All adverse childhood experiences are not equal: The contribution of synergy to adverse childhood experience scores.

Abstract

The operationalization of childhood trauma and adversity into checklists commonly known as adverse childhood experiences, or ACEs, has become the most widely adopted methodology linking traumatic childhoods to adult outcomes. As the number of self-reported ACEs increase from 0 to 4 or more (4+), most studies find a roughly stepwise progression in risk for a wide range of negative medical and mental health outcomes. A score of 4+ ACEs, has become a de facto cutpoint, increasingly used clinically to define “high risk” status for a myriad of outcomes. Comparisons across studies using a 4+ cutpoint, however, find considerable heterogeneity in the degree of risk for the same outcomes. In addition to sample and methodological differences, certain pairs of ACEs comprising the cumulative ACE score interact synergistically to significantly increase the overall risk beyond the sum (or product) of the contributions of each ACE to the outcome. This article reviews the empirical literature on synergistic ACEs including results from a general population adult and a mixed trauma, youth sample both sufficiently powered to examine over 20 different ACE pairings for possible synergy. Synergistic pairs of ACEs vary by gender and age group. About 30–40% of the variance in outcomes is accounted for by additive synergistic interactions between certain pairs of ACEs. Across studies, sexual abuse is the most synergistically reactive ACE. The article concludes with a discussion of the implications of synergistic ACE pairings for psychologists and other allied professionals across clinical practice, prevention, research, and policy.

Child Maltreatment and Long-Term Physical and Mental Health Outcomes: An Exploration of Biopsychosocial Determinants and Implications for Prevention

“…Childhood maltreatment is a known precursor to a range of mental health and high-risk behaviours that compound the risk of ill health [ 22 ]. Child sexual abuse frequently causes immediate and intractable negative physical, psychological, and social problems [ 23 ] and when sexual abuse co-occurs with other ACEs (as it often does), the risks of adverse medical and mental health problems are higher than for other combinations of ACEs [ 24 ]. Consequences commonly include post-traumatic stress disorder (PTSD) [ 25 ], obesity and eating disorders [ 26 – 28 ], alcohol and drug problems [ 29 – 33 ], poor school achievement [ 34 ], depression [ 35 , 36 ], dissociation [ 37 ], social impairment [ 38 ], antisocial behaviour, anxiety [ 39 ], self-harm and suicide [ 40 , 41 ], and increased chance of revictimization [ 42 , 43 ].…”

Patterns of adverse childhood experiences and associations with prenatal substance use and poor infant outcomes in a multi-country cohort of mothers: A Latent Class Analysis

“…However, the pairwise differences between classes suggest that the highly maltreated class and the emotionally abused class, but not the intra-familial violence exposed class, had greater probability of prenatal illicit drug use compared to the normative class. Indeed, child sexual abuse, physical abuse, and exposure to intra-familial violence are synergistically reactive forms of ACEs (Briggs et al, 2021); this may partially explain why the highly maltreated class had increased risk compared to the normative class. However, what is less clear is why the three high-risk ACE classes were statistically indistinguishable from each other.…”

“…This will be burdensome for health system foundations, particularly in LMICs where inadequate resources and ineffective organizational referral systems remain as persistent challenges (WHO, 2021). ACE questionnaires or similar tools, however, can be used as a jumping-off point to introduce the sensitive topic to expectant mothers, followed by a systematic clinical assessment of the nature of their childhood adversity with detailed discussion of, inter alia, developmental chronicity, frequency, and severity (Anda et al, 2020;Briggs et al, 2021). However, this may not always be feasible in already overburdened antenatal health centers.…”

Using network analysis to illuminate the intergenerational transmission of adversity in the ALSPAC cohort

“…Yet, only physical abuse, and not threshold ACEs, demonstrated a direct relationship with LBW. Childhood physical abuse is a prevalent toxic stressor and its far-reaching consequences on health and development is well-established showed that sexual abuse played a central role in bridging ACEs and mental disorders in adulthood (27).Childhood sexual abuse is strongly associated with likelihood of exposure to other ACEs and has been identified as the most synergistically reactive form of ACEs, meaning that interactions with other adversities in childhood or adulthood substantially increased health consequences (56). Thus, sexual abuse can be considered an optimal target for intervention because preventing it may increase the likelihood of destabilizing the entire ACE network and may prevent the occurrence of long-term health consequences (27).…”

“…Physical abuse was the only childhood adversity linked to low birthweight. This highlights the methodological limitation of using threshold ACE scores and provides evidence that individual ACEs are not equal in the strength of their effect and consequently, undercuts the rationale for using the threshold score in policy and practice settings (56). Finally, childhood sexual abuse and prenatal smoking were identified as the most influential factors in the network and may lend themselves as optimal targets for prevention of intergenerational risk transmission.…”