (2) peer reviewed; and (3) focused on multiple forms of adverse childhood experiences as opposed to a single form, such as child sexual abuse. This last criterion was chosen to preserve the intent of the study, i.e. to clarify the concept of adverse childhood experiences as a plural term. The search was expanded in a snowball fashion to include pertinent references cited in the articles initially reviewed. This process resulted in 128 articles for review, published from 1970–2013. Of these, 111 were quantitative research articles, two were meta-analyses and 15 were review articles. Six research studies sampled children and 105 sampled adults who recalled their childhood experiences. Of the 128 reviewed articles, 24 were reports of research conducted outside the USA. Most sources (= 115) were published from 2000–2013; 12 were published in the 1990s and one in 1970.

Both authors independently reviewed each article to extract data on the search terms, a definition of terms, any sub-terms (e.g. abuse, neglect), study sample and findings. The authors met several times to analyse the data. Some articles were reread to further extract data needed to clarify the concept, including essential characteristics needed to identify and recognize it in research and practice. The authors also examined patterns associated with adverse childhood experiences such as a relationship with phenomena that occurred before the experiences (antecedents) or as a result of them (consequences). To appreciate the concept fully, the context in which it occurred, such as family unit and social environment, was also analysed.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Data sources
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author contributions
  12. References

Observe and describe the concept

Adverse childhood experiences were reported by 60% of participants in one large study (Centers for Disease Control & Prevention 2010). These adversities, as reported by adult participants, affected their health and development as children, often influencing their adult health years later (Greenfield & Marks 2009, Dube et al. 2010). Although many articles used the term ‘adverse childhood experiences’, none defined the term; instead, they offered examples of adverse childhood experiences, e.g. physical abuse (Jun et al. 2008), sexual abuse (Leeners et al. 2010), family dysfunction (Edwards et al. 2007) or lack of caregiving (Herman et al. 1997). For a complete list of examples of adverse childhood experiences for the sources reviewed see Table 2. Although examples of a phenomenon are often used in place of a definition, they do not provide a clear meaning of the concept. The reader wonders if there are additional examples and if so, what is included, what is not included and why. Perhaps more importantly, this vagueness obstructs efforts to conduct nursing research and identify and address adverse childhood experiences in the clinical setting.

Table 2. Examples of adverse childhood experiences
ContextAdverse childhood experience
Within the familyPhysical abuse
Sexual abuse
Emotional abuse
Physical neglect
Emotional neglect
Physical punishment
Witnessing domestic violence
Household member's substance misuse
Household member's illness
Household member's incarceration
Parental separation/divorce
Child separation from family
Social contextPoverty/Socioeconomic stratification
Racial segregation
Political conflict
Hospitalization
Community violence
School violence/bullying
Maltreatment by teacher
Natural disaster

Coexisting concepts

Much of the ambiguity surrounding the concept of adverse childhood experiences stems from using many similar terms in the literature. Related terms include childhood maltreatment (Hahm et al. 2010), childhood trauma (Heitkemper et al. 2011), childhood violence (Greenfield & Marks 2009) and childhood misfortune (Schafer & Ferraro 2011). These similar terms, like adverse childhood experiences, include many forms of childhood adversity. The most common adversity, child abuse, may be subdivided into physical, sexual or emotional abuse. Childhood physical abuse has been operationally defined as the ‘deliberate infliction of physical harm that results in bruising by an adult who is at least 5 years older than a child aged 0–18 years (Brodsky & Stanley 2008, p. 225). Childhood sexual abuse is defined as sexual contact with a child, including acts from genital fondling to penetration (Brodsky & Stanley 2008). Psychological abuse, perhaps a more elusive form of abuse, refers to intentional caregiver behaviours that indicate to the child that he/she is worthless, flawed, unloved, unwanted or in danger (Leeb et al. 2008).

Besides childhood physical, sexual and psychological abuse, physical and psychological neglect are often included under the umbrella terms of childhood maltreatment, trauma, victimization and misfortune. Indeed, neglect, even without visible physical signs, can have extremely deleterious results and is considered a form of adverse childhood experience (Chartier et al. 2010). Childhood maltreatment, including child abuse and neglect, is often used interchangeably with adverse childhood experiences, although it differs from the latter term in not capturing family dysfunction or the influence of the social environment. The term maltreatment, i.e. to treat cruelly or roughly, has been operationally defined as any act of commission or omission by a parent/caregiver that results in harm, the potential for harm or threat of harm to a child (Leeb et al. 2008). Commission is further defined as acts of abuse and omission as acts of neglect (Leeb et al. 2008). Current terms that describe different aspects of childhood adversity have similarities and common characteristics, but none captures the breadth of the term adverse childhood experiences.

