Behaviors Affected by Adverse Childhood Experiences

Adverse Childhood Experiences (ACEs) are different events that occur to a child until

they are 18 which could potentially be traumatic to them as they grow older. According to the

Centers for Disease Control (CDC), these could be put into certain categories including

experiencing or witnessing abuse, knowing someone who attempts suicide, alcohol or substance

abuse, mental health, parental separation, etc. (2019b). ACEs can cause serious health problems

and are just now being tested to be correlated to different types of diseases such as cancer and

illnesses as well as behaviors along with adult development. More than half the adults surveyed

in over 25 states reported having experienced at least one ACE. Women and certain minority

groups are at a higher risk to experience them and are likely to have four or more by the end of

their childhood (CDC, 2019b).

Although ACEs are not common for every person, they could potentially be a key factor

for chronic diseases to those that experience numerous ACEs. Since they are not easily

diagnosable and can only be identified through a questionnaire, it is important to know the

effects these traumas bring as early as possible. Many children are misdiagnosed with ADHD,

due to the fact they share similar symptoms and behavior issues (Miller, n.d.). Since these kids

may not have the opportunity to have any sort of trusted adult in their home, the neglect carries

on to their daily life. They don’t feel the confidence to ask for help because of their neglect; they

are disciplined through their actions without knowing the overall reason behind their actions;

they grow not understanding how to manage emotions; they form a hostile attribution bias.

There are many factors that may tie into why certain people experience more ACEs than

others, but there is no clear way to eliminate them completely. Low socioeconomic status along
with being a minority race and living in a hostile environment themselves could be considered

ACEs because they can lead to very high levels of stress as they’re older (Rebicova et al., 2019).

The amount of education can also affect overall performance throughout their life leading to

increased anxiety and stress as well. If someone experiences any ACEs throughout their

childhood, it could potentially affect the rest of their life and needs to be treated with proper care.

Many behaviors including adolescent pregnancy, adult smoking, and sexually transmitted

diseases or risky sexual behavior become present due to ACEs being exposed to their lives.

A population tested through a Kaiser Permanente Medical Care Program in San Diego,

California, was studied to identify whether adolescent pregnancy, defined as between the ages of

11 and 19, increases as types of ACEs increased (Hillis et al., 2004). There was a fairly even

gender distribution in this study with 54.1% being women and 45.9% being men from the 17,

421 respondents. The data from the study was collected in two waves; the first wave was with a

calculation that determined an adolescent pregnancy and the second wave evaluated the validity

and was based on the results in the first wave which resulted to be 89.2% accurate. To measure

the number of ACEs a person in this study experienced, the traditional ACEs questionnaire was

sent home with categories varying from types of abuse, violence, mental illness, to incarcerated

household members.

The sample population included a tendency to have participants over the age of 50 (62%),

had at least some college education (72%), and to be white (77%). With that being said, more

than half of the overall sample size said they had experienced at least one ACE. For those who

said they had experienced more were significantly likely to be black or hispanic over the age of

35. After completing the study, they concluded that one-third of the adolescent pregnancies
could decrease by preventing their exposure to ACEs due to the fact that for a person who has

each of the 8 types, it was associated with a highly increased risk of adolescent pregnancy.

This study proved that as the number of ACEs rises, the rate at which adolescent

pregnancies occur also rises. There was a good gender distribution within the study, however, the

tendency in the population was guided towards white, middle-aged, developed people which

rules out what could be needed to know about other types of populations. Especially when it was

estimated that people who report they experienced more than one were black or hispanic. There

is a possibility the reported cases are not accurate due to the fact that it is a self-report and people

may not want to admit what has happened in the past or simply not wanting to say. The issue

with the ACE questionnaire in terms of the adolescent pregnancies, there is no way to state when

the first ACE occurred, which could give more information about when the age of exposure to

ACE affects a person the most.

The Behavioral Risk Factor Surveillance System (BRFSS) was used to determine the

association between ACEs and smoking in the state of Nebraska in 2011 (Yeoman et al., 2013).

