Melissa T. Merrick

Childhood adversity and adult chronic disease: an update from ten states and the District of Columbia, 2010

BACKGROUND Adverse childhood experiences (ACEs), including child abuse and family dysfunction, are linked to leading causes of adult morbidity and mortality. Most prior ACE studies were based on a nonrepresentative patient sample from one Southern California HMO. PURPOSE To determine if ACE exposure increases the risk of chronic disease and disability using a larger, more representative sample of adults than prior studies. METHODS Ten states and the District of Columbia included an optional ACE module in the 2010 Behavioral Risk Factor Surveillance Survey, a national cross-sectional, random-digit-dial telephone survey of adults. Analysis was conducted in November 2012. Respondents were asked about nine ACEs, including physical, sexual, and emotional abuse and household member mental illness, alcoholism, drug abuse, imprisonment, divorce, and intimate partner violence. An ACE score was calculated for each subject by summing the endorsed ACE items. After controlling for sociodemographic variables, weighted AORs were calculated for self-reported health conditions given exposure to zero, one to three, four to six, or seven to nine ACEs. RESULTS Compared to those who reported no ACE exposure, the adjusted odds of reporting myocardial infarction, asthma, fair/poor health, frequent mental distress, and disability were higher for those reporting one to three, four to six, or seven to nine ACEs. Odds of reporting coronary heart disease and stroke were higher for those who reported four to six and seven to nine ACEs; odds of diabetes were higher for those reporting one to three and four to six ACEs. CONCLUSIONS These findings underscore the importance of child maltreatment prevention as a means to mitigate adult morbidity and mortality.

Safe, Stable, Nurturing Relationships Break the Intergenerational Cycle of Abuse: A Prospective Nationally Representative Cohort of Children in the United Kingdom

PURPOSE To identify contextual and interpersonal factors that distinguish families in which the intergenerational transmission of maltreatment is maintained from families in which the cycle is broken. METHODS The sample was composed of 1,116 families in the United Kingdom who participated in the Environmental Risk (E-Risk) Longitudinal Twin Study. We assessed mothers childhood history of maltreatment retrospectively with a validated and reliable interview. Prospective reports of childrens physical maltreatment were collected repeatedly up to 12 years. We compared families in which mothers but not children had experienced maltreatment with families in which both mothers and children had experienced maltreatment, and with families without maltreatment, on a range of contextual and interpersonal factors known to affect child development. RESULTS In multivariate analyses, supportive and trusting relationships with intimate partners, high levels of maternal warmth toward children, and low levels of partner violence between adults distinguished families in which mothers but not children experienced maltreatment from families in which mothers and children experienced maltreatment. Families in which only mothers experienced maltreatment were largely similar to families in which neither generation experienced maltreatment, except that mothers belonging to the former group were more likely to have a lifetime history of depression and low levels of social support. CONCLUSIONS Safe, stable, nurturing relationships between intimate partners and between mothers and children are associated with breaking the cycle of abuse in families. Additional research is needed to determine whether these factors have a causal role in preventing the transmission of maltreatment from one generation to the next.

Safe, Stable, Nurturing Relationships as a Moderator of Intergenerational Continuity of Child Maltreatment: A Meta-Analysis

PURPOSE The present paper summarizes findings of the special issue papers on the intergenerational continuity of child maltreatment and through meta-analysis explores the potential moderating effects of safe, stable, nurturing relationships (SSNRs). METHODS Studies were selected for inclusion in this meta-analysis if they (1) were published in peer-reviewed journals; (2) tested for intergenerational continuity in any form of child maltreatment, using prospective, longitudinal data; and (3) tested for moderating effects of any variable of SSNRs on intergenerational continuity of child maltreatment. The search revealed only one additional study beyond the four reports written for this special issue that met inclusion criteria for the meta-analysis. RESULTS Estimates of intergenerational stability of child maltreatment from the studies included in this special issue are consistent with several other studies, which find that child maltreatment in one generation is positively related to child maltreatment in the next generation. Furthermore, meta-analytic results from the five studies that met the inclusion criteria suggest a protective, moderating effect of SSNRs on intergenerational continuity of child maltreatment. The calculated fail-safe index indicated that 49 unpublished intergenerational studies with an average null effect would be required to render nonsignificant the overall moderation effect of SSNRs on child maltreatment. CONCLUSIONS This special issue expanded the examination of SSNRs beyond the caregiver-child dyad. That is, these studies considered SSNRs in adult relationships as well as parent-child relationships. Results suggest that certain types of SSNRs between parents and other adults (e.g., romantic partner, co-parent, or adult social support resource) may decrease maltreatment continuity.

