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Building a Framework for Global Surveillance of the Public Health Implications of Adverse Childhood Experiences

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Background

In May 2009, the WHO and the National Center for Chronic Disease Prevention and Health Promotion (CDC, Atlanta GA) met in Geneva, Switzerland, to begin a collaborative effort to build a framework for public health surveillance that can be used to define the global health burden of adverse childhood experiences (ACEs). In addition to WHO and CDC staff, meeting participants included people working in the fields of public health and early child development from Canada, China, the former Yugoslav

Why Adverse Childhood Experiences?

We use the term adverse childhood experiences (ACEs) as a way of moving toward understanding the public health implications of childhood maltreatment and related experiences. The experiences referred to herein include (but should not be conceptually limited to) abuse (emotional, physical, sexual); neglect (emotional, physical); and growing up in households where domestic violence is witnessed, members abuse alcohol or drugs or have mental illnesses, there is relational stress (such as

The ACE Concept and Primary Prevention

The emergence of ACEs as topic of research in public health is a natural evolution in the field of health promotion and disease prevention. This brief background provides a short historical and conceptual framework for understanding this evolution.

The seminal work of McGinnis and Foege, titled “Actual Causes of Death in the United States,”11 quantified the contribution of alcohol, smoking, and other health risk behaviors to mortality in the U.S. In addition, the growth in popularity of the BRFSS

Moving Beyond “Measurement” Controversy and Limitations

A healthy controversy exists about the strengths and weaknesses of using retrospective self-reports of ACEs versus reports validated by child protection services for studying effects of exposure to childhood maltreatment.24, 25 A tendency to focus on the differences in findings between studies using one versus the other of these two methods has overshadowed the fact that both methods have shown substantial effects in multiple areas and are frequently concordant in terms of finding negative

Defining Exposure and Outcomes

A second conceptual hurdle in the assessment of the public health impact of ACEs is the tendency to view reported maltreatment “events” as the public health outcome. Although such events constitute a key target for preventive attention, only a small fraction have acute consequences of sufficient severity to bring them to the attention of public authorities. By far, the largest proportion of the burden of disease due to ACEs arises from the cumulative effect of chronic exposure to multiple

A Cumulative Stressor Approach

The ACE Study has shown that stressors such as abuse, neglect, witnessing domestic violence, and other forms of household dysfunction are common and frequently co-occur during childhood.29 Review of the literature on the public health importance of child abuse emphasizes this pattern.4

The co-occurring nature of ACEs led to the use of an “ACE score,” which is an integer count of the number of categories of ACEs. The ACE score has repeatedly shown a positive graded relationship to a wide variety

Biologic Plausibility

Use of the ACE Score as a measure of the cumulative exposure to traumatic stress during childhood is consistent with recent understanding of the effects of traumatic stress on neurodevelopment.19, 30 Neuroscientists, using experimental animal models as well as case–control studies with humans, have linked childhood maltreatment to long-term changes in brain structure and function involving several interconnected brain regions.31, 32, 33, 34, 35, 36 Early stress is also associated with lasting

Genetics, Epigenetics, and Childhood Adversity

Inclusion of genetic and biological evidence is necessary for understanding the effects of ACEs and their intergenerational transmission.43 A growing body of epidemiologic evidence suggests that genotypes can modify sensitivity to environmental adversity. Promising avenues of research in this arena include gene–experience interaction,44 the influence of early life experience on genomic expression (epigenetics),45 and the role of inflammation.46

The complex interplay of gene–environment

Conclusion

Sufficient amounts of data exist to show that ACEs are common and are associated with many public health problems. Although the bulk of these data are from studies conducted in developed countries, a growing body of research from developing countries suggests that the same relationships exist in these settings. Findings from the Global School–Based Student Health Survey for a pooled sample of 22,256 respondents from five African countries demonstrate significant dose–response relationships

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