Chapman et al (2004) describes adverse childhood experience (ACE) as a traumatic experience in a person’s life occurring before the age of 18 which the person remembers as an adult. Some examples of ACEs are physical abuse, emotional abuse, sexual abuse, alcoholism in the family, drug abuse in the family, depression or any other mental illness in the family, suicide in the family, incarceration of a family member, abuse of mother by her partner, abuse of father by his partner, parent separation, psychological neglect, physical neglect, bullying, involvement in physical fight, community violence, and collective violence.
The revolutionary first study, CDC–Kaiser Permanente ACE Study (Felitti et al., 1998), examined the relationships between these experiences during childhood and reduced health and well-being later in life. According to the latter, childhood experiences have a tremendous, lifelong impact on our health and the quality of our lives. The ACE Study showed dramatic links between ACEs and risky behavior, psychological issues, serious illness and the leading causes of death by altering the development of neurological, immunological and hormonal systems. Subsequently, individuals with greater exposure to ACEs are more likely to develop health-harming and anti-social behaviors, such as drinking, smoking and drug abuse. Moreover, they are also more likely to be involved in violence and other anti-social behavior and perform poorly in schools. Individuals with poor health and behavioral problems are more prone to develop conditions such as diabetes, cancer, cardiovascular disease and mental illness.
According to the WHO definition (WHO, 1999), child maltreatment refers to “all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity, in the context of a relationship of responsibility, trust or power”. Child maltreatment begins in childhood, but may progress through adolescence and adulthood and have consequences on various domains of functioning — physical, mental and social. For instance, neglect refers to a persistent failure of the caregiver to fulfill a child’s basic needs, leading to serious actual or potential damage to the child’s health and development in any key area, and therefore may be manifested as physical, educational, emotional or medical (WHO, 1999). However, when labeling neglect as a form of maltreatment, we have to bear in mind that sometimes it is difficult to distinguish between neglect and limitations of the family to provide in the context of poverty. Child maltreatment and inadequate caregiving, in general, are closely related to other specific ACEs in childhood and adolescence. Having a family member with a mental disorder, especially a parent, may have various negative repercussions on a child’s life. Maternal depression is related to more hostile, negative or disengaged parenting, and to lower parenting warmth. Thus there will be attachment issues where the child will not have a role model or someone to whom to turn to when facing any sort of problems.
Attachment refers to the innate psychobiological system stimulating humans to search for the proximity of significant others (i.e., parental figures), in need of security. It is an ‘internal working model’ of the self, and of self-in-relation to others, rooted in the first relationship between a baby and a caregiver. It is shaped throughout the relationship with significant figures and is closely linked to the reciprocal behavior of the caregiver and parental sensitivity. If early social exchange with the caregivers is compromised, the child may fail to develop secure bonds with significant others throughout life, resulting in the insecure attachment that has been evidenced in victims of child maltreatment. Insecure attachment, on the other hand, has been acknowledged as a risk factor for a variety of maladaptive adult outcomes, such as depression, traumatic symptoms and even problems of physical health. Moreover, the attachment has been repeatedly found to moderate and mediate the relationship between traumatic experiences and post-traumatic stress, and more specifically between childhood adversity on one side, and psychological distress and problems of well-being on the other side. Attachment has been operationalized through two dimensions: attachment anxiety (negative self-perceptions of self, positive perceptions of others, indicates hyperactivating interpersonal strategy) and avoidance (positive perceptions of self, negative perceptions of others, indicates deactivating interpersonal strategy), as well as their combination (negative perception of self and others), with higher values on dimensions implying more insecure attachment. Since attachment patterns may show continuity across time and across social contexts, early attachment insecurity may persist into adulthood affecting adult relationships, such as partner relationships, through insecure romantic attachment styles. This may be associated with serious partner dysfunctions such as relationship dissatisfaction and even relationship violence, contributing to further problems of global functioning.
Physical abuse includes real or potential physical injury produced by behavior or lack of protection by a caregiver, within the reasonable limits (Report of the Consultation on Child Abuse Prevention, 1999). Commonly, physical abuse comes in the form of ‘non-accidental injury’ (NAI) of various tissues, whereas specific forms refer to ‘Shaken baby syndrome’ syndrome of induced. Briere and Runtz (1990) produced data indicating abuse specific outcomes, with physical abuse linked to aggression towards others (Mullen et al., 1996). Physical abuse was damaging to the sense of self which heightened the risks of self-destructive and suicidal behaviors with physical abuse in childhood producing damage to adult functioning. Physical abuse was particularly associated with violence between parents. Separation and divorce were significantly associated with physical abuse. Physical abuse in combination with parental separation was significantly associated with low self-esteem. With other childhood risk factors, physical abuse was a significant contributor to lowered self-esteem, sexual problems.
