Adverse Childhood Experiences

The  adverse childhood experiences study population included 9,367 (54%) women and 7,970 (46%) men (total sample=17,337). Their mean age was 56 years. Seventy-five percent were white, 39% were college graduates, 36% had some college education, and 18% were high school graduates. Only 7% had not graduated from high school.1,13
The Study assessed 10 categories of stressful or traumatic childhood experiences (seen below). The experiences chosen for study were based upon prior research that has shown them to have significant adverse health or social implications, and for which efforts in the public and private sector exist to reduce the frequency and consequences of their occurrence.
Prior research into the effects of childhood maltreatment and related experiences (including witnessing domestic violence) has tended to focus on only one or two categories of experience, such as physical or sexual abuse or domestic violence, and has generally focused on a limited range of outcomes. The ACE Study is unique not only because of its size, but because it was also designed to assess the relationships of a broad range of adverse childhood experiences (ACEs) to a wide range of health and social consequences.

• Childhood abuse

-Emotional

-Physical

-Sexual

• Neglect

-Emotional

-Physical

• Growing up in a seriously dysfunctional household as evidenced by:

-Witnessing domestic violence

-Alcohol or other substance abuse in the home

- Mentally ill or suicidal household members

- Parental marital discord (as evidenced by separation or divorce)

- Crime in the home (as evidenced by having a household member imprisoned)

The first important conclusion to be drawn is that adverse childhood experiences are very common. Moreover, ACE Study estimates of the prevalence of childhood exposures to physical and sexual abuse are similar to population-based surveys. A national telephone survey of adults conducted by Finkelhor et al. used similar criteria for childhood sexual abuse and determined that 16% of men and 27% of women had been sexually abused; in the ACE Study cohort 16% of men and 25% of women in our sample had experienced contact childhood sexual abuse. In our study, 30% of the men had been physically abused as boys; this closely parallels the 31% prevalence recently found in a similarly structured population-based study of Canadian men. The similarity of the estimates from the ACE Study to those of population-based studies suggests that findings would be applicable in other settings.

The other findings from this study are detailed below:

The effects of ACEs are long-term, powerful, cumulative, and likely to be invisible to health care providers, educators, social service organizations, and policy makers because the linkage between cause and effect is concealed by time, the inability to “see” the process of neurodevelopment, and because effects of the original traumatic insults may not become manifest until much later in life. When a child is wounded, the pain and negative long-term effects reverberate as an echo of the lives of people they grew up with—and then they grow up, at risk for taking on the same characteristics and behaviors—thereby sustaining the cycle of abuse, neglect, violence and substance abuse, and mental illness.

References
Anda RF, Felitti VJ, Walker J, Whitfield, CL, Bremner JD, Perry BD, Dube SR, Giles WH. The Enduring Effects of Abuse and Related Adverse Experiences in Childhood: A Convergence of Evidence from Neurobiology and Epidemiology. European Archives of Psychiatry and Clinical Neurosciences, 2006; 256(3):174-86
Dube SR, Miller JW, Brown DW, Giles WH, Felitti VJ, Dong M, Anda RF. Adverse Childhood Experiences and the Association with Ever Using Alcohol and Initiating Alcohol Use During Adolescence. . Journal of Adolescent Health, 2006;38(4):444.e1-444.e10.
Anda, RF, Felitti, VJ, Brown, DW, Chapman, D, Dong, M, Dube, SR, Edwards, VJ, Giles, WH. (2006) Insights Into Intimate Partner Violence From the Adverse Childhood Experiences (ACE) Study. In PR Salber and E Taliaferro, eds. The Physician’s Guide to Intimate Partner Violence and Abuse, Volcano, CA: Volcano Press; 2006.

What causes Abuse?

