Pathways from Childhood Adversities to Health Outcomes
(Originally published October 2013)
Dissemination of findings from the Adverse Childhood Experiences Studies (ACES) has led to widespread interest among human services professionals, advocates and policymakers of how poor health outcomes and elevated rates of early mortality associated with child abuse and neglect and other adversities, such as growing up in families with substance abusing or mentally ill parents, or family violence, can be ameliorated. I have occasionally seen professional audiences become restive or even angry when ACE researchers failed to provide clear answers to questions about how the negative effects of childhood adversities can be prevented or about resilience factors that promote health in children and adult despite multiple early adversities.
The ACES studies include one obvious answer to how early adversities translate into poor health (e.g., diabetes, a heart condition, strokes, some cancers, gastrointestinal problems) throughout life: various types of child maltreatment, parental substance abuse and chronic mental health conditions, family violence and loss of a parent at an early age often occur in combination. Large doses of adversities in early life lead to elevated rates of behaviors that damage health such as overeating, smoking, substance abuse, dangerous sexual practices that serve as coping mechanisms for chronic mental health conditions, or take the edge off of pain and misery. In addition, adolescents and adults who were seriously harmed by caregivers at an early age, or who lived in the midst of community violence or war, may not expect to live long and prosper. The sense of a foreshortened future provides little or no motivation to refrain from self-harming behaviors.
However, as ACE researchers have pointed out, self-harming behaviors of children and adolescents are typically preceded by a range of impairments in cognitive, emotional and social development, including serious interpersonal problems that interfere with the capacity for friendship and intimacy. One pathway to reducing the effects of early adversities lies in interrupting the causal nexus that leads to self-harming behaviors and, for seriously abused and neglected children, this means restoring the capacity for positive relationships with caregivers, as well as early identification and treatment of mental health conditions.
The extent to which severe child maltreatment leads directly to poor health and/ or elevated death rates before there is time for self-harming behaviors to develop, should not be underestimated. Rene Spitz’s famous 1940’s research in foundling homes found that physically well cared for babies in institutional settings who lacked mothers died at alarming rates. In one of Spitz’s studies of a foundling home in a U.S. city, more than a third of infants and toddlers with extended stays died at an early age from natural causes. One plausible interpretation of Spitz’s findings is that severe emotional neglect in infancy damages children’s immune systems. The poor health of many abused and neglected children may be the result of both physical and emotional mistreatment and of the lack of a nurturing relationship with caregivers.
The same early adversities that often lead to poor health in both childhood and adult life also increase the risk of early death due to abuse or neglect, or from accidents, or possibly from disease. Eighty to ninety percent of children who die in abuse/neglect related incidents are 0-4 years old at the time of death. An outstanding (but unpublished) study of child mortality conducted by Washington State’s DSHS Office of Research and Data Analysis (ORDA) in the 1990s found that children 0-3 whose mothers received publicly funded substance abuse treatment died at 3.59 times the rate of other children in a large birth cohort. During the past two decades, co-sleeping deaths of infants of substance abusing parents have become a common cause of child death in families with an open/ recently open CPS case.
Emily Putnam-Hornstein’s study of injury related deaths in California found that a CPS report on children 0-5 was a major risk factor for injury related death. In Putnam- Hornstein’s study, young children with CPS reports were almost six times more likely to die from inflicted injuries and 2.5 times more likely to die from non-intentional injuries than other children of the same age. Public child welfare agencies have had little success in reducing maltreatment related child deaths despite (literally) thousands of child death reviews and decades of research studies with similar findings because (1) only about a third of children who die in abuse/neglect related incidents have been reported to CPS prior to death and (2) waiting for young children in high risk families to be clearly endangered before CPS caseworkers offer voluntary help or remove infants and toddlers from the home through legal action is an ineffective approach to child protection. Public health agencies need to be given a much larger role in the protection of infants and other young children; and CPS programs need to make far bigger investments in provision of early intervention services to at-risk families.
Other pathways to poor health and early death
There is a large body of research regarding the effects of organizational rank and status, and income inequality on health and mortality which Michael Marmot discusses in his book, The Status Syndrome (2004). One of the most surprising findings in this research is that differences in status and income effect all social classes and persons with a wide range of incomes, not just the poor and the wealthy. According to Marmot, “There is a large body of literature supporting the importance of these five characteristics, control, predictability, degree of support, threat to status, and presence of outlets, that modulate the impact of a psychologically threatening stimulus. All five of them are likely to be linked to position in the social hierarchy.” Marmot places a particular emphasis on degree of control of life circumstances, a factor directly related to rank in an organizational structure, social status and income. “Sustained, chronic and long term stress is linked to low control of life circumstances,” Marmot maintains, a condition to which persons with low organizational rank and social status, and lack of resources, are especially vulnerable.
Marmot comments that “… there is a syndrome in humans, which goes by various names, latterly called the metabolic syndrome …thought to be the result of insulin resistance. It is characterized by … fat around the abdomen rather the hips, low levels of HDL cholesterol (…the “good” cholesterol), high levels of plasma triglyceride, high levels of blood glucose and insulin in the fasting state, and high blood pressure. This pattern of metabolic change is associated with increased risk of heart disease.”