Adverse childhood experiences and sexual victimization in adulthood

Understanding the link between adverse childhood experiences (ACEs) and sexual victimization (SV) in adulthood may provide important information about the level of risk for adult SV and sexual re-victimization among childhood sexual abuse (CSA) survivors. In the present paper, we explore the relationship between ACEs, including CSA, and SV in adulthood. Data from the CDC-Kaiser ACE Study were used to examine the effect of experiences of early adversity on adult SV. Adult HMO members (n=7,272) undergoing a routine health exam provided detailed information about ACEs that occurred at age 18 or younger and their experiences of SV in adulthood. Analyses revealed that as ACE score increased, so did risk of experiencing SV in adulthood. Each of the ACE variables was significantly associated with adult SV, with CSA being the strongest predictor of adult SV. In addition, for those who reported CSA, there was a cumulative increase in adult SV risk with each additional ACE experienced. As such, early adversity is a risk factor for adult SV. In particular, CSA is a significant risk factor for sexual re-victimization in adulthood, and additional early adversities experienced by CSA survivors may heighten adult SV risk above and beyond the risk associated with CSA alone. Given the interconnectedness among various experiences of early adversity, adult SV prevention actions must consider how other violence-related and non-violence-related traumatic experiences may exacerbate the risk conferred by CSA on subsequent victimization.

The Association Between Adverse Childhood Experiences and Risk of Cancer in Adulthood: A Systematic Review of the Literature

CONTEXT: Adverse childhood experiences (ACEs) can affect health and well-being across the life course. OBJECTIVE: This systematic review summarizes the literature on associations between ACEs and risk of cancer in adulthood. DATA SOURCES: We searched PubMed to identify relevant publications published on or before May 31, 2015. STUDY SELECTION: We included original research quantifying the association between ACEs and adult cancer incidence. Case reports and reviews were excluded. DATA ABSTRACTION: Two reviewers independently abstracted and summarized key information (eg, ACE type, cancer type, risk estimates) from included studies and resolved all discrepancies. RESULTS: Twelve studies were included in the review. In studies in which ACE summary scores were calculated, significant associations were observed between the scores and an increased risk of cancer in adulthood. Of the different types of ACEs examined, physical and psychological abuse victimization were associated with risk of any cancer in 3 and 2 studies, respectively. Two studies also reported significant associations with regard to sexual abuse victimization (1 for cervical cancer and 1 for any cancer). However, 2 other studies reported no significant associations between childhood sexual or physical abuse and incidence of cervical or breast cancer. LIMITATIONS: Because of heterogeneity across studies, we were unable to compute a summary effect estimate. CONCLUSIONS: These findings suggest that childhood adversity in various forms may increase a person’s cancer risk. Further research is needed to understand the mechanisms driving this relationship and to identify opportunities to prevent and mitigate the deleterious effects of early adversity on long-term health.

Examining the Role of Safe, Stable, and Nurturing Relationships in the Intergenerational Continuity of Child Maltreatment—Introduction to the Special Issue

This special issue is the result of a successful collaboration between the Centers for Disease Control and Prevention (CDC) and researchers leading four important longitudinal studies on intergenerational patterns of violence: The Environmental Risk Longitudinal TwinStudy (E-Risk) [1]; theFamilyTransitionsProject (FTP) [2]; the Lehigh Longitudinal Study [3]; and the Rochester Youth Development Study [4]. The papers that follow investigate the role of safe, stable, and nurturing relationships and social contexts in the lives of children and their caregivers, provide insight into complex relationship factors that influence the intergenerational continuity of child maltreatment, and point to a number of important avenues to improve the lives of children and families by preventing violence and promoting health and well-being. Child maltreatment is a significant public health problem that requires a multifaceted approach to prevention. It is estimated that one out of every ten children in the United States experiences one or more forms of physical, sexual, or emotional abuse or neglect by a parent or other caregiver at some point during their lifetime [5e7]. In 2011, social service workers identified 681,000 children1 in the United States as substantiated victims of maltreatment. This equates to an overall victimization rate of 9.1 per 1,000 children in the U.S. population [8]. It is well-established that experiencing child maltreatment is associated with a variety of negative physical, emotional, and psychological outcomes, including subsequent harsh and/or neglectful parenting in adulthood [9e13]. Yet, it is also clear that not all maltreated children grow up to become maltreating parents [14,15]. Thus, identifying factors that distinguish families in which the cycle of violence is maintained from families in which it is interrupted is critical for violence prevention and optimal child development. The CDC has identified the promotion of safe, stable, nurturing relationships (SSNRs) as a key strategy for the public health approach to child maltreatment prevention [16]. The three dimensions of SSNRs (i.e., safety, stability, and nurturance) each represent significant aspects of the social and physical environments that