Distinguishing the concept

The concept of adverse childhood experiences represents a larger, more overarching concept than the terms child abuse, neglect and maltreatment. Adverse childhood experiences encompass not only harmful acts to a child or neglect of a child's needs, but also familial and social-environmental influence. For example, witnessing violence and substance abuse in the family or social environment are also considered adverse childhood experiences (Chung et al. 2010). Adverse childhood experiences also include family dysfunction (Taylor et al. 2004, Felitti & Anda 2010), i.e. an environment where the child is denied a supportive, nurturing relationship with a parent or other adult in a safe home. Parents in such households may be unable to fulfil their roles as family caregiver and protector due to engaging in substance misuse or criminal activity, having mental illness, abusing others in the household or lacking knowledge of child rearing practices (Maughan & McCarthy 1997). Such parental behaviour can be an antecedent for abuse and neglect (Runyan et al. 2006). Similar terms, such as ‘risky families’, have been used to describe families characterized by conflict and aggression and by relationships that are cold, unsupportive and neglectful towards the child (Repetti et al. 2002). Disruption in the family and social environment such as parental discord, divorce and poverty also threaten the child's development to a healthy adult (Chartier et al. 2010, Taylor et al. 2011). Developmental consequences include interpersonal violence (De Ravello et al. 2008), revictimization in adult life (Jirapramukpitak et al. 2011), alcohol misuse throughout life (Dube et al. 2006, Strine et al. 2012) and delinquency (Hahm et al. 2010).

In the familial context, parents are responsible for the care and welfare of their children. Healthy parental and parent–child relationships are vital to children's ability to develop relationships and a sense of security (Bowlby 1989). Healthy families support their children by making them feel safe and in control. Lack of family support in the presence of recurring adversity has an impact on children's perceptions of the world around them, thus increasing their risk of developmental, behavioural and physical health problems with consequences extending into adulthood. For example, girls who witnessed interpersonal violence had poorer health and an increased risk of exposure to such violence as adults (Cannon et al. 2010). Family dysfunction, which affects the family dynamic and influences children's experiences, should be included in the definition of adverse childhood experiences to broaden the concept beyond childhood victimization or maltreatment.

Social environment, defined as ‘the immediate physical surroundings, social relationships and cultural milieus in which defined groups of people function and interact’ (Barnett & Casper 2001, p. 465), represents the larger context in which adverse childhood experiences occur. For example, children living in impoverished communities have more developmental and health problems than children from affluent communities (Wickrama & Noh 2010, Mock & Arai 2011). These adverse experiences may stem from problems in the social environment such as barriers to healthcare access and education (DELSA/HEA/HD: Directorate for Employment, Labour & Social Affairs Health Committee, Organisation for Economic Co-operation & Development 2008), economic hardship (Bjorkenstam et al. 2013) and lack of social support (Trocmé et al. 2005). Social environment has been found to significantly impact health and development in both urban (Burke et al. 2011) and rural communities (Brody et al. 2010). Among persons ages 19–21, cumulative lifetime exposure to childhood adversity was inversely associated with socio-economic level (Turner & Lloyd 2003).

Adverse childhood experiences occur regardless of country, race, ethnicity or gender. Adverse childhood experiences have been reported around the world from South Africa (Jewkes et al. 2010) to the Philippines (Ramiro et al. 2010) and from Germany (Bader et al. 2007) to the USA (Dube et al. 2010). Race has been associated with greater exposure to adverse childhood experiences (Turner & Lloyd 2003). For example, African Americans reported more adverse childhood experiences than their non-Hispanic White and Hispanic counterparts (Turner & Lloyd 2003). Both boys and girls experience adverse childhood experiences. Boys had more adverse childhood experiences than girls in one study (Turner & Lloyd 2003), but girls in another study experienced more frequent sexual abuse and exposure to family substance use (Lamers-Winkelman et al. 2012). Nonetheless, boys and girls who were exposed to adverse childhood experiences had comparable maladjustment problems, e.g. psychological disturbances, behavioural disorders, anxiety, feelings of loneliness and alienation, intrusive thoughts, lack of enjoyment in activities, inattentiveness, disrupted sleep and nightmares (Chan & Yeung 2009), and lower self-rated health as adults (Chartier et al. 2010).

