Adverse childhood experiences (ACE) and health-risk behaviors among adults in a developing country setting

Abstract

Objective

This study aimed to examine the association among adverse childhood experiences, health-risk behaviors, and chronic disease conditions in adult life.

Study population

One thousand and sixty-eight (1,068) males and females aged 35 years and older, and residing in selected urban communities in Metro Manila participated in the cross-sectional survey.

Methods

A pretested local version of the Adverse Childhood Experiences Questionnaires developed by the Centers for Disease Control and Prevention, USA, was used. Data were collected through self-administration of the questionnaire. Prevalence and estimates of odds ratio were computed to obtain a measure of association among variables. Logistic regression analysis was employed to adjust for the potential confounding effects of age, sex, and socio-economic status.

Results

The results indicated that 75% of the respondents had at least 1 exposure to adverse childhood experiences. Nine percent had experienced 4 or more types of abuse and household dysfunctions. The most commonly reported types of negative childhood events were psychological/emotional abuse, physical neglect, and psychological neglect of basic needs. Majority of respondents claimed to have experienced living with an alcoholic or problem drinker and where there was domestic violence. Health-risk behavior consequences were mostly in the form of smoking, alcohol use, and risky sexual behavior. The general trend shows that there was a relatively strong graded relationship between number of adverse childhood experiences, health-risk behaviors, and poor health.

Conclusion

This study provided evidence that child maltreatment is a public health problem even in poorer environments. Prevention and early intervention of child maltreatment were recommended to reduce the prevalence of health-risk behavior and morbidity in later life.

Introduction

Much is known about the lifetime effects of childhood trauma. An earlier review of the literature by Browne and Filkenhor (1986) shows that depression, feelings of isolation and stigma, poor self-esteem, distrust, substance abuse, and sexual maladjustment are the most frequently reported long-term effects of child abuse and neglect. More recent findings point to the same consequences but include a variety of other psychopathological disorders such as suicide, panic disorder, dissociative disorders, post-traumatic stress disorder, and antisocial behaviors (Bensley et al., 2000, De Bellis and Thomas, 2003, English et al., 2004, Johnson and Leff, 1999, Sher et al., 1991, Silverman et al., 1996, Springer et al., 2007, Teicher, 2000, Zeitlen, 1994). Child abuse and neglect also result in impaired brain development with long-term consequences for cognitive, language, and academic abilities (Watts-English et al., 2006, Zolotor et al., 1999).

In particular, many of the past studies focused on the prospective impact of sexual abuse (Beitchman et al., 1992, Briere and Runtz, 1988, Finkelhor et al., 1990, Windle et al., 1995, to name a few). Jejeebhoy and Bolt (2003) found that those who experience coercive sex are more likely to experience both subsequent non-consensual sex and risky consensual sexual behaviors including abortion in adolescence and early adulthood. Child sexual abuse was shown to be associated with lifetime risks of depression, alcohol or drug dependence, panic disorders, post-traumatic stress disorders, and suicides (Dube et al., 2001, Dube et al., 2005). Furthermore, adult women with a history of childhood sexual abuse show greater evidence of sexual disturbance or dysfunction, homosexual experiences in adolescence or adulthood, and are more likely than non-abused women to be re-victimized. Beitchman et al. (1992) affirmed that the extent of impact depends on the duration of abuse and the threat or use of force. Moreover, greater harm is inflicted if the father (or stepfather) is the perpetrator and if sexual abuse involves penetration.

Similarly, physical maltreatment can result in bruises, broken bones, visual and auditory impairment, brain damage, contusions, burns, and death (Oates, 1996). In particular, the violent shaking of a baby (Shaken Baby Syndrome) has been found to be associated with bleeding of the brain, which may lead to permanent, severe brain damage or death (National Institute of Neurological Disorders & Stroke, 2001). Physical maltreatment was also found to be associated with an array of psychological problems that include major depression, alcohol dependence, and externalizing problems (Brownridge et al., 2006, Miller-Perrin et al., 2009). In addition, adults who were physically maltreated during childhood are at increased risk of harming their own children who, in turn, tend to exhibit insecure attachment patterns (Belsky, 1993, Kaufman and Zigler, 1987, Newcomb and Locke, 2001, Simons et al., 1991, Van Ijzendoorn, 1995). Adolescents with a history of physical maltreatment may even participate in dating relationships that are characterized by violence as well (Wekerle and Wolfe, 1998, Wekerle et al., 2001).