Unpacking the impact of adverse childhood experiences on adult mental health

Exposure to childhood adversity has an impact on adult mental health, increasing the risk for depression and suicide. Associations between Adverse Childhood Experiences (ACEs) and several adult mental and behavioral health outcomes are well documented in the literature, establishing the need for prevention. The current study analyzes the relationship between an expanded ACE score that includes being spanked as a child and adult mental health outcomes by examining each ACE separately to determine the contribution of each ACE. Data were drawn from Wave II of the CDC-Kaiser ACE Study, consisting of 7465 adult members of Kaiser Permanente in southern California. Dichotomous variables corresponding to each of the 11 ACE categories were created, with ACE score ranging from 0 to 11 corresponding to the total number of ACEs experienced. Multiple logistic regression modeling was used to examine the relationship between ACEs and adult mental health outcomes adjusting for sociodemographic covariates. Results indicated a graded dose-response relationship between the expanded ACE score and the likelihood of moderate to heavy drinking, drug use, depressed affect, and suicide attempts in adulthood. In the adjusted models, being spanked as a child was significantly associated with all self-reported mental health outcomes. Over 80% of the sample reported exposure to at least one ACE, signifying the potential to capture experiences not previously considered by traditional ACE indices. The findings highlight the importance of examining both cumulative ACE scores and individual ACEs on adult health outcomes to better understand key risk and protective factors for future prevention efforts.

Does Childhood Disability Increase Risk for Child Abuse and Neglect

In this article we review the empirical evidence for the presumptions that children with disabilities are at increased risk for child maltreatment, and parents with disabilities are more likely to perpetrate child abuse and neglect. Challenges to the epidemiological examination of the prevalence of child maltreatment and disabilities are discussed. We conclude that the evidence for the relationship between child maltreatment victimization of children with disabilities and perpetration by caregivers with disabilities remains equivocal due to variability in research samples, key definitions, and study methodology. Future research examining the link between disability and child maltreatment would benefit from more rigorous methodology and inclusion of a theoretical framework, such as the ecological model of child maltreatment. One potential pathway from disability to child maltreatment is presented. Knowing and understanding the link between disability and child abuse and neglect is an important step toward planning targeted and appropriate prevention and intervention activities.

Spanking and adult mental health impairment: The case for the designation of spanking as an adverse childhood experience

Adverse Childhood Experiences (ACEs) such as child abuse are related to poor health outcomes. Spanking has indicated a similar association with health outcomes, but to date has not been considered an ACE. Physical and emotional abuse have been shown in previous research to correlate highly and may be similar in nature to spanking. To determine if spanking should be considered an ACE, this study aimed to examine 1): the grouping of spanking with physical and emotional abuse; and 2) if spanking has similar associations with poor adult health problems and accounts for additional model variance. Adult mental health problems included depressive affect, suicide attempts, moderate to heavy drinking, and street drug use. Data were from the CDC-Kaiser ACE study (N=8316, response rate=65%). Spanking loaded on the same factor as the physical and emotional abuse items. Additionally, spanking was associated with increased odds of suicide attempts (Adjusted Odds Ratios (AOR)=1.37; 95% CI=1.02 to1.86), moderate to heavy drinking (AOR)=1.23; 95% CI=1.07 to 1.41), and the use of street drugs (AOR)=1.32; 95% CI=1.4 to 1.52) in adulthood over and above experiencing physical and emotional abuse. This indicates spanking accounts for additional model variance and improves our understanding of these outcomes. Thus, spanking is empirically similar to physical and emotional abuse and including spanking with abuse adds to our understanding of these mental health problems. Spanking should also be considered an ACE and addressed in efforts to prevent violence.

Harsh parenting, physical health, and the protective role of positive parent-adolescent relationships.

RATIONALE Harsh, abusive and rejecting behavior by parents toward their adolescents is associated with increased risk of many developmental problems for youth. OBJECTIVE In the present study we address behaviors of co-parents that might help disrupt the hypothesized health risk of harsh parenting. METHOD Data come from a community study of 451 early adolescents followed into adulthood. During early adolescence, observers rated both parents separately on harshness towards the adolescent. Adolescents reported on their physical health at multiple assessments from age 12 through age 20, and on parental warmth. RESULTS Harsh parenting predicted declines in adolescent self-reported physical health and increases in adolescent body mass index (BMI). Although the health risk associated with harshness from one parent was buffered by warmth from the other parent, warmth from the second parent augmented the association between harshness from the first parent and change over time in adolescent BMI. CONCLUSION As appropriate, preventive interventions should include a focus on spousal or partner behaviors in their educational or treatment programs. Additional research is needed on the association between self-reported physical health and BMI in adolescence.