The BRFSS is a health-related telephone survey system that collects state data which includes

issues involving health-related risk behaviors, chronic health conditions, and help to explain

preventative services, ​ (CDC, 2019a). Through a randomly selected subset of the total probability

completed the state added optional modules which included the ACEs questionnaire; 11

questions regarding past experiences and events that occurred before the age of 18 (Strine et al.,

2012). As used in the previous study, the questions varied from the different types of abuse,

household members with mental illnesses or were incarcerated, to types of violence. At the end

of the questionnaire, they were asked to self-report whether the person was a smoker or
nonsmoker. This study focuses on the affirmative responses through those categories and defines

them as environmental ACEs. The defined age categories were listed as those who did not

complete high school, those who did, those who attended some college or technical school, and

those who completed it.

After receiving their questionnaires, 10,293 sent them back. 95%, 9,778 of the

respondents were white. Since the majority of the data was for white people, they decided to

exclude those who were nonwhite as well as former smokers or missing questions in the

questionnaire which accounted to be 38% (3,945) of the respondents. This left the remainder of

the sample population to be 6, 348. Through their results, it was seen that 49% had no exposure

to ACEs, 33% had one or two, 11% had three or four, and 7% had five or more. The exact age

groups from the environmental ACEs exposures consisted of 29.9% who were over the age of

55, 54.3% aged 25-34, 36.9% were college graduates, and 55% did not complete high school.

The results from this study clearly demonstrates that ACEs are common among

Nebraskans, and show the results relate to smoking later in life. Through their aspect of viewing

environmental ACEs they were able to focus on specific reasons that could lead them to act in

specific ways. In terms of numbers, they have a relatively good sample size, however, due to the

fact that they excluded nonwhites in the study reduces the accuracy of the whole state. It was

said to not make much of a difference in their results but removing them completely from the

study could potentially exclude a significant population in the state. It is always useful to see

how ACEs affect all races to get a representation for everyone. Lastly, along with any

self-reported study, the accuracy could be wrong due to the underreported questions due to their

lack of interest in wanting to share their experiences.

 Men and women were studied separately in a study that evaluated the association

between ACEs and Sexually Transmitted Diseases through a Kaiser Health Plan (Hillis et al.,

2000). They chose members from the 13,494 who were at least 25 years old and completed their

standardized medical evaluations as their eligible participants. The participants were mailed

questionnaires which consisted of 60 questions as well as asked about STDs or venereal diseases,

written at the high school reading level because all participants had completed at least some high

school education, with the traditional concepts about types of abuse, issues with household

members, and battered mothers. The relationship between the ACEs and STDs was tested by

behavioral variables that were expected to function as intervening variables.

After the reports were sent home, 70.5% returned it resulted to have the participants as

slightly older with an average of 53, and had an average of 79.5% for them to be white. The total

of men were 4246 men and 5060 women. The majority of them were over the age of 35, had

some college education, were currently married, employed full time or retired, and were white,

however, women were less likely to be married. Half of both men and women were reported to

have experienced at least one ACE during their childhood. From the sample size, only 7.2% of

women and 10.5% of men reported a history of an STD. It was clear that men were more at risk

than women, but the risk for women increased with each category of ACE than men. Overall the

effect of a person experiencing six or seven categories made them five times more at risk than

the others. When put into the categories, the increase in risk for men was also high but not as

high in some categories. For incarcerated family members it was reported to be a 100% increase

for women and 160% for men. For childhood sexual abuse it was 90% for women and men. For

childhood emotional abuse it was 70% for women and 40% for men. For physical abuse, it was
60% for women and 50% for men. For household substance abuse it was 50% for women and

men. For a mentally ill household member, it was 50% for women and 20% for men. And lastly,

for a battered mother, it was 40% for women and 50% for men. Due to these results, ACEs are

determined to influence the risk that are associated with STDs for both men and women.

This study showed great information regarding specific details of both genders in the

study. With the sample size they had, they were able to receive enough data from both and make

the difference in the gender population relatively even. On the other hand, an issue with the

population is the lack of diversity. The majority of the participants seemed to be in the higher

class because of their education and lifestyle as well as having their standardized test done.