Finally, when discussing the meaning of adverse childhood experiences, one must also consider the cultural context in which children live. For example, the perception, interpretation and response to adverse experiences may be influenced by culture (Seedat et al. 2004), which must, therefore, be considered when comparing results of studies on adverse childhood experiences in different cultures. Nonetheless, similar findings of negative health outcomes following adverse childhood experiences have been reported in studies from Nigeria (Oladeji et al. 2010) and Manila (Ramiro et al. 2010). On the other hand, cultures do influence the way families care for their children, e.g. using physical punishment as a form of discipline, gender roles, treatment of women and the importance of family relationships (Runyan et al. 2006). Thus, adverse childhood experiences must include not only family dysfunction but also threatening social environments and detrimental social mores.

Operational definition: characteristics of adverse childhood experiences

To clarify the meaning of a concept, one must identify its salient characteristics. In this section, we propose and discuss five characteristics of adverse childhood experiences gleaned from the literature: harmful, chronic, distressing, cumulative and varying in severity.

Harmful

Adverse experiences are harmful in some way to children. Here, we consider both harm resulting from negative experiences and harm resulting from lack of positive experiences. In other words, harm may be negative towards a child in the form of intentional physical, sexual and psychological abuse, or it may result from omission, such as child neglect and inadequate supervision (Leeb et al. 2008). Neglect is harmful as it sends the message that a child simply does not matter and is not worthy of attention (Klein et al. 2007). Exposure to domestic violence, a family member's substance misuse, mental illness or verbal threats of harm create an environment that may also be damaging or harmful to children (Roustit et al. 2009). Like physical and sexual abuse, psychological maltreatment and environmental distress are destructive and put children at risk of developing health problems (Mock & Arai 2011).

Chronic or recurring

Adverse childhood experiences often recur and are chronic manifestations. Distinguishing between acute and chronic events in childhood is important as chronic adversities have been associated with greater risk for psychopathology (Jirapramukpitak et al. 2011) and physical illness (Schafer & Ferraro 2011). These experiences are considered to represent prolonged or frequent exposures to injury over time (van der Kolk 2005) rather than a single event. The term ‘event’ indicates an occurrence with a distinct beginning and end. Although a single event may in some cases result in significant health consequences, it is not the typical pattern of childhood adversity. Chronicity was a characteristic of adverse childhood experiences in a majority of research studies reviewed (De Ravello et al. 2008, Chartier et al. 2010, Dunn et al. 2011). Adverse childhood experiences can be single traumatic events, but the concept is more often manifested as chronic exposure to hardship over time.

Distressing

Adverse childhood experiences distress children. ‘Stress’ and ‘distress’ are related and often used interchangeably in health care, but do not have the same meaning. Stress results in a systematic neurobiological response (McEwen & Gianaros 2010), whereas distress is the result of exposure to stress, often over a period of time (Selye 1976). A child exposed to frequent or chronic stress becomes distressed, which may lead to negative psychological and physical health outcomes (Dube et al. 2009). Stress and resulting distress may follow a single traumatic event, or may result from chronic exposure to daily hassles (Wheaton 1994). Lack of perceived control over events was also found to significantly affect the stress response (Miller et al. 2007). As adverse experiences occur in childhood when children are not in a position of control, adverse childhood experiences should be considered uncontrollable events and, as such, result in greater distress. The resulting health impacts of stress/distress are discussed under the consequences of adverse childhood experiences.

Cumulative

Nearly all the studies reviewed mention cumulative effect. Synonymous terms such as dose response (Jirapramukpitak et al. 2011), graded response (Chartier et al. 2010) and compounded effect (De Ravello et al. 2008) have also been used to indicate that adverse childhood experiences have an additive effect on the health of affected individuals. The term ‘complex trauma’ has been adopted by many in the field of childhood trauma to indicate experiences of multiple, chronic and prolonged events (van der Kolk 2005). For example, children exposed to interpersonal violence were found to be exposed to other types of childhood adversity, e.g. witnessing violence or parental substance abuse (Lamers-Winkelman et al. 2012). Indeed, the overlap of many different forms of adverse childhood experiences makes it more difficult to specify and separate the experiences and consequently to determine the effect of one single adverse experience (Maughan & McCarthy 1997). This accumulation or overlap of adversities appears to affect health outcomes. The more adverse childhood experiences children suffered, the poorer they rated their health in adulthood (Chartier et al. 2010).