Emotional abuse refers to caregiver’s repeated behavior or absence of behavior that leads or may lead to disturbances in a child’s emotional and social development (WHO, 1999). This may come in various forms, such as rejection, degradation, terror, isolation, being instigated by others to behave badly, exploitation, deprivation of essential stimulation, emotional exchange and availability, as well as unreliable and inconsistent parenting. Witnessing family violence is another form of emotional abuse that may have detrimental effects on child mental health and development (UNICEF, 2006). Bulimia nervosa has a strongest association with emotional abuse (Rorty, Yager and Rossotto (1994); Briere and Runtz (1990)). Emotional abuse by male care givers as against that by females was associated with difficulties with regard to sexuality in adult life. The impact of emotional abuse varied with the gender of the abuser. Emotional abuse from female care givers were more prone to psychiatric difficulties in adult life. Emotional abuse tended to go together with a lack of a confident among one’s childhood peers and not surprisingly a lack of relationship with the mother. In emotional abuse, risk of suicidal behavior and psychopathology are high.
Sexual abuse comprises any sexual activity (with or without touch, with or without penetration) between a child and adult or between a child and another child/adolescent who is dominant by chronological age or developmental stadium; if the child is younger than 14, even consensual sexual activity is considered as sexual abuse (WHO, 1999). Exposure to childhood sexual abuse is associated with increased rates of major depression, anxiety disorder, suicidal ideation, suicide attempt, alcohol dependence and illicit drug dependence. Experiencing both emotional neglect and emotional abuse was associated with increased likelihood of major depression, dysthymia, mania, any mood disorder, panic disorder, social phobia, generalized anxiety disorder, post-traumatic stress disorder, and any Axis I disorder.
Parental depression is associated with various outcomes in children: poorer physical health and well-being, stress-related conditions and different early mental health vulnerabilities such as ‘difficult’ temperament, insecure attachment, emotion dysregulation, aggression, poorer interpersonal functioning, poorer cognitive performance and academic achievements, as well as cognitive vulnerabilities to depression.
Parental alcoholism and substance abuse are another risk factor for child maltreatment and for a variety of adverse outcomes in children. These outcomes mostly refer to lower academic functioning (i.e., failure to pursue secondary education, weaker performance in reading, spelling and maths, etc.), problematic emotional functioning (anxiety, depression, conduct problems, social incompetence), as well as substance abuse. Parental suicide as another adverse experience in a child’s life, leads to a greater risk of psychiatric hospitalization and suicide in children, compared to youth with living parents.
ACEs related to household challenges (exposure to violently treated parent (usually a mother), parental divorce or separation, parental incarceration, a household member with substance abuse problems, and a household member with mental illness) are associated with future violence and victimization, health risk behaviors, chronic health conditions, mental illness, decreased life potential, and premature death. Having an incarcerated household member (family member in a jail) during childhood is associated with higher risk of poor health-related quality of life during adulthood, suggesting that the collateral damages of incarceration for children are long-term.
Exposure to parental separation/divorce is associated with increased risks of disruption of positive developmental outcomes across a number of domains and is associated with adverse adult outcomes, particularly in the realm of intimate relationships. Compared with individuals from families with stable parental relationships, young people exposed to parental separation/divorce are more likely to hold more negative attitudes toward marriage and cohabit rather than marry. When they do marry, young adults exposed to parental separation/divorce are more likely to find a partner who is also from an unstable family, and their relationships can be characterized by lower commitment, poorer relationship quality, particularly for women, and an increased likelihood of repeating the pattern of separation and divorce witnessed in childhood. As the number of an individual’s ACEs or exposure to childhood adversity increases, the risk of experiencing poorer life outcomes as an adult also increases. Researchers suggest that children dealing with a parental death are vulnerable to long-term emotional problems such as symptoms of depression; they are more anxious and withdrawn, with more school problems and generally poorer academic performance than non-bereaved children.
The negative effects are even more severe when children are exposed to domestic violence. Domestic violence is a pattern of assaultive and coercive behaviors used in the context of dating or intimate relationships. Studies showed that being exposed to domestic violence is the single best predictor of transmitting violence across generations. Children exposed to domestic violence are more likely to suffer child maltreatment than non-exposed children; the risk of physical and sexual abuse of children increases dramatically from 30% to 60% in those who witnessed domestic violence. Mothers beaten by their partners are twice as likely to abuse their children, and fathers who frequently beat their wives are more likely to beat their children as well. Witnessing family violence has long been unaddressed, although a growing body of research indicates that these children are affected in various domains, including their physical or biological functioning, behavior, emotions, cognitive development and social adjustment.
Another type of risky behavior associated with ACEs is non-suicidal self-injury (NSSI). It is defined as behavior that is self-directed and deliberate, resulting in injury or potential injury to oneself, without suicidal intent, although it consistently correlates with suicidality. Common forms of NSSI include cutting, burning, scratching, banging, hitting, biting, etc. Studies show that NSSI serves different functions, like brief relief, self-punishment, attracting attention in order to seek help, making others feel responsible for their problems, and as an act of conformity allowing individuals to connect with peers who also self-injure themselves. In spite of the short-term relief that NSSI enables, it leads to long-term negative consequences. Although NSSI can often co-occur with some mental illnesses, most frequently with depression and anxiety, it is also increasingly evident in individuals with no other mental illness. Each type of childhood abuse, occurring at any time within the first 16 years of life is significantly associated with NSSI. Highly lethal self-harm was associated with childhood physical peer victimization, sexual abuse, emotional abuse, and emotional neglect.