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
|Context||Adverse childhood experience|
|Within the family||Physical abuse|
|Witnessing domestic violence|
|Household member's substance misuse|
|Household member's illness|
|Household member's incarceration|
|Child separation from family|
|Social context||Poverty/Socioeconomic stratification|
|Maltreatment by teacher|
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.
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.
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.
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.