J.T. Fuller | December 8, 2022
Adverse childhood experiences (ACEs) are common in the US and worldwide, with predictable, preventable negative outcomes. Behavioral and emotional challenges (EMBs; including ADHD, depression, anxiety, and conduct disorders) become particularly apparent in adolescents while at school, where EMBs become a more significant concern, and there is a strong correlation between EMBs and ACEs. Maltreated children are less likely to have adequate resilience levels to navigate the stressors that are encountered in everyday student life. Minority students are at higher risk for ACEs, EMBs and low resilience levels. Sociological interventions at home, school and healthcare settings are recommended. Evidence-based interventions such as mindfulness have been shown to reduce the adverse outcomes related to ACEs, the intensity of EMBs and increase resilience.
Adverse childhood experiences (ACEs) are traumatic events like abuse, neglect, deprivation, exposure to violence or household stress, and are highly predictive of many adverse outcomes (Bethell et al., 2014). ACEs are a well-established risk factor for EMBs. Resilience is a potential mediator or moderator of this risk in some populations. A recent meta-analysis reconfirmed the significant negative association between ACEs and resilience found throughout the literature (Morgan et al., 2022). Resiliency factors moderate that impact in nuanced ways (Liu et al., 2019; Chen et al., 2022). The long-term effects of the trauma and stress associated with ACEs has been demonstrated to have neurobiological and epidemiological implications that are cumulative and multidimensional (Bethell et al., 2017). Research has shown a significant inverse relationship between ACEs exposure and functional neural connections related to resiliency as well as epigenetic changes related to hippocampus function associated with long-term trauma exposure (Morgan et al., 2022). Maltreated children are unlikely to meet empirical definitions of resilience when defined as adaptive functioning over time or no adjustment problems (Bolger & Patterson, 2003). A single measure of resiliency, “usually or always being able to stay calm and in control when faced with a challenge” has been identified as a critical and observable measure of resilience (Bethell et al., 2016, p. 143).
ACE exposure is an emerging topic of significant concern due to its pervasive nature and predictable long-term negative outcomes. Recent research has suggested more than 40 million children have experienced at least one ACE, increasing the risk of stress-related disorders such as substance use disorders, depression, suicide, and obesity (Morgan et al., 2022). Other research has estimated almost 35 million children (48%) in the United States have experienced one or more ACEs, with 22.6% experiencing at least two ACEs, reaching 30.5% in the 12-17 age range (Bethell et al., 2014). According to the National Child Abuse and Neglect Data System, 12.5% of children have a documented incident by age eighteen (Bethell et al., 2014). Adolescence is a time of increased risk for developing risky behaviors as coping mechanisms (Morgan et al., 2022). Resilience is not common or likely in the maltreated child population (Bolger & Patterson, 2003).
Adolescence is a pivotal developmental phase where ACEs significantly impact life trajectory (Soleimanpour, 2017). ACEs exposure is related to an increase in grade retention and decrease in resiliency manifestations as demonstrated by staying calm when experiencing challenges (Bethell et al., 2016). Maltreated children have shown significantly higher rates of relational challenges and low self-esteem (Bolger & Patterson, 2003). Adolescents experiencing the highest levels of ACEs report significantly higher levels of parental emotional abuse, emotional neglect and exposure to parental conflict, as well as the highest levels of coercive teacher behavior, peer conflict and feeling misunderstood or wrongly blamed by peers or teachers (Chen et al., 2022).
Children with EMBs are disproportionally exposed to more ACEs (Bethell et al., 2016). Given the strong dose-dependent relationship between ACE exposure and adverse health outcomes, this population is particularly vulnerable. The interrelationship between ACEs and EMBs is an area of ongoing research, and the symptoms are often similar. Researchers suggest ACEs may be a significant contributing factor to EMBs (Bethell et al., 2016). In addition to documented mental health challenges, a substantial but unknown portion of adolescents experience unreported EMBs resulting in increased inflammation, putting them at high risk for chronic adult diseases (Huang et al., 2019).
Risk factors for ACEs, EMBs and low resiliency overlap and are interrelated. Higher ACEs scores are correlated with many existing chronic conditions or other health risks including EMBs (Chen et al., 2022). Increased ACEs exposure is associated with lower resilience (Chen et al., 2022). Females exposed to two or more ACEs at particularly high risk of depression. The risk of having two or more ACEs is more than double for children with EMBs like ADHD, behavior problems and for those who bully (Bethell et al., 2014). Children with two or more ACEs were 2.67 times more likely to experience grade retention; children without ACEs were 2.59 times more likely to usually engage in school compared to those with 2 or more ACEs (Bethell et al., 2016). Minority and socioeconomic status are predictive of higher EMBs and ACEs (Liu et al., 2016).
Adolescents with low resilience are more likely to have EMBs (Hinduja & Patchin, 2017; Chen et al., 2022). Coercive parenting or aggressive behavior between adults is a potential mechanism to aggressive child behavior because prosocial behavior is neither demonstrated nor encouraged, and the children in turn use this learned coercive behavior with peers (Bolger & Patterson, 2003). Indeed, recent research has demonstrated parenting aggravation to be a stronger predictor of EMBs than ACEs (Suh & Luthar, 2020).