Having their test done meant they visit the doctor’s office consistently and even have the money

to go to a doctor’s office. This could affect the overall results of how true the association is. It

could be much higher for those in a lower class but was never tested. Apart from the hierarchy

deficiency, younger adults might have reported less because it wasn’t convenient for them, or

was unfamiliar with the term “venereal disease” when asked in the questionnaire. The ACE

categories were described in depth to make sure the reader understands what they all consist of

and follow along with the rest of the study. There were also tables and charts provided that

clearly stated the associated reported in the end. As always, there could be a possibility of

underreported STDs and ACEs in this case which could potentially affect the results. There is

also no way to specify when the STD occurred which could potentially be during their childhood

still which would alter what the study is looking for.

Although every study analyzed each association thoroughly and concluded there was one

with their behaviors tested in the studies. They were all missing an equal variety from every race.
The second study, which was analyzed through the BRFSS decided to take nonwhites out

completely which eliminated useful data that could be used. The third study which verifies an

association with STDs decided to separate the data through men and women. This showed

deeper insight into the outcome of ACEs through genders along with other contributing factors

that were used in all studies which was a good asset to their results. Separating the data in the

most efficient ways can be troublesome to get the best results but all populations should be taken

into account when possible.

I learned a few behaviors that are affected by the ACEs that a person is exposed to. All

races could have similar risks to behaviors affected by ACEs but minority races could have an

increased risk due to their social class or lifestyle. I learned all the categories in the ACE

questionnaire in depth and how they can be tested differently for the studies. I do have some

questions after studying my research, however. Why hasn’t the ACE questionnaire been updated

to suit a more reliable probability of life? This could include changing the questions to fit anyone

they know instead of just a household member or their mother in terms of domestic violence.

households vary tremendously from person to person which means in this case, it would be better

to be vaguer because any experience they encounter could potentially affect them in the future. Is

there any way to reduce the number of unreported cases? Even though it could be impossible to

get 100% of the data, there should be ways to encourage more people to participate and get more

data from. My last question is how could this be incorporated into school lessons? Most people

will experience at least one ACE and I think it is important for students to understand why they

may be feeling or behaving a certain way as well as informed they can talk to trusted adults in

school if they need to.

 Missing from all the research is the information from minority races and data from

younger adults. I recommend this questionnaire to be introduced at regular doctor check-ups and

to be talked about during the visit to see if they need help. There needs to be a way that people

feel they have a support system while growing up so they can overcome the trauma they feel and

are keeping to themselves. All they may be needing is someone to talk to but they do not know

who that person could be.

 References

Centers for Disease Control and Prevention. (2019a). ​Behavioral Risk Factor Surveillance

System (BRFSS). ​https://www.cdc.gov/brfss/index.html

Centers for Disease Control. (2019b). ​Preventing Adverse Childhood Experiences​.

https://www.cdc.gov/violenceprevention/childabuseandneglect/aces/fastfact.html

Hillis, S. D., Anda, R. F., & Dube, S. R. (2004). The association between Adverse Childhood

Experiences and adolescent pregnancy, long-term psychosocial consequences, and fetal

death. ​Pediatrics: Official Journal of the American Academy of Pediatrics, 113​(2), 320.

http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.578.100&rep=rep1&type=pd

Hillis, S. D., Anda, R. F., & Felitti, V. J. (2000). Adverse Childhood Experiences and sexually

transmitted diseases in men and women: A retrospective study. P

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e11-e11. https://doi.org/10.1542/peds.106.1.e11

Miller, C. (n.d.). How trauma affects kids in school. C

​ hild Mind Institute​.

https://childmind.org/article/how-trauma-affects-kids-school/

Rebicova, M.L., Veselska Z. D., & Husarova, D. (2019). The number of Adverse Childhood

Experiences is associated with emotional and behavioral problems among adolescents.

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https://www.mdpi.com/1660-4601/16/13/2446/htm

Strine, T. W., Dube, S. R., & Edwards, V. J. (2012). Associations between Adverse Childhood

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