Akin to physical violence and sexual abuse, psychological maltreatment appears to be as destructive as it puts its victims at equal risk of developing physical and mental health problems (Egeland and Erickson, 1987, O’Leary, 1999). Individuals who underwent psychological abuse are more prone to develop chronic physical and mental illnesses such as depression, injury, drug addiction, and alcoholism (National Research Council, 1996, Tomison and Tucci, 1997). Psychological maltreatment may also result in poor self-esteem that may lower capacities to combat the effects of future abusive events (Walker, 1994). In the Philippines, a community study indicated that depression, feelings of embarrassment, suicidal ideations, and having broken families are most common among psychologically abused men and women (Philippines Department of Health, 2000a, Philippines Department of Health, 2000b).

Directly or indirectly, household insufficiencies and dysfunctions may also lead to negative psychosocial and health outcomes (Flaherty et al., 2006, Springer et al., 2007). Such household insufficiencies include general poverty specific to lack of basic necessities such as food, shelter, clothing, education, and health. Children from families that report multiple experiences of food insufficiency and hunger are more likely to show behavioral, emotional, and academic problems than children whose families do not report such conditions in life (Kleinman et al., 1998). Moreover, household dysfunctions such as living with a family member who is an alcoholic, drug addict, mentally ill, or one who has been incarcerated for certain crimes and offenses may also influence future life outcomes. For instance, children with family histories of substance abuse had higher levels of aggression, delinquency, sensation-seeking, hyperactivity, impulsivity, anxiety, negative affectivity, and difficulties in self-differentiation compared to children with no such histories (Dore et al., 1996, Giancola and Parker, 2001, Maynard, 1997). Family history of alcohol dependence has also predicted poor adolescent neuropsychological functioning (Anda et al., 2006, Dube et al., 2006, Tapert and Brown, 2000). The same is true with situations where a child grew in a family where domestic violence is a common experience, or where parents are separated or divorced. Studies have shown that children who lived under an environment of domestic violence exhibit clinical levels of anxiety or post-traumatic stress disorder (Graham-Bermann & Levendosky, 1998). These children are at significant risk for law breaking, substance abuse, school inattendance, and relationship problems.

Aside from its psychosocial consequences, child abuse and neglect have become a serious public health problem. The health outcomes usually occur in highly inter-related forms. A strong, graded relationship between the number of adverse experiences in childhood, and self-reports of cigarette smoking, alcoholism, drug abuse, obesity, attempted suicide, and sexual promiscuity in later life was reported (Anda et al., 1999, Dietz et al., 1999, Felitti et al., 1998). Similarly, the likelihood that a person develops physical and mental health conditions such as heart disease, cancer, and depression in adulthood is greater, the more childhood adverse experiences were experienced (Chapman et al., 2004, Dong et al., 2003, Dong et al., 2005, Hillis et al., 2000).

In reality, child abuse and neglect do not usually occur as single incidents but rather, they are experienced repeatedly and simultaneously in various forms (Trickett, 1998). The experience of multiple types of maltreatment is associated with greater impairment than experiencing a single form of maltreatment (Higgins & McCabe, 2000). Child maltreatment can become recurrent or repetitive, especially if the child is not withdrawn from the same environment where initial abuses occurred. This is also compounded by the fact that in some cultures, parents and other caregivers regard physical punishment and psychological reprimands as a necessary form of discipline for their children (Lansford and Dodge, 2008, Orhon et al., 2006, Plan Philippines, 2005).

Current knowledge of the effects of negative life events in childhood is mostly focused on experiences in the developed world. Very few pieces of evidence in developing countries are noted. Definitely, poverty and associated environmental and social concerns serve as compounding factors that prevent children in developing countries from attaining their maximum potential. Walker et al. (2007) posited that stunting, nutrition and inadequate cognitive stimulation which are common among children in developing countries, entail exposure to several factors including less opportunities for learning, polluted environment, heavy metal poisoning, and household crowding.

The Philippines is one country in the developing world with fewer resources for health but with a high prevalence of infectious and non-communicable diseases such as TB, cardiovascular diseases, cancers, unintentional injuries, and diabetes (Philippine Health Statistics, 2009). The prevalence of smoking is high at 40%, and alcohol use at 37% among male youth (Domingo & Marquez, 1999). Moreover, the number of abused children reported to the Department of Social Welfare and Development increased 5-fold from 1998 to 2002, although in a population-based study (BSNOH, 2000), it was reported that nearly 90% of the 2,700 adolescent-respondents claimed to have been physically maltreated while about 60% were psychologically abused at least once in their lifetime. About 12% reported having been sexually molested. The main question, therefore, is: In the Philippine setting, are these statistics interrelated? How, if at all, do these findings relate to one another?

This study aimed to determine the interrelationship among adverse childhood experiences, health-risk behaviors and health outcomes in a developing country setting. It sought to examine associations among a number of adverse childhood experiences and health-risk behaviors. Associations between childhood trauma and occurrence of common major diseases were also studied.