May 2, 2014

expert reaction to adverse childhood events and health harming behaviours in adulthood, as published in BMC Medicine

A paper published in BMC Medicine suggested a link between adverse experiences and events in childhood, and health harming behaviours as an adult. These comments were accompanied by a Before the Headlines analysis.

Dr Andrea Danese, Senior Lecturer in Developmental Psychobiology and Psychiatry, King’s College London, said:

“Prevention of childhood adversity is a moral responsibility towards the most vulnerable individuals in society. Increasing evidence suggests that childhood adversity may also negatively impact on the health and wealth of a society. This study expands to the UK previous US research findings showing that many adults report history of adverse childhood experiences. Moreover, adults reporting adverse childhood experiences are at high risk of having maladaptive behaviours including substance use and violent perpetration.

This research is a useful first step in studying childhood adversity, as it highlights the high prevalence of reports in the UK and potential associated health risks. In contrast, as authors state in the paper, this research does not inform on whether childhood adversity causes maladaptive behaviours but it raises important questions.

First, as in most large survey, only a fraction (50-60%) of the target population took part in the study. This is not unusual and, sadly, a worsening phenomenon as people do not find motivation for participation in research. Selective inclusion may raise important methodological concerns. For example, those who did not participate might have been individuals who experienced childhood adversity but did not develop maladaptive behaviours. If that was the case, the effects of childhood adversity on maladaptive bahaviours in the overall population would be diluted.

Second, information on childhood adversity is based on retrospective reports that could be biased by current health status. For example, violent individuals may be more likely to report childhood adversity to explain or justify their behaviour, regardless of whether or not they actually experienced adversity as children.

Finally, even if we assume that the sample is representative and the reports are reliable, study participants might have develop maladaptive behaviours for reasons that are independent from their childhood experiences. For example, parental substance abuse and violence are associated with heightened risk of childhood adversity, and study participants might have developed maladaptive behaviours because of genetic liability and independent of reported childhood adversity.

These are all critical questions for future research. Experimental research in animal models showed that early life stress can lead to biological changes and even medical problems in later life. We now need carefully-designed research to test if evidence from animal models also applies to humans and, ultimately, if and how the effects of childhood adversity can be remediated.”
Dr Jonathan Goldin, Consultant Child and Adolescent Psychiatrist, Great Ormond Street Hospital, said:

“This important paper provides valuable evidence reinforcing what is apparent from clinical experience, namely that adverse child experiences such as abuse or exposure to domestic violence have a profound and lasting effect on the child as they develop into adulthood. Children who are traumatised by such experiences may develop maladaptive coping mechanisms to manage their distress, such as drug use. Their self-esteem is likely to be effected by such ACEs, which will impact on their capacity to look after themselves as adults. This paper demonstrates, for example, a significant increase in the number of teenage pregnancies in this group and so the cycle of deprivation is likely to continue. As a society it is crucial that we do all we can to break this cycle and support stable and safe childhoods for our children and for the benefit of the next generation.”

Tim Leighton, Director of Professional Education & Research at Centre for Addiction Treatment Studies, Action on Addiction, said:

“The odds ratios are more informative as they show the with increasing numbers of adverse events the chances of a person reporting an HHB are greatly increased, so that with 4+ ACEs a person in this survey is 10 times more likely to report some level of heroin/crack use, and 11 times more likely to have gone to prison.

The method seems good (fairly representative sample – sensible modelling as far as one can tell). The definitions of ACEs are a bit broad (so a person reporting 1 ACE could mean their parents split up or it could be they were sexually abused which is a different kind of experience) but this limitation is more or less inevitable.

The more deprived people suffered more ACEs but the link between ACEs and HHBs in independent of deprivation.

Causality is not demonstrated in this design but it is reasonable to hypothesise a causal link.

The stuff about these events causing neurological developmental deficits which then lead on the increased risk of HHBs is speculation. This might be the causal mechanism or it could contribute but other explanations are equally possible.

The results are not surprising to me but it is useful to see such clear and incremental associations laid out in this way.”

Nick Barton, Chief Executive, Action on Addiction, said:

“It would not be surprising to find an association between adverse experiences and HHB later in life. Whatever the evidence base so far established, we have long intuited that family life and the quality of nurturing or lack of it has a negative impact on healthy development. This would provide some additional evidence to support that proposition

To survive, children adapt and find ways to cope which may include compromising their health and safety. Where use of substances is concerned this will partly be due to learned behaviour within the family culture and/or through the discovery and experience of activities that alleviate to some extent the distress of their experiences.

The implications are that it confirms the view that we need to invest in finding ever more effective ways to support families and children to prevent inter-generational harm, including addictive behaviour.”

Declared interests

Dr Andrea Danese’s research has been funded by MRC, Wellcome Trust, NARSAD, and the U.S. National Institute of Health. He is author of several papers on the topics of child stress, trauma, and maltreatment, and wrote a chapter on this topic in the forthcoming new edition of the mainstream Rutter’s Textbook of Child & Adolescent Psychiatry. He is Senior Lecturer at the Institute of Psychiatry, King’s College London, where he directs the Stress & Development Lab. He is Consultant Child & Adolescent Psychiatrist with the National & Specialist Child Traumatic Stress & Anxiety Clinic, South London and Maudsley NHS Foundation Trust.