Some mental health conditions such as depression and PTSD (which often occur in combination) are associated with a sense of powerlessness in regard to both external conditions and one’s own reactions to perceived threats. Over 30 years ago, Richard Totman wrote in his prescient analysis (Social Causes of Illness, 1979) of the relationship between social conditions and illness that “At the heart of this model of psychosomatic influence is the concept of agency – personal commitment – and the assumption that the absence of this is related, in a crucial way, to enhanced susceptibility to illness.” Childhood adversities and other types of trauma are associated with highly elevated rates of mood disorders. Hopeless/helpless reactions to trauma, common among parents with co–occurring substance abuse and mental health disorders (the rule rather the exception among chronically neglecting and chronically maltreating parents), endanger health reflect the loss of self efficacy. Empowerment practices are important in child welfare because parents must regain confidence in their ability to act on their own behalf and the behalf of their children to adequately parent their children.
There is a type of despair that is deeper than demoralized hopeless/helpless reactions and that can undermine the will to live. Social experiences such as loss of family members or comrades during war, or isolation following immigration to a society with a culture vastly different than the culture in which a person was born or raised, or political and social oppression that makes it difficult, if not impossible, to positively affirm cultural identity, destroy a sense of meaning and purpose. The social bonds that protect physical health and mental health depend on shared beliefs, values and cultural traditions that must be expressed to be sustained. Totman comments on the importance of opportunities for the verbal declaration of opinions and attitudes in maintaining health. Expression of beliefs, values and attitudes in the presence of like-minded individuals, or possibly even those who disagree with these views, strengthens social and cultural identity. When cultural identity is stripped away by circumstances or through intentional policies and practices, the health and mental health of members of threatened cultural groups is threatened.
I am old enough to notice groups of elderly persons who meet daily, sometimes for years, in coffee shops and fast food restaurants. Obviously, members of these groups enjoy one another’s company, at least to a minimal degree; but it may be the opportunity to express and strengthen social attitudes and beliefs that keeps the group meeting for months and years. Strong intact social and cultural identity protects health and mental health of members of a group even when they don’t particularly like most other group members.
Preventing the Negative Effects of ACES
What can be done by individuals, philanthropic entities and governments to reduce the health impacts of childhood adversities?
Adolescents and adults can choose to engage in life sustaining behaviors rather than in habits that gradually undermine health and mental health. However, this is easier said than done for persons with chronic mental health conditions or who are emotionally suffering absent a mental health diagnosis. Unfortunately, the decision to forego self-harming behaviors often comes after or as part of (not before), a spiritual decision to seek to stay alive rather than accept the inevitability of an early death. Early identification and treatment of children’s and adolescents’ mental health conditions can limit the appeal of self-harming behaviors.
Social agencies, including public child welfare agencies, must commit to the goal of helping children and adults recover from the effects of early abuse and neglect, and other trauma. Safety and well-being concerns must be connected in both child welfare policy and practice. Concretely, this means that child welfare agencies must be far more concerned with identifying and undoing the emotional effects of child abuse and neglect than is currently the case.
There needs to be much larger federal and state investments in prevention and early intervention programs and services; in particular, parental substance abuse, chronic mental health conditions, family violence and severe poverty should elicit offers of voluntary services before a CPS report leads to coercive interventions. Public health agencies should be given a far bigger role in child welfare, especially in helping young single mothers develop nurturing relationships with their babies. Predictive analytics, as developed by Emily Putnam-Hornstein and several of her colleagues, should be used to develop targeted outreach to at- risk families.
Birth parents, foster parents and adoptive parents should receive training about trauma and its aftermath in addition to ongoing expert consultation regarding how children who have been severely abused or neglected can learn to use parents and other caregivers to calm down and feel safe. Every child (0-3) entering the foster care system should be assessed by an expert in infant mental health. Every possible effort should be made to ensure that the foster care system becomes a therapeutic entity rather than inflicting further harm on vulnerable children through multiple placements and punitive or non-nurturing care.
Programs for both abused and neglected children and their parents can utilize empowerment principles to restore a sense of self efficacy, i.e., personal agency. In practice, this means giving children and adolescents, and their parents, some degree of control over their lives within reasonable limits, even when there is legal structure.
Strong cultural identity can be recognized in policy and practice as essential to the health and mental health of children, their families and communities.
The federal government and state governments should adopt the policy goal of eliminating long term severe poverty, i.e., annual incomes less than half of the federal poverty standard for more than 5 years. Leaving almost one-tenth of U.S. children to grow up in severe poverty invites a host of expensive social ills resulting from multiple adversities, and accepts the destitution and social exclusion of millions of children and adults.
Marmot, Michael, The Status Syndrome (2004), Henry Holt and Company.
“Mortality of CPS Clients in Washington State From Birth to Age Four,” Office of Research and Data Analysis, Department of Social and Health Services, Olympia, Washington, 1998.
Putnam- Hornstein, Emily, “Report of Maltreatment as a Risk Factor for Injury Death,” Child Maltreatment, Vol. 16 (3), August 2011, 163-174.
Spitz, Rene, Cobliner, W. Godfrey, and Freud, Anna, The First Year of Life: A Psychoanalytic Study of Normal & Deviant Development of Object Relations, International Universities Press Inc., June 1966
Totman, Richard, Social Causes of Illness (1979), Pantheon Books.