The causes of interpersonal abuse are complex and overlapping. However, the following are widely regarded to be some of the most important factors:

• Early learning experiences: This factor is sometimes described as the “life cycle” of abuse. Many abusive parents were themselves abused as children and have learned to see hurtful behavior as normal childrearing. At the other end of the life cycle, some adults who abuse their elderly parent are paying back the parent for abusing them in their early years.
• Ignorance of developmental timetables: Some parents have unrealistic expectations of children in terms of the appropriate age for toilet training, feeding themselves, and similar milestones, and attack their children for not meeting these expectations.
• Economic stress: Many caregivers cannot afford part-time day care for children or dependent elderly parents, which would relieve some of their emotional strain. Even middle-class families can be financially stressed if they find themselves responsible for the costs of caring for elderly parents before their own children are financially independent.
• Lack of social support or social resources: Caregivers who have the support of an extended family, religious group, or close friends and neighbors are less likely to lose their self-control under stress.
• Substance abuse: Alcohol and mood-altering drugs do not cause abuse directly, but they weaken or remove a person’s inhibitions against violence toward others. In addition, the cost of a drug habit often gives a substance addict another reason for resenting the needs of the dependent person. A majority of workplace bullies are substance addicts.
• Mental disorders: Depression, personality disorders, dissociative disorders, and anxiety disorders can all affect parents’ ability to care for their children appropriately. A small percentage of abusive parents or spouses are psychotic.
• Belief systems: Many men still think that they have a “right” to a relationship with a woman; and many people regard parents’ rights over children as absolute.
• The role of bystanders: Research in the social sciences has shown that one factor that encourages abusers to continue their hurtful behavior is discovering that people who know about or suspect the abuse are reluctant to get involved. In most cases, bystanders are afraid of possible physical, social, or legal consequences for reporting abuse. The result, however, is that many abusers come to see themselves as invulnerable.

Child abuse linked to adult pain related disorders

According to the researchers, their study and others have found stress caused by abuse can alter children’s brains, making them more likely to develop chronic pain from such conditions as irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia, interstitial cystitis and arthritis.

“Stressful events in childhood, such as abuse, can alter the body’s stress response permanently and predispose to a wide variety of medical and psychiatric conditions in adulthood,” said the study’s lead researcher, Dr. Gretchen E. Tietjen, professor and chairwoman of neurology and director of the Headache Treatment and Research Program at the University of Toledo Medical Center in Ohio.

It is not uncommon, she said, for people who’ve been abused to have a variety of debilitating conditions, including migraine.

“The linking of these comorbidities may be through abuse-mediated brain changes occurring early in life,” Tietjen said. “Understanding the physiology of abuse’s effects on the brain over the life span may lead to prevention or more effective treatment of migraine and associated conditions.”

She was quick to note, however, that not all abused children develop migraines and not everyone who suffers from migraines or any other chronic painful condition was abused.

But those with a history of abuse “are more likely to have the worst cases of migraine,” she said. “They are the ones most likely to have a lot of the other pain conditions.”

The findings are reported in the January 2010 issue of Headache: The Journal of Head and Face Pain.

For the study, Tietjen’s group collected data on 1,348 people with migraines who were seen at 11 outpatient headache centers. About 58% reported being physically, sexually or emotionally abused or physically or emotionally neglected during childhood. Also, 61% reported having at least one painful condition other than migraine.

Those who had been abused or neglected as children were significantly more likely to suffer from other chronic pain conditions than were people who had not been abused as children, the researchers found.

“Childhood abuse, especially emotional abuse and neglect, is very common in the population of persons seeking help for headache,” Tietjen said. “Childhood abuse is linked to high frequency of headache in adults, and to headache-related disability. Persons with migraine who have been abused are more likely to suffer from depression, anxiety and from chronic stress-related pain conditions.”

The researchers noted that different types of abuse appeared to result in different conditions. For example, physical abuse was linked with arthritis, whereas emotional abuse was associated with irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia and arthritis, Tietjen said.

Physical neglect was linked to an increased likelihood of irritable bowel syndrome, chronic fatigue syndrome, interstitial cystitis and arthritis.

Women who suffered physical abuse or neglect as children were also more likely to have endometriosis and uterine fibroids. Emotional abuse was linked to both conditions as well, but emotional neglect was associated with uterine fibroids alone, the study found.

Dr. Walter Lambert, an associate professor and medical director of the child protection team at the University of Miami Miller School of Medicine, said that “adverse childhood events have significant long-term health risks in adulthood.”

“It does not surprise me that people who reported emotional abuses would have more chronic headaches and migraines,” he added.

Lambert also agreed that stress in childhood can change pathways in the brain, with neglect being the worst. Children can take only so much stress before it begins to affect their growing brain, he explained.

“As human beings,” Lambert said, “we need nurturing — both physical nurturing and emotional nurturing — to flourish.” Society needs to find ways to promote nurturing and stable environments for children to prevent maltreatment, he added.