The impact of ACEs on EMBs is reduced by factors that also tend to improve resilience, and resilience is a protective factor for ACEs and EMBs. Resilience research has demonstrated increases in resilience mitigate the effects of EMBs and ACEs on disease and school engagement, thus reducing the likelihood of future EMB development (Huang et al., 2019). Other protective factors include family meals together; low parenting stress, quality parent–child communication; community activity participation; community service work; presence of an adult mentor in the child’s life; school engagement; safe school; safe neighborhood and family-centered care (Liu et al., 2016; Morgan et al., 2022). Additional protective factors include a protective home environment, healthy mother, parents not unusually aggravated by the child and higher parental education level (Bethell et al., 2014; McRae et al., 2020). Variation in protective factors is predictive of health outcomes when adversity is constant (Liu et al., 2016). Protective factors like interpersonal and social skills, peer and educational supports have been shown to moderate the impact of ACEs and related distress (Mesman et al., 2021). Resilience lowered the risk of grade retention and low school engagement for children with two or more ACEs (Bethell et al., 2014). Resilience mediated the effects of bullying on depressive symptoms (Zhou et al., 2016; Hinduja & Patchin, 2017). Perceived internal control is associated with lower levels of internalizing problems and higher levels of self-esteem is protective against EMBs, even in the context of moderate ACEs (Bolger & Patterson, 2003, Chen et al., 2022).
All experiences are filtered through a cultural lens, which informs the context for interpretation and response to stressors. The potential for both risk and protective factors related to culture include potential higher exposure to discrimination but also protective factors from cultural identity (Liu et al., 2019). Discrimination, marginalization, and oppression changes the lens for minority youth and has been linked to negative health outcomes (Liu et al., 2019). Non-white youth have less access to protective factors, lower cumulative protective factors (Liu et al., 2019). Minority youth are at higher risk for poor health regardless of socioeconomic status or other variables, and experience more ACEs compared to white youth (Liu et al., 2019).
Interventions across all sociological facets is recommended to address the many areas of potential risk and opportunities for protective factors. These areas include home, school, healthcare, and community-based efforts (Liu et al., 2019). Parenting interventions can include medication and behavioral training to support struggling parents of children with EMBs (McRae et al., 2020). Positive parenting training is aimed at reducing child maltreatment, and researchers recommend preventative interventions for high-risk parents such as unmarried teenagers and families living without economic stability (Bolger & Patterson, 2003). Schoolwide interventions include self-esteem improvement, prosocial engagement, trauma-informed programming, and resiliency development (Liu et al., 2019, Chen et al., 2022). Schoolwide programming is most effective in creating a prosocial environment to promote resiliency, including teacher training, conflict resolution and individual counseling (Hinduja & Patchin, 2017). Improved resiliency is expected to reduce risky behaviors in adolescents and promote overall health (Morgan et al., 2022). Healthcare interventions include family-centered, trauma-informed culturally-sensitive screening and care and particular focus on minority patients who are consistently experiencing worse health outcomes as compared to white patients (Liu et al., 2019; Soleimanpour et al., 2017).
Intervention practices include mindfulness, skills training, and cognitive-behavioral therapy. There is growing evidence of the efficacy of mindfulness training in improving resilience, trauma healing, self-regulation, and reducing EMBs (Bethell et al., 2016; Zhou et al., 2016; Huang et al., 2019). Mindfulness-based student interventions have been shown to improve cognitive performance and resilience (Zenner et al, 2014) and have been promoted as a potential neurological repair mechanism (Bethell et a., 2014). Life Skills Training is suggested to improve the effectiveness of mindfulness training by addressing skills deficits, although the data is inconsistent (Huang et al., 2019). Mindfulness-based mind-body practices such as biofeedback, guided imagery, yoga, hypnosis and meditation have been included in the American Academy of Pediatrics clinical practice guidelines (Bethell et al., 2016). Cognitive-behavioral therapy is a common evidence-based intervention for trauma-related mental health conditions and the school-based programming, Cognitive-Behavioral Intervention for Trauma in Schools, has demonstrated effectiveness for EMBs (Soleimanpour et al., 2017).
Several important limitations are notable in this review. There are minimal consistencies between published studies (Zenner et al, 2014), particularly with how ACEs and resilience are measured (Morgan et al., 2022). Longitudinal studies are minimal, with the overwhelming majority of studies based on survey data that is subject to self-selection bias and socially acceptable answer selection. Minimal research on cultural variations within this population. Emerging research on ACEs through latent class analysis has demonstrated common patterns and related outcomes, but person-centered analysis is not yet substantially established in the resilience literature. Variable-based research is limited to analysis of simultaneous risk factors and does not inform on stacked or multiple risk factors.
Research suggests a potential causal role between ACEs and the development/exacerbation of ADHD, asthma, obesity and other EMBs during childhood but this link has not been conclusively established yet (Bethell et al., 2014). Additional information to elucidate the relationship between these factors would support the development of effective intervention. Research on practical applications for the existing knowledge of evidence-based effectiveness in different contexts, including cultural sensitivities would guide implementation for specific populations.
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