Varying in severity

Adverse childhood experiences have also been characterized as varying from less to more severe. Some forms of adverse childhood experiences, such as childhood physical and sexual abuse, have been considered to be more severe than others (Benedetti et al. 2011), but witnessing violence had the same effect on children's development and behaviour as being the victim of violence (Sternberg et al. 2006). This confusion over severity may be explained by evidence that a child's individual resilience and support networks significantly affect his or her response to adverse experiences (Chan & Yeung 2009). The severity of an adverse childhood experience cannot be easily determined and seems to depend, at least in part, on the individual child. This interpretation is supported by reports that individuals who grew up in the same home and experienced the same adversity, but interpreted their experiences differently, differed in the number of chronic depressive episodes (Brown et al. 2007) and in the development of psychopathology (Laporte et al. 2011). The experience of adversity is also influenced by a child's racial and ethnic background (Turner & Lloyd 2003). Including ‘experiences’ in the concept suggests that children's perceptions of the adversity are an important part of the phenomenon.

In summary, adverse childhood experiences occur in family and social environments and can be recognized by five identified characteristics: harmful to the child; the result of acute traumas or insidious, repeated exposures to less severe events; cause distress; often cumulative; and vary in severity. However, the severity does not lend itself to objective rating, but rather varies according to individual interpretation by the child. Finally, when clarifying the meaning of adverse childhood experiences, particularly as it applies to nursing and health care, it is important to discuss the many consequences that result from adverse childhood experiences.

Consequences

The link between adverse childhood experiences and negative long-term health outcomes is supported by strong evidence. For example, an early study found that adverse childhood experiences were associated with many leading causes of death, including cardiovascular disease, cancer and diabetes (Felitti et al. 1998). These relationships were confirmed in later research, which expanded the range of negative health consequences to migraines (Tietjen et al. 2012), insomnia (Bader et al. 2007), premature death (Brown et al. 2007), obesity (Dube et al. 2009), more chronic medical conditions such as diabetes, heart disease and liver disease (Greenfield & Marks 2009), suicidal ideation and substance use disorder (Jirapramukpitak et al. 2011), depression (Cannon et al. 2010), anxiety (McLaughlin et al. 2010) and psychosis (Benedetti et al. 2011). In addition, adverse childhood experiences have been associated with several health-risk behaviours including smoking (Ford et al. 2011), substance misuse (Douglas et al. 2010) and risky sexual behaviour (Hahm et al. 2010, Ramiro et al. 2010). Indeed, the more adverse experiences, the greater the effects on a child's mental and physical health (Briere & Jordan 2009, Chartier et al. 2010, Jirapramukpitak et al. 2011). This strong evidence of the long-term negative health consequences of adverse childhood experiences cannot be ignored.

Our synthesis of data from the literature on adverse childhood experiences and our own research and practice knowledge with the long-term effects of childhood adversity have resulted in this operational definition:

Adverse childhood experiences are childhood events, varying in severity and often chronic, occurring within a child's family or social environment that cause harm or distress, thereby disrupting the child's physical or psychological health and development.

Create a model

Our model of adverse childhood experiences represents the social environment that surrounds the family and the family environment that surrounds the developing child (Figure 1). The concept of adverse childhood experiences includes harm to the child in the form of abuse or neglect, exposure to domestic violence, substance abuse, criminal activity or other forms of family dysfunction. Furthermore, adverse childhood experiences vary in number, severity and frequency, indicating a potential for increasing harm and distress to negatively affect the child's health.

image

Figure 1. Model of adverse childhood experiences.

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The social environment, e.g. poverty, racism, gender inequality and neighbourhood violence, may adversely influence the family by increasing its vulnerability, in turn adversely affecting children in the family. In some instances, the social environment may directly affect the child, such as through school violence, which, in turn, may affect the family. Children may also be harmed by events originating in the social environment, but not in the family, e.g. bullying and gang violence. Adverse childhood experiences can be considered a constellation of related negative events and lack of positive events in the family or social environment.

In the model, the child, family and social environment are mutually dependent and inseparable. What affects one, affects all. Just as the family and social environment may be sources of stress, they may also be sources of support protecting the child from social violence or poverty. This model provides a framework for future research to test relationships between its different elements. For example, one could use the model to frame a study to examine the relationship between social support and health disruption in adults with histories of adverse childhood experiences. Furthermore, the model provides order and consistency for the evidence gleaned through research, which can be used to further develop theory about the association of adverse childhood experiences and health.

