JAMA Pediatrics Journal Club Slides: ACEs and Child Health in Early Adolescence

1. JAMA Pediatrics Journal Club Slides:ACEs and Child Health in Early Adolescence Flaherty EG, Thompson R, Dubowitz H, et al. Adverse childhood experiences and child health in early adolescence. JAMA Pediatr. Published online May 3, 2013. doi:10.1001/jamapediatrics.2013.22.

2. Introduction • Background • The incidence of child maltreatment is higher in adolescents than in younger children, but it is less likely to be reported to child protective services. • Child maltreatment and other adverse childhood experiences (ACEs) have been linked to health problems in both adults and children. • Few studies have examined the relationship between ACEs and adolescent health. • Study Objectives • To examine the relationship between previous ACEs and health problems and somatic concerns in early adolescence. • To examine the role of the timing of ACEs.

3. Methods • Study Design • Prospective analysis of the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) consortium interviews and questionnaire data when target children were 4, 6, 8, 12, and 14 years old. • Setting • Children with reported maltreatment or at risk for maltreatment in the South, East, Midwest, Northwest, and Southwest US LONGSCAN sites. • Patients • 933 children who completed an interview at age 14 years, including health outcomes. • Analyses controlled for study site, child’s sex, child’s race/ethnicity, caregiver’s marital status, and family income.

4. Methods • Outcomes • Exposures: 8 categories of adversity experienced during the first 6 years of life, the second 6 years of life, the most recent 2 years, and overall: • Psychological maltreatment. • Physical abuse. • Sexual abuse. • Neglect. • Caregiver’s substance use/alcohol abuse. • Caregiver’s depressive symptoms. • Caregiver treated violently. • Criminal behavior in the household. • Main Outcomes: Child health problems including: • Poor health. • Illness requiring a doctor. • Somatic concerns. • Any health problems at age 14 years.

5. Methods • Limitations • Exposure to some adversities or risks that influence child health may not have been included. • The cumulative effects of adversities over time were not examined. • The ACE exposure may have been even greater than the identified exposure, because the study tools did not assess the entire period during the previous child-parent interview. • Reference group for analysis was a small number of youths who had experienced no adversities.

6. Results • 27.2% of the adolescents reported a health problem. • 7.5% reported poor health. • 9.2% reported somatic concerns. • 11.7% had an illness requiring a doctor. • Most adolescents experienced some ACE during the first 14 years of life. • 57.3% exposed to neglect. • 56.6% exposed to caregiver depression. • 57.2% had experienced ≥3 ACEs. • The frequency of ACE exposures decreased as the children aged. • Only 8.7% of the youths had never experienced any of the measured ACEs.

7. Results • Adjusted odds ratios (AORs) between number of ACEs and health: • Graded relationship between ACE exposures and any health problem. • 1: AOR = 3.09 • 2: AOR = 3.61 • ≥3: AOR = 3.91 • Graded relationship between ACE exposures and somatic concerns. • 1: AOR = 4.19 • 2: AOR = 8.91 • ≥3: AOR = 9.25 • An increased number of ACE exposures trended toward a graded relationship with illness requiring a doctor. • 1: AOR = 3.12 • 2: AOR = 3.40 • ≥3: AOR = 3.68

8. Results • Effects of timing of ACEs in early childhood: • Greater adversities during the first 6 years of life were inconsistently associated with illness requiring a doctor, somatic concerns, and any health problem. • There was little effect of adversities in the second 6 years of life. • Recent adversities had strong effects on poor child health, somatic concerns, and any health problems. • Poor health and 1, 2, and ≥3 adversities: OR = 1.87, 2.59, and 3.78, respectively. • Somatic concerns and 1, 2, and ≥3 adversities: OR = 1.67, 2.27, and 3.47, respectively. • Any health problem and 1, 2, and ≥3 adversities: OR = 1.71, 1.86, and 2.38, respectively.

9. Comment • More than 90% of the adolescent sample had experienced some adversity in their 14 years of life. • Overall exposure to adversity and current exposure to adversity were associated with measures of poor health. • Study showed similar linear relationship between ACEs and health as demonstrated by the Centers for Disease Control and Prevention–Kaiser Permanente ACE studies. • Recent research on the effects of childhood stress and allostatic overload may provide some insight into the effects of ACEs on child health.

10. Comment • Conclusions • Childhood adversities including child maltreatment influence young adolescents’ health, illness, and somatic concerns beginning in childhood and continuing into adolescence. • Greater efforts to minimize, intervene, or treat childhood adversities will have an effect on the health of adolescents and adults.

11. Contact Information • If you have questions, please contact the corresponding author: • Emalee G. Flaherty, MD, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 E Chicago Ave, Box 16, Chicago, IL 60611 (eflaherty@luriechildrens.org). Funding/Support • This work was supported by grants to the Consortium for Longitudinal Studies on Child Abuse and Neglect (LONGSCAN) from the Children’s Bureau, Office on Child Abuse and Neglect, Administration for Children, Youth, and Families. Conflict of Interest Disclosures • Drs Flaherty and Runyan have provided expert testimony in cases of alleged child maltreatment. Any monies received for the testimony are paid to their respective institutions. Dr Dubowitz has provided expert testimony and sometimes received payment for this testimony. Drs Flaherty, Dubowitz, and Runyan have received honoraria and travel reimbursement for speaking at other institutions or conferences.