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Expanding Understanding of Adversity

The Adverse Childhood Experiences (ACEs) Study, published in the American Journal of Preventive Medicine in 1998, marked a major step forward in connecting how a child’s experience of abuse, neglect, and household dysfunction can influence their future health.

Now, a recently published Penn Medicine study in the same journal led by Peter F. Cronholm, MD, MSCE, an associate professor in the department of Family Medicine and Community Health, expands on this valuable work by shedding light on the socioeconomic disparities present in much of American society and their impact on human health.

Before that 1998 study, Cronholm explains, a lot of ACEs (including experiencing physical abuse, emotional neglect, an incarcerated household member, and six other issues) were often viewed as chaos in people’s lives to be managed solely by social workers and not necessarily involving physicians. The 1998 sample revealed that physicians should in many cases play a role, but the study also had some limitations, including an 80 percent white population that was primarily middle and upper middle class, and strictly focused on household-level ACEs.

The Penn sample, consisting of 45 percent white and 44 percent black respondents, as well as other groups, is the first to look at existence of ACEs in a more diverse urban adult population, and also asked additional questions about newly defined community-level “Expanded ACEs” that were not in the previous work, including if the participant has witnessed violence, felt discrimination, experienced an unsafe neighborhood, bullying, and/or lived in foster care. 

As a follow-up to a 2012 Philadelphia Public Health Management Corporation (PHMC) survey on health and health behaviors, the Penn study used the representative sample of more than 13,000 responses from children and adults in Philadelphia from that survey and called 1,784 of them for a phone interview about their experience with conventional and expanded ACEs.

Adversity exposure was more prevalent in the Philadelphia sample than the 1998 study in six of the nine categories, including physical abuse (38.1 percent to 10.8 percent), emotional abuse (33.2 percent to 11.1 percent), and experiencing a mentally ill household member (24.1 percent to 18.8 percent).

Cronholm says researchers have a better appreciation than ever for how toxic stress can change an individual’s biology and their equilibrium.

“These changes can alter a child’s cognitive ability as they get older and impair their coping skills, which leads to developing at risk behaviors and the very underpinnings of the most prevalent chronic diseases,” Cronholm says. “Over the last few years, we have seen greater advances in our understanding of the role of toxic stress in terms of a real biological, pathological mechanism that shortens the quantity and quality of people’s lives.”

This latest study not only helps clinicians treat patients more effectively, but also supports public officials as they strive to serve their constituents in better ways.

“This paper gives policymakers and public health officials data on the depth and distribution of childhood adversity within much more generalizable populations,” Cronholm said. “We have additional health outcomes data and this gives us the ability to expand on this very fundamental concept in terms of things that have relevance in communities as well as households.”

These findings also improve the ability of researchers to see which types of adversity exposure have a stronger effect than others and whether information around childhood diversity can help clinicians better identify and respond to patients who have trauma histories.

“We all see patients who have experienced childhood adversity all the time,” said Cronholm. “Determining root causes is the most effective way to design interventions that target prevention and mitigation of risk, and our understanding of this is critical to improving the health of the population as a whole.”

The Penn team sees these results as broadening the concept of trauma-informed care. Too often, Cronholm notes, clinicians “put out fires without dealing with the source,” by interacting with patients and looking at their behaviors or diseases without taking into account the history and context that led up to the health situation they are in.

Cronholm sees these new expanded ACEs and recent data as a guide in creating the steps in designing prevention and trauma informed efforts that allow care teams to understand how patients end up in the behaviors and chronic diseases that they treat the symptoms of.

The Penn study supports a multi-institution Philadelphia workgroup dedicated to this effort, including the Public Health Management Corporation, the Scattergood foundation, the Robert Wood Johnson foundation, and The Health Federation of Philadelphia.

“There’s a large collaboration of agencies and providers that understand trauma-informed care that are meeting and working on developing an agenda around identifying and responding to childhood adversity to improve the health of Philadelphians and derive insights that can help other communities as well,” Cronholm says.

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