Formulate hypotheses

The process by which adverse childhood experiences lead to negative health outcomes in adulthood is not yet fully understood. Childhood adversity has been theorized to result from alterations in the neurobiological stress response, leading to disease and dysfunction (McEwen & Gianaros 2010). The neurobiological stress response continues to be studied as a possible pathway from adverse childhood experiences to disease (Schafer et al. 2010, Suglia et al. 2010, Blair et al. 2011).

In addition, the mechanisms are unknown by which the long-term health of individuals with histories of childhood adversity is affected by social support and personal characteristics such as resilience and coping. However, retrospective reflections on childhood experiences were found to be influenced by social experiences (Batcho et al. 2011). That is, positive perspectives on childhood experiences were correlated with social support, spiritual growth and health-promoting behaviours in adulthood, whereas negative perspectives were correlated with increased distress and troubled relationships in adulthood (Batcho et al. 2011). Adolescents’ perceived availability of social support has also been directly associated with fewer self-reported trauma symptoms (Bal et al. 2003). Children's resilience and support networks were suggested in a meta-analysis to moderate the effects of living with violent families (Chan & Yeung 2009). These areas of research beckon nurses to investigate how to improve health outcomes for individuals with adverse childhood histories.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Data sources
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author contributions
  12. References

A clear and agreed on meaning for adverse childhood experiences promotes not only recognizing and understanding their complex and important role in human development and health but also building a body of research united by one conceptual understanding. The definition of the concept provided here reflects a middle-range explanatory theory. Our model not only clarifies the concept of adverse childhood experiences by specifying their characteristics, context and related consequences but also promotes a better understanding of their impact on health. The model explains the relationships between social-environmental and family sources of adverse childhood experiences and the development of health problems.

‘Adverse childhood experiences’ is an overarching concept that includes various childhood experiences; this article is but an early step in developing the concept. Attempts to create an exhaustive list of examples for adverse childhood experiences have been particularly challenging. We had difficulty determining which childhood experiences should be included and which should be excluded. Physical abuse, sexual abuse and neglect have frequently been used as examples of adverse childhood experiences. However, other types of adverse childhood experience should perhaps be considered such as acute physical illness, accidental injury, natural disasters, or horrific events such as school shootings. The case for inclusion is supported by evidence that these forms of childhood trauma have health consequences, including posttraumatic stress disorder (Luo et al. 2012).

Limitations

The task of clarifying adverse childhood experiences was challenging due to their scope. The plethora of literature in psychology, medicine, sociology and nursing made it impractical to review every research study that examined childhood adversity or review article on adverse childhood experiences. However, the authors maintained an audit trail of the decision-making and analytic processes and after reviewing 128 articles, agreed that enough articles had been reviewed to clarify the concept as no new data emerged from analysis. Concept development is a dynamic ongoing process; the concept is not static and its definition probably will, and should, continue to be developed over time.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Data sources
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author contributions
  12. References

The concept of adverse childhood experiences is important to nurse scientists who study the aetiology of disease, health consequences of social environments and interventions to improve health. As nurses become more aware of the connection between adverse childhood experiences in its many forms and negative health outcomes, the focus in practice should be on creating an integrated model of primary care that includes attention to social and familial influences on health (Waite et al. 2010). The authors recommend that nurses challenge the existing medical paradigm that promotes a separation of mental and physical health care. Nurses are encouraged to consider the effect of adverse childhood experiences on their patients’ psychological and physical well-being (Felitti et al. 2010).

Exposure to adversity in childhood violates children's basic human rights (Jewkes et al. 2010). To increase nurses’ recognition of adverse childhood experiences in their clientele and enhance nursing research on this topic, we propose this operational definition of adverse childhood experiences: childhood events that vary in severity are often chronic and occur in a child's family or social environment to cause harm or distress, thereby disrupting the child's physical or psychological health and development. Accounting for all the scenarios where adverse childhood experiences may occur is not possible, but our operational definition allows for further examination of the concept in nursing and is meant to raise nurses’ awareness and encourage thoughtful reflection and discussion on its application to practice and research.

Adverse childhood experiences have significant health ramifications. Nurses must engage in research on adverse childhood experiences and in translating research evidence into practice and education. Understanding and appreciating the effect of adverse childhood experiences on health is critical to shaping a future healthcare delivery system that better meets the needs of individuals, families and communities worldwide.

Funding

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Data sources
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author contributions
  12. References

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Author contributions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Data sources
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author contributions
  12. References

All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/ethical_1author.html)]:

  • substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data;
  • drafting the article or revising it critically for important intellectual content.

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  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author contributions
  12. References
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